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Anxiety disorder, OCD, or something else?

Walden University

Psychiatric Mental Health Nurse Practitioner Role 1: Child and Adolescent

NURS 6660



Anxiety disorder, OCD, or something else?

Case # 2

Decision # 1 Differential Diagnosis

Obsessive–compulsive disorder (OCD)

Reason for the Selection

Obsessive-compulsive disorder is a prototypical impulsive, compulsive disorder. The patient experiences an unusual urge to do stereotypic, formal acts despite having full knowledge of how silly and unnecessary these behaviors are and having no genuine desire for the result of these activities. The most widely recognized kinds of compulsions are cleaning and checking (Stahl, 2014). Stress and anxiety may increase the formation of habits, regardless of whether decidedly or contrarily persuaded. In any case, as the patterns turn out to be dynamically impulsive, the experience of alleviation may never again be the driving force, and somewhat the conduct goes under external control as a conditioned reaction.

Obsessive thoughts may incorporate constant feelings of fears of damage beginning to act normally again or a friend or family member, an irrational worry with being contaminated, intrusive and unsatisfactory religious, savage, or sexual considerations, and ridiculously need to do things accurately or correctly. Tyrel case above gave the indications of the Obsessive-impulsive confusion (OCD).

Expected Result with this Decision

The predicted result indicated that he has OCD. Tyrel is alert and oriented, nervous, irritable at times, trouble staying asleep, obsess with continuous handwashing. He denies suicidal ideation. He denies visual or auditory hallucinations. There are no clear overt delusional or paranoid thought processes. Mother reported that Tyrel has been anxious, nervous, irritable at times, trouble staying asleep, obsess with continuous handwashing for about two months. He has difficulty getting to school and nervous around his classmates. Tyler missed school for eight days over the last three weeks. He was no longer playing with his best friend living across the street. He was impulsive with the monotonous behavior of cleaning and washing (Laureate Education, 2017c).Difference between Expected Result and the Achieved Result with Decision #1There was not a contrast between the expected outcome and the achieved outcome as Tyrel has symptoms which indicative of OCD.Decision #2:Treatment Plan for PsychotherapyFluvoxamine immediate release 25mg orally dailyReason for the SelectionFood and Drug Administration authorize fluvoxamine for the treatment of OCD in children eight years and older (Stahl 2014). Fluvoxamine immediate release 25mg orally daily is the medication of choice. Fluvoxamine influences synthetic compounds in the brain that might be uneven in individuals with obsessive-compulsive symptoms. Selective serotonin reuptake inhibitors affect neurotransmitters, chemicals that nerves in the brain use to communicate with each other. Neurotransmitters are released by nerves which travel across the spaces between nerves and then attach to receptors on other nerves.Patient and family will be educated about the side effects of fluvoxamine which are drowsiness and fatigue, headache, sleeping problems, decreased libido, decreased sexual functioning, gastrointestinal problems, dizziness, nervousness, sweating and tremors. These side effects typically get better after taking the medication for a while (Ordacgi, Mendlowicz, & Fontenelle, 2017).Cognitive Behavior Therapy (CBT) has proven to be useful in the treatment of OCD. CBT is created on the impression that distorted thoughts or cognitions cause and preserves harmful compulsions and obsessions (Foa, 2017). Exposure and response prevention (ERP) is an active form of behavioral therapy. ERP expose the patient to anxiety that is activated by the obsessions and after that preventing the utilization of rituals to lessen the uneasiness. This cycle of exposure and reaction prevention action is repeated to the point that the patient never again troubled by the fixations as well as impulses (Foa, 2017).The objective of treatment is complete remission of current indications and additionally aversion of future backslides. Treatment regularly decreases or even eliminates manifestations, however not a fix since signs can repeat after the medication is stopped or therapy not completed.Expected Result with this DecisionThe expectation is that Tyrel will show some sign of improvement from taking the medication when he returns in about four weeks. Fluvoxamine allows serotonin to accumulate; serotonin depletion is thought to obsessions (Ordacgi, Mendlowicz, & Fontenelle, 2017). Tyrel’s mother verbalized that he had been some reduction in his symptoms and that he seemed little relaxes and had decreased handwashing. Tyrel had been able to go out and play with his friend which he had not done for a while. Tyrel seems to be having a little bit of problem embracing school, but his attendance has improved.Difference between Expected Result and the Achieved Result with Decision #2There was no difference between the expected outcome and proficient outcome because a low dosage of fluvoxamine was recommended. The patient can result in any case advantage by increasing the medication dose. Thus, it is suitable to increase fluvoxamine dosage at sleep time since the patient is reacting great to treatment administration.Decision #3Treatment Plan for PsychopharmacologyIncrease Fluvoxamine to 50mg orally at bedtime.Reason for the SelectionIn four weeks when the patient revisited, there was a little improvement noted. He was reassessed, and the patient’s reaction to the medication was excellent with no sign of adverse side effects. It is vital to increase Fluvoxamine from 25mg to 50 mg orally at bedtime because the patient still having little problem embracing school and even handing the problem with handwashing. The dosage can be increased by 50 mg each four to seven day, until the point when the most extreme advantage is accomplished (Stahl, 2014). Fluoxetine has an elongated half-life of about 2–3 days, and its active metabolite an even elongated half-life of about two weeks. The long half-life is advantageous in that it seems to reduce the withdrawal reactions that are characteristic of sudden discontinuation of some SSRIs (Stahl 2014).Expected Result with this DecisionThe expected outcome was that Tyrel reacts appropriately to fluvoxamine 50mg at sleep time.Fluvoxamine works by preventing the uptake of serotonin from the spaces between nerve cells subsequent its release, so the increase of Fluvoxamine will make more serotonin available in the areas to attach to other nerves and stimulate them. Tyler symptom will improve by next visit making him interact in school better and reduce his handwashing.Difference between what you expected to achieve with Decision # 3There will be no difference between the expected results and the negotiated outcome. Tyler will maintain the current dose of medication because he is feeling better and no complaint of side effect. Fluvoxamine is known to have a shorter half-life of 17-22 hours after a steady dose has been established (Stahl, 2014).Ethical Considerations that might Impact Treatment PlanEthical concerns about the safety, acceptability, and humaneness of exposure therapy are essential to objections against the treatment. Beneficence and Nonmaleficence to take care to do no harm and protect the welfare and rights of the patient. The safety and tolerability of exposure therapy may be determined by evaluating the outcomes associated with this treatment. The treatment program that incorporates educating the family about OCD, its treatment, and how to adequately with the patient’s therapy would be valuable, given the high occurrence of relational issues in families of OCD patients (Altis, Elwood, & Olatunji, 2015).ReferenceAltis K.L, Elwood L.S, & Olatunji B.O. (2015) Ethical Issues and Ethical Therapy Associated with Anxiety Disorders. Curr Top Behav Neurosci; 19:265-78. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/Foa, E. B. (2017). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience12(2), 199–207.Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181959/Laureate Education (Producer). (2017c). Anxiety disorder, ODC, or something else? [Multimedia file]. Baltimore, MD: Author.Ordacgi, L., Mendlowicz, M. V., & Fontenelle, L. F. (2017). Management of obsessive-compulsive disorder with fluvoxamine extended release. Neuropsychiatric Disease and Treatment, 5, 301–308.Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699655/Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5thed.). New York, NY: Cambridge University Press.Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.

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