Identifying Information
A.S. is an 18-year-old African American male, who has arrived for a psychiatric examination at a local healthcare facility.
Subjective Data
- Core Complaint: “I feel an excessive urge to eat, I’ve gained about 20 lbs, and whenever I’m not eating, I want to sleep. I feel annoyed and upset the moment I wake up, and I want to immediately go back to sleep.”
History of Present Illness
The patient mentioned that she was diagnosed with general anxiety disorder at the age of 8 due to parents’ divorce and the related family issues. A.S. also reported developing a PTSD due to an instance of sexual assault occurring to him when he was 12. Currently, A.S. used to struggle with studying to enroll into college, yet he is currently at the verge of dropping out of high school, which exacerbates his feeling of fatigue. The patient mentions that his fear of failing gradually transformed into indifference, yet he is still resorting to comfort food, thus, gaining weight increasingly.
ROS
The ROS returned results indicating that the patient has been experiencing gastrointestinal issues, particularly, difficulty digesting food, as well as increases in blood pressure. The observed phenomenon can be attributed to the weight gain observed in the patient and the resulting changes in the performance of the cardiovascular system (Goldberg et al., 2019). Furthermore, according to the patient, the recent sleep patterns have been quite troubling, with the sleep time having increased exponentially.
Past Psychiatric History
The patient mentioned that he developed PTSD as a child after being sexually assaulted by a stranger. According to the patient, the PTSD issue was addressed with the help of trauma-focused CBT.
Previous Psychiatric Medications
After having been diagnosed with PTSD, A.S. was prescribed Fluoxetine (20 mg per day) at the age of 12. Fluoxetine is an SSRI that allows reducing the experiences of anxiety and distress in patient5s aged 8 and older (Muraro et al., 2019). According to A.S., after several months of therapy and Fluoxetine consumption, he experienced improvements.
Current Medications
Methylphenidate (Ritalin) 30 mg 3 times per day to reduce drowsiness.
Substance Use/Addictive Behaviors
- Drug misuse: the patient admits to having experimented with different drugs, marijuana being the most commonly used one. The patient claims that he is resistant to developing dependency on marijuana and asserts that it allows him to feel less depressed and fatigued. The delta-9-tetrahydrocannabinol (THC) component in marijuana is the component that crates the feeling o elation, while leaving little residual effect, causing one to believe that it does not cause dependency (De Gregorio et al., 2019). However, the specified assertion is quite far from the truth, according to recent studies (De Gregorio et al., 2019).
Family’s Psychiatric History
- Father: demonstrating frequent substance and alcohol misuse.
- Mother: suffers from severe anxiety and panic attacks.
- Grandparents: the paternal grandparents are deceased; the maternal ones have estranged the patient’s family, leaving little information about themselves.
- Siblings (older brother): no history of mental health issues.
Medical History
Cognitive behavioral therapy (CBT) was used to address the patient’s trauma and the resulting PSD due to child abuse received at the age of 12. Furthermore, Fluoxetine (20 mg) was administered to the patient orally two times per day in the course of several months to help him counteract the anxiety developed after the abuse. Furthermore, the patient developed asthma at the age of 4 and was treated with albuterol (Ventolin HFA) (2.5 mg 3 times per day via the nebulizer) and levalbuterol (Xopenex HFA) (0.61 mg 3 time per day in a nebulizer). Currently, the patient still resorts to levalbuterol (1.25 mg per day) to control his asthma.
Surgical
A.S. had his tonsils removed at the age of 8 and underwent a surgery for correcting a poorly healed bone fracture at the age of 13.
Allergies
The patient is highly allergic to pollen and other substances of the kind.
Psychosocial
A.S. is an 18-year-old African American male born in a medium-income, middle-class family in Cincinnati, OH. The patient has an older brother, whom he has been viewing as a role model despite the presence of certain destructive behaviors in the latter. Specifically, the patient admits that, similarly to his father, his older brother would resort to substance misuse, particularly, overconsumption of alcohol.
At the age of 12, A.S. was sexually assaulted by a strange man. Afterward, he developed a range of phobias and a strong sense of anxiety, as well as early signs of depression. Due to the overwhelming sense of shame caused by the stigma associated with sexual assault in men, the child refused to disclose it until he began to develop obvious signs of distress and mental health issues. After his mother had taken him to the therapist, A.S. underwent a CBT that lasted several month and was prescribed corresponding medication.
The patient admits to fail to get rid of his anxiety completely. After the patient experienced a series of failures in his academic endeavors and has faced the threat of failing to be accepted into college, he experienced a relapse and started observing exacerbated symptoms. Furthermore, the condition has been aggravating to the point where his fatigue and drowsiness became a significant obstacle to maintaining the required quality of life.
Asset
The patient has several supportive friends; moreover, his mother has been offering him emotional support despite her panic attacks.
Stressors
The key stressors include the increasing range of responsibilities and challenges that A.S. has been feeling unable to manage.
Mental Status Examination
The patient has been showing a significant amount of fatigue and sluggishness I his behavior. However, his orientation in time and space appears to be moderately good. However, the patient is not dressed properly and seems to have abandoned some of personal hygiene routine, which is indicative of developing depression. A. S.’s hands do not shake or tremble; his voice is mostly monotone and is indicative of his low engagement in the conversation. The patient does not seem to have any other psychomotor issues; however, his affect is mostly depressive, which is also a sign of a developing mental health concern. A. S.’s mood can be described as depressed; additionally, the patient has confessed to having experienced suicidal ideation at some point. The patient denies any instances of homicidal ideation; however, A.S. mentions that he has experienced audial and visual hallucinations after consuming substance of unknown nature at a party. The patient denies any presence of compulsions, obsessions, or delusions. The patient demonstrates marginally passable orientation (AOx3), poor concentration skills, and deteriorating long-term memory. The patient’s abstract reasoning, insight, and judgment are fair.
Physical Examination
BP 125/85, P 70/min, RR 18/min, T 97.7 F. Height 5’7, Weight 178.7 Lbs, SPO2 100%.
Differential Diagnoses
- Major depressive disorder (MDD) (F32)
- Posttraumatic stress disorder (F43.1)
- Dysthymic disorder (300.4 (F34. 1))
Diagnostic Impression (Including Formulation)
The phenomenon of the MDD is known as a severe form of depression, as the DSM-V classifies it (American Psychiatric Association, 2014). It is defined as the mood disorder characterized by the consistent feeling of sadness and hopelessness, with the subsequent loss of enthusiasm for and interest in any activities, particularly, those that used by bring joy and excitement prior to the development of the disorder (American Psychiatric Association, 2014). Often conflated with the social anxiety disorder category, the specified condition manifests itself as the feeling of worthlessness, particularly, being “concerned about being negatively evaluated by others because they feel they are bad or not worthy of being liked” (American Psychiatric Association, 2014, p. 207). Furthermore, the condition is known for the feelings of “apathy, loss of energy, low self-esteem, and anhedonia” (American Psychiatric Association, 2014, p. 221). Therefore, the specified condition requires the introduction of a combined approach of medication and CBT.
The current condition of the patient may also be considered a case of posttraumatic stress disorder (PTSD) recidivism. Specifically, according to the DSM-5, PTSD is a condition that evokes consistent feelings o anxiety in a patient due to the exposure to the factors that are linked to the past trauma and the related experiences (American Psychiatric Association, 2014). Furthermore, PTSD is reported to occur only in the situations that are reminiscent of the event that the patient experienced as traumatic. Since the current environment in which the patient finds himself does not contain any factors that could have potentially reminded him of the trauma that he received in his childhood, PTSD does not appear to be plausible enough in the described scenario.
The dysthymic disorder can also be considered one of the main factors behind the patient’s current mental health issue. Specifically, dysthymia, or persistent depressive disorder, is associated with consistently depressed mood, social withdrawal, and feeling of shame or humiliation combined with the strong propensity toward self-criticism. Though some of the signs and symptoms in the patient’s behavior that are currently observed are congruent with the definition of the dysthymic disorder, particularly, the depressed mood and social withdrawal, the specified case still cannot be classified as such due to the duration of the observed symptoms. Specifically, it is believed that the dysthymic disorder takes place for at least two years, which evidently is not the case (American Psychiatric Association, 2014). Furthermore, the symptoms associated with dysthymia are fewer, whereas the ones observed in the patient align with MDD nearly completely (Ventriglio et al., 2020). Therefore, the observed health issue should be classified as MDD.
Risk Assessment
The PHQ-9 test has been used to diagnose MD in the patient. According to the results of the test, A.S.’s score was 18, which represents a case of moderately severe depression (Ardestani et al., 2019). Therefore, immediate treatment must be administered to the patient as a member of a high-risk demographic.
Recommendations and Plan for Treatment with Rationale
Since the patient is currently experiencing an acute case of MDD, it is strongly recommended that the treatment process must start immediately. Specifically, the pharmacological management of the disorder must commence with the introduction of fluoxetine (Prozac) into the patient’s care routine. Being a common selective serotonin reuptake inhibitor (SSRI), fluoxetine (Prozac) allows improving one’s mood and reduce negative emotional experiences.
At the same time, one must keep in mind that fluoxetine (Prozac) is likely to increase the extent of the patient’s appetite. Indeed, due to the presence of Leptine, the hormone that regulates one’s feeling of hunger, an increase in appetite and, therefore, the amount of consumed food, is to be expected (Poter, 2019). Therefore, it is strongly recommended that dietary considerations should be included into the treatment process, with the introduction of healthy eating options. Additionally, the therapist will have to provide A.S. with a means of reducing stress and the feeling of anxiety so that the patient should not resort to comfort food as the way of handling his emotions. Thus, the medication ends to be administered particularly carefully, with a clos focus on the changes in the patient’s mood and behaviors. Thus, progress can be made with the help of the treatment.
Furthermore, to assist the patient in overcoming symptoms of MDD and introduce healthy mechanisms for managing negative emotions, CBT must be incorporated into the treatment process. Specifically, the therapist will need to work with A.S. in order to help him develop a framework for adjusting to a crisis and finding the emotional and psychological resources to manage the current obstacles. For instance, in the case at hand, CBT must be geared toward helping the patient overcome the feeling of guilt caused by his failure to cope with the increasing amount of responsibilities and the resulting emotional pressure. Specifically, face-to-face office sessions should be utilized as the main format for addressing the observe symptoms and encouraging a shift in the patient’s perception of the situation and his ability to influence it.
References
American Psychiatric Association. (2014). The diagnostic and statistical manual of mental disorders (5th ed.). APA.
Ardestani, M. S., Ashtiani, R. D., Rezaei, Z., Vasegh, S., & Gudarzi, S. S. (2019). Validation of Persian version of PHQ-9 for diagnosis of major depressive episode in psychiatric wards in IRAN. International Journal of Applied Behavioral Sciences, 5(2), 1-8.
De Gregorio, D., Dean Conway, J., Canul, M. L., Posa, L., Bambico, F. R., & Gobbi, G. (2020). Effects of chronic exposure to low-dose delta-9-tetrahydrocannabinol in adolescence and adulthood on serotonin/norepinephrine neurotransmission and emotional behavior. International Journal of Neuropsychopharmacology, 23(11), 751-761. Web.
Goldberg, X., Serra-Blasco, M., Vicent-Gil, M., Aguilar, E., Ros, L., Arias, B., Courtet, P., Palao, D., & Cardoner, N. (2019). Childhood maltreatment and risk for suicide attempts in major depression: a sex-specific approach. European journal of psychotraumatology, 10(1), 1-13. Web.
Muraro, C., Dalla Tiezza, M., Pavan, C., Ribaudo, G., Zagotto, G., & Orian, L. (2019). Major depressive disorder and oxidative stress: in silico investigation of fluoxetine activity against ROS. Applied Sciences, 9(17), 1-15. Web.
Potter, D. R. (2019). Major depression disorder in adults: A review of antidepressants. International Journal of Caring Sciences, 12, 107.
Ventriglio, A., Bhugra, D., Sampogna, G., Luciano, M., De Berardis, D., Sani, G., & Fiorillo, A. (2020). From dysthymia to treatment-resistant depression: evolution of a psychopathological construct. International Review of Psychiatry, 32(5-6), 471-476. Web.