Introduction: Identifying Information
Name/age/sex: D.O.E./18/FEMALE
Marital status: Single
Ethnicity or race: Caucasian
Date of appointment:
- Individuals present: Caregivers (foster parents)
- Location of visit: In-person visit to patient’s home.
- Purpose of visit: Comprehensive psych assessment
Chief Complaint
Reason for visit: The foster mother reports the patient gets extremely hyperactive, which has caused the child to self-harm. D.O.E. ran into traffic and was injured after colliding with a motorist. She threatened to slit her wrists in arguments with the foster mother.
History of Present Illness/Interval History
The patient was diagnosed with ADHD after incurring significant brain damage after a car accident when she was 12 years old. After the accident, the patient experienced a lapse of concentration in class and irritability such that she could not keep still in her chair. The teachers considered the child to lack self-esteem, with tendencies of isolation in a social context. Moreover, she experienced daytime sleepiness and daydreaming. Her cutting off her finger in the kitchen could highlight the distinct lapse of concentration. The illness escalated when the child interrupted class, spoke too loudly, and became agitated when required to wait her turn.
Psychiatric Review of Systems
Depression: Socially isolated and low self-esteem.
Anxiety: Restless squirming and fidgeting.
Mania: No reports of manic episodes.
Psychosis: No apparent signs of delusion.
ADHD: Present from past diagnosis and reports.
OCD: No apparent symptoms for diagnosis.
Trauma: Traumatic car crash, losing her parents at age 12.
Sleep Disorder: Irregular sleeping patterns, with nightmares and daytime sleepiness.
Eating Disorder: The patient experiences a binge eating disorder with a high food intake.
Medical
Current medical issues: Elevated aggression and irritability, lack of sleep, and depressive episodes in isolation.
Past medical issues and surgeries and procedures:
- Brain surgery
- Binge eating/compulsive eating disorder
- Type 2 Diabetes
- PCP: Primary care provider is the public hospital physician.
- Current medications: The patient is taking Methylphenidate (MPH amphetamines, a psychostimulant, as the first line of care with a dose of 55 mg once a day.
Risk Assessment
Suicide: The patient has a high risk of suicide, reporting ideas of slitting her wrists, but has not acted on them. She also experiences hyperactivity running into traffic. The intentions to commit suicide are linked to delusional guilt of being different from their peers and her depressive state, isolating herself from social groups. There are no primary motivations for living.
- Level of acute risk of suicide: High
- Level of chronic risk of suicide: Moderate
- Homicidal Ideations and/or Aggression: The patient’s history presents no signs of individual thoughts or intentions of committing suicide.
- Level of acute risk of homicide:Moderate
- Level of chronic risk of homicide: Mild
Past Psychiatric History
Prior diagnoses, treatments, and response: The patient was diagnosed with ADHD and was prescribed amphetamines, later switched to Methylphenidate (MPH) when they experienced substantial outbursts of anger and aggression.
Past medications: Amphetamines, a psychostimulant, were the first line of care with a dose of 5 mg once a day that was increased to twice a day at 15.
Past outpatient treatment: No therapy prescribed
Psychiatric hospitalizations/residential treatments: No prior admissions.
Past suicide attempts: Unintentional cases of the patient running into traffic.
Prior aggressive behaviors: The patient experiences outbursts at school and home, getting agitated, especially when they want something.
Self-harm/injury: Chopped her finger while chopping vegetables.
Symptom scales/questionnaires used, score, and interpretation: The patient was tested using the ADHD-RS 18-question self-report tool. Based on her responses on the Likert scale, she scored 39 with a mean item score >2, presenting too many symptoms, which implies D.O.E. has ADHD and would require further clinical assessment.
Clinical Impression/Formulation/Medical Decision-Making
During the assessment, the patient appears to experience agitation, irritability, squirming, and fidgeting. She was unable to answer my questions in quick succession, presenting inattention. The patient also spoke loudly and interrupted the assessment process, regularly reaching out to touch instruments and equipment around the desk. The presented symptoms are characterized by a neurodevelopment disorder that is potentially an acute level of ADHD
Diagnosis
Based on the clinical impression and assessment, the patient meets the integral criteria for ADHD diagnosis as per the DSM-V-TR. The patient meets the criteria with a combined presentation of inattentiveness, hyperactivity, and impulsivity. Objectively, the diagnosis presents a severe prognosis as the patient exceeds the minimum requirements for diagnosis.
Treatment Plan
The treatment plan will incorporate a combination of psychotherapy and pharmacological mechanisms. The pharmacologic prescription is the use of CBT approaches and psychostimulants.
TREATMENT GOAL(s): The treatment goal is to regulate the compulsive behaviors and hyperactivity of the patient. The care plan is targeted at partial remission of the aggressive behavior of D.O.E., allowing appropriate social interactions and improved sleeping patterns. The sleeping patterns should increase to at least 6 hours. The CBT approach is applied as an alternative medical approach to manage the aggressive behavior seemingly induced by social interaction with peers.
PROGNOSIS: Fair
FOLLOW-UP: Every three week
The case was reviewed and discussed with M.D. Bradley, who concurred with the assessment, clinical impression, and plan of treatment.
Evidence-Based Treatment
Medication: The patient will continue taking methylphenidate with a methylphenidate multi-layer release, prescribing a 55 mg dose daily. Based on clinical trials, discontinuing and continued use after long-term use of methylphenidate was deemed an effective pharmacotherapy option for adults. Matthijssen et al. (2019) conducted the study measuring the symptoms using the ADHD Rating Scale (ADHD-RS). The findings presented a higher score of effective change in those that continued than in the discontinued group, with ADHD-RS scores of 21.4 and 19.76, respectively. The result reflects the empirical connotation that maintaining the prescription is effective even after long-term use of over two years. However, the treatment plans need the supplement of alternative care plans to sustain the remission of symptoms.
Psychotherapy: Cognitive-Behavioral Therapy is a model that is considered an adjuvant evidence-based treatment. Nøvik et al. (2020) postulated that group behavior therapy is effectively applied through a 12 weeks program to influence peer-based management of ADHD patients. Andersen et al. (2021) concurred with the empirical conditions, considering an increased treatment of ADHD and medication adherence. The program was incredibly impactful for patients with a history of recurring symptoms, even with medication. Therefore, the CBT model will supplement the medication regimen prescribed, optimizing patient outcomes.
Development: Based on age, the patient should be in the late stages of Erikson’s identity vs. role confusion stage, occurring between 12-18 years (Mathes, 2019). As Kohlberg prescribed, the patient’s symptoms are in the conventional moral development stage. The symptoms align with D.O.E.’s self-interest, aggression, and motivated vengeance when something is taken from her, with an egotistic sense of individual need. Her actions are not entirely congruent with the conventional stage that supersedes this stage.
Patient Education: The patient requires education and reassurance that her case is a manageable psychological disorder through pharmacological and psychotherapy options or a combination. The impact of the treatment mechanisms will target different elements of the disease, such as the medicine aimed at reducing depressive episodes and the peer-based CBT targeted at managing the patient’s aggression. Ultimately, the patient will be educated on the best ways to report any feelings that may link to suicide risk.
References
Andersen, A. C., Sund, A. M., Thomsen, P. H., Lydersen, S., Young, S., & Nøvik, T. S. (2021). Cognitive behavioural group therapy for adolescents with ADHD: a study of satisfaction and feasibility. Nordic Journal of Psychiatry, 76(4), 1–7. Web.
Mathes, E. W. (2019). An evolutionary perspective on Kohlberg’s theory of moral development. Current Psychology, 40(8). Web.
Matthijssen, A.-F. M., Dietrich, A., Bierens, M., Kleine Deters, R., van de Loo-Neus, G. H. H., van den Hoofdakker, B. J., Buitelaar, J. K., & Hoekstra, P. J. (2019). Continued Benefits of Methylphenidate in ADHD After 2 Years in Clinical Practice: A Randomized Placebo-Controlled Discontinuation Study. American Journal of Psychiatry, 176(9), 754–762. Web.
Nøvik, T. S., Haugan, A.-L. J., Lydersen, S., Thomsen, P. H., Young, S., & Sund, A. M. (2020). Cognitive–behavioural group therapy for adolescents with ADHD: study protocol for a randomized controlled trial. BMJ Open, 10(3), e032839. Web.