Assignment: Practicum: Decision Tree (Due in Week 7)
Students will:
- Evaluate clients for treatment of mental health disorders
- Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical, as well as mental factors that might impact the client’s diagnosis and treatment.
At each Decision Point stop to complete the following:
- Decision #1: Differential Diagnosis
- Which Decision did you select?
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
- Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
- Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients and their family.
Note: Support your rationale with a minimum of three academic resources less than five years In APA Format with proper citation including an introduction and conclusion
Running head:
WEEK 5 DECISION TREE
1
2
WEEK 5 DECISION TREE
Week 5 Decision Tree
The purpose of this paper is to read, assess, and analyze a patient presenting with depressive-like symptoms. The patient presents as a first initial visit. Her presentation and reported history suggest a diagnosis of a cyclothymic disorder and an appropriate treatment plan must be created based on the diagnosis assumed.
Decision #1
Which Decision did you select?
The first decision that I made was to diagnose this patient with cyclothymic disorder. This patient meets criteria for a diagnosis of cyclothymic disorder based on her persistent depressed mood with periodic episodes of feeling “on top of the world,” going 3 days without much sleep and then finally feeling fatigued stating that she eventually “crashes,” her decreased ability to concentrate when she feels sad, and inability to get things done with periodic “bursts of energy.”
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
I selected this diagnosis because the patient meets criteria, according to the DSM-5, for cyclothymic disorder. The patient reports she has been struggling with these symptoms for years and an individual with cyclomania must have had the symptoms for at least 2 years with many episodes of hypomanic symptoms and depressive symptoms without meeting criteria for an episode of either. Also, cyclothymic disorder can have a significant negative impact on functioning in the individual’s social, occupational, or other facets of their life. No other mental illness meets criteria in the DSM-5 with this presentation (American Psychiatric Association, 2013). Because Stefanie does not meet criteria for either hypomanic episode or major depressive episode and because she is not using substance while exhibiting these symptoms, she meets criteria for cyclothymic disorder
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
I was hoping to confirm a diagnosis for this patient so she could be treated accordingly with the appropriate medication based on her symptoms. The patient is not getting an adequate amount of sleep and is not completing daily required tasks by allowing them to pile up. The instability in her mood can be managed with a medication to help stabilize her mood which is why a proper diagnosis is so important.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
I expected that this patient would get some clarity by receiving her diagnosis. It may help her make sense of her behaviors and why she struggling in certain areas of her life, This could also give her hope that her troublesome symptoms can be alleviated with pharmacotherapy treatment options.
Why did you select this Decision 2? Support your response with evidence and references to the Learning Resources.
The second decision that I made was to start this patient on 10 mg of Abilify by mouth daily. Cyclothymic disorder is similar to bipolar disorder and is treated accordingly. Abilify is FDA approved for acute mania/mixed mania, and bipolar maintenance. It works by decreasing dopamine when dopamine is high and increasing dopamine output when dopamine levels are low (Stahl, 2014). Abilify is a good choice because it tends to work sooner than mood stabilizers and can take effect as soon as 1 week.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
By starting this patient on 10 mg of Abilify, I was hoping that this patient would have remission of her symptoms. I was hoping she would be able to get some consistent sleep, her mood would be improved mood and more consistent without random ups and downs, and that she would be able to consistently complete more goal directed activities on a daily basis.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
After Stefanie returned to the clinic in four weeks for a follow-up, she reported that her mood was more stable. I did expect the Abilify to stabilize her mood at least some. The patient reported, she has not felt as sad which goes hand in hand with her mood being more consistent. Stefanie reported that she felt lightheaded upon standing up for the first two weeks of taking the medication which is a common side effect so that was not too surprising. Common initial side effects include dizziness, insomnia, akathisia, activation, nausea, vomiting, and orthostatic hypotension (Stahl, 2014).
Decision #3
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
Stefanie reported orthostatic hypotension after the initial doses for the first 2 weeks but reports that the symptoms have subsided. Therefore, I made the decision to maintain the current dose of Abilify. Orthostatic hypotension is a common side effect when starting the medication and should just be monitored. At this point, because it has not happened in a few weeks and the medication seems to be working well by stabilizing her mood, maintaining the current dose of Abilify at this point seems like the appropriate choice.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
I was hoping that the patient would not have any more dizziness upon standing and that the medication would continue to relieve her symptoms related to her cyclothymic disorder and stabilize her mood. It appears to be working well without major side effects at this point.
Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
An ethical consideration to keep in mind with this patient is her potential to not comply to treatment and medication regimen. Individuals with cyclothymic disorder can have irregular moods and unpredictable behaviors which can make it hard to tell what the patient might do or decide to do. She also could start feeling better and stop taking her medication which would not be productive or benefit a positive prognosis. Before starting a medication, the pros and cons of taking the medication need to be weighed out and the potential side effects must be considered (Newhouse-Oisten, 2017). Considering the patient’s medical history or problems should be considered ethically. For example, if the presents with diabetes mellitus already, an antipsychotic for this disorder may not be the best decision with its potential for negative metabolic effects. Also, monitoring the patient for any movement disorders after taking the medications is important as the patient could potentially develop a movement disorder that could be life-long and interfere with their quality of life.
Conclusion
In conclusion, this patient ended up being diagnosed with cyclothymic disorder. She did not meet criteria for bipolar or depressive disorder. Her symptoms were interfering with her daily life as she was not sleeping or getting daily tasks performed appropriately. Her up and down mood swings was confusing for her as well, and all of her combined symptoms made her want to seek treatment and tell someone what was going on with her. Abilify was the chosen pharmacological treatment options as it can help to stabilize her mood and allow her to get some more consistent sleep.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th edition). Wahsington, D.C: Author.
Laureate Education. (2017d). A young woman with depression [Interactive media file].
Baltimore, MD: Author.
Newhouse-Oisten, M. K., Peck, K. M., Conway, A. A., & Frieder, J. E. (2017). Ethical
Considerations for Interdisciplinary Collaboration with Prescribing Professionals. Behavior analysis in practice, 10(2), 145–153. https://doi.org/10.1007/s40617-017-0184-x
12/29/2020 Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16781899_1&rubric_id=_2083042_1 1/5
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Excellent Good Fair Poor
Quality of Work
Submitted: The
extent of which
work meets the
assignned
criteria and work
re�ects graduate
level critical and
analytic
thinking.
27 (27%) – 30
(30%)
Assignment
exceeds
expectations.
All topics are
addressed with
a minimum of
75% containing
exceptional
breadth and
depth about
each of the
assignment
topics.
24 (24%) – 26
(26%)
Assignment
meets
expectations.
All topics are
addressed
with a
minimum of
50%
containing
good breadth
and depth
about each of
the
assignment
topics.
21 (21%) – 23
(23%)
Assignment
meets most of
the expectations.
One required
topic is either
not addressed or
inadequately
addressed.
0 (0%) – 20
(20%)
Assignment
super�cially
meets some of
the
expectations.
Two or more
required topics
are either not
addressed or
inadequately
addressed.
Quality of Work
Submitted: The
purpose of the
paper is clear.
5 (5%) – 5 (5%)
A clear and
comprehensive
purpose
statement is
provided which
delineates all
required
criteria.
4 (4%) – 4 (4%)
Purpose of the
assignment is
stated, yet is
brief and not
descriptive.
3.5 (3.5%) – 3.5
(3.5%)
Purpose of the
assignment is
vague or o�
topic.
0 (0%) – 3 (3%)
No purpose
statement was
provided.
Name: PRAC_6670_Week7_Assignment2_Rubric
EXIT
Grid View List View
12/29/2020 Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16781899_1&rubric_id=_2083042_1 2/5
Excellent Good Fair Poor
Assimilation and
Synthesis of
Ideas: The extent
to which the
work re�ects the
student’s ability
to:
Understand and
interpret the
assignment’s key
concepts.
9 (9%) – 10 (10%)
Demonstrates
the ability to
critically
appraise and
intellectually
explore key
concepts.
8 (8%) – 8 (8%)
Demonstrates
a clear
understanding
of key
concepts.
7 (7%) – 7 (7%)
Shows some
degree of
understanding
of key concepts.
0 (0%) – 6 (6%)
Shows a lack of
understanding
of key
concepts,
deviates from
topics.
Assimilation and
Synthesis of
Ideas: The extent
to which the
work re�ects the
student’s ability
to:
Apply and
integrate
material in
course rsources
(i.e. video,
required
readings, and
textook) and
credible outside
resources.
18 (18%) – 20
(20%)
Demonstrates
and applies
exceptional
support of
major points
and integrates
2 or more
credible
outside
sources, in
addition to 2-3
course
resources to
suppport point
of view.
16 (16%) – 17
(17%)
Integrates
speci�c
information
from 1
credible
outside
resource and
2-3 course
resources to
support major
points and
point of view.
14 (14%) – 15
(15%)
Minimally
includes and
integrates
speci�c
information
from 2-3
resources to
support major
points and point
of view.
0 (0%) – 13
(13%)
Includes and
integrates
speci�c
information
from 0 to 1
resoruce to
support major
points and
point of view.
12/29/2020 Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16781899_1&rubric_id=_2083042_1 3/5
Excellent Good Fair Poor
Assimilation and
Synthesis of
Ideas: The extent
to which the
work re�ects the
student’s ability
to:
Synthesize
(combines
various
components or
di�erent ideas
into a new
whole) material
in course
resources (i.e.
video, required
readings,
textbook) and
outside, credible
resources by
comparing
di�erent points
of view and
highlighting
similarities,
di�erences, and
connections.
18 (18%) – 20
(20%)
Synthesizes
and justi�es
(defends,
explains,
validates,
con�rms)
information
gleaned from
sources to
support major
points
presented.
Applies
meaning to the
�eld of
advanced
nursing
practice.
16 (16%) – 17
(17%)
Summarizes
information
gleaned from
sources to
support major
points, but
does not
synthesize.
14 (14%) – 15
(15%)
Identi�es but
does not
interpret or
apply concepts,
and/or strategies
correctly; ideas
unclear and/or
underdeveloped.
0 (0%) – 13
(13%)
Rarely or does
not interpret,
apply, and
synthesize
concepts,
and/or
strategies.
12/29/2020 Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16781899_1&rubric_id=_2083042_1 4/5
Excellent Good Fair Poor
Written
Expression and
Formatting
Paragraph and
Sentence
Structure:
Paragraphs
make clear
points that
support well
developed ideas,
�ow logically,
and demonstrate
continuity of
ideas. Sentences
are clearly
structured and
carefully
focused–neither
long and
rambling nor
short and lacking
substance.
5 (5%) – 5 (5%)
Paragraphs
and sentences
follow writing
standards for
structure, �ow,
continuity and
clarity
4 (4%) – 4 (4%)
Paragraphs
and sentences
follow writing
standards for
structure,
�ow,
continuity and
clarity 80% of
the time.
3.5 (3.5%) – 3.5
(3.5%)
Paragraphs and
sentences follow
writing
standards for
structure, �ow,
continuity and
clarity 60%- 79%
of the time.
0 (0%) – 3 (3%)
Paragraphs
and sentences
follow writing
standards for
structure, �ow,
continuity and
clarity < 60% of
the time.
Written
Expression and
Formatting
English writing
standards:
Correct
grammar,
mechanics, and
proper
punctuation
5 (5%) – 5 (5%)
Uses correct
grammar,
spelling, and
punctuation
with no errors.
4 (4%) – 4 (4%)
Contains a few
(1-2)
grammar,
spelling, and
punctuation
errors.
3.5 (3.5%) – 3.5
(3.5%)
Contains several
(3-4) grammar,
spelling, and
punctuation
errors.
0 (0%) – 3 (3%)
Contains many
(≥ 5) grammar,
spelling, and
punctuation
errors that
interfere with
the reader’s
understanding.
12/29/2020 Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16781899_1&rubric_id=_2083042_1 5/5
Excellent Good Fair Poor
Written
Expression and
Formatting
The paper
follows correct
APA format for
title page,
headings, font,
spacing, margins,
indentations,
page numbers,
running head,
parenthetical/in-
text citations,
and reference
list.
5 (5%) – 5 (5%)
Uses correct
APA format
with no errors
4 (4%) – 4 (4%)
Contains a few
(1-2) APA
format errors.
3.5 (3.5%) – 3.5
(3.5%)
Contains several
(3-4) APA format
errors.
0 (0%) – 3 (3%)
Contains many
(≥ 5) APA
format errors.
Total Points: 100
Name: PRAC_6670_Week7_Assignment2_Rubric
EXIT
Case #2
A young woman with Depression with Depression
SUBJECTIVE
Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep.
You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.
Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!”
OBJECTIVE
Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits.
MENTAL STATUS EXAM
Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.
At this point, please discuss any additional diagnostic tests you would perform on Stefanie.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
Cyclothymic disorder
Decision Point One
Bipolar I, current phase, depressed
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:
Begin Latuda 40 mg orally daily
Lamictal 100 mg orally daily
Begin psychotherapy using a psychodynamic approach
Bipolar II, current phase, hypomanic
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:
Begin Lithium 300 mg orally twice a day
Begin Olanzapine 10 mg orally at bedtime
Begin Abilify 10 mg orally daily
Decision Point Two
Begin Depakote 250 mg orally three times daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Stefanie returns to your office and informs you that she had to stop taking the medication last week. “I have been too tired to do anything,” she explains, “plus, I have gained about 2 pounds since I started this medicine… I can’t keep gaining weight like this.”
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Explain to Stefanie that weight gain and sedation are temporary side effects and encourage her to restart the medication
Decrease the dose to 125 mg orally twice a day
Increase the dose to 500 mg orally twice a day, and explain that weight gain and sedation are problematic only at lower doses
Cyclothymic disorder
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:
Begin Depakote 250 mg orally three times daily
Begin Abilify 10 mg orally daily
Arrange to see Stefanie every 3 months for routine follow-up
Decision Point One
Bipolar I, current phase, depressed
Decision Point Two
Lamictal 100 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Stefanie presents today with concerns about a rash that began about 1 week after starting the Lamictal dose. The rash appears as erythematous macules and papules that initially began on her stomach, but spread to the periphery over the past 2 weeks. The lesions multiplied until they became confluent, and now involve the oral mucosa as well as her hands and feet. Stefanie denies fever, chills, lymphadenopathy, sore throat, malaise, or arthralgia.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Restart lithium at 150 mg orally twice a day
Discontinue lithium and start Latuda 40 mg orally daily
Change lithium to extended-release preparation and start Eskalith CR 450 mg orally three times/day
Decision Point Three
Restart lithium at 150 mg orally twice a day
Guidance to Student
In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.
In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have 3 or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.
Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.
Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.
In this case, Stefanie had side effects related to Lithium. Lithium could be restarted at half the dose (150 mg orally twice a day) for several days, then slowly titrated upward. Eskalith CR is the extended-release version of Lithium, but 450 mg orally three times/day is too much.
In consideration of the actual diagnosis and the potential side effects related to Lithium, the PMHNP may consider Latuda as an alternative treatment.