Respond to at least two of your colleagues who were assigned to a different case than you.  Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

    If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

    If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

                                                                   Case #7 

The Case: The case of physician do not heal thyself

The Question: Does the patient have a complex mood disorder, a personality disorder or both?

The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a difficult patient?

*List three questions you might ask the patient if he or she were in your office: 

1. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down (Hirschfeld, 2002)? 

Rationale: This question specifically inquires about whether the client feels they have been their usual self and specifically references their energy levels (Hirschfeld, 2002). These symptoms are important to identify and rule out if a manic episode related to a mood disorder (such as Bipolar I) is occurring. By narrowing down correct symptomologies, the correct and appropriate psychiatric diagnosis can be made, along with the appropriate treatment. 

2. Has your mood or behaviors caused major problems in your life like being unable to work; having a family, money or legal troubles; getting into arguments (Hirschfeld, 2002)?

Rationale: This question specifically focuses on how much of a problem the symptoms have been in a client’s everyday life. Mood disorders such as Bipolar I and Bipolar II can significantly impact a client’s life. Patients suffering from a mood disorder, such as Bipolar I, are at a significantly higher risk for suicide, harm to self, or harm to others (Hirschfeld, 2002). 

3. How frequently would you estimate that you have experienced racing thoughts or elevated energy in relationship to your mood or fights and have any of these issues occurred during the same period of time (Hirschfeld, 2002)? 

Rationale: This particular question addresses if the symptoms that are being experienced, occurred during the same time period, which would be indicative of the diagnosis of Bipolar I mood disorder. This question is important when assessing a client for a mood disorder in those patients who are misdiagnosed may experience rapid cycling or mania (Hirschfeld, 2002). 

*Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

According to Stahl (2013), it is essential for healthcare providers to obtain information from not only the client but also from outside sources. Outside sources for a client may include their spouse, parents, or siblings. Information obtained from outside sources may be significantly different than what the client describes and can assist in accurately diagnosing the client (Stahl,2013). Clients that are accurately diagnosed, can then be appropriately treated with pharmacological agents.  

-Were there any significant triggering factors related to the client’s first major depression episode at age 23? 

These questions can assist in distinguishing between Bipolar Mood Disorders and Borderline Personality Disorder. Bipolar Mood Disorders typically manifest in the early to mid-’20s ( It must be determined if the depression was an initial onset of a hypomanic episode or if it was due to an existing personality disorder. 

-What other moods did the client exhibit when they were not in a depressive episode? How long did these moods last?

According to Stahl (2013), individuals often downplay their manic symptomologies and their duration. These episodes and their duration are essential in order to accurately diagnosing a client. 

-Does the client have any significant psychiatric history, such as Bipolar I, Bipolar II, or other mood disorders?

According to Stahl (2013), first-degree relatives who also have bipolar disorder can indicate the likelihood that the client also suffers from a bipolar disorder. If the client does have a significant family history of bipolar disorder, any effective treatments, the severity of the condition, and any hospitalizations that occurred should be documented in the client record.  

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

Certain diagnostic tests such as a Complete Metabolic Panel (CMP), Liver Function Tests (LFT’s), Hemoglobin A1c, and a urine specific gravity can be ordered to evaluate the functionality of the client’s kidneys, liver, and the presence/risk of diabetes mellitus. A mood stabilizer such as Lithium may be used to manage the client’s severe fluctuation in moods. Lithium, however, can be severely nephrotoxic. Kidney function tests should be drawn prior to initiating therapy and throughout the course of therapy to assess for kidney dysfunction (Tolliver & Anton, 2015). A urine specific gravity can also indicate the functionality of the kidneys. Antipsychotic medications may be used to treat long-term unstable mood disorders. Antipsychotic medications, both first and second generations, can cause metabolic syndrome. The development of metabolic syndrome can be monitored by obtaining a CMP, LFTs, & Hemoglobin A1C prior to starting medication therapy and then throughout the medication therapy course. According to Stahl (2013), clients taking antipsychotic medications should have lab diagnostic studies done every 3-6 months. A urine drug screen (UDS) should also be done to rule out the illicit substances as the causation of the mood disorder. 

It is essential to assess all clients if they have any suicidal ideations. The Columbia-suicide severity rating scale can be used to assess the severity of suicide risk. COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS): This screening tool is used to detect suicidal ideations and their severity. It is scored from 0-5. A score greater than 0 may indicate a need for mental health intervention. A score of 4-5 indicates active suicidal ideation with some intent to act (“Columbia-Suicide Severity,” 2019). 

This client should have a full head-to-toe physical assessment completed including a mental status exam, and vital signs. These initial findings can be used as a baseline for the patient and any future assessment changes can be compared to the initial findings (Tolliver & Anton, 2015).

**List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

1. Recurrent major depression with an anxious/dysphoric temperament Most likely diagnosis

According to the DSM V (2013), the client’s symptoms most likely indicate a mood disorder. Due to the limited amount of time with the patient and limited past mania history, a Bipolar mood disorder could be ruled out. The client’s main symptoms present as depressive in nature, with one suicide attempt 40 years ago (Stahl Online, 2018). Recurrent major depression with an anxious/dysphoric temperament, which is also a complex mixed mood disorder, is the most likely diagnosis given the patient’s current symptoms. According to the scenario provided by Stahl Online (2018), the client has been experiencing a mixed dysphoric state with the depression occurring the majority of the time.

2. Bipolar II mixed episode:

Per the client’s history, he has been experiencing symptoms that are consistent with hypomania since the age of 23, such as inflated self-esteem, irritability, and decreased need for sleep (Stahl Online. 2018). Per the DSM 5, Bipolar II is defined as an abnormally elevated or irritable mood with an increased activity that lasts at least 4 uninterrupted days along with at least three behaviors such as inflated self-esteem, decreased need for sleep, increased talking, flight of ideas, racing thoughts, goal-driven activity, and participating in high-risk behaviors (American Psychiatric Association, 2013). Hypomanic episodes should also be noted by those close to the client per the DSM 5. Further interviewing with the client’s family needs to be completed in order to determine if the client exhibited hypomanic episodes. 

3. Primarily a cluster B personality disorder (antisocial/histrionic/narcissistic/borderline)

The client’s irritability, anxiety, and past failed relationships may be explained by a cluster B personality disorder, per the DSM 5. 

1.    ** 2 Pharmacological Agents: The medications of choice for this client would be those that aim at stabilizing the client’s mood, such as lithium or Lamictal. According to Stahl (2013), Lamictal is a second-line medication therapy that can be used to treat mixed state depression symptoms. The goal dosage of Lamictal would be 200 mg PO Daily. Lamictal dosages need to be titrated up slowly because of the serious side effect known as Steven Johnson’s Syndrome. Dosing Schedule: 25 mg PO daily for 2 weeks-50 mg PO Daily for 2 weeks- 100 mg PO Daily for 1 week-Double dose every week to maintenance at 200 mg Daily PO. Lithium is used for the maintenance treatment for manic-depressive conditions and major depressive disorder (Stahl, 2017). The main goal of treatment with lithium therapy is complete remission of symptoms (Stahl, 2017). The client should have initial kidney function tests done prior to starting therapy and 1 to 2 times a year during therapy. Serum lithium levels should be drawn every 1-2. weeks until the desired serum concentration is achieved, then every 2-3 months for 6 months (Stahl, 2017). After the first 6 months of lithium therapy, stable serum lithium levels should be drawn 1-2 times per year. I would choose Lamictal therapy over lithium therapy due to the lack of lab work needed to maintain and dose Lamictal, compared to lithium. 

**Dosing Considerations in Regard to Ethnicity

This particular client’s race was not identified in the case study. According to Prescribing Information (2005), Lamictal had an oral clearance that was 25% lower in non-Caucasians than Caucasians. If this patient were not Caucasian, he would most likely require a lower dose of Lamictal due to the 25% decrease in oral clearance. 

**Check Points

12 Week Follow Up: 

– The client discontinued his methylphenidate per PMHNP recommendation due to the increased risk of causing the client to have cycling unstable mood states.  

-The client started lamotrigine by his local psychiatrist, 400mg PO Daily. I would decrease this dose to 200mg PO Daily per current lamotrigine initiation recommendations (Stahl, 2013).

16 Week Follow Up:

– The client decided to discontinue his lamotrigine because it was making him more depressed and inhibiting his sex life. I would review the patient’s renal function and urinalysis and initiate lithium therapy in order to stabilize his mood. I would prescribe the patient 400mg PO QHS

20, 24, 28 Week Follow Up:

-The client’s lithium levels are 0.4, his dose finally increased to 1800 mg daily. The client unhappy with his lithium therapy due to it negatively affecting his Chron’s disease. The dose is titrated down to 1500mg of lithium and Lamictal therapy is restarted at 25mg and titrated to a max dose of 200mg, which was half of his initial dosage. The hope is that using two mood stabilizers will work together and produce therapeutic effects

– The client restarted methylphenidate therapy against medical advice. The client attested to restarting it because of his low energy and dysphoric mood.

32, 34, & 36 Week Follow Up:

-The client is non-compliant with prescribed medications and therapy and continues to disregard PMHNP recommendations

 **Lessons Learned and Ethical Considerations

This case study has taught me to always remember that difficult clients will inevitably be difficult to treat. There will be times when I will need to ask those who have more experience than me for help in deciding the appropriate course of treatment in certain challenging clients. I also learned that treating challenging clients will take time and results may not be observed for a while. It is important to give the specific choice of treatment time to work. One ethical consideration that I took away from this case study is that this patient is a physician, who has taken the liberty of making his own therapeutic decisions in the past. As a provider, I need to monitor and observe this client closely in case he chooses to self prescribe his own medications and disregard his care plan. 

                                                        References 

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

Columbia-Suicide Severity Rating Scale. (2016). Retrieved December 9, 2019, from http://cssrs.columbia.edu/scoring_cssrs.html

Hirschfeld, R. M. (2002). The Mood Disorder Questionnaire (MDQ). Retrieved December 9, 2019, from 

     SAMHSA website: https://www.integration.samhsa.gov/images/res/MDQ.pdf 

Perscribing Information for Lamictal. (2005). Retrieved December 11, 2019, from FDA website: 

     https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/ 

     020241s10s21s25s26s27,020764s3s14s18s19s20lbl.pdf

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press

Stahl, S. M. (2017). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press

Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of 

     substance abuse. Dialogues in clinical neuroscience, 17(2), 181-190. 

     https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518701/