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Asked by kyongpower59

 

 

Objectives

To list three criteria for post-traumatic stress disorder
To differentiate between acute stress disorder and PTSD
To compare and contrast PTSD and ODD

Subjective:

CC (chief complaint): “I am having a hard time in summer school”

HPI: D.H.. is a 16-year-old white female with a history of sexual abuse by her grandfather and neglect by her mother who presents for follow-up after being recently discharged from a PRTF. She has a history of being sexually abused by her grandfather. She has symptoms of depression, reports of dissociative identities, emotional reactivity, hypervigilance, intrusive thoughts, nightmares, feeling hopeless, fellings of worthlessness, anhedonia, trust issues, low self-esteem, physical and verbal aggression, defiance, and sexually inappropriate behaviors. She has a history of a kinship placement, one level three group home placement, three foster home placements, one hospitalization, and one PRTF placement. She has recently had lots of changes in her foster placements due to the illness one of her foster parents, leading to instability in her environment from frequent relocation and school reassignments. She has failed trials of Prozac and Methylphenidate. She has past diagnoses of PTSD, ODD, and MDD. She has been in the custody of Wake County Human Services since 2018. She had previously lived with her mother but the home was overcrowded and chaotic.She and her mother then went to live with the grandparents and she was sexually abused by her grandfather. Her mother was unstable due to schizophrenia and substance abuse and left her with a family friend for an extended time before she was placed in Wake County Human services custody. She then went to a kinship home but had to leave due to disruptive behaviors. She had psychological testing at the PRTF and her overall intellectual functioning was below average, according to the Wechsler Abbreviated Scale of Intelligence-Second Edition (WASI-II) and the Wide Range Achievement Test-Fifth Edition (WRAT-5). The Revised Children’s Anxiety and Depression Scale (RCADS) short form was administered and she scored a 52 on total depression, 50 for total anxiety, and 51 for total depression and anxiety. A score of greater than 65 is considered to be moderately elevated and higher than 70 is clinically significant. She is currently living with a foster mother and attending summer school but is having a hard time focusing and continues to have behavior problems.She has had trouble adjusting to school and has been cursing people out and feels out of control and irritated most of the time. She denies mood swings or hypomania.She currently denies suicidal ideation, homicidal ideation, self-injurious behaviors, substance abuse, and audio or visual hallucinations. She has had no legal charges, cruelty to animals, or destruction of property. She denies any history of an eating disorder and has not ever binged, purged or restricted her intake.

Substance Current Use: none

Medical History:

 

Current Medications-Lexapro 10 mg daily, Lamictal 200 mg daily, Guanfacine 4 mg daily, Mirtazapine 15 mg at bedtime, Topamax 100 mg bid, Ortho Tri-cyclen
Allergies: None
Reproductive Hx:LMP 7/1/22

ROS: 

GENERAL: no fever, chills, or fatigue
HEENT: no difficulties with vision, hearing or smell, no rhinorrhea or sore throat
SKIN: no rashes, lesions or urticaria
CARDIOVASCULAR: no chest pain or palpitations
RESPIRATORY: no shortness or breath or cough
GASTROINTESTINAL: no nausea, vomiting, constipation, abdominal pain or diarrhea
GENITOURINARY: no pain or difficulty with urination or blood or foul odor in urine
NEUROLOGICAL: no headache, dizziness, syncope, numbness or tingling
MUSCULOSKELETAL: no stiffness or pain in muscles or joints
HEMATOLOGIC: no abnormal bruising or bleeding
LYMPHATICS: no swollen or tender nodes
ENDOCRINOLOGIC: no polyuria, polyphagia, or polydipsia. No sensitivity to heat or cold

Objective:

Diagnostic results:  Height 5’7″, weight 151 lbs, BMI 23.68, T-98.6, P-76, BP-118/72. O2 Sat-98% on room air. This patient received psychological testing at her most recent placement.  On the  RCADS (Revised Children’s Anxiety and Depression Scale) she scored 52 for total depression, 50 for total anxiety, and 51 for total depression and anxiety. Her WRAT-5 (Wide Range Achievement Test-Fifth Edition) scores revealed reading and spelling scores that were well below average and math calculation scores in the low-average range. Her WASI-II (Wechsler Abbreviated Scale of Intelligence-Second Edition) scores showed her ability to provide definitions for words was low average, verbal reasoning skills were average, non-verbal perceptual reasoning skills were well below average, and her visual spatial skills were significantly below average. Studies have shown that the RCADS is a good instrument with proven validity and specificity in detecting anxiety and depression in school-age children by using a self-reported questionnaire that assesses appetite, anhedonia, motor behavior, mood, energy level, sleep and concentration (Lipps, Lowe, Gibson, & Jules, 2021). Another test that would be beneficial to this patient is the Test of Memory Malingering which was developed to distinguish between a true presentation of dissociative identity disorder and feigned symptoms of DID used to elicit secondary gain (Brand, Weberman,  Snyder,& Kaliush, 2019).

Assessment:

Mental Status Examination:The patient is neat and appropriately dressed and appears her stated age. She is alert and oriented to person, place, time and situation. Her mood is euthymic, her affect is congruent with full-range. She is cooperative with the interview and makes good eye contact. Her speech is goal-directed with normal rate and volume. Her thought processes are logical and coherent. Her thought content is free from delusions, suicidal or homicidal ideation. Her judgement is poor. Her impulse control is poor. Her IQ is below average. Her motor behavior is restless. Her concentration is fair. Her memory is intact.

Diagnostic Impression: 

This patient meets full criteria for post traumatic stress disorder, because she directly experienced being sexually abused by her grandfather, she has intrusive thoughts and ruminations about the abuse, she has been having nightmares, hypervigilance, low self-esteem, anhedonia, irritability, dissociation,and trouble with peer relations at school that have lasted more than six months (American Psychiatric Association, 2013). The client also meets criteria for Major Depressive Disorder because she has been feeling depressed, irritable, having trouble concentrating, anhedonia, low self-esteem and feelings of worthlessness lating longer than six months (American Psychiatric Association, 2013).  Acute stress disorder can be ruled out because although the symptoms meet criteria for post-traumatic stress disorder, her symptoms have been there for six months or more and to meet criteria for acute stress disorder, symptoms must be present for less than one month (American Psychiatric Association, 2013). Oppositional defiant disorder is listd in this patient’s history as a prior diagnosis, but according to the dischare summary from her previous placement and current presentation, oppositional defiant disorder can be ruled out. Although she has had some persistent irritability, defiance, and angry outbursts where she has cursed at other children, there are no reports of her being spiteful or vindictive or deliberately doing things to annoy others (American Psychiatric Association, 2013). Her acting out behaviors are more attributable to reactions to trauma and neglect (American Psychiatric Association, 2013).

Case Formulation and Treatment Plan: 

The patient will continue on Lexapro 10 mg daily, Lamictal 200 mg daily, Guanfacine 4 mg daily, Mirtazapine 15 mg at bedtime, Topamax 100 mg bid, Ortho Tri-cyclen. 

.The patient will continue with trauma focused CBT therapy that was begun at her last placement. Studies have shown that trauma-focused CBT is highly effective at reducing symptoms of PTSD and is considered to be the gold standard for victims of childhood sexual abuse (Joiner & Buttell, 2018).

Risks and benefits of medications were discussed.  The patient was instructed to call 911 and report to the nearest emergency room should she experience thoughts of suicide. She was provided with the number for the suicide hotline 800-273-8255. Time was allowed for questions and answers provided. Patient understands and approves of the proposed plan of care. Provider will follow up with her PCP as needed and return to clinic in one month. 

Reflections

One thing I would like to do differently with this case would be to get a better timeline on when the abuse and neglect occurred and to have IQ scores from before the abuse occurred and after, to see if she functioned at a higher level prior to the abuse. Studies have shown that children who have been victims of abuse and neglect score lower on tests like the Wechsler Abbreviated Scale of Intelligence-Second Edition, but it is unclear if the lower scores are a result of abuse or a risk factor (Young-Southward, Eaton, O’Connor, & Minnis, 2020). Before doing this case, I did not know there was a connection between abuse and lower intellectual functioning. I wonder if the standardized tests, like the Wechsler, are accurate in measuring intellectual functioning in victims of trauma or if there is a need for a screening tool adapted specifically to this population.

 

   References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Arlington, VA: Author

Brand, B.L., Weberman, A.R., Snyder, B.L., & Kaliush, P.R. (2019). Detecting clinical and simulated dissociatve identity disorder with the Test of Memory Malingering. Psychological Trauma: Theory, Research, Practice, and Policy, 11(5), 513. https://doi.org/10.1037/tra0000405 

Joiner, V.C., & Buttell, F.P. (2018). Investigating the usefulness of trauma-focused cognitive behavioral therapy in adolescent residential care. Journal of Evidence-Informed Social Work. 15(4), 457-472. 

Lipps, G., Lowe, G., Gibson, R., & Jules, M. (2021). Validation of the Major Depressive Disorder Subscale (MDDS) of the Revised Child Anxiety & Depression Scale (RCADS) in a sample of Jamaican and Barbadian elementary school children. Carribean Medical Journal, 83(3), 93-106. https://doi.org/10.1007/s10862-018-9702-6 

Young-Southward, G., Eaton, C., O’Connor, R., & Minnis, H. (2020). Investigating the causal relationship between maltreatment and cognition in children: A systematic review. Child Abuse & Neglect, 107, 104603. https://doi.org/10.1016/j.chiabu.2020.104603 

 

   Questions

Do you think lower IQ scores are a risk factor for child abuse or the result of abuse and neglect and why?
Are standardized intelligence tests like the Wechsler accurate, or is there cultural bias?
Do you think undergoing therapy for PTSD like EMDR would cause an increase in IQ scores and overall level of function?

Please help me find the above three questions for me; thank you.

 

SCIENCE
HEALTH SCIENCE
NURSING

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