Comprehensive Psychiatric Evaluation Note

ANSWER

Introduction to the Comprehensive Psychiatric Evaluation Note
Having trouble controlling emotions and behaviors that conform to social standards and expectations is a common symptom of impulse control and conduct disorders. The psychiatric examination and treatment plan for a 15-year-old patient with conduct disorder who displayed persistent behavioral problems, such as violence and disobedience, are described in this evaluation.

Details about the patient: Name: J.A. Age: 15
Male gender
Visit Date: [Insert Date]
Conduct disorder is the diagnosis (DSM-5 criteria).
“Everyone at school thinks I’m a problem; they just don’t understand me,” is the chief complaint (CC).

Current Illness History (HPI)
A 15-year-old boy named J.A. was referred for psychiatric assessment because he had been stealing, acting aggressively at school, and disobeying authority figures over the previous six months. Teachers describe verbal aggressiveness, truancy, and physical altercations with peers. Similar behaviors, such as disputes, disobedience, and staying out late without permission, are described by J.A.’s parents as occurring at home. Since the divorce of his parents two years ago, behavioral problems have gotten worse. There were no reports of homicidal or suicidal thoughts. He acknowledges that he is “angry all the time,” but he gives no explicit explanation for why.

Previous History of Psychiatry
No prior diagnoses have been officially recorded.
No hospitalizations.
Therapy: Family counseling was stopped six months ago because of noncompliance.
No medications.
History of Substance Use: denies using tobacco, alcohol, or drugs recreationally.
History of Family Psychiatry
Father: Untreated depression, history of alcohol abuse.
Mother: Medication-treated anxiety condition.
Health History
There are currently no long-term medical conditions.
No allergies were mentioned.
No prior surgeries.
History of Development
Normal developmental milestones have been reached.
Since age nine, behavioral issues have been observed.
History of Society
resides with his younger sister and mother. little communication with the father.
Poor academic performance; absenteeism and lack of effort caused most topics to be failed.
He has few friends and is characterized by classmates as “intimidating.”
Assessment of Mental Status (MSE)
Look: Dirty, with the hood up on a hoodie, avoiding eye contact.
Conduct: agitated, tapping the chair with fingers.
Irritable mood.
Constricted affect.
Speech: Sarcastically toned, normal volume and rate.
Goal-directed and linear thought process.
Content of Thought: Disavows thoughts of suicide or murder.
Cognitive: Aware and cognizant of time, place, and people.
Poor judgment; unable to understand the repercussions of his actions.
The primary diagnosis is Adolescent-Onset Conduct Disorder (DSM-5 312.82).
Distinctive Diagnoses:
Aggression and a breach of social norms led to the dismissal of oppositional defiant disorder (ODD).
Modification Disorder with Disturbance of Conduct: Disregarded since symptoms go beyond what is typically expected under stress.
Intermittent Explosive Disorder: Dismissed because it involves deliberate rule-breaking rather than just spontaneous outbursts.
Plan of Treatment
Interventions for Therapy:

weekly sessions of Cognitive Behavioral Therapy (CBT) to improve problem-solving and anger management abilities.
The purpose of Parent Management Training (PMT) is to give the mother useful behavioral techniques.
Interventions Using Pharmacology:

Guanfacine (1 mg daily) was started to treat aggression and impulsivity.
In four weeks, plan to assess efficacy.
Local Resources:

referral to a nearby mentorship program that offers scheduled activities and excellent role models.
Collaboration in Schools:

coordinating with the school counselor to track academic achievement and create a behavior intervention plan (BIP).
Follow-up:

set up a follow-up appointment for two weeks from now to evaluate treatment progress and drug response.
In conclusion
J.A.’s conduct issues are consistent with a conduct disorder diagnosis, highlighting the necessity of a multimodal solution. The goal of the treatment approach is to address his underlying emotional dysregulation and promote positive behavioral changes by combining cognitive behavioral therapy, family engagement, and school-based interventions. Improving his quality of life and results requires regular monitoring and cross-system coordination.

Citations
Psychiatric Association of America, 2022. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has been revised.
A. E. Kazdin (2017). Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents: Parent Management Training. Oxford University Press.
P. S. Jensen and associates (2020). Children with disruptive behavior disorders can benefit from multimodal therapies. 501–515 in the Journal of Child Psychology and Psychiatry, 61(5).
This format guarantees that the review is thorough, succinct, and compliant with professional documentation requirements. Please let me know if you require any other help!

 

 

 

 

 

 

 

QUESTION

Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources.

Please include an introduction and conclusion for this assignment.

Scroll to Top