Background Tyrrel Is An 8-Year-Old Black Male ✓ Solved

Backgroundtyrel Is An 8 Year Old Black Male Who Is Brought In By His M

Backgroundtyrel 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 two 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 two 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 eight days over the course of the last three weeks. He has also stopped playing with his best friend from across the street. His mother 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 around you. He warms up 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 questioned as to why, he 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 asked how many times a day he washes his hands, he shrugs his shoulders again. You observe that his bilateral hands are dry. Throughout the assessment, Tyrel reveals that he has been thinking about how dirty his hands are; and no matter how hard he tries, he cannot stop thinking about his “dirty” hands. He reports that he feels “really nervous” and “scared” that he will get sick, and that the only way to feel better is to wash his hands. He states that washing his hands temporarily alleviates his anxiety, but then he questions whether he washed well enough or missed areas, leading to increasing fear and more handwashing.

Mental Status Exam

Tyrel is alert and oriented to all spheres. Eye contact varies throughout the interview. He reports his mood as “good,” admits to anxiety. Affect is consistent with self-reported mood. He denies hallucinations, delusions, paranoia, and suicidal ideation. Laboratory studies from the pediatric nurse practitioner are all within normal limits, except an antistreptolysin O antibody titer which is elevated.

Decision Point One

Which diagnosis corresponds best to Tyrel’s symptoms? Support your choice with specific DSM-5 criteria. Options include:

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

Decision Point Two

Based on the information provided, what is the next appropriate step in management? Justify your choice.

• 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

Decision Point Three

What is the subsequent next step in management? Justify your choice.

• Increase Fluvoxamine to 50 mg orally at bedtime
• Augment with an atypical antipsychotic such as Abilify
• Augment treatment with cognitive-behavioral therapy

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
• Khan, S., & Rapee, R. M. (2010). Family accommodation in childhood anxiety disorders: A systematic review. Clinical Child and Family Psychology Review, 13(4), 324-339.
• Ginsburg, G. S., & Dell'Osso, B. (2011). Pediatric anxiety disorders. In S. H. Zachary, M. M. Haney, & R. G. Williams (Eds.), Child and adolescent psychiatry (pp. 257-269). Springer.
• Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115-1125.
• Walkup, J. T., et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753-2766.
• Freeman, J. B., et al. (2010). Pharmacotherapy for pediatric anxiety disorders: Effectiveness and safety. Journal of Child and Adolescent Psychopharmacology, 20(2), 105–118.
• Peris, T. S., et al. (2015). Cognitive-behavioral therapy for childhood anxiety disorders: A meta-analytic review. Journal of Anxiety Disorders, 29, 44–57.
• Swedo, S. E., et al. (2012). Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): Clinical descriptions and research investigations. American Journal of Psychiatry, 169(8), 239-247.
• McGuire, J. F., et al. (2014). Evidence-based psychotherapies for pediatric OCD: An update. Journal of Clinical Child & Adolescent Psychology, 43(6), 911–927.