SOCIAL ANXIETY

DISORDER
Kelsy Dannenberg

Identifying Data and Legal Status

Data: 14 year old female admitted for suicidal attempt with a plan.
Legal Status: 48 hour hold (MH4) on 9/2/16
This form has multiple purposes, inlcuding allowing the physician or psychologist to have
the patient transported via ambulance for an emergency examination and/or
hospitalization. This form expires after 48 hours.
Patient should have been discharged on 9/4/16 according to her MH4. Patient was actually
discharged on 9/10/16. According to RN on unit floor, patient would not sign MH5 and
therefore, hospital forced to discharge her.

DMS Diagnosis
Axis I: Mood D/O NOS r/o MDD, Panic D/O w/o Agoraphobia, Social Anxiety D/O
Axis II: Deferred
Axis III: Asthma, Eczema
Axis IV: Problems with primary support, environment, and finding out Father has Multiple
Sclerosis
Axis V: GAF 35 on admission
Some impairment in reality testing or communication OR major impairment in several areas (work or
school, family relations, judgment, thinking, or mood).

Reason for Admission

Patient had suicidal ideations with a plan.

Financial Data, Insurance

Patient is covered by her parents insurance with Kaiser.

Patients Description of Problem

I was suicidal.
Patient had planned to overdose on Motrin 8000mg with Vicodin. She had access to
pills at her moms house and researched the lethal dose. Patient stated the pills
were 800mg each, so she had planned to take 10 of them. The lethal dose she
researched online is 3200mg.

Ethnicity/Religion/Spiritual
Concerns
Japanese and Caucasian
Agnostic.
Patient believes in a higher power, but does not have faith nor disbelieve in God.

Belief in a higher power can be beneficial to a person. It can give them something
to look up to, to believe in and to motivate them to better their health.

Patients Strengths and

Limitations
Strengths

Limitations
Recent change to environment
Limited coping skills

Goal oriented
Plans to attend Medical School

Parents had recent divorce (change to

family dynamics)

Artistic

Financial and housing difficulties

Enjoys video games

Father recently diagnosed with

debilitating disease

Positive support system

Outpatient services

Family history of depression, multiple

sclerosis, ADHD, alcoholism, Aspergers.

Medications
Scheduled

PRN
Albuterol
inhaler 90mcg 2 puffs Q 4hrs PRN
Asthma

Escitalopram (Lexapro) 20 mg PO QHS

Class: Antidepressant SSRI
Indication: Social anxiety
Recommended range: 10 mg daily, may
increase to 20 mg after 1 week. (Max dose)
SE: Suicidal thoughts, insomnia, constipation.

Melatonin 3 mg PO QHS
Class: Sedative/hypnotic
Indication: Insomnia
Recommended range:2-5 mg (Med dose)
SE: Change in sleep pattern

Magnesium hydroxide/Aluminum
Hydroxide/Simethicone (Mylanta)
1200mg/1200mg/120 mg per 30ml PO Q 24 hrs
PRN
Dyspepsia

Docusate sodium 100mg PO Q AM PRN

Constipation

Acetaminophen 650mg PO Q 4 hrs PRN

Pain

Epinephrine 0.3ml (1:1000) IM x1 PRN

Anaphylaxis

Medical Issues, Labs

Medical issues
Asthma patient has PRN Albuterol Inhaler
Eczema no treatments listed in charts

Labs
Thyroid function tests - Results WNL
Thyroid abnormalities can cause mood, anxiety, psychotic, and cognitive disorders.
Thyroid function tests are done to see if symptoms caused by abnormal levels.

Drug screen - Negative

MSE
General Appearance: Appears stated age. Casually dressed, neatly groomed. Avoids gaze.
Motor Activity: No evidence of psychomotor disturbance. Able to sit and tolerate intereview and activities.
Speech: Clear and spontaneous.
Interview behavior: Open and cooperative with interview.
Flow of thought: Linear, logical, and relevant.
Affect: Restricted with changing flexibility in correspondence to the flow of conversation. Congruent to
mood. Mood slightly sullen except when discussing things of joy, like video games.
Thought content: Denies any suicidal or homicidal ideations, hallucinations, illusions, or delusions. TM33
score: 9
Sensorium: Pt A&O x4
Memory: Short and long term memory intact, no cognitive impairment noted.
Intellect: Above average intellect.
Insight and Judgement: Patient acknowledges mental health problem, but poor insight to treatment aeb by
patient stating her stay at hospital is unnecessary. Her judgement is fair aeb her knowledge of suicidal
trigger(s).

Hospital treatment plan

Pt will identify and verbalize strength and intensity of suicidal feelings/thoughts and
details of any plans to harm self.

Discharge Plan
Stabilize mood and symptoms
Medical management
Attend groups and activities
Goal: Reduce depression symptoms, eliminate suicidal ideations, help patient
develop more adaptive coping skills.
Patient will be discharged home to live with father and stepmom. Patient has access
to outpatient services.

Community resources
Social Anxiety Institute
Hawaii Suicide Hotlines
Family Matters Group for MS
Friends of Kids First
Al-Anon
Big Brothers Big Sisters of Maui

Standardized assessment tools

Hamilton Depression Rating Scale (HDRS)
Score: 20
0-7 = Normal
8-13 = Mild Depression
14-18 = Moderate Depression
19-22 = Severe Depression
23 = Very Severe Depression

TM33
Score: 8
0-3 = No Precautions
4-9 = Moderate Risk Precautions
10 = High Risk Precautions

Patients symptoms vs DMS criteria

Patients Symptoms
Marked fear about social situations

DSM Criteria
Marked fear or anxiety about social situations
Will avoid situation or endure with intense sx

Last 6 or more months

Fears that anxiety sx will be negatively evaluated

Significant impairment in areas of functioning

Fear/anxiety is disproportionate to the actual threat

School, home

Sx not r/t substances, medical condition,

mental d/o
Rigid body posture

Last 6 months or more

Significant distress or impairment in areas of functioning
Sx not attributed to substances, medical conditions, or mental d/o
Associated features:
Overly rigid body posture

Inadequate eye contact

Inadequate eye contact

Soft voice

Shy/withdrawn

Shy/withdrawn

Tremor, tachycardia, blushing

Tremors, tachycardia
Female

Soft voice,
Self-mediation with substances is common
Females > Males
School drop outs

3 Highest Priorities in Order of

Acuity
#1. Safety r/t + SI
#2. Coping strategies r/t limited appropriate outlets
#3. Change in home dynamics r/t parents recent divorce, dads recent diagnosis,
and recent relocation to Hawaii

Priority #1: Safety r/t + SI

Nursing Dx: Risk for suicide r/t suicidal ideations and plans, panic, and depression.
P: Risk for suicide
E: Suicidal ideations with a plan, TM33 score of 9.
S: Assess SI daily, identify triggers and coping methods. Provide safe environment,
1:1 supervision, written contract, opportunity to express feelings. Educate on
compliance with medications and community/outpatient services.
Short term goal: Pt will report any thoughts of suicide and its severity on this
shift.
Long term goal: Pt will have no thoughts of harming self or will be able to selfmanage suicidal thoughts over the next 4 weeks.

Priority #1: Interventions and rationales

Interventions

Rationales

Nurse will assess the

potential for self harm with
or without a plan daily.
Nurse will assess specific
stressors/triggers and
coping methods.

Patients contemplating suicide may exhibit verbal and behavioral cues about
their intent to end their life. Development of a plan with the ability to carry it
out greatly increase the risk for suicide. Suicide seems an acceptable solution
when the pt can no long problem solve or decrease stressors. Discussing what
has been useful or ineffective is important information.

Staff will provide safe

environment, 1:1
supervision, written or
verbal contract, and an
opportunity to express
feelings.

Suicide precautions are used to prevent the pt from acting on sudden impulses.
A written or verbal contract is an agreement that establishes permission to
discuss the subject, makes a commitment not to act on impulse, and defines a
plan of action in case impulse occurs. The pt benefits from talking about SI with
staff. The opportunity to discuss suicidal feelings and thoughts is needed to
lessen their intensity.

Nurse will educate on

compliance with
medications, self-managing
responses to SI, and
community/outpatient
services.

Drug therapy may help the pt manage underlying health issues, such as
depression. Pts can be taught to identify thoughts that lead to suicidal ideas.
The pt can develop positive approaches to SI and be able to recognize and
respond to early SI. Community and outpatient services will benefit the pt after
discharge for ongoing support.

Priority #2: Coping strategies r/t

limited appropriate outlets
Nursing Dx: Ineffective coping r/t inadequate available resources, preparation for
stressors, and level of confidence in ability to cope aeb inability to ask for help,
inadequate problem solving, poor concentration, sleep disturbances, fatigue, and
destructive behavior towards self.
P: Ineffective coping
E: Limited coping strategies, poor school performance, insomnia, fatigue, suicidal
ideations.
S: Assess previous coping methods and readiness to learn new coping methods.
Short term goal: Pt describes 2 effective coping strategies on this shift.
Long term goal: Pt implicates described coping strategies and reports positive results
from new behaviors within 1 month.

Priority #2: Interventions and rationales

Interventions

Rationales

Nurse will assess stressors, perception of

stressors, previous coping methods, support
systems, and readiness to learn new coping
methods.

Reponses to stress can vary and provide clues to level of

coping difficulty. Persistent stressors may exhaust the pts
ability to maintain effective coping. Successful adjustment is
influenced by previous coping success. Pts may have support
systems in one setting but not the other. Pts with ineffective
coping are unable to hear or understand needed information.

Staff will encourage pt to identity their own

strengths and abilities, and to set realistic
goals. Do not provide more information that
the pt needs or wants. Point out signs of
positive progress or change.

Having a realistic perspective of the situation and being

aware of the pts strengths and abilities allows the pt to
recognize that they have the strength to effectively manage
the situation. Pts who are ineffectively coping have a
decreased ability to take in new information and may not be
able to assess their own progress.

Nurse will educate on the need for adequate

rest and balanced diet. Staff will teach
relaxation techniques, exercise, and
diversional activities as coping methods.

Inadequate diet and fatigue can become stressors themselves

and limit effective coping. A variety of interventions can assist
pts in reducing stress levels.

Priority #3: Change in home dynamics r/t

parents recent divorce, dads recent
diagnosis, and recent relocation to Hawaii
Nursing Dx: Interrupted family processes r/t environmental change, change in health status
of a family member, and modification of family finances aeb changes in availability for
emotional support, expressions of conflict within family, dissatisfaction with family.
P: Interrupted family processes
E: Recent move from mainland to Hawaii, recent divorce of parents, fathers recent diagnosis
of MS
S: Family therapy/counseling
Short term goal: Pt will express (verbal or written) 3 dissatisfactions r/t family on this shift.
Long term goal: Family will express understanding of mutual problems to each other by 1
month.

Priority #3: Interventions and rationales

Interventions

Rationales

Nurse will assess for precipitating events

(divorce, illness, crisis), family members
perception of the problem, strengths, coping
skills, and support systems, and
developmental level of family members.

Assess precipitating events can determine the familys

stress level. Understand each members perception of the
problem can lead to clarification and resolution. Identifying
strengths, coping skills, and support systems can identify
the strength of family relationships and sources of support.
Developmental stages will influence family functioning.

Staff will provide opportunities for family

members to express feelings. Staff will
encourage family members to empathize with
other members and assist the family in setting
realistic goals.

Allowing family members to express feelings promotes

communication among family members and may help with
effective coping. Empathy can increase the understanding
of others feelings and create mutual respect and support.
Setting realistic goals helps family members gain control
over the situation.

Nurse will provide information regarding

stressful situations when its appropriate. Nurse
will provide the family with information about
community resources that may be helpful in
the long term.

Information helps the family understand what they are

experiencing. Groups that come together for mutual support
can be beneficial in helping the family deal with particular
situations.

Evidence based article

Reduced serotonin synthesis and regional cerebral blood flow
after anxiolytic treatment of social anxiety disorder.
DOI: http://dx.doi.org/10.1016/j.euroneuro.2016.09.004

Treated patients dx with social anxiety disorder (SAD)

3 groups: SSRI (citalopram), NK1R antagonist, placebo

Pts received PET scans during a public speaking task before

and after treatment
Results: All treatments reduced serotonin synthesis in the amygdala. Decreased
serotonin synthesis rate was significantly associated with reduced anxiety.

Connecting the dots

1. 14 y.o female. Admit to Kahi for +SI. Dx: MDD, SAD,
Panic d/o. Small group of friends. Skipped a grade of
school = intelligent. Fathers dx of MS, family hx of
depression, Aspergers, ADHD, alcoholism. Divorced
parents. Agnostic. Generation Z. Goals of going to
medical school. Rx: escitalopram.
2. Mother rejected father. Fears losing her father and that
her dx will eventually make her crazy.
3. Mother triggers feelings of anger, fears of being
rejected by step mother. Father triggers feelings of
worry. Feelings of anger towards all mother like figures.
Constant worry about father and other loved ones.
4. Non-compliance with treatment when interacts with
mother figures OR feelings that admission is
unnecessary because wants to be d/c to spend time
with father. Constant worry = increase stress. Racing
against time = increase anxiety.
5. Cant win in a battle against time. Thought suicide was
the only solution.

 What changes (if any) would I make and why?

I would have gotten pt to sign MH5 so she could continue her stay at Kahi.
Would arrange for family therapy sessions.

What must occur for this client to improve their PMH status
Pt must learn more acceptable coping strategies.
Pt must learn to accept her family hx and fathers diagnosis.
Pt must be compliant with medications to manage other dx.

What would you want to see as an outcome?

D/c home with dad and stepmother.
Compete high school while working on self-management of symptoms and attend family therapy.
Successful and efficient use of strategies during Med school

References
DSM-5. (n.d.). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.
doi:10.1176/appi.books.9780890425596.910646
Fortinash, K. M., & Holoday-Worret, P. A. (2004). Psychiatric mental health nursing.
Frick, A., Ahs, F., Appel, L., Jonasson, M., Wahlstedt, K., Bani, M., . . . Furmark, T.
(2016). Reduced serotonin synthesis and regional cerebral blood flow after
anxiolytic treatment of social anxiety disorder. European
Neuropsychopharmacology.
doi:10.1016/j.euroneuro.2016.09.004
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia, PA:
Elsevier.