Pathophysiology

Psychiatric

Case Study

Patient Profile

Name: Jamie Farenheint

Age: 45 years old

Gender: female

History of Present Illness

J.F. is a 45-year-old woman who presents painful joints in both hands and wrists, morning stiffness, periodic fevers, loss of appetite, pain preventing patient from enjoying life, difficulty concentrating and making decisions at work and home, fatigue, poor sleep, difficulty with fine motor tasks.

Past Medical History

Diagnosed with rheumatoid arthritis (RA) 10 years ago, chronic pain for 8 years, and depression for 5 years.

Current Medications

NSAIDs for pain relief; disease-modifying antirheumatic drugs: Methotrexate (DMARD) and adalimumab (biologic DMARD)

Social History

  • Security guard

No alcohol use
Smokes cannabis weekly
Lives alone, adult son lives nearby

Physical Assessment

Vitals

  • Blood pressure: 130/85 mm Hg
  • Heart rate: 78 bpm
  • Respiratory rate: 16 bpm
  • Temperature 98.6°F

General Survey

  • General Appearance: Appears fatigued, with a flat affect.
  • Musculoskeletal: Swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands. Limited range of motion in wrists and fingers. Mild muscle atrophy in the hands. Both hands are warm to the touch.
  • Neurological: Normal reflexes and sensation.
  • Pain: Persistent joint pain, described as aching and throbbing. Pain intensity rated 7/10. Difficulty sleeping due to pain.
  • Psychological: Reports persistent feelings of sadness and hopelessness, loss of interest in activities once enjoyed, fatigue and lack of energy, difficulty concentrating and making decisions at work and home, Patient Health Questionnaire-9 (PHQ-9) score indicating moderate to severe depression, denies suicidal or homicidal ideation.

Diagnostic Assessment

  • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
  • Positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies.
  • Imaging: X-rays from two years ago showing joint erosion and narrowing of joint spaces in the hands. MRI ordered to assess current extent of joint damage and inflammation.

Diagnosis

  • Rheumatoid arthritis with chronic pain.
  • Depression secondary to chronic pain.

Treatment Plan

  1. RA: Continue DMARDs, including methotrexate (DMARD), adalimumab (biologic DMARD), NSAIDs for pain relief.
  2. Chronic Pain: Gabapentin for neuropathic pain.
  3. Depression: Sertraline for depression.
  4. Counseling: Cognitive-behavioral therapy (CBT) referral, reviewed danger signs such as suicidal/homicidal ideation, and to call 911 for immediate assistance if needed.
  5. Physical therapy referral to improve joint flexibility and muscle strength.
  6. Occupational therapy referral to assist with daily activities and use of assistive devices.
  7. Lifestyle Modifications:
    • Balanced diet rich in anti-inflammatory foods. Patient referred to dietician.
    • Regular low-impact exercise as tolerated, such as swimming or walking.
    • Stress management techniques like mindfulness and yoga.
    • Support group for patients living with chronic conditions.
  8. Follow-Up:
    • Regular monitoring of RA activity and medication side effects.
    • Monthly mental health check-ins to assess depression symptoms and therapy effectiveness.

Activity: Pathophysiology of Autoimmune Disorders and Inflammation

(Options: hyperplasia, hypoplasia)

RA is a chronic autoimmune disease characterized by the immune system mistakenly attacking the synovium.  RA involves complex interactions between immune cells and cytokines. This leads to inflammation and _____________________ in the synovium, forming a pannus that invades, erodes, and eventually destroys adjacent cartilage and bone within the joint. The exact cause of RA is unknown; however it is believed to result from a combination of genetic predisposition and environmental factors. Key genetic markers, such as the HLA-DRB1 gene, have been associated with an increased risk of developing RA. Environmental triggers, including smoking, infections, and hormonal changes, can also initiate or exacerbate the disease.

Activity: Pathophysiology of Autoimmune Disorders, Chronic Inflammation and Mental Health

(Options: cytokines, neuroinflammation, exacerbating, alleviating, bidirectional, unilateral, red blood cells, hyperreactivity)

Chronic Inflammation and Mental Health: Chronic inflammation can have systemic effects, including on the central nervous system. Inflammatory _____________________ can cross the blood-brain barrier and influence brain function, potentially leading to changes in mood and behavior. This _____________________ is thought to contribute to the high prevalence of depression and anxiety observed in patients with autoimmune disorders. Depression is a multifactorial disorder involving genetic, biological, environmental, and psychological components. Genetic factors contribute to the risk of developing depression, with heritability estimates around 40% to50%. Biological factors include the dysregulation of neurotransmitters involved in mood regulation, such as serotonin, norepinephrine, and dopamine.

The connection between autoimmune disorders and mental health disorders is complex and _____________________. Chronic inflammation associated with autoimmune diseases can lead to neuroinflammation, which affects neurotransmitter systems and brain structures involved in mood regulation. Additionally, the stress and psychological burden of living with a chronic, painful, and disabling disease can lead to the development of mental health issues or exacerbate previously existing states. Depression and anxiety can also negatively impact the immune system, potentially _____________________ autoimmune disease activity. This interplay underscores the importance of a holistic approach to treating patients with autoimmune diseases, addressing both their physical and mental health needs.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. Which of the following is a common diagnostic marker for RA?
    1. Elevated blood glucose
    2. Positive RF
    3. Low hemoglobin
    4. Elevated thyroid-stimulating hormone (TSH)
Answer:

B) Positive RF. Feedback: Positive RF is a common laboratory marker used in the diagnosis of RA. Not all RA patients test positive for RF; however, its presence is a strong indicator of the disease. Jamie has RF and anti-CCP antibodies, both of which are used to diagnose RA. Blood glucose, hemoglobin, and TSH are not markers for RA.

  1. What is the primary goal of DMARDs in the treatment of RA?
    1. Immediate pain relief.
    2. Reducing inflammation.
    3. Slowing disease progression.
    4. Increasing joint mobility.
Answer:

C) Slowing disease progression. Feedback: DMARDs, such as methotrexate and adalimumab, are used to slow the progression of RA by modifying the underlying disease process and preventing joint damage. While immediate pain relief and increased joint mobility are secondary benefits, the main goal is to halt or slow the disease’s progression.

  1. A deficiency in which neurotransmitter is most commonly associated with depression?
    1. Dopamine
    2. Acetylcholine
    3. Serotonin
    4. GABA
Answer:

C) Serotonin. Feedback: Serotonin is the neurotransmitter most commonly linked to depression. Many antidepressants, including selective serotonin reuptake inhibitors (SSRIs) like sertraline work by increasing serotonin levels in the brain. Dopamine and norepinephrine are also involved, but serotonin is the most commonly associated.

  1. What is a common side effect of long-term corticosteroid use in RA patients?
    1. Hyperthyroidism
    2. Osteoporosis
    3. Hypoglycemia
    4. Hypertension
Answer:

B) Osteoporosis. Feedback: Long-term use of corticosteroids can decrease bone density, increasing the risk of osteoporosis. This risk is monitored in patients on chronic steroid therapy.

  1. What is the primary mechanism of action for selective serotonin reuptake inhibitors (SSRIs) in treating depression?
    1. Blocking dopamine receptors.
    2. Inhibiting serotonin reuptake.
    3. Increasing GABA activity.
    4. Reducing norepinephrine release.
Answer:

B) Inhibiting serotonin reuptake.. Feedback: SSRIs treat depression by blocking the reuptake of serotonin into neurons, increasing its availability in the synaptic cleft. This action corrects the chemical imbalance thought to contribute to depression.

  1. Which of the following is an evidence-based non-pharmacological treatment for chronic pain in RA patients?
    1. Copper bracelets
    2. Physical therapy
    3. Yucca
    4. Mega doses of vitamin C
Answer:

B) Physical therapy. Feedback: Physical therapy is an evidence-based, non-pharmacological approach that helps improve joint function, reduce pain, and increase mobility in patients with RA. The other options (copper bracelets, yucca, mega doses of vitamin C) lack strong scientific evidence for efficacy.

  1. What is a common psychological symptom associated with chronic pain?
    1. Euphoria
    2. Anxiety
    3. Hyperactivity
    4. Mania
Answer:

B) Anxiety. Feedback: Chronic pain is frequently associated with psychological symptoms such as anxiety and depression. In contrast, euphoria, hyperactivity, and mania are not commonly linked to chronic pain.

  1. Which factor is NOT typically involved in the pathophysiology of autoimmune diseases?
    1. Genetic predisposition
    2. Environmental triggers
    3. Viral infections
    4. High cholesterol
Answer:

D) High cholesterol. Feedback: While genetic predisposition, environmental triggers, and viral infections can contribute to the development of autoimmune disease, high cholesterol is not recognized as a factor in the pathophysiology of autoimmune diseases like RA.

  1. What is the role of CBT in managing depression?
    1. Increasing physical activity.
    2. Modifying negative thought patterns.
    3. Enhancing dietary habits.
    4. Improving sleep quality.
Answer:

B) Modifying negative thought patterns.. Feedback: CBT is a structured form of psychotherapy that helps patients identify and change negative thought patterns and behaviors, which can reduce symptoms of depression. While CBT can positively affect sleep and physical activity, its main therapeutic focus is on thoughts and behaviors.

  1. A nurse practitioner is evaluating a patient with depression. Which of the following is the most appropriate initial screening tool for assessing the severity of depression?
    1. Generalized Anxiety Disorder 7 (GAD-7)
    2. Patient Health Questionnaire-9 (PHQ-9)
    3. Beck Anxiety Inventory (BAI)
    4. Mini-Mental State Examination (MMSE)
Answer:

B) Patient Health Questionnaire-9 (PHQ-9). Feedback: The PHQ-9 is a widely used and validated screening tool specifically designed to assess the severity of depression. The GAD-7 and BAI are both used to screen for anxiety, while the MMSE is designed to assess cognitive impairment.

References

Baker, J. (2024). Up to Date. Diagnosis and differential diagnosis of Rheumatoid arthritis. Available at: https://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis#H4237494150

Heavey, E. (2024). Immune System Lecture. [Transcript].

Johns Hopkins Arthritis Center. (2023). RA Pathophysiology. Retrieved from https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-pathophysiology-2/Mayo Clinic. (2023). Rheumatoid arthritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648

Mayo Clinic. (2023). Depression. Retrieved from https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

Merck Manual Professional Edition. (2024). Rheumatoid Arthritis (RA). Available at: https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/joint-disorders/rheumatoid-arthritis-ra

Microsoft. (2024). Copilot (version 4) [Large language model]. Retrieved from https://copilot.microsoft.com

National Institute of Mental Health. (2023). Depression. Available at: https://www.nimh.nih.gov/health/topics/depression

Smolen, J. S., Aletaha, D., & McInnes, I. B. (2016). Rheumatoid arthritis. The Lancet, 388(10055), 2023-2038. https://doi.org/10.1016/S0140-6736(16)30173-8

Tkacs, N. (Ed.). (2020). Advanced physiology and pathophysiology: Essentials for clinical practice. Springer Publishing Company.

You.com. (n.d.). Homepage. You.com. Retrieved February 22, 2025, from https://www.you.com

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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