Transcript case studies

Anxiety & Somatic Symptom
Disorder: CASE STUDY
WI Alliance of Child Psychiatry &
Pediatrics (WACPP)
James Meyer MD
4/14/2015
Disclosure Statement
I, James Meyer, M.D., do not have any relevant
financial interest or other relationship(s) with a commercial
entity producing health-care related product and/or services.
I will indicate during this presentation when a
medication use or dosage is other than an FDA approved
treatment.
Case:
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Angela
Presents at age 16 yrs with both parents for second
opinion with concern regarding daily headaches that
interfere with attendance at school.
Headaches are daily described as tight ache to
throbbing present all day every day.
No night waking but may affect falling asleep. Has a
HA if she wakes at night which happens 1-2 times
per week. Does not think she wakes b/o HA.
Light might bother but no visual spots or vision
change.
Loud noise may bother but no ringing in ears.
Case:
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Angela
May get nausea but no vomiting,
paresthesias, neck pain and no facial
flushing, eye tearing, rhinorrhea or nasal
congestion.
Not correlating with meals or specific
foods and drinks a lot of fluid do to
orthostatic hypotension with prior positive
tilt table test.
Not worse with menses or hormonal RX.
No concussion or whiplash
Denies a specific worry as to cause of HA
Case: Angela HA RX’s
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CT and MRI of brain in past 18months=WNL
Prior amitriptyline up to 50mg at HS.
Prior beta blocker (may have helped
orthostatic low BP) but not HA.
Prior topiramate bid.
Recent Botox injection-changes HA but not
getting rid of them.
Counseling regarding parents divorce.
Case:
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Angela PMHx
No prenatal problems.
No major early colic, developmental or
temperament issues but issues with
difficult transitions (new day care, start
school, separation from parent, etc. ).
Extensive GI evaluation age 9-10 for
recurrent abdomen pain (no formal
diagnosis and all labs/biopsies were
normal)
Case:
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Angela PMHx
Exercise induced asthma diagnosed 2
years ago for feeling like she can’t catch
her breath/take a deep breath in BB
games (not practice). Progresses to
feeling scared, fears she will die and has
had paresthesias. Early response to
albuterol used prior to exercise. Over
time felt that it was not working and
Advair was added(250/50). Has quit BB.
Regional Pain Syndrome after minor foot
injury last year.
Case:
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Angela
Maximum stress is school: good student (A’s & B’s)
but hard to keep up and misses 2-5 days per week.
Missed 80 days last year.
Peers tease her about playing hooky.
Worries about everything-needs to know what is
coming at her in advance. Likes routines.
Upset with worry if parents not home when they are
expected.
Sense of SOB, sweats and dread out of blue
1X/month. Relieved by getting away from people.
Somewhat meticulous with order/neatness.
No abuse, disordered eating or suspected drugs.
Case: Angela Social Hx
 Splits time between mom and dad/dads GF homes.
Parents divorced one year ago. Two older full siblings
(one away at college this year) and one infant half
paternal sib. Mom was a homemaker but now
working as a secretary. Dad a teacher. Misses more
school when staying with her mom.
 11th grade A & B student. Pushes herself hard for
grades. Feels she does not concentrate well. Does
well on statewide achievement tests. No suspected
ADD/ADHD or learning disability.
 Has a few close friends. Not dating.
Case:
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Angela FHx
Mom on meds for anxiety/depression over past
10 years (citalopram with occasional
lorazepam). Has migraines as does MGM.
Maternal aunt with life long panic attacks.
Sister allergic rhinitis but no family member with
asthma or EIA.
No FHx of sudden death, arrythmia, early heart
disease.
Case:
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Angela EXAM
Mom seems worried about her daughter.
Dad seems frustrated with his daughters
many physical symptoms.
Normal exam with stable weight/HT trend
No suggestion of pallor/anemia, thyroid
dysfunction, obstructive nasal breathing,
or other medical conditions.
Jumps up & down 100x with good effort
and no symptoms. No change in pre to
post peak flow.
Case:
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Angela Prior LABs
Labs: WNL CBC with differential,
ferritin 12 (nl >14), TSH, MPC, ESR and
Lyme titer.
Normal spirometry with negative
methacholine challenge.
Prior normal EKG.
Normal Neuro imaging.
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2
15
17
Total score: Average score 4.9
>10 + signif. anxiety
>15 + severe anxiety
Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for
assessing generalized anxiety
disorder. Arch Inern Med. 2006;166:1092-1097.
CASE:
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Angela
Screen for Child Anxiety Related Disorders (SCARED)
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Child Version score is 40
Parent Version score is: mom 44, dad 36
Primary points being attained by noting: not enjoy being
around people does not know, HA’s at school, scared
sleeping away from home, feeling nervous, gets shaky, heart
racing, looking nervous, worries about being liked, being as
good as other kids, about things that have already
happened, and something bad happening to parents.
A SCARED score of over 30 indicates significant anxiety
(normal is less than 25).
Generalized Anxiety Disorder
The Diagnostic and Statistical Manual of Mental Disorders
(4th Ed; DSM-IV)
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Criteria for diagnosis
A. At least 6 months of "excessive anxiety and worry" about a variety of
events and situations.
B. There is significant difficulty in controlling the anxiety and worry or major
struggle to regain control, relax, or cope with the anxiety and worry.
C. The presence for most days over the previous six months of 3 or more
(only 1 for children) of the following symptoms:
1. Feeling wound-up, tense, or restless
2. Easily becoming fatigued or worn-out
3. Concentration problems
4. Irritability
5. Significant tension in muscles
6. Difficulty with sleep.
D. The symptoms cause "clinically significant distress" or problems
functioning in daily life (home, school, peers, relationships and work).
E. The condition is not due to a substance, medical or other mental health
issue
Case:
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Diagnosis
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Angela
Chronic daily headache
Generalized Anxiety Disorder
Plan of Care:
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Reassurance- symptoms are real
but exacerbated by stress and
bodies physical response to
stressors.
Relaxation exercises. Mindfulness
training.
Therapy/counseling
Medication
Case: Angela Treatment
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Therapy/counseling:
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Refer for counseling to address role of stress
response in her physical symptoms.
Will re-focus thoughts on positive thoughts and
actions to relieve symptoms.
Family to avoid over focus on symptoms.
Address school stressors.
Medication- SSRI citalopram 10mg increasing
to 20mg after 1 week.
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Discuss aspects of use, side effects and risks
including the black box warning and needed follow
up. Provide family with a written handout on SSRI’s
and anxiety.
Case:
Angela F/U
Follow upPhone update in 1 week to screen for:
- red flags (agitated, suicidal thoughts, major
sleep issues)
- basic side effects (tremor, nausea, bowel
changes, weight/appetite, fatigue/sleep issues)
- compliance
- any other concerns
Appointment in 2 weeks for review of above plus
thoughts and actions that patient family have used to
decrease stress and focus on positives.
Case:
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Follow up at 2 weeks
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Angela
Some generalized improvement noted by patient and
parent.
No ill effects of SSRI’s and compliant.
Phone follow up at 4 weeks without concerns
believe med is helping
Follow up at 6 weeks
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Overall less stressed and overwhelmed
Has been meeting with counselor every 2 weeks
focusing on relaxation exercises, activities which calm
her down and relieve worried thoughts
Has been doing better with school attendance and less
HA complaints.
Contact Information
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Dr. James Meyer
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Marshfield Clinic
[email protected]
Dr. Joseph O’Grady, Jr.
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715-387-5251
[email protected]
Medical College of WI
414-955-8935
WI Counsel of Child/Adolescent Psychiatrists