Case Study Analysis

Part One

Delusional disorders are characterized by long-standing false beliefs that are unshakeable in the face of ample contradictory evidence. These beliefs can potentially result in serious interference in interpersonal relationships, occupational functioning, and daily functioning. For Ahmed Khan, a 40-year-old accountant, persecutory delusions have resulted in greater social withdrawal and affective detachment. This analysis considers the neuroanatomical substrates, test results, diagnostic issues, and differential diagnoses of Ahmed’s presentation according to evidence-based psychiatric practice: Case Study Analysis.

Overview of the Diagnosed Disorder

Ahmed Khan is experiencing repeated paranoid delusions that involve government spying and control of his ideas. The symptoms have lasted for over two years, resulting in significant impairment in occupational, social, and emotional functioning. Based on the information provided, Delusional Disorder, Persecutory Type, is the most appropriate diagnosis. This illness is characterized by the presence of one or more delusions that must exist for at least a month and with no substantial impairment of functioning except as a result of the delusion itself (American Psychiatric Association, 2022).

The delusions in Ahmed are systematized, not bizarre, and persecutory. His insight is poor, and his functioning has deteriorated in both the work and family settings. Despite the lack of evidence for hallucinations or mood symptoms, his fixed false delusions and guarded affect are most consistent with this disorder.

Neuroanatomy of Delusional Disorder

Delusional disorder has been associated with dysfunction in several crucial brain regions. Neuroimaging implicated the limbic system, particularly the amygdala and hippocampus, and was involved in emotion regulation and memory processing. Dysfunction in these areas can lead to misattribution of salience to neutral events, which can feed paranoid ideation, as stated by Joseph and Siddiqui (2023). Moreover, the prefrontal cortex, more specifically the dorsolateral prefrontal region, plays a role in the impaired reasoning and insight of delusional patients.

Such individuals are more likely to have less activity in the right hemisphere’s frontal and temporal regions, which are accountable for belief evaluation and reality testing. In Ahmed’s case, his intact memory and orientation but poor insight and judgment suggest frontal lobe disturbance rather than generalized cognitive impairment.

Physiological and Mental Status Examination Findings

Ahmed’s physical examination is unremarkable, with normal laboratory studies and stable vital signs, including thyroid function and urine drug screen. However, his mental status examination reveals a number of characteristic features of delusional disorder. He is dressed, oriented, and has clear speech, which would be consistent with spared cognition of this diagnosis.

His avoidant eye contact, guardedness, and refusal to talk are telling signs of paranoia. Although his thinking is rational, he remains preoccupied with the content of his delusions. His mood is described as “nervous,” and he has a flat affect, which is suggestive of underlying blunting of emotions. Insight is limited, and judgment is clouded, which is in keeping with a fixed, non-reality-based system of belief.

Recommended Diagnostic Testing and Screening Tools

Although delusional disorder is most often diagnosed by clinical examination, some diagnostic instruments may be used to aid assessment and eliminate other disorders. According to Zhu et al. (2024), neuroimaging, such as MRI or CT scans, can at least exclude structural abnormalities in middle-aged patients presenting with new-onset psychosis. Ahmed has no psychiatric background; therefore, neuroimaging would be the appropriate course of action.

Routine laboratory examinations, like CBC, CMP, and thyroid panels, already completed, are required to rule out metabolic or endocrine causes. Other psychological assessments, such as the Positive and Negative Syndrome Scale (PANSS), can be applied to quantify symptom severity and evaluate treatment response at follow-up. The Structured Clinical Interview for DSM-5-TR Disorders (SCID-5) is also helpful in establishing the diagnosis based on standard criteria.

Formulation of Primary Diagnosis

Ahmed meets DSM-5-TR Delusional Disorder, Persecutory Type (F22). His delusional notion of being watched and spied on by the government has persisted for over two years with unbroken duration. He lacks hallucinations, disorganized speech, or grossly disorganized behavior, distinguishing this condition from schizophrenia.

No co-occurring mood episode accompanies the duration of delusions, and his functioning, though impaired, is not disorganized or reduced to the extent seen with other psychotic illnesses. His intact memory, coherent speech, and absence of hallucinations support this diagnosis (American Psychiatric Association, 2022).

Differential Diagnoses

Schizophrenia (F20.9)

Schizophrenia is also a potential differential diagnosis in light of Ahmed’s delusions and social isolation. Schizophrenia, however, requires the presence of two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative symptoms. Ahmed does not have hallucinations, disorganized thoughts or behavior, or other basic schizophrenia symptoms.

Secondly, his delusions are well-structured and relatively stable without impairments in speech or function, which are typical in schizophrenia (Hany et al., 2020). Thus, schizophrenia is unlikely because there is no manifestation of several psychotic features.

Paranoid Personality Disorder (F60.0)

Paranoid Personality Disorder (PPD) is also a differential diagnosis characterized by a pervasive distrust and suspiciousness of others. People with PPD are likely to mistake benign intentions for malicious ones. PPD is not an abrupt onset of delusions but a lifelong pattern.

Ahmed’s symptoms started two years ago and do not represent a lifelong suspicious temperament. Also, PPD is not characterized by fixed or very impaired false beliefs or judgment (Jain & Torrico, 2024). Based on Ahmed’s presentation and DSM-5-TR criteria, delusional disorder is still the best-fitting diagnosis.

Part Two

Ahmed Khan’s case illustrates a classic presentation of Delusional Disorder, Persecutory Type. He is a 40-year-old accountant with more than two years of fixed, non-bizarre delusions of being persecuted and watched by the government. Although he does have paranoia, social withdrawal, and impaired work performance, he lacks hallucinations, disorganization of thought, or negative symptoms of schizophrenia. His mental status examination corroborates the diagnosis, highlighting guardedness, poor insight, and flat affect.

This case study section addresses evidence-based pharmacological and non-pharmacologic treatments for Ahmed’s principal diagnosis. It compares them to guideline-recommended treatments for two differential diagnoses: schizophrenia and paranoid personality disorder (PPD).

Evidence-Based Non-Pharmacological Treatment Guidelines for Primary Diagnosis

Non-pharmacological interventions play a key role in the treatment of delusional disorder, especially in patients who, like Ahmed, maintain cognitive coherence but lack insight. Cognitive behavior therapy for psychosis (CBTp) is highly indicated for this condition to help the patient identify and evaluate delusional beliefs. Therapists employ guided discovery and behavioral experiments to challenge gently distorted appraisals and facilitate alternative thinking (Agbor et al., 2022). In contrast to confrontation methods, CBT enables self-reflection and reality testing by guided conversation and is, therefore, appropriate for clients with persecutory delusions, who tend to be defensive.

Another primary intervention is psychoeducation, which helps the patient and their family gain a clear understanding of their condition and how it is impacting the patient. The emotional environment becomes stable as the family members learn to respond calmly and constructively, lowering the chances of worsening symptoms. Without directly disputing delusional content, supportive psychotherapy is also valuable in being empathic, actively listening, and forging alliances (Sarkhel et al., 2020).

Working with persecutory delusions depends on trust: these interventions help patients such as Ahmed feel safe while gradually allowing him to start including cognitive change. However, the fear of reinforcing persecutory themes or triggering distress in these patients causes them to avoid group therapy generally.

Evidence-Based Pharmacological Treatment Guidelines for the Primary Diagnosis

Second-generation antipsychotics are generally used in the pharmacotherapy of delusional disorder and are found to be effective in reducing the severity of delusional beliefs while having a good side effect profile. Risperidone, aripiprazole, and olanzapine are some of the drugs commonly employed. In Ahmed’s case, risperidone would be appropriate, considering its efficacy and balance of tolerability.

Low dose initiation with gradual titration upward will help to reduce side effects and maintain medication adherence (Fabrazzo et al., 2022). Since Ahmed continues to have an organization of thought and language, containment of symptoms takes precedence over sedation or control of behavior.

When there is nonadherence with medication, most frequently because of lack of insight, long-acting injectables (LAIs) can be considered. Although it is not the norm for all delusional disorder patients, they are a viable alternative for patients who have discontinued oral medications on multiple occasions in the past. Response to treatment must be observed using structured instruments such as the Positive and Negative Syndrome Scale (PANSS) to assess the symptom course over time (Maj et al., 2021).

Therapeutic efficacy must be developed through regular follow-up sessions and management of side effects. Pharmacotherapy combined with psychological treatment has a larger and more durable effect.

Comparison of Treatment Recommendations

Delusional Disorder and Schizophrenia

Pharmacologically, schizophrenia necessitates a wider and usually more severe treatment than delusional disorder. Schizophrenia patients typically present with more than one symptom, such as hallucinations, disorganized thinking, and negative symptoms, which need higher doses of antipsychotics. Medications like olanzapine or paliperidone are typically given in dosages that cover a wide range of psychotic symptoms (González-Rodríguez & Seeman, 2022).

Clozapine is also employed in treatment-resistant illness, which is not usually the situation in delusional disorder. LAIs are used more readily in schizophrenia since the threat of noncompliance and relapse is higher.

Non-medication therapies for schizophrenia are more extensive and rehabilitative. In addition to CBT, social skills training, occupational therapy, and supported employment services are usually beneficial for the patient. Assertive Community Treatment (ACT) teams deliver integrated treatment for chronically symptomatic patients with declining functionality. These services are not usually required for delusional disorder since the individual’s functionality is generally intact except for the delusional theme (González-Rodríguez & Seeman, 2022). In contrast to the comparatively circumscribed therapeutic target in delusional disorder, treatment of schizophrenia deals with wider deficits in cognition, affect, and daily life.

Delusional Disorder and Paranoid Personality Disorder

Pharmacological therapy for PPD is usually limited and symptomatic rather than essential. Antipsychotics are not routinely used except for transient psychotic phenomena. Alternatively, SSRIs or anxiolytics may be utilized if there is co-morbid depression or anxiety in patients.

This differs from delusional disorder, for which antipsychotics are typically first-line and are targeted explicitly at extinguishing delusional beliefs’ intensity (Jain & Torrico, 2024). Antipsychotic therapy is a priority in Ahmed, while a person with PPD might not need medication altogether unless emotional distress becomes salient.

In terms of non-pharmacological treatment, PPD is optimally treated through long-term psychotherapy to diminish pervasive suspiciousness and mistrust gradually. The therapy is relational and insight-oriented, with trust establishment and the gradual challenge of maladaptive assumptions regarding others. In contrast to CBTp, which is specifically targeted at delusional beliefs, treatment of PPD tends to eschew abrupt cognitive restructuring because of therapeutic alliance rupture risk.

In delusional disorder, cognitive therapy is goal-oriented and structured, whereas, in PPD, therapy is long-term exploratory and rapport-based (Slamanig et al., 2021). This distinction highlights the requirement for a diagnosis-specific therapeutic approach.

Conclusion

Ahmed Khan’s diagnosis of Delusional Disorder, Persecutory Type, warrants a personalized and evidence-based treatment plan that combines pharmacological and non-pharmacological interventions. CBT, psychoeducation, and supportive psychotherapy establish structure and trust, and antipsychotics such as risperidone actively target psychotic symptoms. Less intensive and, more specifically, delusion management than in schizophrenia is his treatment.

More pharmacologically based and symptom-focused than in paranoid personality disorder is Ahmed’s treatment. Addressing each diagnosis’s needs renders therapeutic interventions effective and respectful of the patient’s experience and function.

References

Agbor, C., Kaur, G., Soomro, F. M., Eche, V. C., Urhi, A., Ayisire, O. E., Kilanko, A., Babalola, F., Eze-Njoku, C., Adaralegbe, N. J., Aladum, B., Oyeleye-Adegbite, O., & Anugwom, G. O. (2022). The role of cognitive behavioral therapy in the management of psychosis. Cureus. https://doi.org/10.7759/cureus.28884

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR). Psychiatry.org; American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/dsm

Fabrazzo, M., Cipolla, S., Camerlengo, A., Perris, F., & Catapano, F. (2022). Second-generation antipsychotics’ effectiveness and tolerability: A review of real-world studies in patients with schizophrenia and related disorders. Journal of Clinical Medicine, 11(15), 4530. https://doi.org/10.3390/jcm11154530

González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini narrative review. World Journal of Psychiatry, 12(5), 683–692. https://doi.org/10.5498/wjp.v12.i5.683

Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2020, January 1). Schizophrenia. PubMed. https://pubmed.ncbi.nlm.nih.gov/30969686/

Jain, L., & Torrico, T. J. (2024, June 5). Paranoid personality disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK606107/

Joseph, S. M., & Siddiqui, W. (2023). Delusional disorder. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

Maj, M., Van Os, J., De Hert, M., Gaebel, W., Galderisi, S., Green, M. F., Guloksuz, S., Harvey, P. D., Jones, P. B., Malaspina, D., McGorry, P., Miettunen, J., Murray, R. M., Nuechterlein, K. H., Peralta, V., Thornicroft, G., Van Winkel, R., & Ventura, J. (2021). The clinical characterization of the patient with primary psychosis aimed at personalization of management. World Psychiatry, 20(1), 4–33. https://doi.org/10.1002/wps.20809

Sarkhel, S., Singh, O., & Arora, M. (2020). Clinical practice guidelines for psychoeducation in psychiatric disorders general principles of psychoeducation. Indian Journal of Psychiatry, 62(8), 319. https://doi.org/10.4103/psychiatry.indianjpsychiatry_780_19

Slamanig, R., Reisegger, A., Winkler, H., De Girolamo, G., Carrà, G., Crocamo, C., Fangerau, H., Markiewicz, I., Heitzman, J., Salize, H. J., Picchioni, M., & Wancata, J. (2021). A systematic review of non-pharmacological strategies to reduce the risk of violence in patients with schizophrenia spectrum disorders in forensic settings. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.618860

Zhu, Y., Maikusa, N., Radua, J., Sämann, P. G., Fusar-Poli, P., Agartz, I., Andreassen, O. A., Bachman, P., Baeza, I., Chen, X., Choi, S., Corcoran, C. M., Ebdrup, B. H., Fortea, A., Garani, R. R., Glenthøj, B. Y., Glenthøj, L. B., Haas, S. S., Hamilton, H. K., & Hayes, R. A. (2024). Using brain structural neuroimaging measures to predict psychosis onset for individuals at clinical high-risk. Molecular Psychiatry, 1–13. https://doi.org/10.1038/s41380-024-02426-7

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Case Study Analysis: Part Two

Purpose

This assignment allows students to evaluate the therapeutic interventions for the diagnosed disorder in Part One of the assignment. The student determined their assigned client’s primary and differential diagnoses in part one of this assignment. Based on the client’s diagnosis, the student will explore the therapeutic treatment recommendations for their client. The student will contrast these recommendations for the primary diagnoses with the evidence-based recommendations for the differential diagnoses.

Part Two – Module Two

The entire paper is completed on the case study assigned  at the beginning .

Part two of the paper should be three pages long (not including title/reference pages), using the current APA formatting requirements with appropriate grammar and spelling. The paper requires at least three peer-reviewed resources, one of which may be Stahl’s Essentials of Psychopharmacology. All peer-reviewed resources used in the paper should be less than five years old.

Part Two of the paper builds on part one and must include:

• Part one of the paper with the title page
• Evidence-based non-pharmacological treatment recommendations for the primary diagnosis
• Evidence-based pharmacological treatment recommendations for the primary diagnosis
• Comparison of treatment recommendations for the primary diagnosis compared to the two differential diagnoses
  • When comparing and contrasting your differential diagnoses, make sure to address the following components for each:
    1. pharmacological treatment recommendations
    2. non-pharmacological treatment recommendations
    3. Complete the reference page with all references used in the entire paper in APA format