Assgn 2 – WK4 (C)
Practicum: Decision Tree
For this Assignment, you examine the client case study in this week’s Learning Resources. Consider how you might assess and treat pediatric clients presenting with symptoms noted in the case.
Note: For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.
The Assignment:
Examine Case 1. You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.
(N: B. A CASE STUDY WITH ANSWER SAMPLE IS ATTACHED WITH THIS ASSIGNMENT)
At each Decision Point, stop to complete the following:
· Decision #1: Differential Diagnosis
o Which Decision did you select?
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
· Decision #2: Treatment Plan for Psychotherapy
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
· Decision #3: Treatment Plan for Psychopharmacology
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
· Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
Case #1
A young girl with difficulties in school
BACKGROUND
In psychopharmacology you met Katie, an 8-year-old Caucasian female, who was brought to your office by her mother (age 47) and father (age 49). You worked through the case by recommending possible ADHD medications. As you progress in your PMHNP program, the cases will involve more information for you to sort through.
For this case, you see Katie and her parents again. The parents have reported that the medication given to Katie does not seem to be helping. This has prompted you to reconsider the diagnosis of ADHD. You will consider other differential diagnoses and determine what information you need to accurately assess the DSM-5 criteria to make the diagnosis of ADHD or another disorder with similar diagnostic features.
When parents bring their child to your office, they may have read symptoms on the internet or they may have been told by the school “your child has ADHD”. Your diagnosis will either confirm or refute that diagnosis.
Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine a differential diagnosis and to begin medication, if indicated. The PMHNP makes this diagnostic decision based on interviews and observations of the child, her parents, and the assessment of the parents and teacher.
To start, consider what assessment tools you might need to evaluate Katie.
· Child Behavior Check List
· Conners’ Teacher Rating Scale
The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised” (Available at: http://www.doctorrudy.com/files/teacher_add_adhd_short.pdf). This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, makes careless mistakes in her schoolwork, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. She has difficulty interacting with peers in the classroom and likes to play by herself at recess.
When interviewing Katie’s parents, you ask about pre- and post-natal history and you note that Katie is the first born with parents who were close to 40 years old when she was born. She had a low 5 minute Apgar score. The parents say that she met normal developmental milestones and possibly had some difficulty with sleep during the pre-school years. They notice that Katie has difficulty socializing with peers, she is quiet at home and spends a lot of time watching TV.
SUBJECTIVE
You observe Katie in the office and she is not able to sit still during the interview. She is constantly interrupting both you and her parents. Katie reports that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds some subjects boring or too difficult, and sometimes hard because she feels “lost”. She admits that her mind does wander during class. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. She offers no other concerns at this time.
Katie’s parents appear somewhat anxious about their daughter’s problems. You notice the mother is fidgeting with her rings and watch while you are talking. The father is tapping his foot. Other than that, they seem attentive and straight forward in the interview process.
MENTAL STATUS EXAM
The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder
315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics
314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
ANSWER CHOOSEN: Attention Deficit Hyperactivity Disorder,
predominantly inattentive presentation 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· You selected Attention deficit hyperactivity disorder, predominantly inattentive presentation. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer
· Decision Point Two
· BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
· Wellbutrin 75 mg orally daily
·
· Strattera 25 mg orally daily
·
· Adderall XR 10 mg orally daily
ANSWER CHOOSEN: Adderall XR 10 mg orally daily
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Katie’s parents seem absolutely delighted upon their return stating that Katie is paying more attention in school, but note that there is still room for improvement, particularly in the afternoon
· They report that Katie’s teacher has reported that Katie is able to maintain her attention throughout the morning classes but come afternoon, she “daydreams.”
· Katie’s parents are also concerned about her decrease in appetite since starting the medication.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Katie’s parents that weight loss is common with stimulant medications
medication with family thearpy
a small dose of immediate release Adderall in the early afternoon
ANSWER CHOOSEN: Add a small dose of immediate release Adderall in the
Guidance to Student
Whereas weight loss is common with stimulant medication, this option does not address Katie’s parents’ concerns about the return of symptoms in the afternoon.
Augmentation with family therapy is also a good idea as it can help Katie with her symptoms and further help her parents to understand the unique challenges that Katie experiences, as well as ways that they can help her with symptoms, however, this option does not address the return of inattentive symptoms in the afternoon.
Adding a small dose of immediate relate Adderall in the afternoon can help Katie to maintain attention throughout the afternoon and into the early evening when she must do homework. This would be the best option.
Learning Resources
Required Readings
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
- Chapter 3, “Contributions of the Sociocultural Sciences” (pp. 131–150)
- Chapter 31, “Child Psychiatry” (pp. 1152–1181, 1244–1253)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- “Neurodevelopmental Disorders”
o “Intellectual Disabilities”
o “Communication Disorders”
- “Disruptive, Impulse-Control, and Conduct Disorders”
Required Media
Optional Resources
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.
- Chapter 51, “Autism Spectrum Disorder” (pp. 665–682)FINANCIAL ANALYSIS REPORT 2
Decision Tree: Personality Disorders
Frank Jones Sam’s University
Nurs 3333: PMHNP Role IV
Dr. Joe Mark
October 20 , 2010
Running head: DECISION TREE 1
DECISION TREE 6
Decision Tree: Personality Disorders
As described by the American Psychiatric Association (APA) (2013), ‘‘personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’’. There are different types of personality disorders classified into three clusters. Cluster A individuals are described as the odd or eccentric, cluster B as the dramatic, emotional, or erratic and cluster C as the anxious or fearful. The purpose of this paper is to discuss the case study of a young woman with personality disorder. This paper will explore threes decisions relating to differential diagnosis, psychotherapy and psychopharmacology based on the presented clinical manifestations.
Decision One
The clinical manifestation presented in the case study are indicative of more than one personality disorder, specifically borderline personality disorder (BPD) and antisocial personality disorder (ASPD). Patients exhibits a fear of abandonment which aligns with BPD. The patient mentioned an interpersonal relationship involvement which she exhibited idolization for the man of her interest, and now is devaluing the man. This is also evident in BPD as outlined by diagnostic criteria set forth by the APA (2013).
My diagnosis for this patient is ASPD, because the client exhibits clinical manifestations of ASPD than BPD. One of the reasons that led me to the diagnosis of ASPD is the client’s lack of remorse. The client stole from a friend, instead of being sorry, client’s blames friend instead. Client exhibits lack of respect for social norm and failure to comply with the law as evidenced by more than one record of arrest. The client fails to upholding financial obligation and is deceitful. Client shows irresponsibility evidenced by inability to keep a job. These presentations are evident in clients with ASPD as outlined in the DSM-5.
The two personality disorders which are classified as cluster B personality disorders by the APA (2013) have clinical manifestations which overlap, thus needs to be ruled out as differential diagnoses for each other. As described on the DSM-5 diagnostic criteria, BPD and ASD have similar features of impulsivity, aggression and manipulative behaviors, which client exhibits in the case study. The differing manifestation between the two is that in BPD, clients seek out interpersonal relationship, while ASPD client is unable to form any attachment to relationship. Clients with BPD exhibit self-mutilating behaviors and self-aggression, while in ASPD, aggression is directed on others. In ASPD clients are egocentric (also seen in narcisstic personality disorder), while BPD clients have a poor image of self.
Decision Two
Since the client exhibits symptoms which are synonymous with one more than personality disorder, specifically borderline and antisocial; the best decision is to opt to conduct a psychological testing. This will to further help the practitioner to decipher between the two diagnoses or conclude that patient indeed has the two personality disorders which is a possible occurrence. Psychological testing can be in the form of rating scales which includes questionnaires, checklists e.t c. According to Sadock, Sadock and Ruiz (2014), these scales are useful for monitoring patient overtime or to provide a comprehensive assessment information that was not obtained during a routine clinical interview.
There is limited evidence from existing literatures on the effectiveness of medications to target the core symptoms of ASPD. Khalifa et al. (2010) mentions that pharmacological interventions are not to be considered as monotherapy but as adjunctive intervention to target associated symptoms of ASPD such as depression, aggression etc. The option of Haldol, an antipsychotic medication can be used to address aggression but does not treat the core features of the disorder such as lack of remorse, deceitfulness. Furthermore, the plethora of side effects known to be caused by the medication can increase noncompliance. Psychotherapy can be beneficial, but psychodynamic is not appropriate for this patient because it may require patient to address emotional states. According to Hesse (2010), probing about ‘feeling states’ is unhelpful because the ASPD client may have difficulty accessing such state and may become aggressive when made to confront personal shortcoming.
Decision Three
In decision three, the recommendation is for a group-based cognitive therapy. Latuda an antipsychotic can be used to treat aggression but not the core symptoms of ASPD. Dialectical behavioral therapy will be more appropriate in the client with BPD than in ASPD. The most cited effective psychotherapeutic approach used in ASPD is cognitive behavioral therapy (CBT). This approach helps the client address distorted beliefs about self, others and the world. CBT can be used to enhance social and intrapersonal functioning.
A group setting may be beneficial for these clients as they may be able to learn from others experience or information shared about self. Psychotherapy for ASPD should be met with skepticism, but Hesse (2010) suggested that approaches that includes employing moral reasoning, cognitive behavioral approach, applying a social information processing approach, and planning for relapse prevention should be used. Additionally, the clients need a high level of external structure that includes supervision of the patient and reinforcement of positive social behaviors to yield increased outcomes for ASPD clients (Hesse, 2010).
Ethical and Legal Considerations
Due to the clinical manifestation of ASPD, some clinicians believe that it is hopeless to treat ASPD clients due to their clinical manifestation of aggression, deceitfulness and manipulation. Clients tends to be noncompliant, fueling the clinician’s pessimism. Existence of pessimism can hinder practitioners from upholding the ethical principles to do no harm and to do the best for the patient to full capacity. Hatchet (2015), implores clinicians to turn to published studies to become more aware of treatment options and to avoid expert opinions or clinical myths in regards to treating clients with ASPD. For these clients, autonomy may be purposely compromised to prevent harm to the patient and to others. This is seen in cases where patient refuse to comply with treatment plan or ordered into treatment and remain in treatment until deemed fit to come out of treatment.
Conclusion
It is essential for the practitioner to be knowledgeable about personality s disorder to effectively care for the patient. The practitioner should explore various options of medication, used to target accompanied symptoms. Psychotherapy, even though some might argue of its effectiveness, should not be ruled out. Assessment tools should be used to guide the clinicians, in diagnosing, especially with disorders that have overlapping symptoms.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Khalifa, N., Duggan, C., Stoffers, J., Huband, N., Völlm, B. A., Ferriter, M., & Lieb, K. (2010). Pharmacological interventions for antisocial personality disorder. The cochrane database of systematic Reviews, (8). Doi: 10.1002/14651858.CD007667.pub2
Hatchett, G. T. (2015). Treatment guidelines for clients with antisocial personality disorder. Journal of mental health counseling, 37(1). Retrieved from Walden University Database
Hesse, M. (2010). What should be done with antisocial personality disorder in the new edition of the diagnostic and statistical manual of mental disorders (DSM-V)? Biomed central medicine, 8(66). DOI: 10.1186/1741-7015-8-66
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
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