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SYMPTOM ANALYSIS VALUATION EMPLATE E T
Symptom: Mark chief complaint includes “horrible mood swings and I get angry easily.” He
complains of increased irritability, racing thoughts, mood swings, and chronic sleep disturbance.
These symptoms last 5-6 days/week for most of the day. States he has thoughts of death when he
becomes severely depressed. His mood instability was first diagnosed in his teens and continues to
worsen. Previously treated with selective serotonin reuptake inhibitors (SSRI) but feel they were
not helping. Over the last three months, I have been drinking 3-4 cans of beer over the weekend.
Uses marijuana twice a month to help relax.
A. Identify appropriate history questions to be asked of your patient to discriminate critical
characteristics or attributes about the above presenting complaint. Incorporate COLDSPA
(Characteristics, Onset, Lingering, Duration, Stressors, Precipitating factors/triggers, Alleviating
factors).
Characteristics: Can you describe your current mood swings? Do these mood swings occur daily? Do you
always experience anger when you have mood swings?
Onset: When did your mood swings and anger start affecting your daily life and activities? You stated the
mood swing are 4-5 times a day, are they all “horrible” with anger issues? How long have you been using
alcohol and marijuana?
Lingering: Compared to last year, are your mood swings lasting longer? Does your symptoms decrease when
you are using alcohol and marijuana?
Duration: How many hours of the day do you experience anger and mood swing issues?
Stressors: What triggers your anger or mood swings? How do you react when you are angry?
Precipitating/triggers: What makes your anger worse? Are you taking any OTC or prescription medication to
treat your mood swings or chronic sleep disturbance?
Alleviating: What helps to alleviate your mood swings? Do you feel that alcohol and marijuana helps you?
B. Delineate 4 hypotheses (differential diagnosis) that could support the above symptoms in
relation to pertinent answers given the history. MOST use appropriate DSM 5 diagnosis and
provide rationale for each choice base on the presenting case.
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Differential 1 Bipolar II: Mark has a long history of mood instability that started in his early teens. The
mood swings have worsened during his twenties and thirties. Mark complains of irritability,
agitation, racing thoughts, anger, and chronic sleep disturbance. Bipolar II: To be diagnosed
with Bipolar 2 according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5), the individual must experience a hypomanic episode and a major
depressive episode. An episode of hypomania requires at least 4 days of elevated mood
change, which may include increased energy, irritability, and expansiveness. During
hypomania, you must have at least three of the following symptoms: an exaggerated sense of
well-being, grandiosity; decrease need for sleep; unusual talkativeness; rushed/scattered
thinking, racing thoughts; attention/focus issues; and psychomotor agitation. A major
depressive episode involves depressive symptoms that last at least two weeks and are severe
enough to cause significate emotional and occupational distress. An episode of depression
must involve a depressed mood or loss of interest and pleasure in addition to at least four of
the following symptoms: a significant change in weight and/or appetite; sleeping too much
or too little; restlessness; loss of energy; feeling extreme worthlessness or guilt; attention
difficulties, indecisive; and thinking about, planning, or attempting suicide.
,
Differential 2 Major Depressive Disorder: Mark presents with anger, depressed mood, difficulty
sleeping, irritability, and severe depression with thoughts of death. DSM-5 criteria for
Bipolar II are a hypomanic episode and a major depressive episode. A hypomanic episode
requires at least 4 days of elevated mood change, which might include feeling of increased
energy, irritability, and expansiveness. During this time, you must have three of the
following symptoms: exaggerated sense of well-being and self-confidence, grandiosity;
decrease need for sleep; unusual talkativeness; rushed/scattered thinking, racing thoughts;
attention/focus issues; psychomotor agitation; impulsivity, poor decision-making, and risk
taking. A major depressive episode must be present for at least two weeks and is severe
enough to produce significant emotional and occupational distress. A depressed mood and
anhedonia with at least four of the following: significant change in weight/or appetite;
sleeping too much or too little; restlessness or sluggishness; loss of energy; feeling extreme
worthlessness; attention difficulties, indecisiveness; thinking about, planning, or attempting
suicide. Mark did not meet DSM-5 criteria for a major depressive episode.
Differential 3 General Anxiety Disorder: Mark presented with insomnia and irritability. DSM-5 criteria
for generalized anxiety disorder is characterized by persistent anxiety and uncontrollable
worry that occurs consistently for at least six months. The following criteria is need to
diagnose GAD: excessive anxiety and worry about various events have occurred more days
than not for at least six months; difficulty controlling worry; the anxiety and worry are
associated with at least three of the following symptoms (restlessness, easy to fatigue,
difficulty concentrating, irritability, muscle tension and sleep disturbance); the anxiety and
worry causes clinically significant distress or impairment; it is not due to the physiological
effects of a substance or medical condition; and the disturbance is not better accounted for
by another mental illness.
Differential 4 Cyclothymic Disorder: Mrk presented with hypomanic and depressive symptoms. DSM-5
criteria are for at least two years there have been numerous periods with hypomanic
symptoms that did not meet criteria for a hypomanic episode and numerous periods with
depressive symptoms that did not meet criteria for a major depressive episode. The
following is also needed to meet criteria: during the above two year period, the hypomanic
and depressive period have been present for at least the time and the individual has not been
without the symptoms for more than two months at a time; criteria for major depressive,
manic, or hypomanic episode have never been met; symptoms aren’t better explained by
another mental illness; symptoms aren’t caused by a substance or another medical condition;
and symptoms cause clinically significantly distress or impair social, occupational, or other
important area of functioning.
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C. What mental status exam findings, would be associated with each listed hypothesis above?
What subjective data might the patient report? Use all component of MSE listed-
Appearance, Behavior, Speech, Affect, Thought process, Thought content, Insight,
Judgement, Cognitive examination (level of awareness, Attention and Concentration,
Memory, Orientation etc). Must support with literature and use the appropriate descriptors
in each component. Avoid using “normal” or “Good” as a descriptor.
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Differential 1
Bipolar II
Appearance: well-groom.
Speech: rapid speech, pressured
Affect: sad, flat, irritable
Behavior: irritable easily agitated
Thought process: rapid, racing thoughts, and easily distracted.
Thought content: grandiose and delusional.
Attention and concentration: short attention span
Memory: immediate, recent, and long term memory intact
Orientation: oriented to person, place, and time
Insight: fair
Judgement: impaired marked by use of alcohol and marijuana
Differential 2
Major
Depressive
Disorder
Appearance: appears older than the age, hair tangled, and clothing stained
Speech: decreased rate and volume. Speech slow.
Affect flat, irritated
Behavior: psychomotor retardation, stooped posture, minimal eye contact
Thought process: thought blocking. Denies suicidal or homicidal ideations. Denies self-
harm
Thought content: linear
Attention and concentration: easily distracted.
Memory: cognitive deficits which include short- and long-term memory
Orientation: oriented to person, place, and time.
Insight: fair insight into the problem
Judgement: fair unless delusions and hallucinations occur
Differential 3
General
Anxiety
Disorder
Appearance: well-groomed, sad facial expression
Speech: volume and rate normal, focused on negative events
Affect: anxious
Behavior: agitated
Thought process: preservative thought
Thought content: obsession thought, denies suicidal or homicidal ideation. Denies self
harm
Attention and concentration: low concentration and attention but generally intact
Memory: immediate, recent, and long-term memory intact
Orientation: intact to person, place, and time.
Insight: shows insight regarding her illness
Judgement: fair
Differential 4
Cyclothymic
Disorder
Appearance: well groom
Speech: pressured
Affect: constricted, limited eye contact
Behavior: irritated
Thought process: linear
Thought content: Denies suicidal or homicidal ideations
Attention and concentration: easily distracted
Memory: cognitive deficits which include short- and long-term memory
Orientation: to person, place, and time
Insight: fair
Judgement: fair
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D. What is the physiology, pathophysiology and/or etiology associated with each hypothesis?
Differential 1 Bipolar disorder-
Physiology: abnormalities in the prefrontal cortex and amygdala are causing an overactive
amygdala and a hypoactive hippocampus and prefrontal cortex.
Pathophysiology
In general, the pathogenesis of bipolar disorder has been demonstrated to include certain
brain areas; however, the particular mechanisms involved are not known. Bipolar disease
clients have shown abnormalities in the prefrontal cortex, amygdala, basal ganglia,
hippocampus, and anterior cingulate (Sekhon & Gupta, 2020). Patients with BD have an
overactive amygdala and a hypoactive hippocampus and prefrontal cortex. This elevates
amygdala activity, combined with decreased cortical activity, and may explain why cognitive
functioning is hampered in mania while emotions remain elevated and unrestricted.
Etiology
There's significant evidence that associations of genetic, psychological, and societal aspects
cause the disorder. Several investigations involving families have revealed that there is a
clear hereditary component. A study involving monozygotic twins reveals that when one of
the siblings is positive for the illness, about 80% of monozygotic twins are concordant for
the disorder. There is also a possibility of environmental factors since monozygotic twins do
not have 100 percent concordance. Anecdotal data suggest that traumatic life events and
other psychosocial aspects play a role in the development and frequency of manic episodes
(Sekhon & Gupta, 2020)
Differential 2 Major depressive disorder
Physiology: there is an enlargement of the amygdala, causing it to be more active, thus
causing sleep disturbance.
Pathophysiology
It has been hypotheses that central noradrenergic system dysfunction plays a part in the
pathogenesis of MDD; based on the proof of reduced norepinephrine metabolism, elevated
levels of tyrosine hydroxylase, and decreased density of norepinephrine transporter in the
locus coeruleus (Bains & Abdijadid, 2020)
Etiology
Major depressive illness is thought to have a complex etiology that includes biological,
genetic, environmental, and psychological elements. GABA, glutamate, and glycine have
been discovered to cause depression. Early life stress can produce substantial changes in
neuroendocrine and behavioral responses and anatomical abnormalities in the cerebral
cortex, contributing to chronic depression later in life (Bains & Abdijadid, 2020).
Differential 3Anxiety disorder
Physiology: Most of the signs are triggered by the autonomic nervous system (ANS), primarily the
sympathetic nervous system
Pathophysiology
Norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid are essential anxiety mediators in the
central nervous system. Most of the signs are facilitated by the autonomic nervous system, primarily the
sympathetic nervous system. The amygdala is accountable for regulating fear and anxiety. The amygdala
reaction to anxiety stimuli has been detected to be higher in clients with anxiety conditions (Chand &
Marwaha, 2020)
Etiology
An interplay of biopsychosocial variables appears to be the cause of anxiety disorders. Clinically significant
syndromes are released when genetic susceptibility interacts with traumatic events. Nervousness can be
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brought on by the following factors: medications, herbal medicine, abuse of drugs and alcohol, and traumatic
childhood memories (Chand & Marwaha, 2020).
Differential 4 Cyclothymic Disorder
Physiology: The phenomenology of cyclothymia overlaps with a multitude of separate
disorders. One similarity is the emotional dysregulation observed in both cyclothymic
patients and those with neurodevelopmental disorders (Scaini et al, 2020).
Pathophysiology
The pathophysiology of cyclothymic individuals involves development along with
depression and anxiety. It is a neurodevelopmental disorder where there is abnormal
development of the neurons in the amygdala and fronto-limbic part of the brain which causes
the brain’s inability to regulate moods.
Etiology
The causes of cyclothymia are unknown. First degree relatives of diagnosed patients have
major depressive disorder, bipolar 1 disorder, and bipolar 2 disorder more often than those in
the general population.
E. What diagnostic tests would you obtain to rule out medical issues that mimic each of the
differential diagnosis? What diagnostic screening tool would you use for each of the
differential diagnosis?
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F. Analysis:
G. What pharmacotherapy and non-pharmacological treatments would you suggest for the
primary diagnosis?
Medications may include:
Mood stabilizers- mood stabilizers help to regulate manic episodes. Examples of mood
stabilizers include lithium, divalproex sodium, carbamazepine, Equetro, and lamotrigine.
Lithium increases GABA levels, which lowers glutamate levels and suppresses the NMDA
receptor. Lithium also stimulates the GABA receptor directly.
Antipsychotics- these drugs are usually added to the treatment plan when the manic signs
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Differential 1 A complete blood count (CBC), complete metabolic panel (CMP), thyroid panel, and
a urine drug screen are done to help determine if other conditions could be causing
the symptoms (Sekhon & Gupta, 2020).
Brain imaging in computed tomography or MRI would be vital in evaluating any
organic root of manic signs.
Mood charting – is used to keep records of the patient sleeping patterns and moods.
Mood DisorderQuentionnaire (MDQ): it is indicative of the existence of bipolar
disease.
Differential 2 s may include CBC, complete metabolic panel (CMP), thyroid panel, and a Lab test
urine drug screen to help determine if other conditions could be causing the
symptoms.
Patient Health Questionnaire-9 (PHQ-9), a depression rating measure commonly
used to screen and diagnose MDD. The PHQ-9 uses nine items equivalent to the
DSM-5 criteria for MDD and also evaluates for psychosocial damage.
DSM-5- the doctor may compare the signs to the criteria for MDD and associated
disorders in the Diagnostic and Statistical Manual of Mental Disorders
Hamilton Rating Scale for Depression (HAM-D) is a clinician-administered
depression rating measure is usually used for the evaluation of depression (Bains &
Abdijadid, 2020)
Differential 3 s include; CBC chemistry profile, thyroid function tests, urinalysis, Laboratory test
and urine drug screen to determine if other conditions such as hypothyroidism could
causing the symptoms.
DSM-5- the doctor may compare the signs to the criteria for anxiety
and associated disorders in Diagnostic and Statistical Manual of Mental Disorders
Imaging techniques such as electroencephalography, brain computed tomography
(CT) scans are done to detect abnormalities in the brain (Chand & Marwaha, 2020)
Differential 4 A complete blood count (CBC), complete metabolic panel (CMP), thyroid panel, and
a urine drug screen are done to help determine if other conditions could be causing
the symptoms (Sekhon & Gupta, 2020).
Mood Charting
Psychological evaluation.
Bipolar II: To be diagnosed with Bipolar 2 according to the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), the individual must experience a hypomanic episode and a major
depressive episode. An episode of hypomania requires at least 4 days of elevated mood change, which may
include increased energy, irritability, and expansiveness. During hypomania, you must have at least three of
the following symptoms: an exaggerated sense of well-being, grandiosity; decrease need for sleep; unusual
talkativeness; rushed/scattered thinking, racing thoughts; attention/focus issues; and psychomotor agitation.
A major depressive episode involves depressive symptoms that last at least two weeks and are severe enough
to cause significate emotional and occupational distress. An episode of depression must involve a depressed
mood or loss of interest and pleasure in addition to at least four of the following symptoms: a significant
change in weight and/or appetite; sleeping too much or too little; restlessness; loss of energy; feeling extreme
worthlessness or guilt; attention difficulties, indecisive; and thinking about, planning, or attempting suicide.
Mark meet the criteria because of hypomanic episodes such as irritability, decrease need for sleep, and
racing thoughts. The major depressive episode was met by a depressed mood, sleeping too little, and
thoughts of suicide.
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persist despite management with other drugs. The drugs olanzapine (Zyprexa), are
risperidone (Risperdal), and quetiapine (Seroquel). The doctor prescribes these
medications along with mood stabilizers.
Antidepressants- the doctor can prescribe antidepressants along with antipsychotics and
mood stabilizers to help manage the depression.
Non-pharmacological treatment
Cognitive therapy aims at relapse reduction rates and improving sadness and mania
symptoms and psychosocial functioning.
Family therapy - provides families with better communication skills to reduce stress and
work together to address difficulties, whether or not the problems are caused by bipolar
disorder.
Psychoeducation aims to educate patients on bipolar disease and its treatment, with the
primary goal of improving pharmacological treatment adherence by assisting patients in
understanding the biological causes of the disorder and the justifications for
pharmacological therapies.
Educate on sleep hygiene.
Provide education for substance abuse use.
Encourage a healthy diet and exercise.
Follow-up every three months unless problems arise.
References
Bains, N., & Abdijadid, S. (2020). Major Depressive Disorder. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK559078/
Chand, S. P., & Marwaha, R. (2020). . PubMed; StatPearls Publishing. Anxiety
https://www.ncbi.nlm.nih.gov/books/NBK470361/
Dr. Lewis Potter. (2010, September 23). . Geeky Medics; Mental State Examination (MSE) – OSCE Guide
Geeky Medics. https://geekymedics.com/mental-state-examination/
Manassa Hany, Baryiah Rehman, & Chapman, J. (2019, June 22). Schizophrenia. Nih.gov; StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/
Sekhon, S., & Gupta, V. (2020). Mood Disorder. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK558911/
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References
Bains, N., & Abdijadid, S. (2020). Major Depressive Disorder. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK559078/
Chand, S. P., & Marwaha, R. (2020). . PubMed; StatPearls Publishing. Anxiety
https://www.ncbi.nlm.nih.gov/books/NBK470361/
Dr. Lewis Potter. (2010, September 23). . Geeky Medics; Mental State Examination (MSE) – OSCE Guide
Geeky Medics. https://geekymedics.com/mental-state-examination/
Manassa Hany, Baryiah Rehman, & Chapman, J. (2019, June 22). Schizophrenia. Nih.gov; StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/
Sekhon, S., & Gupta, V. (2020). Mood Disorder. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK558911/
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