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.
Assignment – assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
• Review the video, Case Study: Petunia Park. https://waldenu.instructure.com/courses/55965/pages/week-4-learning-resources?module_item_id=1348673
Transcript: Case study- Petunia Park
[MUSIC PLAYING] DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you’re here for a mental health assessment today?
PETUNIA PARK: That’s right.
DR. MOORE: OK. So to make sure I have the right patient and the right chart, can you tell me your name and your date of birth?
PETUNIA PARK: Yes. I’m Petunia Park. My birthday is July 1, 1995.
DR. MOORE: And can you tell me what today’s date is?
PETUNIA PARK: So it’s December 1.
DR. MOORE: Do you know the year?
PETUNIA PARK: 2020.
DR. MOORE: And what day of the week is this?
PETUNIA PARK: It’s Tuesday. [CHUCKLING]
DR. MOORE: And do you know where we are today?
PETUNIA PARK: Yes I am here in the beautiful, sunny office at the clinic.
DR. MOORE: OK, great. Thank you. So can you tell me a little bit about why you’re here today? What brings you here today?
PETUNIA PARK: Yes. So I have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am.
DR. MOORE: OK, OK. So I’m going to be able to help you with that. But to begin, I’m going to ask you some questions about your family. I’m going to ask you some history-type questions. I’m going to ask you some symptoms that you might be having. And all of these questions are going to help me work with you on a treatment plan, OK? So I would like to begin with, when was the first time that you ever had any mental health or substance use treatment in your life?
PETUNIA PARK: OK. Well, when I was a teenager, my mom put me in the hospital after I went four or five days without sleeping. I think I may have been hearing things at that time. [CHUCKLES] I think they started me on some medication, but I’m not sure.
DR. MOORE: Oh, OK so you were hospitalized. How many times have you been hospitalized for mental health?
PETUNIA PARK: Oh, I’ve been hospitalized about four times. The last time was this past spring. No detox or residential rehabs, though.
DR. MOORE: OK, good. Were any of these hospitalizations due to any suicide gestures?
PETUNIA PARK: One was in 2017. I overdosed on Benadryl, but I’ve not had those thoughts since then.
DR. MOORE: Well, I’m very glad to hear that you’ve not had any of those thoughts since then. And I’m glad that you turned out OK from that overdose. I’m glad that you’re here today. Can you tell me a little bit about what you’ve been diagnosed with during your past treatments?
PETUNIA PARK: Well, I think depression, and anxiety, had some even say maybe bipolar.
DR. MOORE: OK, and what medications have you been tried on before for those illnesses? And if you can remember, what was your reactions to those medications?
PETUNIA PARK: Oh, let’s see. Oh, I took Zoloft, and that made me feel really high. [CHUCKLES] I couldn’t sleep. My mind was racing, and then I took risperidone. That made me gain a bunch of weight. Seroquel gave me weight, too. I took Klonopin, and that seems to slow me down some. I really can’t remember the others. I think the one I just stopped taking was helping. It started with an L, I think. I don’t really remember the name, but it squashed me in creativity.
DR. MOORE: OK, well, we’re going to try to help you find some medication that doesn’t make you feel squashed or have any of those negative side effects today. But in order to do that, I need some more information. And the next questions I’m going to ask you are about substances you may have used. And I want you to know that you don’t get in trouble in here if you’ve used some of these substances. It really just helps me to make sure that what’s in your system that could be impacting your neurochemistry. And when we do talk about medications, so I don’t give you something that would negatively interact with something you may be using, OK? So do you–
PETUNIA PARK: OK.
DR. MOORE: –use any nicotine?
PETUNIA PARK: Yes. I smoke about a pack a day, and I’m not going to quit for you, either. [CHUCKLES] Oh.
DR. MOORE: That’s OK, that’s OK. And what about alcohol? When was your last drink of alcohol?
PETUNIA PARK: When I was 19 because alcohol and me do not work well together. [CHUCKLES]
DR. MOORE: OK, and what about any marijuana? When was your last use of any marijuana?
PETUNIA PARK: Oh no. I tried that once and got really paranoid.
DR. MOORE: OK. What about any last use of cocaine?
PETUNIA PARK: Never.
DR. MOORE: Last use of any stimulants or methamphetamines?
PETUNIA PARK: Never.
DR. MOORE: What about any huffing or inhalants?
PETUNIA PARK: Never.
DR. MOORE: OK, have you used anything like Klonopin or Xanax, any of those sedative medications?
PETUNIA PARK: Never.
DR. MOORE: All right, good. What about any hallucinogenics like LSD, or PCP, or mushrooms?
PETUNIA PARK: No, never.
DR. MOORE: Wonderful. OK, what about any use of pain pills or opiate medications? Anything prescribed or anything you’ve obtained from the street?
PETUNIA PARK: No, never.
DR. MOORE: Good. And anything synthetic like Spice, or ecstasy, Bath Salts, Mollies, anything like that?
PETUNIA PARK: Never.
DR. MOORE: Oh, wonderful. Well, I’m glad to hear that. You know those things aren’t good for your brain. So I encourage you to continue to stay away from those things. Have you ever had any blackouts or seizures from drugs or alcohol? Or seen things that you weren’t sure were there?
PETUNIA PARK: Never.
DR. MOORE: Good. What about any legal issues or any DUIs?
PETUNIA PARK: Never.
DR. MOORE: OK. Good, good. All right, so I’m just going to ask a little bit about your family right now. Any blood relatives have any mental health or substance abuse issues?
PETUNIA PARK: Yeah, well, well, why would you ask that? It’s not your business.
DR. MOORE: Right. I could see where you might find that wouldn’t be any my business. But really, sometimes these issues can be genetic. They’re alarm behaviors. So my understanding of your family helps me to understand you.
PETUNIA PARK: Huh. Well, my mother was seen as crazy. I think they said she had bipolar or something. And my father went to prison for drugs. And well, we haven’t heard, or seen, or heard from him in 8 or 10 years. My brother, while I think he’s a little schizo, but he hasn’t ever went to the doctor. Nobody else with anything.
DR. MOORE: OK. So that sounds like it must be tough growing up not seeing your father and having some of those issues in your family. But any family, blood relatives commit suicide?
PETUNIA PARK: Well, my mom tried, but nobody really did it, you know?
DR. MOORE: OK. Have you ever done anything like that, or anything like cut on yourself, burn yourself?
PETUNIA PARK: I already told you, I tried to kill myself. Why ask me that again? No, I’m not going to kill myself or anyone else, and I don’t cut myself.
DR. MOORE: OK. Well, I’m glad to hear that. And I want you to know that I am here for you, and we most certainly will make sure you have a crisis like number at the end of this session if you do have those thoughts in the future. So I’m glad to hear that you don’t have those thoughts today. OK. What type of medical issues do you have?
PETUNIA PARK: Oh, hoo. Let’s see. I have a thyroid issue that I take some medicine for, that hypothyroidism. And I take a birth control pill for polycystic ovaries.
DR. MOORE: OK, when was your last menses?
PETUNIA PARK: Oh, well I have a regular one each month. So let’s see. It was last month sometime.
DR. MOORE: OK, so any chance that you’re pregnant?
PETUNIA PARK: [LAUGHS] Lordy, no. I may have a lot of sex around, but I’m safe.
DR. MOORE: Hm. You “have a lot of sex around.” Can you maybe tell me what that means?
PETUNIA PARK: Well, it’s exciting and thrilling to find new people to explore sex with. It helps me keep my moods high, high, high. [CHUCKLES]
DR. MOORE: OK, so that makes you feel really high and kind of what, OK?
PETUNIA PARK: Oh yeah.
DR. MOORE: So who raised you?
PETUNIA PARK: My mom and my older brother, mainly.
DR. MOORE: And who do you live with now? P
PETUNIA PARK: Well, I live with my boyfriend. And sometimes, stay with my mom when he gets mad at me for sleeping around some.
DR. MOORE: So that’s created some issues in your relationship, I see. OK. Are you single, married, widowed, or divorced?
PETUNIA PARK: I’ve never been married.
DR. MOORE: OK. Do you have any children?
PETUNIA PARK: No.
DR. MOORE: All right. Are you working?
PETUNIA PARK: Yes, I work part time at my aunt’s bookstore. She’s more tolerant of the days I don’t come in from feeling too depressed.
DR. MOORE: OK, so I hear some, maybe, feelings of depressed. OK. What is your level of education?
PETUNIA PARK: Oh, I’m in vo-tech school right now for cosmetology. I’m going to do makeup for movie stars. [CHUCKLES]
DR. MOORE: Oh, that sounds really wonderful. OK, so but what about now? What do you do for fun now?
PETUNIA PARK: Well, I am writing my life story, and it’s going to be published. I also paint like Picasso. I’m going to sell those paintings to movie stars, too.
DR. MOORE: Well, that’s wonderful. Maybe someday you can show me your paintings as well. OK, have you ever been arrested or convicted for anything?
PETUNIA PARK: No. The police did pick me up and take me to the hospital once. I didn’t have much sleep that week. And they said I was dancing around in my nightgown in a field with my guitar. I really don’t remember much of that, though. I think maybe my mom made up that story against me because she wanted me to go back to my boyfriend’s house.
DR. MOORE: OK, so that was one of your hospitalizations that we talked about earlier. OK, what about any history of trauma with childhood or adult? Any kind of physical, sexual, emotional abuse?
PETUNIA PARK: Well, my dad was pretty hard on us when he was around. But he didn’t really touch us or anything. More just yelled at us a lot.
DR. MOORE: OK. All right, so I’ve gathered some history here. Now, I want to get into more of some of the symptoms that brought you in to see me today. So you mentioned before that sometimes your depression keeps you from working at your aunt’s bookstore. Can you tell me a little bit more about what that looks like for you?
PETUNIA PARK: Well, about four or five times a year, I have these times when I just don’t want to get out of bed. I have no energy, no motivation to do anything. I just can’t feel any interest in my creativity. I feel like I’m not worth anything because I feel that creativity slipping away. So this is usually happening after I’ve been up for five days working hard on my works with my writing, painting, and music. Everyone says I’m depressed, but I’m not sure. It could be that I’m just exhausted from working so hard.
DR. MOORE: OK, so I hear you talking about these creativity episodes right before you crash. Per se, this depression. Tell me a little bit more about those episodes. What do those look like for you?
PETUNIA PARK: Oh, I love those times. Those are the reasons I don’t always take my medication because I feel like I’m squashed. I have lots of energy to do a lot of things. I can go four or five days with very little sleep. I get lots of things done, but my friends tell me I talk too much and appear scattered. [SIGHS] They’re just jealous of all the accomplishments I’m getting done. These are the times I look to explore my mind and body with feeling good through sex with other people.
DR. MOORE: OK, how long do those episodes last typically when you have them?
PETUNIA PARK: About a week.
DR. MOORE: About a week. OK. So I want to ask a little bit more about some other symptoms that maybe we haven’t talked about. Do you feel like you worry a lot or have any kind of anxiety and panic symptoms?
PETUNIA PARK: No, no no. I’m not a worry.
DR. MOORE: OK, do you do anything that you feel like you have to do repetitively over and over? And if you can’t do them, you feel like the end of the world is coming? Something like maybe count on threes or wash your hands 20 times? Anything like that?
PETUNIA PARK: [LAUGHS] No, no. I don’t have OCD, if that’s what you’re asking.
DR. MOORE: OK, what about hearing or seeing things you’re not sure others see or hear? Anything like that?
PETUNIA PARK: Not right now. It’s been a couple of months since that happened. Sometimes when I’m not sleeping good, I hear voices telling me how great and wonderfully talented I am.
DR. MOORE: OK. So, but no voices right now?
PETUNIA PARK: No.
DR. MOORE: OK, good. What about your appetite? How’s your appetite?
PETUNIA PARK: Well, when I’m really creative, I’m too busy to eat. And when I’m crashing and resting, I eat everything in sight.
DR. MOORE: OK, so what about your sleep? On average, how much time do you think you sleep in a whole 24-hour period? And do you have any bad dreams?
PETUNIA PARK: No bad dreams. Most of the time, I get about five or six hours. When I’m creative, I’m lucky to get three hours and a whole week. Ugh. And when I’m crashed, I sleep about 12 or 16 hours a day.
DR. MOORE: OK, wonderful. So this is great. I have a lot of information from you that I think we will be able to come up with a treatment plan and maybe find some medication that’s going to help you feel better without you feeling so squashed and having negative side effects, but really help you be able to function through the day. [MUSIC PLAYING]
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2, Pulse 90, Respiration 18, B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)
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-TR 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 non-pharmacologic 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: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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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