Demographic Data
- Initials: X
- Age: 13
- Sex/gender: female
HPI
Context: The patient has been experiencing significant pressure due to the rise in anxiety over the separation of her parents. The fact that she started communicating less frequently with her mother as a result of the latter getting another job aggravated the situation, leading to panic attacks in the patient.
Location: X is suffering from an anxiety disorder and needs an urgent intervention.
Duration: X has been experiencing anxiety since he parents’ divorce, which was around 5 months ago.
Severity: While the patient has been developing anxiety at a very slow pace, the first several instances of anxiety being very mild, her current state has reached the stage at which her condition disrupts every facet of her life. Particularly, a panic attack may occur at random and incapacitate the patent from thinking or acting reasonably for about half an hour.
Associated Symptoms: among the key symptoms that X has shown so far, one should mention fatigue, sleep issues, and the continuous feeling of anxiety.
Modifying Factors: as stressed above, the patient has been affected heavily by her parents’ divorce and the lack of communication with her mother. The fact that the father of the patient is unwilling to continue communication with the child has also become a traumatic realization that has aggravated R. S.’s condition.
Subjective
The current state of the patient shows that the problem has not been addressed properly and needs an immediate treatment. According to the information provided by the patient, X has developed stronger symptoms of GAD, with a sharp increase in the number of instances when she feels insecure and experiences anxiety much more often than she used to before. Specifically, the patient states that she has been having troubles performing routine actions.
At present, X experiences difficulties falling asleep and socializing, with any negative factor setting off her anxiety. For instance, X has acquired the fear of using an elevator and now prefers to use a staircase instead. X also feels tired almost all the time and has lost her enthusiasm for any activity from academic ones to her hobbies. The situation is aggravated by the drop in the quality of communication with the mother since the latter has to work two jobs now.
Past Psychiatric History
The patient has a record of seeking professional help in order to deal with mental health issues. Particularly, before the divorce of her parents, X developed mild depression, which manifested itself primarily in R. S.’s social withdrawal. The observed phenomenon is rather common for children suffering from depression and the associated conditions (Kalmijn, 2018).
Substance Abuse History
The patient does not have any substance abuse problems.
Psychosocial/Family History
The existing family history records show that there have been several instances of depression among the patient’s relatives. Particularly, R. S.’s aunt and maternal grandfather have been suffering from severe depression, which has affected the quality of their life significantly.
Medical History
R. S.’s respiratory system has been affected extensively since her birth. Particularly, X has contracted upper respiratory tract infections, which led to the development of bronchitis and even created premises for the development of pneumonia several times. The patient currently has the symptoms of asthma, particularly, the presence of fatigue, sleep issues, and the continuous feeling of anxiety, are characteristic for GAD (American Psychiatric Association, 2013). Therefore, it is critical to introduce the tools that allow addressing the specified condition.
Furthermore, X has been suffering from a biological condition that aggravates the mental and physical problems from which she has been suffering. The difficulty breathing, which is one of the current complaints, can also be explained by anemia, which has been rapidly progressing due to the physical and psychological issues that X has been experiencing (Brozovich et al., 2015).
Medications
The patient currently takes two types of drugs, which include:
- Acetaminophen (Tylenol) to reduce muscle pain caused by the fatigue;
- Medications stimulating the thyroid functions.
Objective Data
The examination of the patient has shown that X has been affected by the lack of sleep and the increasing anxiety significantly. Specifically, X’s blood pressure rate is currently higher than the established norm (121/76), which is a sign for concern. As a result, the patient’s heart rate often increases, creating the threat of tachycardia development (National Institute of Health, n.d.). The observed phenomenon can be explained by the fact that the patient had an instance of anxiety during the examination. Specifically, a rise in heartbeat could be observed when performing the assessment of X’s vital signs.
- Hours of Sleep: 5-6
- Appetite adequate: no
- Attending to Hygiene: yes
- EPS: no
- Patient reports the following side effects from psychiatric medications: rise in anxiety and fatigue levels; drop in the levels of socializing; reduced enthusiasm.
- Patient on more than 1 Antipsychotic: no
- Least Restrictive Environment: (hospital, outpatient, partial hospitalization, incarceration etc.) At present, it will be reasonable to use the approach based on outpatient services. Since X has not been displaying the behavior changes that would make her home environment dangerous for her, it will be a sensible step to create the setting in which X will feel relaxed and inclined to manage her anxiety.
Mental Status Exam (List Each Element of Mse Then Data)
Mood: anxious and slightly depressed; exhausted, and unenthusiastic
According to the results of a mental status examination (MSE), the patient’s mood can be described as anxious and depressed, with a significant drop in motivation and enthusiasm. Specifically, X has lost interest toward her academic process, thus creating a dangerous scenario in which a dropout becomes possible.
Additional Findings
The patient assessment has also shown that X may have several problems associated with the management of her diet. Despite the current efforts of the mother to maintain the patient’s weight within the required limit, X has been gaining weight recently, progressing from 127 to 141 pounds over the past month. The specified change in the dynamics of the patient’s development is a reason for concern.
Standardized Assessment Tool
Since the problems associated with the mismanagement of X’s need for communication and support has been disrupting her sleep and has affected her mental health significantly, it will be crucial to address the problem of anxiety immediately. Jordan, Shedden-Mora, and Löwe (2017) suggest that the tool known as the Generalized Anxiety Disorder 7-item (GAD-7) scale should be used as the key device of determining the presence of GAD in a patient.
Moreover, the presence of asthma and anemia should be taken into account. To diagnose the existence of asthma in the patient, one should apply a combination of spirometry and X-raying since the two will allow producing the most accurate outcome when combined (Yadav et al., 2015). Finally, to diagnose anemia in the patient, the Complete Blood Count (CBC) test will be required (Freeman & Morando, 2016). The results of the specified screening will inform the strategy regarding the management of fatigue levels in the patient.
Differential Diagnoses
As explained above, there are strong indications that the patient has developed GAD over the course of her health problems development. The current symptoms point to the presence of GAD, including the fact that the patient suffers from the increased levels of fatigue and the unceasing sense of worrying (American Psychiatric Association, 2013). Therefore, the current problem has to be seen as the one directly related to GAD.
It could also be assumed that the patient suffers from a panic disorder, which is very similar to the diagnosis mentioned above. The presence of panic attacks that affect the patient immediately and prevent her from managing her health properly align with the symptoms of a panic disorder and, thus will have to be considered the second possible diagnosis (Jordan et al., 2017). Consequently, the specified differential diagnosis should also be seen as possible.
Finally, one may make an assumption that the current problems are the direct manifestations of social phobia in a patient (Hoff et al., 2017). Developmental differences in functioning in youth with social phobia. Journal of Clinical Child & Adolescent Psychology, 46(5), 686-694.). Difficulties breathing and an increased heart rate point to the possibility of social phobia as one of the common anxiety-related disorders in teenagers and children (National Institute of Mental Health, 2017). Therefore, while being less likely than the other two, the specified possibility should also be taken into considerations.
Diagnoses
- GAD
- Asthma
Additional Specific Areas of Concern
- Anemia
- Lack of patient education
Plan
- Improved communication with the mother
- Strategies for relaxation
- Cognitive behavioral therapy
Psychiatric Diagnosis
Epidemiology
The phenomenon of GAD has been defined comparatively recently, which makes it a rather difficult issue to address, especially in teenagers and children. According to the existing definition, GAD is the presence of unceasing worrying and distress observed in a patient for the period of at least six months (American Psychiatric Association, 2013). However, the specified time lapse may be shorter to determine the problem of GAD in children and teenagers (American Psychiatric Association, 2013).
A panic disorder can be termed as sudden and unsubstantiated fear and needs to be observed throughout a month to determine the presence of the problem. Shifts in behavior that show maladaptation are also emblematic of a panic disorder (American Psychiatric Association, 2013). A social phobia, in turn, occurs in approximately 5% of children and implies fear of any social situations (American Psychiatric Association, 2013).
Review of Literature
Fatigue, troubles concentrating, and sleep disruptions are typically listed among the key symptoms of GAD (Louise, O’Donnell Siobhan, & Jean, 2017). The disorder may be linked directly to a traumatic experience that one has suffered (American Psychiatric Association, 2013). However, the symptoms of GAD may vary depending on patient-specific factors, as well as external influences that affect a patient’s well-being. GAD is highly prevalent, with a total of 2.7% of the U.S. population being affected by it (National Institute of Mental Health, 2017). The etiological factors of the disorder include family history and exposure to stress. CBT and relaxation techniques should be used to address the problem.
Health Promotion
At present, patient education and the enhancement of her communication with the mother should be regarded as the key steps toward addressing the problem. By offering X the strategies with the help of which she will be able to manage her fears and reduce the level of worrying, one will create the setting in which she will develop control over her disorder. Thus, a gradual improvement is expected to take place (National Institute of Mental Health, 2017). Similarly, the patient and her parent will need to be educated about the threats of asthma and the means of coping with it. The fact that an asthma attack may be caused by a sudden instance of panic should; also be brought to X and her mother’s attention. Finally, one should suggest changes in the patient’s diet and physical activities to address the problem of anemia.
Medical Diagnosis
Epidemiology
The issue of asthma discussed above also requires the close attention of a healthcare practitioner. Although it is not related to GAD directly, it may be caused by excessive worrying, which common for GAD (Centers for Disease Control and Prevention, n.d.). While GAD does not involve sudden panic attacks, it is best to manage the problem immediately.
Review of Literature
The problem of asthma treatment is rather complex since it requires addressing a vast array of factors that may cause the development of the problem. According to the existing definition, asthma is a chronic respiratory disease that occurs due to the inflammation of airways (Centers for Disease Control and Prevention, n.d.). Studies show that an asthma attack can be triggered by a vast range of irritants, including polluted air, pollen, dust, and other similar factors (Subashini et al., 2018).
Health Promotion
In order to encourage the recovery process, one should consider educating both X and her mother about the threat of an asthma attack. The patient should be instructed about the necessity to carry an inhaler with her all the time to address the problem timely Furthermore, X will have to learn to avoid the environment that may cause an asthma attack.
Integration of Disorders
In order to address the situation, one will need to consider the current disorders as a combination of issues that have to be managed. Specifically, the way in which the health concerns are connected to each other should be explored. For example, one will have to take into account the fact that, as a respiratory issue, an asthma attack may be developed in X as a result of an increase in her GAD levels (Dudeney et al., 2017).
Furthermore, the presence of anemia may cause the aggravation of asthma, as well as some of the symptoms characteristic of GAD, such as fatigue and nausea (Brozovich et al., 2015). Therefore, the three problems have to be seen as a system and approached as such.
Discussion
The patient should receive extensive education about the methods of locating threats to her health and avoiding them. Moreover, the patient will need to be provided with Cognitive Behavioral Therapy (CBT) as the means of helping her manage her anxiety (Newman, Castonguay, Jacobson, & Moore, 2015). Finally, parental support and the involvement of her mother into the intervention should be deemed as a crucial stage in handling the issue. The fact that the patient’s socioeconomic status is rather low indicates that the mother is not going to be available for the treatment process all the time. Consequently, the specified issue should be seen as a major hindrance to the successful therapy.
The patient’s culture, however, will allow managing the specified concern due to the significance of family relationships in African American patients (Alim, Kumari, Adams, Saint-Cyr, & Tulin, 2017). X’s gender and sociology, in turn, imply that the patient should be considered at risk for aggravation since anxiety is especially common in adolescent girls (Alim et al., 2017). X’s neurology will have to be assessed to determine the presence of any comorbid issues that may aggravate the situation. Finally, the patient’s age and developmental stage may imply certain difficulties since, as a teenager, X may be undergoing emotional issues. However, not being an adult yet, X is flexible enough to handle the current health challenges successfully.
Conclusion
Because of the influence of a range of factors that define the presence of GAD, anemia, and asthma in the patient, one will have to adopt a framework for taking each of the specified factors into account. A multifaceted approach toward handling the issue of GAD is critical since X also suffers from anemia and asthma, each being linked to GAD due to the mechanics of the disorders. The case also shows the need to consider social factors, such as the patient’s age and gender. The need of the family involvement also remains strong in the specified case. Therefore, X will require a complex treatment along with an elaborate patient education technique. Particularly, a combination of CBT, medications, and patient education will have to be regarded as essential.
References
Alim, T., Kumari, S., Adams, L., Saint-Cyr, A., & Tulin, S. (2017). Craving and depression in opiate dependent mentally ill African Americans receiving buprenorphine/naloxone and group CBT (Cognitive Behavioral Therapy). Clinical Psychiatry, 3(2), 11-16. Web.
American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
Brozovich, F. A., Goldin, P., Lee, I., Jazaieri, H., Heimberg, R. G., & Gross, J. J. (2015). The effect of rumination and reappraisal on social anxiety symptoms during cognitive‐behavioral therapy for social anxiety disorder. Journal of Clinical Psychology, 71(3), 208-218. Web.
Centers for Disease Control and Prevention. (n.d.). Asthma. Web.
Dudeney, J., Sharpe, L., Sicouri, G., Lorimer, S., Dear, B. F., Jaffe, A.,… Hunt, C. (2017). Attentional bias in children with asthma with and without anxiety disorders. Journal of Abnormal Child Psychology, 45(8), 1635-1646. Web.
Freeman, A. M., & Morando, D. W. (2016). Anemia, screening. Web.
Hoff, A. L., Kendall, P. C., Langley, A., Ginsburg, G., Keeton, C., Compton, S.,… Suveg, C. (2017). Developmental differences in functioning in youth with social phobia. Journal of Clinical Child & Adolescent Psychology, 46(5), 686-694. Web.
Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS One, 12(8), 1-14. Web.
Kalmijn, M. (2016). Father–child contact, interparental conflict, and depressive symptoms among children of divorced parents. European Sociological Review, 32(1), 68-80. Web.
Louise, P., O’Donnell Siobhan, M. L., & Jean, G. (2017). The burden of generalized anxiety disorder in Canada. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 37(2), 54-62. Web.
National Institute of Health. (n.d.). Blood pressure levels for girls by age and height percentile. Web.
National Institute of Mental Health. (2017). Generalized anxiety disorder. Web.
Newman, M. G., Castonguay, L. G., Jacobson, N. C., & Moore, G. A. (2015). Adult attachment as a moderator of treatment outcome for generalized anxiety disorder: Comparison between cognitive–behavioral therapy (CBT) plus supportive listening and CBT plus interpersonal and emotional processing therapy. Journal of Consulting and Clinical Psychology, 83(5), 915-925. Web.
Subashini, S., Ramanathan, R., Jayapal, M., Subramaniyam, M., & Sivalingiah, J. (2018). Correlation of age with lung parameters in asthmatic patients with positive parental history. Indian Journal of Physiology and Pharmacology, 62(2), 174-181.
Yadav, A., Corrales-Medina, F. F., Stark, J. M., Hashmi, S. S., Carroll, M. P., Smith, K. G.,… Mosquera, R. A. (2015). Application of an asthma screening questionnaire in children with sickle cell disease. Pediatric Allergy, Immunology, and Pulmonology, 28(3), 177-182. Web.