Psychotherapy For A Mood Disorder Assignment Paper

Psychotherapy For A Mood Disorder Assignment Paper

Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide.

NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

CC (chief complaint): “I just feel so down and hopeless all the time.”

HPI: Mrs. Smith is a 39-year-old female who presents to the clinic today with complaints of feeling sad, hopeless, and empty most of the time for the past six months. She describes a loss of interest in activities that she used to enjoy, including spending time with her family and friends. Mrs. Smith also reports difficulty sleeping and a significant decrease in her appetite, resulting in weight loss. She reports feeling fatigued and lacking energy, even when she gets enough rest. She denies any suicidal thoughts but admits to feeling like she would be better off dead at times. Mrs. Smith reports that her symptoms have been impacting her work, and she has been finding it hard to concentrate and be productive. She denies any significant medical history, including any previous psychiatric diagnoses. She reports no recent stressors or life changes that could have triggered her symptoms. She is here today seeking help and hoping to feel better Psychotherapy For A Mood Disorder Assignment Paper.

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Past Psychiatric History:

• General Statement: no prior psychiatric diagnoses or treatment.
• Caregivers (if applicable): Spouse
• Hospitalizations: denies history of hospitalizations
• Medication trials: No medications used in the past
• Psychotherapy or Previous Psychiatric Diagnosis: patient has not undergone psychotherapy or been diagnosed with a psychiatric disorder in the past Psychotherapy For A Mood Disorder Assignment Paper

Substance Current Use and History: denies any current or past substance use.

Family Psychiatric/Substance Use History: no known family history of psychiatric or substance use disorders.

Psychosocial History: Mrs. Smith reports that she is married and has two young children. She has a supportive spouse who has noticed her recent struggles with She is currently working full-time as an accountant. She reports feeling overwhelmed at work and struggling to balance her workload and family responsibilities. She denies any history of trauma or abuse.

Medical History: no significant medical history.

 

• Current Medications: Patient is not currently taking any medications.
• Allergies: NKA

• Reproductive Hx: Mrs. Smith reports having two uncomplicated pregnancies and deliveries. She is currently using a non-hormonal form of birth control

ROS:

• GENERAL: reports feeling fatigued and lacking energy.
• HEENT: Denies any abnormalities or complaints related to the head, eyes, ears, nose, throat, or neck.
• SKIN: No rashes, lesions, or skin changes reported.
• CARDIOVASCULAR: No chest pain, palpitations, or edema reported.
• RESPIRATORY: No shortness of breath, cough, or wheezing reported.
• GASTROINTESTINAL: reports a decrease in appetite and some unintentional weight loss. No abdominal pain or gastrointestinal symptoms reported.
• GENITOURINARY: No dysuria, hematuria, or urinary incontinence reported.
• NEUROLOGICAL: Mrs. Smith reports feeling sad, hopeless, and empty most of the time. She denies any cognitive or memory deficits.
• MUSCULOSKELETAL: No joint pain, stiffness, or swelling reported.
• HEMATOLOGIC: No history of bleeding or clotting disorders reported.
• LYMPHATICS: No swollen lymph nodes reported.
• ENDOCRINOLOGIC: No symptoms of endocrine dysfunction reported

Physical exam: N/A

Diagnostic results: Beck Depression Inventory- 24 total score

Assessment

Mental Status Examination: Mrs. Smith appears to be a 39-year-old female who presents with a sad and depressed mood. She is well-groomed and cooperative throughout the interview. Her speech is slow, quiet, and hesitant. She maintains good eye contact with the interviewer but her facial expression appears sad and downcast. Her affect is constricted, and she reports feeling hopeless and empty most of the time. Mrs. Smith’s thought process is coherent and relevant, but she expresses pessimistic and negative thoughts about herself and her life. She denies any current suicidal or homicidal ideation. Her attention and concentration appear intact, but she reports difficulty with memory and concentration. Mrs. Smith’s insight and judgment appear to be mildly impaired due to her depressive symptoms. She is aware that she is experiencing depression and that her symptoms are interfering with her ability to function. Psychotherapy For A Mood Disorder Assignment Paper

Differential Diagnoses:

Major Depressive Disorder (MDD): This diagnosis is characterized by a combination of symptoms, including depressed mood, anhedonia, fatigue, feelings of worthlessness, and thoughts of death or suicide, which cause significant distress and impairment in daily functioning (Christensen et al., 2020).This is the highest priority diagnosis as the patient’s symptoms of depressed mood, anhedonia, feelings of worthlessness, and hopelessness meet the DSM-5 criteria for MDD. A diagnosis of MDD requires the presence of at least five of nine symptoms of depression lasting for at least two weeks, with at least one of the symptoms being either depressed mood or loss of interest or pleasure in activities. The patient’s BDI score also supports this diagnosis.

Adjustment Disorder with Depressed Mood: This is a mental health diagnosis characterized by the development of depressive symptoms, such as feelings of sadness, hopelessness, and tearfulness, in response to an identifiable stressor or life event (O’Donnell et al., 2019)Psychotherapy For A Mood Disorder Assignment Paper.This diagnosis would be considered if the patient’s symptoms are related to an identifiable stressor or life event. Symptoms may include depressed mood, tearfulness, feelings of hopelessness, and difficulty sleeping. This diagnosis is considered if the patient’s symptoms do not meet the criteria for a more severe mental disorder like MDD.

Dysthymia: This is a condition characterized by a chronic and persistent depressed mood lasting for at least two years, along with other symptoms of depression (Patel & Rose, 2021).This diagnosis would be considered if the patient has a more chronic form of depression characterized by a depressed mood that lasts for at least two years. Symptoms may include low self-esteem, feelings of hopelessness, poor concentration, and difficulty making decisions.

The primary diagnosis is Major Depressive Disorder. The patient’s symptoms of depressed mood, anhedonia, feelings of worthlessness and hopelessness, as well as the BDI score support the criteria for MDD in the DSM-5-TR.

Case Formulation and Treatment Plan:

Mrs. Smith is a 39-year-old female presenting with complaints of feeling sad, hopeless, and empty most of the time for the past six months. She reports a loss of interest in activities, difficulty sleeping, and a significant decrease in appetite, resulting in weight loss. Mrs. Smith reports feeling fatigued and lacking energy, even when she gets enough rest. She denies any suicidal thoughts but admits to feeling like she would be better off dead at times. Her symptoms have been impacting her work and daily activities. She denies any significant medical or psychiatric history, recent stressors, or substance use. Based on her clinical presentation, the differential diagnosis includes Major Depressive Disorder (MDD), Adjustment Disorder with Depressed Mood, and Dysthymia. The highest priority diagnosis is MDD as the patient’s symptoms of depressed mood, anhedonia, feelings of worthlessness, and hopelessness meet the DSM-5 criteria for this disorder. Mrs. Smith’s BDI score also supports this diagnosis.

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The treatment plan for Mrs. Smith would include psychotherapy, specifically cognitive-behavioral therapy (CBT). The goal of therapy would be to reduce symptoms of depression and help Mrs. Smith develop coping strategies to manage her depression. The follow-up plan would include weekly therapy sessions for 12-20 weeks. Referrals that may be recommended as a result of this psychotherapy session include a referral to a psychiatrist for medication management. Although medication is not the first-line treatment for mild to moderate depression, it may be considered if symptoms do not improve with psychotherapy alone Psychotherapy For A Mood Disorder Assignment Paper.

Reflections:

 One thing I would do differently is to ensure that I am providing adequate time for the patient to express their concerns and perspectives. In this scenario, the patient may have been more comfortable discussing their symptoms and experiences if I had created a more open and welcoming environment, allowing them to express themselves without feeling rushed or dismissed. One social determinant of health relevant to this patient’s mental health is the social and community context. According to Healthy People 2030, social and community context refers to the “social and physical environments where people live, work, and play, as well as the relationships they have with family, friends, and others in their community.” This determinant can have a significant impact on mental health outcomes, as factors such as social isolation, discrimination, and poverty can all contribute to mental health issues.

To promote health equity and reduce disparities in mental health, the health promotion activity for this patient could be to connect them with community resources, such as support groups or counseling services. Additionally, patient education could focus on strategies for building healthy social connections, such as joining a club or organization or volunteering in the community.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Christensen, M. C., Wong, C. M. J., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: do the perspectives of patients and healthcare providers differ?. Frontiers in Psychiatry, 11, 280.

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of environmental research and public health, 16(14), 2537 Psychotherapy For A Mood Disorder Assignment Paper.

Patel, R. K., & Rose, G. M. (2021). Persistent Depressive Disorder. In StatPearls [Internet]. StatPearls Publishing.

NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

CC (chief complaint):  Being sad, lack of motivation and interest, changes in her mood.

HPI: Mr. Joe visits the hospital claiming that she rarely sleeps., has changes in her mood meaning that at times she feels very happy while on other occasions she is sad, and she states that she has lost interest and motivation in the daily normal activities.  She states that the symptoms started 2 weeks ago and since then her normal life activities have been affected. She also states that her situation has become worse and currently, she is isolated from her family and friends and she wants to stay alone.

Past Psychiatric History:

• General Statement: The patient was well-groomed and very smart and he had challenges paying attention. He could be asked a question and he seemed lost. He also looked terrified when asked about any kind of stressors affecting him.
• Caregivers (if applicable): The caregivers in this case include psychologists, psychiatrists, and general physicians.
• Hospitalizations: The patient has not been hospitalized in the last 5 years showing that he has been healthy.
• Medication trials: The patient has not been part of the medical trials.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient was previously diagnosed with major depressive disorder but the symptoms subsided with time.

Substance Current Use and History:  The patient does not use any drugs about he takes alcohol occasionally during certain life events.

Family Psychiatric/Substance Use History:  Mr. Joe’s parents had a problem with mood disorders and his father had learned how to control it but his mother used to take Lithium to stabilize her mood. The father was a chronic smoker while the mother never used any drugs and substances.

Psychosocial History: Mr. Joe lives with his wife whom they have been married for the last 5 years and they have a two-year-old son. He loves playing basketball and badminton and he loves socializing Psychotherapy For A Mood Disorder Assignment Paper.

Medical History:

• Current Medications: The patient has been taking Zoloft 50 mg once a day to help with the major depressive disorder.
• Allergies: The patient is allergic to dust, proteins and fur but he has no known drug allergy.

• Reproductive Hx:  The patient has no known reproductive history.

ROS:

• GENERAL: The patient has no fever and he has experience decrease in the energy levels. His weight has decreased and the temperature levels have been normal.
• HEENT: The eyes, throat, nose, and ears depict normalcy and there are no health concerns.
• SKIN: Denies any itching and has no rashes on the skin.
• CARDIOVASCULAR: Has no palpitations, chest pains, or even orthopnea.
• RESPIRATORY: The cough is not stubborn and has normal breaths.
• GASTROINTESTINAL:  Lacks any abdominal concerns like vomiting, nausea, and abdominal pain.
• GENITOURINARY:  Has no infection signs or abnormal presentations in the genitourinary system.
• NEUROLOGICAL:  Does not experience lack of consciousness or headaches.
• MUSCULOSKELETAL: The patient has no joint or muscular inflammation.
• HEMATOLOGIC: He lacks any abnormalities in the blood.
• LYMPHATICS: The lymph nodes are not inflamed but are normal.
• ENDOCRINOLOGIC: He has no endocrinology conditions. Psychotherapy For A Mood Disorder Assignment Paper

Physical exam:

Vital Signs:  W: 50 lbs., Resp: 2, Bp: 130/90, H: 4, Pulse rate 78.

General Appearance:   The patient was smart but he seemed distracted.

Respirations:  The patient was not wheezing.

Cardiovascular:  The S1 and S2 sounds had a regular rhythm.

Neurological:  The speech was normal and not slurred and the tone was normal with a stable balance.

Psychiatric: The patient had a hard time concentrating, he did not have any interests or motivation on doing what he liked and he experienced fast changes in the mood.

Diagnostic results:  The patient will undergo a psychiatric test using a PHQ-10 questionnaire.

Assessment

Mental Status Examination:  The patient meets the DSM-IV criteria for treating bipolar disorder and he depicts at least six of the symptoms and this shows that bipolar disorder is the primary diagnosis.

Differential Diagnoses:

1. Major depressive disorder-  This is a condition characterized by a sudden loss of interest, a constant depressed mood and impatient in the daily life (Gutiérrez-Rojas et al., 2020). The patient has all these symptoms but the only difference is that the mood changes he experiences frequently change.
2. Generalized anxiety disorder- The condition is mainly one, which interferes with an individual’s daily life and it is characterized by a constant change in mood and anxiety (Graus et al., 2020)Psychotherapy For A Mood Disorder Assignment Paper. In this case the patient is not anxious and that explains why it is ruled out.

Case Formulation and Treatment Plan:

The treatment plan involves psychotherapy that the patent will undergo to help him get better ad learn how to manage his emotions to avoid them from impacting his daily life.

The patient will also be part of bipolar disorder support groups in the community and they will share their experiences with the condition.

The patient will also undergo education to teach him more about the condition and how to avoid these symptoms (Carvalho et al., 2020).

The patient will be administered with Depakene 20 mg once a day to help in stabilizing his mood and making him feel better.

Reflections:

Since the patient has bipolar disorder, the first line treatment would be for her to take medication to stabilize his mood. She should also get educated to make sure there are improvements in patient adherence.

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References

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.

Graus, F., Saiz, A., & Dalmau, J. (2020). GAD antibodies in neurological disorders—insights and challenges. Nature Reviews Neurology, 16(7), 353-365.

Gutiérrez-Rojas, L., Porras-Segovia, A., Dunne, H., Andrade-González, N., & Cervilla, J. A. (2020). Prevalence and correlates of major depressive disorder: a systematic review. Brazilian Journal of Psychiatry, 42, 657-672 Psychotherapy For A Mood Disorder Assignment Paper