Psychiatric Examination of Insomnia Patient

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Introduction

Identifying Information

Initials: P. E.
Age: 26
Gender: Female
Insurance Status: Has PPO
Ethnicity: Hispanic
Her education comprises a 4-year college degree in English Language Arts.
Information Received from P. E.

Presenting Problem

P.E. decided to address the specialist because of her insomnia and overall problems with sleep, and changes in her mood because of it. The given problem became a serious concern for a patient because of her inability to relieve stress and lack of rest. Moreover, she emphasizes the fear of going to bed because of the inability to fall asleep and the irritation associated with it. For this reason, the patient decided to go to the clinic. Following the P.E. words, she has already been suffering from insomnia for six months. At first, it was not a serious problem as she associated it with the high level of stress and the overall state of the body. However, it became worse as there were no signs of improvement. Currently, she is tired and cannot handle it by herself.

Usually, P.E. has only two or three hours of sleep with numerous wake-ups. She cannot fall asleep immediately when she goes to bed. Instead, she lies for long periods thinking of various unpleasant things and feeling growing anxiety. She might have one hour of rest, and then she starts thinking again. P.E. says that four hours of sleep is a great success for her, but such nights are rare. As a result, she is agitated and restless, with signs of anxiety and depression. Severe insomnia created the basis for the gradual deterioration of her mental health and inability to have the needed rest. She reports that close people admitted changes in her mood and behavior associated with the sleep disorder and the lack of sleep hours. For this reason, she views it as a reason to address a specialist and discuss the current state.

Triggering Factor: Not identified.
Protective Factor: Productive relationship with colleagues and friends.

Current Medication

P. E. does not use any medication for her insomnia and does not take any substances.

Past Psychiatry History

P. E. experienced a similar occurrence when she was 19 years old, although she received no formal diagnosis.

She has never sought the assistance of a professional, never seen a therapist or a psychiatrist, never been hospitalized for a mental health problem, and denied having suicidal ideas.

Social History

P. E. has a higher education: she earned a bachelor’s degree in English Language Arts.

After that, she was employed at several writing and advertisement agencies but regularly left them after several years of work for some reason.

Currently, P. E. is still employed but has a leave. She is considering resigning because of the problems mentioned above and the fact that P. E. plans to publish a book she has been working on for some years.

P. E. believes the book would be a source of her financially independent living.
P. E. has been in a relationship with a woman recently but at some moment considered it sinful and abruptly ended.
P. E. has been living with her girlfriend recently. However, she has returned to her apartment after a breakup.

ROS:

Constitutional: an average temperature, no shivers, cramps, or tremors.
HEENT: No changes in vision and hearing, no difficulty swallowing.
Pulmonary: No signs of shortness of breath and symptoms of cold in the pulmonary system.
Cardiovascular: difficulty with breathing, headaches, fatigue, chest ache, and irregular heartbeat, which signifies that she has high blood pressure.
Gastrointestinal: No gastrointestinal issues, namely, no abdominal pain or regurgitation.
Genitourinary: No difficulty with urination.
Neuromuscular: No muscle weakness or joint pain because of her work that urges her to sit at the table for a long time.
Weight: 183 Height: 5’5” BMI: 30.4
Vital Sign: 140/95 72 96.4 17 93 on R.A.

Mental Status Exam

Appearance: Disheveled, obese
Behavior: cooperative
Speech: Clear
Mood and Affect: Congruent
Thought Perception: Logical
Thought Content: No delusions or hallucinations
Insight/Judgement: Intact
Orientation: Alert and oriented x 3

Assessment

Axis I- Bipolar disorder current episode mania
Axis II- none
Axis III- Asthma
Axis IV- occupational problem
Axis V- 50
DSM-V Diagnosis

The working diagnosis of the patient is F31.1 Bipolar disorder with a current episode of mania without psychotic features (American Psychiatric Association, 2013). P. E. is diagnosed with bipolar illness due to mood swings between depression and, as it seems, mania. According to Marangoni (2018), “bipolar disorder has a lifetime prevalence of 2.1% in adults and 1.8% in children; at least two-thirds of the patients with bipolar disorder report onset before age 18” (p. 19). However, P. E.’s first occurrence of the disorder presented when she was 19 years old. The manic phase of borderline personality disorder manifests itself differently. Some people become sexually promiscuous, indulging in dangerous sexual practices, while others have no desire to sleep, spend excessively, have racing thoughts, and act grandiosely. P. E. seems to have racing thoughts, insomnia, and maybe sexually overwhelmed.

Following a manic episode, people generally have a depressive period in which they become the polar opposite of what they were before, with a lack of energy, drive, and sleeping excessively. According to Jann (2014), “A diagnosis of bipolar disorder is obvious when a patient presents with florid mania but is challenging when the initial presentation includes depressive symptoms; studies generally report that 50% or more of patients initially present with depression” (p. 491). These symptoms correspond to the description of P. E.’s experiences.

Many patients who come to the office with signs of suspected bipolar illness were previously treated with only antidepressants, but their symptoms did not improve. In the instance of P. E., her reluctance towards professional aid and disbelief in the presence of mental illness in her prevented her from going through any treatment. Bipolar illness diagnosis necessitates a thorough examination of prior experiences. The key contrast between the two forms of bipolar illness is the degree of manic symptoms. As such, full mania involves substantial functional impairment, can include psychotic symptoms, and frequently necessitates hospitalization. Hypomania, on the other hand, is not strong enough to cause significant impairment in social or occupational functioning or demand hospitalization (Jann, 2014). P. E. has all symptoms of hypomania and still needs treatment.

Treatment Plan

P. E.’s treatment plan includes several necessary steps described later in greater detail.

The first step is laboratory work, which includes CBC, CMP, TSH, lipid panel, and urine drug screen.
P. E. is prescribed to take 250 mg of Depakote BID as well as 5mg of Abilify Q.D.
After P. E. has followed the instructions (it is also recommended that someone monitor the process of taking medications), she should revisit the clinic for an assessment and instructions in two weeks.

Psychopharmacology

The use of psychopharmacology should be explained in greater depth. Mood stabilizers such as Depakote, Lamictal, and carbamazepine, as well as atypical antipsychotics, have been demonstrated to be useful in the treatment of borderline personality disorder. Depakote has been found in studies to be effective as a mood stabilizer. According to Janicak and Esposito (2015), “lithium and valproate appear to be comparably effective in treating pure manic episodes, while valproate may be more effective for mixed or rapid cycling presentations” (p. 31). Depakote is used as a mood stabilizer in the instance of P. E.

Depakote’s mechanism of action perfectly fits the case of the patient. It is known to entail blockage of “voltage-dependent sodium ion receptor channels and enhancement of gamma-aminobutyric acid activity by increasing its synthesis and release” (Janick & Esposito, 2015, p. 34). Depakote can induce thrombocytopenia and raise liver enzymes; consequently, labs should be done before starting the medicine. There have been concerns about P. E’s hypertension; the significance of close lab monitoring was brought to P. E. and her close friend, who accepted the task of taking care of the patient.

In addition to that, the discussion of Depakote should draw significant attention to the fact that this medication can lead to increased weight gain. Since P. E. has already had some weight issues, and her body-mass index demonstrates that she suffers from obesity, this aspect should be considered with caution. However, a closer analysis of the professional literature indicates that “bipolar disorder and its treatment increase the risk of comorbid medical conditions such as being overweight” (Grootens et al., 2018, p. 1489). This information indicates that every person receiving bipolar disorder treatment faces a risk of gaining weight, and this threat is more significant for people who have already had such health issues. That is why appropriate interventions are necessary to minimize the side effects of the medication. Suitable activities include regular laboratory tests, check-ups, and weight monitoring. Furthermore, P. E. was given the importance of following a healthy diet and involving in mild physical exercise on a regular basis.

Second-generation antipsychotics, such as Abilify, have been found to be successful in the treatment of bipolar illness, either as a monotherapy or in conjunction with a mood stabilizer. It is a great alternative for treating bipolar disease due to its multi neurotransmitter action on dopamine and serotonin. According to Jann (2014), “a vast body of evidence supports the use of atypical antipsychotics in the treatment of bipolar disorder… [and especially] acute mania” (p. 492). Atypical antipsychotics as a class have been shown to increase metabolic risk in individuals with bipolar illness, and monitoring ways to avoid, mitigate, or detect symptoms early so that appropriate actions may be implemented.

Strengths

There are several points that can contribute to the successful result of P. E.’s treatment.

P. E. wants to participate in church activities due to her emerging religiousness. These programs can relieve the obsession of the patient with her “sins” since Christian meetings are supportive in their nature in the region where P. E. resides and plans to visit them.
P. E. has several friends who care about her well-being and might have an impact on her opinion concerning treatment if she is reluctant towards it again. One of her friends agreed to look after while P. E.’s stays at home and monitor her taking the medications, as well as communicate with P. E. for psychological recovery.
P. E.’s conservative parents, who might have caused her disbelief in the treatment and produced some utterances on religious matters, do not maintain any contact with the patient. Thus, they cannot intervene in the process of care or cause even more mania episodes by their possible misconduct.
P. E. has a book to publish and can focus on this project.

Goals

P. E. had discussed her goals by the end of the treatment when she eventually was convinced that it might be helpful.
P. E. wants to publish her book, which she has already written, as soon as her mood is stable.
P. E. desires to reconnect with her friends, some of whom she has been scared or confused by her behavior.
P. E. intends to meet with her ex-girlfriend to discuss some routine matters about her new living and explain the reason for her actions.
P. E. wants to be able to get enough sleep at nighttime so she can be functional during the day.

Expected Outcomes

There are expectations for the first two weeks of treatment.

P. E. will sleep well all night and will be able to think clearly and perform normally.
P. E. is expected to take her medicine exactly as directed.
P. E. will take part in her extracurricular activities, namely church meetings.
P. E. will have minor adverse effects from the drug.
P. E. will continue to see the psychiatrist for medication maintenance.

Conclusion

Completing a psychiatric examination of this patient lends credence to the idea that culture and personality may influence how people perceive mental disease as well as their willingness to seek the necessary care. There are uncertainties about medication noncompliance in a patient like P. E., mainly because of her disbelief in medication and treatment, and there is a risk that she will wish to quit taking medicine once she improves. It is critical to be aware of patients’ surroundings, particular problems, and beliefs and to take them into account while discussing treatment options.

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