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Volume 2, Case #11: The figment of a man who looked upon the lady

 The client is a 42-year-old woman with a chief complaint of depression and interpersonal stress. She has a past psychiatric history of PTSD related to abuse in her childhood that led to a dependency on alcohol and drugs to cope. She has been 10 years sober and attends AA and Narcotics Anonymous meetings regularly which have helped with good results. The client reports occasional PTSD with nightmares, flashbacks and panic attacks. The questions I would ask her during this visit include:

1. When was the last time you had PTSD symptoms of nightmares, flashbacks and panic attacks? What is triggers these symptoms? The rationale behind this question is trying to establish a baseline and know the triggers that may result in flashbacks and panic attacks.
2. What happens when you experience these PTSD flashbacks and what coping mechanisms do you use at that time? Do you have any family support system? Have these coping mechanisms helped? Rationale: it is important to establish what type of behaviors the client exhibits during these times, and also if her coping mechanisms are truly assisting her to cope positively or negatively. Asking about her support system will inform me about what her support systems are outside of attending her regular AA and NA meetings or therapy appointments. It is also good to know if she has a good support system which could be family and friends can be present during her therapies or appointments as they may be able to help with de-escalating her thoughts and calming her down when she experiences these symptoms. Another peer support is defined as the process of giving and receiving nonprofessional help and assistance from people with similar conditions or circumstances to yours is listed as beneficial to the client’s success in treatment (Tracy & Wallace, 2016). 
3. Do you have suicidal or homicidal ideations, auditory or visual hallucinations now or when you are experiencing these PTSD symptoms? Traumatic events such as childhood sexual abuse increase a person’s suicide or homicidal risk (Stahl, 2014). Do the thoughts that you might have nightmares prevent you from going to sleep? How many hours do you sleep at night? What is causing your present stress? Rationale: Ensuring that the patient and others around the patient are safe is a priority, and also knowing if the client is seeing images or hearing voices. Lack of adequate sleep can cause stress that may trigger the other symptoms that the client experiences. If the client is going through any type of stress which may be personal life or work life related, this may also trigger the symptoms she is having. Also, knowing if the client has taken any sleep aid in the past will determine if she can be put on sleep aid medication treatment and monitored. The client had initially stated that she has insomnia, however later in the case study, she talks about “little man” that watches her when she is trying to sleep this could be classified as visual hallucinations that may be related to insomnia. Identifying the specific sleep issues the patient is suffering from dictates the interventions that can be most useful. 

Identify specific people in the patient’s life you would like to speak with and why

           Firstly, I would obtain consent from the client to speak to her specific people in her life. Although she was able to list some of her family members’ medical and psychiatric history, I would like to speak to her parents, siblings, PCP, close friends and work colleagues. I would like to obtain information from her siblings and parents about the child abuse trauma that the client went through, what care did she receive to manage and cope? Did she receive any form of therapy? What behaviors did she exhibit before and after the trauma? What triggers have they observed that has brought about the PTSD symptoms. The data collected from the patient, family members, PCP, psychiatrist, and friends will be helpful to form a baseline to build on. I would suggest these treatments: Prolonged Exposure (PE) therapy, and Cognitive Processing Therapy (CPT) which are trauma-focused treatments that directly address memories of the traumatic event, as well as thoughts or feelings related to the traumatic event (Watkins, Sprang, & Rothbaum, 2018). Based on the information provided by the PCP and psychiatrist, it will help to collaborate well with the Psychiatrist and PCP about the client’s plan of care, to treat current medical comorbidities, and identify any medical issues that may be contributing to the patient’s psychiatric symptoms (Lakdawala, 2015).

Physical Examination and Diagnostic Testing

            CYP4502D6 genetic testing helps to identify whether a patient is a Poor Metabolizer (PM), Intermediate Metabolizer (IM), or Ultrarapid Metabolizer (UM) of medications (Samer, Lorenzini, Rollason, Daali, & Desmeules, 2013).  The group of isoenzymes in the liver called CYP450 cytochromes are responsible for the oxidative metabolism of about 25% of commonly prescribed drugs that include antidepressants, antipsychotics, opioids, antiarrhythmics, and tamoxifen (Samer et al., 2013).  The client was prescribed Paroxetine and Bupropion simultaneously which could cause an increased risk of seizures. It is important to ask if she has a history of seizures or eating disorders, as bupropion products may induce seizures in these patients? (Stahl, 2020). A complete physical examination, blood work like CBC, BMP, TSH, T3, T4, Hgb A1C, Liver function tests and EKG will be ordered to get baseline numbers or values. I would refer the patient for a sleep study to identify pertinent sleep issues such as obstructive sleep apnea and pattern of awakening as this will also give information about the patient’s sleep pattern. From the blood work, the renal or hepatic function will be used to titrate the doses of the medication (Stahl, 2014). She has a history of diabetes so, Hgb A1C will give results of how the patient’s blood sugar has been in the last 120 days as if the client is to be given antipsychotic medication; her blood sugar would need to be monitored closely. Antipsychotic medications have been shown to cause both diabetes and hyperglycemic emergencies (Chen et al, 2017). At least every three months, she would need new fasting blood glucose and possibly even a new A1C to monitor her diabetes control. 

Differential Diagnoses

1.  Post-Traumatic Stress Disorder: is considered trauma and stressor-related disorder, it can occur after someone experiences or witnesses a serious traumatic event such as child abuse in this case study, war combat, natural disaster, murder. Some symptoms can be mild to severe and affect nearly every area of a person’s life. Due to this client’s report of the past history of child abuse, this indicates the experience of traumatic events, with multiple intrusive symptoms including recurrent involuntary memories; recurrent distressing dreams (nightmares), and flashbacks which are indicative of PTSD (American Psychiatric Association, 2013). Criteria D in DSM-5 relates to this report – the patient reports feeling she must “be aware of her environment” because people may mean her harm (paranoia) and reports sporadic participation in college classes (American Psychiatric Association, 2013).  The client also reported that in the past, she engaged in angry outbursts which led to legal issues, and also suffers from sleep disturbances thus fulfilling Criteria E; and symptoms from criteria B, C, D, and E have persisted for more than a month (American Psychiatric Association, 2013).  The patient reports financial difficulties, and is single, never married, without children, and has a history of alcohol and drug abuse, which fulfill criteria G and H respectively as this affects the patient’s life (American Psychiatric Association, 2013).  

2. Major Depressive Disorder:  May or may not be preceded by a traumatic event and should be diagnosed if other PTSD symptoms are absent (specifically criteria B or C symptoms (American Psychiatric Association, 2013). 

3.         Insomnia: The DSM-5 criteria for insomnia includes: 

• A predominant complaint of dissatisfaction with sleep quality or quality, association with one or more of the following symptoms:
• Difficulty initiating sleep, difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakening, finally, early-morning awakening with the inability or difficulty going back to return to sleep
• Sleep difficulty is present for at least 3 months and at least 3 nights per week.
• The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. 
• The insomnia is not better explained by and does not occur exclusively during another sleep-wake disorder
• Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia 
• The insomnia is not attributable to the physiological effects of a substance (SAMHSA, 2016).

List 2 Pharmacological agents and dosing appropriate for the patient’s sleep-wake therapy

Short- or intermediate-acting benzodiazepine receptor agonists (BzRAs) or the melatonin agonist Ramelteon can be prescribed for insomnia (Zammit, 2007). The most common ramelteon-related adverse events include dizziness, nausea, and fatigue. Unlike zolpidem and eszopiclone, ramelteon does not affect patients’ balance, thereby reducing the risk of falls. Also, the drug is not associated with cognitive or psychomotor effects. Typical dosing for Ramelton is 8mg with no titration required (Stahl’s Prescribers Guides, 2020). Another option is using sedating antidepressants (e.g., trazodone, amitriptyline, doxepin, or mirtazapine). Trazodone has a drowsy effect on the client but needs to be taken about an hour before the desired time to sleep, it’s not an instant sleep aid. An appropriate dose for her would be about 100mg. The lowest dose is 50mg, however, considering her size; she could tolerate the next larger dose (Stahl’s Prescribers Guides, 2020).

Check Points

There are no checkpoints in this case study

Lessons Learned

            Understanding how the various medications work allowed the prescriber to utilize SSRI and NDRI to achieve clinical effectiveness for her comorbidities, with the added benefit of canceling out medication side effects such as weight gain (patient is already obese) and improving energy (Stahl, 2020). Finally, prescribing the Ramelton was an effective way to control the more generalized symptoms of insomnia, thus improving the patients sleep by providing an alternative when the Seroquel and its accompanying side effects were not an appropriate intervention (Watkins, Sprang, & Rothbaum, 2018.) 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental     disorders: Dsm-5. Arlington, VA.

Lakdawala, P. D. (2015). Doctor-patient relationship in psychiatry. Retrieved April 7, 2020,             from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381325/

Samer, C. F., Lorenzini, K. I., Rollason, V., Daali, Y., & Desmeules, J. A. (2013, June).   Applications of CYP450 testing in the clinical setting. Retrieved April 7, 2020,         from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663206/

Stahl, S. M. (2014). Stahls essential psychopharmacology. Cambridge: Cambridge University      Press.

Stahl, S. (2020). The figment of a man who looked upon the lady. Retrieved April 7, 2020,           from https://stahlonline-cambridge-            org.ezp.waldenulibrary.org/viewPdf?page=csEP_11.pdf&vol=2

Stahl, S. M. (2020). Prescriber’s Guides. Retrieved April 8, 2020, from https://stahlonline-            cambridge-org.ezp.waldenulibrary.org/prescribers_guide.jsf

Substance Abuse and Mental Health Serviced Administration (SAMHSA). (2016). Impact on the            DSM-IV to DSM-5 changes on the national survey on drug use and health. Rockville,   MD: Substance Abuse and Mental Health Serviced Administration. 

Tracy, K., & Wallace, S. (2016). Benefits of peer support groups in the treatment of addiction. Substance Abuse Rehabilitation, 7, 143-154. doi:10.2147/SAR.S81535

Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018, November 2). Treating PTSD: A           Review of Evidence-Based Psychotherapy Interventions. Retrieved April 7, 2020,          from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224348/

Zammit, G. K. (2007, September). Ramelteon: a novel hypnotic indicated for the treatment of      insomnia. Retrieved April 7, 2020,             from htt