Fletcher is a 29-year-old male referred for court-ordered counseling. He has a long history of repeated offenses including DUI, domestic violence, battery, and other violent acts that fortunately have not yet caused any serious injury or death to the victims. An interview with his wife reveals that for the last few years he has lied about almost everything; he is able to get hired for jobs because he is very engaging and likeable, and then invariably he gets fired because he misses work and doesn’t do his job properly when he is there. According to the wife, they have known each other since high school where Fletcher was very happy and well-adjusted. He was on the soccer team, liked by teachers, and never demonstrated the tendencies he does now. Apparently in college he got involved with a fraternity that was notorious for alcohol and drug abuse, and he started drinking heavily; it was “all downhill from there.” The PMHNP considers that:

A. History and symptoms are most consistent with antisocial personality disorder

B. Fletcher needs a neurological workup to include an EEG and assessment for neurological soft signs

C. Consistent with his symptoms Fletcher will likely respond well to a stress interview

D. It is likely that substance abuse is the underlying cause of symptoms and should be explored further
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YouTube: https://www.youtube.com/watch?v=GINQB976rx4&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=18

Mrs. Bowen is a 33-year-old female who presents as a new patient requesting medication for depression. She reports a long history of mood disorders on and off going back to adolescence. She is very articulate in describing her history and reports that neither sertraline nor fluoxetine “worked for her.” With respect to considering Mrs. Bowen’s medication history, the PMHNP knows that:

A. A SNRI will likely be the most appropriate choice if pharmacotherapy is indicated for this episode

B. This may be an inaccurate characterization as depressed patients tend to overemphasize negatives

C. In some circumstances patients will purposefully mischaracterize the efficacy of medications they feel were ineffective

D. Some forms of recurrent depression are best managed with nonpharmacologic strategies
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YouTube: https://www.youtube.com/watch?v=tkuR-oLi0S8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=17

Chantel is a 19-year-old female who presents for care because she thinks she is bipolar. During her initial interview, she admits that she has a long history of feeling like she was the person in the family of whom there were always high expectations, and she was never able to express her feelings of inadequacy. When asked why she thinks she is bipolar, she says she gets very moody. She was at the grocery store last week and slipped and fell; while waiting for help she could not control her anger and reached up to swipe all the food off of the shelves. She has been fired from jobs because of her uncontrollable temper; she sometimes “just can’t be around certain people.” Chantel also reports that at times she will go two full days and nights without sleep, and that her mind keeps racing and she can’t “shut it down.” When this happens she gets up and does things around the house. Finally, Chantel reports that she cannot hold onto money at all. Whenever she gets a paycheck she immediately spends it on things that she acknowledges she doesn’t even need. When considering a diagnosis of bipolar disorder the PMHNP specifically assesses for:

A. Any history of suicidal attempts of suicidal ideation
B. History and current patterns of substance abuse
C. Concomitant psychotic features such as hallucination or delusion
D. Manic symptoms are sustained most of the day for at least two weeks
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YouTube: https://www.youtube.com/watch?v=X-x8g9wflPg&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=16