Individual & Family Therapy|Legit essays

Posted: February 12th, 2023

 

Diagnostic Assessment

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Jorge Tase

Presentation No. 2

PMHN Across the Lifespan. Practicum I: Individual & Family Therapy

Professor Roxana Orta, DNP, PMHNP, FNP

FNU

Clinical case

Clinical Case: Encounter No. 6

J.R., male, Hispanic, 45-year-old, unemployed since 2020. He suffers from GAD since 2012 which has impaired him to work and behave properly. Patient shows minimal treatment response as of today. He continues to exhibit symptoms of the disorder. Symptoms continue the same in frequency and intensity, and no significant improvement is noted. Symptoms of this disorder occur more days than not. Sleep difficulty continues unchanged. Feelings of increased muscular tension across neck and shoulders continue unchanged. He describes feeling irritable with lack of focus and inability to concentrate. Feelings of fatigue are described as continuing unchanged. Medication has been taken regularly. He has to force herself to socialize with others. A fair night’s sleep is described. Sleep was not continuous and not completely restful.

Brief MSE

Clinical Case: Encounter No. 6

J.R. is irritable, distracted, and fully communicative, casually groomed, and appears anxious. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood is entirely normal with no signs of depression or mood elevation. The affect is congruent with mood. There are no signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content is appropriate. Homicidal ideas or intentions are convincingly denied. Cognitive functioning and fund of knowledge is intact and age appropriate. Short and long-term memory is intact, as is ability to abstract and do arithmetic calculations. This patient is fully oriented. Clinically, IQ appears to be in the above average range. Insight into illness is fair. Social judgment is intact. There are signs of anxiety with his behavior in fidgety stage.

Diagnostic classification

Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat (Boland, Verdiun, & Ruiz, 2021).

Panic attacks feature prominently within the anxiety disorders as a particular type of fear response. The anxiety disorders differ from one another in the types of objects or situations that induce fear, anxiety, or avoidance behavior, and the associated cognition.

The key features of generalized anxiety disorder (GAD) are persistent and excessive anxiety and worry about various domains, including work and school performance, that the individual finds difficult to control.

The individual experiences physical symptoms, including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance.

Individuals with anxiety may be more likely to have suicidal thoughts, attempt suicide, and die by suicide than those without anxiety.

Clinical case

Clinical Case: Encounter No. 6

J.R., presents an anxiety and worry associated with three or more of the previous six symptoms (with at least some symptoms present for more days than not for the past 6 months).

He finds it difficult to control the worry.

Still, the disturbance is not better explained by another mental disorder.

The focus of the anxiety and worry is not confined to features of an Axis I disorder.

The disturbance is not attributable to the physiological effects of a substance.

Result :

DSM-5 diagnostic criteria met.

Diagnosis: Generalized Anxiety Disorder.

Diagnostic criteria SETS

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

The individual finds it difficult to control the worry.

The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item required in children.

Restlessness, feeling keyed up or on edge.

Being easily fatigued.

Difficulty concentrating or mind going blank.

Irritability.

Muscle tension.

Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

The disturbance is not better explained by another medical disorder

Descriptive diagnostic classification

Diagnostic Features:

The essential feature of GAD is excessive anxiety and apprehensive expectation about several events or activities. The intensity, duration, or frequency of the anxiety and worry is out of proportion. The individual finds it difficult to control the worry.

Worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning.

Worries are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants.

Worries are more likely to be accompanied by physical symptoms.

The anxiety and worry are accompanied by at least three of the following additional symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and disturbed sleep.

Descriptive diagnostic classification

Associated Features

Associated with muscle tension, trembling, twitching, feeling shaky, and muscle aches or soreness. Many individuals with generalized anxiety disorder also experience somatic symptoms.

Prevalence

The 12-month prevalence of GAD is 0.9% among adolescents and 2.9% among adults in the United States. The lifetime morbid risk in the United States is 9.0%. Women and adolescent girls are at least twice as likely as men and adolescent boys to experience GAD. European descent tend to have symptoms that meet criteria for GAD more frequently than Asian and African descent (high-income are more likely than low- and middle income to report that they have experienced symptoms).

Development and Course

The symptoms of excessive worry and anxiety may occur early in life but are then manifested as an anxious temperament. GAD symptoms tend to be chronic and wax and wane across the life span, fluctuating between syndromal and subsyndromal forms of the disorder. Rates of full remission are very low. The earlier in life individuals have symptoms that meet criteria for GAD, the more comorbidity and impairment they tend to have. Younger adults experience greater severity of symptoms than do older adults (APA, 2022).

Descriptive diagnostic classification

Supporting Diagnosis

Generalized Anxiety Disorder 2-item (GAD-2): is a very brief and easy to perform initial screening tool for generalized anxiety disorder.

Generalized Anxiety Disorder 7-item (GAD-7): is a easy to perform initial screening tool for generalized anxiety disorder.

Subtypes and/or Specifiers

The existence of interpersonal subtypes in GAD. Four interpersonal subtypes has been identified (Targum et. al., 2018) :

Overly Nurturant

Intrusive

Socially Avoidant

Nonassertive.

Descriptive diagnostic classification

Risk and Prognostic Factors

Temperamental: behavioral inhibition, negative affectivity (neuroticism), harm avoidance, reward dependence, and attentional bias.

Environmental: childhood adversities and parenting practices.

Genetic/Physiological: 1/3 of genetics with neuroticism.

Culture-Related Diagnostic Issues: considerable cultural variation.

Sex- and Gender-Related Diagnostic Issues: more frequently in women than in men.

Association With Suicidal Thoughts or Behavior: most frequent diagnosed in suicides. Both subthreshold and threshold GAD may be associated with suicidal thoughts.

Functional Consequences

Excessive worrying impairs the individual’s capacity to do things quickly and efficiently, whether at home or at work. Linked to decreased work performance, increased medical resource use, and increased risk for coronary morbidity (APA, 2022).

Descriptive diagnostic classification

Diagnosis (clinical judgement, based on history, laboratory findings, physical examination, and MSE).

F41.1 Generalized anxiety disorder: condition marked by excessive worry and feelings of fear, dread, and uneasiness that last six months or longer. Other symptoms of GAD include being restless, being tired or irritable, muscle tension, not being able to concentrate or sleep well, shortness of breath, fast heartbeat, sweating, and dizziness. Some of the more common topics or worries include work, family, health or money. Such worries can continue throughout the day, in some cases every day, disrupting social activities, family, work or school (Munir & Takov, 2022).

Differential Diagnosis

F06.4 Anxiety disorder due to another medical condition.

F19.180 Substance/medication-induced anxiety disorder.

F40.1 Social anxiety disorder.

Descriptive diagnostic classification

Comorbidity

The negative affectivity (neuroticism) or emotional liability is associated with temperamental antecedents and genetic and environmental risk factors shared between other disorders, although independent pathways are also possible (APA, 2022).

Recording Procedures

The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’, respectively, and adding together the scores for the 7 questions (DHHS, 2019).

Scores represent: 0-5 mild. 6-10 moderate. 11-15 moderately severe anxiety. 15-21 severe anxiety.

Clinical case

Clinical Case: Encounter No. 6

J.R. meet the DSM 5-TR criteria. After the review of EMR and implementation of the recording procedures, he was scored 14 (moderately severe anxiety).

Measures of anxiety are seldom used in clinical practice because of their length, proprietary nature, usefulness as a diagnostic and severity measure.

They require the clinician administration rather than patient self-report.

The goal is to identify probable cases of GAD and to assess symptom severity according to the reliability and validity of the tools.

Proposal treatment and actions are implemented accordingly.

Treatment for GAD

 

Conclusions

Clinical Case: Encounter No. 6

Anxiety disorders are common across gender, age, and culture. Accurate diagnosis of an anxiety disorder rests on determining the specific feared stimuli and the presence of functional impairment or distress related to this fear.

The main diagnostic criteria of GAD are excessive anxiety and worry that is difficult to control along with at least 3 from a list of 6 symptoms and duration of the disorder for at least 6 months.

Careful evaluation of an anxious patient will help to determine if thecause of the anxiety is organic or psychological.

Primary care practitioners should incorporate psychological techniques in their medical management.

Medication is frequently used to treat anxiety disorders and is often preferred by many for its initial lower cost in terms of money, time, and effort.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-Tr. APA Publishing.

Boland, R., Verdiun, M., & Ruiz, P. (2021). Kaplan and Sadock’s synopsis of Psychiatry. Wolters Kluwer Health.

Munir , S., & Takov , V. (2022). Generalized anxiety disorder. Statpearls – NCBI bookshelf. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441870/

Targum, S.D., Murphy, C., Khan, J., Zumpano, L., Whitlock, M., Simen, A.A., & Binneman, B. (2018). Audio recording for independent confirmation of clinical assessments in generalized anxiety disorder. Innov Clin Neurosci. 15(3-4):37-42.

Understanding GAD. Generalized Anxiety Disorder (GAD). (2022). Retrieved from https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

U.S. Department of Health and Human Services. (2019). Generalized anxiety disorder: When worry gets out of Control. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/publications/generalized-anxiety-disorder-gad

 

SOLUTION

Based on the symptoms described, J.R. meets the criteria for Generalized Anxiety Disorder (GAD). GAD is characterized by excessive, long-lasting anxiety and worry about a variety of events or activities, often without any clear cause. The symptoms described, including feelings of increased muscular tension, irritability, lack of focus and concentration, fatigue, and difficulty sleeping, are all consistent with a diagnosis of GAD. The fact that he has been experiencing these symptoms for more days than not, and that he continues to have minimal treatment response, further supports a diagnosis of GAD.

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