At the initial assessment you decided that the best interest of the patient and safety would be admission to the psychiatric unit. The patient remained for six days in t

For this assignment, you will build on your initial assessment and safety plan from the Week 4 Case Study. The case study is listed below for your review.

Jill is a 50-year-old woman who lives with her husband and two children (aged 20 and 18). She has come to see her PMHNP with worries about a number of health problems including extreme tiredness, agitation and pains in her chest. Past history Jill has been a frequent attender at the practice over the years, often with concerns about her or her children’s health. She experienced postpartum depression with her second child. She has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. When she was 23 she took an overdose following the break-up of a relationship. She had some sessions of counseling about 10 years ago that she found helpful. She was referred to a primary care mental health worker in the practice two years ago for help with anxiety and low mood. She had some sessions of individual guided self-help, but she found that this made no difference. She was put in touch with a voluntary sector self-help group for people with anxiety around this time – but did not pursue this. She has no other health history or complaints today related to medical health, no military history. She currently takes no medications and has no allergies. She considers herself healthy as she eats a vegan diet and does walk 2 times a week around the local lake.

On examination Jill says she has always been a very ‘nervy’ person who finds dealing with everyday stresses difficult. She worries a lot about herself and her family and easily gets “in a state” and assumes “the worst” – for example, if family members are unwell or if they are late coming home. Sometimes things get so bad that she needs someone around her constantly to reassure her and feels that she can’t be left on her own. The intensity of these problems has varied over the years, but has become worse again during the past eight months following her husband’s diagnosis of heart problems. She has been drinking wine most evenings to try to calm herself down. More recently things have become so bad that she has sometimes felt that if she were left on her own she might harm herself. Her family has been very supportive and stayed with her during these periods until she calmed down, but is now finding this difficult to manage. Last night she had an extended period of feeling like everyone would be better off without her. She describes a plan “to drink alcohol, take some of her husband’s pain medications, start her car in the garage and pass out.” She states the only thing that every helps her is to walk and hum to herself and in the winter she sometimes knits.

 

Vitals: BP: 122/68 HR: 74 R: 18 T: 97 O2: 99% Pain: 2 on 0–10 scale

Wt.: 147

Ht.: 66”

Initial Assessment:

Patient Name: Jane Dolly

MRN: X12674799

Date of Service: 05/12/2024

Start Time: 10:00

End Time: 11:02

Billing Code(s): 90837 90791

Accompanied by: Husband

CC: “I’m extremely tired and agitated. I sometimes have chest pains and I’m worried about my health”

HPI: Patient is a 50-year-old female with hx of GAD, MDD, and past suicide attempt presenting with worsening anxiety, depression, passive SI, and increased alcohol use in context of husband's recent heart condition diagnosis. Symptoms escalated over past 8 months with plans of overdose/carbon monoxide poisoning. After giving birth to her second child, she experienced posttpartum depression. She has used antidepressants intermittently for the past 30 years and has a history of depression and GAD. She overdosed when she was 23 years old, after a relationship ended. She found some counseling sessions she had around 10 years ago to be beneficial. Two years ago, she was referred to the practice's primary care mental health worker for assistance with anxiety and depression.

S- Long-standing struggles with anxiety, worry, difficulty managing stress. Catastrophizes minor issues, needs constant reassurance. Depressive symptoms of low mood, anhedonia, fatigue. Increased alcohol use to cope. Passive SI last night with plan to overdose but did not act on it. Positive supports include family and hobbies like walking, knitting.

Crisis Issues Patient denies current suicidal ideation or intent, but endorsed passive suicidal ideation with a specific plan to overdose the previous night, though she did not act on it. No access to firearms, but has access to medications, alcohol, and car in the home which could be used for an attempt.

Reviewed Allergies: NKA

Current Medications: None

ROS: no complaints

O-

Vitals: BP 122/68, HR 74, RR 18, T 97F, O2 99%, Ht 66", Wt 147 lbs

Labs: Deferred

Results of any Psychiatric Clinical Tests: None

MSE:

Jill is a 50-year-old woman who appears her stated age. She is casually dressed in slacks and a sweater. She makes good eye contact and is cooperative with the interview. Her psychomotor activity is increased, fidgeting frequently in her chair and unable to remain still. Her mood is anxious and depressed, rating her mood as "3/10". Her affect is constricted in range but congruent with her depressed and anxious mood. Her speech is generally regular rate and rhythm, though at times becomes pressured with rapid, uninterrupted speech. Her thought process is circumstantial, going off on tangents frequently before being redirected. Her thought content is notable for excessive worry about minor matters, catastrophizing, and somatic preoccupations. She denies any current auditory or visual hallucinations. No overt delusions are evident. She is oriented to person, place, time, and situation. Her attention and concentration are mildly impaired due to anxiety. Her short and long-term memory appear grossly intact. Her insight is fair, as she recognizes her anxiety and depression are excessive but has difficulty controlling her worry. Her judgment appears impaired given her recent plan to overdose and use carbon monoxide poisoning. She denies any current thoughts of self-harm or suicidal ideation.

A – with (ICD-10 code)

Definitive Diagnosis:

Major Depressive Disorder, Recurrent, Severe with Anxious Distress (F33.2)

Generalized Anxiety Disorder (F41.1)

Alcohol Use Disorder, Mild (F10.10)

Differential Diagnoses:

Anxiety disorder, Unspecified (F41.9)

Persistent depressive disorder (F34.1)

P-

Start sertraline 50mg daily for depression/anxiety

Refer to partial hospitalization program for stabilization

Psychotherapy: CBT for anxiety management, coping skills

Encourage Jill to join a support group

Stress importance of abstaining from alcohol

Safety plan and remove means for self-harm

Follow up in 1 week

Patient Education: Medication risks/benefits, importance of adherence, signs to return to ER on worsening symptoms and acute safety risks

Referrals: none at this time

Provider Signature: T.M, PMHNP

Safety Plan for Jill

1. Remove Access to Lethal Means:

· Have Jill's husband remove all firearms from the home (if present) and store them with a trusted friend/family member or at a gun range/club (Nuji et al., 2021).

· Have Jill's husband remove all alcohol, medications, sharp objects, belts, ropes or anything that could be used for self-harm and store them securely.

· Ensure Jill does not have access to car keys to prevent carbon monoxide poisoning.

2. Develop Emergency Contacts:

· Identify 2-3 people Jill can contact if she feels unsafe or has thoughts of suicide (e.g. husband, close friend, therapist's crisis line) (Nuji et al., 2021).

· Program their numbers prominently in her phone.

3. Identify Emergency Services:

· Provide the phone numbers for local emergency services and the National Suicide Prevention Lifeline (1-800-273-8255) (Nuji et al., 2021).

4. Safety Precautions at Home:

· Have Jill's husband or a trusted friend stay with her at all times until she is stabilized.

· Remove any detached garage door openers to prevent carbon monoxide poisoning.

5. Develop Coping Strategies:

· Identify activities that help Jill cope (walking, knitting, breathing exercises).

· Encourage using these when having thoughts of self-harm (Nuji et al., 2021).

6. Follow-Up:

· Schedule follow-up appointment within 1 week.

· Recommend inpatient hospitalization if safety cannot be assured.

A safety plan was created with Jill and her husband to protect her in light of the recent suicide attempt and continuous self-harming thoughts. This involves taking out all lethal measures in the home setting including firearms, alcohol, medications, car keys among others which are means of death like overdose or carbon monoxide poisoning. Contacts of emergency and suicide prevention hotlines were pre-programmed in her phone. Her husband will not leave her sight until the point that she is stable. Jill’s coping techniques included walking, knitting, and breathing exercises to employ during suicidal urges. Jill and her husband were both trained to keep a safe environment, know the warning signs, use these distress tolerance and grounding techniques during a crisis. With inpatient hospitalization being the most recommended option considering the severity and recent attempt, Jill committed to participate in an intensive outpatient program that featured daily individual and group therapy sessions. A trauma-informed CBT intervention with a focus on anxiety control, behavioral activation, and building emotional regulation skills would be a suitable psychotherapeutic modality. A follow-up was to be done in one week with advice to return to the ER immediately if the safety issue arises. The gravity of the situation was apparent to her husband, and he consented to offer a consistent support system.

References

American Psychiatric Association. (2013).  Diagnostic and statistical manual of mental

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Nuij, C., van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., … & Riper,

H. (2021). Safety planning-type interventions for suicide prevention: meta-analysis.  The

British Journal of Psychiatry,  219(2), 419-426.

At the initial assessment you decided that the best interest of the patient and safety would be admission to the psychiatric unit. The patient remained for six days in the inpatient psychiatric unit. During her stay, she attended group meetings, was started on Zoloft for anxiety and depression and was stabilized. Upon discharge, the patient agreed to attend psychotherapy treatment and continue with her prescription for 50mg Zoloft PO daily.

This is your first follow-up appointment with your patient, Jill, two weeks after her hospital discharge. The goal of today’s appointment is to assess her as follow-up and to develop a psychotherapy treatment plan to continue treatment.

Use the Individual Psychotherapy Treatment Plan template in Course Documents. You are required to use APA format with evidence-based references to support your treatment plan.

Patient Name: XXX

MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00 End Time: 10:54

Billing Code(s): 90213, 90836

(Be sure to include strictly psychotherapy codes or both E&M, and add on psychotherapy codes if prescribing provider visit.)

Accompanied by: Brother

CC: Follow-up appt. for counseling after discharge from inpatient psychiatric unit two days ago

HPI: One week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

Reviewed Allergies: NKA

Current Medications: Fluoxetine 10mg daily

ROS: no complaints

O-

Vitals: T 98.4, P 82, R 16, BP 122/78

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A – with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses

2.

3.

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Psychotherapy Modality used: CBT

See FULL Psychotherapy Treatment Plan attached

Educations: discussed smoking cessation

Reviewed medication side effects and adherence importance

Follow-up: in one week or earlier if any depressive symptoms worsen.

Referrals: none at this time

Psychotherapy Treatment Plan

Risks: isolated, no close family or relationships, high pressure family environment and expectations, full schedule with school and work.

Strengths: XX

Outcome tool used and results: Beck anxiety inventory (BAI): 24

https://res.cloudinary.com/dpmykpsih/image/upload/great-plains-health-site-358/media/1087/anxiety.pdf

Psychotherapy Modality: Cognitive Behavioral Therapy

Frequency: Weekly sessions until further notice

Long Term Goals:

1. Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.

Short Term Goals:

a. Reduce daily frequency of anxiety by recognizing patterns in thought processes.

b. Implement behaviors to recognize triggers for anxiety.

2. Learn and implement coping skills that result in a reduction of anxiety and worry, and improved daily functioning.

Short Term Goals:

a. Learn deep breathing exercises.

b. Implement daily mediation exercises.

OBJECTIVES	INTERVENTIONS
1. Describe situations, thoughts, feelings, and actions associated with anxieties and worries, their impact on functioning, and attempts to resolve them.	1. Focus on developing a level of trust with the client; provide support and empathy to encourage the client to feel safe in expressing his/her GAD symptoms. 2. Ask the client to describe his/her past experiences of anxiety and their impact on functioning; assess the focus, excessiveness, and uncontrollability of the worry and the type, frequency, intensity, and duration of his/her anxiety symptoms (consider using a structured interview such as The Anxiety Disorders Interview Schedule–Adult Version).
2. Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.	1. Discuss how generalized anxiety typically involves excessive worry about unrealistic threats, various bodily expressions of tension, overarousal, and hypervigilance, and avoidance of what is threatening that interact to maintain the problem (see Mastery of Your Anxiety and Worry—Therapist Guide by Zinbarg, Craske, and Barlow; Treating GAD by Rygh and Sanderson). 2. Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively, reduce overarousal, and eliminate unnecessary avoidance. 3. Assign the client to read psychoeducational sections of books or treatment manuals on worry and generalized anxiety (e.g., Mastery of Your Anxiety and Worry — Workbook by Craske and Barlow; Overcoming Generalized Anxiety Disorder by White).
3. Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.	1. Teach the client calming/ relaxation skills (e.g., applied relaxation, progressive muscle relaxation, cue controlled relaxation; mindful breathing; biofeedback) and how to discriminate better between relaxation and tension; teach the client how to apply these skills to his/her daily life (e.g., New Directions in Progressive Muscle Relaxation by Bernstein, Borkovec, and Hazlett-Stevens; Treating GAD by Rygh and Sanderson). 2. Assign the client homework each session in which he/she practices relaxation exercises daily, gradually applying them progressively from non-anxietyprovoking to anxiety-provoking situations; review and reinforce success while providing corrective feedback toward improvement.
4. Learn and implement a strategy to limit the association between various environmental settings and worry, delaying the worry until a designated “worry time.”	1. Explain the rationale for using a worry time as well as how it is to be used; agree upon a worry time with the client and implement. 2. Teach the client how to recognize, stop, and postpone worry to the agreed-upon worry time using skills such as thought stopping, relaxation, and redirecting attention (or assign “Making Use of the Thought Stopping Technique” and/or “Worry Time” in the Adult Psychotherapy Homework Planner by Jongsma to assist skill development); encourage use in daily life; review and reinforce success while providing corrective feedback toward improvement
5. Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety symptoms.	1. Assist the client in analyzing his/her worries by examining potential biases such as the probability of the negative expectation occurring, the real consequences of it occurring, his/her ability to control the outcome, the worst possible outcome, and his/her ability to accept it (see “Analyze the Probability of a Feared Event” in the Adult Psychotherapy Homework Planner by Jongsma; Cognitive Therapy of Anxiety Disorders by Clark and Beck).
6. Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk.	1. Explore the client’s schema and self-talk that mediate his/her fear response; assist him/her in challenging the biases; replacing the distorted messages with reality-based alternatives and positive, realistic self-talk that will increase his/her self-confidence in coping with irrational fears (see Cognitive Therapy of Anxiety Disorders by Clark and Beck). 2. Assign the client a homework exercise in which he/she identifies fearful self-talk, identifies biases in the self-talk, generates alternatives, and tests through behavioral experiments (or assign “Negative Thoughts Trigger Negative Feelings” in the Adult Psychotherapy Homework Planner by Jongsma); review and reinforce success, providing corrective feedback toward improvement.
Provider Signature: ANNA SMITH, PMHNP-BC	Patient Signature: Jill Smith

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