Obsessive Compulsive And Related Disorders Discussion Paper

Subjective

CC (chief complaint)

The patient states that he has severe stress and anxiety towards his upcoming deployment back to active duty station in Iraq. Erikson’s hope to resolve identity confusion and attain a sense of identity integrity is compromised, as he struggles internally with issues stemming from his sexual orientation and the potential consequences that could follow if he reveals his true identity to the military unit.

HPI: 

The situation described is a military reserve patient and the recurring stop-loss policy that forces him back into active duty in Iraq. He shows deep psychological pain of both grief and fear, which, coupled with the isolation resulting from the issue of determination to come out, is an indication of the psychological distress gay soldiers go through. The patient was able to indicate that the extent of the anxiety he goes through was that he felt trapped by the desire, to tell the truth about his gender and the fear of the consequences that making the revelation could yield in terms of relationship breakdown with the other soldiers. He feels that, and he is concerned with the consequences that may be associated with homosexuality concerning the unit, especially in matters that call for physical contact or frequent physical interactions. Obsessive Compulsive And Related Disorders Discussion Paper

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Past Psychiatric History: There are no past psychiatric illnesses present and the patient has had consistently significant homosexual feelings, which have been a source of conflict and have caused considerable emotional strain.

Medical History: Current Medications, The patient is not currently on any medications nor is he under any medication trials.

Medication trials: There is no history of the patient having been on any psychotropic medications.

Psychotherapy or Previous Psychiatric Diagnosis:  The experiences that may have caused the patient emotional distress have not been treated through psychotherapy or by a psychiatrist.

Hospitalizations: The patient has not been admitted previously for psychiatric-related issues.

Substance Current Use and History: The patient had no present use or history of using any substance.

Family Psychiatric/Substance Use History: As much as past medical history, there is no mention of a family history of psychiatric disorders or substance use. Obsessive Compulsive And Related Disorders Discussion Paper

Psychosocial History:

The patient had dedicated several years in military service. It will also remain this way since he can never reveal his sexual orientation because most organizations will send him home as they frown upon such individuals. The social situation within the military I presume makes his living conditions collective and rather friendly which contributes to his stress because of the supposed homosexual tendencies and the subsequent fear of how his colleagues would treat him if they were to learn that he is a homosexual. Ladler also notes that he gets stressed listening to the rude things people say about homosexuality, and thus, he feels lonely.

Allergies: The patient has no known allergies.

Reproductive Hx:  Not mentioned in the case study.

ROS

GENERAL: The patient reports feelings of sadness and fear but does not mention weight changes, fever, nor fatigue. Obsessive Compulsive And Related Disorders Discussion Paper

HEENT: No issues reported.

SKIN: No concerns reported.

CARDIOVASCULAR: No symptoms such as chest pain or palpitations were reported.

RESPIRATORY: No complaints such as shortness of breath or cough.

GASTROINTESTINAL: No gastrointestinal issues were reported.

GENITOURINARY: No concerns reported.

NEUROLOGICAL: No neurological symptoms such as headaches or dizziness mentioned.

MUSCULOSKELETAL: No musculoskeletal complaints.

HEMATOLOGIC: No bleeding or bruising issues were reported.

LYMPHATICS: No lymphatic concerns were mentioned.

ENDOCRINOLOGIC: No symptoms such as heat or cold intolerance were reported.

Objective

Physical exam:

GENERAL: Patient appears well nourished and in no acute distress.

VITAL SIGNS: Blood pressure: 120/80 mmHg, Heart rate: 72 bpm, Respiratory rate: 16 breaths per minute, Temperature: 98.6°F, Oxygen saturation: 98% on room air.

HEENT: Head is normocephalic and atraumatic. Eyes: Pupils equal, round, and reactive to light and accommodation (PERRLA). Ears: Tympanic membranes clear. Nose: No nasal discharge. Throat: No erythema or exudates. Obsessive Compulsive And Related Disorders Discussion Paper

SKIN: No rashes or lesions observed.

CARDIOVASCULAR: Heart sounds are regular with no murmurs, rubs, or gallops.

RESPIRATORY: Lungs are clear to auscultation bilaterally with no wheezes, rales, or rhonchi.

GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended. Bowel sounds are present and normal.

GENITOURINARY: No abnormalities observed.

NEUROLOGICAL: Cranial nerves II-XII are intact. No motor or sensory deficits. Reflexes are 2+ and symmetrical.

MUSCULOSKELETAL: Full range of motion in all extremities. No joint swelling or tenderness.

PSYCHIATRIC: Patient is alert and oriented to person, place, time, and event. The mood is anxious, and the effect is congruent with the mood. No hallucinations or delusions were noted.

Diagnostic Results

Lab Tests: Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), Thyroid Stimulating Hormone (TSH), and Urinalysis. All results are within normal limits.

Imaging: No imaging studies were conducted.

Psychological Assessments:

Beck Anxiety Inventory (BAI): The score indicates moderate anxiety.

PTSD Checklist for DSM-5 (PCL-5): The score suggests the presence of PTSD symptoms, warranting further evaluation.

Generalized Anxiety Disorder 7-item scale (GAD-7): Score indicates moderate to severe anxiety. Obsessive Compulsive And Related Disorders Discussion Paper

Assessment

Mental Status Examination:

The patient is a well-dressed and present well-groomed man with features that are suggestive of the timeframe he mentioned. This patient is oriented on the person, place, time, and event with no impulse control or judgment deficits. This is manifested in his reported mood which is anxious and also as observed from his affect he was distressed and wringing his hands (American Psychiatric Association, 2022). He has no discernible change in the rate or tone of his speaking, however his choice of words displays hidden anxiety and concern.

It can appreciated that the patient’s thinking is logical and coherent, but this is most easily described as being driven by paranoid preoccupations on the part of the patient about his sexuality and how the other young men might respond to him. Concerning psychosis, there are no themes apparent that include hallucinations or delusional thinking (Boland et al., 2022). Although the patient stated no suicidal ideation at this time, the patient did report that he has entertained suicidal thoughts. He is mentally capable of making sound judgments, but the anxiety and fear of rejection that he has will get in the way of his ability to think well.

Differential Diagnoses:

1. Adjustment Disorder with Anxiety:

As the patient initially presented, the client’s concerns over going back to his military duties and the concern about revealing his sexual orientation are therefore not generalized anxiety disorder because they develop due to some identifiable stressor (Roberts, 2019). And based on the DSM-5-TR, Adjustment Disorder with Anxiety could apply to this patient as it requires that the patient has a stressor in his/her life and has a set of emotional/behavioural symptoms related to the stressor.

2. Generalized Anxiety Disorder (GAD):

The patient presented with multiple Axes I and II diagnosis with specific emphasis on anxiety regarding his sexual orientation and any involvement with the military. GAD is diagnosed when the patient demonstrates excessive anxiety and worry for a period of introduction, every day, for not less than six months (Hyman, 2019). The onset and the specific factors to which the anxieties are related make adjustment disorder more likely; however, GAD should be considered for its chronicity in the patient. Obsessive Compulsive And Related Disorders Discussion Paper

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3. Post-Traumatic Stress Disorder (PTSD):

Indeed, because the patient carries a prior military and because the stress inherent in going back in theater can be severe, PTSD has to be a differential. Even if the patient does not report classic PTSD features like flashbacks, the continuous Selye’s stress response together with hypervigilance to social exclusion can certainly meet PTSD criteria particularly within a military setting.

Reflections

This case shows how arriving at a proper diagnosis of a psychiatric disorder in patients exposed to multiple stressors in their lives is always a formidable task. Concerning culturally competent care, the inner conflict regarding his sexual orientation and the possible rejection within the military framework reflect both the patient’s context. He needs a therapeutic setting and support; this will enable him to open up and to effectively address his anxiety conditions. This would mean that besides having to prepare the patient in terms of what is required of him or her before he or she is deployed and while in the foreign country, there must also be available of resources as well as support systems for the patient. Obsessive Compulsive And Related Disorders Discussion Paper