NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
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: NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
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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:
Case Formulation and Treatment Plan:
Reflections:
References
NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
CC (chief complaint): “I can’t control my urges and it’s causing problems in my life.” NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
HPI: B.G is a 29-year-old Caucasian female who presents to the clinic with a history of difficulty controlling her impulses. According to her, she has been experiencing this problem for the past year, and it has been causing her a lot of distress. B.G reports that she frequently engages in impulsive behaviors such as overspending, binge-eating, and substance abuse, which have led to financial difficulties and strained relationships with her family and friends. She also states that she feels guilty and ashamed after giving in to her impulses, but finds it hard to resist them. B.G reports that she has tried to control her urges on her own, but has been unsuccessful. She is seeking medical help to address her impulse control disorder and improve her quality of life.
Past Psychiatric History:
- General Statement: B.G is a generally healthy young adult with no known medical conditions.
- Caregivers (if applicable): currently lives with her partner who is supportive of her seeking medical help.
- Hospitalizations: has never been hospitalized for psychiatric reasons.
- Medication trials: reports no prior trials of psychiatric medications.
- Psychotherapy or Previous Psychiatric Diagnosis: has not been previously diagnosed with a psychiatric disorder or received psychotherapy. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
Substance Current Use and History: reports current occasional use of alcohol and marijuana. She denies any history of other substance use.
Family Psychiatric/Substance Use History: reports no known family history of psychiatric or substance use disorders.
Psychosocial History: works as an accountant and reports no recent changes in her work or living situation. She reports a supportive partner and a good relationship with her family. She denies any recent major life stressors.
Medical History: reports no significant medical history.
- Current Medications: not currently taking any medications.
- Allergies: reports no known allergies.
- Reproductive Hx: reports no pregnancies or history of gynecological issues. She reports using oral contraceptives for birth control.
ROS:
- GENERAL: reports feeling fatigued and having low energy levels. She denies any recent weight changes.
- HEENT: reports no recent changes in her vision or hearing. She denies any headaches or head trauma.
- SKIN:reports no skin lesions or rashes. She denies any recent changes in her skin.
- CARDIOVASCULAR: denies any chest pain, palpitations, or edema.
- RESPIRATORY: reports no cough, shortness of breath, or wheezing.
- GASTROINTESTINAL: reports occasional nausea, bloating, and constipation. She denies any abdominal pain, diarrhea, or vomiting. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
- GENITOURINARY: reports no dysuria, frequency, or hematuria. She denies any vaginal discharge or itching.
- NEUROLOGICAL: reports no recent changes in her mental status or level of consciousness. She denies any seizures or tremors.
- MUSCULOSKELETAL: reports occasional back pain and stiffness. She denies any joint pain or swelling.
- HEMATOLOGIC: reports no history of bleeding disorders or anemia.
- LYMPHATICS: reports no recent lymph node enlargement or tenderness.
- ENDOCRINOLOGIC: denies any history of diabetes, thyroid disorders, or other endocrine problems.
Physical exam: N/A
Diagnostic results: N/A
Assessment
Mental Status Examination:
The patient presents as a cooperative and pleasant young woman with appropriate grooming and hygiene. She appears to be her stated age and her speech is clear and coherent. Her mood is generally depressed and she reports feeling guilty and ashamed about her impulse control issues. Her affect is congruent with her mood and her facial expressions are appropriate. B.G is alert and oriented to person, place, and time. Her attention and concentration are intact, as evidenced by her ability to engage in conversation and answer questions. She has no perceptual disturbances, delusions, or hallucinations. Her thought processes are logical and organized. She denies any suicidal or homicidal ideation. Her cognitive functioning appears to be within normal limits, as evidenced by her ability to recall past events and provide detailed information about her symptoms. Overall, B.G presents with symptoms consistent with an impulse control disorder, and her mental status examination is otherwise within normal limits. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
Differential Diagnoses:
Intermittent Explosive Disorder (IED): This is a mental health disorder characterized by recurrent episodes of impulsive and uncontrolled aggressive behavior. Individuals with IED experience intense anger and irritability, often in response to minor triggers, and have difficulty controlling their emotional reactions. These outbursts can lead to physical assaults, destruction of property, and verbal assaults. The DSM-5-TR diagnostic criteria for IED includes recurrent episodes of verbal and/or physical aggression that are disproportionate to the situation, and are not premeditated.. Symptoms of IED may include feelings of tension and irritability before an outburst, a sense of relief or satisfaction after an outburst, and feelings of guilt or remorse following an outburst. IED can have a significant impact on an individual’s relationships, work, and overall quality of life. It is often comorbid with other mental health disorders, including anxiety and depression. In the case of B.G, her symptoms are consistent with a diagnosis of IED. She reports frequent verbal and physical outbursts, which are not premeditated and are often in response to minor triggers. She also experiences feelings of guilt and shame following these episodes. These symptoms align with the DSM-5-TR diagnostic criteria for IED, and support the primary diagnosis. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
Borderline Personality Disorder (BPD): This is also a possible diagnosis for B.G, given its symptoms of impulsivity, unstable mood, and difficulty regulating emotions. Individuals with BPD often have intense and unstable relationships, engage in self-destructive behavior, and may experience dissociative symptoms. However, B.G’s symptoms are primarily related to aggression and not to mood instability or identity disturbance, making IED a more likely diagnosis.
Generalized Anxiety Disorder (GAD):This is another possible diagnosis for B.G, given its symptoms of excessive worry and anxiety about a variety of events and activities. Individuals with GAD may experience physical symptoms of anxiety, such as muscle tension, restlessness, and fatigue. However, B.G does not report significant symptoms of anxiety, making GAD a less likely diagnosis. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
Case Formulation and Treatment Plan:
B.G reports difficulty controlling her aggressive behavior, which results in verbal and physical outbursts. She experiences intense anger and irritability in response to minor triggers and has low frustration tolerance. These outbursts are often accompanied by feelings of guilt and shame. B.G also reports a history of childhood trauma and stressors in her current life, including financial difficulties and relationship problems.Treatment Plan: The treatment plan for B.G will focus on managing her symptoms of IED, reducing the frequency and severity of her outbursts, and addressing any underlying emotional or psychological issues that may be contributing to her symptoms. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
Cognitive-behavioral therapy (CBT) will be the primary mode of treatment, as it has been shown to be effective in managing anger and aggression in individuals with IED. The focus of therapy will be on identifying triggers for B.G’s outbursts and developing coping strategies to manage her emotional reactions. This may include techniques such as cognitive restructuring, problem-solving, and relaxation techniques. In addition to CBT, B.G may benefit from trauma-focused therapy to address the impact of her childhood trauma on her current mental health. This may include techniques such as eye movement desensitization and reprocessing (EMDR) or prolonged exposure therapy. Medication may also be considered as an adjunct to therapy. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in reducing aggression in individuals with IED. However, medication should be carefully monitored and prescribed by a psychiatrist or other qualified healthcare provider. Furthermore, B.G may benefit from stress management techniques, such as exercise, mindfulness meditation, and yoga, to help her manage stress and improve her overall mental health. She may also benefit from couples therapy to address relationship issues with her partner. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
Reflections: If I were to evaluate a similar patient in the future, I would ensure that I obtain a detailed family psychiatric and substance use history to further understand the patient’s risk factors for developing mental health disorders. In addition, I would also inquire about any past or current social stressors and the patient’s support system to gain insight into their social determinants of health.One social determinant of health according to the HealthyPeople 2030 that is relevant to this case is economic stability. B.G’s financial difficulties have been identified as a significant source of stress in her life, which may contribute to her symptoms of IED. In the realm of psychiatry and mental health, economic stability can impact access to mental health services and medication, and can also affect treatment outcomes. Addressing economic instability is crucial to improving mental health outcomes and reducing health disparities in vulnerable populations.One health promotion activity for this patient could be connecting her with local resources such as financial counseling or job placement services to improve her financial stability. A patient education consideration would be to provide her with information on stress management techniques and coping strategies that are accessible and affordable, such as deep breathing exercises or online resources for guided meditation. Addressing economic instability and providing accessible mental health resources are important steps towards reducing health disparities and improving mental health outcomes for individuals like B.G. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment
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References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (DSM-5). Text Revision.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry, 4.
Scott, K. M., De Vries, Y. A., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Bromet, E. J., … & De Jonge, P. (2020). Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment and suicidality. Epidemiology and psychiatric sciences, 29, e138.
Kendrick, T. (2021). Strategies to reduce use of antidepressants. British Journal of Clinical Pharmacology, 87(1), 23-33.
Munir, S., & Takov, V. (2022). Generalized anxiety disorder.
Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., & Kiernan, M. D. (2018). The use of eye-movement desensitization reprocessing (EMDR) therapy in treating post-traumatic stress disorder—a systematic narrative review. Frontiers in psychology, 9, 923. NRNP 6645: Psychopathology and Diagnostic Reasoning Assignment