Provide a response 3 discussions prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points

PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation

Case Study of a Patient with Bipolar Disorder and PTSD

Modinat Adeleye

PRAC 6675

Dr. Karen Taylor

Walden University

09/18/2023

OBJECTIVES

1. Within three months, the patient will demonstrate an improved ability to analyze their mood swings and identify triggers by recording in a mood journal with a least 80% accuracy as measured by the therapist review. The patient will also track how their mood, impulsivity, and sleep habits change over three months while they are on medication (Lamotrigine and Seroquel).

2. To assess the patient's commitment to and development in Dialectical Behavior treatment (DBT) via tracking their progress in areas such as emotion regulation, impulse control, and coping skills over a full six months of weekly treatment sessions and utilizing coping strategies to manage symptoms resulting in at least 35% reduction in symptom severity (Genedi et al., 2019).

3. To monitor the patient's progress over the course of a year by checking in on their general functioning, sleep quality, and pain management on a consistent basis.

Subjective:

CC (chief complaint): “I have racing thoughts; trouble focusing! My coworkers don’t know what they will get from me, and they are scared of me”

HPI:

The patient is a 43-year-old who presented to the clinic as a new patient for psychiatric evaluation with complaints of having racing thoughts, difficulty focusing, being easily distracted, and sleep issues. The patient reports that she has been having racing thoughts for some days. The patient reported having mood disruptions, which are distinguished by moments of heightened activity, impulsiveness, and rapid thinking. She says that her colleagues fear her because she can be unpredictable at work. The patient reports feeling unaccepted by others. She reports binge shopping when unhappy. She states she goes on "shein" and shops even though she does not have the money. She reports having paranormal experiences and states she sees things sometimes. The patient has been experiencing sleep difficulties, as shown by her decision to stay up for numerous nights without feeling fatigued while doing things like painting and crafts. She reports going to bed at 4 or 5 a.m. and waking up at 7. She reports that her health has deteriorated in the past year due to some pain issues, requiring surgery soon. The patient also reports mood fluctuations, sometimes getting tired and not wanting to do anything for the last few days. She verbalized having suicidal thoughts in the past, but she credits her 17-year-old son with helping her from really carrying them out. Her family believes she underwent a significant personality change after experiencing three miscarriages in her twenties, all of which occurred during her marriage. She presents today, seeking help to manage her symptoms.

Substance Current Use: The patient reports using marijuana daily for both physical and emotional alleviation.

Medical History:

· Pain. Reportedly following a MVA in 2015 requiring a sternum plate installation.

· Varicose veins.

· Maternal ancestry linked to an increased risk of bipolar illness, schizophrenia, and other mental health disorders.

· Current Medications: None reported.

· Allergies: Allergic to morphine and dilaudid.

· Reproductive Hx: She had three miscarriages while married, all in her twenties. She has a son. Also reports having a hysterectomy.

ROS:

· GENERAL: The Patient exhibits a primary concern of pronounced fluctuations in

mood, heightened irritation, and challenges in effectively navigating everyday activities.

· HEENT (Head, Eyes, Ears, Nose, Throat): No headaches or vision problems have been reported by the patient.

· SKIN: The patient's skin showed no signs of abnormalities or rashes.

· CARDIOVASCULAR: No reports of cardiac issues were received.

1. RESPIRATORY: She doesn't seem to be having any trouble breathing, and his breaths are regular.

· GASTROINTESTINAL: Significant findings were not disclosed.

· GENITOURINARY: Hysterectomy reported.

· NEUROLOGICAL: Impulsivity, racing thoughts, and sleep disturbances reported.

· MUSCULOSKELETAL: Chronic pain reported.

1. HEMATOLOGIC: No history of blood-related problems were reported by the patient.

1. LYMPHATICS: The patient reported no lymphatic symptoms.

1. ENDOCRINOLOGIC: The patient did not mention any endocrine issues.

Objective:

Assessment:

Mental Status Examination:

The patient is a 43-year-old female who presented to the clinic for a psychiatric evaluation. She was well-oriented to place, time, place, and situation. The patient’s appearance agreed with her stated age and she was cooperative during the evaluation. The patient answered questions appropriately and was well- dressed and groomed for the occasion and the weather. Patient was talkative during the interview, she also had clear and coherent speech.

Differential Diagnoses: On the basis of the patient's medical history and mental status examination, the following diagnoses are considered:

1. Bipolar Disorder

2. Post-Traumatic Stress Disorder (PTSD)

3. Schzophrenia

Diagnostic Impression:

1. Bipolar II Disorder (BD) DSM-s 296.89 (F31.81):

Bipolar II Disorder is characterized by high periods of euphoria and low periods of depression, also known as hypomania. While hypomania can affect some functioning and quality of life, it is not as severe as manic episodes. The DSM-V criteria for diagnosing Bipolar II Disorder includes a period of abnormally and persistently elevated mood and increased activity or energy lasting at least four consecutive days nearly every day with three or more of the following symptoms – inflated self-esteem, more talkative than usual, flight of ideas, distractibility, increase in goal-directed activity, excessive inclement in activities which would later have painful consequences with the episode not characteristic of the individual when not symptomatic, not severe enough to impair social or occupational functioning, and not as a result of any physiologic substance (Marzani & Price Neff, 2021). Given the patient's mood fluctuations, impulsivity, rapid thoughts, and familial history of bipolar disorder, this diagnosis is consistent with DSM-5 criteria (Genedi et al., 2019) for bipolar II disorder. This patient reports having symptoms of increased energy and activity levels, irritable mood, a dedreased need for sleep sometimes lasting days, increased talkativeness, excessive spending, also some days she reports feeling hopeless and empty, losing interest in things, and having thoughts of suicide. There was no evidence of psychosis or mania.

2. Post-Traumatic Stress Disorder (PTSD) DSM-5 309.81 (F43.10):

The criteria for diagnosis of PTSD includes 1 requirement from each of the following:

A. exposure to death, threatened death, actual or threatened serious injury or sexual violence.

B. Perissitently re-experiencing the tramautic event by having – nightmares, flashbacks, emotional distress, or physical reactivity

C. Avoidance of trauma related stilumi – trauma related thoughts or feelgins or reminders

D. Negative thoughts or feelings that started or worsened after the trauma – negative effect, feeling isolated, blaming self and others

E. Truama related arousal that started or weorsened after the trauma – hypervigilance, risky behavior, torbule with concentration or diffcylt sleeping

F. Symptoms last greater than 1 month

G. Symptoms create distress or functional impariemtn

H. These symptoms are not due to any substance, medication or another illness or disorder (Nutt & Carhart-Harris, 2020).

The patient’s history of trauma and distress is suggestive of PTSD as a diagnosis, she meets the requirement for diagnosis based on the DSM-V criteria. The patient's difficulty in regulating emotions and impulsive behavior may be related to her history of trauma and relationship problems (Nutt & Carhart-Harris, 2020).

3. Schizophrenia DSM-5 295.90 (F20.9):

The DSM-5 criteria for diagnosing schizophrenia includes having two or more of the following sympotms for a significant portion of time during a 1month period or less if treatment is success. Symptoms as – delusions, halluicnations, disorganized speech, catatonic behavior, negative symtoms; social or occupational dysfunction. Although this was chosen as a differential diagnosis given the patient’s report of halluciantions. It was eliminated because she did not meet the other requirements for diagnosis based on the DSM-V criteria.

Case Formulation and Treatment Plan: 

1. Medication Management:

· Pharmacotherapy with mood stabilizers are the primary class of medications recommended for managing Bipolar II Disorder. Since the FDA has approved Lamotrigine for bipolar Disorder, it should be started in the morning at 25mg to stabilize mood (Stapp et al., 2020).

· The second medication prescribed for the patient was Seroquel. Seroquel is often prescribed during depressive episodes in patients with Bipolar II disorder because it an help alleviate depressive symptoms and stabilize the patient’s mood. In the case of this patient, Seroquel is used as an adjunct therapy for mood stabilization. Also, the patient was prescribed Seroquel 50 milligrams at bedtime to help with mood stability and insomnia (Stahl, 2019).

· It is important to take lamotrigine levels into account while making dose changes.

2. Psychotherapy:

· The patient was referred to start psychotherapy. Psychotherapy, such as Cognitive-Behavioral Therapy (CBT), Interpersonal and Social Rhythm Therapy (IPSRT), and Family-Focused Therapy (FFT), Dialectical Behavior Therapy (DBT) can be valuable in helping individuals manage mood swings, develop coping strategies, and improve medication adherence. Suggest and support for the patient to improve their impulsivity, emotional control, and coping abilities (Miklowitz, et. al, 2018).

· Evidence-based psychotherapies like Cognitive-Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) for PTSD symptom reduction was recommended for this patient.

· Make use of therapy services that encourage introspection and self-awareness.

3. Health Promotion:

· Health Promotion involves a holistic approach with the goal of improving overall well being and managing mental health disorders. Patient should be informed to adhere to treatment including psychotherapy, implement some lifestyle modifications, manage stress, have a safety plan, identify triggers that excarbate symptoms and develop strategies to avoid or cope with them, comply with follow-up appointments, and practice self care activities (Singh et. al., 2022). These activities should be tailored to each patient's individual needs and preferences. Regularly monitoring progress and adjusting the plan in collaboration with a mental health professional is essential for effective health promotion in individuals with bipolar disorder and PTSD.

· In order to keep tabs on the medication's effectiveness and adverse effects, patients should be encouraged to keep their scheduled appointments.

4. Patient Education:

· Inform the patient of the hazards associated with suddenly stopping their medicine and the significance of sticking to their prescribed schedule (Nutt & Carhart-Harris, 2020).

· Patient should be educated to take antidepressants with caution. Antidepressant medications may be prescribed during depressive episodes, but they should be used cautiously and in combination with mood stabilizers to prevent the induction of manic or hypomanic episodes (Yatham et. al, 2018).

· It is importance to make some lifestyle modifications such as regular exercise, eating healthy, good sleep hygiene, avoiding stressors and decreasing stress (Fernanda et. al, 2018).

· Medication adherence and regular monitoring is crucial in managing Bipolar II Disorder. Regular follow-up appointments with a mental health provider for medication adjustments and monitoring of symptoms are essential.

5. Social Determinate:

· Providers should screen for social determinants of health because this allows assessment of social factors that can influence one's mental health and access to care. Social factors include social support, food insecurity, poverty, health literacy, trauma, and housing instability (O’Brien, 2019). Strong social support can play a vital role in the mental health of patients with Bipolar Disorder and PTSD. For this patient, an identified social determinant of health impacting her mental health is her lack of or limited access to social support.

· A network of friends, family, or support groups can provide emotional support which can help the patient cope with some of her symptoms, reduce isolation and provide a safe space to express her feelings and provide a sense of security.

6. Referral:

· The patient's tragic past should be taken into account, as should her need for continuing care and attention. Patient was referred to therapy. It is crucial to have the patient see a trauma counselor or expert to deal with her history (Stapp et al., 2020).

· Support groups: Support groups and peer support can provide individuals with Bipolar II Disorder with a sense of community and understanding, which can be valuable in managing their condition.

Reflections:

If I could do the session again, I would dig further into the patient's traumatic history and how it relates to her present problems. In addition, I would evaluate her network of friends and family and, if necessary, include them in her treatment plan.

Evaluation of the treatment and medication's efficacy will depend heavily on follow-up. I would attempt to keep track of her progression so that I can make any necessary modifications. If a follow-up is not possible, the next stage is to ensure that the patient is receiving treatment and has the necessary resources to deal with her symptoms and traumatic past. Providers should assess the patient's social support system as part of their overall mental health evaluation and treatment plan. Addressing and strengthening social support can be a crucial element for managing bipolar disorder and PTSD effectively.

One of the goals for Healthy People 2030 is to improve mental health. About half of all people in the United States will be diagnosed with a mental disorder at some point in their lifetime (Pronk et. al., 2020). Healthy People 2030 focuses on the prevention, screening, assessment, and treatment of mental disorders and behavioral conditions (Pronk et. al., 2020).The patient was provided with National and local crisis helplines, to call should she experience any acute symptoms or emotional distress and also information for wellness programs that focus on mental health and well-being. She was provided with information for yoga classes, meditation groups, art therapy, and other activities that promote relaxation and emotional balance.

Provide a response 3 discussions prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

Responses exhibit synthesis, critical thinking, and application to practice settings…. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources…. Responses demonstrate synthesis and understanding of Learning Objectives…. Communication is professional and respectful to colleagues…. Presenters' prompts/questions posed in the case presentations are thoroughly addressed…. Responses are effectively written in standard, edited English.

Questions:

 

1. What role can patients themselves play in their treatment?

2. In cases of comorbid bipolar disorder and PTSD, how can a trauma-informed care approach enhance treatment outcomes?

3. What other diagnosis can you apply to the patient in this case?

 

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed, text rev.) https://doi.org/10.1176/appi.books.9780890425787

Gabriel, F. C., Oliveira, M., Bruna De M Martella, Berk, M., Brietzke, E., Jacka, F. N., & Lafer, B. (2023). Nutrition and bipolar disorder: a systematic review.  Nutritional neuroscience,  26(7), 637–651. https://doi.org/10.1080/1028415X.2022.2077031

Genedi, M., Janmaat, I. E., Haarman, B. (Benno) C. M., & Sommer, I. E. C. (2019). Dysregulation of the gut–brain axis in schizophrenia and bipolar disorder. Current Opinion in Psychiatry, 32(3), 185–195. https://doi.org/10.1097/yco.0000000000000499

Marzani, G., & Price Neff, A. (2021). Bipolar Disorders: Evaluation and Treatment.  American family physician,  103(4), 227–239.

Miklowitz, D. J., Porta, G., Martínez-Álvarez, R., Martínez-Arán, A., & Depression and Bipolar Disorder Group. (2018). Family-focused treatment for adolescents with bipolar disorder: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 57(11), 757-765.

Nutt, D., & Carhart-Harris, R. (2020). The Current Status of Psychedelics in Psychiatry. JAMA Psychiatry, 78(2). https://doi.org/10.1001/jamapsychiatry.2020.2171

O’Brien, K. H. (2019). Social determinants of health: the how, who, and where screenings are occurring; a systematic review.  Social work in health care,  58(8), 719-745.

Pronk, N., Kleinman, D. V., Goekler, S. F., Ochiai, E., Blakey, C., & Brewer, K. H. (2021). Promoting Health and Well-being in Healthy People 2030.  Journal of public health management and practice : JPHMP,  27(Suppl 6), S242–S248. https://doi.org/10.1097/PHH.0000000000001254

Singh, V., Kumar, A., & Gupta, S. (2022). Mental Health Prevention and Promotion-A Narrative Review.  Frontiers in psychiatry,  13, 898009. https://doi.org/10.3389/fpsyt.2022.898009

Stahl, S. M. (2019).  Stahl's essential psychopharmacology: Prescriber's guide: Children and adolescents. Cambridge University Press.

Stapp, E. K., Mendelson, T., Merikangas, K. R., & Wilcox, H. C. (2020). Parental bipolar disorder, family environment, and offspring psychiatric disorders: A systematic review. Journal of Affective Disorders, 268, 69–81. https://doi.org/10.1016/j.jad.2020.03.005

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., … & Beaulieu, S. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170.

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