This document outlines the rubric for evaluating a student's submission of a focused SOAP note case study assignment. It provides detailed criteria and point values for assessing students' documentation of the patient's subjective history, objective diagnostic results, assessment including a mental status exam and differential diagnoses, and treatment plan. The highest scores are for responses that thoroughly, accurately, and critically describe all required elements of the SOAP note based on the case study provided. References to current evidence and adherence to APA style are also evaluated. The rubric aims to guide students in including all essential information needed for a psychiatric evaluation note.

1. NRNP_6665_Week4_Assignment_Rubric
NRNP_6665_Week4_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeCreate
documentation in the Focused SOAP Note Template about the
patient in the case study. In the Subjective section, provide: •
Chief complaint• History of present illness (HPI)• Past
psychiatric history• Medication trials and current medications•
Psychotherapy or previous psychiatric diagnosis• Pertinent
substance use, family psychiatric/substance use, social, and
medical history• Allergies• ROS
15 to >13.0 pts
Excellent
The response throughly and accurately describes the patient's
subjective complaint, history of present illness, past psychiatric
history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent
histories, allergies, and review of all systems that would inform
a differential diagnosis.
13 to >11.0 pts
Good
The response accurately describes the patient's subjective
complaint, history of present illness, past psychiatric history,
medication trials and current medications, psychotherapy or
previous psychiatric diagnosis, pertinent histories, allergies,
and review of all systems that would inform a differential
diagnosis.
11 to >10.0 pts
Fair
The response describes the patient's subjective complaint,
history of present illness, past psychiatric history, medication
trials and current medications, psychotherapy or previous

2. psychiatric diagnosis, pertinent histories, allergies, and review
of all systems that would inform a differential diagnosis but is
somewhat vague or contains minor innacuracies.
10 to >0 pts
Poor
The response provides an incomplete or inaccurate description
of the patient's subjective complaint, history of present illness,
past psychiatric history, medication trials and current
medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that
would inform a differential diagnosis. Or the subjective
documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Objective
section, provide:• Review of Systems (ROS) documentation and
relate if pertinent to the chief complaint, HPI, and history•
Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses
15 to >13.0 pts
Excellent
The response thoroughly and accurately documents the patient's
ROS for pertinent systems. Diagnostic tests and their results are
thoroughly and accurately documented.
13 to >11.0 pts
Good
The response accurately documents the patient's ROS for
pertinent systems. Diagnostic tests and their results are
accurately documented.
11 to >10.0 pts
Fair
Documentation of the patient's ROS is somewhat vague or
contains minor innacuracies. Diagnostic tests and their results
are documented but contain minor inaccuracies.
10 to >0 pts
Poor

3. The response provides incomplete or inaccurate documentation
of the patient's ROS. Systems may have been unnecessarily
reviewed. Or the objective documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Assessment
section, provide:• Results of the mental status examination,
presented in paragraph form• At least three differentials with
supporting evidence. List them from top priority to least
priority. Compare the DSM-5 diagnostic criteria for each
differential diagnosis and explain what DSM-5 criteria rules out
the differential diagnosis to find an accurate diagnosis. Explain
the critical-thinking process that led you to the primary
diagnosis you selected. Include pertinent positives and pertinent
negatives for the specific patient case.
20 to >17.0 pts
Excellent
The response thoroughly and accurately documents the results
of the mental status exam. Response lists at least three
distinctly different and detailed possible disorders in order of
priority for a differential diagnosis of the patient in the assigned
case study, and it provides a thorough, accurate, and detailed
justification for each of the disorders selected.
17 to >15.0 pts
Good
The response accurately documents the results of the mental
status exam. Response lists at least three distinctly different and
detailed possible disorders in order of priority for a differential
diagnosis of the patient in the assigned case study, and it
provides an accurate justification for each of the disorders
selected.
15 to >13.0 pts
Fair
The response documents the results of the mental status exam
with some vagueness or innacuracy. Response lists at least three
different possible disorders for a differential diagnosis of the

4. patient and provides a justification for each, but may contain
some vagueness or innacuracy.
13 to >0 pts
Poor
The response provides an incomplete or inaccurate description
of the results of the mental status exam and explanation of the
differential diagnoses. Or the assessment documentation is
missing.
20 pts
This criterion is linked to a Learning OutcomeIn the Plan
section, provide:• Your plan for psychotherapy• Your plan for
treatment and management, including alternative therapies.
Include pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters as well as a
rationale for this treatment and management plan. • Incorporate
one health promotion activity and one patient education
strategy.
25 to >22.0 pts
Excellent
The response provides an evidence-based, detailed, and
appropriate plan for psychotherapy for the patient. The response
provides an evidence-based, detailed, and appropriate plan for
treatment and management, including pharmacologic and
nonpharmacologic treatments, alternative therapies, and follow-
up parameters. A strong rationale for the plan is provided that
demonstrates critical thinking and content understanding. ... The
response includes at least one evidence-based health promotion
activity and one evidence-based patient education strategy.
22 to >19.0 pts
Good
The response provides an evidence-based and appropriate plan
for psychotherapy for the patient. The response provides an
evidence-based and appropriate plan for treatment and
management, including pharmacologic and nonpharmacologic
treatments, alternative therapies, and follow-up parameters. An

5. adequate rationale for the plan is provided. ... The response
includes at least one health promotion activity and one patient
education strategy.
19 to >17.0 pts
Fair
The response provides a somewhat vague or inaccurate plan for
psychotherapy for the patient. The response provides a
somewhat vague or inaccurate plan for treatment and
management, including pharmacologic and nonpharmacologic
treatments, alternative therapies, and follow-up parameters. The
rationale for the plan is weak or general. ... The response
includes one health promotion activity and one patient
education strategy, but it may contain some vagueness or
innacuracy.
17 to >0 pts
Poor
The response provides an incomplete or inaccurate plan for
psychotherapy for the patient. The response provides an
incomplete or inaccurate plan for treatment and management,
including pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters. The rationale
for the plan is inaccurate or missing. ... The health promotion
and patient education strategies are incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Reflect on this
case. Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related
to legal/ethical considerations (demonstrate critical thinking
beyond confidentiality and consent for treatment!), social
determinates of health, health promotion, and disease
prevention that takes into consideration patient factors (such as
age, ethnic group, etc.), PMH, and other risk factors (e.g.,
socioeconomic, cultural background, etc.).
5 to >4.0 pts
Excellent

6. Reflections are thorough, thoughtful, and demonstrate critical
thinking.
4 to >3.5 pts
Good
Reflections demonstrate critical thinking.
3.5 to >3.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical
thinking.
3 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomeProvide at least
three evidence-based, peer-reviewed journal articles or
evidenced-based guidelines that relate to this case to support
your diagnostics and differential diagnoses. Be sure they are
current (no more than 5 years old).
10 to >8.0 pts
Excellent
The response provides at least three current, evidence-based
resources from the literature to support the assessment and
diagnosis of the patient in the assigned case study. The
resources reflect the latest clinical guidelines and provide
strong justification for decision making.
8 to >7.0 pts
Good
The response provides at least three current, evidence-based
resources from the literature that appropriately support the
assessment and diagnosis of the patient in the assigned case
study.
7 to >6.0 pts
Fair
Three evidence-based resources are provided to support the
assessment and diagnosis of the patient in the assigned case

7. study, but they may only provide vague or weak justification.
6 to >0 pts
Poor
Two or fewer resources are provided to support the assessment
and diagnosis decisions. The resources may not be current or
evidence based.
10 pts
This criterion is linked to a Learning OutcomeWritten
Expression and Formatting - The paper follows correct APA
format for parenthetical/in-text citations and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors
4 to >3.5 pts
Good
Contains a few (one or two) APA format errors
3.5 to >3.0 pts
Fair
Contains several (three or four) APA format errors
3 to >0 pts
Poor
Contains many (five or more) APA format errors
5 pts
This criterion is linked to a Learning OutcomeWritten
Expression and Formatting - English Writing Standards: Correct
grammar, mechanics, and punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation
errors
3.5 to >3.0 pts

8. Fair
Contains several (three or four) grammar, spelling, and
punctuation errors
3 to >0 pts
Poor
Contains many (five or more) grammar, spelling, and
punctuation errors that interfere with the reader’s understanding
5 pts
Total Points: 100
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric
Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND
TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to
include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in
detail in order not to lose points unnecessarily because you
missed something required. After reviewing full details of the
rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use,
social, and medical history

9. · Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief
complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them
from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential
diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis
to find an accurate diagnosis.
Explain the critical-thinking process that led you to the
primary diagnosis you selected. Include pertinent positives and
pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and
what you might do differently. Also include in your reflection a
discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and
consent for treatment!), social determinates of health, health
promotion and disease prevention taking into consideration
patient factors (such as age, ethnic group, etc.), PMH, and other
risk factors (e.g., socioeconomic, cultural background, etc.).

10. (The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing
this type of note in this course. You will be focusing more on
the symptoms from your differential diagnosis from the
comprehensive psychiatric evaluation narrowing to your
diagnostic impression. You will write up what symptoms are
present and what symptoms are not present from illnesses to
demonstrate you have indeed assessed for illnesses which could
be impacting your patient. For example, anxiety symptoms,
depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A
brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why
presenting for assessment. For a patient with dementia or other
cognitive deficits, this statement can be obtained from a family
member.
HPI: Begin this section with patient’s initials, age, race, gender,
purpose of evaluation, current medication and referral reason.
For example:
N.M. is a 34-year-old Asian male presents for medication
management follow up for anxiety. He was initiated sertraline
last appt which he finds was effective for two weeks then
symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to
discuss previous psychiatric evaluation for concentration
difficulty. She is not currently prescribed psychotropic
medications as we deferred until further testing and screening
was conducted.

11. Then, this section continues with the symptom analysis for your
note. Thorough documentation in this section is essential for
patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is
bringing the patient to your follow up evaluation? Document
symptom onset, duration, frequency, severity, and impact. What
has worsened or improved since last appointment? What
stressors are they facing? Your description here will guide your
differential diagnoses into your diagnostic impression. You are
seeking symptoms that may align with many
DSM-5 diagnoses, narrowing to what aligns with
diagnostic criteria for mental health and substance use
disorders.
Substance Use History: This section contains any history or
current use of caffeine, nicotine, illicit substance (including
marijuana), and alcohol. Include the daily amount of use and
last known use. Include type of use such as inhales, snorts, IV,
etc. Include any histories of withdrawal complications from
tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time
used, and reason for use. Also include OTC or homeopathic
products.
Allergies:
Include medication, food, and environmental allergies
separately. Provide a description of what the allergy is (e.g.,
angioedema, anaphylaxis). This will help determine a true
reaction vs. intolerance.
Reproductive Hx:
Menstrual history (date of LMP), Pregnant (yes or no),
Nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse: oral, anal, vaginal, other, any sexual
concerns

12. ROS: Cover all body systems that may help you include or rule
out a differential diagnosis. Please note: THIS IS DIFFERENT
from a physical examination!
You should list each system as follows:
General:Head:
EENT: etc. You should list these in bullet format and
document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy,
odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness, or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or
stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat
intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other
diagnostics that are needed to develop the differential diagnoses

13. (support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses,
this section must be presented in paragraph form and not use of
a checklist! This section you will describe the patient’s
appearance, attitude, behavior, mood and affect, speech, thought
processes, thought content, perceptions (hallucinations,
pseudohallucinations, illusions, etc.)., cognition, insight,
judgment, and SI/HI. See an example below. You will modify to
include the specifics for your patient on the above elements—
DO NOT just copy the example. You may use a preceptor’s way
of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated
age. He is cooperative with examiner. He is neatly groomed and
clean, dressed appropriately. There is no evidence of any
abnormal motor activity. His speech is clear, coherent, normal
in volume and tone. His thought process is goal directed and
logical. There is no evidence of looseness of association or
flight of ideas. His mood is euthymic, and his affect appropriate
to his mood. He was smiling at times in an appropriate manner.
He denies any auditory or visual hallucinations. There is no
evidence of any delusional thinking. He denies any current
suicidal or homicidal ideation. Cognitively, he is alert and
oriented. His recent and remote memory is intact. His
concentration is good. His insight is good.
Diagnostic Impression:
You must begin to narrow your differential diagnosis to
your diagnostic impression. You must explain how and why
(your rationale) you ruled out any of your differential
diagnoses. You must explain how and why (your rationale) you
concluded to your diagnostic impression. You will use
supporting evidence from the literature to support your
rationale. Include pertinent positives and pertinent negatives for
the specific patient case.

14. Also included in this section is the reflection. Reflect on this
case and discuss whether or not you agree with your preceptor’s
assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do
differently?
Also include in your reflection a discussion related to
legal/ethical considerations (
demonstrating critical thinking beyond confidentiality
and consent for treatment!), social determinates of health,
health promotion and disease prevention taking into
consideration patient factors (such as age, ethnic group, etc.),
PMH, and other risk factors (e.g., socioeconomic, cultural
background, etc.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be
obtained, referrals to other health care providers, therapeutic
interventions including psychotherapy and/or
psychopharmacology, education, disposition of the patient, and
any planned follow-up visits. Each diagnosis or condition
documented in the assessment should be addressed in the plan.
The details of the plan should follow an orderly manner.
*See an example below. You will modify to your
practice so there may be information excluded/included. If you
are completing this for a practicum, what does your preceptor
document?
Risks and benefits of medications are discussed including non-
treatment. Potential side effects of medications discussed (be
detailed in what side effects discussed). Informed client not to
stop medication abruptly without discussing with providers.
Instructed to call and report any adverse reactions. Discussed
risk of medication with pregnancy/fetus, encouraged birth
control, discussed if does become pregnant to inform provider
as soon as possible. Discussed how some medications might

15. decreased birth control pill, would need back up method
(exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal,
alcohol/illegal drugs. Instructed to avoid this practice.
Encouraged abstinence. Discussed how drugs/alcohol affect
mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any
therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or
therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the
Client's Crisis Line
1-800-_______. Client instructed to go to nearest ER or
call 911 if they become actively suicidal and/or homicidal.
(only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative
information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided
supportive listening. Client appeared to understand discussion.
Client is amenable with this plan and agrees to follow treatment
regimen as discussed. (this relates to informed consent; you will
need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test
ordered, rationale for ordering, and if discussed fasting/non
fasting or other patient education)

16. Return to clinic:
Continued treatment is medically necessary to address chronic
symptoms, improve functioning, and prevent the need for a
higher level of care.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-
reviewed journal articles or evidenced-based guidelines which
relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
© 2022 Walden University
Page 1 of 3
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP
Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
·

17. Current Medications:
·
Allergies:
·
Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
References

18. © 2021 Walden University
Page 1 of 3
· Review this week’s Learning Resources. Consider the insights
they provide about assessing, diagnosing, and treating mood
disorders.
· Review the Focused SOAP Note template, which you will use
to complete this Assignment. There is also a Focused SOAP
Note Exemplar provided as a guide for Assignment
expectations.
· Review the video,
Case Study: Petunia Park. You will use this case as the
basis of this Assignment. In this video, a Walden faculty
member is assessing a mock patient. The patient will be
represented onscreen as an avatar.
· Consider what history would be necessary to collect from this
patient.
· Consider what interview questions you would need to ask this
patient.
· Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2
Pulse 90
Respiration 18
B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen
negative. CBC within normal ranges, CMP within normal
ranges. Lipid panel within normal ranges. Prolactin Level 8;
TSH 6.3 (H)

19. Develop a Focused SOAP Note, including your differential
diagnosis and critical-thinking process to formulate a primary
diagnosis. Incorporate the following into your responses in the
template:
·
Subjective: What details did the patient provide
regarding their chief complaint and symptomatology to derive
your differential diagnosis? What is the duration and severity of
their symptoms? How are their symptoms impacting their
functioning in life?
·
Objective: What observations did you make during the
psychiatric assessment?
·
Assessment: Discuss the patient’s mental status
examination results. What were your differential diagnoses?
Provide a minimum of three possible diagnoses with supporting
evidence, listed in order from highest to lowest priority.
Compare the
DSM-5-TR diagnostic criteria for each differential
diagnosis and explain what
DSM-5 criteria rules out the differential diagnosis to
find an accurate diagnosis. Explain the critical-thinking process
that led you to the primary diagnosis you selected. Include
pertinent positives and pertinent negatives for the specific
patient case.
·
Plan: What is your plan for psychotherapy? What is
your plan for treatment and management, including alternative
therapies? Include pharmacologic and nonpharmacologic

20. treatments, alternative therapies, and follow-up parameters as
well as a rationale for this treatment and management plan. Also
incorporate one health promotion activity and one patient
education strategy.
·
Reflection notes: Reflect on this case. Discuss what you
learned and what you might do differently. Also include in your
reflection a discussion related to legal/ethical considerations
(demonstrate critical thinking beyond confidentiality and
consent for treatment!), social determinates of health, health
promotion, and disease prevention that takes into consideration
patient factors (such as age, ethnic group, etc.), PMH, and other
risk factors (e.g., socioeconomic, cultural background, etc.).
[MUSIC PLAYING] DR. MOORE: Hi. Good afternoon. My
name is Dr. Moore. Am I understanding you're here
for a mental health assessment today? PETUNIA PARK: That's
right. DR. MOORE: OK. So to make sure I have the right
patient and the right chart, can you tell me your name
and your date of birth? PETUNIA PARK: Yes. I'm Petunia Park.
My birthday is July 1, 1995. DR. MOORE: And can you tell
me what today's date is? PETUNIA PARK: So
it's December 1. DR. MOORE: Do you know the year?
PETUNIA PARK: 2020. DR. MOORE: And what day
of the week is this? PETUNIA PARK: It's Tuesday.
[CHUCKLING] DR. MOORE: And do you
know where we are today? PETUNIA PARK: Yes I am here
in the beautiful, sunny office at the clinic. DR. MOORE: OK,
great. Thank you. So can you tell me a little bit
about why you're here today? What brings you here today?
PETUNIA PARK: Yes. So I have a history of taking
medications and then stopping them. I don't think I need them. I
really feel like the

21. medication squashes who I am. DR. MOORE: OK, OK. So I'm
going to be able
to help you with that. But to begin, I'm going
to ask you some questions about your family. I'm going to ask
you some
history-type questions. I'm going to ask
you some symptoms that you might be having. And all of these
questions are going to help me work with you
on a treatment plan, OK? So I would like to
begin with, when was the first time that you
ever had any mental health or substance use
treatment in your life? PETUNIA PARK: OK. Well, when I was
a teenager,
my mom put me in the hospital after I went four or five
days without sleeping. I think I may have been
hearing things at that time. [CHUCKLES] I think they
started me on some medication, but I'm not sure. DR. MOORE:
Oh, OK so
you were hospitalized. How many times have you been
hospitalized for mental health? PETUNIA PARK: Oh, I've been
hospitalized about four times. The last time was
this past spring. No detox or residential
rehabs, though. DR. MOORE: OK, good. Were any of these
hospitalizations due to any suicide gestures? PETUNIA PARK:
One was in 2017. I overdosed on
Benadryl, but I've not had those thoughts since then. DR.
MOORE: Well, I'm very glad
to hear that you've not had any of those thoughts since then.
And I'm glad that you turned
out OK from that overdose. I'm glad that you're here today. Can
you tell me a
little bit about what you've been diagnosed with
during your past treatments? PETUNIA PARK: Well,
I think depression, and anxiety, had some
even say maybe bipolar. DR. MOORE: OK, and
what medications have you been tried on

22. before for those illnesses? And if you can remember,
what was your reactions to those medications? PETUNIA
PARK: Oh, let's see. Oh, I took Zoloft, and that
made me feel really high. [CHUCKLES] I couldn't sleep. My
mind was racing, and
then I took risperidone. That made me gain
a bunch of weight. Seroquel gave me weight, too. I took
Klonopin, and that
seems to slow me down some. I really can't
remember the others. I think the one I just
stopped taking was helping. It started with an L, I think. I don't
really
remember the name, but it squashed
me in creativity. DR. MOORE: OK, well,
we're going to try to help you find some
medication that doesn't make you feel squashed or have any of
those negative side effects today. But in order to do that, I
need some more information. And the next questions I'm going
to ask you are about substances you may have used. And I want
you to know that you
don't get in trouble in here if you've used some
of these substances. It really just helps
me to make sure that what's in your
system that could be impacting your neurochemistry. And when
we do talk
about medications, so I don't give you something
that would negatively interact with something
you may be using, OK? So do you-- PETUNIA PARK: OK. DR.
MOORE: --use any nicotine? PETUNIA PARK: Yes. I smoke
about a pack
a day, and I'm not going to quit for you, either. [CHUCKLES]
Oh. DR. MOORE: That's OK, that's OK. And what about
alcohol? When was your last
drink of alcohol? PETUNIA PARK: When I
was 19 because alcohol and me do not work
well together. [CHUCKLES] DR. MOORE: OK, and what

23. about any marijuana? When was your last
use of any marijuana? PETUNIA PARK: Oh no. I tried that once
and
got really paranoid. DR. MOORE: OK. What about any last
use of cocaine? PETUNIA PARK: Never. DR. MOORE: Last
use of any
stimulants or methamphetamines? PETUNIA PARK: Never. DR.
MOORE: What about
any huffing or inhalants? PETUNIA PARK: Never. DR.
MOORE: OK, have
you used anything like Klonopin or Xanax, any
of those sedative medications? PETUNIA PARK: Never. DR.
MOORE: All right, good. What about any hallucinogenics
like LSD, or PCP, or mushrooms? PETUNIA PARK: No, never.
DR. MOORE: Wonderful. OK, what about any use of pain
pills or opiate medications? Anything prescribed
or anything you've obtained from the street? PETUNIA PARK:
No, never. DR. MOORE: Good. And anything synthetic like
Spice, or ecstasy, Bath Salts, Mollies, anything like that?
PETUNIA PARK: Never. DR. MOORE: Oh, wonderful. Well,
I'm glad to hear that. You know those things
aren't good for your brain. So I encourage you to continue
to stay away from those things. Have you ever had any
blackouts or seizures from drugs or alcohol? Or seen things that
you
weren't sure were there? PETUNIA PARK: Never. DR.
MOORE: Good. What about any legal
issues or any DUIs? PETUNIA PARK: Never. DR. MOORE:
OK. Good, good. All right, so I'm just
going to ask a little bit about your family right now. Any blood
relatives have any
mental health or substance abuse issues? PETUNIA PARK:
Yeah, well,
well, why would you ask that? It's not your business. DR.
MOORE: Right. I could see where you
might find that wouldn't be any my business. But really,

24. sometimes these
issues can be genetic. They're alarm behaviors. So my
understanding
of your family helps me to understand you. PETUNIA PARK:
Huh. Well, my mother
was seen as crazy. I think they said she
had bipolar or something. And my father went
to prison for drugs. And well, we haven't heard,
or seen, or heard from him in 8 or 10 years. My brother, while I
think
he's a little schizo, but he hasn't ever
went to the doctor. Nobody else with anything. DR. MOORE:
OK. So that sounds like
it must be tough growing up not
seeing your father and having some of those
issues in your family. But any family, blood
relatives commit suicide? PETUNIA PARK: Well, my mom
tried, but nobody really did it, you know? DR. MOORE: OK.
Have you ever done anything
like that, or anything like cut on yourself, burn yourself?
PETUNIA PARK: I already told
you, I tried to kill myself. Why ask me that again? No, I'm not
going to kill
myself or anyone else, and I don't cut myself. DR. MOORE:
OK. Well, I'm glad to hear that. And I want you to know
that I am here for you, and we most certainly
will make sure you have a crisis like number
at the end of this session if you do have those
thoughts in the future. So I'm glad to
hear that you don't have those thoughts today. OK. What type of
medical
issues do you have? PETUNIA PARK: Oh, hoo. Let's see. I have
a thyroid issue that
I take some medicine for, that hypothyroidism. And I take a
birth control
pill for polycystic ovaries. DR. MOORE: OK, when

25. was your last menses? PETUNIA PARK: Oh, well I have
a regular one each month. So let's see. It was last month
sometime. DR. MOORE: OK, so any
chance that you're pregnant? PETUNIA PARK:
[LAUGHS] Lordy, no. I may have a lot of sex
around, but I'm safe. DR. MOORE: Hm. You "have a lot of sex
around." Can you maybe tell
me what that means? PETUNIA PARK: Well, it's
exciting and thrilling to find new people to explore sex with. It
helps me keep my
moods high, high, high. [CHUCKLES] DR. MOORE: OK, so
that makes
you feel really high and kind of what, OK? PETUNIA PARK:
Oh yeah. DR. MOORE: So who raised you? PETUNIA PARK:
My mom and
my older brother, mainly. DR. MOORE: And who
do you live with now? PETUNIA PARK: Well, I
live with my boyfriend. And sometimes, stay with my
mom when he gets mad at me for sleeping around some. DR.
MOORE: So that's
created some issues in your relationship, I see. OK. Are you
single, married,
widowed, or divorced? PETUNIA PARK: I've
never been married. DR. MOORE: OK. Do you have any
children? PETUNIA PARK: No. DR. MOORE: All right. Are
you working? PETUNIA PARK: Yes, I work part
time at my aunt's bookstore. She's more tolerant of
the days I don't come in from feeling too depressed. DR.
MOORE: OK, so I hear some,
maybe, feelings of depressed. OK. What is your level of
education? PETUNIA PARK: Oh,
I'm in vo-tech school right now for cosmetology. I'm going to
do makeup
for movie stars. [CHUCKLES] DR. MOORE: Oh, that
sounds really wonderful. OK, so but what about now? What do
you do for fun now? PETUNIA PARK: Well, I am

26. writing my life story, and it's going to be published. I also paint
like Picasso. I'm going to sell those
paintings to movie stars, too. DR. MOORE: Well,
that's wonderful. Maybe someday you can show
me your paintings as well. OK, have you ever been arrested
or convicted for anything? PETUNIA PARK: No. The police did
pick me up and
take me to the hospital once. I didn't have much
sleep that week. And they said I was dancing
around in my nightgown in a field with my guitar. I really don't
remember
much of that, though. I think maybe my mom made
up that story against me because she wanted me to go
back to my boyfriend's house. DR. MOORE: OK, so that was
one of your hospitalizations that we talked about earlier. OK,
what about any history of
trauma with childhood or adult? Any kind of physical,
sexual, emotional abuse? PETUNIA PARK: Well, my
dad was pretty hard on us when he was around. But he didn't
really
touch us or anything. More just yelled at us a lot. DR. MOORE:
OK. All right, so I've
gathered some history here. Now, I want to get
into more of some of the symptoms that brought
you in to see me today. So you mentioned before that
sometimes your depression keeps you from working
at your aunt's bookstore. Can you tell me
a little bit more about what that
looks like for you? PETUNIA PARK: Well, about
four or five times a year, I have these times when I just
don't want to get out of bed. I have no energy, no
motivation to do anything. I just can't feel any
interest in my creativity. I feel like I'm not worth
anything because I feel that creativity slipping away. So this is
usually
happening after I've been up for five

27. days working hard on my works with my writing,
painting, and music. Everyone says I'm
depressed, but I'm not sure. It could be that I'm just
exhausted from working so hard. DR. MOORE: OK, so I hear
you
talking about these creativity episodes right before you crash.
Per se, this depression. Tell me a little bit more
about those episodes. What do those look like for you?
PETUNIA PARK: Oh,
I love those times. Those are the reasons
I don't always take my medication because
I feel like I'm squashed. I have lots of energy
to do a lot of things. I can go four or five days
with very little sleep. I get lots of things
done, but my friends tell me I talk too much
and appear scattered. [SIGHS] They're just jealous
of all the accomplishments I'm getting done. These are the times
I
look to explore my mind and body with feeling good
through sex with other people. DR. MOORE: OK, how long do
those episodes last typically when you have them? PETUNIA
PARK: About a week. DR. MOORE: About a week. OK. So I
want to ask a little bit
more about some other symptoms that maybe we
haven't talked about. Do you feel like you worry
a lot or have any kind of anxiety and panic symptoms?
PETUNIA PARK: No, no no. I'm not a worry. DR. MOORE:
OK, do
you do anything that you feel like you have to
do repetitively over and over? And if you can't do them, you
feel like the end of the world is coming? Something like maybe
count on threes or wash your hands 20 times? Anything like
that? PETUNIA PARK: [LAUGHS] No, no. I don't have OCD, if
that's what you're asking. DR. MOORE: OK, what about
hearing or seeing things you're not sure
others see or hear? Anything like that? PETUNIA PARK: Not

28. right now. It's been a couple of
months since that happened. Sometimes when I'm
not sleeping good, I hear voices telling me how
great and wonderfully talented I am. DR. MOORE: OK. So, but
no voices right now? PETUNIA PARK: No. DR. MOORE: OK,
good. What about your appetite? How's your appetite?
PETUNIA PARK: Well, when
I'm really creative, I'm too busy to eat. And when I'm
crashing and resting, I eat everything in sight. DR. MOORE:
OK, so
what about your sleep? On average, how much time
do you think you sleep in a whole 24-hour period? And do you
have any bad dreams? PETUNIA PARK: No bad dreams. Most
of the time, I get
about five or six hours. When I'm creative,
I'm lucky to get three hours and a whole week. Ugh. And when
I'm crashed, I sleep
about 12 or 16 hours a day. DR. MOORE: OK, wonderful. So
this is great. I have a lot of
information from you that I think we will be able to
come up with a treatment plan and maybe find some
medication that's going to help you feel better
without you feeling so squashed and having negative
side effects, but really help you be able
to function through the day. [MUSIC PLAYING]