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Assessing, diagnosing, and Treating Adults With Mood Disorders
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
To Prepare
Watch the video provided. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a university faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
The Assignment
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment??
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient.?Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
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Assessing, diagnosing, and Treating Adults With Mood Disorders
Subjective:
CC (chief complaint): Lack of adherence to medication
HPI: P. P. a 26-year-old female presents to the clinic for regular mental health assessment. She complains of having trouble adhering to the medication regime. She expresses that the medication overshadows who she is. The patient expresses going through periods of high activity that last up to one week followed by periods of depressed moods. The patient notes that she feels unworthy, loses interest in doing creative stuff that she loves, feels fatigued, as well as sleeping and appetite issues. The patient cannot remember current medication but has taken several in the past such as Zoloft, Risperidone with undesirable effects including weight gain and feeling as if the mind is racing high.
Substance Current Use: Nicotine, smokes about 1 pack a day
Last used alcohol at 19 years
Past psychiatric history
Hospitalized four times for mental health, in 2017 for attempted suicide
History of hospitalization as a teenager for trouble sleeping and hallucinations
Psychotherapy or previous psychiatric diagnosis
Depression, anxiety, bipolar diagnoses
Medication trials and current medications
Past medications: Zoloft, Risperidone, Clonidine
Recent medication: unable to remember the name
Pertinent substance use, family psychiatric/substance use, social, and medical history
History of mental illness in the family, mother diagnosed with bipolar, history of suicide
Father imprisoned for drugs
Brother possibly schizophrenic but never diagnosed
Raised by the mother and partly elder brother
No history of abuse as a child
-
Hospitalization history:
Thyroid issues, currently under medication
-
Allergies: No allergies
Reproductive Hx: Takes birth control pills, last menstrual last month (November 2020)
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ROS:
GENERAL: No weight loss, fever, chills, weakness, feel fatigued when depressed.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: DSM-5 assessment: bipolar disorder
Assessment:
Mental Status Examination: the patient a 26-year-old female, appears oriented to place and time, neatly dressed for the weather, and well-groomed. History of hospitalization due to suicidal attempt by overdose, but denies any current suicidal or homicidal ideation. Her current mood is anxious with intense affect. The patient’s speech is coherent, organized with the right tone and volume. The patient’s thought process is logical and goal-oriented. The patient denies current hallucinations but experienced the latest one in the past month. The patient’s concentration and insight are good. Her memory is intact.
Diagnostic Impression:
Differential diagnosis
Bipolar disorder
Major depressive disorder
Persistent depressive disorder
The patient presents with feelings of unworthiness, loss of interest in activities, fatigue, hyperactive episodes, hallucinations in the past month. When depressed, the patient has a high appetite and excessive sleep of up to 12 hours a night. When experiencing a high mood, the patient experiences low appetite, insomnia, and extreme sexual desire. Combining these symptoms with the patient’s psychiatric medical history and assessment shows the possibility of several psychiatric conditions, the top three: bipolar disorder, persistent depressive disorder, and major depressive disorder (Severus & Bauer, 2013). The first rationale for bipolar disorder is the alternating episodes of mania and depressed moods. According to DSM-5 criteria for diagnosing bipolar disorder, the period of mania characterized by elevated moods must last for at least a week with three or more symptoms including high self-esteem, racing thoughts, no need for sleep, irresponsible behavior, and goal-oriented activity. The depressed phase involves the depressed mood, increase/decrease in appetite, fatigue, feelings of worthlessness, and suicidal ideation (Cordner, 2020). Considering the patient, she sleeps approximately 3 hours for a whole week when in the manic phase, has high energy for creativity, engages in excessive sexual behavior, and experiences racing thoughts. Additionally, she experiences increased appetite, feelings of unworthiness, fatigue, and loss of pleasure. The assessment is further supported by psychiatric history, which gives a previous diagnosis of bipolar.
Secondly, the DSM-5 criteria for the persistent depressive disorder include depressive symptoms lasting for the better part of the day. Concurrent observable depression for more than two years. Other requirements are the presence of two or more manifestations including hopelessness, decreased/increased appetite, insomnia/hypersomnia, fatigue, low self-esteem. The patient presents with most of these symptoms, however, the DSM-5 criteria dismiss persistent depressive disorder because of the presence of mania.
For major depressive disorder, the DSM-5 criteria for diagnosis include depressed mood lasting almost throughout the day, loss of interest, decreased/increased need for sleep, increased/decreased appetite, fatigue, recurrent thoughts of death, and feelings of unworthiness. The symptoms cause social impairment such as failure to fulfil employment responsibility. However, the criteria rule out this diagnosis because of the occurrence of manic or hypomanic episodes. The critical thinking process that led me to the diagnosis of bipolar as the primary condition includes the patient’s history involving recurrent hospitalizations, hallucinations, and family history of the mother being diagnosed with bipolar and episodes of either depressed or elevated moods. The absence of current suicidal ideation and no substance abuse. These symptoms impact daily life and social relationships, for example, during the manic periods the patient experiences relationship challenges because of excessive sexual desire that makes her engage in irresponsible sexual behavior with multiple partners.
Case Formulation and Treatment Plan:
The patient expresses problems with past medications, thus, the first item in the treatment plan is to prescribe mood medication that will not give undesirable side effects. The patient’s pharmacological therapy will involve Lamotrigine 25 mg daily, which is a mood stabilizer with minimal side effects (Young Sup Woo, et al., 2020). The medication is unlikely to create the effect. t of “squashing” as the patient describes it. The patient will be given education on the risks and benefits of the medication and the importance of adherence to the medication regime. For psychotherapy, the patient will be introduced to CBT, which is a form of talk therapy that will allow her to share her experiences, explore feelings and thoughts, as well as learn to develop negative thought patterns. As a health promotion, the patient will be engaged in education on healthy health education on the effects of smoking. The strategy that will be used is one-on-one talk with the patient, as well as give out a flier with additional information.
Reflection
The case provides a comprehensive assessment that allows the gathering of the patient’s data. If I were to do something differently, I will question the patient further on social life to understanding her support system and socioeconomic background. The assessment process is informative and helpful and insightful
References
Cordner, Z. A. (2020). The Care of Patients With Complex Mood Disorders. FOCUS, https://doi.org/10.1176/appi.focus.20200007.
Severus, E., & Bauer, M. (2013). Diagnosing bipolar disorders in DSM-5. Int J Bipolar Disord, 1, 14. https://doi.org/10.1186/2194-7511-1-14.
Young Sup Woo, Yoon, B.-H., Song, J.-H., Seo, J., Nam, B., & Lee, K. (2020). Clinical correlates associated with the long-term response of bipolar disorder patients to lithium, valproate or lamotrigine: A retrospective study. PlosOne, https://doi.org/10.1371/journal.pone.0227217.
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