Subjective
In this instance, a 20-year-old male patient with depression visits therapy treatment twice a week. Jo is his name. The patient was angry, agitated, and exhausted when he and his mother arrived at the renowned clinic. The parents have split up. The thing that most annoys him, according to the fishing statement, is that he wants his father to be a part of his life. He is not currently living with his biological father. Neither has it been since he was six years old. The deficiency is that his father pushes him to overcome emotional obstacles to become an adult and a man. Due to the negativity his father brought into his life, he had given up communicating with him. He has suffered from significant sadness due to the circumstance, anxiety attacks, memory loss, and problems concentrating. He struggles in school, struggles to concentrate, lacks energy, and feels powerless.
Objective
The patient is irate, worn out, and was raised by an uncaring father. He has a weak support structure and has had trouble telling his parents what he needs. The patient claimed to be grumpy and downhearted every day. The patient seems to have trouble focusing, has memory issues, is exhausted, and lacks motivation. The vision disputes that he has ever had suicidal ideas or acts of self-harm, such as cutting his arms, emotional harm, or auditory hallucinations. The majority of the time, he is restless and wrings his arm. He has poor judgment, and his energy level is low. He is clothed logically and according to his age and the weather. The ability to think is still present. He is intelligent. Evaluation of one’s knowledge demonstrates intelligence.
Assessment
This patient is a 20-year-old Jo who suffers from depression. He is frustrated, agitated, lonely, and worn out. Bipolar disorder is the most likely differential diagnosis. Furthermore, there is no convincing proof of a history of trauma or other illnesses that would favor one diagnosis over another. An underlying mood disorder may be the source of a mood problem. Adolescents frequently suffer from depression, bipolar illness, and many personality problems. Examining the patient’s mental state revealed increased anxiety and despair. The drug they were taking, which had a high conversion rate, caused the disparity between the V12 level and the results of the lab tests. His visits to the doctor’s office were also irregular, but this could have been due to fear or a lack of available treatments due to financial concerns.
I think these symptoms are consistent with bipolar disorder with psychotic aspects. I wonder if he might have depression, though, because he doesn’t want his parents to be engaged in his life or wants to feel better about himself. Irritability, depression, anxiety, and mania are the possible differential diagnoses for bipolar disorder (Carvalho, 2020). Due to his depressive symptoms, e.g., inability to attend school and dramatic mood swings between periods when his father is absent, the patient, whose history of depression began at a young age, can be diagnosed with a bipolar mood disorder or a specified bipolar disorder. A person must experience at least one of the following symptoms for a month in order to be diagnosed with a mental illness, according to the DSM-5-TR: irritability and rage; depression and lack of interest or pleasure; anxiety and tension; decreased appetite and weight loss (Nussbaum, 2022). The patient mentioned having trouble remembering things, being depressed, sobbing, withdrawing from people, and wanting to injure himself. These elements appear to be signs of bipolar mood disorder and are associated with depression.
Plan
In this instance, the patient could receive Cognitive Behavioural Therapy based on the empirical data and clinical observations. The goal of cognitive behavioral therapy (CBT), a particular form of psychotherapy, is to assist patients in creating positive and constructive mental and behavioral patterns so they can better control the emotions and behaviors that get in the way of their capacity to function (James, 2020). In this circumstance, the patient should be treated per CBT principles by being aware of how his responses to his circumstance could lead to increased rage or sadness. He will be pushed to alter his ways for the better. This can be done by administering an assessment to parents, families, and friends through local support organizations. Such is the online discussion forum for parents at transfer.org. The patient should also prepare to adhere to the suggested Twitter schedule that helps in Cognitive behavioral Therapy. Therapy Official is one of the Twitter handles that could be beneficial. The client should also follow up with the nurse practitioner preceptor in two days to continue the treatment and should participate in activities at a psychotherapy class.
According to my findings, the purpose of treatment in a psychotherapy session is to foster a therapeutic association between the patient and the therapist. The ability to impart knowledge and skills to the other person will be advantageous to both the client and the therapist due to this interaction (Saxon, 2017). To create a safe setting for the client, the first step in the therapy treatment plan would be to build trust between the patient and therapist. Anyone would then be able to use what they have learned and gain from the knowledge that they both share. Following up on the suggested psychotherapy appointment, I suggest the client have friends or family who can offer support or empathy for what transpired during the appointment.
Reflection
In a similar patient evaluation in the future, I would go over the history in greater detail. A comprehensive history facilitates diagnosis. Furthermore, I am better equipped to develop a treatment plan and determine whether it can be successfully carried out with the more specific information acquired during the patient assessment. The social determinants of health include education, wealth, social support, and income (OPDHP, 2030). Of course, these and many other factors, such as certain personality traits and availability of resources that might boost stability and financial stability but also reduce stress, all affect mental wellness. The American Community Survey uses the social determinant of health (OPDHP, 2030) to categorize individual, societal, and economic elements that impact health. Poverty, food security, education, housing, community quality, and resources are a few of these elements, but they are not all (OPDHP, 2030). Jo wants his father to be absent from his life since, first, his parents have separated, and he is no longer living with his father. Second, the young man thinks he might receive better treatment if he can persuade his father to once again treat him with more respect or love. Addressing the issues at home rather than at a hospital or school would help to enhance mental health.
It should be mentioned that the side effects of drugs, which include nausea, vomiting, and insomnia, are quite unpredictable. In order to aid the patient with agitation, social engagement, and less rage, the patient’s vegetation was first ordered. He denies having an idolatrous streak. Jo attended therapy for four weeks, during which time his condition seemed to have improved, and his depressive symptoms decreased. He is less worried, and his mood is consistent. His parents also noted that he and his siblings could communicate more effectively at home. During following treatment sessions and interactions with others, he is reportedly less isolated and makes eye contact with them. His ability to communicate has greatly increased. When caring for children and teenagers, it’s crucial to take their ethical and logical demands into account (Grootens, 2017). To avoid shortcomings or adverse effects, the practitioner should adhere to the prescription guidelines.
References
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.
Grootens-Wiegers, P., Hein, I. M., van den Broek, J. M., & de Vries, M. C. (2017). Medical decision-making in children and adolescents: developmental and neuroscientific aspects. BMC pediatrics, 17(1), 1-10.
James, A. C., Reardon, T., Soler, A., James, G., & Creswell, C. (2020). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane database of systematic reviews, (11).
Nussbaum, A. M. (2022). The Pocket Guide to the DSM-5-TR™ Diagnostic Exam. American Psychiatric Pub.
OPDHP. (n.d.). Social Determinants of Health. Social Determinants of Health – Healthy People 2030. Retrieved September 21, 2022, from https://health.gov/healthypeople/priority-areas/social-determinants-health
Saxon, D., Barkham, M., Foster, A., & Parry, G. (2017). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical psychology & psychotherapy, 24(3), 575-588.
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