Symptom Analysis Evaluation (SAE)
Symptom Analysis Evaluation (SAE) Essay
Symptom Analysis Evaluation (SAE) Essay

Chief complaint: “I have a horrible mood swings and I get angry easily.”

HPI: Mark is a 37 years old Caucasian male with no prior psychiatric hospitalizations who presents to outpatient clinic for evaluation and treatment of symptoms of mood swings. He reports long history of mood instability beginning in his early teens and continue to worsen throughout his twenties and thirties. Mark reports irritability, agitation, raising thoughts, chronic sleep difficulties. Reports using marijuana to calm down once- twice a month, drinks alcohol 3-4 cans of beer on weekend. Denies bad dreams or nightmares, denies obsessive thoughts, denies hallucinations, and paranoia. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue. Symptom Analysis Evaluation (SAE) Essay

Psychiatric History: Mark has never been hospitalized for psychiatric illness, no history of suicide attempts, no homicide attempts, and no history of violence. However, he reports frequent thoughts of deaths when very depressed in the past three months. He has never seen a psychiatric provider prior to this visit. He has been prescribed selective serotonin reuptake inhibitors (SSRI) by his PCP in the past for treatment of depression. Mark reports that the medication did not make much difference in treating his symptoms.

Past Medical History: Mark reports childhood asthma, depression and anxiety.

Surgical History: Tonsillectomy

Family Medical History: Mother has depression, type 2 diabetes mellitus, CKD, CVA; died of kidney failure at age 75. Father- Schizophrenia, HTN, CAD; died at age 50-years. Brother has bipolar and has alcohol problems. Sister is healthy but has “very mean attitude.”

Social History: Lives with girlfriend of one year in a rental apartment. Mark works part time at a local construction company. Girlfriend works full time at a departmental store. Denies history of tobacco use.

Family History- Mark and his brother were physically and emotionally abused by father as a child. He did not recall mother stepping in to provide protection when father was abusive. Mark has a strong relationship with his cousin who is two years younger. Mark’s sister is 20 years old and lives at mother’s house along with her two years old daughter. Brother lives with his friends.

Review of Systems: 10-system ROS negative except symptoms noted in HPI. Symptom Analysis Evaluation (SAE) Essay

Medications: None

Allergies: NKDA

Vital Signs: BP 110/60 HR 65bpm, T 98.9F, RR 12/min Weight 170lbs without significant recent changes.

SAE Instruction: Review the above case study and complete the SAE assignment. Please use the SAE template that is provided to complete the assignment and follow the instructions. Remember to use appropriate APA in-text citations and reference list.

A Psychiatric Symptom Analysis Evaluation (SAE) of a 37 Year-Old Caucasian Male with a Chief Complaint of Long-standing Mood Swings

Symptom Analysis Evaluation

Symptom: Chronic and severe mood swings.
Identify appropriate history questions to be asked of your patient to discriminate critical characteristics or attributes about the above presenting complaint. Consider COLDSPA (Characteristics, Onset, Lingering, Duration, Stressors, Precipitating factors/triggers, Alleviating factors).
The history questions that this patient would be asked concerning his presenting complaint include the following:
Characteristics

● Have you at any time felt an exaggerated sense of euphoria, excessive optimism, been unusually talkative, had high regard for yourself, felt a compulsion to engage in risky behavior, been irritable, hyperactive, unable to sleep, unable to pay attention or felt an unusual excessive drive to achieve a goal for any duration of time?

● Have you at any time felt hopeless, cried for no obvious reason, felt disinterested in activities you normally enjoy, blamed yourself, been unable to remain calm, felt unusually tired, or been unable to concentrate for any duration of time?

● Do you feel that you have lost weight? Symptom Analysis Evaluation (SAE) Essay

● Have you at any time thought of death or suicide?

Onset
● When did you start having these symptoms for the first time? Was it in your teenage years, early adulthood, or just recently?

Lingering
● Have the symptoms you are having been there for a long time and do they occur erratically or they have some consistent pattern?

Duration
● What was the average period of time that these symptoms lasted in a given episode before subsiding for a while?

Stressors
● Would you associate the severity ofthese symptoms with any particular event, activity or thought?

Precipitating factors or triggers
● What are some of the things that lead to the occurrence of these symptoms? Are there any that you can remember?

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Alleviating factors
● Are there any particular events, thoughts, or activities that appear to cancel the effects of these symptoms or stop them when they are manifest?

Others
● Have you ever had any unusual visions, feelings, or heard any unusual sounds and movements?

● Have you ever used any drugs or substances such as cannabis, cocaine, or alcohol?

Delineate 4 hypotheses (differential diagnosis) that could support the above symptoms in relation to pertinent answers given the history.MOST use appropriate DSM 5 diagnosis and provide rationale for each choice base on the presenting case.
Differential 1 Cyclothymic Disorder or Cyclothymia – 301.13(F34.0)
This is the most befitting diagnosis as per the subjective history of this patient and the symptom characteristics. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5, for a diagnosis of Cyclothymia to be made; six criteria (A to F) have to be met (APA, 2013). In criterion A, the patient must have had alternating hypomanic and depressive symptoms for at least two years. These must have however not met the DSM-5 criteria for a diagnosis of either hypomanic episode or major depressive episode. In criterion B, the symptoms must have been present for at least half of the time of their duration. The patient must also have not been symptom-free for more than two consecutive months. In criterion C, these symptoms must not meet the criteria for hypomanic episode, mania, or major depressive episode. As for criterion D, the symptoms in a Cyclothymia diagnosis must not be better explained by other concurrent psychiatric disorders the patient may be suffering from. For criterion E in Cyclothymia, the patient’s symptoms should not be attributable to a medical condition, medications taken, or substance abuse. Lastly, in criterion F the symptoms must be significantly impairing the functioning and productivity of the patient in daily life for a diagnosis of cyclothymic disorder to be made (APA, 2013). Symptom Analysis Evaluation (SAE) Essay

The rationale for choosing this diagnosis is that this 37 year-old Caucasian male patient fulfils almost perfectly all the points in the DSM-5 diagnostic criteria for cyclothymic disorder as outlined above. For instance, he has distinct chronic fluctuating symptoms that are alternately hypomanic and depressive in nature (like difficulty sleeping and irritability) (criterion A). His symptom profile also does not meet the DSM-5 diagnostic criteria for major depressive, manic, or hypomanic episode (criterion C). Furthermore, this patient does not have any other demonstrable psychiatric or physical illness (criterion D). He only took marijuana once and has since stopped. As such, his symptoms cannot currently be attributed to drugs and substance abuse (criterion E). Lastly, this patient’s symptoms started way back in his teenage years (this is typical of Cyclothymia) and have worsened over time to a point of him seeking help from a professional. This means the intensity and severity of the symptoms are such that they are now interfering with his normal daily functioning (criterion F) (APA, 2013).

Differential 2 Borderline Personality Disorder (BPD) – 301.83(F60.3)
This is a strong differential diagnosis because several DSM-5 diagnostic criteria for it are met by the symptom profile of this patient. This is the sole rationale for its inclusion here. Specifically, this patient’s symptoms meet DSM-5 criteria 5, 6, and 8 for BPD diagnosis. These are affective instability that is characterised by chronic irritability and anxiety, baseless anger followed by difficulty in controlling it, and the fact that he says he has been thinking of death in the last 12 weeks depressed (APA, 2013). The other strong contributory rationale for this differential diagnosis is that physical abuse and parental neglect are common findings in people who are diagnosed with BPD (APA, 2013). However, a few factors in the diagnostic profile (criteria) of BPD are admittedly missing from this patient’s symptoms. These include fear of abandonment and having low self-esteem. This patient has reported that he had been abused by his father as a child without getting any help from his mother.

Differential 3 Bipolar I Disorder
The rationale for including this differential diagnosis is that several DSM-5 diagnostic criteria for it are also met by this patient’s symptom profile. For instance, he displays manic episode symptoms of lack of sleep, disturbance of mood with irritability, impairment of functioning, and the fact that these symptoms cannot be attributed to substance abuse. Moreover, he also shows the major depressive episode symptom of thinking about death. However, some criteria for this diagnosis are missing, such as grandiosity and being talkative (APA, 2013).Symptom Analysis Evaluation (SAE) Essay

Differential 4 Substance/ Medication-Induced Bipolar and Related Disorders
Lastly, this is the other differential diagnosis for this patient. The rationale for including this alternative impression is that some of its DSM-5 diagnostic criteria are satisfied by this patient’s symptoms. These include mood disturbance and intense irritability, and the fact that these symptoms impair his daily functioning and cause him much distress. The unsatisfied criteria for this diagnosis, however, include that the symptoms should occur after substance abuse and subside only after withdrawal of the substance (APA, 2013).

What mental status exam findings would be associated with each listed hypothesis above? What subjective data might the patient report? Use all seven component of MSE- Appearance, Behavior, Speech, Affect, Thought process, Thought content, Cognitive examination (level of awareness, Attention and Concentration, Memory, Orientation etc.).
Differential 1 App Appearance – well-groomed
Speec Behavior – candid

Affect Speech – talkative but normal

Beh Affect – almost flat

Tho Thought process – tangible

Thoug Thought content – he is full of anxiety

Cognitive Examination:

Level of awareness – average

Attention and concentration – poor

M Memory – adequate

OriOrientation – oriented in all four spheres (time, space, place,and person).

Differential 2 App Appearance – appropriate
Speec Behavior – dull and withdrawn

Affect Speech – slow and muffled

BehAffect – not compatible to thought

ThoThought process – fear with only loose associations

Thoug Thought content – feelings of boredom and anger

Cognitive Examination:

Level of awareness – average. Symptom Analysis Evaluation (SAE) Essay

Attention and concentration – poor

M Memory – recent memory impaired, remote memory adequate, and immediate memory poor.

OriOrientation – oriented in TSPP.

Differential 3 App Appearance – ill-appearing
Speec Behavior – guarded

Affect Speech – paucity/ slow/ soft/ hesitant/ but coherent.

Beh Affect – flat

Tho Thought process – troubled

Thoug Thought content – feels helpless and useless

Cognitive Examination:

Level of awareness – good

Attention and concentration – average

M Memory – average

Ori Orientation – oriented.

Differential 4 App Appearance – unkempt
Speec Behavior – congenial

Affect Speech – alogia

Beh Affect – nit compatible to thought

Tho Thought process – winding

Thoug Thought content – nebulous

Cognitive Examination:

Level of awareness – little

Attention and concentration – poor

M Memory – impaired

Ori Orientation – disoriented.

What is the physiology, pathophysiology and/or etiology associated with each hypothesis? Symptom Analysis Evaluation (SAE) Essay
Differential 1 The exact pathophysiology of Cyclothymia is not well understood. However, there is strong empirical evidence that suggests that heredity is involved. Many patients with this condition have a family history of mental illness (Huether & McCance, 2017; Hammer & McPhee, 2018).
Differential 2 Developmental and environmental factors in childhood have been shown to combine with genetic predisposition to give rise to borderline personality disorder. Thus the disorder has a multifactorial etiology and pathophysiology (Huether & McCance, 2017; Hammer & McPhee, 2018).
Differential 3 There is a strong genetic argument in the etiology and pathophysiology of bipolar disorder. This is because in most patients the condition runs in the family (Huether & McCance, 2017; Hammer & McPhee, 2018).
Differential 4 The etiology and pathophysiology of substance/ medication-induced bipolar and related disorders have their root in the use of addictive and habit-forming drugs and substances (Hammer & McPhee, 2018; Stahl, 2017).
What diagnostic tests would you obtain? What diagnostic screening tool would you use?
Differential 1 ● Complete blood count (CBC): to rule out physical illness.
● Urinalysis and chest X-ray (CXR): to eliminate physical illness.

● MRI: to rule out an organic brain syndrome.

Differential 2 ● CBC, Urinalysis, and CXR: to rule out physical illness.
● MRI: to rule out organic brain syndrome.

Differential 3 ● CBC, urinalysis, thyroid function tests, and CXR: to rule out physical illness.
Differential 4 ● Blood test for addictive substances.
● CXR and urinalysis. Symptom Analysis Evaluation (SAE) Essay

● MRI.

Analysis:
After taking the comprehensive history, doing the mental status examination, and conducting laboratory tests; the primary diagnosis was decided to be Cyclothymia (cyclothymic disorder). To manage this patient, there will be need for both psychopharmacologic and psychotherapeutic interventions. According to the available evidence-based practice guidelines, a combination of both approaches has the best chance of success. Of note is that the therapy will be prolonged and complicated by the fact that there are no official medications approved for the treatment of Cyclothymia (MFMER, 2020; Drugs.com, 2019). However, several medications have shown some level of efficacy in clinical trials.

What pharmacotherapy (class of medication) and non-pharmacological treatments would you suggest for the primary diagnosis?
Pharmacotherapy

Mood stabilisers such as valproate 15mg/kg/day taken orally (Stahl, 2017; Katzung, 2018).
Antipsychotics like olanzapine (Zyprexa) 2-6 mg/day orally (Stahl, 2017; Katzung, 2018).
The antipsychotic medication is important as it has been shown to be useful in controlling the irritability of Cyclothymia (Stahl, 2017). Antidepressants are contraindicated as they may worsen Cyclothymia (MFMER, 2020).

Psychotherapy

Two measures have been shown to be effective in managing Cyclothymia. They are:

Cognitive Behavioral Therapy or CBT, and
Interpersonal and Social Rhythm Therapy or IPSRT (Corey, 2013).
References
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Arlington, VA: Author.

Corey, G. (2013). Theory and practice of counseling and psychotherapy, 9th ed. Belmont, CA: Cengage Learning.

Drugs.com (2019). Valproic acid dosage. Retrieved 24 January 2020 from https://www.drugs.com/dosage/valproic-acid.html

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

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. St. Louis, MO: Elsevier, Inc.

MFMER (2020). Cyclothymia (cyclothymic disorder). Retrieved 24 January 2020 from https://www.mayoclinic.org/diseases-conditions/cyclothymia/diagnosis-treatment/drc-20371281

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. New York, NY: McGraw-Hill Education.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. New York, NY: Cambridge University Press.Symptom Analysis Evaluation (SAE) Essay