ASSESSING AND DIAGNOSING PATIENTS WITH MOOD DISORDERS

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Subjective: What details did the patient provide regarding their chief complaint and symptomology 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 priority 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? 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.).
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.

 

 

Sample Solution

Case Study: Navigating the Labyrinth of the Mind

Disclaimer: This case study is for educational purposes only and does not constitute a real patient encounter or diagnosis. Please consult with a qualified healthcare professional for any mental health concerns.

Presenting Complaint:

A 35-year-old woman presents to the clinic with a chief complaint of excessive worry and difficulty concentrating, affecting her work and relationships. She reports feeling constantly on edge, with a racing mind that fixates on worst-case scenarios. This has been ongoing for the past six months, significantly impacting her ability to focus at work, maintain intimacy with her partner, and enjoy social activities. Her sleep has become fragmented, and she wakes up feeling exhausted and overwhelmed.

Objective Observations:

During the interview, the patient appears visibly anxious. Her speech is rapid and punctuated by long pauses as she struggles to organize her thoughts. She fidgets with her hands and maintains direct eye contact. Her affect is tense and worried, and she readily expresses feelings of apprehension and helplessness.

Mental Status Examination:

  • Alert and oriented to all spheres: The patient is aware of her surroundings, understands the purpose of the interview, and can accurately recall events.
  • Thought content: Preoccupied with intrusive thoughts focused on potential financial ruin, relationship failures, and health problems. She reports no suicidal or homicidal ideation.
  • Mood: Anxious and apprehensive, with occasional bursts of irritability.
  • Perception: No abnormalities in perception noted.
  • Psychomotor: Increased psychomotor activity observed, characterized by fidgeting and a rapid speech pattern.

Differential Diagnoses:

  1. Generalized Anxiety Disorder (GAD): The patient’s excessive worry, difficulty concentrating, and physical symptoms like sleep disturbances and restlessness strongly align with the DSM-5-TR criteria for GAD. The lack of specific phobias or situational triggers further supports this diagnosis.

  2. Major Depressive Disorder (MDD): While the patient presents with anxiety, her sleep difficulties, low energy, and decreased enjoyment of activities could also suggest MDD. However, the absence of key MDD symptoms like sadness, anhedonia, and changes in appetite makes this diagnosis less likely.

  3. Obsessive-Compulsive Disorder (OCD): Although the patient reports intrusive thoughts, they are not accompanied by compulsive behaviors or rituals, making OCD a less probable diagnosis. Additionally, the focus of her worries is predominantly on future events rather than specific internal or external stimuli.

Critical Thinking Process:

  • The primary diagnosis of GAD is supported by the presence of most core symptoms in the DSM-5-TR criteria and the absence of key features for alternative diagnoses like MDD and OCD.
  • The patient’s worries are excessive, uncontrollable, and interfere with daily functioning, highlighting the severity of her anxiety.
  • The duration of symptoms exceeding six months further strengthens the diagnosis of GAD.

Pertinent Positives:

  • Excessive worry and difficulty concentrating
  • Physical symptoms like sleep disturbances, restlessness, and muscle tension
  • Apprehension and irritability
  • Racing thoughts and intrusive thoughts focused on future events

Pertinent Negatives:

  • No suicidal or homicidal ideation
  • No specific phobias or situational triggers
  • Absence of key MDD symptoms like sadness, anhedonia, and appetite changes
  • No compulsive behaviors or rituals

Reflection Notes:

  • Building rapport and validating the patient’s emotional distress would be crucial to establishing trust and encouraging open communication.
  • Utilizing active listening techniques and open-ended questions could gain a deeper understanding of the specific content and triggers of her anxiety.
  • Exploring potential contributing factors like past traumas, stressors at work or home, and substance use would provide a more holistic picture.

Legal/Ethical Considerations:

  • Informed consent for assessment and treatment would be obtained at the outset.
  • Confidentiality would be maintained throughout the process, with exceptions only for situations involving risk of harm to self or others.

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