Assessing and Diagnosing Patients With Mood Disorders DQ
CC (chief complaint): “ I lost my temper and feels wound up.”
HPI: A forty-nine-year-old patient walks into our clinic and complains of losing her temper. She states that most of the time, she is moody, particular at the same time every year. She has recently gained weight and has problems getting sleep. The patient easily gets bored, and her concentration has substantially reduced. She finds it difficult to keep her friends since she easily gets bored with them.
Past Psychiatric History:
- General Statement: The patient has an unremarkable psychiatric history.
- Caregivers (if applicable): The patient lived with her mother during her young years, who has a fatty liver and alcoholic.
- Hospitalizations: The patient has no history of previous hospitalizations.
- Medication trials: she currently has no prescription for a psychiatric illness.
- Psychotherapy or Previous Psychiatric Diagnosis: has had no psychotherapy intervention for a psychiatric condition.
Substance Current Use and History: The patient denies tobacco or alcohol use. She has no history of substance abuse.
Family Psychiatric/Substance Use History: She is currently married and has three teenage boys. She denies any form of substance and drug abuse such as alcohol or cigarette use.
Psychosocial History: The patient currently lives in Indianapolis with the family, a husband, and three teenage boys. She works full-time as a logistic buyer in a medical facility and has an MBA.
Medical History: The patient
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- Current Medications: She currently uses no medications to relieve her symptoms.
- Allergies: Latex
- Reproductive Hx: She is currently married to one partner and has three teenage boys together. She reports no history of STIs.
- Family History: The father passed on the patient was two years old. Therefore she was raised by her mother together with two other sisters. While one of her siblings has been diagnosed with depression, the mother is a functioning alcoholic and was recently informed that she has a “fatty liver.”
- GENERAL: The patient has recently gained weight and claims to be having problems getting sleep. She easily gets bored every time and loses her temper.
- HEENT: Eyes: normal vision with no vision changes observed. The sclera is also normal, with no unusual discoloration noted. Ears are normal, with no notable hearing loss. NO scratch or sore throat. No cough nor sneezing
- SKIN: The skin is normal with no lesions or rashes observed. No skin itchiness was noted.
- CARDIOVASCULAR: No palpitations or edema, no chest pain, pressure, or any other chest discomfort.
- RESPIRATORY: No congestions or respiratory challenges seen.
- GASTROINTESTINAL: no abdominal pain, diarrhea, anorexia, vomiting, or nausea.
- GENITOURINARY: No pain passing urine or polyuria.
- NEUROLOGICAL: No variations in bowel movement or bladder control. No numbness or tingling, paralysis, ataxia, dizziness, syncope, or headache.
- MUSCULOSKELETAL: No stiffness, joint pain, back pain, or muscle pain.
- HEMATOLOGIC: No bleeding, anemia, or bruises. No bruises, anemia, or bleeding
- LYMPHATICS: no swollen lymph node and no history of splenectomy.
- ENDOCRINOLOGIC: No excessive thirst or sweat observed.
Vital Signs: T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt. 135lbs
HEENT: The head is normocephalic and atraumatic. Pupils are reactive to light, equal, and round. No observed effusion or erythema in the tympanic membrane. No observable ear canal swelling or discharge. The neck was observed to be flexible with anterior cervical lymphadenopathy. Tonsils are normal and not swollen. The throat is no normal and clear, with no swelling observed.
Chest/lungs: upon auscultation, the breathing sounds were clear.
Heart: normal and regular heart rate and rhythm with no murmurs heard
Abdomen: Bowel sounds heard in all the quadrants. Upon palpation, the abdomen is non-tender, non-distended, and soft
Diagnostic results: To obtain the diagnostic result, various screening tools have been applied. For instance, the Mood-Disorder Questionnaire (MDQ) and the Child Behavior Checklist (CBCL)
Mental Status Examination: Appearance: maintains eye contact, upright posture, neat and well-groomed. Motor activity seems uneasy and agitated. Speech: through fluent, the speech becomes pressured at various times. Mood and Affect: Irritable, angry, and sad sometimes. Thought and perception: has her ideas flowing in sequence; however, her thoughts are delusional. Attitude and Insight: She appears to understand her current mental health status and is cooperative. The threat of causing harm to others or self: She denies any suicidal thoughts or attempts or harm to others or self. The reaction of the examiner to the patient: she appears depressed and frustrated. Cognitive behavior: The patient got distracted easily during the examination.
- Intermittent explosive disorder (IED): The condition presents with frequent behavioral outbursts, with the patients usually unable to control aggressive impulses (Fanning et al., 2019). This illness is more common among young adults and adolescents. Having been raised by her mother after the death of the father, chances are high that she might have had some traumatic experience (MacQueen & Memedovich, 2017). The claim that she loses her temper, which is a prominent sign of Intermittent Explosive Disorder.
- Major depressive disorder (MDD): From the diagnostic criteria using DSM-5, this condition presents with anhedonia and low mood, among other symptoms. In the case of this patient, she presented with a lack of concentration, agitation, sleeping difficulties, weight gain, dwindled interest in normal activities, and depressed mood. The symptoms, therefore, make a considerable case for MDD as one of the differentials (MacQueen & Memedovich, 2017).
- Cyclothymic disorder (CD): Cyclothymic disorder as a condition entails periods of elevated mood and depression symptoms; this condition is classified under the bipolar disorder subtype according to the DSM-5 tool (Hørlyck et al., 2021). Some of the symptoms include periods of depression and elevated mood symptoms for two years or more among the adult population, stable mood period of two or more months, substantial problems in the individual’s life, bipolar diagnosis symptoms as well as the symptoms presented not resulting from substance abuse or medical condition. This patient presented with a higher percentage of the mentioned symptoms.
Diagnostic result: Intermittent explosive disorder (IED)
The intermittent explosive disorder can be treated and managed in various ways, both pharmacological and non-pharmacological.
Pharmacological management: The Food and Drug Association allows the use of various medications such as serotonin reuptake inhibitors and anticonvulsant mood stabilizers in treating the condition. One of the appropriate drugs is Fluoxetine, taken for a period of twelve weeks, given orally in doses of 20 mg. The medication has been shown to be effective in controlling impulsive aggressive behavior (Amare et al., 2017).
Psychotherapy: effective psychotherapy techniques include individual or group therapy focusing on skill-building. The therapies are instrumental in identifying the situation or behavior that can lead to aggressive responses; hence plans could be made in time to react to them effectively. The patients are also taught how to control and manage their anger through attitude change, learning skills of problem-solving and relaxation techniques (MacQueen, & Memedovich, 2017).
Reflections: This female patient is suffering from a mood disorder, and in particular, intermittent explosive disorder. Successful management requires careful planning, with the healthcare practitioner required to be aware of the ethical and legal considerations when taking care of such patients. For example, while it may be ethically wrong to expose the health condition of such patients by reporting it to authorities in case the patient has an indication of potential harm to others and self, it may be necessary for a complete prognosis plan (Malhi et al., 2018). The patient has the right to be informed of how the treatment plan looks like and how it will be done since they play a significant role in ensuring that the plan works successfully.
Amare, A. T., Schubert, K. O., Baune, B. T., & SpringerLink (Online service). (2017). Pharmacogenomics in the treatment of mood disorders: Strategies and Opportunities for personalized psychiatry. EPMA Journal 8, 211–227. https://doi.org/10.1007/s13167-017-0112-8.
Fanning, J. R., Coleman, M., Lee, R., & Coccaro, E. F. (2019). Subtypes of aggression in intermittent explosive disorder. Journal of psychiatric research, 109, 164-172.
Hørlyck, L. D., Obenhausen, K., Jansari, A., Ullum, H., & Miskowiak, K. W. (February 01, 2021). Virtual reality assessment of daily life executive functions in mood disorders: associations with neuropsychological and functional measures. Journal of Affective Disorders: Part A, 280, 478-487. https://doi.org/10.1016/j.jad.2020.11.084
MacQueen, G. M., & Memedovich, K. A. (January 01, 2017). Cognitive dysfunction in major depression and bipolar disorder: Assessment and treatment options. Psychiatry and Clinical Neurosciences, 71, 1, 18-27. https://doi.org/10.1111/pcn.12463
Malhi, G. S., Irwin, L., Hamilton, A., Morris, G., Boyce, P., Mulder, R., & Porter, R. J. (January 01, 2018). Modelling mood disorders: An ACE solution?. Bipolar Disorders, 20, 4-16. https://doi.org/10.1111/bdi.12700