Assessing, Diagnosing, and Treating Adults With Mood Disorders

Assessing, Diagnosing, and Treating Adults With Mood Disorders

Subjective:

CC (chief complaint): “I stop taking my medications because they make me feel like they squash who I am.”

HPI: Petunia Park is a 30-year-old female with a history of mood symptoms presenting for psychiatric evaluation due to ongoing mood instability and medication nonadherence. She reports recurrent episodes of elevated mood lasting about one week, marked by increased energy, decreased need for sleep, excessive goal-directed activity such as writing and painting, pressured speech, racing thoughts, and hypersexual behavior. During these episodes, she sleeps very little and feels highly productive and euphoric. She reports discontinuing medications during these periods because she feels they reduce her creativity. She also reports depressive episodes occurring four to five times per year, characterized by low energy, lack of motivation, hypersomnia, increased appetite, and inability to function at work. She endorses feelings of worthlessness related to decreased creativity. She reports intermittent auditory hallucinations during periods of sleep deprivation but denies current psychotic symptoms. Psychiatric history includes four prior hospitalizations and one suicide attempt in 2017. She denies current suicidal or homicidal ideation. Substance use is negative except for daily nicotine use. Medical history is significant for hypothyroidism.

Substance Current Use: The patient reports daily nicotine use, smoking approximately one pack per day. She denies current or past use of alcohol since age 19, stating alcohol caused negative effects. She denies use of marijuana due to prior paranoia and denies use of cocaine, stimulants, opioids, hallucinogens, inhalants, or synthetic substances. She also denies misuse of prescription medications.

Medical History: The patient reports daily nicotine use, smoking about one pack per day. She denies current alcohol use and states last use was at age 19 due to poor tolerance. She denies use of marijuana, cocaine, stimulants, opioids, hallucinogens, inhalants, and synthetic substances. She denies misuse of prescription medications.

• Current Medications: The patient reports taking a thyroid medication for hypothyroidism and an oral contraceptive for polycystic ovarian syndrome. She also reports recently stopping a psychiatric medication because she felt it reduced her creativity.
• Allergies: No known drug allergies reported.

• Reproductive Hx: The patient reports regular monthly menstrual cycles, with her last menstrual period occurring about one month ago. She denies being pregnant. She is sexually active with multiple partners and reports using protection. She has no children.

ROS:

GENERAL: Reports low energy during depressive episodes and increased energy during elevated mood episodes. Denies fever or chills.

HEENT: Denies headaches, vision changes, hearing issues, or sore throat.

SKIN: Denies rashes or lesions.

CARDIOVASCULAR: Denies chest pain, palpitations, or edema.

RESPIRATORY: Denies shortness of breath, cough, or wheezing.

GASTROINTESTINAL: Reports increased appetite during depressive episodes and decreased appetite during elevated mood periods. Denies nausea or vomiting.

GENITOURINARY: Denies urinary symptoms. Reports regular menses.

NEUROLOGICAL: Denies seizures or syncope. Reports decreased need for sleep during elevated episodes and hypersomnia during depressive periods.

MUSCULOSKELETAL: Denies joint pain or weakness.

HEMATOLOGIC: Denies bleeding or bruising.

LYMPHATICS: Denies lymph node swelling.

ENDOCRINOLOGIC: History of hypothyroidism. Denies heat or cold intolerance.

Objective:

Patient is alert and oriented, cooperative, and engaged during the interview. Speech is coherent. No acute distress noted. Vital signs are stable with temperature 98.2°F, pulse 90 bpm, respirations 18 per minute, and blood pressure 138/88 mmHg.

Diagnostic results:

Urine drug and alcohol screen negative. Complete blood count within normal limits. Comprehensive metabolic panel within normal limits. Lipid panel within normal limits. Prolactin level 8. Thyroid-stimulating hormone (TSH) 6.3, elevated. Vital signs: temperature 98.2°F, pulse 90, respirations 18, blood pressure 138/88.

Assessment:

Mental Status Examination:

Mental Status Examination:

The patient is a 30-year-old female who appears her stated age. She is casually dressed with appropriate hygiene. She is cooperative during the interview, though at times displays mild irritability when discussing past history. Speech is rapid and pressured at times, but remains coherent and goal-directed. Mood is described as “high” during elevated periods and low during depressive episodes. Affect is expansive and congruent with stated mood. Thought process is linear, but becomes tangential when discussing creative ideas. Thought content is notable for grandiosity, including beliefs about exceptional creativity and future success. She reports past intermittent auditory hallucinations during periods of poor sleep but denies current hallucinations or delusions. The patient denies current suicidal or homicidal ideation. Insight is limited, as evidenced by medication nonadherence and lack of recognition of illness severity. Judgment is impaired, particularly during elevated mood episodes, as shown by impulsive behaviors and hypersexual activity. She is alert and oriented to person, place, time, and situation. Attention and concentration are mildly impaired during elevated states. Memory appears intact.

Diagnostic Impression:

1. Bipolar I Disorder, current episode manic – ICD-10-CM: F31.1
   The patient meets DSM-5-TR criteria for a manic episode lasting at least one week with marked impairment. She reports elevated mood, decreased need for sleep, pressured speech, racing thoughts, increased goal-directed activity, hypersexual behavior, and grandiosity. She has a history of multiple psychiatric hospitalizations and one suicide attempt. Intermittent auditory hallucinations during periods of sleep deprivation suggest possible psychotic features (Nierenberg et al., 2023).

Pertinent positives: decreased need for sleep, hypersexuality, pressured speech, grandiosity, impaired functioning, hospitalizations.
Pertinent negatives: no current suicidal ideation, no substance use contributing to symptoms.

2. Bipolar II Disorder – ICD-10-CM: F31.81
   DSM-5-TR criteria require hypomanic episodes and major depressive episodes without a history of full mania. The patient has depressive episodes; however, her elevated episodes meet criteria for full mania due to severity, duration, and functional impairment (Swartz & Suppes, 2023). This rules out Bipolar II Disorder.

Pertinent positives: depressive episodes, mood instability.
Pertinent negatives: presence of full manic episodes excludes this diagnosis.

3. Major Depressive Disorder, recurrent – ICD-10-CM: F33.1
   DSM-5-TR criteria require depressive episodes without any history of manic or hypomanic episodes. The patient reports depressive symptoms, including low energy, hypersomnia, increased appetite, and anhedonia (Marx et al., 2023). However, the presence of manic episodes rules out Major Depressive Disorder as the primary diagnosis.

Pertinent positives: recurrent depressive symptoms, functional impairment.
Pertinent negatives: history of manic episodes excludes this diagnosis.

Reflections:

This case highlighted how bipolar disorder can present with poor insight and resistance to treatment. The patient minimizes symptoms and views manic episodes as beneficial, which complicates diagnosis and management. I learned the importance of exploring functional impact, such as missed work and relationship conflict, rather than relying only on mood description. I would improve my assessment by further evaluating risk-taking behaviors, including hypersexual activity and safety concerns. Ethical issues include protecting the patient from harm during impaired judgment while still respecting autonomy. Capacity assessment becomes important during manic episodes. There are also concerns related to sexual health and potential exposure risks. Social factors such as limited family support, strained relationships, and inconsistent employment increase vulnerability and affect continuity of care.

Health promotion should focus on building structure in daily routines, especially sleep and activity scheduling, to reduce mood instability. Disease prevention includes relapse prevention planning, identifying early warning signs, and strengthening coping strategies. The patient would benefit from education on how untreated mania can lead to long-term consequences, including financial, social, and occupational decline. I would also emphasize the importance of regular medical follow-up for thyroid management since endocrine issues can affect mood. Cultural and personal beliefs about creativity and identity should be respected while guiding treatment. A collaborative approach with therapy, medication management, and support systems can improve adherence, reduce risky behaviors, and support long-term stability.

Case Formulation and Treatment Plan:

Psychotherapy:
The patient will be referred for individual psychotherapy with focus on Cognitive Behavioral Therapy (CBT) to address mood regulation, impulsive behaviors, and medication adherence. Psychoeducation will be included to improve insight into bipolar disorder. Interpersonal and Social Rhythm Therapy (IPSRT) will be recommended to stabilize daily routines, especially sleep patterns, which directly impact mood episodes (Nierenberg et al., 2023).

Pharmacologic Treatment:
Initiate a mood stabilizer such as lithium, with baseline and ongoing monitoring of renal function and thyroid levels. Lithium is selected due to strong evidence for reducing manic episodes and suicide risk (Nierenberg et al., 2023). Consider adding an atypical antipsychotic such as quetiapine if manic symptoms persist or if psychotic features recur. Avoid antidepressant monotherapy due to the risk of inducing mania. Evaluate and manage elevated TSH in coordination with primary care, as hypothyroidism can worsen mood symptoms.

Nonpharmacologic Treatment:
Encourage strict sleep hygiene with a consistent sleep schedule. Recommend reduction of nicotine use, as it may worsen mood instability. Support structured daily activities to reduce mood fluctuation.

Alternative Therapies:
Discuss adjunctive options such as omega-3 fatty acid supplementation, mindfulness-based stress reduction, and yoga to support mood stability. These may help reduce stress and improve overall functioning.

Health Promotion:
Promote regular physical activity, such as 30 minutes of moderate exercise most days of the week, to improve mood stability and overall health.Assessing, Diagnosing, and Treating Adults With Mood Disorders

Patient Education Strategy:
Provide education on bipolar disorder, emphasizing the importance of medication adherence even during periods of feeling well. Explain early warning signs of mania and depression and when to seek help. Use the teach-back method to confirm understanding.

Follow-Up:
Schedule follow-up in 2 weeks to assess medication response, side effects, and safety. Monitor for mood changes, adherence, and any emergence of suicidal ideation. Coordinate care with psychotherapy and primary care for thyroid management.

 

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing.

Marx, W., Penninx, B. W., Solmi, M., Furukawa, T. A., Firth, J., Carvalho, A. F., & Berk, M. (2023). Major depressive disorder. Nature Reviews Disease Primers, 9(1), 44. https://doi.org/10.1038/s41572-023-00454-1

Nierenberg, A. A., Agustini, B., Köhler-Forsberg, O., Cusin, C., Katz, D., Sylvia, L. G., & Berk, M. (2023). Diagnosis and treatment of bipolar disorder: A review. JAMA, 330(14), 1370-1380. https://doi.org/10.1001/jama.2023.18588

Swartz, H. A., & Suppes, T. (2023). Bipolar II disorder: Understudied and underdiagnosed.  Focus, 21(4), 354–362. https://doi.org/10.1176/appi.focus.20230015

CLICK HERE TO ORDER A PLAGIARISM-FREE PAPER

Assessing, Diagnosing, and Treating Adults With Mood Disorders

It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.

In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare

• Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Petunia Park . You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Consider patient diagnostics missing from the video:Provider Review outside of interview:

  Temp 98.2  Pulse  90 Respiration 18  B/P  138/88

  Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

The Assignment

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment? 
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
• Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

By Day 7 of Week 4

Submit your Focused SOAP Note.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK1Assgn+last name+first initial.
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6665_Week4_Assignment_Rubric

NRNP_6665_Week4_Assignment_Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS	15 to >13.0 ptsExcellentThe response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 13 to >11.0 ptsGoodThe response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 to >10.0 ptsFairThe response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 10 to >0 ptsPoorThe response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.	15 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses	15 to >13.0 ptsExcellentThe response thoroughly and accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 13 to >11.0 ptsGoodThe response accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are accurately documented. 11 to >10.0 ptsFairDocumentation of the patient’s ROS is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor inaccuracies. 10 to >0 ptsPoorThe response provides incomplete or inaccurate documentation of the patient’s ROS. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.	15 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.	20 to >17.0 ptsExcellentThe response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 17 to >15.0 ptsGoodThe response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 15 to >13.0 ptsFairThe response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 13 to >0 ptsPoorThe response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.	20 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Incorporate one health promotion activity and one patient education strategy.	25 to >22.0 ptsExcellentThe response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding. … The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 22 to >19.0 ptsGoodThe response provides an evidence-based and appropriate plan for psychotherapy for the patient. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided. … The response includes at least one health promotion activity and one patient education strategy. 19 to >17.0 ptsFairThe response provides a somewhat vague or inaccurate plan for psychotherapy for the patient. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general. … The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 17 to >0 ptsPoorThe response provides an incomplete or inaccurate plan for psychotherapy for the patient. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing. … The health promotion and patient education strategies are incomplete or missing.	25 pts
This criterion is linked to a Learning Outcome• Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).	5 to >4.0 ptsExcellentReflections are thorough, thoughtful, and demonstrate critical thinking. 4 to >3.5 ptsGoodReflections demonstrate critical thinking. 3.5 to >3.0 ptsFairReflections are somewhat general or do not demonstrate critical thinking. 3 to >0 ptsPoorReflections are incomplete, inaccurate, or missing.	5 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).	10 to >8.0 ptsExcellentThe response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 to >7.0 ptsGoodThe response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 to >6.0 ptsFairThree evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 6 to >0 ptsPoorTwo or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.	10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.	5 to >4.0 ptsExcellentUses correct APA format with no errors 4 to >3.5 ptsGoodContains a few (one or two) APA format errors 3.5 to >3.0 ptsFairContains several (three or four) APA format errors 3 to >0 ptsPoorContains many (five or more) APA format errors	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation	5 to >4.0 ptsExcellentUses correct grammar, spelling, and punctuation with no errors 4 to >3.5 ptsGoodContains a few (one or two) grammar, spelling, and punctuation errors 3.5 to >3.0 ptsFairContains several (three or four) grammar, spelling, and punctuation errors 3 to >0 ptsPoorContains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding	5 pts

Total Points: 100