Case #2
Anxiety disorder, OCD, or something else?

8-year-old black male

 

Decision Point One


 Generalized Anxiety Disorder (GAD)
Decision Point Two
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


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 Student

While 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 Student

While 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 Student

While 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.


Begin cognitive behavior therapy (CBT)

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 Student

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.

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 Student

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.

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 Student

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.

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.


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.


Increase Zoloft to 100 mg orally daily
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.

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 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.

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 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.

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.