Initial psychiatric evaluation

HPI: J.T. is a 33-year-old African American female who was seen for an initial psychiatric evaluation after being referred by her probation officer. She was released from jail one month ago for drug possession and stealing. Stated that even if she has money to buy items, she will steal from the store and that she can’t control wanting to steal. Admitted auditory hallucinations that tell her to steal and stated that her parents are the reason for her current issues.

She stated she cannot keep a job due to not being able to get along with coworkers and that she also has arguments with her dad. Stated that for the past two months, she has been irritated easily, has decreased need for sleep, relationship problems, not being able to keep employment, legal problems/tendencies, euphoria, mood swings, and impulsiveness.

Stated that she hates people because she gets used and that God often talks to her and no one else. Denied depression and S/HI. Denied current A/VH and paranoia although appeared to respond to internal stimuli. Denied drug/alcohol use. Initially refused to give a urine sample for testing but eventually complied. Currently on probation for stealing and drug possession.

Past Psychiatric History:

• General Statement: Has hx of mental illness but never treated
• Caregivers (if applicable): N/A
• Hospitalizations: Denied previous psychiatric hospitalizations
• Medication trials: Did not report any previous medications
• Psychotherapy or Previous Psychiatric Diagnosis: Stated she was told in the past that she has bipolar and stated she had conduct disorder in grade school

Substance Current Use and History: Denied current drug/alcohol use although initially refused urine drug screen (UDS) and has been arrested and is on probation for drug possession and stealing.

Family Psychiatric/Substance Use History: Stated her mother used drugs in the past but unsure of mental illness. Unsure of father mental illness.

Psychosocial History: J.T. was born and raised in Dallas, TX. Her mother used drugs and stated her father was around but “in and out” of her life. She has never been married and initially stated she had two children but then stated she has three children, aged 11, 13, and 15. Stated she graduated high school and received special education services from grades 1-12.  Currently does not work and lives alone with her three children. She has been arrested multiple times for stealing and drug possession and currently on probation. Denied childhood or adult trauma.

Medical History: 

• Current Medications: None
• Allergies: NKDA
• Reproductive Hx: LMP 8/20/2021

ROS:

• GENERAL: No reported fatigue or weight loss
• CARDIOVASCULAR: No complaints of chest pain/pressure/discomfort. No reported edema/palpitations
• RESPIRATORY: No shortness of breath
• GASTROINTESTINAL: No complaints of decreased/increased appetite, nausea, vomiting, or diarrhea
• GENITOURINARY: No complaints of burning on urination, hesitancy, urgency, odor, or odd color
• NEUROLOGICAL: No complaints of headaches/fainting or numbness/tingling of extremities. No issues of bowel/bladder control reported

Physical exam: B/P 120/72, T 98.5, R 19, P 82, Wt. 137 Ht 5’5, BMI 22.8

Diagnostic results: No current labs to review.

Assessment:

Mental Status Examination: J.T. is a 33-year-old African American female that appeared her stated age. She was dressed inappropriately in pajamas with a head wrap for interview. Cooperative with interview although seemed to be a poor historian. She had childlike behavior. Clear speech and is pressured with childlike tone. Mood was anxious mood with blunt affect. Thought process with loose associations, jumped from subject to subject, and delusional. Some interview questions were answered inappropriately. Appeared to respond to internal stimuli at times although she denied current A/VH. Denied depression and S/HI. Her insight was poor.

Differential Diagnoses: 

1. Bipolar I disorder, current or most recent episode manic, with psychotic features: 296.44 (F31.2). This client met the diagnostic and statistical manual of mental disorders 5^th edition (DSM-5) criteria for bipolar I disorder with psychotic features. She had pressured speech, flight of ideas, hallucinations with delusional thinking, involvement in activities that have high potential for painful consequences, irritable mood, grandiosity, easily distracted, an irritable mood (American Psychiatric Association, 2013).
2. Other (or unknown) Substance-induced bipolar and related disorder with moderate or severe use disorder: 292.84 (F19.24). Due to past drug use, she could have this diagnosis and it could possibly be the contributing factor to her mania symptoms. Due to her denying current drug use and a pending UDS, this diagnosis can be ruled out for now.
3. Kleptomania: 312.32 (F63.2).
4. This client met most of the criteria for the kleptomania diagnosis including recurrent failure to resist stealing items that are not needed, anxiety and tension before stealing the object, pleasure after stealing the object, and stealing not committed to express anger or vengeance (American Psychiatric Association, 2013). However, the stealing is in the presence to a hallucination as she stated that she hears voices that tell her to steal. Therefore, this diagnosis can be ruled out.

Treatment Plan:

1. Order UDS, CBC without diff, CMP
2. Start Risperdal 1mg po at HS
3. Refer to drug rehab depending on UDS results
4. Refer to psychotherapy
5. Call crisis hotline or 911 for suicidal thoughts with a plan
6. Follow up in 4 weeks

Reflections:

This client has a history of untreated bipolar disorder, possible drug use, and is currently on probation for habitual stealing. Her initial refusal to take a UDS suggests that she has possibly used drugs recently and according to Mondi et al. (2022), 20% of those with a mental illness have concurrent substance use disorder and almost 50% of those with substance use disorder have a mental illness.

Although she did not meet the kleptomania diagnosis per the DSM-5, her impulsiveness to steal is likely due to her bipolar I disorder.

Research has shown that those who are in a manic episode related to bipolar I disorder are at a high risk for acting impulsively as there is a strong association of manic symptoms and impulsiveness (Richardson et al., 2018). Also, shoplifting can be a part of the impulsive behaviors related to mania (Torales et al., 2020).

Although Lithium is typically the first line treatment for bipolar I disorder, it is sometimes not well tolerated. In this case, the second-generation antipsychotic (SGA) Risperdal was chosen for initial treatment. According to Lindstrom et al. (2017), SGAs are frequently used to manage the acute manic episodes of bipolar I disorder.

Psychotherapy treatment and drug rehabilitation for this client may also be beneficial and will likely result in a positive client if she remains compliant.

References

American Psychiatric Association. (2013). Depressive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). doi.org/10.1176/appi.books.9780890425596

Lindstrom, L., Lindstrom, E., Nilsson, M., & Höistad, M. (2017). Maintenance therapy with second generation antipsychotics for bipolar disorder – A systematic review and meta-analysis. Journal of Affective Disorders, 213, 138-150. doi.org/10.1016/j.jad.2017.02.012

Mondi, C. F., Giovanelli, A., Ou, S.-R., & Reynolds, A. J. (2022). Psychiatric and substance use disorders in a predominately low-income, black sample in early midlife. Journal of Psychiatric Research, 148, 332-339. doi.org/10.1016/j.jpsychires.2022.02.008

Richardson, T., Jansen, M., & Fitch, C. (2018). Financial difficulties in bipolar disorder part 1: longitudinal relationships with mental health. Journal of Mental Health, 27(6), 595-601. doi.org/10.1080/09638237.2018.1521920

Torales, J., González, I., Castaldelli-Maia, J. M., & Ventriglio, A. (2020). Kleptomania as a neglected disorder in psychiatry. International Review of Psychiatry, 32(5/6), 451-454. doi.org/10.1080/09540261.2020.1756635

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Questions

1. Even though you rule out Kleptomania, do you believe using medication for impulse control would benefit her? why or why not.
2. 9 barriers to effective treatment what is for the client? 
3. What will be the initial medical treatment why or why not?

Please help me with the 3 questions for me. Thank you.