Posted: September 7th, 2024

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Week 4: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

College of Nursing-PMHNP, Walden University
NRNP 6645: Psychotherapy with Multiple Modalities

Week 4: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Patient Initials: ___Edwin____ Age: ___24____ Gender: ___M____ Ethnic group: Hispanic
Subjective:
CC (chief complaint): “ I feel trapped; I feel like I can’t escape my depression; it seems to bring me back to feeling down and stuck. I feel like I am getting testy with people, and my anger is gradually growing inside of me, built up anger causing my depression; little things get me angry such as strangers when people speak rudely to me. I get stuck with the emotion and can’t act out. My anger is causing me to have anxiety; it is gradually rising. COVID has made me feel like something is wrong; if I feel down, I will never get my life back; I feel trapped. I feel insecure. I feel like a bad friend, and I feel like they are avoiding me. I wonder where did I go wrong? My depression has made me feel like I hit a bumper and that I caused my depression. My friends and family who know me know that I am compassionate and funny. I am afraid that I am going to be annoying. I also feel like I’m missing a special relationship; I have a good supportive family and would like a romantic friendship. I said Hi to my best friend at work I have a crush on her. It felt nice to see her before I left work as she was coming in to work. I feel comfortable talking to her with ease, she is kind, nice, and a good listener. I feel our friendship is gradually growing.”
HPI: Edwin is a 34-year old Hispanic male who comes to the clinic complaining of depression and anger. He is experiencing a poor relationship with people. He feels trapped and insecure.
(include psychiatric ROS rule out)
Past Psychiatric History:
• General Statement: Diagnosed with depression last year.
• Caregivers (if applicable): Lives with both parents and two sisters
• Hospitalizations: No past hospitalizations.
• Medication trials: Multivitamin daily,
• Psychotherapy or Previous Psychiatric Diagnosis: Psychotherapy twice a week. Diagnosis: Autism Spectrum Disorder and Mood D/O related to ASD
Substance Current Use and History: No history of substance use
Family Psychiatric/Substance Use History: No family history for psychiatric or substance use.
Psychosocial History: Edwin works at a local manufacturing plant. He has no history of alcohol or drug abuse. He lives with his parents.
Medical History:

• Current Medications: No medication
• Allergies: No known allergies
• Reproductive Hx: The patient is not sexually active and has no children. He is planning to marry in the future.
ROS:
GENERAL: No unintentional body weight increase or decrease. No fever or chills.
HEENT: No nasal congestion, sore throat, or teary eyes.
SKIN: No skin rashes, itching, sores, or bruises.
RESPIRATORY: No shortness of breath, coughing, or sputum.
CARDIOVASCULAR: No chest pressure, palpitation, chest pain, or tightness of the chest.
MUSCULOSKELETAL: Negative for back pain, myalgias, arthralgias, and gait problem.
NEUROLOGICAL: No dizziness or headache.
PSYCHIATRIC: Positive for depression and anger.
ENDOCRINOLOGIC: Negative for abnormal sweating.
REPRODUCTIVE: Not sexually active and single.
ALLERGIES: No known allergies for weather changes, dust, or pollen.
Objective:
Diagnostic results: negative results for anemia or thyroid.
Assessment:
Mental Status Examination: Negative for dementia with a score of 28/30.
Differential Diagnoses:
Autism Spectrum
Autism spectrum disorder is a complex developmental condition that involves persistent challenges in social interactions. The symptoms of the disorder include difficulty in understanding others, anxiety, rude conversations with other people, finding it hard to express opinions (Grove et al., 2019). The DSM-5 criteria aligns with the current symptoms including failure to make quality relationships, abnormal social approach, lack of interest in peers. According to the patient’s chief complaint, he is finding it hard to make friends and is afraid of hurting them, and difficulty in understanding others. Anger is building up inside him and he feels trapped.
There is no medication for people with ASD, treatment methods are meant to improve the quality of life by suppressing the symptoms. Some of the best treatment methods include occupational therapy, physical therapy, and pharmacology (Grove et al., 2019). In some cases, children who present with ASD may experience a reduction of the severity of the symptoms as they grow up.
Social Anxiety
Soial anxiety is a disorder that causes social phobia or fear in social settings. People who suffer from social anxiety have problems attending social events, meeting people or talking to new people (Leichsenring & Leweke, 2017). The basis of the fear is to judged by others. The symptoms include irrational fear, embarrassment, excessive fear, and the fear of offending others. Demands or stress may trivver social anxiety disorder (Leichsenring & Leweke, 2017). Talk therapy is an important therapt that can help the patients to improve confidence and interaction with others.
Major depressive disorder
Major depressive disorder is a mental health disorder that triggers a persistent depressive mood and loss of interest in daily activities. Depression causes a change in the brain’s chemical composition and functioning (Layton et al., 2019). The disorder triggers behavioral and physical symptoms. Some of the symptoms include loss of interest in daily activities, change in sleep patterns, low appetite, and low self-esteem (Hasin et al., 2018). The mental disorder can alter the life of a person drastically by affecting their relationships with other people.
Borderline personality disorder
A borderline personality disorder is a mental condition that affects how individuals feel about themselves and others. The changes in perceptions and feelings affect relationships and the ability to participate in daily activities (Hasin et al., 2018). Some of the indicators of the disorders include self-image issues and unstable relationships with people. Other symptoms of BPD include self-destructive behavior, emotional swings, a chronic feeling of emptiness, and explosive anger (Hasin et al., 2018). Patients with BPD require elaborate treatment since the disorder can undermine the quality of their life.
Adjustment disorder with depressed mood
Adjustment disorder is an emotional and behavioral reaction to stressful life events. The condition triggers an unhealthy and unstable reaction to life events. For example, some people experience adjustment disorder within three months after a major life event occurs (Chanen et al., 2020). Some of the changes may include relocating, separation or divorce, marital difficulties, retirement, losing a job, or moving to a new school (Chanen et al., 2020). Treatment of adjustment disorder requires psychotherapy, support groups, and family therapy.
Reflections:
The case study of the patient shows the changes in personal life are affecting the mood and mental condition of the patient. The patient appreciates that the pandemic is a major trigger of the current mental disorder. Symptoms are affecting the relationship with other people and making the patient angry. Immediate treatment is necessary to avoid the disruptions that may create poor relationships with other people (Maerckers & Lorenz, 2018). The treatment options require both psychotherapy and pharmacological strategies. It is important to emphasize the importance of adherence to the psychotherapeutic approaches and pharmacological treatments.
Patients with autistic conditions require support from family members and friends. Family therapy is necessary to ensure they understand the patient’s condition. Support will relieve the severity of the symptoms and improve the quality of life. Another kind of support is from groups of people living with autism. It is important to recommend the support to ensure the patient enjoys daily activities. Supporting them makes them feel loves and worthy.
Case Formulation and Treatment Plan:
The case formulation of the autism spectrum includes specific genes that increase the risk of the disorder (Grove et al., 2019). The occurrence is high with the complex interaction of genetic, nongenetic, and environmental factors.
The best treatment methods include occupational therapy, physical therapy, and pharmacology. Patients should start the therapy early to ensure successful treatment. Applied behavior therapy is one of the common methods of providing care to patients in schools or clinics (Grove et al., 2019). The purpose of applied behavior therapy is to encourage positive behaviors that improve quality of life and discourage negative behaviors (Grove et al., 2019). Parents or teachers should encourage the children by being emphatic, making the children feel safe and loved.
The focus of autism treatment is to reduce the severity of the symptoms. The family can consider animal assisted therapy. Animal-assisted therapy is to improve physical, emotional, and social wellbeing of people living with autism. The long-term solution is crucial to improve the life of the patient. Another necessary treatment approach is anger management that involves minimizing destructive emotional outbursts. Anger management improves the social life of a patient in school and workplaces. Embracing diverse treatment methods minimizes the the symptoms and helps patients to live a normal life.
Conclusion
The symptoms of autism spectrum disorder include difficulty in understanding others, anxiety, rude conversations with other people, finding it hard to express opinions. The patient in the case study has similar symptoms that align with the DSM-5 criteria. The symptoms include failure to make quality relationships, abnormal social approach, lack of interest in peers. Treatment involves occupational therapy, physical therapy, and pharmacology. While autism has no known cure, treatment reduces the severity of the symptoms and improves ability to participate in daily activities.

References
Chanen, A. M., Nicol, K., Betts, J. K., & Thompson, K. N. (2020). Diagnosis and treatment of borderline personality disorder in young people. Current Psychiatry Reports, 22(5), 1-8.
Grove, J., Ripke, S., Als, T. D., Mattheisen, M., Walters, R. K., Won, H., … & Børglum, A. D. (2019). Identification of common genetic risk variants for autism spectrum disorder. Nature Genetics, 51(3), 431-444.
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336-346.
Layton, T. J., Barnett, M. L., Hicks, T. R., & Jena, A. B. (2018). Attention deficit–hyperactivity disorder and month of school enrollment. New England Journal of Medicine, 379(22), 2122-2130.
Leichsenring, F., & Leweke, F. (2017). Social anxiety disorder. New England Journal of Medicine, 376(23), 2255-2264.
Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry, 19(sup1), S3-S13.

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