Case 3: Volume 2, Case 21: Hindsight is always 20/20, or attention deficit hyperactivity disorder
This case study presents a 31-year-old male who presents with a chief complaint of “anxiety of different types.” He has had a history of feeling anxious throughout college and reports having symptoms of feeling tense, restless, irritable, and worried, which has made him argumentative and temperamental. He is employed, married, denies substance use, and denies having any medical history. He has had psychotherapy in the past, which reveals that he encountered issues with his abusive, alcoholic father. In the past, he has taken hydroxyzine for his allergic skin reaction and noticed anxiety with that medication and has taken paroxetine augmented with tiagabine, in which he has had a reasonable response. Three different providers prescribe all three medications that he is on. This client has a chronic generalized anxiety disorder and reported to be adherent to his medication and reports minor sexual side effects and fatigue from the medications.
Three Questions to Ask
It was reported that the client likes to stay busy all of the time and that he has no time for all of the things. I would ask this client if he has any hyperactivity or impulsivity symptoms, such as fidgeting, often on the go, talks excessively, difficulty waiting his turn, or interrupting or intruding on others. These symptoms are aligned in the criteria within the Diagnostic and statistical manual of mental disorders 5th edition (DSM-5) that is characterized by the hyperactivity portion of attention deficit hyperactivity disorder (ADHD) diagnosis (American Psychiatric Association, 2013). I would also ask about the inattention symptoms of ADHD, such as failing to give close attention to detail, not listening when spoken to, difficulty organizing tasks, forgetful in daily activities, or easily distracted by extraneous stimuli (American Psychiatric Association, 2013). I would ask about his history with his father and inquire about the type of abuse he had with him and then assess if the patient has experienced any dreams, flashbacks, avoidance of certain places or people, and having any reactivity associated with the traumatic event, such as irritable behavior, hypervigilance, startled response, or sleep disturbances; in which these symptoms align with the criteria of having posttraumatic stress disorder (PTSD) (American Psychiatric Association, 2013). The client did mention that he noticed to be more argumentative and temperamental, so it would be ideal to rule out PTSD.
Source of Information from Family Members
This case study reveals that the client is married. Asking the spouse about any symptoms that he or she has witnessed can gain insight about the client’s condition. It would be wise to obtain another perspective of the client to gain more evidence that the symptoms interfere with the quality of his interpersonal relationships or occupational functioning, especially if the patient has poor insight and judgment.
Physical Exam and Diagnostic Testing
Since this patient is suspected of having a chronic generalized anxiety disorder (GAD), this patient will require a careful history and physical exam and an evaluation of generalized anxiety disorder. Any medical disorder which may induce anxiety or depressive symptoms should be ruled out. Patients with late-set anxiety, weight loss, or cognitive disability are known to be at higher risk of having a physical-related cause of anxiety in which laboratory tests may include a complete blood count, chemistry panel, urinalysis, thyroid-stimulating hormone, rapid plasma reagin, and urinal toxicology screen (Wilde, Kim, Schulz, & Yudofsky, 2014). For any life-stressors that have caused anxiety or depression, the assessment will include any drug abuse history, medical history, family psychological history, and social history.
Three Differential Diagnoses
This patient has a differential diagnosis of generalized anxiety disorder. The DSM-5 determines that the diagnosis of a general anxiety disorder requires the development of chronic anxiety and worry for more than six months, issues of worry management, and the presence of three or more anxiety symptoms. (American Psychiatric Association, 2013). Such signs can include restlessness, exhaustion, difficulty concentrating, irritability, muscle tension, and sleep disturbances. Such symptoms must have distress or impairment in the daily life of the patient, and no other cause or reason is explained in a better way. Another differential diagnosis that this patient may have is a posttraumatic stress disorder. As mentioned earlier, this diagnosis requires having six or more symptoms of inattention and or six or more symptoms of hyperactivity and impulsivity (American Psychiatric Association, 2013). Such symptoms must have occurred before age 12, symptoms are present in two or more environmental contexts, symptoms interfere with social, academic, or occupational functioning, and these symptoms are not explained adequately by another condition. The third differential diagnosis would be mania, since ADHD shares some characteristics with manic symptoms of distractibility, impulsivity, and increased talkativeness (American Psychiatric Association, 2013). Mania, however, is more distinguishable by other symptoms of grandiosity, increased sexual drive, elevated mood, and rapid cycling.
Pharmacologic Therapy
For this clinical case study and based on the information provided, the goal of helping the patient have fewer anxiety symptoms will need to be addressed. The patient is noted to be on three different medications, hydroxyzine, paroxetine, and tiagabine, all of which have different mechanisms of action. He is considered to be partially responding to his current medication regimen as he is having symptoms of feeling tense, restless, irritable, and worried, which has made him argumentative and temperamental. Given the limited information from this case study and assuming that his diagnosis of generalized anxiety disorder is correct as assumed by the initial portion of the case study, this patient should have his paroxetine dosage increased. Selective-serotonin reuptake inhibitors, such as paroxetine, have been shown to improve symptoms of generalized anxiety disorder, as shown in randomized controlled clinical trials (Stocchi, 2003). Since the client is currently taking paroxetine-CR 25 mg per day, he can have his paroxetine dose increased by 12.5 mg per day once a week of up to 75 mg per day (Stahl, 2014). This dosage increase would be dependent on reassessing the client first to see if he has an appropriate response. If the patient meets the diagnostic requirements for ADHD after providing a detailed assessment and gaining further information, the patient should initially be treated with a non-stimulant drug based on his family history of substance use disorder. He would be discontinued from the hydroxyzine and tapered from the tiagabine and paroxetine first. To avoid any risks of misuse or habit forming behavior due to his family history of alcohol dependency, it is suggested to a non-stimulant medication, such as atomoxetine, instead of an amphetamine or methylphenidate, as atomoxetine is efficacious in treating adults with ADHD (Cunill, Castells, Tobias, & Capella, 2013). This medication blocks the reuptake of norepinephrine reuptake pumps and increases noradrenergic neurotransmission to help reduce symptoms of ADHD (Stahl, 2014).
Check Points and Therapeutic Changes
At the first meeting, the client requested to increase his hydroxyzine dose to 100 mg per day; however, he returned to the clinic complaining of the same symptoms with increased sedation. At this point, I would decrease his hydroxyzine dose back to 50 mg per day and reassess for the potential of having ADHD, as discussed earlier. At this point in treating his symptoms, however, we could opt for increasing his paroxetine dose, as also explained earlier.
At the two-month follow-up visit, the client has tapered off hydroxyzine, and his dose of paroxetine and tiagabine were increased, in which he reported feeling 20-30% better than his last appointment. At this point in the case study, I would wait and reassess in the future follow up appointments to see if he continues to improve as he reported to have a response in his medication increase. If he has not achieved remission, his paroxetine-CR can be titrated to a higher dose of up to 75 mg per day, as long as his side effects are manageable (Stahl, 2014).
At the five-year follow up, the client reports having performance anxiety and hyperarousal with additional stressors in his life and increases in his generalized anxiety disorder symptoms. We can continue to try and prescribe a serotonin-norepinephrine reuptake inhibitor (SNRI), or we can reassess for ADHD. Individuals with anxiety disorders may be overwhelmed by the disorder’s emphasis, which is close to the distractibility seen in ADHD (American Psychiatric Association, 2013). Using an SNRI, such as venlafaxine or duloxetine, have been found to be efficacious in the treatment of generalized anxiety disorder (Carter & McCormack, 2009; Stahl, Ahmed, & Haudiquet, 2007).
The six-year follow up shows that the patient was started on propranolol 30 mg as needed for his performance anxiety with a good response. He has augmented on Deplin 7.5 mg per day to help decrease his anxiety. Deplin did not produce a response and was discontinued, and instead, buspirone 30 mg per day was augmented, while tiagabine was tapered off. This combination did not help treat the patient’s anxiety. At this time, his paroxetine can be increased, or he can be switched over to an SNRI, such as venlafaxine, as mentioned earlier.
The next follow up outcome reports that the patient has tapered off paroxetine and is started on duloxetine, an SNRI, with a dose of 60 mg per day. He is given 0.5 mg of Xanax to help manage his anxiety while transitioning to duloxetine. During his monotherapy of duloxetine, he reports improvement in his symptoms; however, he reports having inattention, inability to focus, which raises his anxiety. He also endorsed having hyperactivity while he was physically injured and experiencing the same feeling during his childhood. This raises the question of this client likely having the diagnosis of ADHD, and the treatment should be based on pharmacological therapy to manage ADHD, as mentioned earlier.
Lessons Learned
There were several lessons learned from this clinical case study. This patient has been initially diagnosed with a generalized anxiety disorder, and the treatment was based on his symptoms surrounding his anxiety. Instead, his generalized anxiety was related to his ADHD, and treatment should have been centered around managing his ADHD. This lesson can be brought into my professional practice by ensuring a thorough initial psychiatric exam is performed and to consider ADHD as a diagnosis earlier if suspected by utilizing diagnostic rating scales.
