Thorough Psychiatric Assessment Note.

Patient Information

Initials: J.K.
Age: 16 years
Gender: Male
Evaluation Date: April 9, 2026.

Subjective

Chief Complaint

Easily angered and fighting.

History of Present Illness (HPI)

The patient is a 16-year-old man with a history of growing anger outbursts and impulsive behavior, which started around two years ago. The symptoms have gradually aggravated in the course of time and are currently prevalent about three to four times a week. The patient claims the episodes to be moderate and severe, and can be triggered by small disagreements, frustration, or the feeling that peers and family members are disrespectful towards them. In these instances, he will be involved in violent activities such as screaming, physical violence, and even damaging property. He also mentions that he feels relieved following such outbursts, but he is not very repentant following the outbursts (Liu et al., 2025). These symptoms have hugely affected his functioning. The patient has had low grades and has been suspended from school several times due to fights. At home, there is continuous fighting with family members (particularly his mother). In the social aspect, he has difficulties with friends and a lot of fights with peers that lead to social isolation.

Past Psychiatric History

There is no previous formal psychiatric diagnosis. There is no history of psychiatric hospitalizations. He has neither undergone any psychiatric medicines nor psychotherapies.

Substance Use History

The patient does not have frequent alcohol use in social settings. He denies taking illegal drugs and tobacco products.

Medical History

The patient does not have any serious history of health problems. He does not have any medications.

Family Psychiatric History

According to the patient, his father is violent and may have a substance use disorder but has never been diagnosed with anything negative: a family history of other mental illnesses.

Social History

The family is a single-parent family, the mother and her younger brother. He complains of a poor relationship with family members, as there is a lot of fighting and misbehavior. He has low grades and discipline problems and is already in school. The patient also says he has been exposed to violence in his society, and this is what can make him develop the patterns of his behavior. He has peer social issues, and he has a lot of unsupervised time outside of school.

Objective

Mental Status Observations

Look: Male teen, relaxed in clothing, somewhat disheveled, age mentioned.
Behavior: Irritable, sometimes agitated; irritable during the interview, cooperative.
Speech: Speech rate and rhythm are normal; there is talk of yellish tone with frustrating situations.
Mood: I am most of the time irritated.
Affect: Limited, consistent with expressed mood.
Thought Process: Linear and goal-oriented, but impulsive in some cases in responding.
Thought Content: Denies having delusions, hallucinations, paranoid ideation. Denies suicidal and homicidal thoughts.
Insight: poor; patient has minimal knowledge about the effects of his behavior on other people.
Judgment: Low, according to the frequent involvement in violent episodes.
Impulse Control: Dysfunctional, which is demonstrated by an overall incapacity to restrain anger and behavior.

Assessment

Mental Status Examination (MSE)

The patient is time, place, and person oriented. His report gives an irritable mood with a constricted effect, which is a consistent mood. It is not well-informed because he is not aware of the adverse effects of his aggressiveness. There is poor judgment, as evidenced by frequent fights, school, and domestic disobedience. The patient denies any suicidal/homicidal ideation and denies any psychotic symptoms. The impulse control is poor as it is expressed by frequent outbursts of anger and physical aggression (et al., 2025).

Differential Diagnoses

Conduct Disorder (Most Likely)

The patient has a long-term history of behavior that violates the rights of other people, such as aggression towards other people and property, repetition of infringement, and the absence of guilt. This is the diagnosis most likely, as they are chronic behaviors that significantly affect school, family, and social functioning.

Intermittent Explosive Disorder

Taken into account because of frequent anger outbursts. The aggression in this case, however, is long-term, goal-oriented, and associated with the breach of rules, not the bursts of aggression, and thus a secondary possibility.

Oppositional Defiant Disorder

Considered due to defiance and irritability, however, the extent and type of behaviors (physical aggression, property damage) are greater than would be typical of this disorder, which puts it at the bottom of the differential.

Primary Diagnosis

Conduct Disorder in childhood (CD).

DSM-5-TR Justification

Referring to the DSM-5-TR criteria, it is possible to diagnose the patient with Conduct Disorder. He brings out a highly prevalent and generic form of violation of societal norms and the rights of other individuals, including violence among peers and family members, as well as property and lies. The patient started to have the symptoms before the age of 10, and his practices have continued for more than two years, therefore, qualifying the duration criterion. These symptoms cause significant social, academic, and family disabilities. The patient is also not remorseful and insightful, which is also in line with the DSM-5-TR criteria of Conduct Disorder.

Plan

Psychotherapy Approach

Cognitive Behavior Therapy (CBT).

Family Therapy

Rationale

CBT is chosen to assist the patient in finding out and changing dysfunctional thought patterns that elicit aggressive and impulsive behaviors. This treatment involves learning coping mechanisms, emotional control, and problem-solving in order to lessen anger outbursts and enhance impulse control. This is accompanied by family therapy to deal with environmental and relationship factors that have led to the behaviors of the patient. It is concerned with the enhancement of communication, the setting of consistent behavioral boundaries, and equipping caregivers with the strategies to strengthen positive behavior.

Treatment Plan

Frequency: Psychotherapy (individual CBT) once a week and family therapy sessions twice a week.

Goals:

Lessen the occurrence and severity of aggressive outbursts.
Enhance emotional control and impulse control.
Enhance family communication and support.
Enhance academic and social functioning.

Follow-Up

Reassess at 2 weeks to determine the improvement of symptoms and adherence to treatment.
Modify treatment plans when necessary according to progress.

Referrals

Psychiatrist: To assess whether pharmacotherapy is needed because of constant aggression.

School Counselor: To help with behavior interventions within the learning environment.

Social Worker: To help with community resources and minimize exposure to environmental stressors.

Reflection

What Would You Do differently?

In evaluating a similar patient in the future, I would incorporate more behavioral assessment strategies and information supplied by the teachers and the family members earlier. It would allow gaining a better understanding of the antecedents and patterns of aggression and the effects of the environment on the patient. Furthermore, I would implement early interventions on the emotion regulation skills at the initial sessions of the therapy so as to reduce the severity of behavior situations within a reduced time span.

Social Determinant of Health

Access to and Quality of Education (Healthy People, 2030)

School issues and frequent school suspensions are key factors that influence the mental health of the patient and the results of his behavior. The frustration can be aggravated by poor attendance at school and a lack of support mechanisms in the shape of learning materials, which may result in violent acts. The obstacles to education may be overcome by providing tutoring or counseling at school, and this will contribute to the success in academic achievement and more efficient emotional control.

Health Promotion

Encourage structured extra-curricular programs, e.g., sport or a mentorship program. These activities help in positively utilizing the energy, learning to be a team player, learning to control impulses, and reducing the possibility of engaging in acts of aggression or confrontation.

Patient Education

Educate the patient to cope with anger, including breathing deeply, time-outs, and triggers. Teach the need to use these methods in practice to avoid escalation and encourage self-control (Menefee et al., 2022).

References

for R., Ernstmeyer, K., & Christman, E. (2025). MENTAL HEALTH CONDITIONS. Nih.gov; Chippewa Valley Technical College. https://www.ncbi.nlm.nih.gov/books/NBK615348/

Liu, F., Yin, X., & Jiang, W. (2025). Comprehensive Review and Meta‐Analysis of Psychological and Pharmacological Treatment for Intermittent Explosive Disorder: Insights From Both Case Studies and Randomized Controlled Trials. Clinical Psychology & Psychotherapy, 32(1). https://doi.org/10.1002/cpp.70016

‌Menefee, D. S., Ledoux, T., & Johnston, C. A. (2022). The Importance of Emotional Regulation in Mental Health. American Journal of Lifestyle Medicine, 16(1), 28–31. https://doi.org/10.1177/15598276211049771

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Assignment 2
TO PREPARE
Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorderduring the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Include at least five scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.