Case: Anxiety disorder OCD

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Case: Anxiety disorder OCD

Case: Anxiety disorder OCD

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Discussion: Comprehensive Integrated Psychiatric

Examine Case 2: Anxiety disorder, OCD, or something else?

Background Information

The Assignment:

 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. At each Decision Point, stop to complete the following:

  • Decision #1: Differential Diagnosis
    • Which Decision did you select?
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • 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
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • 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
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • 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.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?

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.

Generalized Anxiety Disorder (GAD)

Obsessive Compulsive Disorder

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)

My Decision: Obsessive Compulsive Disorder

Decision Point Two

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Begin Zoloft 50 mg orally daily

Begin Fluvoxamine immediate release 25 mg orally at bedtime

Begin Fluvoxamine controlled release 100 mg orally in the morning

My decision: Begin Fluvoxamine immediate release 25 mg orally at bedtime

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  • Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.
  •  She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.

 Examine Case 2: Anxiety disorder, OCD, or something else?

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Fluvoxamine to 50 mg orally at bedtime

Augment with an atypical antipsychotic such as Abilify

Augment treatment with cognitive behavioral therapy

My decision: Increase Fluvoxamine to 50 mg orally at bedtime

 

Guidance to Student
In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

 Examine Case 2: Anxiety disorder, OCD, or something else?

BACKGROUND

Tyrel is an 8-year-old black male who is brought in by his mother for a variety of psychiatric complaints. Shaquana, Tyrel’s mother, reports that Tyrel has been exhibiting a lot of worry and “nervousness” over the past 2 months. She states that she notices that he has been quite “keyed up” and spends a great deal of time worrying about “germs.” She states that he is constantly washing his hands because he feels as though he is going to get sick like he did a few weeks ago, which kept him both out of school and off the playground. He was also not able to see his father for two weekends because of being sick. Shaquana explains that although she and her ex-husband Desmond divorced about 2 years ago, their divorce was amicable and they both endeavor to see that Tyrel is well cared for.

Shaquana reports that Tyrel is irritable at times and has also had some sleep disturbances (which she reports as “trouble staying asleep”). She reports that he has been more and more difficult to get to school as he has become nervous around his classmates. He has missed about 8 days over the course of the last 3 weeks. He has also stopped playing with his best friend from across the street.

His mother reports that she feels “responsible” for his current symptoms. She explains that after he was sick with strep throat a few weeks ago, she encouraged him to be more careful about washing his hands after playing with other children, handling things that did not belong to him, and especially before eating. She continues by saying “maybe if I didn’t make such a big deal about it, he would not be obsessed with germs.”

Per Shaquana, her pregnancy with Tyrel was uncomplicated, and Tyrel has met all developmental milestones on time. He has had an uneventful medical history and is current on all immunizations.

OBJECTIVE

During your assessment of Tyrel, he seems cautious being around you. He warms a bit as you discuss school, his friends at school, and what he likes to do. He admits that he has been feeling “nervous” lately, but when you question him as to why, he simply shrugs his shoulders.

When you discuss his handwashing with him, he tells you that “handwashing is the best way to keep from getting sick.” When you question him how many times a day he washes his hands, he again shrugs his shoulders. You can see that his bilateral hands are dry. Throughout your assessment, Tyrel reveals that he has been thinking of how dirty his hands are; and no matter how hard he tries to stop thinking about his “dirty” hands, he is unable to do so. He reports that he gets “really nervous” and “scared” that he will get sick, and that the only way to make himself feel better is to wash his hands. He reports that it does work for a while and that he feels “better” after he washes his hands, but then a little while later, he will begin thinking “did I wash my hands well enough? What if I missed an area?” He reports that he can feel himself getting more and more “scared” until he washes his hands again.

MENTAL STATUS EXAM

Tyrel is alert and oriented to all spheres. Eye contact varies throughout the clinical interview. He reports his mood as “good,” admits to anxiety. Affect consistent to self-reported mood. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes were apparent. He denies suicidal ideation.

Lab studies obtained from Tyrel’s pediatric nurse practitioner were all within normal parameters. An antistreptolysin O antibody titer was obtained for reasons you are unclear of, and this titer was shown to be above normal parameters.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?

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.
 Generalized Anxiety Disorder (GAD)
 Obsessive Compulsive Disorder
 Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)

Examine Case 2: Anxiety disorder, OCD, or something else?

Decision Point One

 Generalized Anxiety Disorder (GAD)

Decision Point Two

Begin Paxil 10 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She notices that he is still handwashing frequently, but thinks that the frequency has decreased “a bit.” She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Paxil to 20 mg orally daily

Guidance to StudentWhile GAD was not the actual diagnosis in this case, the child’s OCD symptoms did decrease with Paxil. Although Paxil is not FDA-approved for treatment of OCD in children, it is an SSRI like Sertraline and Fluvoxamine, which are FDA-approved for the treatment of OCD. So if there are no objectionable side effects and the symptoms appear to be decreasing, there may be no need to change drugs, but optimizing the dose may be a better choice. Augmentation with psychotherapy may also be useful, but the current dose of Paxil is still somewhat low, so augmenting with psychotherapy would be a good idea, but in and of itself would not be sufficient to meet this child’s needs.

Finally, while the PMHNP could consider changing to Fluvoxamine, the “controlled release” preparation is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation.

Discontinue Paxil and begin Fluvoxamine controlled release, 100 mg orally every morning

Guidance to StudentWhile GAD was not the actual diagnosis in this case, the child’s OCD symptoms did decrease with Paxil. Although Paxil is not FDA-approved for treatment of OCD in children, it is an SSRI like Sertraline and Fluvoxamine, which are FDA-approved for the treatment of OCD. So if there are no objectionable side effects and the symptoms appear to be decreasing, there may be no need to change drugs, but optimizing the dose may be a better choice. Augmentation with psychotherapy may also be useful, but the current dose of Paxil is still somewhat low, so augmenting with psychotherapy would be a good idea, but in and of itself would not be sufficient to meet this child’s needs.

Finally, while the PMHNP could consider changing to Fluvoxamine, the “controlled release” preparation is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation.

Augment Paxil with psychotherapy

Guidance to StudentWhile GAD was not the actual diagnosis in this case, the child’s OCD symptoms did decrease with Paxil. Although Paxil is not FDA-approved for treatment of OCD in children, it is an SSRI like Sertraline and Fluvoxamine, which are FDA-approved for the treatment of OCD. So if there are no objectionable side effects and the symptoms appear to be decreasing, there may be no need to change drugs, but optimizing the dose may be a better choice. Augmentation with psychotherapy may also be useful, but the current dose of Paxil is still somewhat low, so augmenting with psychotherapy would be a good idea, but in and of itself would not be sufficient to meet this child’s needs.

Finally, while the PMHNP could consider changing to Fluvoxamine, the “controlled release” preparation is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation.

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to the clinic, Tyrel’s mother reported that Tyrel dislikes his therapist. He feels that she treats him like a baby and is condescending toward him. She stated that she has decided to discontinue psychotherapy.
  • Tyrel’s mom states that Tyrel is still washing his hands frequently. She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Tell Tyrel’s mom that you agree with her appraisal of the psychotherapist and assure her that Tyrel’s anxiety disorder can be treated with medication instead

Guidance to StudentCognitive behavioral therapy is the psychotherapy of choice for treating OCD. However, in this case, the PMHNP assumed he/she was working with GAD, which may have delayed some of the work of CBT—that is, the focus of the sessions would have focused on the obsessive thoughts/compulsive behaviors versus a generalized anxiety. However, in this case, the diagnostic challenge made it difficult.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Many times, PMHNPs will be employed by agencies to manage patient medications. Many PMHNPs will not be able to engage clients in psychotherapy because of this. The PMHNP should be able to work with a variety of psychotherapists in the management of their clients. Sometimes, clients will tell the PMHNP that they feel as though they are getting “nothing” out of the relationship with the psychotherapist. Other times, the client will blatantly tell the PMHNP that they “hate” the therapist. In these cases, the PMHNP should assess the client in greater detail for clues as to the “style” of therapist that they are looking for, and based on the network of professionals, consider referring to another therapist, if the client is willing.

Psychologists generally handle clients with higher complexity needs than psychotherapists, and while referral to a clinical psychologist is not “incorrect,” nothing in the case tells us that Tyrel needs this level of intervention at this point.

Encourage Tyrel’s mom to consider taking Tyrel to a different psychotherapist for treatment

Guidance to StudentCognitive behavioral therapy is the psychotherapy of choice for treating OCD. However, in this case, the PMHNP assumed he/she was working with GAD, which may have delayed some of the work of CBT—that is, the focus of the sessions would have focused on the obsessive thoughts/compulsive behaviors versus a generalized anxiety. However, in this case, the diagnostic challenge made it difficult.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Many times, PMHNPs will be employed by agencies to manage patient medications. Many PMHNPs will not be able to engage clients in psychotherapy because of this. The PMHNP should be able to work with a variety of psychotherapists in the management of their clients. Sometimes, clients will tell the PMHNP that they feel as though they are getting “nothing” out of the relationship with the psychotherapist. Other times, the client will blatantly tell the PMHNP that they “hate” the therapist. In these cases, the PMHNP should assess the client in greater detail for clues as to the “style” of therapist that they are looking for, and based on the network of professionals, consider referring to another therapist, if the client is willing.

Psychologists generally handle clients with higher complexity needs than psychotherapists, and while referral to a clinical psychologist is not “incorrect,” nothing in the case tells us that Tyrel needs this level of intervention at this point.

Refer Tyrel’s case to a psychologist

Guidance to StudentCognitive behavioral therapy is the psychotherapy of choice for treating OCD. However, in this case, the PMHNP assumed he/she was working with GAD, which may have delayed some of the work of CBT—that is, the focus of the sessions would have focused on the obsessive thoughts/compulsive behaviors versus a generalized anxiety. However, in this case, the diagnostic challenge made it difficult.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Many times, PMHNPs will be employed by agencies to manage patient medications. Many PMHNPs will not be able to engage clients in psychotherapy because of this. The PMHNP should be able to work with a variety of psychotherapists in the management of their clients. Sometimes, clients will tell the PMHNP that they feel as though they are getting “nothing” out of the relationship with the psychotherapist. Other times, the client will blatantly tell the PMHNP that they “hate” the therapist. In these cases, the PMHNP should assess the client in greater detail for clues as to the “style” of therapist that they are looking for, and based on the network of professionals, consider referring to another therapist, if the client is willing.

Psychologists generally handle clients with higher complexity needs than psychotherapists, and while referral to a clinical psychologist is not “incorrect,” nothing in the case tells us that Tyrel needs this level of intervention at this point.

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She notices that he is still handwashing frequently, but thinks that the frequency has decreased “a bit.” She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. Tyrel’s mom is concerned about the decrease in Tyrel’s appetite. She reports that he has been having some decreased appetite and has complained of feeling “sick to his stomach.”

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Zoloft to 100 mg orally daily

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Although the child had OCD and not GAD, Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescribers Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. However, in this case, the PMHNP assumed he/she was working with GAD, which may have delayed some of the work of CBT—that is, the focus of the sessions would have focused on the obsessive thoughts/compulsive behaviors versus a generalized anxiety. However, in this case, the diagnostic challenge made it difficult.

Change to Fluvoxamine controlled release 100 mg orally every morning

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Although the child had OCD and not GAD, Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescribers Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. However, in this case, the PMHNP assumed he/she was working with GAD, which may have delayed some of the work of CBT—that is, the focus of the sessions would have focused on the obsessive thoughts/compulsive behaviors versus a generalized anxiety. However, in this case, the diagnostic challenge made it difficult.

Begin cognitive behavioral therapy

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Although the child had OCD and not GAD, Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescribers Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. However, in this case, the PMHNP assumed he/she was working with GAD, which may have delayed some of the work of CBT—that is, the focus of the sessions would have focused on the obsessive thoughts/compulsive behaviors versus a generalized anxiety. However, in this case, the diagnostic challenge made it difficult.

Obsessive Compulsive Disorder

Decision Point Two

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Begin Zoloft 50 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She notices that he is still handwashing frequently, but thinks that the frequency has decreased “a bit.”
  • She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved.
  • Tyrel’s mom is concerned about the decrease in Tyrel’s appetite. She reports that he has been having some decreased appetite and has complained of feeling “sick to his stomach.”

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Discontinue Zoloft and begin Fluvoxamine controlled release 100 mg orally every morning

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. However, between ages 6 and 12, it should be started at 25 mg orally daily. If starting doses are too high, the child may experience side effects that he associates with the medication and as such, may refuse to take the medication. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

Augment with cognitive behavioral therapy

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. However, between ages 6 and 12, it should be started at 25 mg orally daily. If starting doses are too high, the child may experience side effects that he associates with the medication and as such, may refuse to take the medication. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

Increase Zoloft to 100 mg orally daily

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. However, between ages 6 and 12, it should be started at 25 mg orally daily. If starting doses are too high, the child may experience side effects that he associates with the medication and as such, may refuse to take the medication. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

Begin Fluvoxamine immediate release 25 mg orally at bedtime

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.
  • She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.

Examine Case 2: Anxiety disorder, OCD, or something else?

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Fluvoxamine to 50 mg orally at bedtime

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

Augment with an atypical antipsychotic such as Abilify

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

Augment treatment with cognitive behavioral therapy

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

Begin Fluvoxamine controlled release 100 mg orally in the morning

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Tyrel’s mom reports that Tyrel took the medication for the first week, but she stopped giving it to him after that because “he was so drugged up.” She reports that Tyrel was impossible to wake up, and missed an entire week of school due to his sedation from the medication.
  • She reports that during that week, the frequency of handwashing decreased because “poor Tyrel was too doped up to wash his hands.” However, she reports that 2 days after she stopped giving him the medication, he resumed handwashing behaviors.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Tyrel’s mom to continue the current medication dose and educate her that the side effects will abate with time

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation.

Recall that it is generally not appropriate to treat the side effects of one medication with another medication, especially when those side effects can be overcome by changing to a different preparation of the medication (in this case, immediate release), or can be minimized by a change in timing of the medication (in this case, changing the medication to bedtime). In some cases, medications are used to treat side effects of medication (for example, propranolol is often used to treat tremors associated with lithium); but these types of “exceptions” are few and far between. Always try to treat side effects by a different preparation, or different administration time. Avoid polypharmacy whenever possible.

Change to immediate-release Fluvoxamine 25 mg orally at bedtime

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation.

Recall that it is generally not appropriate to treat the side effects of one medication with another medication, especially when those side effects can be overcome by changing to a different preparation of the medication (in this case, immediate release), or can be minimized by a change in timing of the medication (in this case, changing the medication to bedtime). In some cases, medications are used to treat side effects of medication (for example, propranolol is often used to treat tremors associated with lithium); but these types of “exceptions” are few and far between. Always try to treat side effects by a different preparation, or different administration time. Avoid polypharmacy whenever possible.

Administer Armodafinil 50 mg orally daily to overcome sedation associated with the medication

Guidance to StudentIn terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation.

Recall that it is generally not appropriate to treat the side effects of one medication with another medication, especially when those side effects can be overcome by changing to a different preparation of the medication (in this case, immediate release), or can be minimized by a change in timing of the medication (in this case, changing the medication to bedtime). In some cases, medications are used to treat side effects of medication (for example, propranolol is often used to treat tremors associated with lithium); but these types of “exceptions” are few and far between. Always try to treat side effects by a different preparation, or different administration time. Avoid polypharmacy whenever possible.

Examine Case 2: Anxiety disorder, OCD, or something else?

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)

Decision Point Two

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Refer client to a pediatric neurologist

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • You learn that the pediatric neurologist completed a comprehensive assessment on Tyrel, and although symptoms of OCD seem to have occurred after he was sick, and although antistreptolysin O titers were elevated, there is insufficient evidence for the diagnosis of PANDAS.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Begin Zoloft 75 mg orally daily

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? The PMHNP should consider working in collaboration with the pediatric neurologist to optimize outcomes for this client and his family. Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. In this scenario, Fluvoxamine (immediate release) 25 mg orally daily would be the most appropriate agent.

Begin Fluvoxamine 25 mg orally daily

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? The PMHNP should consider working in collaboration with the pediatric neurologist to optimize outcomes for this client and his family. Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. In this scenario, Fluvoxamine (immediate release) 25 mg orally daily would be the most appropriate agent.

Begin Risperdal 0.5 mg orally twice a day

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? The PMHNP should consider working in collaboration with the pediatric neurologist to optimize outcomes for this client and his family. Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Zoloft is FDA-approved to treat OCD in children. The starting dose is 25 mg orally daily. However, it is important to increase from the starting dose to an appropriate therapeutic dose to effectively manage symptoms. In this scenario, Fluvoxamine (immediate release) 25 mg orally daily would be the most appropriate agent.

Begin Methylprednisolone 60 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to your office, you learn that Tyrel has had no change in symptoms. His mother reports that his handwashing remains unchanged and that he is still avoiding school.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Methylprednisolone to 60 mg orally twice a day

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? For instance, in this decision, the dose of Methylprednisolone offered is far below what would be considered appropriate if this were PANDAS (Methylprednisolone would be started at around 1000 mg daily ×3 days with a slow taper over the course of several weeks).

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Geodon are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.

Add Geodon 20 mg orally daily to current regimen

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? For instance, in this decision, the dose of Methylprednisolone offered is far below what would be considered appropriate if this were PANDAS (Methylprednisolone would be started at around 1000 mg daily ×3 days with a slow taper over the course of several weeks).

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Geodon are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.

Reconsider diagnosis

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management, which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? For instance, in this decision, the dose of Methylprednisolone offered is far below what would be considered appropriate if this were PANDAS (Methylprednisolone would be started at around 1000 mg daily ×3 days with a slow taper over the course of several weeks).

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Geodon are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.

Begin Risperdal 0.5 mg orally twice a day

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to your office, you learn that Tyrel has had no change in symptoms. His mother reports that his handwashing remains unchanged, but he seems more accepting of going to school. Tyrel’s mom is also concerned about how tired Tyrel seems to be 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.

Change regimen to 1 mg of Risperdal at night to decrease daytime sedation

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? Risperdal is not an approved drug to treat this condition, and this medication would only be used if psychotic symptoms were present. However, an atypical antipsychotic in and of itself would not address the underlying pathophysiology of PANDAS.

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Risperdal or Abilify are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.

Switch to a nonsedating antipsychotic such as Abilify

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? Risperdal is not an approved drug to treat this condition, and this medication would only be used if psychotic symptoms were present. However, an atypical antipsychotic in and of itself would not address the underlying pathophysiology of PANDAS.

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Risperdal or Abilify are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.

Reconsider initial diagnosis

Guidance to StudentIf the PMHNP believes that PANDAS is the most likely diagnosis, he or she should consider the nature of the disorder and the extent of the management which may include high doses of steroids, the potential for plasma exchange therapy, and possibly monoclonal antibody therapy. A scope of practice considerations should be undertaken—that is, does the PMHNP have the necessary knowledge, skills, and abilities to undertake the care of this client? Risperdal is not an approved drug to treat this condition, and this medication would only be used if psychotic symptoms were present. However, an atypical antipsychotic in and of itself would not address the underlying pathophysiology of PANDAS.

Although antistreptolysin O and other titers indicate recent alpha streptococci infection, it should be noted that these titers can remain elevated for weeks after the infection and do not necessarily represent the development of negative sequelae such as PANDAS.

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Based on this diagnosis, antipsychotics such as Risperdal or Abilify are not first-line agents. The PMHNP should consider an SSRI such as Fluvoxamine.

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