Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent

Week 5: Anxiety Disorders in Childhood and Adolescence

The provided case study is about an 8-year-boy named Tyrel and presented accompanied by his mother due to various psychiatric symptoms. The mother reported that the son had become excessively worried and nervous and he spent a lot of time worrying about germs. The client washed his hands constantly because he did not want to become sick again. The client is also irritable and experiences sleep disturbances. The symptoms have interfered with his academics as he becomes nervous around his classmates. He has also stopped interacting with his best friend. His bilateral hands are dry. Tyrel reveals about having constant and uncontrollable thoughts about dirty hands. He also admits to being very nervous and scared and reports that washing his hands is what makes him feel better. However, handwashing only offers temporary relief and he starts being scared again and until he cleans his hands again. The MSE indicates that Tyrel is alert and well-oriented. His self-reported mood is “good” and “anxious”. His mood is affect. No apparent paranoid or delusional thought processes. He also denies suicidal thoughts and visual/auditory hallucinations. The findings from the lab analysis are okay, while the antistreptolysin O antibody titer is above the normal parameters. From the subjective and objective data, this paper will make a diagnosis for the client and select the appropriate treatment decisions for the client. All ethical considerations relevant to the client’s treatment will be discussed.

Decision Point One

The diagnosis of Tyrel is obsessive-compulsive disorder (OCD). OCD was chosen as his diagnosis because the symptoms manifested by Tyrel meet the DSM-5 diagnostic criteria of OCD. According to American Psychiatric Association (2013), symptoms of OCD include obsessions/compulsions like persistent urges and thought accompanied by repetitive behaviors like fear of contamination and performing ritualistic behaviors of persistent hand-washing in order to eradicate germs. These symptoms lead to the impairment of an individual’s normal functioning (Davide et al., 2020). Similarly, Tyrel has persistent thoughts about his hands becoming contaminated with germs and as a result, he performs hand-washing constantly to get rid of the germs. His worry about germs and being sick, followed by constant hand-washing has impaired his functioning as indicated by him stopping to play with friends and no longer attending school. Nonetheless, symptoms such as social withdrawal and not attending school need to be assessed further in order to confirm or rule out any comorbidity. The reason why generalized anxiety disorder and PANDAS were not chosen as the diagnoses for Tyrel is that the client’s symptoms are not consistent with DSM-5 diagnostic criteria of generalized anxiety disorder and PANDAS.

Selection of obsessive-compulsive disorder as the client’s diagnosis hoped that this is the correct diagnosis and thus the appropriate treatment plan for Tyrel will be developed.

When diagnosing the patient, the ethical principle of beneficence was applied to ensure that the correct diagnosis was chosen to ensure the right treatment plan was developed. The confidentiality of the client’s diagnosis was also maintained (Roberts & Williams, 2015).

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Decision Point Two

Fluvoxamine immediate release 25 mg during bedtime was prescribed for Tyrel. The reason for selecting fluvoxamine is because the pharmacological agent is n SSRI that increases serotonin and thus improves the mood and thus improves the OCD symptoms (Lenze et al., 2020). Fluvoxamine is supposed to be administered at bedtime since the medication has a sigma-1 antagonist and hence it is a sedative. The decision to have fluvoxamine administered in the morning was not considered due to the sedative effects of the medication (Garland et al., 2016). Zoloft was not prescribed since fluvoxamine is well-tolerated better when compared to Zoloft.

Prescription of fluvoxamine expects that Tyrel would manifest a good response to the medication as manifested by decrease the OCD symptoms. This would manifest by the client showing reduced fear of germs and reducing the frequency of washing his hands. The expected symptom improvement is due to Fluvoxamine’s efficacy in the treatment of OCD symptoms (Garland et al., 2016). It is also hoped that Tyrel would not experience side effects from the medication.

The treatment outcome was that Tyrel manifested significant improvement as the frequency of washing his hands had reduced. The anxiety levels also reduced as Tyrel appeared more relaxed. The mother also reported that Tyrel had started to partially attend school and playing with the friend. The improvements are attributable to Fluvoxamine’s efficacy in the treatment of OCD symptoms (Garland et al., 2016). No side effect was reported.

The ethical principles of informed consent and beneficence were applied when selecting fluvoxamine. Informed consent was sought from the mother before the medication was prescribed (Roberts & Williams, 2015). Moreover, fluvoxamine was selected because it is the medication expected to bring out the best treatment outcomes for Tyrel.

Decision Point Three

Fluvoxamine should be augmented using a psychotherapy treatment, cognitive behavioral therapy (CBT). The reason why CBT was chosen is because psychotherapy has been demonstrated to be effective in changing negative and maladaptive thinking patterns, feelings, and behaviors (Zhang et al., 2020). As a result, an individual then adopts a more adaptive and positive thinking pattern, which leads to positive behavior change. Moreover, through CBT, the client will be equipped with the appropriate coping skills to be able to handle different situations, including situations that evoke fear and anxiety. CBT is also expected to reduce the client’s social anxiety and thus he will resume school fully and interact with friends fully. Increasing fluvoxamine dose to 50 mg was not deemed appropriate since Tyrel is already showing a good response to fluvoxamine 25 mg and hence there is no clinical reason to titrate the dose upwards. Augmenting fluvoxamine 25 mg with an atypical antipsychotic such as Abilify was not deemed suitable since antipsychotics are not recommended to treat OCD.

The treatment goal for augmenting fluvoxamine with CBT hopes that Tyrel will continue having symptom decrease and finally achieve full symptom remission. This will manifest by Tyrel stopping having anxiety and fears about germs and becoming sick and stopping performing the ritualistic hand-washing behavior. This is because by augmenting fluvoxamine with CBT, CBT will improve the client’s response due to CBT’s effectiveness in altering the maladaptive and negative thoughts and thus facilitating positive behavior change (Wu et al., 2016).

Non-maleficence and beneficence were applied in this decision. The risks and benefits associated with every decision were analyzed and the treatment decision with minimal risks and maximum benefits was selected (Coombes et al., 2020). Moreover, augmenting fluvoxamine with CBT was considered to be the treatment decision with the best care outcomes for Tyrel.

Conclusion

The diagnosis for Tyrel of the compulsive-obsessive disorder. This is because the symptoms he manifests such as high levels of anxiety and nervousness, fear of germs, and ritualistic handwashing meet the DSM-5 criteria of OCD. The fear of germs is the obsession, while the constant hand washing is compulsive behavior. After the diagnosis of OCD, Fluvoxamine 25 mg at bedtime was chosen as the appropriate medication. This is because fluvoxamine is effective in treating OCD symptoms. After prescribing fluvoxamine 25 mg, after four weeks Tyrel manifested a good response to the medication as the anxiety levels and nervousness as well as his obsession against germs reduced. Moreover, the frequency of handwashing reduced and he also started attending school partially and socializing with his friend. For the third decision, it was decided that fluvoxamine would be augmented using CBT. This is because CBT is effective in improving OCD symptoms because it changes the negative thinking pattern and behaviors into a more positive thinking pattern and more adaptive behaviors. It is expected that augmenting fluvoxamine with CBT will lead to further symptom reduction for Tyrel. During the treatment of this client, informed consent was sought before the treatment process started. Additionally, the risks and benefits associated with all medication choices were analyzed as per the non-maleficence principle, while the medication with the best care outcomes for Tyrel was chosen.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Coombes, I., Markwell, A., Kubler, P., Redmond, A. M., McGurk, G., & Roberts, J. A. (2020). Principles of ethical prescribing for self and others: hydroxychloroquine in the COVID‑19 pandemic. AN INDEPENDENT REVIEW, 76.

Davide, P., Andrea, P., Martina, O., Andrea, E., Davide, D., & Mario, A. (2020). The impact of the COVID-19 pandemic on patients with OCD: Effects of contamination symptoms and remission state before the quarantine in a preliminary naturalistic study. Psychiatry Research, 291, 113213. https://doi.org/10.1016/j.psychres.2020.113213

Garland, E., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4–10.

Lenze, E. J., Mattar, C., Zorumski, C. F., Stevens, A., Schweiger, J., Nicol, G. E., … & Reiersen, A. M. (2020). Fluvoxamine vs placebo and clinical deterioration in outpatients with symptomatic COVID-19: a randomized clinical trial. JAMA, 324(22), 2292-2300.

Roberts, L. W., & Williams, N. (2015). Ethics Commentary: Obsessive-Compulsive and Related Disorders: Ethical Issues in the Care of Obsessive-Compulsive Disorder: Clinical Ethics Case Examples. Focus, 13(2), 191-194.

Wu Y, Lang Z & Zhang H. (2016). Efficacy of Cognitive-Behavioral Therapy in Pediatric Obsessive-Compulsive Disorder: A Meta-Analysis. Med Sci Monit, 1(22), 1646–1653.

Zhang, Y. Y., Chen, J. J., Ye, H., & Volantin, L. (2020). Psychological effects of cognitive behavioral therapy on internet addiction in adolescents: A systematic review protocol. Medicine, 99(4), e18456. https://doi.org/10.1097/MD.0000000000018456

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“I don’t know why everyone is worried that I don’t want to go out with my friends anymore. I just like to stay home. There is nothing wrong with that. I go to school and get good grades, but I don’t know what to say to those other girls in my class. They ask why I can’t go to the mall with them on the weekend and I get all embarrassed. They don’t understand that I don’t know what to say to them. When I do say something, it is always wrong, or they laugh. I can just stay home and read my books.”

Emma, age 15

Anxiety disorders that plague many individuals in adulthood often have their origins in childhood and adolescence. By identifying those children and adolescents with anxiety disorders, the PMHNP can intervene and teach skills that the client can use to control anxiety throughout his or her life.

This week, you analyze case studies to determine the diagnosis and treatment of anxiety disorders.

Learning Resources

Required Readings

American Academy of Child & Adolescent Psychiatry (AACAP). (2012a). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98–113. Retrieved from http://www.jaacap.com/article/S0890-8567(11)00882-3/pdf

 

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

  • Standard 8 “Education” (pages 69-70)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

  • “Anxiety Disorders”

McClelland, M., Crombez, M., Crombez, C., Wenz, C., Lisius, M., Mattia, A., & Marku, S. (2015). Implications for advanced practice nurses when pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is suspected: A qualitative study. Journal of Pediatric Healthcare, 29(5), 442-452. doi:10.1016/j.pedhc.2015.03.005

 

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

  • Chapter 31, “Child Psychiatry” (pp. 1253–1268)

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

 

Note: All Stahl resources can be accessed through the Walden Library using the link. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear.

 

To access information on the following medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.

 

Review the following medications:

Generalized anxiety disorder Social anxiety disorder
alprazolam
citalopram
desvenlafaxine
duloxetine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
paroxetine
pregabalin
sertraline
tiagabine (adjunct)
venlafaxine
citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
moclobemide
paroxetine
phenelzine
pregabalin
sertraline
tranylcypromine
venlafaxine
Obsessive-compulsive disorder Panic disorder  
citalopram
clomipramine
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
vilazodone
alprazolam
citalopram
clonazepam
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
lorazepam
mirtazapine
nefazodone
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tranylcypromine
venlafaxine
 

Note: Many of these medications are FDA approved for adults only. Some are FDA approved for disorders in children and adolescents. Many are used “off label” for the disorders examined in this week. As you read the Stahl drug monographs, focus your attention on FDA approvals for children/adolescents (including “ages” for which the medication is approved, if applicable) and further note which drugs are “off label.”

Required Media

Laureate Education (Producer). (2017c). Anxiety disorder, ODC, or something else? [Multimedia file]. Baltimore, MD: Author.

YMH Boston. (2013b, May 22). Vignette 3 – Asking about depression in a preventive services visit [Video file]. Retrieved from https://www.youtube.com/watch?v=TO8aITpMG5E

 

Note: The approximate length of this media piece is 3 minutes.

YMH Boston. (2013d, May 22). Vignette 5 – Assessing for depression in a mental health appointment [Video file]. Retrieved from https://www.youtube.com/watch?v=Gm3FLGxb2ZU

 

Note: The approximate length of this media piece is 3 minutes.

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Optional Resources

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.

  • Chapter 60, “Anxiety Disorders” (pp. 822–840)
  • Chapter 61, “Obsessive Compulsive Disorder” (pp. 841–857)

Assignment: Decision Tree (Due in Week 7)

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting symptoms of a mental health disorder.

Learning Objectives

Students will:

  • Evaluate clients for treatment of mental health disorders
  • Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

The Assignment:

Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

  • Decision #1: Differential Diagnosis
    • Which Decision did you select?
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
  • Decision #2: Treatment Plan for Psychotherapy
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
  • Decision #3: Treatment Plan for Psychopharmacology
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
  • Also include how ethical considerations might impact your treatment plan and communication with clients and their families.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

No Assignment is due this week. 

Submit your Assignment By Day 7 of Week 7

 

 

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