Assessing and Diagnosing Patients With Mood Disorders

Assessing and Diagnosing Patients With Mood Disorders

Subjective:

CC (chief complaint): I just can’t shake off this overwhelming sadness and constant worry about not being good enough for my baby. I’m here because I can’t stop crying and I feel so hopeless all the time.”

HPI: Mrs. Abrianna Tilman presents for psychiatric evaluation, complaining of persistent depressive symptoms and severe anxiety that began two months ago following the birth of her first child. Symptoms include chronic sadness, inability to experience pleasure in previously enjoyed activities, excessive crying, significant sleep disturbances, and profound maternal anxiety. These symptoms have drastically reduced her functional capacity at home and strained her interpersonal relationships. She describes a continuous feeling of inadequacy and fear that she is not caring adequately for her newborn daughter, Jessica. She reports that these feelings persist throughout the day and are exacerbated by minimal triggers around the home.

Past Psychiatric History:

• General Statement: No reports of any mental health illness.
• Caregivers (if applicable): At the moment, her major support comes from her husband and family.
• Hospitalizations: Tilman denies any past hospitalization.
• Medication trials: Tilman denies having undergone any medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: She has no history of mental health illness or psychotherapy.

Substance Current Use and History: Mrs. Tilman, the patient, denies having used any substances including Marijuana, cocaine, and other social drugs. She also denies any use of alcohol, nicotine, or caffeine at present and in the past.

Family Psychiatric/Substance Use History: There is no history of substance use amongst her family members

Psychosocial History: Mrs. Tilman was born and raised by her parents. She has a husband, Rick, and a two-month-old daughter named Jessica. She is a housewife at present. Before the birth of her child, Mrs. Stillman used work and sometimes write as a hobby.

Mrs. Tilman denies any legal and trauma background. She has not indicated or described any safety concerns or violence in her private, house, or community life. She complains about her current state and how she is dealing with the changes of becoming a mother.

Medical History:

• Current Medications: There’s no history of current medication use.
• Allergies: No specific medication, food, or environmental allergies reported.

Reproductive Hx: Mrs. Abrianna Tilman gave birth to her first baby, Jessica, two months ago by vaginal delivery without any complications. She is still in the postpartum period, which may influence her menstrual cycle patterns. Despite that, Mrs. Tilman is strongly engaged in breastfeeding, but she feels disgusted while feeding, and this may suggest that she has severe psychological problems such as bonding. Such an emotional response during such an intimate act of caregiving may imply that she possibly suffers from other unresolved postpartum psychological conditions that require psychological intervention to maintain her mental health as well as enhance the mother-child bond.

ROS:

• GENERAL: Tilman reports significant fatigue, which may be linked to her postpartum status and sleep disturbances. She also reports weight changes post-pregnancy and expresses dissatisfaction with her body image
• HEENT: Denies headaches, changes in vision, hearing impairment, congestion, nasal problems, or sore throat.
• SKIN: Denies any skin rash or itching on her skin
• CARDIOVASCULAR: Denies chest pain, pressure, or palpitations.
• RESPIRATORY: Denies shortness of breath or cough.
• GASTROINTESTINAL: Reports loss of appetite, but denies nausea, vomiting, or pain in the abdominal region
• GENITOURINARY: No reports of urnary problems
• NEUROLOGICAL: No reports of dizziness, headaches, or numbness.
• MUSCULOSKELETAL: No reports any muscle or joint pain. However, her fatigue may include the general musculoskeletal fatigue from attending to the newborn baby.
• HEMATOLOGIC: No reports of maladies like anemia, bruising, or bleeding
• LYMPHATICS: No reports of symptoms concerning the endocrines, like, heat or cold intolerance or excessive sweating
• ENDOCRINOLOGIC: Reports of postpartum fatigue and/or emotional distress

Objective:

Physical exam: She seems sad and exhausted.

Diagnostic results: N/A

Assessment:

Mental Status Examination: Mrs. Tilman appears her stated age. She is neatly groomed, clean, and dressed appropriately for the setting. There is no evidence of abnormal motor activity, though she appears visibly fatigued, with a slumped posture at times. Her speech is clear, coherent, and normal in volume and tone, though slightly slower when discussing emotionally challenging topics. Her thought processes are logical and goal-directed, with no evidence of looseness of association, flight of ideas, or tangential thinking. She however looks sad and has even shed tears.

Differential Diagnoses:

1. Major Depressive Disorder (MDD), Moderate to Severe, with Postpartum Onset ICD-10 code F53.0

This diagnosis can be evidenced by Mrs. Abrianna Tilman’s low mood, tearfulness, guilt, and inadequacy, mainly due to her motherhood status. Some of the symptoms of major depressive disorder that she presents include the inability to derive pleasure from her baby, crying most of the time, and the desire to “get out” of her current life circumstances, which are hallmark symptoms of Major Depressive Disorder. Also, her sleep disturbances, fatigue, and loss of interest in previously enjoyable activities are consistent with MDD. The postpartum onset is relevant, especially in her case, as she was having the symptoms after the birth of her daughter two months ago.

Rationale: It is a form of depression that occurs not more than months after delivery and affects a large number of women. Mrs Tilman has reported her symptoms for more than two weeks, and the severity means that MDD is more probable. The lack of psychotic symptoms and absence of mania however exclude other mood disorders, making this diagnosis more accurate (DNP, 2019).

Pertinent Positives: Persistent sadness, fatigue, loss of interest in activities, difficulty bonding with her baby.

Pertinent Negatives: No psychotic features, no history of manic or hypomanic episodes.

1. Generalized Anxiety Disorder (GAD) ICD-10 Code F41.1:

GAD is deemed in Mrs. Tilman because she overly worries, distresses or stresses about her incompetency as a mother and wife. She has increased irritability, cannot sleep well, and tends to worry incessantly even over little things like, her husband throwing a diaper in the wrong bin. She may be developing anxiety or irritation or she may be overwhelmed that may lead to more stress and concern.

Rationale: While anxiety is present, Mrs. Tilman’s depressive features are more prominent in her clinical presentation. The anxiety that she has is comorbid with the depression that she is already diagnosed with. The absence of some cardinal Somatic Anxiety Symptoms like tension or Panic Attacks decreases the possibility of diagnosing the client with GAD (Mishra & Varma, 2023).

Pertinent Positives: Excessive worry, irritability, sleep disturbances.

Pertinent Negatives: No panic attacks, no somatic symptoms such as muscle tension.

1. Adjustment Disorder with Depressed Mood- ICD-10 Code F43.21

This diagnosis is made because the symptoms that are manifested by Mrs. Tilman are due to a major life stressor- the birth of her daughter. Adjustment disorder with depressed mood is defined as the presence of emotional upset following a stressor; the symptoms can be observed in this case after childbirth. However, the severity and duration of mood disturbances indicate that they are more severe than a simple adjustment disorder.

Rationale: Despite this, her symptoms started at the same time as an adjustment disorder; they are far too severe to be attributed to this: she is unable to take care of herself, and she is filled with guilt and worthlessness. The persistent duration and severity of her symptoms make Major Depressive Disorder the most probable diagnosis (Bains & Abdijadid, 2023).

Pertinent Positives: Stressful life event (childbirth), emotional distress.

Pertinent Negatives: Symptoms more severe and persistent than typical for Adjustment Disorder.

Primary Diagnosis

Major Depressive Disorder (MDD), Moderate to Severe, with Postpartum Onset ICD-10 code F53.0

Based on a series of symptoms evidently manifested by Mrs. Tilman’s pervasive sadness, emotional distress, and substantial impairment of daily activities, the most suitable diagnosis is Major Depressive Disorder with Postpartum Onset. This did not allow her to interact with her child, and she experienced feelings of guilt and inadequacy, described as MDD, and the onset of symptoms in the postpartum period unambiguously confirms the diagnosis. PPA is prevalent in postpartum women; however, no psychotic or manic episodes necessitate this diagnosis over the more common PPA, exclusive of psychotic or manic features, than GAD or adjustment disorder. It is, therefore, important to intervene early in order to avoid the worsening of the situation and improve the health of both the mother and child.

Reflections:

In reflecting on Mrs. Abrianna Tilman’s case, I largely agree with my preceptor’s assessment and diagnostic impression, particularly regarding the diagnosis of Major Depressive Disorder (MDD) with postpartum onset. Mrs. Tilman’s pervasive sadness, feelings of inadequacy, and difficulty bonding with her child strongly indicate MDD rather than adjustment disorder or generalized anxiety. The intensity of her symptoms and the significant impact on her daily life, including her relationship with her husband and child, support this diagnosis. My preceptor’s focus on postpartum depression aligns well with the literature, which highlights the importance of early intervention in such cases to prevent further deterioration.

What I got from this case as the most valuable lesson is the necessity to notice not only the typical somatic signs but also psychological symptoms in a patient. Even though Mrs. Tilman is a mother, it is much easier to explain her fatigue and sleeplessness as a result of her having an infant, but after closer examination of the case, it is evident that Ms. Tilman is exhibiting noticeable signs of major depressive disorder. The balance between new motherhood and her psychological condition is a learning point from this case for the importance of an evaluation in postpartum women.

If I were to approach the case differently, I would investigate possible physiologic causes of her symptoms earlier, such as hypothyroidism or anemia that may present with fatigue and mood changes. Also, I would pay more attention to her desires to ‘get out’ of the situation and ensure her thoughts are evaluated to determine the level of threat as far as transitioning into suicidal thoughts. In ethical/legal considerations, assessing Mrs. Tilman’s capacity to make treatment decisions and involve her family if she lacks decision-making capacity would be important. Additionally, complying with mandatory reporting laws if there are concerns about child abuse or neglect should be considered. Consistently, some of the factors that would put her at risk include, her ethnic background and cultural beliefs as they may have an  influence on her attitudes towards mental health treatment. Also,  her socioeconomic status and access to healthcare could also have a major impact on her ability to engage in and adhere to treatment. In regard to promoting health (Caron et al., 2024), it is crucial to teach the patient suitable coping mechanisms in order to prevent and promote her health.

References

Bains, N., & Abdijadid, S. (2023). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Caron, R. M., Noel, K., Reed, R. N., Sibel, J., & Smith, H. J. (2024). Health Promotion, health protection, and disease prevention: Challenges and opportunities in a dynamic landscape. AJPM Focus, 3(1), 100167. https://doi.org/10.1016/j.focus.2023.100167

DNP, R. (2019). The Psychiatric-Mental Health N. Springer Publishing Company.

Mishra, A., & Varma, A. (2023). A comprehensive review of the generalized anxiety disorder. Cureus, 15(9). https://doi.org/10.7759/cureus.46115

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Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE:
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
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.
BY DAY 7 OF WEEK 3
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. 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-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.).