Final Case Analysis Part B Psychiatric Evaluation

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Part A: Cultural Assessment

This cultural assessment is based on a composite case of an adult patient with a history of Adverse Childhood Experiences (ACEs) observed in a community mental health setting. The assessment follows Madeleine Leininger’s Culture Care Theory (CCT) to implement culturally appropriate care interventions across various dimensions of nursing practice.

Component of CCT	Cultural Characteristics	PMHNP Intervention
Technological factors	The patient has restricted access to dependable technology. The patient has limited access to a basic mobile phone and unreliable internet connectivity, which reduces her ability to use digital healthcare systems or virtual therapy services.	Introduce digital tools into care routines in a stepwise approach while providing in-person care whenever possible. Provide printed psychoeducational materials in the patient’s preferred language and offer support in learning to navigate simple mental health apps, if appropriate (Finley et al., 2024).
Religious, spiritual, and philosophical factors	Spirituality stands as the main support source for patients who seek comfort. The patient performs individual prayers and engages in religious and cultural rituals. The patient holds these beliefs for emotional stability and protection, although she keeps them private because she fears being judged.	The healthcare plan must validate and incorporate meaningful spiritual beliefs. Collaborate with culturally relevant spiritual advisors whenever possible to support emotional recuperation (Van Dusseldorp et al., 2023). Approval of culturally aware spiritual advisors will provide insight into emotional recovery support through spiritual strengths research.
Kinship and social factors	The patient resides with individuals from different generations under one roof, sharing a strong bond with female family members, yet distrusts authority figures stemming from previous traumatic experiences. Patient reluctance to access treatment had previously been linked to both social isolation and issues with trusting medical personnel.	A trauma-informed approach should develop trust between the patient and therapist and create a solid therapeutic connection (Van Dusseldorp et al., 2023). The nurse should include families in care planning as much as possible while maintaining patient independence and personal space.
Cultural values, beliefs, and lifeways	Respect, endurance, and family loyalty make up the core values. The practice of showing emotional vulnerability is considered weak, so individuals avoid therapy because of negative social views about therapy.	The therapist should implement CBT methods that match cultural sensibilities to reinforce beliefs about coping with emotional struggles. Strengthen the awareness of looking for support and promoting emotional expression, which serves as a pathway toward recovery (Henshaw, 2022).
Biological factors	The patient has recurring bodily symptoms, such as headaches and fatigue, which stem from early-life traumatic experiences. The patient chooses to use traditional medicines instead of pharmaceutical drugs.	The healthcare provider should give the patient access to integrative treatment methods, including mindfulness practice, aromatherapy, and guided breathing strategies (Burrows, 2025). Educate gently about medication options, involving the patient in shared decision-making.
Political and legal factors	Legal and immigration worries cause the patient to hold back from accessing care and sharing personal details.	Create a space where patients feel secure and get the support they need. PMHNPs should establish care rights and connect the patient with required legal and social advocacy resources (Burrows, 2025).
Economic factors	High financial burdens obstruct access to routine medical services, transportation, and the ability to obtain medications. Health insurance is unavailable.	Refer to community-based services that offer sliding scale fees. Adjust care frequency and location to accommodate economic realities.
Educational factors	Educational disruptions during childhood limited academic progress. The patient shows interest in vocational training, although she feels discouraged.	Help patients grow by connecting them to adult education and vocational programs while encouraging their recovery journey (Burrows, 2025).

 

Part B Psychiatric evaluation

PMHNP Psychiatric Assessment

Student name:

Semester/Year:

Course:

Patient encounter date: 04/05/2025

Patient to be given a pseudonym: J. M

Student/Preceptor Collaboration

Please confirm this psychiatric assessment was completed on a patient whom you saw in clinical this semester.	Yes        No  Explain_____________________ __________________________________________
Please confirm this is your own original work.	Yes        No  Explain_____________________ __________________________________________
Please confirm you and your preceptor saw this patient, and the psychiatric assessment is accurate to your best knowledge.	Yes              No  Explain_____________________
Student signature/date
Preceptor signature/date   Alebachew Kindie DNP, PMHNP-BC	04/12/2025

Chief Complaint

What brought you here today…? (Put this in quotes.)

“I’ve been feeling really low for months now, constantly anxious, and I can’t sleep or enjoy anything anymore. It’s getting harder to get through the day.”

Information

Identifying information: Gender, age, race/ethnicity, allergies, etc.	Mr. John is a 34-year-old African American male. No known drug allergies. He identifies as heterosexual. He is single, divorced for approximately one year
General overview of reason for visit: Follow up, new patient, updates since last visit, response to medication changes (if any)	Mr. John is a new psychiatric patient referred by his primary care provider due to persistent depressive and anxiety symptoms. He reported no prior psychiatric diagnosis or treatment history.
Vital signs, height/weight (if obtained) Allergies to medications (Females only): LMP Method of birth control	BP: 130/82 mmHg HR: 78 bpm Temperature: 98.6°F RR: 16 bpm Height: 5’10” Weight: 178 lbs BMI: 25.5 Allergies: None reported (Females only- LMP): Not applicable Birth Control: Not applicable.

History of Present Illness

HPI Overview: Tell us updates about what is currently going on with patient since the last visit. Any updates? Medication changes? Life changes?	Mr. John reported experiencing persistent low mood, sadness, and emotional numbness for the past six months. Symptoms worsened following his divorce, which he describes as traumatic and life-changing. He also reports low motivation, excessive worry, sleep disturbances, irritability, and decreased ability to concentrate, all of which are impairing his performance at work and affecting his interpersonal relationships
Depression symptoms: Sleep, interest, guilt, energy, concentration, appetite, psychomotor changes, suicidality When did it first start? Single episode? Recurrent episodes (When was last episode?)? Persistent (What’s the longest amount of time you have not felt depressed?)? Can you describe your depression symptoms? What makes the depression better; what makes the depression worse? Does the depression come and go?	Onset: Six months ago Course: Recurrent depressive episodes, with current episode lasting over four weeks Symptoms: Early morning awakening, fatigue, poor concentration, anhedonia, low self-worth, passive suicidal ideation Fluctuations: Symptoms are worse in the morning and during periods of isolation; mild improvement with exercise. Longest symptom-free period: Approximately one year before the current episode.
Anxiety: Does the anxiety come and go; is it situational? Or is it there all the time/more often than not? When did anxiety start? How does patient recognize they are anxious (what symptoms do they experience)? What triggers the anxiety? Panic? What triggers panic levels of anxiety (or are they spontaneous/unexpected/unprovoked)? What physical panic symptoms do they experience? How long do panic symptoms last? How often do panic levels of anxiety occur? When was last panic attack?	Onset: Also began approximately six months ago. Nature: Persistent and generalized; occurs most days. Symptoms: Muscle tension, restlessness, excessive worry, racing thoughts. Triggers: Work deadlines, conflicts, parenting concerns. Panic attacks: Denied Impact: Feels mentally and physically exhausted.
Mania/Hypomania: DIGFAST Disturbance of mood, increased energy/goal-directed activity, grandiosity, flight of ideas, activities that might get them in trouble, sleep decreased, talkativeness (pressured speech) “Have there been periods of time where all day/every day for at least 4 to 7 days or longer your mood was unusually elated/euphoric or irritable and it was so dramatically out of character that people wondered or asked if you were on drugs?” AND “Have you had so much energy that you could go days and days with little-to-no sleep, and you didn’t miss it or need it because you were so revved up?” What’s the longest period of time you’ve experienced the mood/energy disturbance? When is the last time you had an episode? What problems did this cause you/your life?	Denies any periods of elated mood, decreased need for sleep, or increased goal-directed activity.
PTSD: FIGHT Flight—avoidance symptoms, avoiding memories or external reminders of trauma Intrusive symptoms—nightmares, intrusive memories, flashbacks Gloomy cognition—negative cognition of self/others/world, negative mood Hypervigilance—easily startled, irritable/angry outbursts, reckless behavior Trauma—exposure to traumatic event	Denies trauma history or symptoms suggestive of PTSD.
Anger/irritability: Do you get angry more than you should? How do you act when you get angry?	Mild irritability during periods of stress; no verbal or physical aggression.
Attention and focus: Have you had problems with thinking, concentrating, or making decisions? When did it start? Does it come and go, or has it persisted? What does this interfere with?	·         Reports decreased concentration at work and forgetfulness in daily tasks. ·         Began approximately six months ago; persistent. ·         Interferes with job performance and task completion.
Obsessions: Do you experience recurrent thoughts, urges, or mental images that distress you and do not make sense, but they keep repeating even though you do not want them? Compulsions: Are there certain behaviors that you have to do over and over and you can’t resist them even though you do not want to do them? If yes to either/or/both: How much time in your day does this take up? How much does this disrupt or interfere with your life?	Obsessions: None reported     Compulsions: None Reported
Current self-harm, suicidal/homicidal ideations: Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself?	Denies current suicidal thoughts Admits to passive ideation (says “I wish I wouldn’t wake up”) after divorce Denies plan or intent; protective factors include his son and religious beliefs
Hallucinations: Do you ever hear or see anything that other people may not hear and/or see?	Denies auditory or visual hallucinations
Paranoia: Do you feel like people are talking about you or following you?	Denies feeling followed or watched
Disordered Eating: Anorexia: Weight significantly low? Fear of being fat? Body image distortion? Bulimia: Binging, out of control feeling while eating, concern with body shape, purging (or other compensatory behaviors)? Binge eating: Recurrent episodes (1x/wk for 3 months), eating out of control, more rapidly than normal, uncomfortably full, when not hungry, alone (because embarrassed), feeling disgusted/guilty/depressed afterwards	Patient denies any symptoms of anorexia nervosa. He is at normal weight for height and has no fear of gaining weight or becoming fat. There is no distortion of body image, restrictive eating, or excessive concern with body size. Patient also denies any bulimia nervosa behaviors. He does not have a history of binge-eating episodes followed by compensatory mechanisms such as self-induced vomiting, laxative use, or excessive exercise. He does not feel a sense of loss of control when he eats, and there is no obsession with body weight or shape that influences self-evaluation. The patient does not meet the criteria for binge eating disorder. He does not report regular incidents of eating large quantities of food in a short space of time. He denies eating more rapidly than normal, feeling uncomfortably full, eating when he is not hungry, or eating alone due to embarrassment. He also denies guilt, shame, or distress after eating. There is no indication of disordered eating patterns at this time. Decreased appetite appears to be associated with depressive symptoms rather than an eating disorder
Sleep: Do you have trouble falling or staying asleep? How long does it take you to fall asleep? After you get to sleep, do you stay asleep all night, or are you up and down throughout the night? Do you have trouble falling asleep, staying asleep, or sleeping too much? How much sleep do you get on average? How many nights per week do you have trouble sleeping or sleep excessively?	Difficulty initiating and maintaining sleep Averages 4–5 hours per night Reports waking up frequently and feeling unrefreshed

Family History

Pertinent mental health history—Include parents, siblings, grandparents if applicable/known

Father: Diagnosed with major depressive disorder. Maternal grandmother: History of bipolar disorder, treated with hospitalization. No known substance use disorders or suicide history in the family.

Personal/Social History

If an adult, who did they grow up with? Education level (How far did you get in school?), marital status, occupation, work history, and legal history, number of children, living situation (lives alone/with family, homeless, etc.)

Mr. John was raised by his mother and maternal grandmother after his parents separated when he was six years old. He completed a bachelor’s degree in Business Administration and is currently employed as a financial analyst. He was married for five years but divorced one year ago due to infidelity and communication issues. He has a five-year-old son who lives with his ex-wife. Mr. John resides alone in an apartment

Any environmental factors that are affected by or contributing to patient’s current state? For example: marital problems/divorce, death in the family, job loss, financial stress, social isolation, transportation issues, etc.

Divorce and co-parenting stress Work-related stress due to reduced performance Limited social engagement and isolation

Substance Use History

Do you currently use or in the past have used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used? Method of use, inhalation, IV, etc. Any SUD treatment history (inpatient, residential, outpatient, detox). Longest period of time sober/clean? Any sober support persons?	Illicit Drugs: Denies current or past use SUD Treatment: None Support system: Mother, close friend, and son
Do you currently have or in the past have had an issue with alcohol use? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past?	Alcohol: Occasionally drinks 1–2 drinks/month; no blackouts or dependency
Do you currently smoke cigarettes or vape?	Tobacco/Vaping: Denies use
Do you smoke marijuana?	Marijuana: Denies use
Daily caffeine intake	Caffeine: Consumes 2–3 cups of coffee daily

Past Psychiatric History

At what age did the symptoms start?	Patient indicates that the low mood and anxiety symptoms first appeared at 29 years; at the period when he started experiencing marriage conflict. He recalled having been tired, irritable, and sad but these were minor and transient until they became much worse six months ago at 34 years.
Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis?	Patient has no formal previous psychiatric diagnosis. He reports that although he experienced depressive symptoms in the past, he never sought out assessment or treatment until this current episode. The worst symptoms began following his divorce, which occurred approximately one year ago.
Were there any environmental factors that could have contributed to the symptoms? For example, divorce, death in the family, etc.	Yes. The patient implies his recent divorce, co-parenting challenges, and stress regarding work as significant environmental factors for his current depressive and anxious presentation. He talks about emotions of loss, loneliness, and self-blame on the breakdown of the marriage.
Prior suicide attempts? If so, when did they happen, what was the attempt (method, potential lethality, context of alcohol/substance use, etc.).	Denies prior suicide attempts. Never had suicidal intent behaviors and denies alcohol or substance use in connection with suicidal ideation.
Prior suicidal thoughts? If so, active thoughts with plans? Passive thoughts (just wanting to die or not wanting to live) without plans? How often do thoughts occur? When was last time you had suicidal thoughts? Reasons for living? Reasons for not killing yourself? What is your safety plan?	Patient reports having passive suicidal ideation following his divorce, six months ago. He had reported hopelessness and thoughts such as “I don’t want to wake up,” but he did not have a plan or intent in progress. Thoughts occurred intermittently over a period of two months but subsequently remitted. His motivations for remaining alive as he described them were his child, wishing to improve regarding his mental health, and his faith. He has never made an explicit plan to kill himself. He understands how to use a crisis to get help and has agreed to notify his provider or go to the emergency department if suicidal thoughts recur.
Prior/current intentional self-injury (cutting, scratching, burning, headbanging, etc.)? If so, when did it start, how often does it happen, when did it last happen?	Patient denies any past or current intentional self-injury behavior.
Any current or previous psychotherapy? Adherence to current/past therapy?	The patient had two individual counseling sessions approximately eight months ago, shortly after his divorce. Therapy was put on hold due to financial constraints and scheduling conflicts. He reports that he benefited from those sessions and is willing to return to therapy.   The patient had initial enthusiasm to attend therapy, but was unable to maintain it due to outside factors. He did not follow up thereafter, but now shows willingness to attend regularly.
Any previous treatment? If so, what was it and did it work? List any previous psychiatric medications that have been tried and why the medication was stopped.     Please include details on response, side effects, dosing, and timeline of how long the patient was on or took the medication.	The patient has never been on psychiatric medications. This is his first mental health evaluation and first referral for pharmacologic treatment.       Not applicable – no prior treatment with psychiatric medication.
Any other treatments, such as ECT, TMS, ketamine?	No ECT, TMS, or ketamine treatment has been received or referred by the patient. He has never heard about these treatments.

Medical History

Medical problems	Conditions: Mild hypertension managed with diet and exercise Current medications: Lisinopril 10 mg PO daily
Previous surgeries	Surgical history: Appendectomy at age 12

Mental Status Exam

Observations

Appearance: Gait, posture, clothes, grooming (Appropriate to weather? Appear stated age?)	Neatly dressed, good hygiene, normal posture and gait, appears to be of stated age.
Behaviors: Mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions	Cooperative, engaged, maintains good eye contact, no abnormal movements.
Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive	Open, cooperative, and demonstrates insight into symptoms.
Level of consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating	Alert and fully conscious
Orientation: “What is your full name?” “Where are we (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?”	Oriented to person, place, time, and situation
Additional comments	The patient presented a calm and cooperative demeanor throughout the interview. He related properly to the examiner, responded freely to questions, and maintained normal eye contact. Speech was clear and coherent, and there were no signs of agitation or psychomotor retardation. There was no sign of internal preoccupation or responding to internal stimuli.

Speech

Quantity descriptors: Talkative, spontaneous, expansive, paucity, poverty	Normal
Rate: Fast, slow, normal, pressured	Normal
Volume (tone): Loud, soft, monotone, weak, strong	Normal volume: Tone is clear and coherent
Additional comments	There was no evidence of pressured speech, latency, or blocking of thought

Affect and Mood

Mood (how the person tells you they’re feeling): “How are you feeling?”	(Self-reported): “Sad and worried most days”
Affect (what you observe): Appropriateness to situation, consistency with mood, congruency with thought content ·         Fluctuations: labile, even, expansive ·         Range: broad, restricted ·         Intensity: blunted, flat, normal, hyper-energized ·         Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable	Affect is consistent with the situation and patient’s reported mood. Affect is consistent with thought content since it was presented during the session. Patient is emotionally engaged but limited emotionally.   Fluctuations: Even – no sudden or abrupt mood changes reported during the interview.   Range: Restricted – there is emotional expression but limited range and depth.   Intensity: Blunted – emotional responses are diminished in intensity but not absent.   Quality: Dysphoric – patient displays symptoms of sadness and low emotional tone, consistent with depressive symptoms.
Congruency: Congruent or not congruent mood?	Congruent with mood
Additional Comments:	The affect of the patient was also flat, with minimal spontaneous smiling and affect variation. While cooperative and interested, his facial affect and tone of voice reflected a pervasive low mood. Incongruent affect or inappropriate affect was not observed during the interview. His affect was congruent with his clinical presentation of moderate depression.

Perception

Paranoia	Patient denies ideation of paranoia. No report of being observed, trailed, or singled out by others is present. Suspicions against others and suspicious thoughts were absent during the session.
Auditory/Visual/Other hallucinations	Patient denies any hallucinations, auditory, visual, tactile, olfactory, or otherwise. He denies perceptual disturbance and does not show any behavior that is characteristic of responding to internal stimuli.
Additional Comments	There are no signs of perceptual disturbances during the interview. Patient’s answers were based on reality, and he did not demonstrate signs of misinterpretation of environmental or internal experiences

Thought Content

Suicidal	Patient denies current suicidal ideation, intent, or plan. Reports that he had experienced passive suicidal ideation in the past since his divorce (“Sometimes I wished that I wouldn’t wake up”), but this was transient and not with intent or planning. Denies history of suicide attempts. Protective factors include his child, close family, and personal values. He has a verbal safety plan and can access crisis support if needed.
Homicidal	Patient denies having any current or past homicidal ideations, thoughts, or intentions. He denies any resentment or anger towards others, suggesting a danger of hurting.
Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?) ·         Delusions are fixed, false beliefs. ·         These are unshakable beliefs that are held despite evidence against it and despite the fact there is no logical support for it. ·         Is there a delusional belief system that supports the delusion?	Patient denies fixed false beliefs or delusional thoughts. There are no erotomanic, grandiose, jealous, persecutory, or somatic delusional themes. He possesses logical and coherent thinking, and no belief system that would allow delusional content was observed.
Additional comments:	Thought processes appear to be goal-directed and reality-based. There were no signs of ideas of reference, magical thinking, or paranoia reported during the assessment. The patient remained open to insight and feedback during the session.

Insight/Judgement

What is their understanding of the world around them and their illness?	The patient’s insight is fair to good. He understands that his symptoms of low mood, anxiety, and difficulty concentrating are psychological and attributable to his recent life stressors, particularly his divorce. He demonstrates awareness of how these symptoms affect his daily functioning, interpersonal relationships, and work performance.
Are they able to do reality-testing (i.e., are they able to see the situation as it really is)?	Yes, the patient is able to perform reality-testing. His thinking is logical, coherent, and goal-directed. He denies hallucinations, delusions, or paranoia, and he is oriented to person, place, time, and situation. There is no sign of psychosis or distorted thinking during the evaluation.
Are they help-seeking? Help-rejecting?	The patient is help-seeking. Although he dropped therapy in the past due to external constraints (scheduling and finances), he expresses a need to return to treatment and resume care. He acknowledges the usefulness of prior sessions and is receptive to psychotherapy as well as drug therapy.

 

Psychiatric Diagnosis

Rating scales (If no rating scales were used, what could have been used?) Please indicate the name of the rating scale, the score of the rating scale, and what the score means in relation to the diagnosis.	PHQ-9 (Patient Health Questionnaire-9): Score = 17 Interpretation: Moderately severe depression Clinical Relevance: Indicates severe depressive symptomatology that impairs daily functioning and is consistent with Major Depressive Disorder.   GAD-7 (Generalized Anxiety Disorder-7): Score = 14 Interpretation: Moderate anxiety Clinical Relevance: Aids diagnosis of Generalized Anxiety Disorder, with functional impairment resulting from excessive worry, restlessness, and poor concentration.
Current diagnosis, including specifiers	·         F33.1 – Major Depressive Disorder, Recurrent, Moderate   ·         F41.1 – Generalized Anxiety Disorder
Case formulation/biopsychosocial assessment (a summary of the genetic vulnerabilities, attachment styles, employment, relationships, triggers/modifiable factors, medical conditions and adverse experiences that may impact the clinical picture.)	Mr. John is a 34-year-old male with moderate recurrent depression and anxiety symptoms. He developed symptoms six months ago after undergoing a traumatic divorce. Work stress and co-parenting stress have added to his symptoms.   Biological Factors-   ·         Family psychiatric disease history: Father with Major Depressive Disorder, maternal grandmother with bipolar disorder.   ·         No drug use or significant medical conditions aside from mild hypertension.   Psychological Factors-   ·         Depressive cognitions of low self-esteem, hopelessness, and passive suicidal thoughts.   ·         Generalized anxiety with hurried thoughts and complaints about the body (e.g., tension).   ·         Good to fair insight and willingness to be treated.   Social Factors- ·         Social isolation following divorce   ·         Work stress due to poor work performance   ·         Tiny support system, although he gets along with his son and mother.   Protective Factors- ·         Parenting role   ·         Spiritual beliefs   ·         Previous good experience of therapy   ·         No substance abuse or suicidal attempts in history
Differential Diagnosis	I.            Adjustment Disorder with Depressed Mood: Considered due to stressor (divorce), but symptom severity, duration, and impairment are more in favor of MDD diagnosis. II.            Persistent Depressive Disorder (Dysthymia): Excluded because symptoms did not persist all along; symptom-free for roughly one year before.
Rule Out Diagnosis	Bipolar II Disorder: Excluded. No history of hypomania, elevation in mood, or decreased need for sleep. No evidence of increased goal-directed behavior or grandiosity.

Medications

Medical medications	Lisinopril 10 mg PO daily (for mild hypertension)
Psychiatric medications—list name (generic name). If the person does not take any current psychiatric medications, please indicate this, along with at least one medication that could work with their diagnosis and presenting symptoms.	Sertraline 50 mg PO daily (SSRI, for depression and anxiety) (Howlett & Schatzberg, 2024).
Medication education provided to patient	·         Described the mechanism of SSRIs in mood regulation ·         Onset of therapeutic effect: 2–4 weeks ·         Common side effects: nausea, headache, sleep changes, sexual dysfunction ·         Emphasized adherence and reporting of side effects
Risks, benefits, side effects, and alternatives discussed with the patient	Informed Consent: Patient consented to start medication after discussion of risks, benefits, and alternatives, including therapy as the only option.

Treatment Plan

Next visit scheduled
The rest of the treatment plan will be addressed in Part C: The PMHNP Role in Patient Care	·         Begin Sertraline 50 mg PO daily ·         Refer for biweekly Cognitive Behavioral Therapy (CBT). ·         Educate on sleep hygiene, journaling, and mindfulness skills (Johnson, 2022). ·         Follow-up in 2 weeks to monitor tolerance to medication and response. ·         Use PHQ-9 and GAD-7 on each visit to monitor symptom trend. (Kroenke, 2020; Sapra et al., 2021).

Billing/Coding

ICD 10 Code	F33.1 – Major Depressive Disorder, Recurrent, Moderate F41.1 – Generalized Anxiety Disorder (Kroenke, 2020; Sapra et al., 2021)
Billing Code	CPT CODE 99205 – Initial comprehensive psychiatric diagnostic evaluation, moderate complexity

 

 

Part C: Therapy Session

Client Name: Zara

Age: 36

Ethnic/Cultural Background: Pakistani-American

Setting: Community Mental Health Clinic

Zara: Hello,

Therapist: I am pleased to see you today, Zara. How are you feeling?

Zara: To be honest, my inner state exhibits diverse feelings right now. Since the previous session, a sense of weight has remained, while this week brought additional stress due to family interactions.

Therapist: I appreciate you sharing that. Let us start our conversation here. Could you elaborate on the situation regarding your family?

Zara: Sure. We were planning our Eid activities as usual when my sister commented that I always make things complicated. This casual remark from her hit me powerfully, although it was intended to be casual. It reminded me of old wounds.

Therapist: The words seemed to weigh on you in ways beyond what their literal meanings implied. You must have experienced something profound at that precise moment.

Zara: My body experienced a swift surge of anxiety. I experienced throat constriction while barely managing to stay in the space. Despite the anger I experienced, it seemed to me that others judged me and thought I was inadequate.

Therapist: I hear that, Zara. Your body and emotional state return, and you must constantly be on guard. Listening to your descriptions helps me visualize all the weight you have from your years as a child.

Zara: Yes, exactly. As a child, I recall when my father, together with other family members, would criticize me because they believed my sensitivity levels were excessive. They called me weak any time I displayed strong emotions. The evident pattern has continued from my childhood into my adult years.

Therapist: Carrying such a weight feels extremely hard, Zara. It sounds like you internalized that message, and now even gentle words, like your sister’s comment, can trigger those painful memories.

Zara: That is right. My reaction makes others feel I have gone too far. Deep inside, I feel bad because I understand that my emotional state is not meant to cause problems, but only to express myself.

Therapist: It is entirely normal to experience such feelings. Your response patterns through sensitivity represent the outcomes of experiencing difficult situations. Our professional alliance recognizes your entire self at every level. Your genuine feelings hold value, whereas being sensitive is an essential part of your adaptive abilities.

Zara: It becomes difficult to notice this change at times. A hidden part of me questions why I cannot move past it, since I ought to act differently at this stage.

Therapist: I understand, Zara. People face difficulties when cultural norms compel them to stay quiet. Children raised in Pakistani families sometimes faced criticism for exhibiting emotions because it was considered a sign of weakness. According to Leininger’s Culture Care Theory, we must recognize cultural values and the natural requirement for emotional communication.

Zara: You are right. I battle to comply with my family traditions, yet I must respect my emotions. Sometimes, they seem at odds.

Therapist: Experiencing tension is typical because cultural norms often become deeply embedded in people. The practice of honoring your culture does not require emotional suppression. Honoring your heritage while staying true to your authentic self is achievable through finding a path that connects both elements. What does honoring both sides feel like to you?

Zara: My expression of feelings will combine English and Urdu while honoring traditional practices when I communicate emotional experiences. I experience occasional conflicts but desire an integrated combination of these cultural aspects.

Therapist: That is a beautiful insight, Zara. Combining your cultural expressions alongside both languages creates a strong healing process to celebrate your heritage. The utilization of your home language gives you access to feelings that seem genuine and nuanced.

Zara: I have noticed that. I connect with my close friends on a deeper emotional level when discussing matters in Urdu, as compared to the manner in which I express myself in English.

Therapist: The ability to speak two languages and maintain two cultural identities creates a powerful strength. Through a bilingual and bicultural identity, you get expanded avenues to communicate who you are. You can use this dual identity to unite separate parts of your identity that previous judgments had suppressed.

Zara: It makes sense. I never thought about it that way. I usually feel conflicted and sometimes guilty for these emotional reactions.

Therapist: The suppression of emotions produces the typical emotional response called guilt. The experience of emotions should never be dismissed as a weakness because such sensations prompt your awareness of inner emotional experiences. Making yourself vulnerable by revealing your feelings enables you to recover through methods that match your authentic self.

Zara: That resonates. Years have passed while I tried to conform to basic standards that did not apply to me. How I deeply interact with people and myself represents a strength rather than a weakness.

Therapist: Your words display a strong character, which I recognize through your words. As our dialogue progresses, you must envision a conversation with your younger self about the lesson of silence instead of communication, which she mastered then. What might she say if she knew you were here today, ready to honor her cultural heritage and emotional truth?

Zara: (Pauses) I would tell her, “I understand things have been tough and you were taught to suppress emotions, but now you have another way to express yourself honestly while respecting your traditions.” You maintain the right to stay faithful to your customs while embracing your authentic self.

Therapist: Your words hold great strength, Zara, because they inspire us to be sympathetic to ourselves and others. Being compassionate remains vital since it applies equally to others and oneself. The choice to redefine previous suffering enables you to create a more authentic existence.

Zara: When I express that openly, it creates an uplifting sensation inside me. It is like I am finally permitting myself to be whole, embracing both the parts steeped in my cultural past and the parts evolving now.

Therapist: Absolutely. Using dual-language expressions may help you link past moments with the current version of yourself. The next time you feel overcome with emotions, you should use the Urdu phrase “Āp merī himmat ho” (You are my strength) to create a soothing connection between your past and current self. What do you think about that?

Zara: I love that idea. Wearing the Hijab fosters a bond with my cultural roots while building personal strength.

Therapist: The core value in culturally congruent care appears through this approach. Your healing process benefits from therapy experiences that integrate your cultural background components. Utilizing cultural expressions as our therapeutic foundation in later sessions can enhance the effectiveness of your care.

Zara: I feel curious and hopeful. When I share details about my cultural origins, the experience becomes authentic since it recognizes what makes me unique.

Therapist: I am glad to hear that. The healing space needs to build security feelings while strengthening each element of your identity. You gain tremendous strength by using your cultural heritage as a healing mechanism.

Zara: Exposure in my full, authentic form brings positive value to me. Showing my genuine self to others creates apprehension because I believe they will view it as a sign of weakness. Today, I learned that displaying my exposed side contains a genuine strength.

Therapist: Exactly, Zara. Openness represents a brave quality that most individuals encounter challenges in upholding. Making openness a foundational principle leads people to form a new life story that combines cultural standards with individual needs.

Zara: I continue to reshape the societal narratives that were forced upon me. The once voiceless, sensitive, broken child is reshaping into someone who respects her previous identities while designing a better future.

Therapist: This statement provides an exquisite description of the idea. Each meaningful talk steers the narrative of your life ahead because of your practice of patience over time. Your cultural heritage includes healing possibilities that you can develop through the environment you build. The useful components of endurance and social ties, and family connections from your cultural background can now serve to improve your health and wellness.

Zara: My previous understanding of cultural expectations operated quite differently from this perspective. I considered cultural expectations as limitations before this realization. The cultural norms I once considered restrictive barriers now seem to be the essential basis for a nurturing setting.

Therapist: The change requires minimal adjustment. Your acceptance of cultural heritage protects the positive aspects of your heritage while you improve elements that cause you discomfort. During our sessions, we will expand this examination until you recover.

Zara: I would like that. An endless internal struggle exists between my duty to traditional beliefs and my requirement for personal independence. All these tendencies demonstrate their capacity to peacefully maintain coexistence.

Therapist: That is an incredible insight, Zara. Together, we will establish this harmonious relationship as part of our ongoing professional partnership. Others share this path toward success with you. Your ability to use both languages can establish a connection between different cultures by respecting old knowledge and new possibilities.

Zara: I felt entirely understood during this conversation, which gives me a new emotional experience. The experience lets me express myself through both verbal language and emotional communication without facing any criticism.

Therapist: I am happy to hear that. Your personal experience holds immense importance. Your present-day commitment to showing bravery helps you understand and value your cultural identity while accepting your weaker points. How do you feel about the way our conversation has unfolded?

Zara: I feel lighter. I plan to apply the concepts I learned here to implement changes at home when I reunite with my family next week. I wish to remain in the present moment, even though I need to protect certain parts of myself.

Therapist: That sounds like a significant step forward. When those initial feelings of tension appear, use one of the comforting statements we have examined before. The phrase is a gentle reminder of your strength, which supports your ability to merge cultural heritage and emotional truth during that time.

Zara: Yes, I think I will. I plan to journal in Urdu for specific instances to express my feelings through words that contain the depth of my experience.

Therapist: That is an excellent idea, Zara. Writing in your mother tongue through journaling provides exceptional validation. The practice enables you to keep subtle meanings that disappear from your writings in English while strengthening your holistic identity.

Zara: I appreciate that. The constant pressure to control my authentic self resulted in feeling detached from essential parts of my identity. I have started recognizing that all elements of my heritage, including feelings, language, and traditions, belong to my recovery process.

Therapist: I am privileged to help you move forward on this journey. Each dialogue serves as a path toward knowing you better, both mentally and emotionally. Zara, I believe in you as you explore the diverse aspects that shape your authentic self.

Zara: Thank you so much. The support I receive makes me feel understood in all aspects of myself, including my cultural background and my individual path. This makes all the difference.

Therapist: I am glad to hear that, Zara. The purpose of our work is to establish complete recognition of your voice as the central focus. Our upcoming session holds the promise of further exploring these important themes together. We will stop here for now to value this progress that you have made. You have done wonderfully today.

Zara: I appreciate that. I now recognize that uniting my cultural heritage with emotional reactions makes me stronger than before, when it seemed restrictive.

Therapist: Indeed, it is empowering. Moving ahead, you should continue drawing upon the strength you discovered today. Every time you make this effort, you create an environment where you will eventually be perceived precisely as you want.

Zara: I will do that. Your platform has created a space for me to share my emotions freely through various languages.

Therapist: You are very welcome, Zara. You have my full support during our sessions, for every breakthrough while speaking, and even during moments of silence. Our upcoming discussion will advance the progress we made during this session. With its full spectrum of diversity, your voice stands as a priceless asset that you should nurture. Your voice, in all its diversity, is a treasure.

Zara: Thank you. I leave today with a new sense of peace, which has brought happiness to my soul.

Therapist: See you next week, Zara.

Part D: The PMHNP Role in Patient Care

Part A: Patient Education

When working with a 34-year-old patient who faced Major Depressive Disorder and Post-Traumatic Stress Disorder from multiple Adverse Childhood Experiences, I delivered thorough information about her treatment medication. Given her persistent low mood, hypervigilance, intrusive thoughts, and insomnia, I advised initiating Fluoxetine at 20 mg daily. This selective serotonin reuptake inhibitor (SSRI) is effective in treating both depression and PTSD symptoms (Edinoff et al., 2022).

Through my explanation, I described how Fluoxetine increases brain serotonin levels for mood regulation and symptom reduction in anxiety treatment (Daws et al., 2022). The treatment requires 2–4 weeks until patients start feeling better and takes complete effect within 6–8 weeks. I informed her about typical Fluoxetine side effects, such as nausea and headache, while also addressing dry mouth symptoms alongside short-term elevation of anxiety before describing the potential risk of suicidal thoughts and serotonin syndrome. I provided written handouts, used the teach-back method to confirm understanding, and reassured her that we would monitor her closely.

During our session, we evaluated how important medication adherence was, and I validated her prior unfavorable experiences with psychiatric drugs. The treatment approach would involve joint decision-making while adjusting her medications when intolerable side effects occur. She voiced concern about losing the ability to feel things or developing dependence on drugs. I explained that the goal was to create a stable mood and enhance trauma therapy readiness while preventing the suppression of her emotional response (Daws et al., 2022). During our conversation, I described that I could be reached anytime between sessions and provided details for crisis hotlines. The discussion was intended to give her information that would boost her confidence, along with fear reduction and establishing trusting relationships throughout treatment.

Part B: Evidence-Based Interventions

Medical care for patients who have experienced childhood adverse events requires implementing integrated trauma-based treatment, which combines medication-based therapy with drug-free interventions. Interactions for patient treatment were selected using guidelines provided by the American Psychiatric Association (APA) and Veterans Affairs/Department of Defense (VA/DoD), together with the National Institute for Health and Care Excellence (NICE).

1. Pharmacological Intervention – SSRIs (Fluoxetine)

The American Psychiatric Association, together with the Veterans Affairs and Department of Defense, classifies SSRI Fluoxetine as a primary choice treatment for PTSD and its associated depression (APA and VA/DoD PTSD Clinical Practice Guidelines 2023). Fluoxetine served as the selected treatment medication because the patient previously experienced depressive episodes combined with anxiety symptoms. Scientific research has established Fluoxetine as effective for managing emotional dysregulation as well as irritability with its ability to control ruminative thoughts stemming from untreated trauma (Edinoff et al., 2022).

I performed a detailed assessment to determine any treatment limitations, particularly regarding previous bad reactions to SSRIs and emotional numbing from her medical history. The treatment started with modest dosages followed by periodic dosage augmentations because we required precise monitoring of adverse effects and therapeutic changes.

2. Trauma-Informed Cognitive Behavioral Therapy (TI-CBT)

Trauma-informed Cognitive Behavioral Therapy (TI-CBT) represents an evidence-based methodical process for treating PTSD, which works exclusively for people who have faced multiple traumatic events, especially those with Adverse Childhood Experiences (ACEs). TI-CBT fulfils NICE and APA treatment recommendations by helping people identify distorted thoughts, increase emotional control, and develop coping skills (Daws et al., 2022). This client suffered from severe adverse childhood experiences (ACES), which made them find acceptance in TI-CBT since it matched their practical needs as well as its professional therapeutic tools.

Internal stability creation represented the first therapeutic phase since victims of trauma generally stay in a constant state. Psychoeducation helped the client comprehend how early trauma affected her nervous system operations, along with emotional reactions and her relational behaviour. Her complete understanding of physical symptoms brought about a critical decline in self-shame, which in turn created an environment for self-love. The insight into her intense emotions helped her accept a rational perspective because she learned she was responding the way an ordinary human would when her needs matched the treatment plan.

Multiple grounding techniques, such as the “5-4-3-2-1” sensory technique, diaphragmatic breathing, and safe-place visualization, were taught to help her maintain presence when facing emotionally challenging situations. She initially got irritated about her inability to control her emotions, but eventually made these tools essential for her self-regulation. The client informed me that she utilized breathing techniques beforehand to manage difficult talks with relatives, showing how therapeutic lessons are applied in real-life situations.

3. Eye Movement Desensitization and Reprocessing (EMDR)

The patient’s unwillingness to remember traumatic memories led to the integration of EMDR to serve as additional therapy. The US Department of Veterans Affairs and Department of Defense, along with the American Psychological Association, endorse EMDR as an evidence-based trauma therapy. The therapeutic method provided an avenue for memory processing while minimizing verbal communication, which lowered her mental obstacles toward treatment (Daws et al., 2022).

During the sessions, the patient received bilateral stimulation when recalling emotional memories. Through time, the patient’s intensely emotional memories became less overwhelming, so she could regain her balance without feeling anxious. Through EMDR sessions, she developed stronger emotional connections between different memories and learned to practice self-compassion.

4. Mindfulness-Based Stress Reduction (MBSR)

MBSR was incorporated into her clinical program because it helps patients develop self-regulation abilities and combat hyperarousal symptoms that frequently affect those diagnosed with complex PTSD. Mindfulness-based therapies are recommended treatments for depressive and anxiety symptoms according to NICE guidelines. During MBSR practice, the patient learned breathing techniques, body examination, and self-awareness strategies (Moyes et al., 2022).

Being aware of her own body turned out to be challenging because the patient was uncomfortable being by herself, a typical issue that ACE survivors face. However, with gentle pacing and trauma-informed instruction, the patient was able to use mindfulness techniques that controlled persistent thoughts and minimized her emotional outbursts (Moyes et al., 2022).

5. Peer Support and Group Therapy

Since the patient showed intense emotional isolation and mistrust, together with difficulties making connections, I sent her to a specialized trauma-oriented support group targeting people who experienced Adverse Childhood Experiences. Through group therapy sessions, she interacted with other individuals who were also survivors of childhood trauma in a protected space featuring structured protocols. Through this approach, we achieved a trauma recovery goal by helping her develop trust in people alongside building relationships that provided a sense of belonging (Lorenc et al., 2020). She started by watching the group members without speaking, but gradually revealed her personal experiences. The act of hearing others express emotions that matched her struggles reduced her internalized shame and made her feel less separate from others. Individual therapy progress received confirmation through group interactions, which demonstrated that the painful reactions she experienced were normal among people who survived trauma (Moyes et al., 2022). Her participation in the group fostered her confidence levels while making her more emotionally exposed and leading to better consistency in her therapeutic engagement.

Part C: Ethical/Legal Considerations

1. Legal Considerations and Risk Reduction Strategies

Texas law requires PMHNPs to carry out three responsibilities for treating patients with trauma history: mandatory reporting for active abuse suspicions, the duty to warn clients or potential victims about dangerous situations, and informed consent requirements. The patient revealed to me about childhood sexual abuse experiences, yet stressed that her offender had passed away and she currently faced no risk.

Texas Family Code §261.101 mandates me to report child or vulnerable individual abuse in current cases, yet, being historical with no ongoing danger meant I was not required to report. I thoroughly documented the confession and provided links to legal advocacy support she could access in case she decided to seek justice later.

I explored risk management concerns due to the patient’s history of constant suicidal thoughts, which were currently without any immediate plans or intentions. By using the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment, I created a safety plan together with the patient. I provided her with emergency contact information along with crisis solutions. I provided detailed information about voluntary and involuntary admission procedures under Texas Health & Safety Code §573.001 in case her risk level changes.

To mitigate future risk in practice, I will:

1. I will ensure optimal patient outcomes by using validated screening tools as staff systematically record all clinical actions and patient interactions. The established documentation process enables holistic patient care delivery and risk management control. It fulfils all legal documentation needs, specifically when treating patients whose lives have been affected by childhood adversity (Moyes et al., 2022).
2. I will stay updated with Texas laws regarding the reporting of Adverse Childhood Experience (ACE) combined with knowledge of suicide prevention methods and involuntary psychiatric restraint techniques. The adherence to updated laws protects both patients’ rights and ensures the ethical delivery of safe healthcare to trauma victims with a tendency to harm themselves or experience critical conditions (Moyes et al., 2022).
3. Legal and ethical consultants will provide support whenever patients offer complex information about past traumas, as well as suicidal thoughts and confidentiality matters. The role of legal and ethical consultants is to provide ethical guidance that defends patient rights and practitioner responsibilities within Texas law when the clinical picture becomes ambiguous.
4. Leadership and Advocacy

The patient received advocacy support through trauma-specific care coordination and systemic barrier resolution delivered by me. Through a partnership with a behavioural health coordinator, I initiated telehealth trauma therapy services at a community clinic because my patient needed appropriate care providers. This intervention made patient care continuity and continuing support possible regardless of her location or financial challenges.

I led an interdisciplinary case review meeting focused on trauma-informed methods to support better patient care planning. The process improved planning with ACE-sensitive protocols for this specific patient and all patients with ACE experience (Loveday et al., 2022).

In future leadership roles, I intend to:

1. I plan to lead efforts to introduce Adverse Childhood Experiences (ACEs) screening as a mandatory part of behavioral health assessments through policy development. Healthy outcomes result from early trauma identification because it enables appropriately targeted interventions, which lead to better results, patient safety compliance, and long-term mental health improvement (Loveday et al., 2022).
2. I will actively work as a clinical committee member who develops specialized trauma-informed care procedures for marginalized populations. My involvement in these committees provides cultural sensitivity and evidence-based, accessible care for affected individuals who experience Adverse Childhood Experiences and systemic or historical trauma.
3. Through mentorship, I will teach students and new PMHNPs to offer ethical patient-centred trauma care where they can observe evidence-based, compassionate practice examples. My guidance regarding clinical choices and cultural understanding, alongside trauma-appropriate communication methods, will equip mental health practitioners with skills to help patients with adverse childhood experiences.
4. Ethical Concerns and Future Practice

The patient’s care required protection against nonmaleficence, preservation of personal autonomy, and guarded confidentiality. The patient demonstrated rightful suspicions toward authority figures because of her traumatic past experiences. I supported her autonomy to share information when she felt ready by emphasizing that sharing was entirely her decision.

We built the treatment plan together and included her specific requests, particularly focusing on the pace and therapeutic rules. The privacy laws in Texas Health and Safety Code §611.002 protected her confidentiality while staff practised sensitive management of trauma documentation (Loveday et al., 2022).

In future practice, I will continue to:

1. My practice will operate exclusively from trauma-informed ethical principles to guarantee patient safety alongside autonomy and empowerment during care delivery, where I treat patients with Adverse Childhood Experiences through evidence-based, compassionate mental health treatment (Fusar‐Poli et al., 2021).
2. I will equip patients with information about their treatment choices, rights, and therapeutic steps to help them make informed decisions and support their self-advocacy and trust-building process, especially for patients with a history of adverse childhood experiences (Fusar‐Poli et al., 2021).
3. I will schedule regular ethical consultations to optimize clinical choices in trauma-related situations, thus maintaining care quality that meets standards as well as legal principles and the complex patient needs of ACE-affected individuals.
4. Facilitators and Barriers to Care

Her treatment was delayed by three main barriers: living in a remote location, inadequate access to appropriate healthcare providers, and emotional response patterns developed following past abandonment experiences. The cultural prejudices about mental disorders, combined with her suspicions about healthcare professionals, prevented her from seeking help (Fusar‐Poli et al., 2021).

Three key factors that aided her recovery included her internal need to end family patterns of trauma, together with developing strong bonds with her therapist and friends. The support she used helped her start healing, even though she faced difficulties.

To reduce barriers in future practice, I plan to:

1. Support organizations in implementing ACE screening and early trauma intervention services in every health system.
2. Expand access to telehealth trauma services in Texas.
3. To aid ACE survivors, organizations must establish strong partnerships that provide housing solutions, legal help, and peer mentoring.

References

Burrows, I. P. (2025). NeuroIntegrative Psychiatric Nursing: Bridging Neuroscience and Holistic Care for Optimal Patient Outcomes. Irvin Phornello Burrows.

Daws, R. E., Timmermann, C., Giribaldi, B., Sexton, J. D., Wall, M. B., Erritzoe, D., Roseman, L., Nutt, D., & Carhart-Harris, R. (2022). Increased global integration in the brain after psilocybin therapy for depression. Nature Medicine, 28(4), 844–851. https://doi.org/10.1038/s41591-022-01744-z

Edinoff, A. N., Raveendran, K., Colon, M. A., Thomas, B. H., Trettin, K. A., Hunt, G. W., Kaye, A. M., Cornett, E. M., & Kaye, A. D. (2022). Selective serotonin reuptake inhibitors and Associated bleeding Risks: A Narrative and Clinical review. Health Psychology Research, 10(4). https://doi.org/10.52965/001c.39580

Finley, B. A., Shea, K. D., Gallagher, S. P., & Taylor-Piliae, R. (2024). Psychiatric mental health nurse practitioners experiencing therapeutic alliance while using tele-mental health: A phenomenological study. Archives of Psychiatric Nursing, 49, 56–66. https://doi.org/10.1016/j.apnu.2024.01.016

Fusar‐Poli, P., Correll, C. U., Arango, C., Berk, M., Patel, V., & Ioannidis, J. P. (2021). Preventive psychiatry: a blueprint for improving the mental health of young people. World Psychiatry, 20(2), 200–221. https://doi.org/10.1002/wps.20869

Henshaw, L. A. (2022). Building trauma-informed approaches in higher education. Behavioral Sciences, 12(10), 368. https://doi.org/10.3390/bs12100368

Howlett, J. R., & Schatzberg, A. F. (2024). Sertraline and Paroxetine. The American Psychiatric Association Publishing Textbook of Psychopharmacology, 425.

Johnson, D. (2022). A good night’s sleep: Three strategies to rest, relax, and restore energy. Journal of Interprofessional Education & Practice, 30, 100591. https://doi.org/10.1016/j.xjep.2022.100591

Kroenke, K. (2021). PHQ‐9: global uptake of a depression scale. World psychiatry, 20(1), 135.  doi: 10.1002/wps.20821

Lorenc, T., Lester, S., Sutcliffe, K., Stansfield, C., & Thomas, J. (2020). Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews. BMC public health, 20, 1-10.

Loveday, S., Hall, T., Constable, L., Paton, K., Sanci, L., Goldfeld, S., & Hiscock, H. (2022). Screening for adverse childhood experiences in children: a systematic review. Pediatrics, 149(2), e2021051884. https://doi.org/10.1542/peds.2021-051884

Moyes, E., Nutman, G., & Mirman, J. H. (2022). The Efficacy of Targeted Mindfulness-Based Interventions for Improving Mental Health and Cognition Among Youth and Adults with ACE Histories: A Systematic Mixed Studies Review. Journal of Child & Adolescent Trauma, 15(4), 1165–1177. https://doi.org/10.1007/s40653-022-00454-5

Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus, 12(5). doi: 10.7759/cureus.8224

Van Dusseldorp, L., Groot, M., Van Vught, A., Goossens, P., Hulshof, H., & Peters, J. (2023). How patients with severe mental illness experience care provided by psychiatric mental health nurse practitioners. Journal of the American Association of Nurse  Practitioners, 35(5), 281–290. https://doi.org/10.1097/jxx.0000000000000867

Final Case Analysis Part B Psychiatric Evaluation

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PMHNP Psychiatric Assessment

Student name:

Semester/Year:

Course:

Patient to be given a pseudonym Mr. John

Student/Preceptor Collaboration

Please confirm this psychiatric assessment was completed on a patient whom you saw in clinical this semester.	Yes        No  Explain_____________________ __________________________________________
Please confirm this is your own original work.	Yes        No  Explain_____________________ __________________________________________
Please confirm you and your preceptor saw this patient, and the psychiatric assessment is accurate to your best knowledge.	Yes        No  Explain_____________________
Student signature/date	SIGN HERE                                         9Th April 2025
Preceptor signature/date

Chief Complaint

What brought you here today…? (Put this in quotes.)

“I’ve been feeling really low for months now, constantly anxious, and I can’t sleep or enjoy anything anymore. It’s getting harder to get through the day.”

Information

Identifying information: Gender, age, race/ethnicity, allergies, etc.	Mr. John is a 34-year-old African American male. No known drug allergies. He identifies as heterosexual. He is single, divorced for approximately one year
General overview of reason for visit: Follow up, new patient, updates since last visit, response to medication changes (if any)	Mr. John is a new psychiatric patient referred by his primary care provider due to persistent depressive and anxiety symptoms. He reported no prior psychiatric diagnosis or treatment history.
Vital signs, height/weight (if obtained) Allergies to medications (Females only): LMP Method of birth control	BP: 130/82 mmHg HR: 78 bpm Temperature: 98.6°F RR: 16 bpm Height: 5’10” Weight: 178 lbs BMI: 25.5 Allergies: None reported (Females only- LMP): Not applicable Birth Control: Not applicable.

History of Present Illness

HPI Overview: Tell us updates about what is currently going on with patient since the last visit. Any updates? Medication changes? Life changes?	Mr. John reported experiencing persistent low mood, sadness, and emotional numbness for the past six months. Symptoms worsened following his divorce, which he describes as traumatic and life-changing. He also reports low motivation, excessive worry, sleep disturbances, irritability, and decreased ability to concentrate, all of which are impairing his performance at work and affecting his interpersonal relationships
Depression symptoms: Sleep, interest, guilt, energy, concentration, appetite, psychomotor changes, suicidality When did it first start? Single episode? Recurrent episodes (When was last episode?)? Persistent (What’s the longest amount of time you have not felt depressed?)? Can you describe your depression symptoms? What makes the depression better; what makes the depression worse? Does the depression come and go?	Onset: Six months ago Course: Recurrent depressive episodes, with current episode lasting over four weeks Symptoms: Early morning awakening, fatigue, poor concentration, anhedonia, low self-worth, passive suicidal ideation Fluctuations: Symptoms are worse in the morning and during periods of isolation; mild improvement with exercise. Longest symptom-free period: Approximately one year before the current episode.
Anxiety: Does the anxiety come and go; is it situational? Or is it there all the time/more often than not? When did anxiety start? How does patient recognize they are anxious (what symptoms do they experience)? What triggers the anxiety? Panic? What triggers panic levels of anxiety (or are they spontaneous/unexpected/unprovoked)? What physical panic symptoms do they experience? How long do panic symptoms last? How often do panic levels of anxiety occur? When was last panic attack?	Onset: Also began approximately six months ago. Nature: Persistent and generalized; occurs most days. Symptoms: Muscle tension, restlessness, excessive worry, racing thoughts. Triggers: Work deadlines, conflicts, parenting concerns. Panic attacks: Denied Impact: Feels mentally and physically exhausted.
Mania/Hypomania: DIGFAST Disturbance of mood, increased energy/goal-directed activity, grandiosity, flight of ideas, activities that might get them in trouble, sleep decreased, talkativeness (pressured speech) “Have there been periods of time where all day/every day for at least 4 to 7 days or longer your mood was unusually elated/euphoric or irritable and it was so dramatically out of character that people wondered or asked if you were on drugs?” AND “Have you had so much energy that you could go days and days with little-to-no sleep, and you didn’t miss it or need it because you were so revved up?” What’s the longest period of time you’ve experienced the mood/energy disturbance? When is the last time you had an episode? What problems did this cause you/your life?	Denies any periods of elated mood, decreased need for sleep, or increased goal-directed activity.
PTSD: FIGHT Flight—avoidance symptoms, avoiding memories or external reminders of trauma Intrusive symptoms—nightmares, intrusive memories, flashbacks Gloomy cognition—negative cognition of self/others/world, negative mood Hypervigilance—easily startled, irritable/angry outbursts, reckless behavior Trauma—exposure to traumatic event	Denies trauma history or symptoms suggestive of PTSD.
Anger/irritability: Do you get angry more than you should? How do you act when you get angry?	Mild irritability during periods of stress; no verbal or physical aggression.
Attention and focus: Have you had problems with thinking, concentrating, or making decisions? When did it start? Does it come and go, or has it persisted? What does this interfere with?	·         Reports decreased concentration at work and forgetfulness in daily tasks. ·         Began approximately six months ago; persistent. ·         Interferes with job performance and task completion.
Obsessions: Do you experience recurrent thoughts, urges, or mental images that distress you and do not make sense, but they keep repeating even though you do not want them? Compulsions: Are there certain behaviors that you have to do over and over and you can’t resist them even though you do not want to do them? If yes to either/or/both: How much time in your day does this take up? How much does this disrupt or interfere with your life?	Obsessions: None reported     Compulsions: None Reported
Current self-harm, suicidal/homicidal ideations: Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself?	Denies current suicidal thoughts Admits to passive ideation (says “I wish I wouldn’t wake up”) after divorce Denies plan or intent; protective factors include his son and religious beliefs
Hallucinations: Do you ever hear or see anything that other people may not hear and/or see?	Denies auditory or visual hallucinations
Paranoia: Do you feel like people are talking about you or following you?	Denies feeling followed or watched
Disordered Eating: Anorexia: Weight significantly low? Fear of being fat? Body image distortion? Bulimia: Binging, out of control feeling while eating, concern with body shape, purging (or other compensatory behaviors)? Binge eating: Recurrent episodes (1x/wk for 3 months), eating out of control, more rapidly than normal, uncomfortably full, when not hungry, alone (because embarrassed), feeling disgusted/guilty/depressed afterwards	Patient denies any symptoms of anorexia nervosa. He is at normal weight for height and has no fear of gaining weight or becoming fat. There is no distortion of body image, restrictive eating, or excessive concern with body size. Patient also denies any bulimia nervosa behaviors. He does not have a history of binge-eating episodes followed by compensatory mechanisms such as self-induced vomiting, laxative use, or excessive exercise. He does not feel a sense of loss of control when he eats, and there is no obsession with body weight or shape that influences self-evaluation. The patient does not meet the criteria for binge eating disorder. He does not report regular incidents of eating large quantities of food in a short space of time. He denies eating more rapidly than normal, feeling uncomfortably full, eating when he is not hungry, or eating alone due to embarrassment. He also denies guilt, shame, or distress after eating. There is no indication of disordered eating patterns at this time. Decreased appetite appears to be associated with depressive symptoms rather than an eating disorder
Sleep: Do you have trouble falling or staying asleep? How long does it take you to fall asleep? After you get to sleep, do you stay asleep all night, or are you up and down throughout the night? Do you have trouble falling asleep, staying asleep, or sleeping too much? How much sleep do you get on average? How many nights per week do you have trouble sleeping or sleep excessively?	Difficulty initiating and maintaining sleep Averages 4–5 hours per night Reports waking up frequently and feeling unrefreshed

Family History

Pertinent mental health history—Include parents, siblings, grandparents if applicable/known

Father: Diagnosed with major depressive disorder. Maternal grandmother: History of bipolar disorder, treated with hospitalization. No known substance use disorders or suicide history in the family.

Personal/Social History

If an adult, who did they grow up with? Education level (How far did you get in school?), marital status, occupation, work history, and legal history, number of children, living situation (lives alone/with family, homeless, etc.)

Mr. John was raised by his mother and maternal grandmother after his parents separated when he was six years old. He completed a bachelor’s degree in Business Administration and is currently employed as a financial analyst. He was married for five years but divorced one year ago due to infidelity and communication issues. He has a five-year-old son who lives with his ex-wife. Mr. John resides alone in an apartment

Any environmental factors that are affected by or contributing to patient’s current state? For example: marital problems/divorce, death in the family, job loss, financial stress, social isolation, transportation issues, etc.

Divorce and co-parenting stress Work-related stress due to reduced performance Limited social engagement and isolation

Substance Use History

Do you currently use or in the past have used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used? Method of use, inhalation, IV, etc. Any SUD treatment history (inpatient, residential, outpatient, detox). Longest period of time sober/clean? Any sober support persons?	Illicit Drugs: Denies current or past use SUD Treatment: None Support system: Mother, close friend, and son
Do you currently have or in the past have had an issue with alcohol use? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past?	Alcohol: Occasionally drinks 1–2 drinks/month; no blackouts or dependency
Do you currently smoke cigarettes or vape?	Tobacco/Vaping: Denies use
Do you smoke marijuana?	Marijuana: Denies use
Daily caffeine intake	Caffeine: Consumes 2–3 cups of coffee daily

Past Psychiatric History

At what age did the symptoms start?	Patient indicates that the low mood and anxiety symptoms first appeared at 29 years; at the period when he started experiencing marriage conflict. He recalled having been tired, irritable, and sad but these were minor and transient until they became much worse six months ago at 34 years.
Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis?	Patient has no formal previous psychiatric diagnosis. He reports that although he experienced depressive symptoms in the past, he never sought out assessment or treatment until this current episode. The worst symptoms began following his divorce, which occurred approximately one year ago.
Were there any environmental factors that could have contributed to the symptoms? For example, divorce, death in the family, etc.	Yes. The patient implies his recent divorce, co-parenting challenges, and stress regarding work as significant environmental factors for his current depressive and anxious presentation. He talks about emotions of loss, loneliness, and self-blame on the breakdown of the marriage.
Prior suicide attempts? If so, when did they happen, what was the attempt (method, potential lethality, context of alcohol/substance use, etc.).	Denies prior suicide attempts. Never had suicidal intent behaviors and denies alcohol or substance use in connection with suicidal ideation.
Prior suicidal thoughts? If so, active thoughts with plans? Passive thoughts (just wanting to die or not wanting to live) without plans? How often do thoughts occur? When was last time you had suicidal thoughts? Reasons for living? Reasons for not killing yourself? What is your safety plan?	Patient reports having passive suicidal ideation following his divorce, six months ago. He had reported hopelessness and thoughts such as “I don’t want to wake up,” but he did not have a plan or intent in progress. Thoughts occurred intermittently over a period of two months but subsequently remitted. His motivations for remaining alive as he described them were his child, wishing to improve regarding his mental health, and his faith. He has never made an explicit plan to kill himself. He understands how to use a crisis to get help and has agreed to notify his provider or go to the emergency department if suicidal thoughts recur.
Prior/current intentional self-injury (cutting, scratching, burning, headbanging, etc.)? If so, when did it start, how often does it happen, when did it last happen?	Patient denies any past or current intentional self-injury behavior.
Any current or previous psychotherapy? Adherence to current/past therapy?	The patient had two individual counseling sessions approximately eight months ago, shortly after his divorce. Therapy was put on hold due to financial constraints and scheduling conflicts. He reports that he benefited from those sessions and is willing to return to therapy.   The patient had initial enthusiasm to attend therapy, but was unable to maintain it due to outside factors. He did not follow up thereafter, but now shows willingness to attend regularly.
Any previous treatment? If so, what was it and did it work? List any previous psychiatric medications that have been tried and why the medication was stopped.     Please include details on response, side effects, dosing, and timeline of how long the patient was on or took the medication.	The patient has never been on psychiatric medications. This is his first mental health evaluation and first referral for pharmacologic treatment.       Not applicable – no prior treatment with psychiatric medication.
Any other treatments, such as ECT, TMS, ketamine?	No ECT, TMS, or ketamine treatment has been received or referred by the patient. He has never heard about these treatments.

Medical History

Medical problems	Conditions: Mild hypertension managed with diet and exercise Current medications: Lisinopril 10 mg PO daily
Previous surgeries	Surgical history: Appendectomy at age 12

Mental Status Exam

Observations

Appearance: Gait, posture, clothes, grooming (Appropriate to weather? Appear stated age?)	Neatly dressed, good hygiene, normal posture and gait, appears to be of stated age.
Behaviors: Mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions	Cooperative, engaged, maintains good eye contact, no abnormal movements.
Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive	Open, cooperative, and demonstrates insight into symptoms.
Level of consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating	Alert and fully conscious
Orientation: “What is your full name?” “Where are we (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?”	Oriented to person, place, time, and situation
Additional comments	The patient presented a calm and cooperative demeanor throughout the interview. He related properly to the examiner, responded freely to questions, and maintained normal eye contact. Speech was clear and coherent, and there were no signs of agitation or psychomotor retardation. There was no sign of internal preoccupation or responding to internal stimuli.

Speech

Quantity descriptors: Talkative, spontaneous, expansive, paucity, poverty	Normal
Rate: Fast, slow, normal, pressured	Normal
Volume (tone): Loud, soft, monotone, weak, strong	Normal volume: Tone is clear and coherent
Additional comments	There was no evidence of pressured speech, latency, or blocking of thought

Affect and Mood

Mood (how the person tells you they’re feeling): “How are you feeling?”	(Self-reported): “Sad and worried most days”
Affect (what you observe): Appropriateness to situation, consistency with mood, congruency with thought content ·         Fluctuations: labile, even, expansive ·         Range: broad, restricted ·         Intensity: blunted, flat, normal, hyper-energized ·         Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable	Affect is consistent with the situation and patient’s reported mood. Affect is consistent with thought content since it was presented during the session. Patient is emotionally engaged but limited emotionally.   Fluctuations: Even – no sudden or abrupt mood changes reported during the interview.   Range: Restricted – there is emotional expression but limited range and depth.   Intensity: Blunted – emotional responses are diminished in intensity but not absent.   Quality: Dysphoric – patient displays symptoms of sadness and low emotional tone, consistent with depressive symptoms.
Congruency: Congruent or not congruent mood?	Congruent with mood
Additional Comments:	The affect of the patient was also flat, with minimal spontaneous smiling and affect variation. While cooperative and interested, his facial affect and tone of voice reflected a pervasive low mood. Incongruent affect or inappropriate affect was not observed during the interview. His affect was congruent with his clinical presentation of moderate depression.

Perception

Paranoia	Patient denies ideation of paranoia. No report of being observed, trailed, or singled out by others is present. Suspicions against others and suspicious thoughts were absent during the session.
Auditory/Visual/Other hallucinations	Patient denies any hallucinations, auditory, visual, tactile, olfactory, or otherwise. He denies perceptual disturbance and does not show any behavior that is characteristic of responding to internal stimuli.
Additional Comments	There are no signs of perceptual disturbances during the interview. Patient’s answers were based on reality, and he did not demonstrate signs of misinterpretation of environmental or internal experiences

Thought Content

Suicidal	Patient denies current suicidal ideation, intent, or plan. Reports that he had experienced passive suicidal ideation in the past since his divorce (“Sometimes I wished that I wouldn’t wake up”), but this was transient and not with intent or planning. Denies history of suicide attempts. Protective factors include his child, close family, and personal values. He has a verbal safety plan and can access crisis support if needed.
Homicidal	Patient denies having any current or past homicidal ideations, thoughts, or intentions. He denies any resentment or anger towards others, suggesting a danger of hurting.
Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?) ·         Delusions are fixed, false beliefs. ·         These are unshakable beliefs that are held despite evidence against it and despite the fact there is no logical support for it. ·         Is there a delusional belief system that supports the delusion?	Patient denies fixed false beliefs or delusional thoughts. There are no erotomanic, grandiose, jealous, persecutory, or somatic delusional themes. He possesses logical and coherent thinking, and no belief system that would allow delusional content was observed.
Additional comments:	Thought processes appear to be goal-directed and reality-based. There were no signs of ideas of reference, magical thinking, or paranoia reported during the assessment. The patient remained open to insight and feedback during the session.

Insight/Judgement

What is their understanding of the world around them and their illness?	The patient’s insight is fair to good. He understands that his symptoms of low mood, anxiety, and difficulty concentrating are psychological and attributable to his recent life stressors, particularly his divorce. He demonstrates awareness of how these symptoms affect his daily functioning, interpersonal relationships, and work performance.
Are they able to do reality-testing (i.e., are they able to see the situation as it really is)?	Yes, the patient is able to perform reality-testing. His thinking is logical, coherent, and goal-directed. He denies hallucinations, delusions, or paranoia, and he is oriented to person, place, time, and situation. There is no sign of psychosis or distorted thinking during the evaluation.
Are they help-seeking? Help-rejecting?	The patient is help-seeking. Although he dropped therapy in the past due to external constraints (scheduling and finances), he expresses a need to return to treatment and resume care. He acknowledges the usefulness of prior sessions and is receptive to psychotherapy as well as drug therapy.

 

Psychiatric Diagnosis

Rating scales (If no rating scales were used, what could have been used?) Please indicate the name of the rating scale, the score of the rating scale, and what the score means in relation to the diagnosis.	PHQ-9 (Patient Health Questionnaire-9): Score = 17 Interpretation: Moderately severe depression Clinical Relevance: Indicates severe depressive symptomatology that impairs daily functioning and is consistent with Major Depressive Disorder.   GAD-7 (Generalized Anxiety Disorder-7): Score = 14 Interpretation: Moderate anxiety Clinical Relevance: Aids diagnosis of Generalized Anxiety Disorder, with functional impairment resulting from excessive worry, restlessness, and poor concentration.
Current diagnosis, including specifiers	·         F33.1 – Major Depressive Disorder, Recurrent, Moderate   ·         F41.1 – Generalized Anxiety Disorder
Case formulation/biopsychosocial assessment (a summary of the genetic vulnerabilities, attachment styles, employment, relationships, triggers/modifiable factors, medical conditions and adverse experiences that may impact the clinical picture.)	Mr. John is a 34-year-old male with moderate recurrent depression and anxiety symptoms. He developed symptoms six months ago after undergoing a traumatic divorce. Work stress and co-parenting stress have added to his symptoms.   Biological Factors-   ·         Family psychiatric disease history: Father with Major Depressive Disorder, maternal grandmother with bipolar disorder.   ·         No drug use or significant medical conditions aside from mild hypertension.   Psychological Factors-   ·         Depressive cognitions of low self-esteem, hopelessness, and passive suicidal thoughts.   ·         Generalized anxiety with hurried thoughts and complaints about the body (e.g., tension).   ·         Good to fair insight and willingness to be treated.   Social Factors- ·         Social isolation following divorce   ·         Work stress due to poor work performance   ·         Tiny support system, although he gets along with his son and mother.   Protective Factors- ·         Parenting role   ·         Spiritual beliefs   ·         Previous good experience of therapy   ·         No substance abuse or suicidal attempts in history
Differential Diagnosis	I.            Adjustment Disorder with Depressed Mood: Considered due to stressor (divorce), but symptom severity, duration, and impairment are more in favor of MDD diagnosis. II.            Persistent Depressive Disorder (Dysthymia): Excluded because symptoms did not persist all along; symptom-free for roughly one year before.
Rule Out Diagnosis	Bipolar II Disorder: Excluded. No history of hypomania, elevation in mood, or decreased need for sleep. No evidence of increased goal-directed behavior or grandiosity.

Medications

Medical medications	Lisinopril 10 mg PO daily (for mild hypertension)
Psychiatric medications—list name (generic name). If the person does not take any current psychiatric medications, please indicate this, along with at least one medication that could work with their diagnosis and presenting symptoms.	Sertraline 50 mg PO daily (SSRI, for depression and anxiety) (Howlett & Schatzberg, 2024).
Medication education provided to patient	·         Described the mechanism of SSRIs in mood regulation ·         Onset of therapeutic effect: 2–4 weeks ·         Common side effects: nausea, headache, sleep changes, sexual dysfunction ·         Emphasized adherence and reporting of side effects
Risks, benefits, side effects, and alternatives discussed with the patient	Informed Consent: Patient consented to start medication after discussion of risks, benefits, and alternatives, including therapy as the only option.

Treatment Plan

Next visit scheduled
The rest of the treatment plan will be addressed in Part C: The PMHNP Role in Patient Care	·         Begin Sertraline 50 mg PO daily ·         Refer for biweekly Cognitive Behavioral Therapy (CBT). ·         Educate on sleep hygiene, journaling, and mindfulness skills (Johnson, 2022). ·         Follow-up in 2 weeks to monitor tolerance to medication and response. ·         Use PHQ-9 and GAD-7 on each visit to monitor symptom trend. (Kroenke, 2020; Sapra et al., 2021).

Billing/Coding

ICD 10 Code	F33.1 – Major Depressive Disorder, Recurrent, Moderate F41.1 – Generalized Anxiety Disorder (Kroenke, 2020; Sapra et al., 2021)
Billing Code	CPT CODE 99205 – Initial comprehensive psychiatric diagnostic evaluation, moderate complexity

 

 

 

 

References

Howlett, J. R., & Schatzberg, A. F. (2024). Sertraline and Paroxetine. The American Psychiatric Association Publishing Textbook of Psychopharmacology, 425.

Johnson, D. (2022). A good night’s sleep: Three strategies to rest, relax, and restore energy. Journal of Interprofessional Education & Practice, 30, 100591. https://doi.org/10.1016/j.xjep.2022.100591

Kroenke, K. (2021). PHQ‐9: global uptake of a depression scale. World psychiatry, 20(1), 135.  doi: 10.1002/wps.20821

Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus, 12(5). doi: 10.7759/cureus.8224