How to diagnose a nursing case study (Solved)

How to diagnose a nursing case study (Solved)

Case Study: Katie Peterson, an 18-year-old woman, has been referred to you by her primary care provider for recommendations and treatment for autism spectrum disorder (ASD). Throughout childhood and adolescence, Katie’s support has not been consistent in managing her ASD, and her parents are seeking a PMHNP to address Katie’s anxiety, frequent temper outbursts, and increasing difficulties interacting with her peers throughout the day.

Her medical history includes seizures since the age of 11 months. A baseline SPECT scan revealed overactivity in the basal ganglia and marked increased patchy uptake throughout her cerebral cortex.
You start the interview with her dad present.

Katie’s Dad’s Transcript

Dad: Thanks for seeing us today. Katie has been getting more frequently restless and irritable at home. Her teachers report this behavior at school, too. This causes problems there and has made it hard for her to make friends. And maintaining the few friends she has. She has the skills to navigate social interactions, generally. But on the other hand, she is often inappropriate by approaching strangers and asking their name and age.

Her teachers report Katie having trouble more days than not, especially in her morning classes. Her problems often result in incomplete assignments even when she’s capable of doing them. When she is calm, she can sit by herself to complete work. But she often will make loud spontaneous noises, disturbing others.

Things had been going so well, but now that’s getting older… Well, we’re getting a little scared about what used to just be called temper tantrums, but I don’t think we can say that now that she’s an adult?

During her psychiatric interview, you observe Katie with repetitive behaviors and poor eye contact. At one point, she turns the lights on and off repetitively for several minutes before she can sit down to complete her evaluation.

From your perspective as Katie’s psychiatric nurse practitioner, answer the following questions in a four-page double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.

1. Confirm Katie’s diagnosis based on the information you have been given. Discuss the importance of the baseline SPECT scan.
2. Outline the types of resources you would recommend to help Katie function better.
3. What, if any, medications could help Katie improve her mood swings and anxiety? Provide rationale.
4. List two types of psychotherapy and a rationale that would help Katie. Explain why these psychotherapies are significant to your evaluation or diagnosis.

Solution to Case Study: Katie Peterson

Diagnosis of Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a complex developmental condition characterized by challenges with social communication, repetitive behavior, and restricted interests (Centers for Disease Control and Prevention (CDC), 2020). Early signs can be noticed as early as one year but they may be mild and not apparent until the child goes to school (Yu et al., 2020). Katie is a patient with ASD and has been inconsistent in managing the disease throughout childhood and adolescence. The justification of Katie’s diagnosis is based on the criteria described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as follows:

The areas used to assess for ASD include social communication, social interaction, and restricted and repetitive behaviors (CDC, 2020)). The patient must have deficits in social communication that may include social-emotional reciprocity challenges, problems with non-verbal communication, or deficits in maintaining and understanding relationships. Non-verbal communication is another challenge observed in patients with ASD. The individual will have problems with maintaining eye contact, problems understanding gestures, or a total lack of non-verbal communication (CDC, 2020). Secondly, an individual with ASD demonstrates restricted repetitive behavior patterns characterized by instances of stereotyped or repetitive motor movements, the insistence on sameness, or fixated interests that are abnormal. For example, ASD patients have an abnormal fixated interest in objects and have an unusual interest in sensory aspects of the environment (CDC, 2020). During diagnosis, the provider should ascertain the presence of the symptoms in the early developmental period and the symptoms should cause clinically significant impairment in important areas of current functioning.

Katie is a patient with ASD that has been present throughout her childhood and adolescence. Her medical history indicates that she has had seizures since the age of 11 months and a baseline SPECT scan reveals overactivity in the basal ganglia and patchy uptake throughout her cerebral cortex. Katie has challenges with developing and maintaining relationships that are consistent with ASD. Her father explains that she is irritable at home and frequently restless at school. Her teacher reports her having trouble with making friends and maintaining the few that she has. Kate has problems with establishing and maintaining communication despite having skills for social interaction. For instance, she is often inappropriate by approaching strangers and asking their names and age. During the interview, Katie demonstrates repetitive behavior by turning the lights on and off and maintaining poor eye contact indicating poor non-verbal communication skills. Additionally, she demonstrates hyperactivity to sensory input because she occasionally makes loud spontaneous noises disturbing others.

SPECT scan. Single-Photon Emission Computed Tomography (SPECT) scan is a nuclear study that evaluates blood flow activity in the brain. The most relevant areas when assessing for ASD in the brain include the cerebellum, anterior cingulate gyrus, frontal lobe, temporal lobe, and amygdala (Amen et al., 2017). A SPECT scan usually shows healthy activity, too little activity, or too much activity in these parts of the brain. Increased blood flow to the anterior cingulate gyrus and lateral cortex is associated with symptoms like repetitive speech and problems with transition and change. Overall increased activity in the brain observed in the scan translates to mood instability, emotional problems, and anxiety (Amen et al., 2017). Low activity patterns in the scan can be used to explain poor motor skills and problems with learning observed in ASD. Decreased activity in the parietal and temporal lobes contributes to communication difficulties, learning challenges, and problems with abstract thinking observed in patients with ASD.

Resources

Adults with ASD can benefit from several federal resources that highlight the journey through ASD. The resources I recommend to Katie include:

  1. Autistic Self-Advocacy Network (ASAN). ASAN is a non-profit organization run by people with autism and was created to support people with ASD while educating the community to improve public perceptions of autism (CDC, 2022).
  2. National autism resource and information center. This federal center provides information for adults with ASD and other developmental disabilities.
  3. Autism speaks. This resource provides information to adults about post-secondary educational opportunities for students with autism, employment opportunities, and a guide to special financial needs (CDC, 2022).
  4. Autism source, Autism Society of America (ASA). ASA provides a wide range of resources for local communities including contact information for local supports and ASA chapters.
  5. Autism treatment network. This organization creates standards of medical treatment and can be used by parents, healthcare providers, and patients who want to improve care for ASD (CDC, 2022).

Medications

Using medications to manage mood swings and anxiety is considered safe and effective. When used along with behavioral interventions, medications can help individuals cope well. I will recommend the management of mood swings and anxiety using selective serotonin reuptake inhibitors (SSRIs) (Kerns et al., 2016). The drugs work by improving the availability of serotonin neurotransmitters in the brain leading to improved mood and anxiety. Examples include fluoxetine and sertraline which are commonly used. I will recommend the use of SSRIs because they have fewer side effects than other antidepressants. Despite the use of medications like Citalopram to manage anxiety in ASD, non-pharmacological interventions have significant benefits over drug therapies.

Psychotherapy

Psychotherapy approaches that can help Katie include:

  1. Cognitive behavioral therapy (CBT)
  2. Applied behavior analysis (ABA)

Cognitive-behavioral therapy (CBT) is an option for the management of ASD, especially in patients with other mental conditions like anxiety and depression. This approach focuses on the connection between thoughts, feelings, and behaviors (Kerns et al., 2016). Because children with autism may have communication and challenges with expressing feelings, a special type of CBT can be applied to effectively manage their condition. CBT can also be an effective approach to managing Katie’s anxiety which affects communication and the establishment of relationships.

Applied behavioral analysis (ABA) is an approach to autism management that is based on the science of learning and behavior. It helps patients to understand how behavior works and how learning takes place (Yu et al., 2020). Using interventions like discrete trial training, ABA can help patients achieve desired behavior or responses by ignoring incorrect behavior (Yu et al., 2020). Aspects of ASD that can be improved using ABA include language and communication, attention, focus, memory, and social skills.

References

Amen, D. G., Sarabi, M. S., Willeumier, K., Taylor, D., Raji, C., Meysami, S., & Raghavendra, C. (2017). Functional SPECT neuroimaging using machine learning algorithms distinguishes autism spectrum disorder from healthy subjects. Journal of Systems and Integrative Neuroscience, 3(3). http://dx.doi.org/10.15761/JSIN.1000160

Centers for Disease Control and Prevention. (2020). Autism spectrum disorder (ASD): Diagnostic criteria. https://www.cdc.gov/ncbddd/autism/hcp-dsm.html

Centers for Disease Control and Prevention. (2022). Autism spectrum disorder (ASD): Links to other resources. https://www.cdc.gov/ncbddd/autism/links.html

Kerns, C. M., Wood, J. J., Kendall, P. C., Renno, P., Crawford, E. A., Mercado, R. J., Fujii, C., Collier, A., Hoff, A., Kagan, E. R., Small, B. J., Lewin, A. B., & Storch, E. A. (2016). The Treatment of anxiety in autism spectrum disorder (TAASD) study: Rationale, Design and Methods. Journal of Child and Family Studies, 25(6), 1889–1902. https://doi.org/10.1007/s10826-016-0372-2

Yu, Q., Li, E., Li, L., & Liang, W. (2020). Efficacy of Interventions based on applied behavior analysis for autism spectrum disorder: A meta-analysis. Psychiatry Investigation, 17(5), 432–443. https://doi.org/10.30773/pi.2019.0229

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