Comprehensive Psychiatric Evaluation

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.Comprehensive Psychiatric Evaluation

Incorporate the following into your responses in the template:

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 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.

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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.).

This assignment includes a comprehensive psychiatric evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis

Comprehensive Psychiatric Evaluation in a Female Child with Disruptive Mood Dysregulation Disorder (DMDD)

Patient Initials:   K.J.            Age:    8 Years                        Gender:    Female

CC (chief complaint): The mother to patient K.J. presented her to the clinic with a complaint of recurrent verbal temper outbursts and physical aggression occurring at least three times every week. Comprehensive Psychiatric Evaluation

History of Presenting Illness (HPI): This is an 8 year-old female Caucasian child who presents with a complaint of recurrent temper outbursts that are not commensurate with her developmental stage or age. The outbursts always seem disproportionate to the trigger that causes them. The mother reports a clear previous history of the same symptoms when the child was still younger. The onset of the symptoms was noted quite early in the child’s life. The mother states that the temper outbursts started as early as when patient K.J. was still just 3 years old. The temper tantrums usually last for between 5-15 minutes each time. The tantrums are violent, menacing, and uncontrollable for a child. They are aggravated by trying to calm the girl down. This only makes the situation worse. The symptom is relieved by just letting the girl go off on a tantrum tangent and waiting for her to cool down on herself. There is no specific timing for the tantrums. They can occur at any time. On a scale of 1-10, the mother rates the severity of the tantrums at 8/10.

Past Psychiatric History:

• General Statement: Patient K.J. has achieved all her developmental milestones without any problems. Apart from her temper tantrums, she does not appear depressed and is actually quite shy. She is doing well in her academic work and has also received all the immunizations that she is supposed to receive up to now. However, when she gets the temper tantrums she becomes violent and uncontrollable. She destroys property and may herm herself or someone else.
• Caregivers (if applicable): Patient K.J. does not require caregivers as she has no notable disability. She has been independent and can eat on her own, bathe, and dress herself.
• Hospitalizations: K.J. does not have an extensive history of hospitalization. She has only been admitted once in 2016 for second degree burns which she suffered on her right foot after kicking the cooker in one of her episodes of temper.
• Medication trials: K.J. has never been involved in any medication trials and neither has she been given any psychopharmacologic medication.
• Psychotherapy or Previous Psychiatric Diagnosis: This is the first time that K.J. has been brought to seek psychiatric attention. She has never been diagnosed previously with any psychiatric condition. She has also never undergone any psychotherapy resulting from a psychiatric diagnosis.

Substance Current Use and History: Being a child, patient K.J. does not have a history of substance abuse.

Family Psychiatric/Substance Use History: K.J.’s father has a long history of alcohol abuse and is currently a member of Alcoholics Anonymous. He has gone through many psychotherapeutic sessions of cognitive behavioral therapy (CBT) for cognitive remodeling (Corey, 2017). The mother has been treated for major depressive disorder and is currently actually taking sertraline (Zoloft) as maintenance therapy (Stahl, 2017). There is no one else in the family with a significant psychiatric or substance use history.

Psychosocial History: The client has a good social support system as the uncles and the aunts together with their children are close to the family. However, there are obvious risks to her mental health presented by psychological and environmental or social factors surrounding her. As stated above, the mother has been battling depression caused by the father’s alcoholism and lack of parental responsibility. All this has been happening as the client watches growing up. Comprehensive Psychiatric Evaluation

Medical History:

• Current Medications: Client K.J. does not currently have any medications that she is taking.
• Allergies: She also has no known drug allergies (NKDA) as well as allergies to food or environmental irritants.

• Reproductive Hx: Client K.J. is just 8 years old and has not yet reached puberty.

ROS:

• GENERAL: The patient denies having any fever, chills, or fatigue. The mother also denies any recent weight changes in the child.
• HEENT: She denies any headache. There is no photophobia, diplopia, tearing, or short-sightedness. Her eye check-up was one year ago. Patient K.J. does not use or wear glasses. She has intact sense of smell and denies rhinorrhea, nasal polyps, sneezing, allergic rhinitis, or epistaxis. She denies having otorrhea or tinnitus, denies hearing loss and does not use any hearing aids. She denies bleeding of the gums, gingivitis, and any oral ulceration. She also denies dysphagia or a sore throat. Her last ENT examination was done six months ago.
• SKIN: She denies any rashes or itching of the skin.
• CARDIOVASCULAR: She denies the occurrence of any chest pain or tightness of the chest. The mother denies any history of edema in the child.
• RESPIRATORY: The client denies having any cough, difficulty in breathing, hemoptysis, or chest pain. She denies getting breathless when doing physical activity.
• GASTROINTESTINAL: She denies having nausea, diarrhea, or vomiting. She also denies having any recent changes in her bowel habits and does not also have any abdominal pain or discomfort. The mother states that she had her last bowel movement the previous night before the visit for psychiatric evaluation.
• GENITOURINARY: She denies frequent urination as well as oliguria. She also denies dysuria and nocturnal enuresis. She is prepubertal.
• NEUROLOGICAL: She denies difficulty with movement, fainting attacks, dizziness, or loss of consciousness. The mother denies any history of seizures.
• MUSCULOSKELETAL: Patient K.J. denies any joint or muscle pain. The mother denies a history of trauma or fractures.
• HEMATOLOGIC: The mother denies any history of clotting difficulties or blood disorders in the family.
• LYMPHATICS: She denies any swollen glands such as cervical or inguinal.
• ENDOCRINOLOGIC: She denies ever experiencing excessive sweating or thirst. She also denies having heat intolerance. The mother denies ever taking her for any sort of hormonal therapy.Comprehensive Psychiatric Evaluation

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Physical exam:

General: A&O x 3. The girl was well-groomed and had cloths that were appropriate for the weather and time of the day. Vital signs: BP 110/70 mmHg pediatric cuff and sitting; P 82 regular; T 98.0°F; RR 17 non-labored.

HEENT: Both pupils equal, round, and reacting to light and accommodation (PERRLA), EOMI. No nasal discharge. No hypertrophy of nasal turbinates. Nasal septum is intact. External auditory canal is clear with no otorrhea. Tympanic membranes are clear and non-perforated. No exudate noted.

Cardiovascular: S1 and S2 clear and audible (RRR) with no murmurs. No rub or gallop evident.

Respiratory: Clear lung fields on auscultation. No wheezing, rales, rhonchi, or crepitations.

Neurological: GCS score of 15/15. No hemiparesis or facial palsy.

Diagnostic Results:

1. Laboratory: RBC 4.95 millions/ mm³; WBC 11.25 x 10³/mcL (Hammer & McPhee, 2018).
2. Radiologic: MRI of the head (normal features).
3. Psychiatric: Children’s Interview for Psychiatric Syndromes or ChIPS (positive for DMDD) (McTate & Leffler, 2016).

ASSESSMENT

Mental Status Examination (MSE)

The client is an 8 year-old Caucasian female who is alert and oriented to place, person, event, and time. Her speech is clear and goal-directed. She displays no notable tics or gestures. Her self-reported mood is “angry”. Affect is labile and appropriate and appropriate to the self-reported mood and interview environment.  She exhibits no hallucinations or delusional thought content. Generally shows a lack of insight and judgment and impaired impulse control. The diagnosis is disruptive mood dysregulation disorder or DMDD (Sadock et al., 2015; APA, 2013; Stahl, 2013), consistent with DSM-5 diagnostic criteria.

Differential Diagnoses:

1. Disruptive mood dysregulation disorder (DMDD)

DMDD is classified as a depressive disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Its diagnostic code in the DSM-5 is 296.99 (F34.8). Its diagnostic criteria are as follows (McTate & Leffler, 2016; Sadock et al., 2015; APA, 2013):

1. Severe verbal and/ or behavioral (physical aggression) outbursts of temper that are disproportionate to the triggering situation.
2. Inconsistency of the severity of the tantrums with the child’s developmental stage.
3. The outbursts of temper have to occur at least three times in a week.
4. In-between the temper outbursts, the observable mood is consistently angry or irritable most of the time.
5. The above criteria A-D have to be present for not less than 12 months. Within the 12 months, there must never have been a period of three or more consecutive months when the client is free of all of the symptoms in A-D.
6. Specifically, criteria A and D have to be present in at least two of the three settings that the child would normally find themselves in. That is at school, at home, or with peers/ age mates. In one of those two occasions, the criteria (A and D) must have been severe.
7. The diagnosis is not being made for the very first time before age 6 or after 18 years of age.
8. The onset of the criteria A-E above must be before the age of 10 years.
9. The full symptom criteria have never been met within a period lasting more than one day.
10. Behavior cannot be linked to major depressive disorder or any other mental disorder.
11. The symptoms cannot be attributed to another physical or medical condition, neurological condition, or the effects of substance use.

The pertinent positives include irritability, anger, and violence during outbursts. The pertinent negatives include suicidality, elation (euphoria), and social isolation. The critical thinking process that led to the diagnosis was based on identifying behavior that conforms to the DSM-5 diagnostic criteria. This is because the DSM-5 is the authoritative tool for the diagnosis of mental disorders.Comprehensive Psychiatric Evaluation

2. Bipolar disorders

This is the second most likely diagnosis after DMDD in client K.J. Some of the symptoms of bipolar disorders are lack of concentration, a rise in impulsivity, and increased activity. In BPD, these are however episodic and accompanied by elevated mood (APA, 2013). Therefore, the difference in diagnostic criteria is that both bipolar I and bipolar II disorders have distinct episodic manifestation that is clearly different from DMDD (APA, 2013).

3. Oppositional defiant disorder

This differential diagnosis shares the diagnostic criterion of severe outbursts of temper with DMDD. Other symptoms of the disorder are anger, resentment, irritability, lack of respect for authority figures, and vindictiveness (APA, 2013). However, it is the least likely diagnosis as many other criteria are not congruent with those of DMDD (APA, 2013).

Reflections:

I would not do anything differently with this client if I were to conduct the session all over again. This is because all that I carefully ruled out any physical (medical) conditions that may be responsible for the symptoms by meticulous physical examination and laboratory investigations. The girl’s RBCs and WBCs were within physiological limits. I also ruled out any neurological deficit that may have been the cause by ordering an MRI that returned no abnormality in the CNS. Most importantly, a combination of the ChIPS, the girl’s symptoms (conforming to DSM-5 criteria), and the MSE unequivocally determined that she is suffering from DMDD. Ethically, any interventions that I would give (especially psychotherapy) would require extensive counseling and concordance with the client and her parents. This will be in respect for bioethical principle of autonomy (Haswell, 2019). Coercion into accepting therapy would deny the client and the parent autonomy and may also harm them psychologically (violating the principle of nonmaleficence too). On health promotion, I would consider family therapy to help the parents cope with their daughter’s condition.

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

McTate, E.A., & Leffler, J.M. (2016). Diagnosing disruptive mood dysregulation disorder: Integrating semi-structured and unstructured interviews. Clinical Child Psychology and Psychiatry, 22(2), 187–203. https://doi.org/10.1177/1359104516658190

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2013). Stahl’s essential Psychopharmacology: Neuroscientific basis and practical application, 4th ed. Cambridge University Press.Comprehensive Psychiatric Evaluation

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):

HPI:

Past Psychiatric History:

• General Statement:
• Caregivers (if applicable):
• Hospitalizations:
• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

• Current Medications:
• Allergies:

• Reproductive Hx:

ROS:

• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

Comprehensive Psychiatric Evaluation