Anxiety and Depression Case Study

Please read the case study and answer the questions at the end. This is part of group work, and the questions included at the end are my part. Please include the appropriate references. Thank you

Data Clinic Patient:

Veronica is a 22 -year-old Hispanic female. She is a full-time student and works PRN as a C.N.A at the hospital. Her mother passed away 2 years ago, and she has 2 younger siblings that she helps her dad care for when she is able. She has been worrying for about 8 months on how she is going to finish school on time and helping her father with the all the bills. She started having trouble concentrating when studying as well. Her family member suggested an Marplan (Isocarboxazid), an MAOI. She came today for a follow-up.(Anxiety and Depression Case Study)

Current Diagnoses:

·   Major depressive disorder (MDD)

·   Generalized anxiety disorder (GAD)

Prescribed Medications:

·       Escitalopram (Lexapro): SSRI

·       Buproprion (Wellbutrin): Atypical

·       Buspirone (Buspar): antianxiety

Social History: Denies drug use. Vapes only when at parties; reports an occasional alcohol drink 2-3 times per week

Review of Systems:

• General: Complains of occasional fatigue; lost a few pounds this month.
• Skin: Denies rashes, lesions or itching
• HEENT: Denies visual changes but wears contacts
• Cardiac: Denies palpitations or chest pain
• Respiratory: denies and SOB or respiratory issues; occasional seasonal allergies
• GI: Complains of nausea and diarrhea at times but is starting to get better. Denies GERD, or gallbladder problems, normal BM daily
• GU: Denies pain or burning when voiding; reports urine is clear yellow
• MS: Denies any pain or difficulty with ROM and normal ADLs
• Neuro: Denies paresthesia’s or changes in speech or memory; complains of sometimes having problems sleeping and difficulty with concentration when studying.
• Psych: Has feelings of depression sometimes because she is too busy studying, working or caring for her siblings to have time for herself or her friends.(Anxiety and Depression Case Study)

Physical Examination:

• General: Patient appears fatigued, stressed and with a flat affect. She has lost 10 pounds since her last visit 2 months ago. She is friendly and cooperative. She seems distracted at times during conversation but will answer if you repeat the question.
• Height: 5’3” Wt. 115 lbs., T 98.9 F, P 90, R 18; SpO2 99% , BP 135/90
• Skin: Pink, warm dry; feet cool to touch
• Eyes: PERRLA; EOM intact
• Neck: Negative JVD; negative thyromegaly; trachea midline; absent lymphadenopathy
• Cardiovascular: S1, S2 with no extra heart sounds or murmurs
• Lungs: Symmetrical expansion; lung sounds clear bilaterally
• Abdomen: (+) BS x 4; soft, non-tender, no masses, no organomegaly or bruits
• Extremities: 2+ pedal pulses; not edema

Questions:

1.     Additional Questions: Veronica returns to the clinic after using her new antidepressant (Wellbutrin) for 3 weeks and states it does not work.

a.     What do you think the physician would recommend for her treatment and why? Should it be stop, continued or switched to another drug class?

b.     Veronica asks about starting an herbal product for her depression. What herbal product has shown to help with her major depression? Provide and explain the data and any teaching needed.

2.     Drug-Drug Interactions & Teaching:

Using the drug-drug interaction checker: https://reference.medscape.com/drug-interactionchecker, input Veronica’s current medications.

a.     Discuss any major and moderate interactions for Veronica.

b.     How would you respond to the patient regarding the addition of Marplan (Isocarboxazid) to her current medications?

c.     Is Veronica at risk for a hypertensive crisis? How can she prevent this and what teaching needs to be included?

d.     Is Veronica at risk for serotonin syndrome? How can she prevent this and what teaching needs to be included?

Anxiety & Depression Case Study-sample solution

(Anxiety and Depression Case Study) CC (chief complaint): “How would I approach my parents? I am keyed up. I find it hard to concentrate. I am losing control of myself.”

(Anxiety and Depression Case Study)HPI: AT is an 18-year-old Palestinian-American who presents with complaints of depression and anxiety, which are getting worse. “Hope you will not inform my parents, will you?” AT reports that she is unhappy with her life. She does not like anything about herself. “This is not me, isn’t it?” AT reports that the parents don’t see it, her sadness. The parents are concerned about her finishing high school, getting good grades, joining college, and helping her find a man. “They don’t understand me.” AT reports struggling with the school since she identified herself. “I am not really into boys.” Her parents would be sad and heartbroken. (Anxiety and Depression Case Study)I broke up with my boyfriend, and my current girlfriend is understanding. “People are already talking, and I am afraid of what my family, friends, and relatives will think of me. I find it hard to sleep at night and struggle to concentrate in school. I heard you can help me come out and manage my depression and anxiety?” She reports taking alcohol to keep her worries away. She believes she is different from other girls since she grows facial hair and has small breasts. She reports going to the gym to build muscles and looking for hormonal treatment and surgery for her breast. She cannot tell anyone about her intentions, especially her family, whom she considers religious and would not tolerate her orientation. She worries that her parents will get hurt and does not want them to feel bad about her.(Anxiety and Depression Case Study)

Past Psychiatric History:

General Statement: This is the first time the client is seeking treatment.

Caregivers (if applicable): N/A

Hospitalizations: None

Medication trials: None

Psychotherapy or Previous Psychiatric Diagnosis: Denies psychotherapy or previous psychiatric diagnosis.

Substance Current Use and History: Reports taking alcohol at night to help calm down and sleep.

Family Psychiatric/Substance Use History: Denies psychiatric diagnosis or substance abuse in the family.

Psychosocial History: No significant legal history.

Social History: AT lives with her extended family, who are respected in the neighborhood. They are religious and strict. She has two older brothers, alive and healthy. She is in 12^th grade.

Medical History:

Current Medications: None.

Allergies: KNFDA

Reproductive Hx: The client has irregular periods. She is sexually active.

ROS:

GENERAL: Alert and oriented in all spheres.

HEENT: No visual loss, hearing loss, running nose, and throat discomfort.

SKIN: No bruising or marks?

CARDIOVASCULAR: No chest pain or discomfort. Regular pulses.

RESPIRATORY: RRR without a murmur. LCTA. No coughing.

GASTROINTESTINAL: No nausea, vomiting, or diarrhea. Flat abdomen. No bowel sound.

GENITOURINARY: No urinary hesitancy, frequency, or urgency.

NEUROLOGICAL: No numbness or tingling in extremities.

MUSCULOSKELETAL: No joint pain or discomfort.

HEMATOLOGIC: No bleeding disorder

LYMPHATICS: No swollen lymph nodes.

ENDOCRINOLOGIC: No history of diabetes

Physical exam: NA

Diagnostic results: N/A

Assessment

Mental Status Examination: AT is alert and oriented to self, space, time, and situation. She is appropriately groomed and dressed. AT appears to be in acute psychological distress. She is agitated and interactive. She does not make appropriate eye contact. Her speech is clear and coherent. Her stated mood of “depressed” is congruent with affect. Her thought form and content are resigned. She had some attentional difficulties. Has normal insight. Memory/cognition is grossly intact. Has the ability to abstract, and judgment is sound. Suicide ideation resolved(Anxiety and Depression Case Study)

Differential Diagnosis:

1. Gender Dysphoria with congenital adrenal hyperplasia – Gender dysphoria is a disorder common in adolescents and adults associated with marked discordance between the gender assigned at birth and one expressed or perceived gender experienced over six months. Gender dysphoria is manifested by discordance in primary/secondary sexual characteristics and expressed gender, desire to get rid of one’s primary/secondary sex characteristics of having the other gender’s primary/secondary sex characteristics, desire to be the other gender other than the assigned gender, desire to be treated as the other gender other than the assigned gender, and convictions of having the characteristic reactions and feelings of the other gender (Association, American Psychiatric [APA], 2019). These manifestations are associated with significant clinical impairment and distress and impact an individual’s occupational, social and interpersonal functioning.(Anxiety and Depression Case Study)
2. Major Depressive Disorder – Major depressive disorder (MDD) is mental health condition whose symptoms persist over two weeks affecting a range of functions. MDD is manifested by a depressed mood and loss of pleasure. Affected individuals express symptoms such as depressed mood, diminished pleasure in activities, significant weight loss, feelings of worthlessness/inappropriate guilt, fatigue/loss of energy, inability to concentrate/indecisiveness, psychomotor agitation/retardation, and thoughts of death (APA, 2019). These symptoms present most of the day and dearly every day affecting the individual’s social, interpersonal, and occupational activities. Individuals report sadness, hopelessness, and emptiness (APA, 2019). (Anxiety and Depression Case Study)Irritability is also a common observation among affected individuals. Weight loss among MDD patients happens without dieting or a decrease in appetite.(Anxiety and Depression Case Study)
3. Generalized Anxiety Disorder – Generalized anxiety disorder is a mental condition characterized by excessive worry/anxiety that occurs for at least six months. Individuals worry about various activities/events related to school, family, or occupation on most days during the six months or more (APA, 2019). Moreover, individuals find it difficult to control their worries. Individuals experience difficulty concentrating, restlessness, fatigue, muscle tension, irritability, and sleeplessness (APA, 2019). Significantly, the symptoms cause significant distress and impairment of areas of functioning, including occupation and social life.(Anxiety and Depression Case Study)

Reflection

I accede to the preceptor’s assessment and diagnostic impression. The patient presents symptoms that justify the diagnosis of gender dysphoria. These symptoms include marked discordance between the gender assigned at birth and one’s expressed or perceived gender experienced over six months. She reports being unhappy with her life and disliking everything about herself. She reports that she is not into boys. She notes that she is not what her family wants her to be. She finds it hard to sleep at night and concentrate in school. She reports taking alcohol to keep her worries away. She believes she is different from other girls since she grows facial hair and has small breasts. She reports going to the gym to build muscles and looking for hormonal treatment and surgery for her breast.(Anxiety and Depression Case Study)

The presented symptoms meet the DSM-5 diagnostic criteria for gender dysphoria with congenital adrenal hyperplasia. With gender dysphoria, individuals experience a sense of unease between their gender identity and biological sex features, leading to self-dissatisfaction, anxiety, and depression, which harm daily life (Kaltiala-Heino et al., 2018). Girls with gender dysphoria tend to conceal primary sex features they don’t like, such as breasts, through surgery or other mechanisms, including binding, walking with a stoop, or wearing sweaters (APA, 2019). Moreover, affected adolescents increasingly request hormonal prescriptions or request for gender reassignment surgery. However, before any of these interventions, individuals experience suicide ideation or attempts with others succumbing.(Anxiety and Depression Case Study)

(Anxiety and Depression Case Study)Furthermore, treatment-seeking adolescents present significant psychiatric comorbidity. For instance, the present patient experience significant depression and anxiety, and alcohol abuse. Depression and anxiety are the most commonly reported psychiatric disorders among individuals with gender dysphoria (Kaltiala-Heino et al., 2018). Besides, suicidal ideation or self-harm behavior are also common. Adolescents presenting with gender dysphoria are six times more likely to develop depression and three times more likely to engage in self-harming behavior or suicide attempts.(Anxiety and Depression Case Study)

The ethical considerations for adolescents with gender dysphoria include autonomy, confidentiality, and disclosure. When dealing with adults capable of giving consent, subjective experience is considered crucial for assessing an individual’s well-being (Nieder et al., 2020). Respecting the patient’s autonomy is critical in understanding the legal and moral requirements of psychiatric practice that anchor ethical and legal norms. In this case, a patient is consent able, and a PMHNP should uphold self-determinants such as not informing the patient’s parents about her sexual orientation. Ideally, this is important because issues of sexual identities and orientations deviate from patriarchal and heteronormativity that define a female and male during adulthood.(Anxiety and Depression Case Study)

Ethical concerns for confidentiality and disclosure of patient information are crucial when dealing with any mental health patient. It is a responsibility of a PMHNP to uphold confidentiality and waive it off when clinically and legally appropriate (Bipeta, 2019). In this case, the patient does not want her parent to know about her mental health concerns; legally, this should remain so unless otherwise determined by the court. (Anxiety and Depression Case Study)Studies have shown that unwillingness to disclose is prevalent among young females with higher education status, and factors such as these should be considered when making ethical decisions (Bipeta, 2019). Moreover, a PMHNP should ensure that enough information is available for diagnosis. In this case, additional information from the parents could have helped make a definitive diagnosis since PMHNP should not entirely rely on mental examination. Without coercing the patient, it would be ideal to involve the parent to ensure a definitive diagnosis and consequent intervention since the patient is more concerned about the parental’ response to her orientation.(Anxiety and Depression Case Study)

Various risks and prognostic factors are associated with gender dysphoria. (Anxiety and Depression Case Study)Individuals with sex development disorder and uncharacteristic gender behavior are more likely to develop gender dysphoria (APA, 2019). Moreover, habitual fetishistic transvestism risks the development of gender dysphoria. Lastly, the genetic contribution is associated with the development of gender dysphoria. Significantly, gender dysphoria has been reported across cultures and countries. Considering the societal view of sexual orientation, individuals face the challenge of coming out as gay due to social discrimination and stigma.(Anxiety and Depression Case Study)

Consequently, affected individuals resort to drug and substance abuse (Kerr & Oglesby, 2017). Therefore, it is necessary to promote a healthy lifestyle by discussing the dangers of drug and substance abuse on health. Equally, providing information on community support centers is crucial in the mental health treatment continuum.(Anxiety and Depression Case Study)

Conclusion

The patient, in this case, presents symptoms that meet the diagnostic criteria for gender dysphoria. The present patient’s dissonance with primary sexual features and expressed gender ideation primarily leads to significant distress and impairment of essential areas of functioning, including social and academic life.(Anxiety and Depression Case Study) Consequently, the patient experience comorbid psychiatric concerns diagnosed as secondary to gender dysphoria, including depression and anxiety. Usually, individuals diagnosed with gender dysphoria express depressive symptoms associated with the need to express their gender orientation against familial and societal conception. Drug and substance abuse are commonly related to perceived discrimination and stigma. Sometimes, individuals abuse drugs due to interpersonal discordance. In this case, ethical concerns of autonomy, confidentiality, and disclosure are crucial and should be upheld otherwise permitted by the existing legislature.(Anxiety and Depression Case Study)

References

Association, American Psychiatric. (2019). Diagnostic and statistical manual of mental disorders. American Psychiatric Publishing.(Anxiety and Depression Case Study)

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine, 41(2), 108-112. https://doi.org/10.4103%2FIJPSYM.IJPSYM_59_19

Kaltiala-Heino, R., Bergman, H., Työläjärvi, M., & Frisén, L. (2018). Gender dysphoria in adolescence: current perspectives. Adolescent Health, Medicine and Therapeutics, 9, 31. https://doi.org/10.2147/AHMT.S135432

Kerr, D. L., & Oglesby, W. H. (2017). LGBT populations and substance abuse research: An overview. Research methods in the study of substance abuse, 341-355.(Anxiety and Depression Case Study)

Nieder, T. O., Güldenring, A., Woellert, K., Briken, P., Mahler, L., & Mundle, G. (2020). Focus: Sex & Reproduction: Ethical Aspects of Mental Health Care for Lesbian, Gay, Bi-, Pan-, Asexual, and Transgender People: A Case-based Approach. The Yale Journal of Biology and Medicine, 93(4), 593. https://pubmed.ncbi.nlm.nih.gov/33005124/