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Running head: ADULT MENTAL HEALTH EVALUATION
Symptom Analysis Evaluation: Adult Mental Health Evaluation
Onyeisi Stephen Ogbomeh
Liberty University
Neurobiology and Differential Diagnosis of Mental Disorders
NURS 751
Dr. Folashade Odedina
August 29, 2025
Chief Complaint:
“I have horrible mood swings and I get angry easily.”
Symptoms:
Mark is a 37-year-old male with a six-month history of mood instability, irritability,
agitation, racing thoughts, and chronic sleep difficulties. Symptoms are present 5-6 days a week
and are described as pervasive throughout the day. Patient reports that he has experienced
similar symptoms, albeit less severe, since his early teens. Patient reports family history of
schizophrenia, bipolar disorder, and depression. Patient admits to infrequent marijuana use and
ADULT MENTAL HEALTH EVALUATION 2
alcohol use. He denies any other psychiatric symptoms, such as hallucinations, delusions, or
suicidal ideation.
Question A
Questions are provided for further assessment of the patient’s chief complaint and
history of present illness. The questions are open-ended and incorporated into the COLDSPA
format for a comprehensive dialogue.
Characteristics: Can you describe what these ‘horrible mood swings’ feel like? What does it look
like when you get angry? What are the high points like, and what are the low points like? Onset:
When did you first notice these symptoms? Can you remember a time when you felt differently
or when these mood swings were not a part of your life?
Location/Lingering: Do you feel these mood swings in a particular way in your body? Do they
linger throughout the day, or do they come and go in a more rapid fashion?
Duration: How long do these angry episodes or mood swings last? Do they last for hours, days,
or even weeks at a time?
Severity: On a scale of 1 to 10, with 10 being the most severe, how would you rate the intensity
of these mood swings and irritability?
Precipitating Factors/Triggers: Is there anything that seems to trigger these moods? Are there
specific situations or people that make you feel this way?
Associated Symptoms: When you are experiencing these mood swings, do you have any other
symptoms, such as changes in your sleep, appetite, energy level, or thoughts?
Alleviating Factors: Is there anything you do or that happens that seems to make these
symptoms better, even temporarily? Does the use of marijuana or alcohol have an impact on
these symptoms?
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Impact on Functioning: How are these symptoms affecting your daily life, your relationships,
your work, and your overall ability to function?
Question B
Bipolar II Disorder (F31.81): Bipolar II disorder is a psychiatric illness characterized by at
least one hypomanic episode and one severe depressive episode (American Psychiatric
Association, 2022). Mark's symptoms of increasing irritability, anxiety, racing thoughts, and
chronic sleep issues, which have persisted for 6 months, point to a hypomanic episode.
Furthermore, he had a history of "terrible mood swings" and depression (for which he was given
an SSRI), indicating a long-term pattern of mood instability. Bipolar disease in his brother
suggests a genetic susceptibility (American Psychiatric Association, 2022), and the persistent
nature of his mood symptoms (from his early teens) corresponds to the development of bipolar
disorder.
Major Depressive Disorder (F33.2): Major Depressive Disorder (MDD) is a mood
disorder that is characterized by a persistent depressed mood or loss of interest or pleasure in
most activities, accompanied by at least four other symptoms of depression for a minimum
duration of two weeks (American Psychiatric Association, 2022). Mark’s history of depression
and present complaints of having been “severely depressed in the past” with “thoughts of
death” also fit the criteria for MDD. His irritability and agitation could be seen as atypical for a
major depressive episode (American Psychiatric Association, 2022). However, the racing
thoughts and agitation are not congruent with depression and may point to an alternative
diagnosis.
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Cyclothymic Disorder (F34.0): Cyclothymic disorder is characterized by numerous
periods of hypomanic symptoms and numerous periods of depressive symptoms over at least
two years. The symptoms never meet the criteria for a hypomanic episode or a major
depressive episode (American Psychiatric Association, 2022). Mark’s long history of mood
instability that began in his early teens and has worsened over time is consistent with the long-
standing chronic course of cyclothymic disorder. While his symptoms are bothersome, they may
not be severe enough to meet the full criteria of a hypomanic episode. As such, cyclothymic
disorder is a viable alternative.
Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation (F90.2):
ADHD is a neurodevelopmental disease defined by a consistent pattern of inattention and/or
hyp eractivity-impulsivity that impairs functioning or development (Hirschfeld, Cass, & Holt,
2020). Symptoms of restlessness, impulsivity, irritability, and racing thoughts could also be
present in ADHD (American Psychiatric Association, 2022). Mark’s long history of these
symptoms since his early teens and racing thoughts and agitation could be a manifestation of
ADHD. The symptoms seen in ADHD can mimic or co-exist with mood disorders, and as such,
this disorder is an important differential to rule out.
Question C
Bipolar II Disorder:
Appearance: Unkempt, with disheveled hair and wrinkled clothes.
Speech: Rapid, pressured, or loud in hypomanic periods; slow, soft, and monotone in depressive
periods. Subjectively, the patient may complain of “My thoughts are racing, and I can’t get them
out fast enough.”
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Affect: May vary from irritable or expansive in hypomanic states to blunted and restricted in
depressive states.
Mood: May range from irritable, euphoric, or agitated in hypomanic states to dysphoric,
discouraged, or depressed in depressive states. Subjectively, the patient could state, “I’m always
on edge and ready to snap at someone.”
Behavior: Psychomotor agitation, evidenced by restless movements and inability to sit still,
during hypomania; psychomotor retardation during depressive episodes.
Thought Process: Flight of ideas or racing thoughts with rapid shifting of topics (American
Psychiatric Association, 2022).
Thought Content: Grandiosity, a belief in one’s own inflated importance or abilities, or nihilistic
and hopeless thoughts.
Attention and Concentration: Poor attention and concentration, with difficulty staying on topic
with racing thoughts and agitation.
Memory: Memory for immediate, recent, and remote events intact.
Orientation: Oriented to person, place, and time.
Insight: Poor insight into the severity and impact of symptoms, with a tendency to view
hypomanic periods as “highly productive” and not a problem.
Judgment: Poor, evidenced by impulsive, risky decisions during hypomanic periods (e.g.,
spending sprees, substance use).
Intelligence: Patient appears to be of average intelligence, as evident by history of employment
and coherent conversation.
Major Depressive Disorder:
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Appearance: Appropriate, with evidence of poor hygiene or self-care (unkempt hair, wrinkled or
dirty clothes).
Speech: Soft, slow speech (bradykinesia). Subjectively, patient may say, “It’s so hard to get the
words out.”
Affect: Constricted or flat, with a narrow range of emotion.
Mood: Depressed, sad, irritable, or hopeless. Subjectively, patient may state, “I feel empty
inside” or “I’m always irritable.”
Behavior: Psychomotor retardation, with a lethargic and slow presentation.
Thought Process: Slow thought process, with delayed responses and a reduced number of
thoughts (poverty of thought).
Thought Content: Focused on themes of guilt, worthlessness, hopelessness, and suicide.
Attention and Concentration: Attention and concentration are poor, with marked difficulty
staying on topic or with the task at hand.
Memory: Intact.
Orientation: Oriented.
Insight: Insight is often present and intact; the patient is aware of their symptoms and the
extent to which they are affecting them.
Judgment: May be poor due to lack of motivation or concentration.
Intelligence: Average, as evident by conversation.
Cyclothymic Disorder:
Appearance: Variable, depending on the phase. May appear energized, with well-groomed
appearance, in hypomanic periods or weary, unkempt in depressive periods.
Speech: Rapid but not pressured during hypomanic periods. Slow, quiet speech during
depressive periods.
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Affect: Labile, with frequent shifts between elevated/irritable affect and downcast/sad affect.
Mood: Varies from being “on top of the world” to “down in the dumps.”
Behavior: Active, energetic during hypomanic periods, but not to the extent of overt
agitation. Inactive, sluggish during depressive periods.
Thought Process: Racing thoughts may be present, but without the flight of ideas or the degree
of racing thoughts in bipolar disorder.
Thought Content: Dependent on mood, but lacking in grandiosity or the level of nihilistic and
hopeless suicidal thoughts in bipolar or major depressive disorders.
Attention and Concentration: Attention and concentration may be poor, due to frequent mood
shifts.
Memory: Intact.
Orientation: Oriented.
Insight: Insight is often present. The patient may recognize that the mood swings are a problem,
but may not fully understand or appreciate the impact.
Judgment: Judgment may be impaired, especially during hypomanic periods, resulting in risky
behaviors.
Intelligence: Average.
ADHD, Combined Presentation:
Appearance: Fidgety or restless.
Speech: Rapid, impulsive speech, may interrupt conversations.
Affect: Anxious or irritable.
Mood: Labile, with rapid shifts in emotional state (irritated to calm and vice versa).
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Behavior: Behavior may include restless, fidgety movements, or an inability to remain seated.
Thought Process: Speech and thought process may quickly jump between different topics
without clear connections, which may reflect inattention or distractibility.
Thought Content: No delusional or hallucinatory content.
Attention and Concentration: Markedly impaired. The patient may have difficulty following a line
of questioning or may lose focus quickly.
Memory: Intact.
Orientation: Oriented.
Insight: Insight may be present. The patient may recognize that their inattention and
hyperactivity are problematic for their work and relationships.
Judgment: Judgment may be impaired, especially due to impulsivity.
Intelligence: Appears to be average.
Question D
Bipolar II Disorder: The etiology of bipolar disorder is considered to be complex and
multifactorial. Bipolar disorder is thought to result from a combination of genetic and
neurobiological abnormalities. Dysregulation of neurotransmitter systems such as dopamine,
norepinephrine, and serotonin are believed to play an important role (Stahl, 2021). This is also
known as the “monoamine hypothesis” of bipolar disorder. The manic/hypomanic symptoms in
bipolar disorder are thought to be related to an excess of monoamines, whereas the depressive
symptoms are thought to be related to a deficit of monoamines (Stahl, 2021). In addition, there
are believed to be structural and functional abnormalities in the brains of people with bipolar
disorder, particularly in the prefrontal cortex, amygdala, and hippocampus (Stahl, 2021). These
abnormalities may affect mood regulation, emotional processing, and executive functioning.
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Major Depressive Disorder:The exact etiology of MDD is unknown but is thought to be
complex and multifactorial. MDD is often considered to be caused by a combination of genetic,
environmental, and neurobiological factors. A common theory of the etiology of MDD is the
“monoamine hypothesis,” which suggests that MDD is caused by a deficiency of monoamine
neurotransmitters such as serotonin, norepinephrine, and dopamine (Stahl, 2021). In addition,
abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis, which regulates the body’s
stress response, are often found in people with MDD (Stahl, 2021). This can lead to an
overproduction of cortisol, the stress hormone, and can cause symptoms such as anxiety and
insomnia.
Cyclothymic Disorder: It is thought to have a similar neurobiological basis to bipolar
disorder, with dysregulation of neurotransmitters such as serotonin and dopamine. The milder,
chronic, and fluctuating nature of the symptoms may suggest a less severe form of
neurobiological imbalance.
A strong genetic component is also suspected, as the disorder tends to run in families
with a history of bipolar disorder.
ADHD, Combined Presentation: ADHD is believed to be caused by abnormalities in the
dopamine and noradrenaline neurotransmitter systems in the prefrontal cortex and basal
ganglia, which are involved in executive functions such as attention, planning, and impulse
control. Dopamine and norepinephrine are neurotransmitters that play a role in regulating
attention and arousal, and deficits in these neurotransmitters in the prefrontal cortex and basal
ganglia have been associated with the symptoms of ADHD (Stahl, 2021).
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Genetic factors are also thought to play a significant role in the development of ADHD, as
it is highly heritable. Environmental factors, such as early life adversity, may also contribute to
the development of the disorder.
Question E
Bipolar II Disorder:
Medical Rule-out: Order CMP and TSH
Psychiatric Screening Tool: Mood Disorder Questionnaire (MDQ)
Major Depressive Disorder:
Medical Rule-out: Order CMP, CBC, TSH, Vitamin B12, and Folate level
Psychiatric Screening Tool: Patient Health Questionnaire-9 (PHQ-9)
Cyclothymic Disorder:
Medical Rule-out: Order TSH and CMP
Psychiatric Screening Tool: Hypomania Checklist-32 (HCL-32)
ADHD, Combined Presentation:
Medical Rule-out: Order TSH and CMP
Psychiatric Screening Tool: Adult ADHD Self-Report Scale (ASRS) v1.1
Rationale for Choosing Screening Tools and Diagnostic Tests
Rationale for choice of Medical Rule-Outs: For Mark, a CMP, TSH, and CBC are justified
as initial medical tests, as they are standard for all patients presenting with psychiatric
symptoms (Dehghan & Arfken, 2021).. They are used to rule out physiological contributors to
mood dysregulation, irritability, and changes in energy or sleep. A CMP can reveal problems like
electrolyte imbalances or issues with liver and kidney function, which can have neuropsychiatric
ADULT MENTAL HEALTH EVALUATION 11
manifestations. TSH testing is also standard for mood symptoms as thyroid disorders can closely
mimic mood disorders (Khan, Siddiqui, & Khan, 2021). Hyperthyroidism can lead to agitation,
anxiety, irritability, and racing thoughts, which can be mistaken for hypomania. Hypothyroidism
can cause fatigue, low mood, and psychomotor retardation that can be indistinguishable from a
major depressive episode. As Mark’s symptoms could be the result of either, it’s important to
check TSH levels for a complete picture. A CBC is useful for Mark because fatigue and mood
changes could be the result of anemia or other conditions that would be indicated by an
abnormal CBC. For the differential diagnosis of Major Depressive Disorder, this would rule out
physical causes of fatigue and low energy as a primary concern.
Rationale for Screening Tools: The self-report scales that are selected are commonly
used, validated measures that can be used to quickly and accurately identify the presence of
conditions in the differential. They provide objective measures that will either support or rule
out a diagnosis and help guide clinical interviews.
MDQ: The Mood Disorder Questionnaire (MDQ) is a highly effective, 13-item selfreport
questionnaire that screens specifically for bipolar disorder (Wang, Zhou, & Wang, 2021). Its
questions pertain to a wide range of manic and hypomanic symptoms like elevated mood,
irritability, racing thoughts, and a decreased need for sleep. As all of these are key symptoms for
Mark and fall specifically in the realm of bipolarity, the MDQ is the most fitting tool to screen for
Bipolar II Disorder.
PHQ-9: The Patient Health Questionnaire-9 (PHQ-9) is a 9-item questionnaire that is
specifically designed to screen for and measure the severity of major depressive episodes. It is
also specific to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
criteria for depression. It is standard and effective to use the PHQ-9 to get a sense of the
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severity of Mark’s depressive symptoms, as Major Depressive Disorder is one of the primary
differentials, and to track these symptoms over time (Levis, Sun, & He, 2020).
HCL-32: The Hypomania Checklist-32 (HCL-32) is a self-report questionnaire that
provides a more detailed assessment of hypomanic symptoms, which is useful to differentiate
between the various possible mood disorders. It is used in patients who have mood disorders
but the primary differential diagnosis is Bipolar II or Cyclothymic Disorder. It measures
symptoms of hypomania on a spectrum, which is useful for the latter in detecting the less
obvious or lesssevere hypomanic symptoms of Cyclothymic Disorder. Due to Mark’s extensive
and chronic mood instability history, the HCL-32 provides a more in-depth view of his
hypomanic traits that may not meet the threshold for a hypomanic episode (Wang et al., 2021).
ASRS: The Adult ADHD Self-Report Scale (ASRS) v1.1 is a standardized scale that screens
for adult ADHD. It is necessary for Mark to take this scale due to the large overlap between his
symptoms and ADHD (irritability, racing thoughts, pressure to talk, decreased need for sleep,
etc.). The ASRS has 18 questions about symptoms of ADHD, specifically inattention,
hyperactivity, and impulsivity, and differentiates between these symptoms. This differentiation is
key in making sure that these are either not a primary concern or part of a larger mood disorder
(Kessler et al., 2022).
Question F
The most probable diagnosis is Bipolar II Disorder. This diagnosis is most likely because
his present symptoms and lifelong history support this diagnosis. First, the requirement of at
least one major depressive episode in the lifetime is fulfilled by his report of having had a severe
depression that he received treatment with an SSRI for. Thoughts of death can qualify as
symptoms of a depressive episode (Hirschfeld, Cass, & Holt, 2020). The current duration of the
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mood swings is consistent with a hypomanic episode of six months. The other elements of the
presentation are chronic irritability, mood lability, racing thoughts, agitation, and chronic sleep
difficulties. His past history also includes irritability, depression, and hospitalizations for suicidal
ideations. His family history of bipolar disorder (brother) also supports this diagnosis. Why
other differentials are less likely:
Major Depressive Disorder: This differential is less likely due to his current presentation
and past treatment. Thoughts of death can qualify as symptoms of a depressive episode. The
current duration of the mood swings is consistent with a hypomanic episode of six months. The
other elements of the presentation are chronic irritability, mood lability, racing thoughts,
agitation, and chronic sleep difficulties. His past history also includes irritability, depression, and
hospitalizations for suicidal ideations. His family history of bipolar disorder (brother) also
supports this diagnosis. Mark was previously treated with an SSRI, but it “did not make much
difference in treating his symptoms.” If the patient had MDD and was treated with an SSRI for it,
it should have helped to some extent, so it is more likely that he has bipolar disorder. While
irritability, mood lability, and agitation could be related to ADHD, this does not explain his other
symptoms and previous history of depression and hospitalizations for suicidal ideation. The
racing thoughts, agitation, and sleep difficulties are more characteristic of mood disorders than
ADHD.
Cyclothymic Disorder: Cyclothymic disorder is less likely because this diagnosis requires
chronic mood lability symptoms that do not meet the full criteria for a hypomanic or major
depressive episode but persist for a longer duration (usually two years). While Mark has a long
history of mood swings, his current symptoms are more severe and pervasive, including
agitation, racing thoughts, and chronic sleep difficulties, suggesting a full-blown hypomanic
ADULT MENTAL HEALTH EVALUATION 14
episode rather than sub-threshold symptoms. Furthermore, the history of severe depression
treated with an SSRI would not be consistent with this diagnosis as this diagnosis precludes
major depressive episodes.
ADHD, Combined Presentation: ADHD, combined presentation is less likely due to
Mark’s current symptoms, age of onset, and past history. The racing thoughts, agitation, and
irritability can be a symptom of ADHD. However, it is less likely because he does not have a
history of these problems since childhood. Furthermore, his primary presenting complaint is
episodic mood lability and not inattention or hyperactivity. Mark has also had a past history of
severe depression, hospitalizations for suicidal ideations, and treatment with an SSRI, which
would not fit with the diagnosis of ADHD.
Question G
Mood Stabilizer (Used in conjunction with 2nd Gen Antipsychotic for Severe Depressive
or Hypomanic Symptoms)
Medication: Lamotrigine (Lamictal)
Dosing: Starting dose: 25 mg daily x 2 weeks
Titration: 50 mg daily x 2 weeks
Maintenance: 100-200 mg daily (increase dose by 50 mg every 1-2 weeks)
Rationale: This is the first-line treatment for Bipolar II Disorder, as described above.
Mood stabilizers are indicated for mood lability. In this case, the patient has symptoms of
chronic irritability, mood lability, racing thoughts, agitation, and chronic sleep difficulties. In
addition, this medication is used in conjunction with a 2nd Gen Antipsychotic if the depressive
or hypomanic symptoms are more severe, as is likely the case for this patient.
Safety Information and Black Box Warnings:
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Black Box Warning: This medication has a black box warning for serious skin rashes,
including Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). The clinician
should educate the patient on the signs of a rash (hives, blisters, blistering skin, peeling skin,
etc.) and instruct the patient to stop taking the medication and seek medical attention if a
rash ]occurs (U.S. Food and Drug Administration, 2018).
Safety Monitoring: No special monitoring is indicated with this medication; however,
patient education is critical. Inform the patient that this medication should not be stopped
abruptly, as this can cause a rebound worsening of mood symptoms. Instruct the patient to use
caution with this medication in combination with other drugs that can interfere with drug
metabolism (e.g., valproic acid) as this may increase the risk of adverse effects.
Non-Pharmacological Treatment:
Psychotherapy: Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy
(DBT) are effective treatments for mood symptoms, coping skills, and trauma from childhood
abuse (Stahl, 2021). CBT can help the patient identify and change negative thought patterns,
and DBT can teach Lifestyle modifications should be encouraged to include regular sleep
hygiene, as chronic sleep difficulties are one of the patient’s primary presenting symptoms. The
patient should be advised to avoid or significantly cut down on alcohol and marijuana use, as
these can also contribute to mood instability and interfere with the effectiveness of mood
stabilizers. Regular exercise, a balanced diet, and stress reduction techniques such as
mindfulness or meditation are also recommended.
Psychoeducation: Provide psychoeducation about Bipolar II Disorder, including its
episodic nature, treatment, and medication adherence. Provide resources such as the National
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Alliance on Mental Illness (NAMI) or the Depression and Bipolar Support Alliance (DBSA) for
peer support groups and further education.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders,
fifth edition, text revision. American Psychiatric Publishing.
Dehghan, N., & Arfken, A. (2021). Medical rule-outs for psychiatric symptoms. Current
Psychiatry Reports, 23(1), 1-8.
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Hirschfeld, R. M. A., Cass, A. R., & Holt, C. S. (2020). The Mood Disorder Questionnaire: A simple,
patient-rated screening instrument for bipolar disorder. Journal of Clinical
Psychiatry, 61(8), 651–659.
Kessler, R. C., Adler, L., & Barkley, R. A. (2022). The Adult ADHD Self-Report Scale (ASRS)
screener: Validation in the World Health Organization World Mental Health Surveys.
Psychological Medicine, 52(2), 296-305.
Khan, S. I., Siddiqui, U., & Khan, Z. R. (2021). The neuropsychiatric manifestations of thyroid
disorders: An update. International Journal of Environmental Research and Public
Health,
Levis, B., Sun, Y., & He, C. (2020). The Patient Health Questionnaire-9 (PHQ-9): A systematic
review and meta-analysis of its diagnostic accuracy. Psychological Medicine, 50(9), 1541-
1555.
Stahl, S. M. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical
applications (5th ed.). Cambridge University Press.
U.S. Food and Drug Administration. (2018). Lamictal (lamotrigine) medication guide. Retrieved
from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/020241s057lbl.pdf
Wang, G., Zhou, Q., & Wang, D. (2021). Psychometric properties of the Mood Disorder
Questionnaire (MDQ) and Hypomania Checklist-32 (HCL-32) in clinical practice.
Journal of Affective Disorders, 281, 523-529.
