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Comprehensive Psychiatric Assessment Discussion Paper

Comprehensive Psychiatric Assessment Discussion Paper

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Patient’s Particular’s

Initials: A.Y

Age: 36years

Gender: male

Ethnicity: American

Subjective Data

Chief Complaint: loss of interest and difficulties in sleeping.

History Of Presenting Illness: A.Y., a 36-year-old American male presents with difficulties in sleeping, diminished interest, feelings of guilt, obsessive thoughts, compulsive behaviors, low self-esteem, excessive worry and tension, and difficulty finishing tasks. The symptoms began approximately six years ago, coinciding with the separation from the patient’s girlfriend. The onset of symptoms was gradual but has progressively intensified over time. The patient reports difficulties in falling asleep, maintaining sleep, and experiencing restless sleep. Sleep-related disturbances contribute to increased fatigue and impact the patient’s ability to function during the day. He has a noticeable decrease in interest and participation in once-enjoyable activities. The patient expresses pervasive feelings of guilt, particularly about the death of his brother. The patient continuously replays past events and experiences self-blame. The patient describes recurring, intrusive thoughts related to the breakup, leading to ritualistic behaviors aimed at reducing distress. He has a significant decrease in self-esteem, with the patient expressing feelings of worthlessness and self-criticism, largely stemming from the failed relationship. The patient experiences pervasive worry and tension related to various aspects of life, extending beyond the relationship. These concerns contribute to a heightened state of anxiety. Concentration difficulties are reported, resulting in an inability to complete tasks efficiently. Procrastination and a sense of being overwhelmed by responsibilities are evident. The patient describes strained family relationships, citing disagreements between the dad and stepmom, a consistent year-long illness of the mother, and a lack of close relationships with siblings. The patient reports involvement in a car accident a few years ago, which may contribute to ongoing distress and potentially exacerbate symptoms related to the recent breakup. The combined impact of these symptoms has led to a significant impairment in daily functioning, affecting the patient’s work, social interactions, and overall well-being. Comprehensive Psychiatric Assessment Discussion Paper

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Past psychiatric history: The patient has a history of major depressive mood disorder and post-traumatic stress disorder.

Medication Trials: The patient has been prescribed and has trialed antidepressant medications in the past with variable responses.

Psychotherapy Sessions: The patient has engaged in psychotherapy, specifically cognitive-behavioral therapy for PTSD symptoms.

Substance Use History: The patient denies current substance use. However, there is a history of previous substance abuse as a maladaptive coping mechanism related to trauma.

Family Psychiatric/Substance Use History: Positive family history of depression and anxiety disorders. There are no reported substance use disorders.

Psychosocial History: The patient is currently unemployed, citing difficulties in maintaining focus and motivation. Relationships with family and friends have become strained due to the emotional and psychological impact of trauma. Social withdrawal is noted.

Medical History: No significant medical comorbidities were reported. General health is stable.

Current Medication: The patient is currently prescribed sertraline (SSRI) for depression and anxiety.

Allergies: the patient has no known drug, environmental, food, or latex allergies.

Objective Data

Diagnostic Results

  1. Beck depression inventory: A score indicating moderate to severe depression.
  2. Hamilton anxiety rating scale HAM-A: Elevated score indicating significant anxiety symptoms.
  3. obsessive-compulsive inventory: Elevated scores indicating obsessive thoughts and compulsive behaviors.
  4. clinical review: Revealed the patient’s difficulty in family relationships, recent separation, and the impact of the car accident on emotional well-being. Comprehensive Psychiatric Assessment Discussion Paper

Assessment

Mental State Examination

The patient appears disheveled, with minimal eye contact. Grooming and hygiene are somewhat neglected, suggesting a possible decline in self-care. The patient’s behavior is subdued, and there are signs of psychomotor retardation. Movements are slow, and the overall demeanor is consistent with a low energy level. The mood is flattened, and the patient expresses feelings of sadness, hopelessness, and guilt related to the recent separation from their girlfriend and the death of his brother. The effect is constricted, with limited variability in emotional expression. The maintains a predominantly negative emotional tone. The thought process is characterized by frequent rumination, replaying past events, and experiencing self-blame. There is evidence of perseveration on distressing thoughts, contributing to a sense of entrapment. The patient has Obsessive thoughts centered around themes of guilt, loss, and fear of rejection. The patient expresses a pervasive sense of worthlessness and self-criticism, linking these thoughts to the failed relationship. The patient is oriented to time, place, and person and has no hallucinations. The Insight is limited and there is a lack of awareness regarding the broader impact of symptoms on daily functioning. Comprehensive Psychiatric Assessment Discussion Paper

Differential Diagnoses

The patient’s presentation strongly suggests the presence of Major Depressive Disorder (MDD), evidenced by the following hallmark symptoms: The patient reports a pervasive and persistent loss of interest in once enjoyable activities. The inability to derive pleasure from previously rewarding activities contributes to a decreased quality of life. The patient expresses pervasive feelings of guilt, particularly due to the recent separation from their girlfriend. The intensity of guilt exceeds what is considered normative for the situation and is not proportionate to the circumstances. Excessive and irrational guilt is a common feature of depressive disorders. The patient reports low self-esteem, describing feelings of worthlessness and inadequacy. These negative self-appraisals contribute to the overall sense of despair and are consistent with the negative cognitive schema often observed in MDD (Gutiérrez-Rojas et al., 2020). Impaired concentration and difficulties in completing tasks are reported by the patient. This cognitive slowing is a manifestation of psychomotor retardation, a common feature in MDD. It reflects the impact of the disorder on executive functions and overall cognitive efficiency (McGuinness et al., 2022)Comprehensive Psychiatric Assessment Discussion Paper. The patient reports difficulties falling asleep and maintaining sleep. Sleep disturbances, including insomnia or hypersomnia, are diagnostic criteria for MDD. Changes in sleep patterns contribute to the overall disruption of circadian rhythms and exacerbate feelings of fatigue (Dwyer et al., 2020). The patient’s presentation aligns with the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for Major Depressive Disorder. The combination of affective, cognitive, and somatic symptoms supports the diagnosis, and further evaluation will be necessary to determine the severity, duration, and impact of the disorder on the patient’s daily functioning.

The patient’s presentation raises concerns about the possibility of Post-Traumatic Stress Disorder (PTSD) because he reports a history of a car accident a few years ago. Traumatic events, such as accidents, are common triggers for PTSD. The intrusive memories, nightmares, and flashbacks described by the patient could be indicative of the re-experiencing symptoms characteristic of PTSD (Bryant, 2019). The patient experiences persistent and distressing memories related to the traumatic event. Intrusive memories are a core symptom of PTSD and involve the involuntary recall of traumatic experiences, contributing to emotional distress. Frequent nightmares involving themes related to the car accident disrupt the patient’s sleep. Nightmares are a specific type of re-experiencing symptom in PTSD and are often vivid and distressing, leading to sleep disturbances (Ressler et al., 2022). The patient mentions experiencing flashbacks related to the traumatic event. Flashbacks involve a dissociative state where the individual feels as if they are reliving the traumatic experience. This is a hallmark symptom of PTSD. The patient reports feeling constantly on edge and hyper-vigilant. Hyper-vigilance is a common symptom of increased arousal and reactivity in PTSD. Individuals may be overly alert to potential threats, leading to heightened stress and anxiety. The patient’s symptoms, including difficulties in sleeping, diminished interest, excessive worry, tension, and challenges in completing tasks, suggest a significant impact on daily functioning. Impairments in occupational, social, and personal domains are consistent with the functional impairment often seen in PTSD. Comprehensive Psychiatric Assessment Discussion Paper

The patient’s presentation suggests that Adjustment Disorder may be an appropriate diagnosis because he is experiencing significant emotional distress following a recent separation from their girlfriend. Adjustment Disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor, and the breakup is a clear precipitating event in this case (O’Donnell et al., 2019). The patient reports difficulties in family relationships, specifically mentioning disagreements between their dad and stepmom. Ongoing conflicts within the family environment can contribute to chronic stress and emotional dysregulation. Adjustment Disorder takes into account stressors beyond the immediate aftermath of the precipitating event. The patient states involvement in a car accident a few years ago. While not recent, the lingering impact of the accident is evident in the overall distress and potential exacerbation of symptoms. Adjustment Disorder recognizes that stressors can have a delayed onset or a prolonged impact on mental health.

plan

  1. Psychotherapy: Engage the patient in cognitive behavioral therapy to address negative thought patterns, guilt, and maladaptive coping strategies. CBT can help modify dysfunctional beliefs and behaviors associated with depression and trauma. Exposure therapy may be beneficial to address intrusive memories and flashbacks related to the car accident (González-Prendes et al., 2019). Gradual and systematic exposure to trauma-related stimuli can assist in desensitization. Provide a supportive therapeutic environment to explore and process the emotional impact of the recent separation and ongoing family conflicts. This can involve validating the patient’s emotions and helping them develop healthier coping mechanisms.
  2. Pharmacotherapy: Consider initiating or adjusting antidepressant medication, such as selective serotonin reuptake inhibitors such as sertraline 10mg once daily, and Monitor closely for side effects and treatment response (Gutiérrez-Rojaset al., 2020)Comprehensive Psychiatric Assessment Discussion Paper.
  3. Family therapy and psychoeducation: Consider involving family members in therapy sessions, especially if ongoing family disagreements contribute to the patient’s distress. Family therapy can improve communication, resolve conflicts, and provide support (Carr, 2020). Provide psychoeducation to the patient about depression, adjustment difficulties, and potential PTSD. Enhance their understanding of how these conditions manifest and the role of treatment in promoting recovery.
  4. Lifestyle modification: Implement sleep hygiene practices to address difficulties in sleeping (Gutiérrez-Rojas et al., 2020). Encourage regular physical activity, which has been shown to have positive effects on mood and can serve as a complementary strategy to other interventions.

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Reflection Note

The session provided a valuable opportunity to connect with the patient and gain deeper insights into their experiences and challenges. The patient presented with a complex array of symptoms, encompassing depressive features, adjustment difficulties, and potential post-traumatic stress concerns. Establishing rapport with the patient was a priority during the session. I focused on creating a safe and non-judgmental space for the patient to share their thoughts and feelings. Active listening and empathy were crucial in building trust and encouraging open communication. During the session, I remained mindful of the potential cultural influences on the patient’s experiences and coping mechanisms. Moving forward, it will be essential to delve deeper into the trauma-related symptoms and assess their impact on daily functioning. Regular monitoring of the patient’s response to treatment, collaboration with other healthcare providers, and adjusting the treatment plan as needed will be key considerations for future sessions.

 References

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World psychiatry18(3), 259-269. https://doi.org/10.1002/wps.20656

Carr, A. (2020). Evidence for the efficacy and effectiveness of systemic family therapy. The handbook of systemic family therapy1, 119-146. https://doi.org/10.1002/9781119438519.ch6

Dwyer, J. B., Aftab, A., Radhakrishnan, R., Widge, A., Rodriguez, C. I., Carpenter, L. L., … & APA Council of Research Task Force on Novel Biomarkers and Treatments. (2020). Hormonal treatments for major depressive disorder: state of the art. American Journal of Psychiatry177(8), 686-705. https://doi.org/10.1176/appi.ajp.2020.19080848

González-Prendes, A. A., Resko, S., & Cassady, C. M. (2019). Cognitive-behavioral therapy. In Trauma: Contemporary directions in trauma theory, research, and practice (pp. 20-66). Columbia University Press. https://www.degruyter.com/document/doi/10.7312/ring18886-003/html

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 Psychiatry42, 657-672. https://doi.org/10.1590/1516-4446-2020-0650

McGuinness, A. J., Davis, J. A., Dawson, S. L., Loughman, A., Collier, F., O’hely, M., … & Jacka, F. N. (2022). A systematic review of gut microbiota composition in observational studies of major depressive disorder, bipolar disorder and schizophrenia. Molecular psychiatry27(4), 1920-1935. https://doi.org/10.1038/s41380-022-01456-3

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 health16(14), 2537. https://doi.org/10.3390/ijerph16142537

Ressler, K. J., Berretta, S., Bolshakov, V. Y., Rosso, I. M., Meloni, E. G., Rauch, S. L., & Carlezon Jr, W. A. (2022). Post-traumatic stress disorder: clinical and translational neuroscience from cells to circuits. Nature Reviews Neurology18(5), 273-288. https://doi.org/10.1038/s41582-022-00635-8

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide: Comprehensive Psychiatric Assessment Discussion Paper

  • 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
  • Read rating descriptions to see the grading standards!

In the Objective section, provide:

  • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
  • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
  • Read rating descriptions to see the grading standards!

In 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.
  • Read rating descriptions to see the grading standards!

Reflect on this case. Include 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!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:

N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.) Comprehensive Psychiatric Assessment Discussion Paper

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.

Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

  • Where patient was born, who raised the patient
  • Number of brothers/sisters (what order is the patient within siblings)
  • Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
  • Educational Level
  • Hobbies
  • Work History: currently working/profession, disabled, unemployed, retired?
  • Legal history: past hx, any current issues?
  • Trauma history: Any childhood or adult history of trauma?
  • Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

 

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

 

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?

Example:

Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.) Comprehensive Psychiatric Assessment Discussion Paper

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Follow up with PCP as needed and/or for:

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

Any other community or provider referrals

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Comprehensive Psychiatric Assessment Discussion Paper

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