Description
Respond at least 2 times each to all colleagues, Need at least 2 references. Need 2-3 paragraphs in response.The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
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Week 4 Assignment 1: Case Study Presentation
Ijeoma Arubaleze
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan Il
Demesia Brown
12/20/2023
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): “I am here to establish a new provider”
HPI: MH is a 29-year-old white female who presents for an initial psychiatric evaluation. She reports
that she stopped seeing her former psychiatrist because she could not afford to pay him. She reports
that her job changed insurance, and the clinic did not accept the insurance. She has been diagnosed
with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and AttentionDeficit/Hyperactivity Disorder (ADHD). The client states that she is currently on Adderall 50mg to treat
her ADHD, Lexapro 10mg for her depression, and propranolol to alleviate her anxiety. According to her,
she started the use of Adderall during her childhood, but “it was too much for her.” So, her former
provider switched her to Strattera, which works well for her. She states that it has been 5 months since
she saw her psychiatrist. She reports that lately, she has been feeling very low and depressed, her
anxiety is really bad, and she always thinks that something will go wrong. She states that she is really
unhappy, despite having everything that will make anyone happy. According to her report, she inflicted
a minor injury on her wrist three weeks ago, which required a seven-day hospital stay. She further
stated that she got married 4months ago but was not excited about getting married. She said that she is
easily irritated and sleeps a lot. She reports that her appetite is poor and she experiences low
motivation. The symptoms have been present for a majority of each day, consistently, for at least two
consecutive weeks. She rates her mood/irritability 9/10. She endorses low energy. She denies having SI
and self-harm. She said she wants to be happy and be able to enjoy her marriage. She reports being in
therapy in the past but stopped two years ago. She denies ever being diagnosed with anorexia or any
eating disorder.
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Substance Current Use: Marijuana (recreational) twice a week. Alcohol: red wine once every week, 2
bottles of beer when out with friends. Coffee 1 cup daily
Medical History: Denies
Surgical Hx; brain tumor surgery (benign).
Hospitalization: Twice
Current Medications: Atomoxetine 60mg, Lexapro 10mg increased to 20mg at the
hospital.
Allergies: Denies
Reproductive Hx: LMP Nov 28th, heterosexual female, never being pregnant, on birth control – IUD.
Family Psychiatric Hx: Maternal Grandfather: alcoholic, Mom: depression. She reports that her
mom is on Cymbalta, and it helps with her depression. Older sister: ADHD and Depression. Her
Immediate older sister has ADHD and depression. Maternal Aunt takes Adderall.
Psychosocial Hx: pt is a 29-year-old female. She was born in Texas and grew up with both parents and
two older sisters. At the age of 9, she received a diagnosis of a brain tumor and subsequently underwent
surgery to remove it. The tumor was determined to be benign. She stated that she received a diagnosis
of ADHD at the age of 12 and was prescribed Adderall, which she continued to use until after completing
high school. She felt it was too much for her; it made her anxious, and her psychiatrist then prescribed
Strattera. She earned a baccalaureate degree in arts. She is currently employed in a financial institution
and runs her own art business. She denies any financial problems. She recently got married and now
lives with her spouse. She confirms that she has insurance and visits her Primary Care Physician and
gynecologist annually. She denies any legal issues.
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ROS:
GENERAL: weight loss, fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or
edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or
blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or
polydipsia.
Objective:
Diagnostic results: BP 118/76, RR- 16, HR- 78, O2 97, weight 105lbs, HT, 5’5, BMI 16.9.
Labs: TSH T3 /T4, CBC/ CMP baseline electrolytes, Vit 25 hydroxy, and folate.
PHQ-9 Score 20/27. The PHQ-9 is a questionnaire consisting of nine items that are commonly used
to measure the severity of depression in patients. It is a highly reliable tool in the field of mental health,
widely recognized for its ability to assist doctors in diagnosing depression and monitoring the
effectiveness of treatment(Karrouri et al.,2021)
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GAD: Score 17/21
The GAD-7 is a reliable and effective instrument for identifying and evaluating the severity of
Generalized Anxiety Disorder (GAD) in both clinical and research settings(Munir & Takov, 2022).
ASRS: The Adult ADHD Self-Report Scale (ASRS v1.1) is a questionnaire consisting of 18 items that
individuals aged 18 and above can complete to evaluate symptoms of Attention Deficit Hyperactivity
Disorder (ADHD) in adults (Gair et al.,2021). The scale utilized in this study is derived from the
Composite International Diagnostic Interview (2001) developed by the World Health Organization. The
items in the scale align with the diagnostic criteria outlined in the DSM but have been modified to
capture the manifestation of symptoms in adults more accurately (Gair et al.,2021). The utilization of
this scale is advantageous for the purpose of evaluating and identifying ADHD in individuals aged 18 and
above. It is recommended to employ this scale alongside a clinical interview (Gair et al.,2021).
Assessment:
Mental Status Examination: The patient is appropriately dressed, looks stated age somewhat restless
with goal-directed fidgety movements while talking. She maintains good eye contact. Speech and
language functions are intact and adequate. Her mood is still depressed. Her affect is appropriate and
depressed. The thought process is linear and coherent. Thought content shows no current suicidal
ideation or plans. The patient denies hallucinations but admits to suicidal ideas, but has no current plans
to harm herself. She exhibits no signs of paranoia or grandiose thinking. Cognitively, she is alert and
oriented. Her recent and remote memory is intact. Her concentration is good. Her insight is good.
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Diagnostic Impression: ADHD Combined type (f90.2). Attention Deficit Hyperactivity Disorder
(ADHD) is a prevalent neurodevelopmental disorder that often persists into adulthood, even though
diagnostic criteria and research primarily focus on the childhood manifestation of the condition(Ginapp
et al.,2022). This discrepancy in research and diagnostic criteria has resulted in a lack of understanding
and recognition of the disorder in adults, leading to underdiagnosis and undertreatment(Ginapp et
al.,2022). Therefore, it is imperative to expand research efforts and diagnostic criteria beyond
childhood to encompass the full spectrum of ADHD manifestations, which will lead to the development
of effective interventions for adults with ADHD(Ginapp et al.,2022).
MDD recurrent and severe without psychotic features( F33.2). The diagnosis of depression is typically
made when a person experiences a persistently low or depressed mood, loss of interest in activities they
once enjoyed, feelings of guilt or worthlessness, lack of energy, difficulty concentrating, changes in
appetite, agitation or psychomotor retardation, and sleep disturbances—thoughts of suicide(Karrouri et
al.,2021) According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), in
order to be diagnosed with Major Depressive Disorder (MDD), a person must exhibit at least five of the
symptoms stated earlier, with one of them being a depressed mood or anhedonia, which causes
problems in their social or occupational functioning(Karrouri et al.,2021). To diagnose Major Depressive
Disorder (MDD), it is necessary to exclude the possibility of a previous episode of mania or
hypomania(Karrouri et al.,2021).
.
GAD F41.1 Generalized anxiety disorder affects about 20% of adults annually, causing persistent feelings
of worry, apprehension, and being overwhelmed. (Munir & Takov, 2022). Generalized anxiety disorder is
a condition where a person experiences excessive and unfounded fear or worry about everyday matters.
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This concern can be related to different areas of life, including finances, family, health, and future
events(Munir & Takov, 2022). The condition is challenging to manage and often accompanied by several
physical and psychological symptoms. The primary symptom of generalized anxiety disorder is excessive
worry that can be overwhelming(Munir & Takov, 2022).
.
Reflections:
Each year, nearly 30 million Americans are affected by depression. Around 20% of people will
experience a mood disorder at some point in their life (Bains & Abdijadid, 2023). The highest frequency
of depression cases occurs between the ages of 25 and 44 (Bains & Abdijadid, 2023, p.2). About 33% of
all depression cases are severe enough to require medical treatment( Bains & Abdijadid, 2023). The
exact etiology of major depressive disorder remains unknown. However, its initiation is associated with
a neurochemical deficit of norepinephrine, serotonin, and/or dopamine in the brain(Bains & Abdijadid,
2023). Pt is 29 years old female seeking treatment for worsening depression and anxiety and continuity
of treatment with a new psychiatrist. She reports that her atomoxetine is helping with her AdHD, but
the medication for depression is no longer supporting. On reviewing her medical record from her former
psychiatrist, it was noted that she was given the diagnosis of MDD recurrent moderate, but with this
visit, her diagnosis changed to MDD severe without psychosis. Her GAD-7 score reveals an increase and
severe anxiety and worry. She stated that she is compliant in taking her medications and has some refills
at the pharmacy. Pt is underweight for her height and age but denies an eating disorder and claims she
has not weighed past 110lbs since college. All diagnoses were previously determined, except for the
F33.2, which was identified based on recent self-harm, suicidal ideation, heightened anhedonia, and
other symptoms related to Major Depressive Disorder (MDD). After gathering intake information, a
treatment plan was established with the aim of alleviating the client’s depression symptoms. As we
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learn more about social determinants, we can see that they are split into two types: upstream and
downstream (Alegria et al., 2018). According to Alegria et al. (2018), upstream determinants like job
opportunities are considered the root causes that can affect our health through downstream
determinants like our living conditions. In addition, they expand the definition of social determinants to
encompass any nonmedical factors that impact health(Alegria et al., 2018, p.3). This encompasses both
inherent individual traits such as gender and race/ethnicity, as well as more adaptable aspects like
educational achievement, occupational position, and social assistance(Alegria et al., 2018).
Case Formulation and Treatment Plan:
The co-occurrence of anxiety and depression is frequently observed in clinical settings. The DSM-5
introduced an ‘anxious distress’ specifier to identify individuals who suffer from both anxiety and MDD.
This specifier is intended to assist clinicians in identifying and treating patients who may require
additional interventions due to their heightened levels of anxiety (American Psychiatric Association,
2013). The inclusion of this specifier in the DSM-5 reflects the recognition of the significant impact that
comorbid anxiety can have on the course and outcome of MDD( American Psychiatric Association,
2013). Individuals diagnosed with MDD who additionally experience anxiety have notably impaired
psychosocial functioning and a lower quality of life in comparison to individuals diagnosed with MDD but
without anxiety (Hopwood, 2023). This client has been taking Lexapro 10mg for the past 3 years.
Recently, her dosage was increased to 20mg after a visit to the hospital. During her consultation with
the preceptor, the benefits of Cymbalta, an SNRI, were discussed. My preceptor also suggested
recommencing therapy and offered to provide referrals if the client was unsatisfied with her previous
therapist. Psychotherapy should be considered a crucial part of treating depression. Combining
medication with therapy can lead to better treatment outcomes and a lower risk of relapse, especially in
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cases of severe depression or depression with psychotic symptoms. It is important to alleviate
symptoms as quickly as possible in such cases(Hopwood, 2023).
Medication: Pt will continue taking Atomoxetine 60mg and begin weaning off Lexapro before starting
Cymbalta 30mg in three days. The patient was educated on the potential side effects of medications and
was told to call if she experiences any adverse effects. Pt will return to the clinic in 2weeks. Plan: pt will
resume therapy.
Conclusion: Effective psychopharmacology aims to achieve remission in the patient. If remission is not
achieved, the chances of recurrence and ongoing psychosocial constraints such as work-related
impairments are higher. In my opinion, the clinician made a wise decision by switching the patient’s
medication to a selective norepinephrine reuptake inhibitor (SNRI) due to her previous prolonged use of
Lexapro.
Questions.
What other treatment options do you believe can be provided to this patient?
Do you believe that initiating Cymbalta at a dosage of 30mg will be beneficial for his condition?
Do you think anxiolytics should be added to the medication list? If not, what will be the reason?
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at
their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
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Date: ________________________
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References
Alegría, M., NeMoyer, A., Falgas, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health:
Where We Are and Where We Need to Go. Current Psychiatry Reports, 20(11), 95.
https://doi.org/10.1007/s11920-018-0969-9
American Psychiatric Association. (2013). Diagnosis and statistical manual of mental disorders, 5th
edition. Arlington, VA: Author.
Bains, N & Abdijadid, S. (2023). Major Depressive Disorder In StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing;. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK559078/.
Gair, S. 1., Brown, H. R., Kang, S., Grabell, A. S., & Harvey, E. A. (2021). Early Development of
Comorbidity Between Symptoms of ADHD and Anxiety. Reseorch on Child ond Adolescent
Psychopothology, 49(3),371. httos:l/doi.orelLO.7OO7 /sLO8O2-02O-OO724-6
Ginapp, C. M., Macdonald-Gagnon, G., Angarita, G. A., Bold, K. W., & Potenza, M. N. (2022). The lived
experiences of adults with attention-deficit/hyperactivity disorder: A rapid review of
qualitative evidence. Frontiers in
Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.949321
Hopwood, M. (2023). Anxiety Symptoms in Patients with Major Depressive Disorder: Commentary on
Prevalence and Clinical Implications. Neurology and Therapy, 12(Suppl 1), 5–12. http
s://doi.org/10.1007/s40120-023-00469-6
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Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated
treatments and future challenges. World journal of clinical cases, 9(31), 9350–9367.
https://doi.org/10.12998/wjcc.v9.i31.9350
Munir, S., & Takov, V. (2022). Generalized Anxiety Disorder. In StatPearls. StatPearls Publishing.
Retrieved January 2023 from https://www.ncbi.nlm.nih.gov/books/NBK441870/
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Hello Yolanda,
The persistent presence of depressed mood, low energy, and severe sleep disturbance
strongly suggest a diagnosis of major depressive disorder (MDD). Additionally, the
inability to shut off racing thoughts, a constant feeling of being on edge, and an inability to
quiet the mind are highly indicative of generalized anxiety disorder (GAD). These
persistent and interrelated symptoms suggest the possibility of both MDD and GAD cooccurring. I agree with the use of both sertraline and quetiapine to address his reported
symptoms.
However, after analyzing your case presentation, I found the patient’s unspecified
personality disorder diagnosis intriguing. According to the DSM-5-TR, this group includes
cases where personality disorder symptoms are present and cause significant distress or
problems in social, occupational, or other important areas of functioning. Still, the person
does not fully meet the criteria for any of the disorders in this personality disorder
diagnostic class (APA, 2022). The “unspecified personality disorder” category is used
when the clinician does not want to say why the standards for a specific personality
disorder are not met and when there is not enough information to make a more specific
diagnosis (APA, 2022).
According to your presentation, your patient was prescribed olanzapine while
incarcerated. Medications do not target personality disorders directly, although they can
effectively treat accompanying symptoms such as anxiety, depression, or mood
fluctuations (Gartlehner et al., 2021). I am assuming that his reported paranoia and
delusions of divine guidance were the negative symptoms targeted by this medication.
Antipsychotics, mood stabilizers, and antidepressants can provide alleviation of
symptoms and aid in achieving psychotherapy treatment objectives (Gartlehner et al.,
2021).
This patient reports emotional abuse and abandonment issues. Emotional abuse during
childhood can leave lasting scars, increasing the risk of developing anxious attachment
styles characterized by fear of abandonment (Erkoreka et al., 2022). These insecure
attachment patterns, in turn, can act as a breeding ground for emotional dysregulation,
making individuals more susceptible to experiencing intense and difficult-to-manage
emotions later in life (Erkoreka et al., 2022).
Childhood trauma is not a one-time thing, and its effects last a long time after the event
itself. It has the power to change the way we think, feel, and act in the world without us
even realizing it. A lot of the time, symptoms like depression, anxiety, recklessness, and
mood swings hide the complex web of trauma that is going on behind them (Erkoreka et
al., 2022).
At first glance, the idea of this patient having a personality disorder might seem extreme.
But when I look more closely, I can see how the group of symptoms—impulsivity, mood
swings, and trouble sleeping—could point to deeper patterns set up by stress in childhood.
These patterns, which are frequently a result of issues with bonding and skewed
perceptions of oneself and others, can manifest in ways that make it difficult to be socially
and emotionally stable, which is similar to some personality disorders (Gartlehner et al.,
2021).
As a future PMHNP, I will always keep in mind that a diagnosis is meant to help, not to
describe. Diagnoses only help guide us in the direction of effective treatment, and this can
change over time with the discovery of more relevant information that could provide
answers to the patient’s symptoms.
References
Diagnostic and statistical manual of mental disorders (DSM-5-TR) (2022). American
Psychiatric Association. Personality disorders. American Psychiatric Association. (5th ed.,
text rev.).
Erkoreka, L., Zamalloa, I., Rodriguez, S., Muñoz, P., Mendizabal, I., Zamalloa, M. I., Arrue, A.,
Zumarraga, M., & Gonzalez, T. M. A. (2022). Attachment anxiety as mediator of the
relationship between childhood Psychotherapy, 29(2), 501–
511. https://doi.org/10.1002/cpp.2640Links to an external site.
Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Fortman, R.,
Wines, R., Persad, E., & Viswanathan, M. (2021). Pharmacological Treatments for
Borderline Personality Disorder: A Systematic Review and Meta-Analysis. CNS
Drugs, 35(10), 1053–1067. https://doi.org/10.1007/s40263-021-00855-
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