Assign 3-WK 7(A)

Assignment 1: Decision Tree

For this Assignment, as you examine the client case study1 (See Below) in this week’s Learning Resources, consider how you might assess and treat adult and older adult clients presenting symptoms of a mental health disorder.

 

Learning Objectives

Students will:

· Evaluate clients for treatment of mental health disorders

· Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

 

 

THE ASSIGNMENT

 

 

Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

 

INSTRUCTION

(N: B. A CASE STUDY WITH ANSWER SAMPLE IS ATTACHED WITH THIS ASSIGNMENT

At this point, please discuss any additional diagnostic tests you would perform on Stefanie.

At each Decision Point, stop to complete the following:

 

 

Decision #1: Differential Diagnosis

· Which Decision did you select?

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?

 

Decision #2: Treatment Plan for Psychotherapy

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?

 

Decision #3: Treatment Plan for Psychopharmacology

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

 

· Also include how ethical considerations might impact your treatment plan and communication with clients and their family.

 

Note:  Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

PLEASE INCLUDE INTRODUCTION, CONCLUSION AND REFERENCES LESS THAN 5 YEARS OLD

 

Case #2 A young woman wi

 

SUBJECTIVE

Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep.

You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.

Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!”

OBJECTIVE

Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits.

 

MENTAL STATUS EXAM

Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.

 

 

 

 

 

 

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

 

Bipolar I, current phase, depressed

 

Bipolar II, current phase, hypomanic

 

Cyclothymic disorder

 

Answer Chosen:  

 

 Cyclothymic disorder

 

 

 

 

 

 

 

 

 

 

 

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Begin Depakote 250 mg orally three times daily

 

Begin Abilify 10 mg orally daily

 

Arrange to see Stefanie every 3 months for routine follow-up

 

Answer Chosen:  

 

 Arrange to see Stefanie every 3 months for routine follow-up

 

 

 

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in twelve weeks

·  Stefanie returns to the clinic in 12 weeks and reports that she feels no different. Her symptoms continue to follow the same pattern as they did when she first came to your office

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

 

Begin cognitive behavioral therapy

 

Begin Latuda 40 mg orally daily

 

Begin Abilify 10 mg orally daily

 

 

 

Answer Chosen:  

 

 

 

Begin Latuda 40 mg orally daily

 

 

 

 

 

 

Some Guidance and Rationale for Answer to Chosen

 

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

The PMHNP’s assessment should include an assessment of the impact of Stefanie’s symptoms on her overall functioning. The PMHNP should discuss treatment options with Stefanie. It could be that the management approach would be simply to monitor Stefanie on an ongoing basis for worsening of symptoms if Stefanie is averse to using medications. Should any future worsening of symptoms be noted, Stefanie may opt to receive pharmacologic treatment at that point. Treatment with psychotherapy to address baseline depression could be beneficial as well. Again, it is important for the PMHNP to determine the severity of existing symptoms; their impact on Stefanie’s life; and, of course, to discuss risks/benefits of treatment so that Stefanie can make an informed choice.

 

Learning Resources

Required Readings

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

· Chapter 8, “Mood Disorders” (pp. 347–386)

 

Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.

· Chapter 13, “Acute and Maintenance Treatment of Bipolar and Related Disorders”

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

· “Bipolar and Related Disorders”

 

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

 

To access information on specific medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.

 

 

Bipolar depression	Bipolar disorder	Bipolar maintenance	Mania
amoxapine aripiprazole armodafinil asenapine bupropion carbamazepine fluoxetine iloperidone lamotrigine lithium lurasidone modafinil olanzapine olanzapine-fluoxetine combination quetiapine risperidone sertindole valproate (divalproex) ziprasidone	alprazolam (adjunct) amoxapine aripiprazole asenapine bupropion carbamazepine chlorpromazine clonazepam (adjunct) cyamemazine doxepin fluoxetine flupenthixol fluphenazine gabapentin (adjunct) haloperidol iloperidone lamotrigine levetiracetam lithium lorazepam (adjunct)	loxapine lurasidone molindone olanzapine olanzapine-fluoxetine combination oxcarbazepine paliperidone perphenazine pipothiazine quetiapine risperidone sertindole thiothixene topiramate (adjunct) trifluoperazine valproate (divalproex) ziprasidone zonisamide zotepine zuclopenthixol	aripiprazole asenapine carbamazepine iloperidone lamotrigine lithium lurasidone olanzapine olanzapine-fluoxetine combination quetiapine risperidone (injectable) sertindole valproate (divalproex) ziprasidone	alprazolam (adjunct) aripiprazole asenapine carbamazepine chlorpromazine clonazepam (adjunct) iloperidone lamotrigine levetiracetam lithium lorazepam (adjunct) lurasidone olanzapine quetiapine risperidone sertindole valproate (divalproex) ziprasidone zotepine

 

Marsee, K., & Gross, A. F. (2013). Bipolar disorder or something else? Current Psychiatry, 12(2), 43–49. Retrieved from http://www.mdedge.com/currentpsychiatry/article/66320/bipolar-disorder/bipolar-disorder-or-something-else

Miller, L. J., Ghadiali, N. Y., Larusso, E. M., Wahlen, K. J., Avni-Barron, O., Mittal, L., & Greene, J. A. (2015). Bipolar disorder in women. Health Care for Women International, 36(4), 475–498. doi:10.1080/07399332.2014.962138

 

Schouws, S. M., Comijs, H. C., Dols, A., Beekman, A. F., & Stek, M. L. (2016). Five-year follow-up of cognitive impairment in older adults with bipolar disorder. Bipolar Disorders, 18(2), 148–154. doi:10.1111/bdi.12374

Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20(3), 17–25.

Required Media

Laureate Education (Producer). (2017d). A young woman with depression [Multimedia file]. Baltimore, MD: Author.

 

Redfield Jamison, K. (Producer). (n.d.). Assessment & psychological treatment of bipolar disorder [Video file]. Mill Valley, CA: Psychotherapy.net.

 

Optional Resources

Malhi, G. S., McAulay, C., Gershon, S., Gessler, D., Fritz, K., Das, P., & Outhred, T. (2016). The lithium battery: Assessing the neurocognitive profile of lithium in bipolar disorder. Bipolar Disorders, 18(2), 102–115. doi:10.1111/bdi.12375

Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., & Llorca, P. (2016). Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disorders, 18(2), 164–173. doi:10.1111/bdi.12376