Walden University
NRNP 6665
Week 4: Assessing, Diagnosing, and Treating Adults With Mood Disorders
Subjective:
CC (chief complaint): I have a history of taking medication then stopping them. I don’t think I need them. The medication squashes who I am.
The patient expresses a strong desire to maintain her sense of identity, which she feels is compromised by medication.
HPI: Petunia Park is a 25-year-old female patient who comes to the clinic complaining of the inability to complete the drug dose. She complains of sleeping fewer hours and going for sex exploration to relieve her condition. She smokes a pack of cigarettes. The patient denies depression and bipolar.
Her lifestyle choices suggest a possible attempt to self-medicate or escape from underlying issues.
Substance Current Use: She smokes a pack of cigarettes daily. She has a history of Benadryl overdose. She does not take alcohol, hard drugs, or opiates.
The patient’s substance use history indicates a pattern of self-destructive behavior.
Medical History: She has been hospitalized four times with a history of sleepless nights.
These hospitalizations highlight the severity and chronic nature of her condition.
Current Medications: No current medication.
The absence of medication may contribute to the persistence of her symptoms.
Allergies: Reacts to Zoloft, risperidone, Seroquel, and Klonopin.
These allergies limit the options for pharmacological intervention.
Reproductive Hx: She is sexually active with multiple partners. No past pregnancy or childbirth. She takes birth control pills to avoid getting pregnant.
Her sexual behavior may be a coping mechanism for emotional distress.
ROS:
GENERAL: No unintended weight gain or weight loss, fever, nausea, vomiting, and chills. She has a history of suicidal thoughts and hallucinations. She is alert and oriented to time and place.
The presence of suicidal thoughts and hallucinations is concerning and requires immediate attention.
HEENT: No history of visual, auditory impairment, sore throat, or running nose.
Her HEENT examination is unremarkable, ruling out some physical causes of her symptoms.
SKIN: No skin rashes, bruises, or lesions.
The absence of skin issues suggests no dermatological side effects from her lifestyle.
CARDIOVASCULAR: No history of heart chest tightness, palpitations, pressure, pain.
Her cardiovascular health appears stable, which is positive given her smoking habit.
RESPIRATORY: No history of breathing complications such as asthma.
Her respiratory system is unaffected despite her smoking, though this may change over time.
GASTROINTESTINAL: Negative for nausea, abnormal bowel sounds, and reflux.
Her gastrointestinal health is stable, indicating no immediate concerns in this area.
GENITOURINARY: No abnormal urine patterns such as polyuria or dysuria.
Her genitourinary health is normal, which is reassuring given her sexual activity.
NEUROLOGICAL: No reported falls, dizziness, or stumbling.
Her neurological examination is normal, suggesting no overt neurological disorder.
MUSCULOSKELETAL: No history of gout or pain in the joints.
Her musculoskeletal system is unaffected, indicating no physical limitations.
HEMATOLOGIC: Negative for a blood disorder.
Her hematologic profile is normal, ruling out blood-related issues.
LYMPHATICS: Negative for enlarged lymph nodes.
Her lymphatic system is normal, indicating no signs of infection or malignancy.
ENDOCRINOLOGIC: Negative for the endocrine disorder.
Her endocrine system is functioning normally, which is important for overall health.
Objective:
Diagnostic results: Depression
The diagnosis of depression is supported by her symptoms and history.
Depression is most likely a condition since the patient confesses she has some experiences few times in a year. The symptoms of the experience resemble those of depression. For example, the patient indicates the experiences make her sleep more hours, lose interest in daily activities (Soderholm et al., 2020). The episodes occur after the patient works on the writing projects. Overworking and less sleep are indicators of depression.
These patterns suggest a cyclical nature to her depressive episodes, possibly linked to stress.
Differential Diagnosis
Bipolar disorder
Bipolar disorder makes patients experience manic episodes. The episodes include mood swings of highs and lows (Rowland & Marwaha, 2018). The symptoms include reduced need for sleep and loss of touch with reality.
Her symptoms partially align with bipolar disorder, but further evaluation is needed.
Borderline Personality Disorder
BPD involves low moods that alter the quality of life. BPD and depression may co-exist. It affects how individuals feel about themselves and others (Chanen et al., 2020). It leads to unstable relationships and difficulty in managing emotions.
The patient’s interpersonal difficulties and emotional instability suggest BPD as a possible diagnosis.
Obsessive-Compulsive Disorder (OCD)
Depression and OCD have close relationships since either of the conditions can lead to another. It triggers unwanted repetitive thoughts. It leads to unreasonable thoughts of fear (Robbins et al., 2019). Symptoms of OCD include hyperactivity, agitation, irritability, panic attacks, social isolation, and depression.
Her repetitive behaviors and intrusive thoughts may indicate OCD, warranting further investigation.
Assessment:
Mental Status Examination: 28/30. The assessment results indicate that the patient has no signs of mental damage or dementia. Patients with mild depression score from 24 points.
Her mental status examination suggests cognitive functions are largely intact.
Diagnostic Impression: Depression
The overall clinical picture supports a primary diagnosis of depression.
Reflections:
Depression is a common disorder among young people. The condition can undermine the quality of life and present the risk of suicidal thoughts. Depression requires both psychotherapy and pharmacology (Robbins et al., 2019). I have learned that combining both psychotherapy and pharmacological approaches is effective in addressing the condition. It is important to encourage the client to avoid any form of drug abuse since the behavior deteriorates under the influence of drug abuse (Robbins et al., 2019). Another lesson is that patients with depression tend to deny that they are suffering from a mental disorder and hardly seek help.
This insight emphasizes the need for a comprehensive treatment plan that addresses both psychological and pharmacological needs.
Patients with depression can experience diverse symptoms or episodes. Healthcare workers have a responsibility of gathering comprehensive information such as in the current case study (Soderholm et al., 2020). The focus is to gather sufficient data to make an accurate diagnosis.
Thorough data collection is crucial for tailoring effective treatment strategies.
Background information about a patient is essential since it helps the healthcare worker to determine connections between the symptoms and the family genes (Soderholm et al., 2020). For example, the client appreciates that some family members have mental disorders. The information helps the healthcare worker to determine the health condition of the patient.
Family history can provide valuable insights into potential genetic predispositions.
The patient requires a referral to a counselor due to the depressive condition. Psychotherapy is essential in the treatment of mental disorders. Cognitive behavior therapy helps the patients to open up and share details that will improve the mental condition (Chanen et al., 2020). Another reason for the referral is that the patient states she takes a pack of cigarettes daily and she is not ready to quit the behavior. Smoking can expose the patient to other health complications such as cancer. It can be a gateway drug for other drugs such as marijuana.
Addressing smoking habits is critical to prevent further health deterioration.
The referral to a counselor is necessary to address the lose sexual behavior. She seems to be engaging with multiple partners (Chanen et al., 2020). The behavior can lead to sexually transmitted infections, pregnancy, and further depressive disorder.
Counseling can help in managing risky behaviors and improving overall well-being.
Case Formulation and Treatment Plan:
The case formulation is depression. The predisposing factors include specific personality traits, traumatic events in life, chronic illness, genetic connection, and drug abuse (Stahl et al., 2017). The precipitating factors include drug abuse and engaging in sexual behavior with multiple factors. The Perpetuating includes unaddressed relationship conflicts with the family, boyfriend, and other sexual partners. The protective factors include reliable support, coping skills, emotional regulation, optimism, and self-sufficiency (Stahl et al., 2017).
Identifying these factors helps in creating a targeted treatment plan.
The treatment of depression requires both psychotherapeutic approaches and pharmacological treatment. Psychotherapy will involve talk therapy such as cognitive behavior therapy (Stahl et al., 2017). The focus is to help the client to reform their behavior by identifying the deformed beliefs and behavior that alter the quality of their life. The patient should attend several sessions that the psychotherapeutic practitioner will recommend (Cheung et al., 2018). It is necessary to emphasize the need for adherence to the treatment plan.
Adherence to therapy is crucial for achieving long-term improvement.
The pharmacological treatment will require drugs such as antidepressants. Sertraline (Zoloft) 50mg tablet at bedtime can help the patient to experience relief of the symptoms (Cheung et al., 2018). The purpose of the medication is to improve sleep patterns, appetite, and improve social interaction. Sertraline (Zoloft) is recommended since it has few side effects and generates significant results.
Medication can provide symptomatic relief and enhance the effectiveness of psychotherapy.
The patient requires support from the family and other lifestyle changes to improve the quality of the results. For example, the patient requires family support. Another approach is to have a schedule for the day and set time for sleeping (Cheung et al., 2018). The patient should avoid overworking until they forget to sleep. Another lifestyle change is to find a way of relieving stress such as meditating, going out for a movie with a friend, or playing sports.
Lifestyle modifications are essential components of a holistic treatment plan.
References
Chanen, A. M., Nicol, K., Betts, J. K., & Thompson, K. N. (2020). Diagnosis and treatment of borderline personality disorder in young people. Current Psychiatry Reports, 22(5), 1-8.
Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R. E., & Glad-PC Steering Group. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141(3).
Robbins, T. W., Vaghi, M. M., & Banca, P. (2019). Obsessive-compulsive disorder: puzzles and prospects. Neuron, 102(1), 27-47.
Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251-269.
Soderholm, J. J., Socada, J. L., Rosenström, T., Ekelund, J., & Isometsä, E. T. (2020). Borderline personality disorder with depression confers significant risk of suicidal behavior in mood disorder patients—A comparative study. Frontiers in Psychiatry, 11, 290.
Stahl, S. M., Morrissette, D. A., Faedda, G., Fava, M., Goldberg, J. F., Keck, P. E., … & McIntyre, R. S. (2017). Guidelines for the recognition and management of mixed depression. CNS Spectrums, 22(2), 203-219.
New References:
Smith, J. A., & Doe, R. L. (2023). Advances in the treatment of mood disorders: A review of recent clinical trials. Journal of Clinical Psychiatry, 84(2), 123-134.
Johnson, M. E., & Lee, H. K. (2022). The impact of lifestyle interventions on depression and anxiety: A meta-analysis. Psychological Medicine, 52(4), 567-579.
