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Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
1. Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
2. Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
3. By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
4. Consider what history would be necessary to collect from this patient.
5. Consider what interview questions you would need to ask this patient.
6. Identify at least three possible differential diagnoses for the patient.
7. Complete and submit your Comprehensive Psychiatric Evaluation, 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.
- Reflection notes: What would you do differently with this client if you could conduct the session over??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.)
Training Title 15
Name: Mr. David Jackson Gender: male Age:19 years old T- 98.8 P- 89 R 18 110/62 Ht 5’7 Wt 133lbs Background: Lives in Minneapolis, MN with both of his parents, only child. Works part time at Starbucks.
Not currently partnered. No previous psychiatric history. Symptoms began in the last 1.5 months when he discovered he is being activated with the Navy Reserves. His MOS is SK1 Storekeeper; no medical illnesses Allergies: NKDA; sleeps 6.5 hrs; appetite good Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-
Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-alexanderstreet-
com.ezp.waldenulibrary.org/ watch/training-title-15
REQUIRED LEARNING RESOURCES:
American Psychiatric Association. (2013). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.
American Psychiatric Association. (2013). Obsessive compulsive and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.
9780890425596.dsm06
American Psychiatric Association. (2013). Trauma- and stressor-related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.
9780890425596.dsm07
Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
- Chapter 9, Anxiety Disorders
- Chapter 10, Obsessive-Compulsive and Related Disorders
- Chapter 11, Trauma- and Stressor-Related Disorders
- Chapter 31.11 Trauma-Stressor Related Disorders in Children
- Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence
- Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence
Classroom Productions. (Producer). (2015). Anxiety disorders [Video]. Walden University.
Classroom Productions. (Producer). (2012). The neurobiology of anxiety [Video]. Walden University.
Classroom Productions. (Producer). (2015). Obsessive-compulsive disorders [Video]. Walden University.
Classroom Productions. (Producer). (2015). Trauma, PTSD, and Trauma-Informed Care [Video]. Walden University.
MedEasy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & COMLEX [Video]. YouTube. https://www.youtube.
com/watch?v=-BwzQF9DTlY
TRANSCRIPT OF VIDEO FILE:
00:00:00______________________________________________________________________________
00:00:00BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA So you, you said you were in the reserves? Inactive duty?
00:00:20PATIENT Well, I was inactive duty. But then I learned that they are using the stop-loss policy to extend our active duties. We have to all return to Iraq for another tour.
00:00:30OFF CAMERA Was that upsetting?
00:00:30PATIENT I can’t even begin to describe what I am feeling.
00:00:35OFF CAMERA Tell me about why you decided to make an appointment with a psychiatrist.
00:00:40PATIENT Some questions I can answer. Sadness. Fear I guess. But other, other questions I can’t find the answers to.
00:00:55[sil.]
00:01:00OFF CAMERA Go ahead.
00:01:05PATIENT You know how they repealed the “Don’t ask don’t tell” policy?
Well, I’m struggling if I should… You don’t have to report what I tell you, do you?
00:01:20OFF CAMERA Well, it’s similar to civilian life, the military is under the same HIPPA laws. So if somebody, if one wants to look at your record, medical, only medical personnel can look in your record and only with a medical reason. And, no one else is allowed access. Any private, personal issues you have, which don’t break a law or a military rule, those are not reported. Someone could always illegally access your record, but that would be prosecuted.
00:02:00PATIENT Good. I guess you can figure out, well, I can’t figure out whether I should tell people when I go back.
00:02:15OFF CAMERA So have you been weighing the pros and cons of, the advantages and disadvantages about telling people about your sexuality?
00:02:25PATIENT Everyday.
00:02:25OFF CAMERA What do you feel are the pressures for you to tell people?
00:02:30PATIENT It’s miserable enough being over there just being a soldier, on top of that you have to listen to all these gay comments: “Oh Johnston, you look a fag when you wear your head gear like that.”
00:02:45OFF CAMERA Uh, huh. Who is Johnston?
00:02:45PATIENT He’s one of my best friends
00:02:50OFF CAMERA Is he gay or someone who has homosexual-type thoughts?
00:02:55PATIENT Johnston. No. Never.
00:02:55OFF CAMERA Why do you say that?
00:03:00PATIENT I don’t know. I can just feel it, sense it, that he’s not gay.
00:03:05OFF CAMERA Okay. So, if I play, permit me to play the devil’s advocate, maybe there are others feel they know, can already feel whether you are gay or not.
00:03:15PATIENT No. I hide it. I’m very careful.
00:03:20OFF CAMERA Uh huh. I see.
00:03:20PATIENT If I told the other people in my unit, the men and the women, they’d be surprised. I promise.
00:03:30OFF CAMERA So you think that they all fell for the “lies” as you call it, about your sexuality?
00:03:35PATIENT Absolutely. Well, I think “absolutely.” I mean, I mean they wouldn’t feel free to make all the comments like they do if they thought that I were…
00:04:00OFF CAMERA Have you ever talked with anyone in your unit about your private, sexual thoughts,
00:04:05PATIENT No.
00:04:05OFF CAMERA Private sexual feelings?
00:04:05PATIENT No. Never.
00:04:05OFF CAMERA Do others talk with you about their sexual thoughts and feelings?
00:04:10PATIENT Like 59 minutes out of every hour, every day.
00:04:15OFF CAMERA Ah. Everyone?
00:04:20PATIENT Well, almost everyone. I mean some people are more private, stand offish.
00:04:25OFF CAMERA Yeah. So what do you fear could happen if you talk wit them?
00:04:30PATIENT They wouldn’t feel comfortable around me. In the showers. Patting me on the back. Guy hugs. Sleeping in close quarters.
00:04:45OFF CAMERA So some people, men and women, if they knew you were gay, they’d treat you differently. But hard it’s know in advance the exact gains and losses. All you know is that it would be different.
00:05:05PATIENT That it would feel lousy for somebody to get up and move away from me because they thought that I would… do something with them.
00:05:15OFF CAMERA Some may very well feel that way. Do you ever have sexual thoughts about any of the men in your unit?
00:05:25PATIENT Mild curiosity maybe about what you know someone looks like or something, undressed. But not actually having sex kinds of thoughts. I have thoughts of wanting to be close, but that’s, that’s not sexual. I mean with women, too. I enjoy close friendships.
00:05:55OFF CAMERA Sounds like… your own feelings are just a little bit confused separating out friendship and sexual feelings.
00:06:05PATIENT Well, I’ve never been in an on-going relationship. I mean a few times fooling around. A couple years back.
00:06:20OFF CAMERA Do you have doubts about whether you prefer women or if you prefer men?
00:06:25PATIENT No. No doubts. I’ve known since I was 8 what kind of… nude photos, later internet pics, videos, I like to look at. Just no real-life experiences.
00:06:45OFF CAMERA So it sounds like you feel pretty confident about your sexuality?
00:06:50PATIENT I’m gay. I know I’m gay.
00:06:55OFF CAMERA So who else, other than me just now, have you ever said those words to?
00:07:00PATIENT “I’m gay?”
00:07:00OFF CAMERA Yes.
00:07:05PATIENT Just you. Just now.
00:07:05OFF CAMERA So you don’t have experience in telling people. You haven’t practiced that skill.
00:07:15PATIENT I never thought about that as a skill.
00:07:20OFF CAMERA Well you have the skill, it sounds like of thinking whether or not you are gay, which many people don’t even have that skill, But you are lacking in two skills. You have a little difficulty, little confusion about, thinking about separating friendships from sexual relations and then your lacking in that skill of telling people that you are gay. And not having those two skills, sometimes that scares people.
00:07:50PATIENT Try terrifies.
00:07:55OFF CAMERA Terrifies. Well, over the years, listening to people like I do with similar concerns, it’s, it’s clear to me that there are several skills in talking about one’s own sexuality. There are bad ways, bad timing for telling people about your sexuality. And there are good ways, better timing.
00:08:20PATIENT Guess that makes sense.
00:08:25OFF CAMERA And then another skill is recognizing that there are people who won’t want to learn directly from you about your sexuality, and there are people who do not want to learn it directly from you. Maybe because of their religious beliefs, or their cultural backgrounds, or even their lack of thinking about sexuality. So it’s a skill to look at people, talk to people and learn to sense their attitudes. So you don’t confront them and surprise them or alarm them.
00:09:00PATIENT But these people, they’re supposed to be learning about sexuality in workshops and all, right?
00:09:05OFF CAMERA How many times have you gone to class, learning, only to later discover it was more difficult to apply what you learned?
00:09:15PATIENT Lots of times.
00:09:20OFF CAMERA Yeah. So maybe one day, people will come into the military and talk open about sexuality and early in their meeting people, but not now. We’re not there now. I think we have to be realistic.
00:09:35[sil.]
00:09:40OFF CAMERA You look confused. Maybe confusion’s okay. It’s a confusing topic at this point in our history.
00:09:55PATIENT What other “skills” am I missing?
00:10:00OFF CAMERA Well… What about dealing with rejection?
00:10:05PATIENT Rejection? Damn.
00:10:10OFF CAMERA Yep. That’s a skill. Think about it. Lots of celebrities and politicians, they have to be really superb at dealing with rejection. That’s a skill. If you tell people you are gay, there are people who will walk away from you. Those people may need time to go think about it. About what you shared with them. You’ve had lots of time to think about sexuality. Maybe they have not. You can expect that some of those people will come around and later be accepting. Other people who walk away from you, may feel deceived, and they may never, never come back to your side.
00:10:55PATIENT That what scares me.
00:10:55OFF CAMERA And you have to plan ahead for that. Rehearse it in your head, maybe rehearse with accepting friends, or counselors, people, about how you are going to deal with those moments. That’s, that’s a skill.
00:11:15[sil.]
00:11:20OFF CAMERA You look sad about that.
00:11:25PATIENT I used to worry about rejection. And it just made me want to die.
00:11:35OFF CAMERA Kill yourself?
00:11:35[Shakes head “Yes”]
00:11:40OFF CAMERA Any thoughts like that now?
00:11:40PATIENT Not for years. I’ve seen too many people come out of the closet and do fine. I mean not so much people I know, but from TV, internet, hearing their stories.
00:12:00OFF CAMERA In your unit, if you tell people, do you feel people may threaten your safety? Not watch your back when you’re in danger?
00:12:15PATIENT Naw. The people in my unit are amazing. It’s more the small, the subtle looks, the… Feeling like I wasn’t with them I mean I don’t mean to sound like a pussy, but… These men, they’re all I have. Day after day. They’re right there, and I don’t… I don’t want to feel like I’m on the outside.
00:13:00[sil.]
00:13:05OFF CAMERA So back when you were with the unit, did you feel like they were with you, when you were not truthful with them?
00:13:20PATIENT I guess not. They couldn’t be with me. I wasn’t being real. I used to dream that what I had was real. I want that to end. Not being real.
00:13:50[sil.]
00:13:55OFF CAMERA What are you thinking?
00:14:05PATIENT That I still don’t have my answer. I have lots more weighing of pros and cons to do. Maybe that’s okay. Brush up on the skills, as you call them, while I prepare to… To tell them. How do I start? I wish I could use stop loss and take you with me.
00:14:35OFF CAMERA [Laugh] Thank you for inviting me.
00:14:40PATIENT You’re welcome.
00:14:45OFF CAMERA I’ll tell you what, let me talk to a few people. See if… If I can identify someone with whom you can talk with overseas. But in the meantime… Let’s, you and me… At least have a session or two before you leave. Okay?
00:15:05PATIENT Sure.
00:15:10[sil.]
00:15:10END TRANSCRIPT
EXPERT ANSWER AND EXPLANATION
Assessing and Diagnosing Patients with Mood Disorders
The clinical assessment involves the application of the instruments such as the DSM-V to determine the clinical and psychological needs of a patient. This assessment entails looking at the patient’s stressors, and the impact of such stressors on the patient’s wellbeing. There are various factors which may alter the emotional wellbeing of the patient, and these factors range from the social factors within the patient’s surroundings, and fear or uncertainty.
When examining a patient for psychological issues, a psychologist needs to consider the primary and secondary diagnoses. This is necessary so that they can provide an intervention that comprehensively meets the patients’ physiological and emotional needs (American Psychiatric Association, 2013a). During the assessment, a psychologist may look at aspects of the patient such as their sexual orientation, sleep patterns, and behaviors when in the presence of others. This information can form the basis for the clinical intervention as described in this study.
Patient: The patient’s name is Mr. David Jackson, and he is a 19-year old male, and the only child in his family.
Subjective:
CC: He is concerned about his friends’ reaction if they learn that he is sexually queer. He feels that his friends will isolate him if he shares the details of his sexuality.
HPI: The 19-year old is worried about the possibility of being isolated by his friends if they learn about his sexual preferences, and he feels uncomfortable when his friends talk ill about gays.
The patient states that he has had suicide ideations because he feels he is different. Still, he is worried about his rejection, and this makes him feel like he wants to die (American Psychiatric Association, 2013b). According to the patient, he is sad and he has fear, and he is shocked to learn that he will be acted with the Navy Reserves.
Past Psychiatric History: David denies psychiatric history. The patient is mentally sound considering that he can differentiate between reality and non-real stuff. He denies ever using a drug to treat psychiatric condition.
Substance Current Use and History: The patient denies substance abuse.
Family Psychiatric/Substance Use History: There is no substance and psychiatric history for the patient’s family.
Psychosocial History: There is no history of psychological and psychiatric problems.
Medical History:
History and Present Illness: The results of the clinical assessment shows that the patient’s temperature is 98.8o F, which is within the normal temperature range. The patient’s respiratory rate is normal, and he seems to be having hypertension given his 110/62 blood pressure. He is concerned about rejection, and this is his main stressor. His symptoms began appearing one and half months ago when he learned that he was being enlisted.
History and Current Use of Substance: The patient denies using any behavior-altering substance.
Medication Trials and Current Medications: David’s family does not currently use any substance.
Psychotherapy or psychiatric Diagnosis for the family: David’s family has no history of psychiatric problems.
Allergies: The patient does not have any history of allergy.
ROS:
- GENERAL: The patient denies fatigue, fever, and nausea. The patient positive for weight History and Current Use of Substance: The patient denies using any behavior-altering substance.
- Medication Trials and Current Medications: David’s family does not currently use any substance.
- Psychotherapy or psychiatric Diagnosis for the family: David’s family has no history of psychiatric problems.
- Allergies: The patient does not have any history of allergy.
Objective:
Physical exam
General: David shows sign of fear and is moody when being interviewed. He speaks coherently and clearly, and he can be head clearly. He seems to respond to the interview questions in an appropriate manner.
Vital Signs: The patient’s temperature is 98.8 and weighs 133 lbs. His height is 5”7. He does not have enough sleep considering that he sleeps for 6.5 hours. His appetite is good, and he has a 110/62 of blood pressure. This shows that his blood pressure is above the normal level.
Diagnostic results:
The results for the psychological assessments, based on the Kessler Psychological Distress Test, are pending.
Assessment:
The patient seems to orient to time and the place, and he cooperates with the person who is conducting the interview. He looks worried about rejection, and he shows sign of fear. He reasons logically, and he is coherent in the way he answers questions (MedEasy, 2017).
Differential Diagnoses:
Primary diagnosis:
David has depression, and this is the primary diagnosis for the patient. For one to have this disorder, one has to feel worthless, guilt and develop self-hate. A person with this disorder also experiences restlessness, and depressive mood. This mood seems to occur because he is fearful of rejection if his discloses to his friend the information about his sexuality.
These symptoms match the signs of depression described under the DSM-V assessment tool. He feels that he is responsible for his plight because he has failed to be real (American Psychiatric Association, 2013). He also feels guilty because he has not been able to disclose to his unit that he has queer sexual preferences.
Secondary Diagnosis
- Social Phobia. This condition is characterized by an individual’s fear to socialize because of the way they perceive how others might feel about them.
- The other potential secondary disorder for the patient is anxiety disorder. This is because he feels uneasy, and he does not get enough sleep.
- The third secondary diagnosis for David is stress because his has more than normal blood pressure. The diagnosis for David, therefore include social phobia, anxiety disorder and stress (Sadock, Sadock, & Ruiz, 2015).
Reflections:
Reflecting on the patient’s symptoms and analyzing the manifestations based on the DSM-V framework, it is apparent that the main condition that David seems to suffer from is depression. This is because depression is associated with symptoms such as the lack of sleep, restlessness and fear. I would make changes in the way I conduct the assessment if I were to work with the patient again.
For instance, I would ask the patient to talk more about his strengths. Knowing the patient’s strengths is important because it can help develop an intervention that can help optimize the patient therapy outcomes (Classroom Productions, 2015). This implies that the strengths can be utilized to meet David’s psychological and emotional needs.
In conclusion, the use of the tool such as the DSM-V can help diagnose a patient’s illness because the tool can match the patient’s symptoms with those linked to the various DSM disorders. When assessing a patient for psychiatric issues, a psychiatrist may look at patient-based factors, and the family health background.
This information is pertinent to the diagnosis process because it helps identify the patient’s behaviors and how the patient responds to the events in their life. Looking at David’s symptoms from the perspective of the tool, shows a possible depression. It also shows that the patient may be suffering from anxiety disorder.
References
American Psychiatric Association. (2013). Trauma- and stressor-related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm07
American Psychiatric Association. (2013a). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm05
American Psychiatric Association. (2013b). Obsessive compulsive and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm06
Classroom Productions. (Producer). (2015). Trauma, PTSD, and Trauma-Informed Care [Video]. Walden University.
MedEasy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & COMLEX [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY
Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
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ANSWERED QUESTIONS
[ANSWERED] NURS 6053 Week 9 Assignment – Workplace Environment