Mood Disorder Essay

Patient Information:

Initials: NA      Age: NA      Sex: Female      Race: NA

CC “I have a history of taking medications and then stopping.”

HPI:

A young adult female presents to the clinic for mental assessment. The patient notes that she has a problem with medication adherence because she feels that the drugs “squash” her. Further investigation reveals that the patient experiences instances of high energy, going for up to a week without sleeping or sleeping only 3 hours the entire week, engaging in risky sexual behaviors, and doing creative stuff such as painting or writing. Consequently, the hyper period is followed by moments of low mood, sleeping 12-16 hours a day, high appetite, and missing work. The onset of the current symptoms is unclear, but the patient has been having mental issues since she was a teenager. She adds that medication makes her feel worse while being off medication is better because she experiences high energy, enabling her to do many things. However, she admits that taking Klonopin slowed him down.

Current Medications: medication for hyperthyroidism

N/A

Allergies: No known allergies

PMHx: Up to date with tetanus immunization. Last flu vaccine October 2021. COVID-19 Vaccine 4/10/2021

Surgical history: No surgical history

Family mental history

Mother has a history of bipolar and attempted suicide. Father is imprisoned for drugs, and the brother may be schizophrenic.

Gynecology: No history of pap smear, has not started MMG.

Menstrual history: Menarche at age 14. Regular menses. Last period 14/03/2022.

Sexual history: Sexually active. Multiple sexual partners and engages in high-risk sexual behavior with strangers. She takes birth control pills for polycystic ovaries

Obstetrics: No children

Soc Hx: the patient is not married. She lives with her brother and sometimes her mother. She works at her Aunt’s store. She is also a student of cosmetology

She admits nicotine use, smokes one pack a day. She denies drug and alcohol use.

ROS

GENERAL:  The patient reports no recent weight gain or loss. Ne fatigue, fever, headache. She notes increased appetite during the low mood periods and low appetite during the hyper periods.

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 or nausea. No abdominal pain

GENITOURINARY: No urine leakage.

NEUROLOGICAL:  No fatigue, headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No joint pain, back pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical Examination

Temperature: 98.2 F

RR: 18

BP: 138/88 mmHg

P 90

General: A&O x4, alert and oriented to time and place, dressing is appropriate for the weather. Affect is broad, and the mood elevated. She is conscious and comfortable.

HEENT: Normocephalic, PERRL, no eye discharge or EOMI

Neck: No bruit, or jvd

Chest/Lungs: CTA AP&L. normal breath sounds, unlabored breathing, no rales, wheezes, or rhonchi, vesicular breath sounds, no adventitious sounds in the left lung.

Heart/Peripheral Vascular: Regular heart rate, no S3, S4 or murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial

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ABD:  Non-tender on palpation of all the four quadrants.

Genital/Rectal: external genitalia intact. No tenderness.

Musculoskeletal: Muscle strengths 5/5 all groups

Neuro: no compression of the nerves.

Skin/Lymph Nodes: warm skin, no swollen lymph nodes

Assessment

Diagnostic tests

Urine drug and alcohol screen – negative

CBC, CMP, and lipid panel – normal range

Prolactin Leve – 8

TSH – 6.3 (H)

DSM-5 Diagnostic Criteria – bipolar I disorder

Mental assessment

The patient has no recent suicide ideation, although she attempted suicide some years back. Mood and affect are good. The patient does not have suicidal ideation or self-harm tendencies. Additionally, delusions and visual hallucinations are absent, but the patient experienced auditory hallucinations a few months ago. Other pertinent positives in the patient’s case include a history of mental illness in the family, experiences of childhood abuse (verbal abuse by the father), absentee father, and a history of trouble with mental illness since teenagehood, including attempted suicide.

Primary diagnosis

Bipolar disorder 1

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), bipolar disorders are a collection of disorders characterized by extreme mood and energy fluctuations, which affect the ability to function normally (McIntyre & Calabrese, 2019). The common types of bipolar disorders are bipolar I and bipolar II. Bipolar 1 is distinguished by a manic phase that causes severe mood disturbance than can lead to hospitalization. On the other hand, bipolar II has a hypomanic phase with less severe mood disturbances (McIntyre & Calabrese, 2019). The patient presents with bipolar disorder because her manic symptoms are severe. Diagnosis of bipolar 1 using the DSM-5 involves the following criteria. First, two phases are present: mania and depressive phase. The patient experiences elevated mood for one week during mania, occurring almost every day and lasting nearly throughout the day. Additionally, at least three of the following symptoms must be present: decreased need to sleep, increased talkativeness, inflated self-esteem, goal-directed activity, racing thoughts, and engaging in activities with potential for dangerous consequences such as irresponsible sexual behavior.

Similarly, during the depressed mood period, at least five of the following symptoms must be present: depressed mood that lasts nearly throughout the day, for most days, increase or decrease in appetite, loss of interest in activities, fatigue, feelings of guilt, excessive sleeping, and suicide ideation (McIntyre & Calabrese, 2019). Referring back to the case, the patient’s symptoms are consistent with the DSM-5 criteria. For example, during the manic period, she engages in goal-directed activities such as painting, becomes highly talkative, and sleeps only 3 hours in one week. Additionally, she becomes sexually active in sleeping with strangers because of the thrill, which is dangerous. Similarly, the high energy episodes are followed by low mood, feeling sad, eating a lot, loss of interest, feelings of guilt, and diminished ability to concentrate at work. Finally, the symptoms cause significant impairment in the patient’s personal and work life.

Differential diagnosis

Borderline personality disorder – according to the DSM-5, a borderline personality disorder is the DSM-5 described borderline personality disorder as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts” (Lubit & Pataki, 2018, p. 6). Clinical manifestations of borderline personality disorder include impulsivity, unstable relationship, fear of abandonment, extreme emotional swings, self-harm, and explosive anger. Some of the patient’s symptoms are consistent with these clinical manifestations, but they do not meet the DSM-5 criteria to confirm borderline personality disorder.

Major Depressive Disorder (MDD) – MDD is characterized by persistent low mood and feelings of sadness. According to the DSM-5, diagnosis for MDD involves loss of interest, low mood, loss or gain of weight, hypersomnia or insomnia, fatigue, and decreased concentration (Hasin et al., 2018). These symptoms should be present in the past two weeks. Additionally, the experienced symptoms should cause a clinically significant problem or social impairments. Similarly, the episodes should not be related to substance abuse or explained by another mental disorder such as schizophrenia. The patient should also have no history of hypomania or mania. In this case, the patient experiences mania, which makes the MDD diagnosis unlikely.

Plan:

Treatment/medication

• Prescribe Lithobid 600mg (2 tabs) in the morning and night. Lithium is an effective and safe choice for the patient as she notes a good response to the medication. Additionally, the medication targets mood stabilization, while most of the patient’s medications were antidepressants. According to Alessio et al. (2020), in patients with bipolar, the most effective treatment approach is mood stabilization than treating depression. Aanother advantage of the drug is that it has extended-release, which is helpful in patients who lack medication adherence. Finally, studies establish the safety and efficacy of Lithium for mood stabilization as it is well tolerated in most patients with bipolar (Volkmann et al., 2020).
• The patient will be monitored to evaluate drug tolerance and identify potential side effects.
• The second intervention is psychotherapy. Often, pharmacotherapy works effectively when combined with psychosocial interventions. Cognitive Behavioral Therapy will be used to provide psychosocial assistance. CBT helps people with troubling behavior adopt healthy thinking patterns and coping skills to navigate challenging life situations.
• Follow up observation will occur after four weeks

Health promotion

• The patient will be given education on his medication, medication management, and the importance of adherence to the prescribed drugs. She will be taught about the possible side effects of the prescribed medications and what to do in case of adverse reactions. Additionally, she will be advised not to stop taking any medication before consulting the practitioner.
• The patient will also be educated on smoking cessation and adopting a healthy lifestyle that promotes positive health outcomes.
  

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Reflection

The primary diagnosis is bipolar I disorder. The patient’s history is pertinent to the diagnosis decision. Some of the information missing in the video is the patient’s childhood/adolescent history of mental illness. Only fractions of this are provided by the patient, which is not enough to give a clear picture; for example, when the problems started and if there was any major event in the patient’s life before the onset are critical to understanding the case. Additionally, it would have been essential to get some of the histories from the mother. Other diagnostics that could have been provided include urine and blood analysis to show if there are any issues with vitamin B deficiency or anemia. A thyroid test may have also been necessary. Similarly, the Rafaelsen Mania Rating Scale (MAS) results could have also supported the diagnosis.

References

Alessio, S., Alexia E., K., & Georgios D., K. (2020). Stabilization Beyond Mood: Stabilizing Patients With Bipolar Disorder in the Various Phases of Life. Frontiers in Psychiatry, 11, https://doi.org/10.3389/fpsyt.2020.00247.

Hasin, D., Sarvet, A., & Meyers, J. (2018). Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry, 75(4):336–346. doi:10.1001/jamapsychiatry.2017.4602.

Lubit, R. H., & Pataki, C. (2018). What are the DSM-5 diagnostic criteria for borderline personality disorder (BPD)? Medscape, https://www.medscape.com/answers/913575-165741/what-are-the-dsm-5-diagnostic-criteria-for-borderline-personality-disorder-bpd.

McIntyre, R. S., & Calabrese, J. (2019). Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Current Medical Research and Opinion, 35:11, 1993-2005, https://doi.10.1080/03007995.2019.1636017.

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment Over the Lifespan in Bipolar Disorders. Frontiers in psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377.

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Week 4: Mood Disorders in Adults