wk4 ASSIGN NRNP 6665

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Week 4: Mood Disorders in Adults

Jacey Duffy

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Dr. Ngyia

March 29, 2021

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Assessing, Diagnosing, and Treating Adults with Mood Disorders

Mood disorders are a category of psychiatric illnesses that typically affect a

person’s psychological state of well-being (Sadock et al., 2015). Although mood

disorders can negatively impact an individual’s life, relationships, and employment, they

can be successfully treated with the proper use of psychotropic medications and

psychotherapy. The purpose of this assignment is to develop a SOAP note based on

the evaluation of the client in case study for this week’s assignment. A comprehensive

assessment will be provided, along with a diagnosis, and a designed treatment plan

based on best-evidence-based practice standards and clinical guidelines.

Focused SOAP Note

Subjective:

CC: The client presents today for a mental health assessment complaining of having a history of taking medications, then stopping them, because she does not think she needs them. She reports that the feels as if the medications “squashes” who she is (Walden University, 2021).

HPI: Petunia Park is a 25-year-old white female who presents today for a mental health assessment. The client reports that she has been admitted to the hospital four times for mental health issues. The client reports that she was first hospitalized as a teenager by her mother because she had gone 4-5 days without sleeping. In 2017, the client was hospitalized for an attempted suicide when she overdosed on Benadryl, at which time she reports hearing voices. The client reports that she was hospitalized after being found by the cops dancing around in a field in her nightgown with her guitar. Although she feels as if her mom made up this story to force her to go back to live with her boyfriend.

The client reports that she has been diagnosed with depression, anxiety, and bipolar disorder in the past. She has been prescribed Zoloft in the past and reports that it made her feel really “high” and she couldn’t sleep due to racing thoughts. Risperdal and Seroquel caused her to gain weight which she did not like. The medication Klonopin she reports slowed her down some which she did not like either.

The client reports that four to five times a year she has times where she does not want to get out of bed, has no energy, no motivation to do anything, loss of interest in things she enjoys, and feels worthless. The client also reports “creativity” where she

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has lots of energy and gets lots of things done. She reports that during these times she will go four to five days without sleeping. She reports that her friends tell her that she talks too much during these times as well. She reports that her mind is scattered at that time and reports that she has sex with multiple people during these times because she reports that it is exciting and thrilling to explore new sexual situations with other people because it helps to keep her mood high. The client reports that these episodes last about a week. The client reports on average she gets 5-6 hours of sleep per night but when she is “creative” she only gets three hours that week. The client reports when she “crashes” she sleeps 12-16 hours a day. She denies any suicidal or homicidal thoughts. She denies any visual or auditory hallucinations or blackouts at this time but does report hearing voices in the past telling her how wonderful she is. The client reports that when she is really “creative” she is too busy to eat but when she crashes and in her “resting” state she over eats.

The client lives with her boyfriend but sometimes stays with her mother because her boyfriend gets mad due to her promiscuous behavior during her “creativity” period. The client was raised by her mother and older brother. She has never been married and has no children. She works part-time at her Aunt’s bookstore but reports missing work due to her depression. She is currently in a vocational school studying cosmetology which she reports a goal of doing make up for movie stars. She reports for fun she enjoys writing her life story which she states is going to be published and reports painting like Picasso and that she plans on selling her paintings to movie stars as well.

Family History: The client’s mother attempted suicide but was unsuccessful. Mother has been diagnosed with Bipolar disorder. Father has been in prison for drugs. Client reports not seeing her father for years. Client reports brother has mental health issues but has never sought treatment or been given a diagnosis. No report of any other family members with mental health issues.

Substance Current Use: Client reports no current substance abuse. She reports trying cannabis once but reports she did not like it as it made her paranoid. The client admits to smoking cigarettes 1 pack per day. Denies alcohol use – last drink was age 19.

Current Medications: Birth control. No other medications reported.

Allergies: No allergies reported.

Reproductive History: Client reports last menses one month ago. Denies pregnancy and has no children.

Medical History: Client reports suffering from hypothyroidism. The client reports that she has been diagnosed with depression, anxiety, and bipolar disorder in the past. The client currently takes birth control for polycystic ovarian disease. Last menses was one month ago.

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ROS:

• GENERAL: Client reports appetite is increased during “crashing” periods and is decreased during “creativity” periods.

• HEENT: Denies auditory or visual hallucinations at present but has had in the past when not sleeping well

• GENITOURINARY: Client reports last menses approximately one month ago.

• NEUROLOGICAL: Client reports trouble concentrating at times and racing thoughts.

• ENDOCRINOLOGIC: Client reports a diagnosis of hypothyroidism

Objective:

ROS:

• GENERAL: The client is clean, well-groomed and dressed appropriately. Affect and mood is congruent and appropriate.

• HEENT: Head is normocephalic without trauma or deformity noted.

• SKIN: Warm and dry without rashes, cuts or lesions observed.

• CARDIOVASCULAR: Not evaluated.

• RESPIRATORY: Respirations are easy, nonlabored with no wheezes or shortness of breath noted.

• NEUROLOGICAL: The client is alert, oriented x 4, pleasant and cooperative.

• MUSCULOSKELETAL: Able to move all extremities without difficulty.

Diagnostic Results: No reports of diagnostic testing were completed at this time. Baseline blood levels should be obtained prior to starting medication as certain medications can have a negative impact on the kidneys, liver, and heart (Stahl, 2017). An EKG may be warranted as well for comparison in the future if needed.

Assessment: Mental Status Examination (MSE): The client is a 25-year-old white female who appears her stated age. Appearance is clean, well-groomed and she is dressed appropriately. The client is alert, oriented x4, pleasant and cooperative. Affect and mood is congruent and appropriate. Speech is normal with periods of pressured speech noted. Thought processes appear illogical at times with grandiose ideas and delusional thinking of becoming famous by doing make-up, selling her paintings to movie stars, and writing and publishing her autobiography. During the assessment process the practitioner is objectively monitoring and evaluating the client’s mood and

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affect, her ability to concentrate, her thought processes and insight to gain a perspective on the client’s behavior and cognitive functions (Carlat, 2017). The client reports feeling anxious at times, with reports of periods of “creativity” which lasts about a week. The client reports that during these times, she has trouble concentrating, has lots of energy, is overly talkative, has an increased desire to engage in sexual situations with strangers, and reports only sleeping three hours that week. The client reports that following the week of her “creativity” period, she does not want to get out of bed, has no energy, no motivation to do anything, loss of interest in things she enjoys, and feels worthless. No visual or auditory or visual disturbances at this time but reports hearing voices in the past telling her how great and talented she is. Short-term and long-term memory is intact. Judgment and impulse control appear to be inadequate during her “creativity” periods as she has been found in her nightgown in a field with her guitar by the police and feels as if it is okay to have sex with many different people during this time even though she has a boyfriend at home. The client denies having any suicidal thoughts or plans. The client works part-time at her Aunt’s bookstore which she reports missing work at times due to her depressive states. The client also attends a vocational school to obtain her cosmetology degree. She enjoys writing and painting in her spare time.

Diagnostic Impression:

1. Bipolar Disorder – Chosen due to her manic episodes lasting at least one week followed by a major depressive episode. The client’s manic symptoms include inflated self-esteem, decreased need for sleep, more talkative than usual, flight of ideas and racing thoughts, increase in goal-directed activity and excessive involvement in activity that could result in severe consequences such as her sexual desires during this time which all meet the DSM-5 criteria for manic episode (APA, 2013). The manic periods are followed by major depressive episodes which is common in bipolar I disorder (APA, 2013).

2. Generalized Anxiety Disorder – Considered due to the client’s anxious ruminations which can be mistaken for racing thoughts which could lead to her impulsive behavior as a way of decreasing the anxious feelings that she is feeling (APA, 2013). The criteria in this diagnosis that correlates with the client’s symptoms are restlessness, difficulty concentrating, easily fatigued and sleep disturbance, however, this diagnosis would be ruled out due to the fact that the criteria does not list the manic behavioral traits as listed in bipolar disorder criteria.

3. Borderline Personality Disorder – Mood liability and impulsivity is common in both personality and bipolar disorders (APA, 2013). The DSM-5 criteria for this disorder does not seem to meet the client’s subjective and objective symptoms at this point since she has less than five of the criteria required to meet this diagnosis as per the DSM-5 criteria (APA, 2013).

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Reflections: I think the practitioner did a good job with assessing the client and reviewing her past medical history and medications. I learned the importance of reviewing past medications with the client which can be helpful when determining the best psychotropic medication to prescribe to the client based on her past experiences and side effects of past prescribed medications. The ethical and legal considerations for this case study would include discussing confidentiality to ensure that the client feels safe when discussing her symptoms and behaviors with the practitioner. The practitioner should also ensure that the client thoroughly understands her treatment options in order for her to make an informed decision as to her treatment plan. The client should also be educated and informed of the risks and benefits associated with taking psychotropic medications, such as side effects and lessening of symptoms. The practitioner should also evaluate the client’s safety relative to her behaviors, making sure to evaluate any suicidal thoughts or plans as per the ethical guidelines of nonmaleficence. Omitting the assessment of this ethical guideline could result in legal issues for the practitioner if it had not been addressed. The ethical guideline of autonomy should be followed as the client has the right to decide on their treatment plan once thoroughly educated and provided with all their treatment options. Health promotion and disease prevention wise, the client should be instructed on safe sex practices as to avoid any STD’s since the client reports having sex with several partners during her manic stages. She should be instructed and educated on taking her birth control as prescribed and that medications can sometimes lessen the effects of birth control to avoid any unwanted pregnancy.

Case Formulation and Treatment Plan: The client is diagnosed with Bipolar Personality Disorder which is based on the client’s symptoms that correlate with this diagnosis listed in the DSM-5 criteria. These symptoms include her inflated self- esteem, decreased need for sleep, improper judgment and inadequate impulse control due to her promiscuous activity, more talkative than usual, flight of ideas and racing thoughts, illogical thought processes with grandiose ideas and delusional thinking. After these bouts of “creativity” the client reports lacking energy, not being able to get out of bed, lack of interest in things she typically enjoys, no motivation and feelings of worthlessness. The client will be started on Lamotrigine 25 mg BID and titrated slowly to the desired affect to avoid side effects (Stahl, 2017). The client will be referred to psychotherapy as well. Since the client has expressed a concern with gaining weight in the past with her past prescribed medications, Lamotrigine was chosen since weight gain is not common and because it has been approved by the FDA in the treatment of Bipolar disorder (NAMI, 2020). Many of the other mood stabilizers and atypical antipsychotic medications tend to cause weight gain which is an undesirable side effect reported by the client. To ensure medication compliance, the client will be educated that it may take several weeks to improve her symptoms and on the common side effects such as rash, dizziness, and nausea (Berk et al., 2010). Due to the side effect of dizziness the client is precautioned about driving if dizziness should occur. She is also instructed to take the medication as prescribed and not to abruptly stop the medication without consulting the practitioner first. She is also educated on the fact that taking this medication can cause birth defects and can decrease the effects of birth control so these issues should be discussed with the client prior to starting the medication. The client is instructed to use an additional form of birth control while taking the medication.

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The client is also instructed to have baseline lab work prior to starting the medication since it can affect the kidneys, liver, and heart (Stahl, 2017). She is also educated that psychotherapy is warranted because studies have shown that psychosocial interventions, such as CBT, IPSRT, and family-focused therapy have increased the rate of recovery and reduce recurrence of symptoms in these clients (Stern et al., 2016). The client should be provided a suicide hotline number and instructed to call the hotline or report to the nearest ER for treatment and evaluation if this should occur. The client will be provided time to ask questions and to discuss her treatment plan. At the end of the session, the client will be instructed to follow up in one week to discuss any side effects and to evaluate her disease progress.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author

Berk, L., Hallam, K. T., Colom, F., Vieta, E., Hasty, M., Macneil, C., & Berk, M. (2010). Enhancing medication adherence in patients with bipolar disorder. Human psychopharmacology, 25(1), 1–16. https://doi.org/10.1002/hup.1081

National Alliance on Mental Health (NAMI). (2020). Lamotrigine (Lamictal). https://nami.org/About-Mental-Illness/Treatments/Mental-Health- Medications/Types-of-Medication/Lamotrigine-(Lamictal)

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Stahl, S. M. (2017). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (6th ed.). Cambridge University Press.

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://class.waldenu.edu

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