Posted: November 13th, 2022

Week 3: Anxiety, Obsessive-Compulsive and Related

NRNP 6675: PMHNP Care Across the Lifespan II
Week 3: Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders

Anxiety disorders provide a good opportunity to take a close look at the nature/nurture debate as well as the gene/environment interactions that influence the nervous system and neurochemistry. A significant part of most of Sigmund Freud’s theories, the concept of anxiety has been debated and discussed over many years in the psychiatric literature. While Freud’s theories focused on the “mind” and the unconscious, another way to look at anxiety is with Hans Selye’s concept of “fight or flight” in which the sympathetic nervous system activates a response to stress. As you explore anxiety disorders, you will notice that no two cases of anxiety are the same.

Obsessive-compulsive disorder is characterized by the presence of obsessive thoughts, which manifest as persistent thoughts, images, or even “urges.” The only way that the individual can disperse the anxiety of these persistent thoughts/images and urges is to perform a behavior (the compulsion). The compulsion could be checking things, counting, reciting a silent prayer, or repeating a number of phrases. The disorder becomes so pervasive that the person can spend a significant amount of time each day attending to the compulsion in order to relieve the anxiety caused by the obsession.

Although trauma and stressor-related disorders stem from exposure to a traumatic or stressful event, not all exposures to trauma or stress will result in a disorder. However, following these types of events, patients may report symptoms that interfere with their ability to function well in one or more areas of their life, such as flashbacks, nightmares, or intense psychological or physiological distress. Although trauma and stressor-related disorders are caused by exposure to a traumatic or stressful event, not all trauma or stress exposures result in a disorder. Patients may, however, report symptoms that interfere with their ability to function well in one or more areas of their life following these types of events, such as flashbacks, nightmares, or intense psychological or physiological distress.

This week, you will explore evidence-based treatment methods for patients with anxiety, obsessive-compulsive, as well as trauma and stressor-related disorders.
Learning Objectives

Students will:

Assess patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Develop differential diagnoses for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Develop appropriate treatment plans for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Advocate health promotion and patient education strategies for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders

Learning Resources

Required Readings (click to expand/reduce)

Required Media (click to expand/reduce)

Medication Review

Review the FDA-approved use of the following medicines related to treating anxiety disorders, OCD, PTSD, and related disorders:

Anxiety Generalized anxiety disorder Panic disorder
alprazolam
amitriptyline
amoxapine
buspirone
chlordiazepoxide
citalopram
clomipramine
clonazepam
clonidine
clorazepate
cyamemazine
desipramine
diazepam
dothiepin
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
gabapentin (adjunct)
hydroxyzine
imipramine
isocarboxazid
lofepramine loflazepate
lorazepam
maprotiline
mianserin
mirtazapine
moclobemide
nefazodone
nortriptyline
oxazepam
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tiagabine
tianeptine
tranylcypromine
trazodone
trifluoperazine
trimipramine
venlafaxine
vilazodone alprazolam
citalopram
desvenlafaxine
duloxetine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
paroxetine
pregabalin
sertraline
tiagabine (adjunct)
venlafaxine alprazolam
citalopram
clonazepam
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
lorazepam
mirtazapine
nefazodone
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tranylcypromine
venlafaxine

Posttraumatic stress disorder Reversal of benzodiazepine effects Social anxiety disorder
citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
nefazodone
paroxetine
prazosin (nightmares)
propranolol (prophylactic)
sertraline
venlafaxine flumazenil

citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
moclobemide
paroxetine
phenelzine
pregabalin
sertraline
tranylcypromine
venlafaxine

Obsessive-compulsive disorder
citalopram
clomipramine
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
vilazodone

Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.

Photo Credit: Photographee.eu / Adobe Stock

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.
To Prepare

Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar. Examine the Learning Resources for this week. Consider the information they offer on assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
Examine the Focused SOAP Note template that will be used to complete this Assignment. As a guide for Assignment expectations, a Focused SOAP Note Exemplar is also provided.
Examine the Case Study: Dev Cordoba video. This case will serve as the foundation for this Assignment. In this video, a Walden faculty member evaluates a dummy patient. Onscreen, the patient will be represented by an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.

The Assignment

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

By Day 7 of Week 3

Submit your Focused SOAP Note.

Week 3: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Assessment

Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date

Subjective:
CC (chief complaint): I feel worried and I have bad dreams. I worry about my mum and my little brother while I am at school. People do not like me at school and call me names.
HPI: D.C. is a 7-year-old male child who presents to the clinic for the first time for Assessment due to past abnormal behavior. He is accompanied by the mother who complains about his worsening behavior. The patient is worried and have bad dreams. He is worried about his mum and little brother and can hardly concentrate in school. His mother complains he cannot sleep with the lights on and the door open. He has not been in psychiatric care in the past. Teachers in school can hardly make him concentrate or stop him from looking outside the window. He has difficulty sleeping. A pediatrician prescribed DDVAP but it does not seem to help. Complains of headache, stomachache almost daily. He does not eat. He has lost three pounds of weight in the last three weeks.
Substance Current Use: No history of substance use.
Medical History: Taking DDVAP but it does not seem to help.

• Current Medications: DDVAP
• Allergies: No known drug allergies
• Reproductive Hx: Not sexually active.
ROS:
• GENERAL: Untentional weight loss of 3 pounds in the past 3 weeks. No appetite.
• HEENT: No hearing loss, blurred vision, sore throat, and no bleeding or discharge. Complains of headache almost every day.
• SKIN: No skin lesions or itching.
• CARDIOVASCULAR: No chest pain, pressure, edema, or palpitation.
• RESPIRATORY: No breathing challenges.
• GASTROINTESTINAL: No abdominal pain, reflux, nausea, vomiting, or diarrhea.
• GENITOURINARY: Unable to control bladder at night. Still wets his bed despite his age and medication (DDVAP).
• NEUROLOGICAL: Complains of headache almost daily.
• MUSCULOSKELETAL: No history of itching muscles, joint, or gout.
• HEMATOLOGIC: No bleeding or bruising.
• LYMPHATICS: No enlarged nodes.
• ENDOCRINOLOGIC: No endocrine disorder.
Objective:
Diagnostic results:
Diagnosis of the condition will require a thorough medical Assessment to establish the possible cause of the symptoms. One of the likely diagnostic tools is Child PTSD Symptom Scale (CPSS-5), which effectively assesses post-traumatic stress in children between 8 and 18 years. It consists of 24 questions in both parts one and two. However, the tool cannot be applied since the child is less than eight years. A psychiatrist would require additional information to explore possible conditions such as separation anxiety disorder or generalized anxiety disorder. A psychiatrist will require a structured interview to evaluate the child’s feelings, thoughts, moods, and experiences. Separation anxiety can co-occur with other conditions. To assess the child for generalized anxiety disorder, the child may require blood and urine tests to rule out the possibility of drug abuse. Drug abuse such as marijuana can cause worry or anxiety.
Assessment:
Mental Status Examination:
D.C is a 7-year-old male who looked like the stated age. The client is calm and cooperative during the psychiatric interview. The thought process is organized, and his memory is intact. He is aware that he came to see a psychiatrist help him with his mood. He denies abusing drugs. He is often worried while at home and school. The pupil is concerned while at school about the safety of the mother and the baby brother. The patient is calm and maintains eye contact during the conversation. He has been experiencing anxiety and mood changes.
Diagnostic Impression:
F93. 0 Separation Anxiety Disorder (SAD)
SAD involves excessive anxiety involving separation from significant people such as parents, close friends, or guardians. Anxiety can occur due to separation from homes or schools where individuals had created a strong bond (Schneier et al., 2017). The condition shows a possibility of mental and mood issues. Statistics indicate that at least 4 percent of the population of children experience SAD. Some of the possible causes include life stressors such as divorce among parents, which affect children or the death of a loved one (Schneier et al., 2017).
It is most likely that the child is suffering from a separation anxiety disorder. One of the reasons is that the loss of the father makes the child feel unsafe. The mother did not explain to him that his father died in the military. The child could be feeling unsafe when he is away from his mother and baby brother. He is also worried about sleeping without putting the lights on.
F43. 12 Posttraumatic Stress Disorder (PTSD)
PTSD is a condition that occurs as a result of traumatic experiences such as natural disasters. Psychologists refer to the condition as the inability to recover after experiencing a traumatic experience (Cloitre et al., 2019). Some causes include a terrorist attack, violence, child abuse, sexual abuse, and losing a loved one. Scary thoughts of the past can affect mood in children. Failure to treat the condition can have profound effects on children (Cloitre et al., 2019).
F41. 1 Generalized Anxiety Disorder (GAD)
GAD is caused by excessive worry and anxiety about life issues. People with GAD always experience fear and anticipate disaster. Biological factors, life experiences, and background may trigger GAD (Toussaint et al., 2020). Sometimes just the thought of going through the day creates anxiety.
F40. 10 Social Phobia (Social Anxiety Disorder)
Social phobia is an overwhelming fear of social situations. The worry can be distressing and affect the quality of life (Dobos et al., 2019). Although the condition starts during the adolescent stage, it can start earlier in some children depending on the genetic background and life stressors.
Reflections:
I agree with my preceptor on the assessment and diagnostic impression.
The patient’s symptoms include mood swings and excessive worry. The patient is concerned about the mother and the baby brother’s well-being. He is occasionally concerned that his mother will not come to pick him up from school. Due to his anxiety, he is unable to concentrate in school. The patient denies drug use, which may cause concern and anxiety. His mother never told him that his father had died in battle. The most likely source of his concern is his fear that his mother and baby brother will vanish without a trace. He is concerned about being away from his family.
To confirm the diagnosis, a second psychiatric Assessment is required. For example, urine and blood tests will be required to rule out other causes of concern or anxiety, such as drug abuse. The mother should provide more information about the worry’s history. The additional information will Help a psychiatrist in determining the potential causes of the symptoms (Schneier et al., 2017). Additional information from the teacher is required to explain the child’s behavior. The information will Help a psychiatrist in narrowing down to a single disorder and initiating treatment.
It will be critical to restore the ability to concentrate in school and eliminate worry during the delivery of care. Ethical considerations are important because they ensure professional and ethical care. For example, the child is under the age of 18 when consenting to treatment (McDermott-Levy et al., 2018). A psychiatrist will need the mother’s permission. Another ethical consideration is the single mother’s justice and fairness. Regardless of what has happened in the past, such as failing to inform the son that his father died in the military, it will be critical to show respect and empathy. Another critical ethical issue that involves telling the truth is veracity (McDermott-Levy et al., 2018). For example, it will be critical to inform the mother of the father’s fate. The combination of disclosure and therapeutic interventions can reduce the child’s anxiety. Maleficence and beneficence are critical considerations because they involve the use of professional knowledge to provide the best care possible while minimizing the risk of medical errors (McDermott-Levy et al., 2018).
Case Development and Treatment Strategy:
To rule out the impact of drug abuse on mood changes, the patient’s condition necessitates additional diagnostic tests such as urine and blood tests (Cloitre et al., 2019). Additional information about the patient’s history will be required from the parent and teacher. The psychiatrist will need to conduct a more thorough medical examination of the patient’s condition in order to determine the disorder from which the patient is suffering (Cloitre et al., 2019).
The mother must learn the value of developing rapport and a close relationship with her child. The boy needs assurance from his mother that she will always look after his well-being. The assurance is critical to ensuring that the boy is not concerned about whether his mother will come to pick him up from school. It will be effective to educate the mother and school teachers on how to handle the boy in light of his psychiatric condition. For example, it will be critical to always keep promises, to leave with a goodbye and a promise to return, and to avoid exposing the child to new environments. The psychiatrist should educate the teacher on how to control the behavior of the boy’s bullies. He complains that his classmates call him names, making him feel bad.
The patient should begin treatment with cognitive behavior therapy for at least 12 sessions. The therapy will consist of 45-minute sessions for at least three months. Following treatment, the client should return for follow-up to avoid relapse (Schneier et al., 2017). In the event of co-occurring conditions, other healthcare workers can intervene and refer. Family therapy is required to build trust and harmony within the family. Palliative care, which includes assurance and watchful waiting, is critical in the delivery of care.
To achieve positive results, treatment will include a combination of medication and psychotherapeutic interventions, such as selective serotonin reuptake inhibitors (SSRIs) for anxiety (Schneier et al., 2017). Cognitive behavior therapy will alter thought patterns and address mood swings.
The symptoms of the patient include mood changes and excessive worry. The patient is worried about the welfare of the mother and the baby brother. Sometimes he is worried that the mother will not come for him in school. He can barely concentrate in school due to excessive worry. The patient denies drug abuse which is likely to cause worry and anxiety. The mother did not explain to him that his father died in combat. The probable cause of the worry is that he believes the mother and the baby brother may vanish without notice. He is worried about staying away from the family.
A further psychiatric Assessment is needed to confirm the diagnosis. For instance, the patient will require urine and blood tests to rule out other causes of worry or anxiety, such as drug abuse. The mother should provide additional information on the history of the worry. The additional information will help a psychiatrist understand the possible causes of the symptoms (Schneier et al., 2017). Additional details from the teacher are needed to explain the behavior of the child. The information will help a psychiatrist to narrow down to one disorder and start treatment.
During the delivery of care, it will be critical to restoring the ability to concentrate in school and eliminate worry. Ethical considerations are vital since they will ensure professional and ethical care. For instance, the child is below the standard 18 years of consenting to treatment (McDermott-Levy et al., 2018). A psychiatrist will require the consent of the mother. Another ethical consideration is justice and fairness for the single mother. It will be essential to show respect and empathy despite what has happened before, such as failing to tell the son that his father died in the military. Veracity is another vital ethical issue that involves telling the truth (McDermott-Levy et al., 2018). For instance, it will be crucial to tell the mother to disclose the fate of the father. The disclosure combined with therapeutic interventions can lessen the worry of the child. Maleficence and beneficence are vital considerations since they involve using professional knowledge to provide the best care without the risk of medical errors (McDermott-Levy et al., 2018).
Case Formulation and Treatment Plan:
The patient’s condition requires further diagnostic tests such as urine and blood tests to rule out the impact of drug abuse on mood changes (Cloitre et al., 2019). Additional information will be required from the parent and the teacher on the history of the patient. The psychiatrist will require further medical review of the patient’s condition to ascertain the disorder the patient is suffering from (Cloitre et al., 2019).
The mother needs to learn the importance of creating rapport and a close relationship with the child. The boy requires assurance from the mother that she will always take care of his welfare. The assurance is vital to ensure the boy is not disturbed about whether the mother will come for him in school. It will be effective to educate the mother and the teachers in the schools on how to handle the boy bearing in mind his psychiatric condition. For instance, it will be crucial always to keep promises, leave with a goodbye and promise to come, and avoid exposing the child to new surroundings. The psychiatrist should educate the teacher to control the behavior of other children that bully the boy. He complains the classmates call him names which makes him feel bad.
The patient should begin treatment for at least 12 sessions using cognitive behavior therapy. The therapy will comprise sessions 45 minutes long at least for three months. After the treatment, the client should come back for follow up to prevent relapse (Schneier et al., 2017). Interventions from other healthcare workers and referrals can be made in case of co-occurring conditions. Family therapy is necessary to create trust and harmony in the family. Palliative care that involves assurance and watchful waiting are vital in the provision of care.
Treatment will involve a combination of medication and psychotherapeutic interventions to generate positive outcomes, such as selective serotonin reuptake inhibitors (SSRIs) to address anxiety (Schneier et al., 2017). Cognitive behavior therapy will change the thinking patterns and address the mood changes.

References
Schneier, F. R., Moskow, D. M., Choo, T. H., Galfalvy, H., Campeas, R., & Sanchez‐Lacay, A. (2017). A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder. Depression and Anxiety, 34(12), 1085-1095.
Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD‐11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population‐based study. Journal of Traumatic Stress, 32(6), 833-842.
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
Dobos, B., Piko, B. F., & Kenny, D. T. (2019). Music performance anxiety and its relationship with social phobia and dimensions of perfectionism. Research Studies in Music Education, 41(3), 310-326.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, d6(5), 473-481.

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