Appropriate treatment plan for transgender youth with depressive and anxiety disorder 

Appropriate treatment plan for transgender youth with depressive and anxiety disorder 

Appropriate treatment plan for transgender youth with depressive and anxiety disorder

Master of Science in Nursing, Walden University

PRAC-6675-33: PMHNP Care Across the Lifespan 11 Practicum

Date:

Complex Case Study

This case study is about a 13-year-old Caucasian female to male transgender patient. He wanted to be addressed with masculine pronouns, but his parents are not accepting his transgender identity causing him a lot of stress, anxiety, and depression for the past two years (Sadock et al,2015). The purpose of this paper is to assess and diagnose a transgender youth, develop a focused SOAP note with differential diagnosis, and formulate a treatment plan of care and a case presentation.

Learning Objectives:

By the end of this presentation, my audience should be able to :

· Recognized the signs and symptoms contributing to distress in a transgender individual.

· Outline the typical presentation of transgender youth with gender dysphoria.

· Identify the appropriate treatment plan for transgender youth with depressive and anxiety disorder and the rationale for the treatment (Garg et al., 2022).

Patient Information: Initials: PK Age: 13 years Sex: Male Race: Caucasian

Appropriate treatment plan for transgender youth with depressive and anxiety disorder 

Subjective

Chief complaint: “They don’t understand is my life.”

HPI: 13 years old Caucasian female to male transgender youth presented to the clinic for psychiatric evaluation. The patient reports he recently came out as transgender. Stated, “when I told my parents and other family members to call me Alex and address me as he and him they refuse to honor my wish”. He stated I like to wear only boys’ clothes and want to do things like boys but my parents are not accepting my wish and won’t let me. Reports increased anxiety, depression, difficulty concentrating on school work, and afraid he is going to fail his final examination (Sadock et.al, 2015). He expresses frustrations in developing secondary characteristics associated with females. Reports feeling very sad for the past month and sleeping a lot during the day because he does not want to see anybody. He endorses low self-esteem, eats a lot more causing him to gain 7 pounds weight within a month, anger, and suicidal thought. But he denies any plans of harming herself, and others currently (Walkup, 2017).

Past Psychiatric History:

Medications trials and current medications: No medication trial reported

· Currently taking Fluoxetine 40 mg orally daily. For anxiety and depression.

Psychotherapy or previous psychiatric diagnosis:

· Reports family psychotherapy- 6 months ago.

· History of anxiety and depression r/t gender identity issues.

Substance Current Use:

· Denied any past or current substance use.

Family Psychiatric/Substance Use History

Brother: Died from Opioid overdose at 21 years old.

Psychosocial History:

· PK is in 8th grade and lives at home with his parents and younger sister.

Medical History: Denied any

· Current Medications: Fluoxetine 40 mg orally daily. For anxiety and depression.

· Allergies: Denied any food or drug allergies

· Reproductive History: Full-term child, currently not sexually active.

ROS:

· GENERAL: Claims he gained 7 pounds in a month. No fever/ chills.

· HEENT: Normal headache size, no dizziness, hearing loss, runny nose, or sore throat.

· CARDIOVASCULAR: No palpitation or chest discomfort.

· RESPIRATORY: No SOB, cough, or wheezing.

· NEUROLOGICAL: No tremors or seizures activity

· HEMATOLOGIC: No bruises or bleeding issues.

· ENDOCRINOLOGIC: Reports weight gain, no heat or cold intolerance.

Objective

· Vital signs: BP =108/66, P = 68, T = 97.2°F, R = 17, Wt.:112 lbs.; Ht: 5’0; BMI = 21.87.

Diagnostic results:

· The SIGECAPS: – this tool was utilized in the screening process to come up with the diagnosis. Each letter in this mnemonic represents the criteria for diagnosing depressive disorder (American Psychiatric Association,2013).

· Studies have shown that thyroid-stimulating hormone (TSH) abnormality such as high or low can contribute to the patient’s behavioral issues. It is therefore important to assess to rule out other diseases and as a baseline for treatment (Naidu et al., 2017).

· Assessing the level of the patient’s hemoglobin A1c (HbA1c) is important to serve as the baseline for the choice of antipsychotic medication and also to rule out the risk for metabolic syndrome, and diabetes (Naidu et al., 2017).

· The initial evaluation of Complete Blood Count(CBC) and Comprehensive Metabolic Panel(CMP) is necessary as the baseline for treatment and any electrolytes abnormality which can interfere with the patient’s behavior (Sadock et.al, 2015).

Assessment

Mental Status Examination

13-year-old Caucasian female to male transgender youth, well-groomed with good eye contact. Presented to the clinic for psychiatric evaluation. Appears to be sad, and anxious with a depressive mood, but cooperative with the evaluation. Rapid pressured speech with a coherent goal-directed thought process. He denied any auditory or visual hallucination but endorses suicidal thoughts with no intention of harming himself or others currently. He is alert and orientated to place, time, and person. Intact memory during the assessment with moderate insight and judgment (Mullen, 2018).

Differential Diagnoses

Major depressive disorder (MDD), severe, single episode: 296.23 (F32.2): MDD would be the primary diagnosis for PK. The rationale for this disorder is that PK reported feeling depressed most of the day, nearly every day over the past two weeks, as evidenced by reporting increased anxiety, depression, difficulty concentrating on school work, and afraid he is going to fail his final examinations (American Psychiatric Association,2013). He also presented with feeling sad, sleeping a lot during the day, and eating a lot, causing her to gain weight and even thought of suicide but with no intent currently. He denied symptoms of mania and psychosis. His symptoms are contributing to his distress. These manifestations are classic signs of MDD and meet the DSM-5 criteria for the diagnosis (APA,2013).

Gender dysphoria (GD) in Adolescents: 302.85 (F64.0):- This would be the first differential diagnosis for this patient. The symptoms the patient presented meet the criteria for gender dysphoria. He has expressed a cross-gender identity from female to male for the past two years. He expressed a strong desire to be addressed as Alex and be treated as a boy but his parents are not accepting his transgender identity causing him a lot of distress, anxiety, and depression (Garg et al., 2022). This disparity has been ongoing for over six months now. PK exhibit at least two or more of the DSM-5 criteria for diagnosing gender dysphoria (American Psychiatric Association, 2013).

Body Dysmorphic Disorder ( BDD): 300.7 (F45.22): This is the second differential diagnosis for PK. It is a condition in which the individual has an extreme preoccupation with self-perceived defects in the appearance of the body, leading to distress and impairment of social and occupational functioning (APA,2013). Studies have shown that the typical age of onset of Body Dysmorphic Disorder is ages 12-13 (American Psychiatric Association, 2013). PK is 13 years old transgender female to male who expresses distress in developing secondary characteristics associated with females. Reports being self-conscious, obsessively examining himself in the mirror, and grooming to hide or fix his perceived flaw as evidenced by binding his breast to create the shape of a flatter chest (Garg et al., 2022). These identifiable symptoms meet the DSM-5 diagnostic criteria for BDD.

Treatment Plan

The first line of the treatment plan for this patient is to initiate cognitive-behavioral therapy (CBT) to address depression and anxiety symptoms (Mullen, 2018). The cognitive part focuses on the patient’s thinking and negative ideas, while the behavioral component focuses on the client’s emotions and behavior modification (Mullen, 2018). In view of this, CBT with a focus on the patient’s specific anxiety and concerns was initiated. The patient was referred to a support group for transgender youth for increased peer support. He was also referred to support therapy to address gender-related stressors. The patient and his parents and other family members were referred to family psychotherapy (David et al,.2018). Psychoeducation was also initiated to educate the patient and his parents about gender identity. The parents were also encouraged to be advocates for their transgender youth. Studies have also shown the effectiveness of psychotherapy in conjunction with psychopharmacology in the management of psychotic issues such as anxiety disorder and depressive mood (Mullen, 2018). In view of this fluoxetine (SSRI) was increased to 50 mg orally daily. The rationale for this is that Fluoxetine has been approved by FDA for children between the ages of 8-18 years (Walkup, 2017). The patient reports he has been taking this medication and has experienced some benefits from the medication but his symptoms have not improved, therefore an increase in the dose would be indicated. The patient was educated about the importance of being compliant with treatment and the signs and symptoms to watch for and when to report to the provider (Walkup, 2017). He was also advised to return to the clinic as needed and in four weeks. He was also provided with and advised to call the 1-800- 273-8255 suicidal hotline or to go to the nearest emergency room if the thought of suicide becomes an instance (Sadock et al., 2015).

Reflections

What I learned from this case is, that as healthcare providers, we are our patient’s advocates. One of the responsibilities we have is to help the patients through their health journey by providing culturally competent care (Sadock et.al, 2015). I also learned about the need for family involvement in the treatment plan as support to promote healing (Sadock et.al, 2015). Education about informed consent, in order to be able to collaborate with other health care providers as needed, was given to the patient. The legal and ethical considerations during this assessment were assuring the patient about confidentiality as well as ethical decision-making on their behalf (Goldsmith et al., 2016). PK would return to the clinic in a month’s time for follow-up. He would be assessed about his family situation and identity since they have started going to family psychotherapy.

Discussion Questions:

· Would you have another differential diagnosis for this patient? If yes why?

· Would you recommend any other medications for the patient? What is your rationale?

· What other therapy would you have recommended for the patient and his family?

Summary

Transgenders have a gender identity problem from actual birth gender leading to increased stress, anxiety, and other mental health problems (Goldsmith et al, 2016). Most transgenders experience discrimination, alienation, unappreciated, and scorned, as a result of living in a society composed of a stratified gendered cultural environment (Goldsmith et al., 2016). It is important that healthcare providers, family members, and friends accept them unconditionally (Sadock et al., 2015).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the

Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4.

https://doi.org/10.3389/fpsyt.2018.00004

Garg G, Elshimy G, Marwaha R. Gender Dysphoria. [Updated 2022 May 5]. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK532313/

Goldsmith, M., & Roberts, L. W. (2016). Ethical issues in child and adolescent psychiatry. Focus

(American Psychiatric Publishing), 14(1), 64–67. https://doi.org/10.1176/appi.focus.20150032

Mullen, S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275

Naidu, P., Churilov, L., Kong, A., Kanaan, R., Wong, H., Van Mourik, A., Yao, A., Cornish, E.,

Hachem, M., Hart, G. K., Owen-Jones, E., Robbins, R., Lam, Q., Samaras, K., Zajac, J. D., & Ekinci, E. I. (2017). Using Routine Hemoglobin A1c Testing to Determine the Glycemic Status in Psychiatric Inpatients. Frontiers in endocrinology, 8, 53. https://doi.org/10.3389/fendo.2017.00053

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.

Walkup, J. T. (2017). Antidepressant efficacy for depression in children and adolescents:

industry-and NIMH-funded studies. American Journal of Psychiatry, 174(5), 430-437. https://doi.org/10.1176/appi.ajp.2017.16091059

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