Aron Muñoz is a 46-year-old Latino male referred to you by his primary care provider, Dr. Gerard Phillips, after repeated evaluations and follow-ups for a skin rash on both arms.
Case Study
Hello. My doc told me this is all in my head and so that’s why I’m here. I really don’t like being told that. He’s assured me I’m in good health. But I’m not. Let me prove it to you that it’s not in my head.
I go on a daily walk through the wooded trails over on the south side of the city.
A little over six months ago, I developed a skin rash one day. The rash comes and goes and so I make an appointment with my PCP, that’s Doctor Gerry Phillips, who just tells me it’s a minor allergic reaction to the trees and flowers bloomin’ at the time.
He tells me to take Benadryl as needed. I love Gerry, but I know it’s more than that. I know it’s a serious skin disease. See? It’s been six months and I still have a rash on both arms.
Since the doctors won’t help, I’ve had to spend a lot of time researching it myself. I could bring in what I’ve found, if you want. I’ve even missed some family parties and taken time off work.
My sister Maria wasn’t too happy I missed her Marcella’s quinceanera last week. I love my niece, but I also don’t want to give it to anyone else, you know?
To make sure it’s not spread any further, I examine my whole body at least 20 or more times a day.
Sometimes I make same-day appointments with my doctor–thank goodness Gerry, Dr. Phillips, offers those–when it looks like it’s spreading. I really like and trust Gerry. He’s the only doctor I really can trust.
I’m afraid of causing further reactions, so nope, I haven’t gotten the yearly flu vaccine.
You know, this rash could be something life-threatening like Steven-Johnson Syndrome, a Methicillin-resistant Staphylococcus aureus infection, or leprosy.
This is definitely controlling my life. My sleep is restless, I toss and turn all night. I wake up and my muscles are tense. I feel tired more than usual. I’m pretty preoccupied with my health. Could this result in multi-organ failure? It’s difficult to concentrate. I feel nervous and tense all the time.
As a child, I suffered from serious asthma and respiratory problems.
My father left us when I was 14. My parents…they’d always had a pretty tumultuous relationship. I remember mama and papa screaming and yelling a lot. At times they would get into physical fights. Yeah, it scared me pretty bad.
But that doesn’t matter now. So doc, what can you do for me about this rash?
Chart Notes:
Aron is a 46-year-old Latino male
Height: 5 feet 11inches
Weight: 180 lbs
Vital Signs: Stable
Medications: None except Benadryl initially taken for rash
Labs: All laboratory work has been normal, including a complete blood count, comprehensive metabolic panel., blood glucose tests, and drug screening. Urine drug screen was negative.
Medical History: Known factions or past infections of herpes virus, pneumonia, HIV, hepatitis; No History of graph versus host disease. He has not followed up. With psychiatry until this visit. He denies any history of therapy, intensive outpatient, or inpatient admissions. There is no sign of rash; It looks like he has been scratching himself.
Social history: reports no history of substance use except trials in college. Drinks occasionally socially, which has decreased because he rarely socializes now.
Family history.: father and sister taking medication for anxiety and panic attacks.
PCP notes: Aron’s preoccupation with this rash is debilitating, causing his PCP great concern for Aron’s emotional, social, and economic well-being.
Questions:
1. What questions will you ask Aaron during his psychiatric evaluation?
2. What DSM 5 criteria support these differentials for Generalized Anxiety disorder, obsessive compulsive disorder, and illness anxiety disorder?
3. What is 1 screening tool you could use to confirm Aron’s diagnosis? Explain your rationale.
4. You diagnose Aron with illness anxiety disorder, what types of psychotherapy would be beneficial for him? Give a rationale for your recommendations.
5. What pharmacology, if any, would you prescribe? Explain the mechanism of action, risk, and benefits.
6. How would you build a therapeutic alliance with Aron to address the connection between his physical symptoms and his mood disorder?
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