I NEED A RESPONSE TO THIS ASSIGNMENT

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Case 2: Volume 1, Case #14: The scatter-brained mother whose daughter has ADHD, like mother, like daughter

This is a 26-year-old female patient with a recent diagnosis of ADHD and GAD after finding out that her 8-year-old daughter had ADHD. The patient reported symptoms of missing appointments and late for appointments, disorganized behavior, feeling overwhelmed from taking care of her two children and life in general, and unable to maintain a regular schedule. The patient reported that she always had poor academic performances, intimidated by exams, always worried about the future, and says sometimes mentally “freezes when it gets to be too much.” She reports exhibiting the same symptoms as her 8-year-old daughter who also had ADHD during her childhood. The patient had a history of dropping out of high school after getting pregnant. She was married at age 17 and divorced at age 19 which led to two children ages 8 and 6. She worries a lot about the children’s future and education. The children’s father is not involved with their care children. The patient is adopted, therefore her biological parents’ past medical and mental histories are not known. The patient smokes cigarettes but denies alcohol and drug use. She has a full-time job in a retail store

3 Questions 

The mental healthcare nurse practitioner needs to ask this patient what exactly makes her worry about the future of her children. Obtaining this information would alert the mental health nurse if she has any intension of harming herself or others. The patient is worried about her children’s future. She has ADHD and GAD. Maintaining safety should always be the #1 priority of the mental health professional. Untreated ADHD can also lead to, or contribute to depressive disorder. It is estimated that 20% of patients diagnosed with ADHD also have major depressive disorder and depression (Kulacaoglu, & Kose, n.d.). The mental health nurse should ask this patient if she was abused growing up. This patient was adopted and was not brought up by her biological parents. Obtaining this information would alert the mental healthcare nurse to know the kind of upbringing that she had. Information on how long she has been experiencing these symptoms should be obtained; Untreated or under-treated adult ADHD may result in impaired occupational functioning and interpersonal and legal difficulties. ADHD in adults is associated with higher separation and divorce rates and more frequent job change (Gentile, Atiq, & Gillig, 2006).

People in the Patient’s Life

Obtaining information from the patient’s immediate family members like her adopted parents or any close relative, people she had lived with growing up, co-workers who work with her, her teachers who taught her in schools, her ex-husband including her 2 children, and close friends if any. Questions such as what kind of person she is? What kind of student was she like at school? What kind of employee is she? and how was her behavior like growing up? What kind of mother and wife is she? I believe that her immediate family members can uncover some of her personality, past physical and mental histories, and social behaviors that would assist the healthcare practitioner to properly diagnosed and provide the treatment needed. The patient’s coworkers, I believe would provide this patient’s social history, how she interacts with them at work; is she outgoing, lonely, depressed, lovely, reserved, etc. Furthermore, obtaining the patient’s medical record from her primary care physician would be beneficial to know the patient’s medical condition and mental condition when she was younger. This would alert the healthcare practitioner if manifested any symptoms of ADHD before the age of 12 years. 

Physical Exams and Diagnostic Tests

It would be beneficial for the healthcare nurse practitioner to in-addition to obtaining this patient physical assessment, mental assessment including past and present, to also obtain her accurate medication history to properly diagnose and treat her and to get a baseline of her present condition. Several disorders such as seizure disorder, encephalopathy, developmental disorder, and Lyme disease can mimic the symptoms of ADHD. Laboratory testing; thyroid levels. Studies have shown that low thyroid and high thyroid levels can cause a decrease in memory, attention, and concentration. Low cerebral blood flow in the brain region that arbitrate attention and decision-making effectively, and reduced hippocampal capacity, consequently the cognitive profile in these patients can look like and can be confused with those of ADHD patients (Gentile, Atiq, & Gillig, 2006). Urine drug screen; several illicit and anticholinergic drugs can mimic symptoms seen in ADHD. Blood sugar to rule out hypoglycemia. Genetic testing can be useful here to rule out DRD4 7 since there is a possibility that this patient might not know her family medical history and according to our reading, ADHD has a significant genetic influence especially if both parents have this disorder the child has a 75% chance of being affected by it. Studies also suggest that genetics plays a major role in ADHD approximately half of parents who have been diagnosed with ADHD themselves will have a child with this disorder. The clinician-rated Conner’s Adult ADHD Rating Scale, the ADHD Rating Scales or psychological tests to rule out brain injury will be helpful for proper diagnosis and sleep disorders can produce chronic tiredness that affects attention, concentration, and cognitive functioning. Studies have shown that sleep deprivation is associated with attention difficulties due to changes in the brain that would also be beneficial to make an accurate diagnosis of ADHD (Gentile, Atiq, & Gillig, 2006).

3 Differential Diagnoses

Borderline personality disorder (BPD)is a serious mental illness that usually begins in the 20s. More women have it than men. There’s no known cause, but it’s believed to be a combination of the brain mechanism and the experience in life. Some of the characteristics include emotion dysregulation, impulsivity, and unsta­ble relationship. These symptoms often result in impulsive actions and problems in relationships with other people. The individual may experience episodes of anger, depression, and anxiety that may last from a few hours to days. Studies believed that People who have a close family member with the disorder may be at a higher risk of developing borderline personality disorder or borderline personality disorder traits Studies also show that people with this disorder can have structural and functional changes in the brain especially in the areas that control impulses and emotional regulation. Furthermore, many people with borderline personality disorder report experiencing traumatic life events, such as abuse, abandonment, or adversity during childhood. Others may have been exposed to unstable, invalidating relationships, and hostile conflicts. Because borderline personality disorder often occurs with other mental illnesses, it makes difficult to diagnose and treat especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder. The comorbidity of ADHD has been reported in 20% of BPD patients in several studies since impulsivity is a central feature of BPD and ADHD, impulsivity has been examined as part of adult ADHD symptomatology in BPD patients. According to Philipsen et al., ADHD should be considered as a potential risk factor in patients with BPD with impulsivity. A recent study on the association between impulsivity and ADHD in BPD patients, it was reported that higher comorbidity of ADHD in the BPD group, and motor impulsiveness has been shown as a potential predictor of ADHD symptoms in BPD group. In terms of the relationship between BPD, ADHD, and impulsivity, BPD-ADHD has been considered a severe, more impulsive, and homogeneous subtype of BPD (Kulacaoglu, & Kose, n.d.). This patient exhibited most if not all the symptoms here, making the #1 differential diagnosis on my list. 

Chronic stress disorder, also known as complex post-traumatic stress disorder (C-OTSD) is a serious psychological condition that often stems from being a witness to a, particularly traumatic incident. As a result of that traumatic incident, chronic stress disorder sufferers lose control, power, and then begin to feel trapped. Although chronic stress disorder is very like posttraumatic stress disorder (PTSD), it is not one the same. PTSD, according to many researchers, does not encompass all the symptoms that a case of chronic stress disorder typically carries within itself. Even though numerous mainstream journals and authors have written about chronic stress disorder, it is not recognized formally in more prominent diagnostics systems. This disorder can manifest itself from the following symptoms difficulties regulating emotions, forgetting traumatic events, reliving traumatic events, or having episodes of dissociation, anxiety or worry, feeling of inability to deal with problems, difficulty performing completing daily activities, and the feeling of inability to plan ahead of time. It has been estimated that between 5-20% of the population that has been assisted by psychological problems suffer an adaptation disorder. Stress can facilitate the onset of psychoactive substance use (Matheson, & Weightman, 2019). This patient is a single mother of 2 children, was adopted, always worried about the future of her 2 children. All these symptoms placed her on the #2 list of my differential diagnoses.

Bipolar Disorder (BD)is a persistent kind of change in mood between thoughts of deep mania and severe depression. This disorder can cause one not to have unhappiness and interrupt the individual’s ability to function normally. It has been reported to be frequently comorbid with ADHD approximating 6% and 15% of female and male sufferers respectively, and rates higher than 20% have even been reported in some studies. Several studies have shown that BD is found in approximately 20% of individuals suffering from ADHD and could even reach as much as 50% of ADHD cases if bipolar symptoms are considered. Symptoms, such as mood lability, distractibility or increased activity, some doubt has been cast on the usefulness of self-report questionnaires for the detection of ADHD in BD subjects (Perroud, Cordera, Zimmermann, Michalopoulos, Bancila, Prada, Dayer, & Aubry, 2014). Bipolar disorder may occur due to genetics, stress or trauma, chemical imbalances in the brain, or even hormonal imbalances. Heredity is the main cause. About 60 to 80% of cases are hereditary related. To obtain an accurate diagnosis, a mental health nurse practitioner must consider the client’s family history of mental illness as well as a family history of suicide (Otto, 2011). The fact that this patient manifested some of these symptoms makes the #3 list on the differential diagnosis. 

Two Pharmacologic Agents

Ritalin(Methylphenidate) (MPH) alleviates symptoms of ADHD and, as such, is currently considered as a first-choice medication. It works by blocking dopamine and norepinephrine transporters leading to an increase in extracellular dopamine. It should be noted that its subjective effects are highly dependent on the pharmacokinetic and especially on the rate of input, which highlights the importance of choosing a sustained release formulation (Castells, Antoni Ramos-Quiroga, Rigau, Bosch, Nogueira, Vidal, & Casas, 2011). Two separate studies done on 474 individuals suffering from ADHD showed that improvement in core clinical ADHD symptoms of hyperactivity, impulsivity, and inattentiveness, and overall other psychiatric symptoms like anxiety and depression were alleviated with methylphenidate when compared to those of the placebo group. Also, trial data suggest that adverse effects of immediate-release methylphenidate for adults with ADHD are not of serious clinical significance (Epstein, Patsopoulos, & Weiser, 2014). The usual dose for an adult patient with ADHD is 20 to 30 mg PO daily and 10 to 30 mg transdermally per 9 hours and it be can be titrated upward to a maximum of 40 to 60 mg PO daily. For this 26-year-old patient with a new diagnosis of ADHD, I would start her treatment with 10 mg PO twice a day that is (10 mg in am and 10 mg PO at lunchtime) and then titrate it weekly as tolerated (Stahl, 2008).

Adderall(Amphetamine) is a dopamine norepinephrine reuptake inhibitor and releaser (DN-RIRe). A stimulant approved by the FDA for the treatment of ADHD, Narcolepsy, and obesity. The XR version of it used in the treatment of the adult with ADHD. The Adderall XR capsule contains two types of drug-containing beads designed to give a double-pulsed delivery of amphetamines, which prolongs the release of amphetamine from Adderall XR compared to the immediate-release tablet formulation. The most common side effects in patients using these medications are loss of appetite, insomnia, nausea, dizziness, heart palpitations, headache, changes in blood pressure or pulse, and rash. Amphetamines have a high potential for abuse. Abuse of Adderall/Adderall XR may lead to tolerance and dependence. If the drug is withdrawn suddenly after prolonged high-dosage administration, extreme fatigue or depression may occur. The usual dosage treatment for adult initial 10 mg per day in the morning; can increase by 5–10 mg per day at weekly intervals to maximum dose generally 30 mg per day (Stahl, 2008). A multicenter double-blind trial of 248 adult patients with ADHD demonstrated significant control of ADHD symptoms as early as week 1 after the initiation of treatment and maintained this significant improvement throughout the four-week study. At the end of the trial, the average ADHD-RS Total Scores for patients taking Adderall XR were 49% lower compared with the average scores at the beginning of the trial before receiving the medication. Another data demonstrated significant symptom improvement was maintained over 18 months (FDA, 2004). For this patient who is new to this medication, I would start her therapy with 5 mg PO BID (5 mg in am and 5 mg in the evening) and then gradually increase the dose every week as tolerated.

The Rationale

Both Ritalin and Adderall share similarities in their treatment, action, side effects, and cost prize but according to Edmunds & Mayhew 2014, Adderall is an intermediate-acting amphetamine/dextroamphetamine compound with Adderall XR being long-acting Ritalin is short-acting methylphenidate with Ritalin SR being intermediate-acting and Ritalin LA being long-acting (Moore, 2014). Meaning Ritalin works sooner and reaches peak performance more quickly than Adderall does. However, Adderall stays active in the body longer than Ritalin does. Adderall works for four to six hours. Ritalin is only active for two to three hours. This is a hard selection to make on these two drugs, but I would choose Adderall for this patient at this time over Ritalin because, this patient is very occupied with so many things; a full-time job, single mother of 2, with 1 of them diagnosed with ADHD, and her issue with ADHD, I believe that prescribing her with medication such as Adderall that stays active in the body for a long period would help her in managing the activities and be able to engage in social life.

Lessons Learned

Adderall is a stimulant so do Ritalin. They are the most widely prescribed drug for ADHD and is classified as a Schedule II substance by the United States Drug Enforcement Administration because of its potential for psychological and physical dependency and abuse. They both work Like how cocaine works and some other illicit drugs. Prescribing them to someone who has not been determined to need this drug due to a true neurobiological disorder can be considered the Nonmedical use of prescription drugs (NMUPD). Their most common side effects are anorexia, weight loss, nausea, abdominal pain, diarrhea or constipation, and xerostomia. Side effects are typically worse during initial days of treatment. They are considered as “Black Box” warnings for high abuse potential, drug dependence, and increased risk of serious cardiovascular adverse events and sudden death. The medical indications for both Adderall and Ritalin, in-addition, to ADD and ADHD, include narcolepsy and short-term weight loss. Management of these conditions with pharmacological treatment should be under the supervision of a healthcare provider (Moore, 2014).

References

Castells, X., Antoni Ramos-Quiroga, J., Rigau, D., Bosch, R., Nogueira, M., Vidal, X., & Casas, M. (2011). Efficacy of Methylphenidate for Adults with Attention-Deficit Hyperactivity Disorder A Meta-Regression Analysis. CNS DRUGS, 25(2),

157–169.

Epstein, T., Patsopoulos, N. A., & Weiser, M. (2014). Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database of Systematic Reviews, 9, CD005041. https://doi org.ezp.waldenulibrary.org/10.1002/14651858.CD005041.pub2

FDA approves ADDERALL XR to treat ADHD in adults. (2004). Medical Letter on the CDC & FDA.

Gentile, J. P., Atiq, R., & Gillig, P. M. (2006). Adult ADHD: Diagnosis, Differential Diagnosis, and Medication Management. Psychiatry (Edgmont (Pa. : Township)), 3(8), 25–30.

Kulacaoglu, F., & Kose, S. (n.d.). Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe. BRAIN SCIENCES, 8(11). https://doi-org.ezp.waldenulibrary.org/10.3390/brainsci8110201

Matheson, C., & Weightman, E. (2019). Research and recovery: Can patient participation in research promote recovery for people with complex post-traumatic stress disorder, CPTSD? Health Expectations : An International Journal of

Public Participation in Health Care and Health Policy. https://doi-org.ezp.waldenulibrary.org/10.1111/hex.13014

Moore, S. C. (2014). Adderall and Ritalin: potential influence on perinatal health. International Journal of Childbirth Education, 4, 72.

Otto, M. W. (2011). Living with bipolar disorder. [electronic resource]: a guide for individuals and families (Updated ed.). Oxford University Press.

Perroud, N., Cordera, P., Zimmermann, J., Michalopoulos, G., Bancila, V., Prada, P., Dayer, A., & Aubry, J.-M. (2014). Comorbidity between attention deficit hyperactivity disorder (ADHD) and bipolar disorder in a specialized mood disorders outpatient clinic. Journal of Affective Disorders, 168, 161–166. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jad.2014.06.053