Comprehensive Psychiatric Evaluation

Subjective:

The patient, a 32-year-old female with no prior psychiatric history, presented with a chief complaint of feeling “down” and unmotivated for the past two months. She reported difficulty concentrating at work, leading to increased errors and potential disciplinary action. Sleep has been disrupted, with early morning awakenings and difficulty falling asleep. She described a lack of interest in activities she used to enjoy, like socializing with friends or going to the gym. Her appetite has decreased, and she has lost 10 pounds in the past two months. The patient denied any suicidal ideation or thoughts of harming herself or others.

Objective:

During the interview, the patient appeared sad and tearful. Her speech was slow and monotone, with psychomotor retardation evident. Eye contact was minimal. She denied any hallucinations or delusions.

Assessment:

Mental Status Examination:

• Appearance: Disheveled clothing, poor hygiene.
• Mood: Depressed.
• Affect: Blunted.
• Speech: Slow, monotone.
• Thought Process: No thought disorders evident.
• Thought Content: No suicidal or homicidal ideation.
• Sensorium: Alert and oriented to time, place, and person.
• Concentration: Impaired.
• Insight and Judgment: Intact.

Differential Diagnoses:

1. Major Depressive Disorder (MDD) – This is the most likely diagnosis given the patient’s presentation of depressed mood, anhedonia, sleep disturbances, weight loss, and psychomotor retardation. The duration of symptoms (two months) meets the DSM-5-TR criteria for a Major Depressive Episode.
2. Adjustment Disorder with Depressed Mood – This diagnosis is less likely because the patient does not report a specific stressor that triggered the onset of symptoms.
3. Bipolar Disorder – While the patient experiences depressed mood, there is no evidence of manic episodes or hypomania in her history. Additionally, she denies symptoms like racing thoughts, grandiosity, or increased energy levels.

Critical Thinking Process:

The patient’s symptoms align more closely with MDD criteria than the other diagnoses. The duration and severity of her symptoms significantly impact her daily life. The absence of a clear stressor and the lack of manic or hypomanic episodes rule out Adjustment Disorder and Bipolar Disorder, respectively.

Pertinent Positives for MDD:

• Depressed mood for at least two weeks
• Anhedonia
• Sleep disturbances (early morning awakening, difficulty falling asleep)
• Weight loss
• Psychomotor retardation
• Difficulty concentrating

Pertinent Negatives for Bipolar Disorder:

• No history of manic or hypomanic episodes
• No symptoms of racing thoughts, grandiosity, or increased energy levels

Primary Diagnosis:

Major Depressive Disorder, Single Episode, Moderate Severity (DSM-5-TR code: 296.21 [F32.1])

Reflection Notes:

If I could conduct the session again, I would delve deeper into the patient’s social history and explore potential social stressors that might have contributed to the development of the MDD. Additionally, a more detailed family history regarding mood disorders would be beneficial.

Legal/Ethical Considerations:

• Confidentiality: Maintain patient confidentiality except in cases of imminent harm to self or others, or a court order.
• Duty to Warn: If the patient expresses suicidal ideation or intent, the appropriate steps must be taken to ensure their safety, which might involve contacting emergency services or informing a family member.
• Least Restrictive Treatment: Explore non-medication treatment options first, such as psychotherapy, before considering medication.

Health Promotion and Disease Prevention:

• Lifestyle Changes: Encourage regular exercise, healthy sleep habits, and a balanced diet.
• Stress Management: Teach stress management techniques like relaxation exercises and mindfulness meditation.
• Social Support: Encourage the patient to maintain strong social connections and engage in activities they used to enjoy.

Risk Factors:

• Age: The patient’s age (32) puts her in a high-risk group for MDD.
• First Episode: This is the patient’s first reported episode of MDD, but it increases her vulnerability to future episodes.
• Family History: A family history of mood disorders would be a significant risk factor, though this information wasn’t explored in detail during the initial session.

Socioeconomic and Cultural Considerations:

• Socioeconomic Status: Financial insecurity can contribute to stress and exacerbate symptoms of depression. Exploring the patient’s socioeconomic situation could reveal additional stressors.
• Cultural Background: Cultural factors might influence the expression of symptoms and the help-seeking behavior of patients with MDD. It is important to be culturally sensitive during the evaluation and