Post-Starr

Respond to at least two of your    colleagues who were assigned to a different case than you. Explain how    you might apply knowledge gained from your colleagues’ case studies  to   you own practice in clinical settings. 

NOTE: Positive comment

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 Case  Study: Volume 2, Case #21 focuses on the treatment of an adult  client  diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).   

Questions 

Question 1: Are you having problems with your loved one’s due being “argumentative and temperamental”?  

Rationale:  The client may have additional stress due to broken  relationships and  this could be due to his disorder.  “Emotional  dysregulation is  increasingly recognized as a core feature of ADHD”  (Stralen, 2016).  Signs of ADHD include low frustration tolerance and  explosive behavior  (Stralen, 2016).  

Question 2: 

What causes you the most anxiety?

It  is important to determine the triggers of the anxiety to help the   patient prepare for times when he is likely to be in high stress   situations. Planning a response when feeling overwhelmed can help the   patient remain in control of his emotions and allow the patient to   monitor his behavior. 

Question 3: 

You  stated that your father was abusive, was this physical or verbal  abuse  or both? Do you contribute some of your anxiety from previous  issues  with your father? 

It  is important for the provider to understand the client’s point of  view  in regards to his upbringing. He realizes it has affected in him  in some  way, as he has obtained psychotherapy in the past. I would want  to know  if he has ever spoken to his father about this and if his  father has  ever apologized for his actions. 

Questions for family

I  would want to talk with his mother to ask her how he did as a  child in  school and at home in regards to schoolwork, chores and would  want to  know if he had friends. Although  social problems are not part  of the diagnostic criteria for ADHD, the  peer relationship difficulties  faced by youth with this disorder are  profound (Hoza, 2007)

Diagnostics & Exams

A  full psychiatric evaluation which would include the Adult  Self-Report  Scale (ASRS). ASRS was been developed by the World Health  Organization  to determine if an individual (adult) may have ADHD. The  scale is made  up of 6 questions, and if a client has at least 4 of 6  symptoms, there  may need to be a diagnosis of ADHD made by a  professional (ADDA, 2018). Seay  et al. (2009) suggests the PMHNP should  utilize intelligence test,  broad-spectrum scales, tests of specific  abilities, and brain scans to  confirm the diagnosis and to rule out  other disabilities, autism,  auditory processing disorders or mood  disorders. In addition, a full medical work-up by a PCP in order to rule  out other medical conditions that could present similarly to ADHD. 

Differential DX

General Anxiety Disorder: The  patient exhibits symptoms of  generalized anxiety disorder, DSM-5 300.02  (F14.1). He has had the  symptoms for greater than six months with the  symptoms being severe  enough to interfere with the patient’s daily  functioning. The patient  complains of feels of worry that is difficult  to control, irritability,  restlessness, difficulty concentrating and  feeling on edge. The  patient symptoms have not been linked to a physical  condition or to  substance use (Reynolds & Kamphaus,2013).

ADHD:  client consistently complains of feeling tense, irritable, and  anxious  (Stahl Online, 2019).  Questions arise once the general  anxiety symptoms  are resolved and the client is left feeling  hyperactive, inattentive,  and the inability to focus (Stahl Online).

Post-Traumatic  Stress Disorder: The client’s diagnosis of anxiety  may have been  related to underlying issues related to a traumatic event  that he  experienced as a child. The client’s father was verbally  abusive to him  and was an alcoholic. It is a possibility that the  client’s issues could  have some relations to previous exposure as a  child. Post-Traumatic  Stress Disorder is a serious condition that can  occur in clients who  have experienced various incidents including abuse  (PTSD, 2018).

Medications

The  case states by year six the client has failed to achieve  remission on  an SSRI, a 5-HT1A receptor partial agonist, an  antihistamine anxiolytic  and an SGRI (Stahl Online, 2019).

Based on the pharmacological agents, I would select either  Cymbalta  60mg or Effexor XR 150mg.  Cymbalta did illicit a response,  but side  effects prevented the escalation of the dosage.  Augmenting  with  guanfacine an alpha-adrenergic agonist proved to be the therapy  that  elicited remission for this client.

Lessons Learned

I  learned to always consider additional differential diagnosis and   evaluate and re-evaluate every situation separately to be sure of the   correct diagnosis.  Patient’s  often have comorbid diagnosis and  treating both is vital to a  successful outcome for the patient.  Symptoms of mental illness change  overtime making continued care  necessary for the patient. The provider  must always be approachable and  helpful for the client to feel  comfortable in his/her presence. 

                                                References

Attention Deficit Disorder Association. (2018). Adult ADHD Test. Retrieved from https://add.org/adhd-test/

Generalized Anxiety Disorder. (2018). Anxiety and Depression Association of America. Retrieved from https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

Posttraumatic Stress Disorder. (2018). Anxiety and Depression Association of America. Retrieved from https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd

Seay, B., McCarthy, L. F., and Williams, P. (2009). Your complete ADHD/ADD diagnosis guide.

            Retrieved from https://www.additudemag.com/adhd-testing-diagnosis-guide/

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

            Applications (4th ed.). New York, NY: Cambridge University Press.

Stralen, J. W. (2016). Emotional dysregulation in children with attention-deficit/hyperactive disorder.

            Attention Deficit Hyperactivity Disorder. 8(4). p. 175-187. Retrieved from

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110580/

Hoza  B, Mrug S, Gerdes AC, Bukowski WM, Kraemer HC, Wigal T, et al.  What  aspects of peer relationships are impaired in children with   attention-deficit/hyperactivity disorder? Journal of Consulting and  Clinical Psychology. 2005b;73:411–423. 

Reynolds, C. & Kampaus, R. (2013). Generalized Anxiety Disorder. Pearson. Retrieved from:

www.images.pearsonclinical.com/images/assets/basc-3/basc3resources/DMS-5_

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