Stress and Anxiety

1. Title Page

(Include a title that reflects the case study, your name, the course name and number, the instructor’s name, and the date.)

Example Title: Assessment and Differential Diagnosis of a Young Adult Presenting with Compulsive Behavior and Anxiety

2. Introduction

This paper will analyze the case of a 24-year-old, single, Asian-American female graduate student presenting with a chief complaint of self-consciousness regarding scarred fingers due to chronic finger-biting. The patient reports an exacerbation of this behavior coinciding with the increased stress of starting a demanding graduate program two months prior. This analysis will encompass the utilization of screening tools and laboratory tests for further evaluation, the development of a differential diagnosis with DSM-5-TR and ICD-10 codes and justifications, a working diagnosis, and consideration of potential pharmacological interventions. The goal is to provide a comprehensive understanding of the patient’s current presentation and to outline appropriate steps for her care.

3. What screening tools (if any) or laboratory tests (if any) would you use to further evaluate this patient?

To further evaluate this patient, the following screening tools and laboratory tests could be considered:

Screening Tools:

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS): Given the patient’s repetitive, uncontrollable finger-biting and associated distress, the Y-BOCS would be a valuable tool to assess the severity and nature of these compulsive behaviors. It can help determine if the finger-biting meets criteria for an Obsessive-Compulsive and Related Disorder.
• Generalized Anxiety Disorder 7-item (GAD-7) scale: The patient reports feeling anxious and overwhelmed. The GAD-7 is a brief, reliable, and valid tool to screen for and measure the severity of generalized anxiety symptoms.
• Patient Health Questionnaire-9 (PHQ-9): The patient reports feeling tired and having difficulty sleeping, which can be symptoms of depression. The PHQ-9 is a widely used screening tool for depression and can help assess the presence and severity of depressive symptoms.
• Pittsburgh Sleep Quality Index (PSQI): The patient reports difficulty falling asleep and staying asleep. The PSQI is a self-report questionnaire that assesses sleep quality and disturbances over the past month.
• Brief Behavioral Activation Scale (BBAS): Given the recent transition to graduate school and potential for reduced engagement in pleasurable activities due to workload, the BBAS could help assess the level of behavioral activation, which is often reduced in anxiety and mood disorders.

Laboratory Tests:

• Complete Blood Count (CBC) with differential: The patient’s father has a history of anemia, and she reports feeling tired. A CBC can screen for anemia and other hematological abnormalities that could contribute to fatigue.
• Thyroid Stimulating Hormone (TSH): Hypothyroidism is a common condition that can cause fatigue, difficulty sleeping, and changes in mood and anxiety levels. Checking TSH can rule out thyroid dysfunction.
• Vitamin D levels: Vitamin D deficiency has been linked to fatigue and mood disturbances in some individuals. Assessing Vitamin D levels could be helpful.
• Basic Metabolic Panel (BMP): This panel can assess overall metabolic function and electrolyte balance, which could indirectly contribute to fatigue or other symptoms.

Rationale for Selection:

The screening tools are chosen to explore the potential underlying psychological factors contributing to the finger-biting and the reported anxiety and sleep difficulties. The laboratory tests are selected to investigate potential medical conditions that could be contributing to the patient’s fatigue and sleep problems, as these can often exacerbate psychological distress. Ruling out medical causes is an important step in a comprehensive evaluation.

4. What are your differential diagnoses for this patient?

a. Include DMS-5 TR codes and ICD-10 codes:

* **Excoriation (Skin-Picking) Disorder (F42.3 [DSM-5-TR], L98.1 [ICD-10]):** This disorder involves recurrent skin picking resulting in skin lesions, and repeated attempts to decrease or stop the behavior. While the patient bites her fingers, the resulting scars and inability to stop despite self-consciousness align with the repetitive, distressing, and difficult-to-control nature of an Obsessive-Compulsive and Related Disorder. The focus is on the behavior and its consequences.
* **Body-Focused Repetitive Behavior Disorder, Other Specified (F42.8 [DSM-5-TR], F98.8 [ICD-10]):** This category is used when symptoms characteristic of an obsessive-compulsive and related disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the specific disorders in the diagnostic class. Finger-biting that leads to scarring and self-consciousness, without prominent obsessions, could fall under this category.
* **Generalized Anxiety Disorder (GAD) (F41.1 [DSM-5-TR], F41.1 [ICD-10]):** The patient reports feeling anxious and overwhelmed, particularly related to academic demands. Difficulty concentrating and sleep disturbance are also consistent with GAD. The recent onset or exacerbation of these symptoms coinciding with the start of graduate school supports this possibility.
* **Adjustment Disorder with Anxiety (F43.22 [DSM-5-TR], F43.2 [ICD-10]):** This diagnosis is considered when identifiable stressors (in this case, starting a demanding graduate program) cause clinically significant emotional or behavioral symptoms (anxiety, difficulty coping, finger-biting exacerbation) that develop within three months of the onset of the stressor and cease within six months after the stressor or its consequences have terminated.
* **Major Depressive Disorder, Single Episode, Mild (F32.0 [DSM-5-TR], F32.0 [ICD-10]) or Other Specified Depressive Disorder (F32.8 [DSM-5-TR], F32.8 [ICD-10]):** The reported fatigue and sleep difficulties could indicate a mood disturbance. While the information provided doesn't fully meet criteria for major depression (lack of pervasive low mood or anhedonia), exploring depressive symptoms further with the PHQ-9 is warranted.
* **Iron Deficiency Anemia (D50.9 [ICD-10]):** Given the family history of anemia and the patient's report of fatigue, iron deficiency anemia should be considered as a potential medical contributor to her tiredness. The CBC would help rule this out.
* **Primary Insomnia (G47.0 [ICD-10]):** The difficulty falling asleep and staying asleep could be a primary sleep disorder, although it is likely secondary to anxiety or stress in this context. The PSQI would provide more detailed information about her sleep patterns.

b. Include rationale for ruling in or ruling out the diagnoses:

* **Excoriation (Skin-Picking) Disorder / Body-Focused Repetitive Behavior Disorder:**
    * **Ruling In:** The core symptom of repetitive finger-biting leading to skin damage (scars) and the patient's expressed inability to stop despite wanting to (impaired control) strongly suggest one of these diagnoses. The distress and self-consciousness about the appearance of her fingers further support this.
    * **Ruling Out:** Ruling out Excoriation Disorder specifically would depend on whether the primary behavior is described as picking at existing skin irregularities versus the act of biting itself causing the damage. Body-Focused Repetitive Behavior Disorder, Other Specified, is a broader category that fits if the full criteria for a specific OCD-related disorder are not met.
* **Generalized Anxiety Disorder:**
    * **Ruling In:** The patient's report of feeling overwhelmed and worried about academic performance, coupled with difficulty concentrating and sleep disturbance, are key symptoms of GAD. The recent increase in stress from graduate school likely acts as a trigger.
    * **Ruling Out:** While anxiety is present, the focus of the distress seems significantly tied to the finger-biting and its consequences. Further assessment with the GAD-7 will help determine if the level and pervasiveness of anxiety meet the full diagnostic criteria for GAD beyond the situational stress.
* **Adjustment Disorder with Anxiety:**
    * **Ruling In:** The onset of anxiety and the exacerbation of finger-biting within two months of starting a significant stressor (graduate school) align with the timeframe for Adjustment Disorder.
    * **Ruling Out:** If the anxiety and finger-biting persist beyond six months after the stressor resolves (or if the finger-biting has a long-standing history predating the current stressor as a primary issue), Adjustment Disorder would be less likely as the primary diagnosis, and a more enduring condition like GAD or a Body-Focused Repetitive Behavior Disorder would be favored. The history indicates finger-biting started in childhood, suggesting it's not solely an adjustment issue.
* **Major Depressive Disorder / Other Specified Depressive Disorder:**
    * **Ruling In:** Fatigue and sleep difficulties can be symptoms of depression. The recent increased stress could also contribute to a depressed mood.
    * **Ruling Out:** The current presentation lacks the core symptoms of persistent low mood or anhedonia. The patient's primary complaints and the content of her thoughts are focused on anxiety and academic demands, and the finger-biting. The PHQ-9 will provide more clarity on the presence and severity of depressive symptoms.
* **Iron Deficiency Anemia:**
    * **Ruling In:** Family history and reported fatigue raise suspicion.
    * **Ruling Out:** A CBC will definitively rule out or confirm anemia.
* **Primary Insomnia:**
    * **Ruling In:** Difficulty falling and staying asleep is reported.
    * **Ruling Out:** The sleep disturbance appears likely secondary to anxiety and stress. Addressing the underlying anxiety and stress may resolve the insomnia. The PSQI will provide a clearer picture of the nature of her sleep problems.

c. What diagnosis would you rule in as your working diagnosis?

Based on the initial presentation, the working diagnosis would be Body-Focused Repetitive Behavior Disorder, Other Specified (F42.8 [DSM-5-TR], F98.8 [ICD-10]) with Provisional Generalized Anxiety Disorder (F41.1 [DSM-5-TR], F41.1 [ICD-10]).

Rationale: The long-standing history of finger-biting, its exacerbation under stress, the resulting physical consequences (scars), and the patient’s self-consciousness and inability to stop strongly point towards a Body-Focused Repetitive Behavior Disorder. The significant anxiety related to academic demands and the associated sleep difficulties warrant a provisional diagnosis of Generalized Anxiety Disorder, pending further assessment with the GAD-7 and exploration of the pervasiveness and intensity of her anxiety symptoms beyond the situational stress of graduate school. Adjustment Disorder is less likely as the primary issue due to the chronic history of finger-biting. While fatigue and sleep issues are present, depressive symptoms do not currently appear to meet full criteria for a depressive disorder, but this will be further evaluated with the PHQ-9. Medical causes for fatigue will be investigated with laboratory tests.

5. What pharmacological interventions would you include, if any?

At this initial stage, pharmacological interventions may not be the first-line treatment. Given the recent onset of increased stress and the likely connection to the exacerbation of her long-standing finger-biting, psychotherapeutic interventions should be prioritized.

However, if the anxiety symptoms are found to be significant and impairing based on the GAD-7, or if the finger-biting proves highly resistant to behavioral interventions and causes significant distress, the following pharmacological options could be considered in conjunction with therapy:

• Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs such as fluoxetine, sertraline, or escitalopram are often used to treat ¹ anxiety disorders and Obsessive-Compulsive and Related Disorders. They can help reduce overall anxiety levels and may indirectly reduce the urge to engage in repetitive behaviors. Starting at a low dose and titrating gradually based on response and side effects would be important.  
• N-Acetylcysteine (NAC): Some research suggests that NAC, an amino acid that modulates glutamate levels in the brain, may be helpful in reducing body-focused repetitive behaviors. It is generally well-tolerated and could be considered as an adjunctive treatment.
• Buspirone: This is a non-benzodiazepine anxiolytic that can be effective for generalized anxiety. It has a lower risk of dependence compared to benzodiazepines and may be considered if SSRIs are not well-tolerated or fully effective for anxiety symptoms.

Rationale for Caution and Prioritizing Therapy:

• The patient has no prior psychiatric medication history, so starting with the least invasive and potentially long-lasting interventions (therapy) is generally recommended.
• The finger-biting has a long history, suggesting a deeply ingrained behavioral pattern that will likely require behavioral strategies to address effectively.
• The increased stress of graduate school appears to be a significant trigger for the exacerbation of her symptoms. Addressing stress management and coping skills through therapy is crucial.
• Pharmacological interventions can have side effects, and it is important to weigh the potential benefits against these risks, especially in a young adult with no prior medication history.

If pharmacological intervention is deemed necessary after further assessment and a trial of therapy, the choice of medication would depend on the predominant symptoms (anxiety vs. compulsive behaviors) and the patient’s individual response and tolerability. Regular monitoring of efficacy and side effects would be essential.

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