wk4 ASSIGN NRNP 6665

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Assessing, Diagnosing, and Treating Adults With Mood Disorders

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College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

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June 28, 2021

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Assessing, Diagnosing, and Treating Adults With Mood Disorders

CC (chief complaint): “I have a history of taking medications and then stopping them. I

feel like the medications squashes who I am.”

Subjective: P.P is a 36 year old Caucasian (appears to be) female presenting for a

psychiatric assessment for symptoms of depression. She reports the depressive symptoms occur

about 4 times a year where she doesn’t want to get out of bed, loses creative interest which leads

to feeling worthless, reports having no motivation or energy to do anything. She states these

depressive episodes usually come after having been awake for 4-5 days working on projects and

using a lot of creative energy (music, painting, writing). She states others have told her she is

depressed but she is not sure and thinks her depressive symptoms have more to do with feeling

exhausted after being awake for days at a time. She reports the energy highs during the days she

doesn’t sleep are her favorite experiences as she feels most creative and excited. Denies

excessive worrying or obsessive tendencies. She states she will hear voices sometimes after not

sleeping for days and the voices tell her she’s wonderful and creative. She reports lack of

appetite and not eating much at all when she’s in those creative high episodes of not sleeping but

will be hungry and eat “everything in sight” when she’s exhausted and depressed. Denies having

nightmares and reports averaging 5-6 hours of sleep per night. When she’s experiencing the

creative high she feels lucky if she gets 3 hours in a week. When she’s exhausted and depressed

she sleeps between 12-16 hours per day.

HPI: Patient reports her mental health symptoms include depression and some anxiety

and has been told by others she could be bipolar. Her symptoms began as a teenager and she first

received treatment when her mother had her hospitalized after she had not slept for 4 or 5 days

straight and experienced auditory hallucinations. She reports having been hospitalized a total of 4

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times with her most recent being this past spring. She reports one of the hospitalizations was due

to suicide attempt in 2017 where she overdosed on Benadryl. The patient denies a history of

detox or residential treatment. States she has not had suicidal ideation or attempts since 2017.

Psychosocial History: Patient reports she was raised mostly by her mother. She denies

any legal history minus an incident she recalls where police picked her up for dancing in a

nightgown in a field with her guitar but believes her mother may have lied and made-up the

incident to get her to return to her boyfriend. Patient reports “having lots of sex” with different

people because it makes her feel good and high. She has never been married and currently lives

with her boyfriend but has moved in with her mother periodically when her boyfriend becomes

angry about her sexual activities with other people. The patient works part-time at her aunt’s

book-store and is tolerant of her missing occasional workdays due to feeling depressed. She is

also going to school for cosmetology and plans to do make-up for movie stars. She states that

she’s currently writing her life-story and paints “like Picasso” and plans to sell her paintings to

movie stars as well.

Substance Current Use: patient reports smoking a pack per day of cigarettes and has no

desire to quit. She reports no use of ETOH since she was 19 years old. Denies use of marijuana,

stimulants, cocaine, huffing, or inhalants. Denies use of hallucinogenics or benzos for recreation

use.

Family Psychiatric/Substance Use History: Patient reports her mother had bipolar and

was seen as “crazy” and had tried to kill herself once to her knowledge. The patient’s father went

to prison for drugs and hasn’t heard from him in 8-10 years. She states her brother is “a little

schizo.”

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Medical History: Patient reports hypothyroidism which she takes medication for and

polycystic ovarian syndrome (PCOS) which she takes birth control for.

 Past Psychiatric Medications: Zoloft – states it made her feel “high” and couldn’t

sleep, mind was racing. Risperidone – made her gain “a bunch of weight.” Seroquel –

made her gain weight too. Klonopin – states that made her “slow down some.” She

reports not remembering the other names of medications she’s tried and believes the

medication she was most recently taking started with an “L” and that “it was

working” before she stopped taking it because “it squashed my creativity.”

 Current Medications: Possibly taking Klonopin based on patient’s comment about it

being effective in slowing her down, medication for hypothyroidism, birth control for

PCOS (no medication names, doses or frequencies were provided); she reports

recently taking a medication for her mood that starts with “L.”

 Allergies: No known allergies (none disclosed).

 Reproductive Hx: LMP one month ago; PCOS.

ROS:

 GENERAL: no reports of significant weight gain or loss and no fever, night sweats,

or exercise intolerance.

 HEENT: No reports of visual loss, blurred vision, double vision, or yellow sclerae.

Ears, Nose, Throat: No reports of hearing loss, sneezing, congestion, runny nose, or

sore throat.

 SKIN: intact; no reports of jaundice, rash or itching.

 CARDIOVASCULAR: no reports of shortness of breath, palpitations or chest pain or

pressure, known heart murmur, or edema.

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 RESPIRATORY: no reports of cough, wheezing, shortness of breath or sputum.

 GASTROINTESTINAL: no reports of vomiting, diarrhea, anorexia, abdominal pain

or blood.

 GENITOURINARY: no reports of urinary issues or pain; positive for PCOS.

 NEUROLOGICAL: no reports of headache, syncope, paralysis, ataxia, weakness,

numbness, seizures, dizziness, or changes in bowel or bladder control.

 MUSCULOSKELETAL: no reports of muscle aches or weakness, no joint pain or back pain, no

stiffness.

 HEMATOLOGIC: no reports of bleeding, anemia, or bruising.

 LYMPHATICS: no reports of enlarged lymph nodes or history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance; no polyuria or

polydipsia; positive for hypothyroidism.

Objective:

Diagnostic results: No measurement scales were completed or lab tests ordered. I would

have administered the following measurement instruments: Sexual Addiction Screening Test

(SAST) to determine if the patient is engaging in sexually compulsive or addictive behavior;

Mood Disorder Questionnaire (MDQ) as it screens for bipolar spectrum disorder to include

bipolar I, bipolar II, and unspecified bipolar disorder).

Assessment:

Mental Status Examination: The patient’s attitude is mostly cooperative with short

periods of defensiveness when asked certain questions but does not appear to be in acute distress.

She is fully oriented to person, place, and time. The patient is dressed appropriately for her age

and adequately groomed. Her psychomotor activity appears normal with no involuntary or

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abnormal movements and she maintains decent eye contact throughout the interview. Her affect

is slightly labile with brief moments of irritability, indifference, and euphoria. The patient does

present with some mood dysregulation that ranges between mild elevation, irritability, and

indifference. Speech is predominantly of normal rate, rhythm, volume, and tone with fleeting

increased rate and volume while discussing grandiose ideas. Her thought content is positive for

delusion of grandeur. Thought process is illogical but goal-oriented. The patient’s memory

appears to be intact for recent events but historical events are questionable based on the patient’s

self-report of being picked up by police for dancing in pajamas in a field and then stating that she

believes her mother made that story up to get her to go back to her boyfriend. She denies current

suicidal or homicidal ideation, hallucinations or delusional thoughts. Her cognition appears

grossly intact with normal attention span and concentration during interview session. The

patient’s insight is limited and judgment is poor.

Diagnostic Impression: The patient presents with symptoms of bipolar I disorder as

evidenced in her mental status exam (American Psychiatric Association, 2013). She also has a

history of having at least 4 depressive episodes per year where she sleeps excessively, is

depressed and hopeless, and lacks motivation, among other symptoms (First, 2015). However,

she did not specify how long her depressive episodes last except that they were at least a week or

so long. Depressive episodes in bipolar I disorder patients last at least 2 weeks (American

Psychiatric Association, 2013). Although this information was not specified clearly, all the other

criterion for a diagnosis of bipolar I disorder are met (American Psychiatric Association, 2013).

She also reports experiencing manic episodes of at least 4 days that usually precede her

depressive episodes (American Psychiatric Association, 2013). She describes her mania as

increased creativity, a decreased need for sleep often getting 3-4 hours over the course of 4 or 5

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days, and thoughts of grandeur (First, 2015). The patient has been hospitalized for psychotic

behavior and for attempted suicide. Bipolar I disorder is characterized by episodes of euphoric or

irritable mood, referred to as mania (American Psychiatric Association, 2013). Additionally,

people with this disorder often present with reduced sleep, thoughts of grandeur, loquaciousness,

racing thoughts, and impulsivity or risk-taking behaviors (American Psychiatric Association,

2013). In some cases, a person’s mood can change quickly between mania, irritability, rage, or

depression, which demonstrates having the “mixed features” type of bipolar disorder (First,

2015).

Differential Diagnoses:

1) Bipolar I disorder, current episode manic without psychotic features, moderate

(American Psychiatric Association, 2013). F31.12 (World Health

Organization, 2019).

a. The patient meets this diagnosis based on the required criterion

(American Psychiatric Association, 2013):

i. The patient has had at least one manic episode consisting of

abnormally and persistently elevated, expansive or irritable

mood AND increased activity or energy lasting at least one

week and present for most of those days nearly every day, or

any duration of hospitalization is necessary) (American

Psychiatric Association, 2013).

ii. During the manic episode the patient met at least 3 symptoms

(American Psychiatric Association, 2013): (indiscretion,

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grandiosity, decreased sleep, talkative, and distractibility)

(American Psychiatric Association, 2013).

iii. The mood disturbance caused significant social or occupational

functioning or necessitated hospitalization (American

Psychiatric Association, 2013). The patient was hospitalized at

least once and has had severe disturbances in her relationships

with boyfriend and mother, and missing work at her job

(American Psychiatric Association, 2013).

2) Bipolar II disorder (First, 2015). F31.81 (World Health Organization, 2019).

a. The patient doesn’t meet this diagnosis because bipolar II disorder

includes hypomania episodes of 4 days that are considered to have

only a minor or no impairment in social and occupational functioning,

no hospitalizations, and no psychosis (First, 2015).

3) Bipolar disorder, unspecified (First, 2015). F31.9 (World Health Organization,

2019).

a. The patient does not meet this diagnosis as it is for patients who

experience periods of clinically significant mood elevation or

irritability but not enough criterion to meet bipolar I or bipolar II

diagnoses (First, 2015).

Reflections: The practitioner in the video case study did a good job of reviewing what

questions and information she would be asking from the patient and explained why she needed

the information. The practitioner did a decent job providing empathy and recognizing how

difficult some of her life experiences were. I might have offered a little more explanation and

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reassurance that I have her best interests in mind. I would also let her know that she should feel

free to ask questions, let me know if she is uncomfortable answering any questions and that I

would do my best to explain how they relate to her treatment, and if she would like to add

anything at any time during our discussion to do so if she’s worried about forgetting to mention it

later. Additionally, when the patient reported she stopped taking her most recently prescribed

medication that started with an “L”, the provider should have inquired about how long she was

taking it for and exactly when she stopped taking it. I would also ask her to describe what she

meant when she said the medication was helping her. When the provider asked about her family

psychiatric history, the patient commented that her brother is a little “schizo,” but did not

elaborate so I would follow-up on that by asking her to provide some examples of what she

meant. I would have asked if the patient had a history of self-harm when I questioned her about

past suicide attempts to maintain a more cohesive flowing discussion. Additionally, I would have

asked follow up questions about the patient’s sexual activities including how frequently she

engages, with how many people, if she has contracted a sexually transmitted disease,

experienced sexual trauma, and what methods of protection she uses, rather than jumping to the

next question about who raised her. I would ask her if she had a good support system or what

steps she would take if she felt unsafe. Finally, I would have gone through the review of systems

(ROS) with her and asked if she had allergies or bad reactions to medications, which wasn’t

asked of her.

Case Formulation and Treatment Plan: The patient indicated during the interview that

she felt the lithium she was taking helped her but it was unclear how it helped her or why she

stopped taking it. She did comment that she often stops medications because she feels it takes

away her creativity. Substantial patient education is needed to help the patient understand the

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differences between her mental illness and her ability to be creative yet safe and using sound

judgment (Samalin et al., 2018). Since lithium is the gold standard for treating bipolar I disorder

and she stated it was helping her in some way, I would discuss restarting lithium (Malhi et al.,

2017). First I would like to get baseline labs on liver enzymes, CMP, and blood sugar and A1C

(Malhi et al., 2017). The other medication option I would discuss is aripiprazole as it has shown

to be effective in treating symptoms of bipolar disorder and may not cause some of the adverse

side effects the patient experiences regarding decreased energy and creativity (Muneer, 2016).

However, I would be concerned that her manic symptoms might not be adequately controlled

(Muneer, 2016). With all of that being said, I would likely begin lithium again if she was in

agreement and we would have frequent follow ups for the first 6 months and then spaced out

carefully from there to avoid and minimize opportunities for noncompliance with treatment plan

(Malhi et al., 2017). The starting dose of lithium would be 600mg BID, to address her acute

manic symptoms (Malhi et al., 2017). She would complete a lithium level check one week after

starting lithium to ensure it is within therapeutic levels, and check lithium levels 7 days after

every dose change (Malhi et al., 2017).

I would help identify barriers for treatment plan adherence, provide patient education on

primary diagnosis, prognosis with treatment, medication options and potential side effects, and

inquire about cultural practices or beliefs that may enhance or prevent certain treatment goals or

plans (Samalin et al., 2018). I would describe in detail and strongly encourage participation in a

dialectical behavior therapy (DBT) program as it has proven to be very effective in bipolar

disorder patients, particularly those with a history of hospitalizations (Afshari et al., 2019).

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References

Afshari, B., Omidi, A., & Ahmadvand, A. (2019). Effects of dialectical behavior therapy on

executive functions, emotion regulation, and mindfulness in bipolar disorder. Journal of

Contemporary Psychotherapy, 50(2), 123–131. Retrieved June 25, 2021, from

https://doi.org/10.1007/s10879-019-09442-7

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA, American Psychiatric Publishing.

Dubovsky, S., Ghosh, B., Serotte, J., & Cranwell, V. (2020). Psychotic depression: Diagnosis,

differential diagnosis, and treatment. Psychotherapy and Psychosomatics, 90(3), 160–

177. Retrieved June 24, 2021, from https://doi.org/10.1159/000511348

First, M. (2015). Dsm-5® handbook of differential diagnosis. American Psychiatric Publishing.

https://doi.org/10.1176/appi.books.9781585629992.mf02

Malhi, G. S., Gessler, D., & Outhred, T. (2017). The use of lithium for the treatment of bipolar

disorder: Recommendations from clinical practice guidelines. Journal of Affective

Disorders, 217, 266–280. Retrieved June 25, 2021, from

https://doi.org/10.1016/j.jad.2017.03.052

Muneer, A. (2016). The treatment of adult bipolar disorder with aripiprazole: A systematic

review. Cureus. Retrieved June 24, 2021, from https://doi.org/10.7759/cureus.562

Samalin, L., Honciuc, M., Boyer, L., de Chazeron, I., Blanc, O., Abbar, M., & Llorca, P. M.

(2018). Efficacy of shared decision-making on treatment adherence of patients with

bipolar disorder: A cluster randomized trial (shared-bd). BMC Psychiatry, 18(1).

Retrieved June 23, 2021, from https://doi.org/10.1186/s12888-018-1686-y

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World Health Organization. (2019). International statistical classification of diseases and

related health problems (11th ed.). https://www.cdc.gov/nchs/icd/icd10cm.htm