Week 3: Training Title 43 – Comprehensive Psychiatric Evaluation

Subjective

CC: “I just want to go home now. I feel a lot better.”

History of Present Illness (HPI)

Mr. Will Loman is a young, 19-year-old Caucasian who is now in the hospital because of his manic status. He was admitted one week ago following a period of markedly decreased need for sleep (2-3 hours/night), overspending on video games, and grandiose ideation (composing a book about video game mastery). He also engaged in sexually inappropriate behavior, including public exposure and lewd comments. His appetite was reduced: Week 3: Training Title 43 – Comprehensive Psychiatric Evaluation.

He was initially resistant to medication but currently reports improved mood and awareness. He expresses motivation to return home, has insight into prior disorganized behavior, and acknowledges benefits from current medications. His symptoms began to escalate one week before admission. There is no evidence of suicidal ideation, hallucinations, or substance use.

Past Psychiatric History

• General Statement: At the age of 15, a mood disorder diagnosis was made. Past symptoms include periods of hyperactivity, poor judgment, and disorganized behavior. He was previously noncompliant with medication due to weight gain side effects.
• Caregivers (if applicable): He resides in Jacksonville, Florida, with his mother, father, and sister. His parents are involved in his care.
• Hospitalizations: One year ago, after being discovered wandering close to a freeway, the patient was admitted to a mental health facility.
• Medication trials: Previously trialed on Depakote and Olanzapine, both withdrawn due to side effects (notably weight gain), and recently prescribed 1 mg of risperidone QHS and 300 mg of lithium TID during this hospitalization.
• Psychotherapy or Previous Psychiatric Diagnosis: Treatment history for mood disorders. There is no indication of consistent psychotherapy engagement. There is no formal documentation of prior psychotherapy in the case history.

Substance Current Use and History

Mr. Will Loman denies any present or past use of alcohol, tobacco, or illegitimate substances. The admission urine drug screen (UDS) was negative, and there is no indication of substance-induced symptoms. He has not required detoxification or substance-related interventions in the past.

Family Psychiatric/Substance Use History

Mr. Loman’s father has a documented history of bipolar disorder, which makes mood instability genetically susceptible. The family does not have a history of suicide, psychosis, or substance use disorder. His mother seems supportive and involved in his care; no psychiatric history has been reported.

Psychosocial History

Mr. Loman resides with his parents and sister in Jacksonville, Florida. He has already finished high school and is not currently employed or enrolled in school. He has no romantic partner. His recent psychosocial stressors include impaired functioning due to mania, inappropriate public behavior, and a court date for indecent exposure, which is still pending.

As a juvenile, he had a history of trespassing. He spends considerable time playing video games and recently showed impulsivity by overspending. His inappropriate behaviors have caused distress in social settings, particularly interactions with female neighbors. His social support is primarily from his family, who remain involved despite concerns.

Medical History

There are no documented long-term health issues affecting Mr. Loman. He is medically stable. He has no history of neurological, cardiovascular, or endocrine disorders.

• Current Medications: 300 mg of lithium orally three times a day and 1 mg of risperidone before bed.
• Allergies: Penicillin (PCN)
• Reproductive Hx: Loman is not currently sexually active. There is no reported history of sexually transmitted infections, contraceptive use, or pregnancies. However, he has exhibited sexually inappropriate behaviors such as public exposure and unsolicited lewd remarks toward female neighbors, which raise concerns about judgment and impulse control during manic episodes.

ROS

• GENERAL: The patient states that the need to sleep, in general, has decreased, averaging only 2-3 hours per night over the past week. He denies fever, chills, fatigue, or unintentional weight changes. Appetite is reported as decreased.
• HEENT: No complaints of headache, changes in vision or hearing, congestion in the nose, sore throat, or other symptoms related to the head and neck were reported or observed.
• SKIN: No reported rashes, lesions, or pruritus. No evidence of self-harm or dermatological conditions was noted during the evaluation.
• CARDIOVASCULAR: Denies experiencing palpitations, dizziness, chest discomfort, or a history of hypertension.
• RESPIRATORY: Denies experiencing coughing, wheezing, shortness of breath, and unlabored breathing.
• GASTROINTESTINAL: Admits a decreased appetite but no nausea, vomiting, abdominal pain, constipation, or diarrhea. No signs of GI distress.
• GENITOURINARY: No urinary complaints, dysuria, frequency, or incontinence noted. Denies any history of genitourinary infections.
• NEUROLOGICAL: No seizures, tremors, or syncope. The patient demonstrates clear speech, normal gait, and intact motor function during the assessment. Alert and oriented.
• MUSCULOSKELETAL: He denies any joint pain, stiffness or muscle weakness. No abnormal movements or musculoskeletal complaints were observed.
• LYMPHATICS: No enlarged lymph nodes were reported or observed, and there is no history of lymphatic disease.
• ENDOCRINOLOGIC: No polydipsia, polyuria, or signs of thyroid dysfunction.

Objective

Physical Exam: N/A

Diagnostic Results

• Urine Drug Screen (UDS): Negative
• Hospital Admission Labs: Within normal limits

Assessment

Mental Status Examination

Mr. Will Loman is a 19-year-old Caucasian male who presents for the stated age. He is alert and oriented to person, place, and time. He is also cooperative during the interview. However, his grooming and hygiene are adequate, with occasional intrusive and impulsive behavior.

He is euphoric and expansive, and his effect is bright and labile. Sometimes, speech is rapid, pressured, and maybe tangential, with an occasional flight of ideas. He shows grandiosity as he writes a book on master video games and will become famous. He gives no evidence of hallucinations or overt delusions but has poor insight into his state at present.

Impairment in judgment is also evident in recent inappropriate behaviors, such as public indecency and disproportionate spending. The overall thought process is circumstantial but goal-directed. He has neither homicidal nor suicidal thoughts.

Sleep is drastically reduced, and attention and concentration are mildly affected. His presentation is generally consistent with manic episodes.

Differential Diagnoses

Bipolar I Disorder, Current Episode Manic, Severe Without Psychotic Features (ICD-10 F31.13)

Mr. Loman’s elevated mood, decreased sleep, excessive energy, grandiosity, and impulsive behaviors, including indecent exposure and hypersexuality, have lasted over one week, meeting DSM-5-TR criteria for a manic episode. His symptoms have caused significant impairment, requiring hospitalization. He also has a family history of bipolar disorder in his father. Pertinent positives include hyperactivity, disinhibition, and decreased need for sleep.

Negatives relevant to the case include no hallucinations or delusions except mood symptoms. These findings, combined with impaired judgment and risky behaviors, support bipolar I disorder as the primary diagnosis (Jain & Mitra, 2023). Treatment response to lithium and risperidone further confirms the appropriateness of this diagnosis.

Schizoaffective Disorder, Bipolar Type (ICD-10-F25.0)

Schizoaffective disorder includes mood episodes with psychotic features persisting for at least two weeks without mood symptoms. Mr. Loman presents with grandiosity and disorganized thinking, which may resemble psychosis; however, no hallucinations, fixed delusions, or disconnected speech were observed. His symptoms occur only during mood elevation, and there is no evidence of psychotic symptoms independent of affective disturbance.

Among the essential negatives is that there are no hallucinations, delusions, or negative symptoms like flat affect or avolition. Since he lacks sustained psychotic features outside his manic episode, this diagnosis is ruled out based on DSM-5-TR criteria and the patient’s observed clinical course (Wy & Saadabadi, 2023).

Substance/Medication-Induced Bipolar and Related Disorder (ICD-10- F19.94)

This diagnosis requires mood disturbance caused by substance use or medication. Mr. Loman denies using alcohol or drugs, and urine drug screening was negative. He had no medicines initiated before his symptoms began. Therefore, the timing does not support a substance-induced cause.

His current symptoms of mania, impulsivity, and hyperactivity predate hospital treatment (Revadigar & Gupta, 2022). Pertinent negatives include lack of recent substance use and absence of medication triggers before symptom onset. As such, this diagnosis is not supported by DSM-5-TR criteria. The mood disorder appears to be primary rather than secondary to a medical or substance-related etiology, ruling this out confidently.

Reflections

I agree with the diagnostic impression of bipolar I disorder; the current episode is manic. Mr. Loman’s symptoms of grandiosity, reduced sleep, impulsive spending, pressured speech, and socially inappropriate behavior meet the DSM-5-TR criteria for a manic episode. His hospitalization, poor insight, and functional impairment confirm the severity.

This case emphasized the importance of distinguishing mood-related symptoms from primary psychotic disorders, especially when psychosis is mood-congruent. Given the chance to conduct the session, I would incorporate a structured risk assessment earlier in the interview to evaluate his potential for harm and determine the need for involuntary treatment.

Ethical and Legal Considerations

Ethically and legally, Mr. Loman’s impaired judgment raises concerns about capacity and risk to others, especially given his legal issues. His young age, cultural background, family history of bipolar disorder, and socioeconomic challenges (unemployment, no college) are vital to consider. Health promotion should focus on psychoeducation, medication adherence, and engaging his family for support. Preventative care should address sleep hygiene, emotional regulation, and long-term treatment planning to reduce relapse (Singh et al., 2022).

References

Jain, A., & Mitra, P. (2023, February 20). Bipolar disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558998/

Revadigar, N., & Gupta, V. (2022). Substance-induced mood disorders. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555887/

Singh, V., Kumar, A., & Gupta, S. (2022). Mental health prevention and promotion—A narrative review. Frontiers in Psychiatry, 13(13). https://doi.org/10.3389/fpsyt.2022.898009

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective disorder. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/

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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.).
  

  Week 3: Training Title 43 – Comprehensive Psychiatric Evaluation

Video Selection
You must select one of the following training videos provided in Week 3: video #43

• Symptom Media. (Producer). (2016). Training title 43. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-43