Stahl Case 21: Hindsight is Always 202/20, or Attention Deficit Hyperactivity Disorder

Stahl Case 21: Hindsight is Always 202/20, or Attention Deficit Hyperactivity Disorder

In certain cases, mental health professionals find it difficult to manage some symptoms associated with mental disorders. In these situations, the primary symptoms such as those of generalized anxiety disorder may undergo remission yet other symptoms including inattention remain. Indeed, the remission of residual inattention does not occur easily. The present case study involves such as case wherein the GAD symptoms of a 31-year old man get eliminated whereas the inattention remains. This situation occurs in spite of the administration of a combination of relevant drugs by the psychiatrist. However, the standard procedure in the management of such conditions dictate that a mental health professional tries different combinations and therapies in order to manage the presenting symptomatology. Therefore, the present paper will attempt to reconstruct the situation via assessment and even prescription of drugs to the patient.

Patient’s Clinical Interview Questions

            The patient clearly has suffered from these symptoms for a long time. The evidence for this assertion derives from the fact that he states that his anxiety has affected him since graduate school and college. Therefore, to accurately diagnose the underlying condition, the nurse will ask the patient the following questions as per American Psychological Association (2013):

• In the past six months, have you experienced too much anxiety or worry?
• If yes, have you found it challenging to manage the above symptoms?
• Out of the following restlessness, fatigue, inattention, irritability, muscle tension, and sleep problems, which ones have you experienced in the last six months?

These questions play an integral role in the evaluation of a patient for GAD. Clearly, the first two questions will reveal the presence of obvious symptoms of the conditions. However, the third question confirms the presence of the condition in an adult. Whereas in children only one of the symptoms in the third question need to occur, adults need to present with three of them to confirm the existence of GAD. Therefore, the answers provided to the above questions will help the mental health professional to diagnose generalized anxiety disorder in the patient.

Questions to Close Persons

The clinical evaluation of patients suspected to have GAD can extend to people in a close relationship with a patient. In the present circumstance, the wife and his physician will provide useful insights into the behaviors of the patient. In order to get the information, the wife will have to answer the following question: Does his anxiety strain your marriage? The question will seek to reveal the impact of the anxiety on the patient’s relationship and even confirm whether he gave a correct answer (In Cutler, 2014). On the other hand, the physician will answer the following question: Have you ever ordered a complete blood test that revealed the presence of hormonal conditions related to the thyroid hormone? This questions will illuminate for the physician whether the GAD and inattentiveness experienced by the patient result from a medical condition. Thus, we cannot overstate the importance of asking individuals close to the patient some questions.

Physical Exams and Diagnostic Tests

            As already mentioned elsewhere, other medical conditions can also cause GAD. Therefore, for purposes of ruling them out, a mental health professional will order for a physical test. The physical test will specifically pursue the presence of anemia and an overactive thyroid gland in the patient (Van & Polack, 2012). The existence of other conditions such as angina, asthma, tachycardia, and adrenal gland tumors may also form the basis of the physical test.

In addition to the physical tests, the nurse practitioner will order for the performance of other diagnostic tests.  To this end, the patient will have to do tests such as the Zung-Self-Rating Anxiety Scale. Afterwards, the mental health professional may also order a complete blood test and urinalysis (Llewelyn, 2014). The purpose of having these tests entails eliminating the possibility of other medical conditions causing the generalized anxiety disorder in the patient.

Differential Diagnosis

            In a manner similar to most mood disorders, generalized anxiety disorder also has comorbidities. Consequently, it becomes imperative to differentially diagnose the condition so as to accurately confirm its presence. Indeed, the diagnostic criteria adopted by the DSM-5 tool reveals that anxiety symptoms overlap with symptoms of other mental health conditions (American Psychiatric Association, 2013). Hence, as mentioned, differentially examining the condition ensures accuracy in the diagnostic process. Thus, during the evaluation, the ADHD, social anxiety disorder, and generalized anxiety disorder will undergo consideration. However, the patient has generalized anxiety disorder since he meets the criteria enumerated for the condition by the DSM-5 tool.

Pharmacological Agents

            Given the history of the patient, the nurse practitioner has to take precautions regarding the psycopharmacotherpay that she will adopt for him. Based on the evidence revealed by the evaluation, the nurse practitioner can start the patient on either duloxetine 60 mg/d or venlafaxine at a dosage of between 37.5mg/d to 75 mg/d (Stahl, 2013).  Duloxetine combats GAD symptoms by inhibiting the selective reuptake of norepinephrine and serotonin in the central nervous system. It enhances the concentration of dopamine in the prefrontal cortex due to the presence of few DA reuptake pumps (Stahl, 2014). This increases the concentration of the catecholamine in the brain, leading to resultant remission of GAD symptoms. The drug possesses a good bioavailability, with 50% average after every 60 mg dose. Absorption of the drug occurs at two hours while it achieves its plasma concentration within 6-10 hours. Further, the drug achieves stead-sate after 3 days.

On the other hand, Venlafaxine also acts by inhibiting the reuptake of norepinephrine, serotonin and dopamine. After the blockage of the above neurotransmitters’ transporter “reuptake” proteins, they increase in concentration at the synapse (Stahl, 2014). The drug has superior pharmacokinetic properties. According to Stahl (2014), almost 92% of the drug gets absorbed into the systemic circulation. Additionally, it achieves its steady-state on the third week of administration.

However, much as the two molecules are effective in the treatment of generalized anxiety disorder, the nurse practitioner cannot prescribe them both. She will have to choose between them. Based on the mechanism of action, the mental health professional will prescribe the venlafaxine agent for the sole purpose that it comparatively modulates the reuptake of three neurotransmitters.

Contraindications/Dosing Adjustment

            Studies have revealed that venlafaxine acts as a substrate of P-glycoprotein. The gene that encodes the above glycoprotein known as ABCB1 contains a SNP rs2032583 alongside alleles T and C. According to a Diercx et al. (2014), 70% of Caucasians as well as 90% of East Asians have the TT variant of the gene. Another study in 2007 concluded that those individuals with the TT variant of the allele have a higher probability (7.72 times) of achieving remission after four weeks of treatment using venlafaxine (Uhr et al., 2008). Therefore, this means that those patients with the CC variant will have to use a higher dosage for them to gain the benefits of the molecule.

Checkpoint Data

            The data provided indicates the challenge present in the management of GAD symptoms as the patient demonstrates residual inattention. During the treatment of the patient, the nurse will first of all use the checkpoints to determine the optimum dosage for the patient. Since the symptoms will prove difficult to completely vanquish, the nurse practitioner will consider augmenting the molecule with another one that will address the sexual dysfunction side-effect as well as increase its effect. In specific terms, the nurse practitioner will include buspirone to the therapy.

Lessons Learned

            The case study has enabled the nurse practitioner to learn important lessons in the management of such complicated conditions. The treatment of the condition has particularly revealed that SNRI medications have the ability to utilize its dual mechanism of action to manage both GAD and ADHD symptoms. Further, the nurse learnt of the existence of a multiplicity of approaches regarding the management of GAD symptoms. Also, the case has highlighted the fact that even GAD can become resistant to treatment and thus rational polypharmacy may prove paramount.

Therefore, the case study via the above lessons, will influence the future practice of the nurse. Because of the lessons, the nurse will consider utilizing evidence-based monotherapies instead of using irrational polypharmacy that has little to no backing from literature. Moreover, in the event that the present nurse chooses to use polypharmacy, she will utilize drugs having multifarious mechanisms of action to reduce redundancy.

Reference

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

Dierckx, R. A. J. O., Otte, A., Vries, E. F. J., Waarde, A., & den, B. J. A. (n.d.). PET and SPECT in Psychiatry [recurso electrónico].

In Cutler, J. L. (2014). Psychiatry. Oxford : Oxford University Press.

Llewelyn, H. (2014). Oxford handbook of clinical diagnosis. Oxford: Oxford University Press.

Stahl, S. M. (2014). Essential psychopharmacology: The prescriber’s guide, 5^th ed. Cambridge, NY: Cambridge Univ. Press.

Stahl, S.M. (2013).Stahl’s Essential Psychopharmacology, 4th ed. New York, NY: Cambridge University Press.

Uhr, M., Tontsch, A., Namendorf, C., Ripke, S., Lucae, S., Ising, M., Dose, T., Ebinger, M., Rosenhagen, M., Kohli, M., Kloiber, S., Salyakina, D., Bettecken, T., Specht, M., Pütz, B., Binder, E.B., Müller-Myhsok, B., Holsboer, F. (2008). “Polymorphisms in the drug transporter gene ABCB1 predict antidepressant treatment response in depression”. Neuron. 57 (2): 203–209. :.  

Van, A. M., & Pollack, M. H. (2012). Generalized anxiety disorder. Oxford: Oxford University Press.

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Important information on Writing a Discussion Question

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• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
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• Follow APA-7th edition
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