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 Assessing, Diagnosing, and Treating Adults With Mood Disorders 

Subjective:

CC: “I have a history of taking medications then stopping them, I don’t think I need them. I feel like the medication squashes who I am”.

HPI: P.P is a 25 years-old female in the clinic for a mental health assessment following her anti-psychotic medication non-compliance.

Past psychiatric history:

-She has been hospitalized for 4 times for mental health.

-Hospitalized as a teenager after going for five days without sleeping and hearing things. She was put on anti-psychotics but has a history of non-compliance. She was hospitalized on 2017 for suicide gestures after overdosing on Benadryl. The last hospitalization is the past spring season.

-She has had no suicidal ideations since 2017 after hospitalization. She convincingly denies any danger to self through suicide or self-injury.

-She has been diagnosed with depression, anxiety, and bipolar in her last treatments.

-She has been treated with Zoloft (made her feel high, sleeplessness, heart racing), Risperidone (weight gain), and Clozapine (‘it slowed her down’).

-Patient has grown up without a father after he was arrested for drug abuse. Her brother has -mental health issues but has never been diagnosed. The mother is bipolar with a history of attempted suicide.

-She had no trauma in childhood but her father was hard on the family and yelled at them a lot.

-She engages in irresponsible sexual behaviour because it helps with her moods. It has created problems with her partner and they often have relationship issues that often push her to live with her mother. 

-She works part-time at her aunt’s bookshop but she often misses work because of feeling depressed.

-She reports lots of energy and creativity lasting a week and then proceeds to the depressive state where she has no energy, no motivation, feels worthless, and sleeps a lot.

-She is a cosmetology student and intends to do make-up for movie stars. She is writing her life story and states that it is going to be published. She also reports that she is a painter like Picasso.

Substance Current Use: Nicotine (Smokes a packet/day). No other history of substance use.

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Past Medical History:

Current Medications: She takes medications for hypothyroidism and birth control pills for polycystic ovaries.

Allergies: No history of food or drug allergies.  

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

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 tests required- Thyroid function test- Thyroid hormone deficiencies are diverse and often overlooked. Hypothyroidism is a potential cause for various somatic and psychological disturbances (Dickerman & Barnhill, 2012). The condition is common in women and is often associated with cognitive and emotional disturbances. The patient has a positive history of hypothyroidism, it is necessary to check the T3 and T4 levels for comprehensive care.

Results: The T3 and T4 levels for the patient are 115 ng/dL and 6.1 μg/dL respectively.

Nucleic acid amplification test - Chlamydia and Gonococcal infections have a high infection rate among women aged 20-24 (CDC, 2014). Other risk factors include multiple sexual partners and sex without a condom. Incidences for the two diseases are low due to their asymptomatic nature. Consequently, the CDC (2014) recommends chlamydia screening for all sexually active females aged 25 years or younger and in all women engaging risky sexual behaviors. It is a necessary test for the patient.

Results: -The Nucleic acid amplification test results returned negative for gonorrhea and chlamydia.

Assessment:

Mental Status Examination: P.P is a 25-years old Asian American female with a normal appearance for age. She is well groomed and hair well kept.  Her speech is clear, coherent, and audible. She presents with a euthymic mood during the assessment. She laughs at some of the questions during the interview. She is delusional in her thought content through unrealistic optimism in her level of imagination and creativity. She experiences auditory hallucinations during her hyperactive periods. She is alert and oriented to date, time, and place. She has a good memory of recent and past events and her level of concentration and insight is good.

Diagnostic Impression: Major depressive disorder is a differential diagnosis for the patient. The diagnostic criteria for Major depression according to DSM-V is having either a depressed mood or a loss of interest/pleasure with a significant change from previous functioning (Kaltenboeck et al., 2016). The patient experiences a depressed mood with diminished interest/ pleasure, hyper-insomnia, loss of energy, and worthlessness. The symptoms make her miss going to work and are highly consistent with MDD. However, to diagnose MDD, the symptoms must be present during the same 2-week period with a depressed mood most of the day/nearly every-day (Kaltenboeck et al., 2016). In contrast, the patient only feels depressed about 4 times a year. It is a variation in the severity and duration of depression enough to support a MDD diagnosis.

Thyroid disorders- Thyroid disorders are often associated with psychiatric manifestations. According to evidence, mood disturbance is a common occurrence for patients with thyroid dysfunctions. Precisely, hyperthyroidism is significantly associated with bipolar disorder (Pilhatsch et al., 2011). The patient has a positive history of hypothyroidism which is associated with fatigue, mental slowness, and emotional liability. Moreover, the thyroid function test is within the normal T3 and T4 range.

Bipolar II disorder- According to DSM-5 bipolar II is characterized by at least one hypomanic episode and one major depressive episode (Kaltenboeck et al., 2016). However, there should never be a manic episode to make the diagnosis. The patient has presented with manic episodes and, therefore, rules out the possibility of a bipolar II diagnosis.

Bipolar disorder-1- The patient presents with symptoms consistent with bipolar 1 disorder. The DSM-5 diagnostic criteria requires a patient to meet at least one lifetime manic episode criteria and the episode followed by hypomanic or MDD (Kaltenboeck et al., 2016). The patient meets the criteria by reporting that she spends at least one week in her elevated mood. She also meets the one lifetime manic episode during her hospitalization as a teenager after going for four days without sleeping. It is the most likely diagnosis for the patient. 

Preceptor’s Assessment- The preceptor does well in conducting the psychiatric assessment for the patient. She conducts the interview skillfully to obtain data sufficient to confirm the existence of a psychiatric disorder, support the differential diagnoses, and collaborate with the patient in developing a treatment plan. However, if I were in the same assessment with the patient, I would be interested in understanding the dosage of the patients past medications and their efficacy. It is crucial for a comprehensive approach in the care plan.

Ethical and legal decision making is critical to provide astute and compassionate psychiatric care. One of the ethical guidelines in psychiatric assessment is the issue of competence (Arslan, 2018). The goal of an assessment is to provide information about a patient’s cognitive skills, behaviour and abilities; understand past psychological concerns, constraints and underlying issues; and the patient’s functionality and therapeutic requirement (Arslan, 2018). Competence is evident in the preceptors approach throughout the assessment. She also maintains a therapeutic client-provider relationship through approving comments and feedback to the patient’s response.  

Case Formulation and Treatment Plan: 

Therapy- Patient was referred for cognitive behaviour therapy. Interventions focus on managing unhelpful thinking patterns and relapse prevention (Chiang et al., 2017). They will include psycho-education, cognitive restructuring, sleep hygiene, and mindfulness.

Medication- Lithium initiated as a maintenance treatment for the patient’s bipolar. It remains as the mainstay treatment by reducing the severity and frequency of bipolar disorder symptoms (Hirschfeld et al., 2002).

Patient education- Discussed the disease process of bipolar and the need for medication adherence. The patient was informed to call in a case of side-effects or adverse reactions with Lithium. She was taught on safe sex practices and the risk of STD’s with irresponsible sexual behaviour. She was also advised to bring her mother and boyfriend in the next visit for health education. They will be a source of moral support towards the patient’s better outcomes. 

 

 

References

Arslan, R. (2018). A review on ethical issues and rules in psychological assessment. Journal of Family Counseling and Education, 3(1), 17-29. DOI: 10.32568/jfce.310629

Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014. MMWR Recomm Rep. 2014; 63:1-19.

Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PloS one, 12(5), e0176849.

Dickerman, A. L., & Barnhill, J. W. (2012). Abnormal thyroid function tests in psychiatric patients: a red herring? American Journal of Psychiatry, 169(2), 127-133. https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2011.11040631

Hirschfeld, R., Bowden, C. L., Gitlin, M. J., Keck, P. E., Suppes, T., Thase, M. E., & Perlis, R. H. (2002). Practice guideline for the treatment of patients with bipolar disorder. American Psychiatric Association.

Kaltenboeck, A., Winkler, D., & Kasper, S. (2016). Bipolar and related disorders in DSM-5 and ICD-10. CNS spectrums, 21(4), 318-323.

Pilhatsch, M., Marxen, M., Winter, C., Smolka, M. N., & Bauer, M. (2011). Hypothyroidism and mood disorders: integrating novel insights from brain imaging techniques. Thyroid research, 4(1), 1-7.

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