Wk7 prac 6675 assign 1

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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #7 ): Grand Rounds Discussion: Complex Case Study Presentation: ADHD

Angele Patricia Lemanga

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Dr. Elizabeth Connole-pond



1- To identify three different diagnoses with supporting evidence, listed in order from highest priority to lowest priority.

2- To understand the DSM-5 criteria for ADHD, Bipolar Disorder, and Generalized Anxiety Disorder.

3- To develop an appropriate care plan for the patient in the presented case including pharmacological and non-pharmacological interventions.


CC (chief complaint): “My daughter is irritable and blows up frequently. She cannot stay still, doesn’t pay attention in school, and has poor grades.”

HPI: MT is a 14-year-old African American female with a past psychiatric history of ADHD who was referred to the clinic by her pediatrician for psychiatric evaluation. The patient and mother were seen at the clinic for initial evaluation. MT was diagnosed with ADHD two years ago, and the mother declined pharmacological treatment. Then, MT started on psychotherapy for anger management and social skills, but she was not consistent with therapy sessions due to her mother’s work schedule conflict. According to her mother, MT does not share her feelings, and sometimes she will explode in anger. Recently she punched a hole in the walls on two occasions. She gets irritated when she is asked to complete house shores like washing dishes, cleaning her room, or organizing things. She will either start crying or hit the wall. MT mother is concerned about her daughter behavior because MT father has bipolar disorder and she wanted to know at which point MT could be affected by the same or similar condition. MT denies feeling depressed or losing interest in her pleasurable activities. She has been self-isolated from her friends, and sometimes, from her family. MT stated: “Sometimes I just don’t want to be bothered”. MT denies suicida/homicidal ideations. She also denies hearing voices or seing things that are not there.

Medications Trial: None

Psychotherapy or Previous psychiatric diagnosis: MT has a psychiatric history of ADHD. She is enrolled in psychotherapy for anger management and social skills.

Substance Current Use: MT denies smoking, drinking alcohol, or using illicit drug.

Medical History: None

· Current Medications: None

· Allergies: No known Drug, Food, or environmental allergy.

· Reproductive Hx: First menses at 13 y/o. Regular menses. Never been pregnant. Denies being sexually active. She is single and has no children.

Psychosocial History: MT is a 9th-grade student who lives with her mother and younger brother in a townhouse in Bowie, Maryland. She enjoys reading and playing card games. She denies having any legal issues. She denies any history of trauma or abuse. MT denies using illicit drug, alcohol, or smoking. She reports poor grades in school and a lack of interest in school activities.

General Statement: MT is a 14-year-old African American with a history of ADHD, not on medication but currently managed with psychotherapy. She has never been hospitalized. She denies suicidal/homicidal thoughts. ST is alert and oriented to person, time, place and situation.

Family Psychiatric/Substance Current Use:

– Father:
Bipolar Disorder

– Mother:
Depression, Anxiety

– Brother:


GENERAL: No chills, subjective fever, night sweats, weight loss.

HEENT: No headache, vision changes, eye pain, sore throat.

SKIN: No rashes, lesions, jaundice, bruising

CARDIOVASCULAR: No chest pain, palpitations, syncope.

RESPIRATORY: No SOB, coughing, orthopnea, wheezing.

GASTROINTESTINAL: No n/v/d, abdominal pain, bloody stool, melena.

GENITOURINARY: No frequency, dysuria, or hematuria.

NEUROLOGICAL: No sensation/strength deficits. Endorsed inattention,

impulsivity, fidgeting, and difficulty following instructions.

MUSCULOSKELETAL: No joint aches, pain, swelling

HEMATOLOGIC: Denies anemia, bruising, or recent blood loss.

LYMPHATICS: Denies swelling of lymph nodes or pain.

PSYCHIATRIC: Denies visual/auditory hallucination, SI, HI.

ENDOCRINOLOGIC: Denies increased thirst, excessive sweating, heat,

or cold intolerance.


Diagnostic results:

· Connor’s parent and teacher rating scales for ADHD

· Swan rating scale (helps differentiate the types of ADHD) (Magnus et al., 2021).

· L aboratory test to rule out any medical condition:

CBC with differential, CMP, lipid panel, drug and alcohol level test, LFT, TSH, free T4,

Hep C, Hep B antigen, HIV, urinalysis, pregnancy test.


Mental Status Examination: MT is a 14-year-old African American female who presents for a psychiatric evaluation. The patient is alert and oriented to person, time, place and situation. She looks her stated age. Patient is well nourished, appropriately groomed and dressed for the season and situation. Her gait is steady. Her affect is neutral, and her mood is euthymic. MT speech is soft with regular tone and volume. Her thought process is goal-directed. Her memory is within normal limit. MT denies suicidal and homicidal ideations. She also denies visual and auditory hallucination. MT is unable to remain still and maintain eye contact during interview.

Diagnostic Impression:

1. Attention Deficit Hyperactivity, predominantly inattentive (HDHD) (F90.0)

ADHD is a psychiatric disorder that affects children’s functioning potential and can last throughout adulthood if not managed adequately. Affected patients demonstrate inappropriate developmental levels of impulsivity, hyperactivity, and inattentiveness. The manifestations begin at a young age and typically present as being forgetful, difficulties in completing tasks, lack of concentration, lack of attention, interrupting during a conversation, talking excessively, and disorganization, which present before the age of twelve years and last at least six months (Magnus et al., 2017). MT struggles with concentration, forgetfulness and does not listen to her mother. She is irritable and blows up frequently. She is also unable to sit still and fidgets a lot. The behavior occurs both at home and in school. The condition is ruled in based on the findings from the mental status examination indicating predominantly inattentive presentation with the interference of daily life activities at school and home.

2- Bipolar Disorder F31.9

Bipolar disorder is described as co-occurrence of manic or hypomanic episodes and depressive manifestations within the same mood episodes (Bartoli et al., 2020). The patient mood is characterized as high, irritable, or expansive with increased overall energy for at least one week. The patient should exhibit three or more of the following symptoms: grandiose thinking, diminished sleep, racing thoughts, increased goal-directed activities, and psychomotor agitation (Bartoli et al., 2020). Although MT presents symptoms of depresion, she does not endorse three of the core symptoms of bipolar disorder as mentioned above, ruling out the condition.

3- Generalized Anxiety Disorder (GAD) F41.9

GAD is a condition that causes excessive worry and anxiety for at least six months and can be found in multiple situations or settings (American Psychiatric Association, 2013). These symptoms must be accompanied by at least three of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, and muscle tension (Patriquin & Mathew, 2017). GAD is more common in females than in men, with approximately 55 to 60% of people with the disorder being female (American Psychiatric Association, 2013). MT is irritable and will sometimes punch the wall. She has trouble concentrating, has sleep problems, and is restless. Although MT presents some symptoms of GAD, this condition is ruled out due to the patient history of impulsity, fidgeting, and inattention.


Diagnozing this patient with ADHD was not obvious because she presented mixed symptoms of anxiety, hyperactivity, and depression. The patient could have had an anxiety disorder as her primary diagnosis, as she is be irritable, punches walls, and is isolated from others. Collateral information from the therapist, teachers, and other encounters with the patient could have strengthened the diagnosis impression. Because her mother didn’t want the patient to try medication, this patient was not on any medication trial. Research shows that combining psychotherapy and medications may be more effective than either treatment alone (Magnus et al., 2017). MT might benefit from low-dose Prozac or Zoloft to help her anxiety and irritable mood (Magnus et al., 2017). Legal and ethical considerations are essential to ensure that patients’ values, preferences and opinions are respected when treating mental disorders. It is important that the mother gives informed consent to allow the team to make the best decisions for the patient’s treatment (Magnus et al., 2017).

Case Formulation and Treatment Plan: 

The patient appears to be suffering from anger issues, as evidenced by an irritable mood by punching the wall. Factors that predispose the patient to mental health disorders are the brother’s history of ADHD, the father history of bipolar, and the mother history of depression/anxiety. MT’s symptoms influence her daily life at home and in school. The mainstay treatment of ADHD entails pharmacological stimulants. However, MT mother declined pharmacological intervention. MT will begin psychotherapy, especially cognitive behavioral therapy (CBT). CBT teaches how to modify beliefs and behaviors that lead to negative thoughts and emotions (NYULangone Health, 2022). Through therapy, the patient would learn how to manage her anger and impulsivity. Since ADHD is associated with increased health risk such as drug use, binge eating, obesity, and unsafe sexual behaviors, It is paramount to monitor the patient for these conditions (Schoenfelder & Kollins, 2015).

One way to promote healthy behavior is by strengthening the patient’s social and environmental factors, such as resilience and academic engagement (Schoenfelder & Kollins, 2015). Programs that support parenting and family functioning have been shown to reduce the risk of substance use and obesity in ADHD patients (Schoenfelder & Kollins, 2015). Family Therapy assists siblings and parents in coping with difficulties in living with a child diagnosed with ADHD. Treatment with counseling enhances everyday functioning and avoids the need for more intensive treatment. The patient and her mother should be given the phone numbers for their local crisis hotline and suicide hotline, and instructions on how to get to the nearest local emergency facility in case of emergency.

Follow-Ups/ Referrals

Follow-up in four weeks or PRN

Provided the mother and patient the HelpLine 1-800-950-NAMI (National Alliance on Mental Illnesses) to get assistance in locating appropriate resources and finding support.

Discussion Questions:

1. What medications would you have started this patient on if the mother was amenable to pharmacological intervention?

2. What other assessment/screening tools would you have used to enhance the diagnostic impression?

3. What would you have done differently to promote effective treatment outcomes for this patient?


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition: Dsm-5 (5th ed.). American Psychiatric Publishing.


Bartoli, F., Crocamo, C., & Carrà, G. (2020). Clinical correlates of DSM-5 mixed features in bipolar disorder: A meta-analysis. Journal of affective disorders, 276, 234-240. https://www.sciencedirect.com/science/article/pii/S0165032720324800

Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics, 9(Suppl 1), S104.

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention deficit hyperactivity disorder (ADHD).

NYULangone Health. (2022). Cognitive behavioral therapy for schizophrenia.

https://nyulangone.org/conditions/schizophrenia/treatments/cognitive-behavioral-therapyforschizophrenia#:~:text=Cognitive%20behavioral%20therapy%2C%20also%20known,be %20leading%20to%20negative%20emotions.

Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 2470547017703993.

Schoenfelder, E. N., & Kollins, S. H. (2015). Topical review: Adhd and health-risk behaviors:

Toward prevention and health promotion. Journal of Pediatric Psychology, 41(7), 735–

740. https://doi.org/10.1093/jpepsy/jsv162

© 2021 Walden University

Page 9 of 9

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 7: Bipolar I Disorder

Christina Miller

College of Nursing-PMHNP, Walden University

PRAC 6675-25: PMHNP Care Across the Lifespan II

Dr. Connole-Pond



CC (chief complaint): “I thought nothing was real and they lied to me. I had the ideology of suicide and I had knives and pepper spray.”

Patient is a 54 year old Caucasian/White male who presented to the ED via police with complaints of suicidal ideation with a plan to be murdered by police and was subsequently admitted for psychiatric treatment.

Patient reports having difficulties with a neighbor and expresses paranoid thoughts, stating “he is a man who can’t let it go. He is going to beat me up but I told him he would be dead. I can make myself invincible, and you can tell by my teeth.”

Patient reports feeling sad, down, depressed, hopeless, helpless and worthless for periods of months at a time, spanning his entire lifetime. He reports increased energy and a decreased need for sleep. Patient reports not sleeping for 3-4 days at a time, “as many times as I want.” Patient reports his appetite as good but states he often does not eat enough because he talks too much. Patient states “it’s one of those times when all I need is a small bowl of pasta salad and a glass of water for the whole day.” He reports poor concentration and has difficulty staying on-topic throughout the assessment due to flight-of-ideas. He has rapid, pressured, and tangential speech throughout the assessment. Patient reports impulsive, excessive spending on non-essential items, such as baskets to soak his feet in and comic books. He also reports spending in excess of five thousand dollars on a game called “League of Nations.”

Patient makes many grandiose and bizarre statements, such as “all of this is evidence so I can go to prison and get shanked. I would rather go to prison not to rat out people in Texas who are helping me defraud the government of five thousand dollars per week. I have a lot of money and like to spend more than five thousand dollars per week.”

Patient reports having obsessions and compulsions, such as needing to arrange items by their size and then re-arrange the items the opposite way, multiple times. Patient reports being particular about cleaning beer cans from guests and expressed he becomes upset when they do not follow the exact directions on how he wants them cleaned and disposed of. Patient reports excessive collecting of items, such as comic books. Patient states “I live in a hoarder house. It’s filled with stacks of comic books.”

Patient reports a compulsion with watching pornography. He reports having spent time in prison due to child pornography charges. Patient states “I love it. I love child porn. It gives me a rush because I know it is so wrong. It’s exhilarating and titillating. I also like to watch virtual reality porn, where they depict children getting tortured and raped. I looked at the Princess Diana car crash photos because I was curious about their mangled bodies. I like to look for murder scene photos, beheadings, and different kinds of torture. You can buy all this stuff online.”

Patient reports a history of sexual abuse from his cousins as a child. Patient states “I told my mom and we never saw them again.” Patient also reports sexual assault by his uncle. He states “My uncle told me and my cousins that we were going to play a game. He made me and my cousin each touch the tip of our tongues to the other’s penis. It only lasted a second.” He denies emotional or physical abuse.

Patient reports episodic periods of auditory and visual hallucinations. He reports hearing voices but cannot understand what they say. He reports a history of “seeing a leprachan who stole my shit and hid it.”  He denies current auditory or visual hallucinations.


Patient reports episodes of rage. He describes becoming upset with a neighbor and “running over a box six times and then burning it.” He states “if people piss me off, I go crazy. I won’t cooperate. Just last night I got pissed off that they wouldn’t give me a pen to write with and I threatened to write with my own shit! It’s too bad I didn’t have a banana turd, or I would have.” Patient also reports destroying three computers in an episode of rage and setting his home on fire. 

Substance Use: Denies past or current use of ETOH, nicotine, or illicit drugs

Psychosocial: Patient was raised by his mother and does not know his father. He currently lives alone, with a pet dog, in a single family home. Patient has no children. Patient is a high school graduate and is unemployed. Patient has no military history. Patient served time in prison after being convicted of possessing child pornography.

Medical History: Type II Diabetes. No surgical history

Psychiatric History:

· Previous Diagnoses: Bipolar I Disorder, OCD

· Hospitalizations: Patient reports multiple inpatient hospitalizations but is a poor historian and is unable to recall when or facility names

· Suicide Attempts/Self-Harm Behaviors: Patient states he attempted to burn his house down in a suicide attempt and “walked into the woods and down a hill in a death march.”

· Current Medications: Seroquel 50 mg “as needed” Pt unable to recall number of times per day

· Previous Medication Trials: Patient is unable to recall

· Allergies: Lithium – hives

Family Medical History: Mother – diabetes

Family Psychiatric/Substance Use History: Patient states this information is unknown


· GENERAL: denies fever, fatigue, chills, night sweats, weight gain/loss

· HEENT: denies headache. Denies ear pain, change in hearing or discharge. Denies visual changes, eye pain, or discharge.  Denies nasal congestion, epistaxis, or rhinorrhea. Denies tooth pain, sore throat, difficulty swallowing or voice changes

· SKIN: Denies hair loss or hirsutism, rash, abnormal growths, sores, lesions, skin, hair, or nail changes

· CARDIOVASCULAR: denies chest pain/pressure, SOB, orthopnea, paroxysmal nocturnal dyspnea, extremity edema, syncope, palpitations, claudication, excessive/abnormal diaphoresis

· RESPIRATORY: Denies SOB, chest pain, cough, wheezing, hemoptysis

· GASTROINTESTINAL: Denies sub-sternal discomfort/burning, abdominal pain, dysphagia, nausea/vomiting, abdominal swelling, jaundice, constipation, diarrhea, melena, or abnormal changes in bowel habits

· GENITOURINARY: Denies hematuria, dysuria, disruption in initiation or stream or urine, incontinence, changes in urge/frequency

· NEUROLOGICAL: denies change in LOC, tics, tremors, tardive dyskinesia, drooling, seizures, headache, dizziness, disruptions in balance or proproception

· MUSCULOSKELETAL: Denies joint pain/swelling, weakness, arthralgia, myalgia, dystonia

· HEMATOLOGIC: Denies fevers, chills, weight loss, abnormal bleeding or bruising

· LYMPHATICS: Denies lymph node enlargement or tenderness

· ENDOCRINOLOGIC: Denies polyuria, polyphagia, polydipsia, fatigue, weight loss/gain, hirsutism


Physical Exam: BP 132/85  | Pulse 88  | Temp 37 °C (98.6 °F) (Temporal)  | Resp 16  | Ht 1.778 m (5′ 10″)  | Wt 108.9 kg (240 lb)  | SpO2 99%  | BMI 34.44 kg/m²

General Appearance: Obese, alert, no apparent distress

Musculoskeletal: ROM WNL, Gait WNL, No tics, tremors, agitation, retardation, rigitiy, cogwheeling or gait disturbance

Neurological: speech normal, mental status intact, cranial nerves 2-12 intact, muscle tone normal and muscle strength normal

Diagnostic results:

The following lab values were within normal limits: CBC, CMP, TSH, Folate, Vitamin B12, Lipids

SARS-CoV-2 PCR – Not detected

Alcohol: < 10 mL/dl

UDS: Negative for all


Glucose: 188

A1C: 7.2


Mental Status Examination: Patient is alert and oriented to person, place, time and situation. General appearance is obese and dissheveled, with poor hygiene. Eye contact is intense and psychomotor functions are within normal limits. No abnormal movements noted. His behavior is cooperative until periods when he is redirected to stay on topic, and he becamomes visibly agitated. His speech has a rapid rate with normal rhythm and volume. His language has good syntax and sematics with no language deficits. His mood is anxious with an irritable affect. His thought processes and associations are tangential with flight of ideas present throughout. His thought content is positive for delusions, grandiosity, obsessions, compulsions, and paranoia. Perception is positive for paranoia. His insight, judgement, and attention span are poor. His fund of knowledge, intellectual functioning, recent and remote memory are average.

Diagnostic Impression:

1. Bipolar I Disorder, current episode manic – The following criteria justify this diagnosis: chronic, daily, expanisive, elevated mood, and increased energy, lasting most of the day for months at a time, with unusual behavior consisting of grandiosity, descreased need for sleep, descreased food intake, flight of ideas, pressured, tangential speech, racing thoughts, difficulty concentrating, psychomotor agitation, impulsivity, and excessive risk-taking activities (American Psychiatric Association, 2013). These disturbances cause significant impairments in functioning and are not attributed to substance use (American Psychiatric Association, 2013). Additionally, sleep disturbances, circadian rhythm disturbances, heightened impulsivity, and mood disturbances are hallmark symptoms of disorders on the Bipolar spectrum (Titone et al., 2022). Though the following disorders are also present, this diagnosis is primary due to the exacerbation of numerous symptoms that are contributing most to the disruption in the level of functioning.

2. Obsessive-Compulsive Disorder (OCD) – The following criteria justify this diagnosis: receuurent, persistent intrusive thoughts and urges that cause anxiety and distress in the form of anger, attempts to ignore or suppress the thoughts but the individual is compelled to participate in compulsive behaviors to alleviate the distress (American Psychiatric Association, 2013).The driven urge to participate in repetitive behaviors, such as rearranging items by size, having to wash and re-wash items a certain way, continuous seeking of disturbing imagery to induce sexual arousal and relieve anxiety and distress, with these activities consuming a considerable amount of time (American Psychiatric Association, 2013). These urges and behaviors have caused significant impairments in functioning, are not better explained by another mental health disorder or medical condition, and are not attributed to the use of substances (American Psychiatric Association, 2013). OCD has been shown to be highly comorbid with other psychiatric disorders, including pedophilia-themed OCD (Bruce et al., 2017). However, this patient differs from others studied because he does not experience discomfort and shame.

3. Pedophilic Disorder – The following criteria justify this diagnosis: For a period lasting greater than six months, the patient has experienced recurrent, instense sexual fantasies and arousal/behaviors involving children, the patient acts on these fantasies by seeking out graphic pornography with images specifically depicting scenarios involving exploitation, sexual acts, and sexual acts involving torture of children (American Psychiatric Association). The patient also meets the age requirement of being over the age of 16 (American Psychiatric Association, 2013). Despite the consequences and having spent time in prison for the possession of child pornography, the patient continues to actively seek this illegal media for sexual gratification. A pedophilic orientation, not an actual disorder, would require a lack of acting on impulses and legal history (Jordan, et al., 2020). Interestingly, paraphilic disorders have been shown to have a co-occurance with Bipolar disorders, which is the primary diagnosis in this case (Ghoreishi & Assarian, 2018).

Reflections: If I had the opportunity to do this case again, I would have preempted the interview by informing the patient of the purpose of the discussion and approximately how long the encounter was expected to last. It was extremely difficult to keep this patient on-topic when answering questions, and he became irritable and aggravated when re-directed. Unfortunately, I was not able to follow-up with this patient, as he was discharged before I returned to practicum the following week. However, if I were to conduct a follow-up examination and discovered the patient was not at an optimal level of functioning, I would likely consider an adjunct medication, such as valproate sodium. Valproate sodium, an antiepilieptic that is used off-label as a mood stabilizer, has been demonstrated to be effective in treating aggression and behavioral problems, as well as improve mood dysregulation (Einberger et al., 2020).

Case Formulation and Treatment Plan: 

1.   Outpatient medications: Seroquel, 50 mg po prn (to be modified during inpatient stay)

2.   New medications: Initiate Seroquel 50 mg po BID at 08:00 and 12:00, and Seroquel 100 mg po QHS for the management of mania and psychotic symptoms. Patient educated on risks and benefits and provided verbal consent. Printed information to be provided by nursing.

3.   Admit to acute psychiatric inpatient unit. The patient will be seen in multidisciplinary staffing, and an individualized treatment plan will be created to include nursing, medication management, individual and group psychotherapies, social work, safety planning, and involvement in the ward milieu.

4.   Patient was counseled about the negative effects of cigarettes and smoking. Patient was offered tobacco cessation therapy and nicotine gum and patches. Tobacco cessation counseling was provided.

5.   Suicide Precautions.

6.   Other Precautions: Sexual precautions, Aggression precautions

7.   Discharge Plan: Plan to discharge to home with outpatient follow up once mania, suicidal ideation, and paranoia are improved.

Class Objectives

1. Descibe knowledge of the association between obsessive-compusive behaviors and paraphelias

2. Demonstrate knowledge of the importance of evaluating and differentiating between disorders on the bipolar spectrum

3. Evaluate strategies for self-care and preventing vicarious trauma when managing the care of patients who have the potential to trigger bias and negative emotions.


1. Is there a relationship between obsessive-compulsive behaviors and paraphilic disorders and how would you treat them?

2. Why is it important to consider a spectrum of bipolar symptoms in order to formulate an accurate diagnosis and treatment plan?

3. What can you do to promote self-care and guard against vicarious trauma, while also providing optimal care for patients whose actions are morally challenging to acceptable standards of societal behavior?


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.)

Bruce, S., Ching, T. W., & Williams, M. T. (2017). Pedophilia-themed obsessive–compulsive disorder: Assessment, differential diagnosis, and treatment with exposure and response prevention. Archives of Sexual Behavior, 47(2), 389–402.

Einberger, C., Puckett, A., Ricci, L., & Melloni Jr., R. (2020). Contemporary pharmacotherapeutics and the management of aggressive behavior in an adolescent animal model of maladaptive aggression. Clinical Psychopharmacology and Neuroscience, 18(2), 188–202.

Ghoreishi, F., & Assarian, F. (2018). A case report of pedophilia symptoms in a patient with bipolar disorder. Journal of Kashan University Medical Sciences, 22(4), 429–432.

Jordan, K., Wild, T., Fromberger, P., Müller, I., & Müller, J. (2020). Are there any biomarkers for pedophilia and sexual child abuse? a review. Frontiers in Psychiatry, 10.

Titone, M. K., Goel, N., Ng, T. H., MacMullen, L. E., & Alloy, L. B. (2022). Impulsivity and sleep and circadian rhythm disturbance predict next-day mood symptoms in a sample at high risk for or with recent-onset bipolar spectrum disorder: An ecological momentary assessment study. Journal of Affective Disorders, 298, 17–25.

© 2021 Walden University

Page 1 of 3




1 Great post Cynthia Nash

Response1 to question 1

1. Based on information presented, what medication might you have started the patient on if she was not currently on Seroquel, and why?

Lamictal would be my choice of treatment for Unspecified Mood Disorder with Anxious Distress especially because of the history of suicidal thought with and without a plan. In an exploratory study of  lamotrigine’s role in mood stabilization in adolescent with BPD. It found  effective in maintaining symptom control of a broad range of manic, depressive, irritable, and aggressive symptoms in PBD. There was no increase in suicidal ideation. Lamotrigine can be added to SGAs to gain effective symptom control and maintenance at an average dose of 200 mg/day. There was no weight gain or related metabolic abnormalities (Pavuluri et al., 2009).

Since  the rate of serious rash is greater in pediatric patients than in adults, Lamictal is approved only for use in pediatric patients below the age of 16 years who have seizures associated with the Lennox-Gastaut Syndrome or in patients with partial seizures. However, when confronted with the poor prognosis and suicide risk associated with treatment-resistant depression, LTG can be considered as a 3rd-line treatment option, as the benefits may outweigh the risks. Lamotrigine in Adolescent Mood Disorders: A Retrospective Chart Review study revealed that lamotrigine might be associated with a significant risk of benign rash. No serious rash such as Stevens Johnson Syndrome, Toxic Epidermal Necrolysis has occurred.  (Carandang et al., 2007).

Carandang, C., Robbins, D., Mullany, E., Yazbek, M., & Minot, S. (2007, February). Lamotrigine in adolescent mood disorders: A retrospective chart review. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent. Retrieved July 14, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276172/

Pavuluri, M. N., Henry, D. B., Moss, M., Mohammed, T., Carbray, J. A., & Sweeney, J. A. (2009, February). Effectiveness of lamotrigine in maintaining symptom control in pediatric bipolar disorder. Journal of child and adolescent psychopharmacology. Retrieved July 11, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2692234/

2 Response 1 question 1

1. Describe knowledge of the association between obsessive-compulsive behaviors and paraphilias.

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions are repetitive and persistent thoughts, images, impulses or urges that are intrusive and unwanted, and are commonly associated with anxiety. Compulsions are repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession according to rigid rules, or to achieve a sense of ‘completeness’.  Common sets of obsessions and compulsions in patients with OCD include concerns about contamination together with washing or cleaning, concerns about harm to self or others together with checking, intrusive aggressive or sexual thoughts together with mental rituals, and concerns about symmetry together with ordering or counting (Stein et al., 2019).

Paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. A recent study focusing on neurotransmission of paraphilic disorders found evidence to suggest that central dopamine plays a key role in the pathogenesis of paraphilic disorders and the general disturbance of the conscious regulation of behavior. The results of this study revealed increased levels of serotonin and norepinephrine, with a decreased concentration of DOPAC (3,4-dihydroxyphenylacetic acid) in urine samples of the test population diagnosed with paraphilic disorders. Researchers have established a correlation between serotonin and norepinephrine with obsessive disturbances and an association of DOPAC with affective and dissociative disorders. Studies have  also shown SSRIs to be particularly useful in the adolescent population and milder paraphilias, including exhibitionism and patients suffering from comorbidities of obsessive-compulsive disorders (OCD) or depression ( Fisher; Marwaha., 2022).

A relationship has been suggested between clinical presentation of paraphilias and obsessive-compulsive disorder (OCD) with respect to the unwanted repetitive nature and insight into the irrationality of the paraphiliac behavior. This has led to speculation that paraphiliac disorders might belong to an “obsessive compulsive spectrum.”  (Kruesi ;Fine ;Valladares ;Phillips ;Rapoport ;, 2021).

Fisher; Marwaha., K. A. R. (2022). Home – books – NCBI. National Center for Biotechnology Information. Retrieved July 14, 2022, from 

Kruesi ;Fine ;Valladares ;Phillips ;Rapoport ;, M. J. S. L. R. A. J. L. (2021). Paraphilias: A double-blind crossover comparison of clomipramine versus desipramine. Archives of sexual behavior. Retrieved July 14, 2022, from 

Stein, D. J., Costa, D. L. C., Lochner, C., Miguel, E. C., Reddy, Y. C. J., Shavitt, R. G., van den Heuvel, O. A., & Simpson, H. B. (2019, August 1). Obsessive-compulsive disorder. Nature reviews. Disease primers. Retrieved July 14, 2022, from 

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