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Answer these 2 questions.
1. What other therapy approaches can be easily applied to this patient? (different therapy than the one she developed here)
2. How can we help the patient stick to the treatment plan?( based on what it says here, how I can help the patient.)
At least 2 references
Complex Case Study Presentation
CC (chief complaint): “I need medication. I don't feel good.”
HPI: C is a 15-year-old African American female who came for a psychiatric evaluation with her case manager. She states, ” I need medication. I don't feel good.” The client noted that the other day, she had a breakdown where she was crying and laughing. Also, she mentioned that she started thinking about bad things. Most of the time she feels sad, that is why she feels “better when I’m with my friends.” She also noted that she can be agitated very easily. Her concentration is poor, and she said “everything” stresses her out. The client denies any symptoms of suicidal ideations, but she said, “I don't want to kill anybody, but when I'm upset, I make threats to kill people.” She said she suddenly has difficulty meeting new people, has problems with crowds in the grocery store or big box stores, and feels judged when out in person. The client reports verbal, physical, and sexual abuse that started in childhood. She experiences painful flashbacks and nightmares in the past. She reports abuse and misuse of ADHD medications and no complaints with medications. Also, she mentioned to be on probation, and she would like to be out of prison.
Diagnostic Impression:
Major depressive disorder
Approximately 12.8% of people between 12-17 years have been diagnosed with Major depression in the United States. (Mullen, 2018) The client presents most of the diagnosis criteria for this disease. She is showing a depressed mood irritation that is typical for adolescents. She has a poor interest in activities, low energy, and poor appetite. Also, she mentioned that she has trouble falling asleep and staying asleep. These symptoms caused social impairment, evidenced by the frequent fights. It is essential to mention that her family is dysfunctional, and her mom and brother are diagnosed with major depression.
Generalized anxiety disorder F41.1
Generalized anxiety disorder is a common mental health disorder affecting more females. Anxiety leads to restlessness, feeling keyed up or on edge, fear, and difficulty concentrating. (APA,2022 ) The client presents excessive anxiety and difficulty controlling worry and concern that something will happen. She has problems being around crowds, feels anxious, and feels judged. Also, she is always irritable, losing her temper, involving her in multiple fights. This client's diagnosis criteria are restlessness, difficulty concentrating, irritability, sleep disturbance, and muscle tension.
Post-Traumatic Stress Disorder F43.10
This disorder results from exposure to one or more traumatic events. Usually, the symptoms start showing up within three months of the traumatic events. The symptoms interfere with the daily tasks. The client reports verbal, physical, and sexual abuse that started in childhood, and she experiences painful flashbacks and nightmares from the event. This situation met the first criterion for this diagnosis because she was exposed to a traumatic event. Also, she mentioned recurrent and intrusive thoughts about something terrible that would happen. She avoids speaking about the incident and has persistent negative feelings. The client said to be hypervigilance.
Reflection:
The client comes for the first-time evaluation, saying she needs medications because she doesn't feel good. This client is presenting almost all the symptoms of major depression. She lacks energy, and most of the time, she is irritated, evidenced by getting involved in many fights. Also, she stated being sad almost every day and having breakdowns. She was sexually, mentally, and physically abused, which is most likely why she presents all those symptoms. Women victims of child sexual assault are twice as likely to have more depression and anxiety than no female victims. Also, major depressive episodes among those with PTSD have a higher risk of suicide than those with PTSD. (Alix,2020) She mentioned the sexual abuse and said that she was thinking about crazy stuff. We suspect she was thinking about suicide, which is why the primary diagnosis is Major depression. Alix (2020) states that self-blame is an internal attribution, a cognitive process by which some individuals with traumas can attribute the event of an unfavorable event to themselves. She also said that she feels guilty about what happened to her.
The second diagnosis is Generalized anxiety disorder because the client finds it difficult to control her concern about something wrong will happen. She stated feeling restless, having problems concentrating, muscle tension, and sleep disturbance. Also, she is presenting poor concentration. This affects her daily tasks even though she mentioned that she couldn't be around people anymore. De Beru (2020) states that the only two disorders significantly associated with suicide ideation were MDD and GAD. For this reason, this will be my secondary diagnosis and the one I will pay more attention to.
The third differential diagnosis will be post-traumatic stress disorder. As mentioned above, this client came from a household where she suffered a lot of violence, including physical, sexual, and emotional damage. She has problems falling asleep due to the trauma and avoided discussing the incident by changing the topic. The US Department of Veteran Affairs (2018) states that survivors of child sexual abuse show symptoms of PTSD that include agitated behavior, and they may exhibit anxiety. Also, another behavior that they may exhibit is inappropriate sexual behavior or seductiveness. The school sent her to a psychiatry evaluation in the 6th grade because of her aggressiveness and promiscuity. That was one of the indicators that she was suffering from sexual abuse. Also, she mentioned recurrent and intrusive thoughts about something terrible that would happen.
I agree with the PMHNP treatment plan, where she will start working with the depression symptoms. Since the client reports feeling sad, having low energy, and thinking about “crazy stuff,” we will prioritize those symptoms and treat them to avoid future serious problems like Suicide Ideations.
Case Formulation and Treatment Plan
C is a 15-year-old African American female client being seen for a first-time psychiatric evaluation. She is alert and oriented in person, place, time, and situation. She is restless, acting out, and looks irritable but cooperative. She mentioned being referred to a psychiatry evaluation in 6th grade, and since then, she has been in and out of treatment. The client presents depression symptoms like sadness, low energy, decreased activities that cause joy, irritability, poor concentration, and sleep disturbance. Also, she mentioned the difficulty in controlling her concern about something terrible will happen. She verbalizes a history of sexual, physical, and emotional abuse. The client avoids talking about the abuse. However, she will follow recommendations and continue with a treatment plan.
Most adolescents with major depression symptoms reported severe impairment in home life, school/work, family relationships, and social life. Studies have revealed that neurologic changes happen in the brain structure of those who have suffered sexual abuse during their childhood, and, therefore, they become more predisposed to suffer depression, anxiety, substance use, and other mental and behavioral problems. (Gokten, 2021) It is essential to start working with the adolescent since symptoms are notable, like in this client's case. The PMHNP chose Lexapro 5 mg PO daily; this medication is one of the two approved by the FDA. Lexapro has been approved for use in adolescents aged 12 years and older. (FDA, Nd) Jiang (2017) mentioned in his research that Lexapro helps to decrease depression and anxiety levels and significantly improve the quality of life, helping with the enjoyment and satisfaction of patients taking this medication. Besides the depression, she suffers from anxiety, which is why this medication is the first line of treatment since it helps to improve the two primary diagnoses for her. Anvari (2020) also recommends using Lexapro as a first-line antidepressant treatment for children and adolescents, optimally in conjunction with cognitive behavior therapy. He stated the conjunction of this therapy should optimize school, peer, and family communication, given a patient's sense of connectedness.
The second medication that the PMHNP prescribed is Lamotrigine 25 mg PO daily. Lamotrigine is an anticonvulsant medication that can be used as adjunctive treatment as a mood stabilizer. Prabhavalkar (2015) found Lamotrigine to be outstandingly effective in preventing bipolar depression in patients experiencing episodes of major depression. Lamotrigine can be a mood stabilizer that calms mood swings by lifting the depression symptoms. Also, he found that in 64.5% of the adjunctive treatment using lamotrigine, the symptoms of depression improved during the initial treatment and maintained for about one year.
Psychotherapy will be crucial to the treatment plan; changing the behavior and developing coping skills can benefit her treatment goal. Cognitive behavioral therapy is showing efficacy in GAD and MDD symptom reduction. In his research, Oud (2019) found that 63% of the child/adolescent has less risk of having a depressive disorder at follow-up and a 36% more chance of recovery. Also, CBT can be used to treat clients with PTSD. For that reason, this will be the therapy of choice.
Also, as part of the plan, the PMHNP ordered blood work CBC, BMP, Vit D, lipid panel, and thyroid function test. EKG will be ordered as well.
The risks, benefits, side effects, and dosage schedules of medication were explained to the client. Otherwise, the benefits of continuing psychotherapy were explained for managing and controlling her emotions. We will recommend daily exercise, good hygiene, and a balanced diet. She was educated and encouraged about abstinence from drugs and alcohol. The potential risks, long-term consequences of Tardive Dyskinesia, and treatment alternatives were discussed with and understood by the client. The client has emergency numbers: Emergency Services 911, Suicide & Crisis Lifeline 988, and National Suicide Prevention Lifeline 1800-273-8255
