Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders and Medication-Induced Movement Disorders

Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders and Medication-Induced Movement Disorders

CC (chief complaint): Potential substance use

HPI: The patient is a 48-year-old Asian who presents to the clinic due to alcohol abuse complaints by parents, students, and colleagues. The principal requested this session since the patient had been late to classes for twenty-two days. She denies these statements and is clearly agitated by the accusations. After being pressed further, she states that there was a party at Darrel’s house where everyone drank much and not just her. She wonders why Darrel was not brought up for questioning. She also states that she got angry since Darrel did not wake her up the day after, making her late for class. She denies being drunk while teaching and is agitated by the same complaints. The complaints included sleeping in class while students were writing notes. She further claims that it is Alexis who is saying things about her. After being told that the administration required her cooperation, she agrees that she drank a lot the previous night and admits that she drinks every night. She drinks alone at home. She began drinking heavily in her freshman and less during her college years.

Past Psychiatric History:

General Statement: The patient has a history of substance abuse but has never been committed to an institution.

Caregivers (if applicable): None

Hospitalizations: None

Medication trials: None

Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: The patient has a history of drinking alcohol during her college days. She currently drinks alcohol every day, causing her issues at work.

Family Psychiatric/Substance Use History: Her father had an alcohol use disorder. He went to Alcoholics Anonymous and got sober.

Psychosocial History: The patient is an only child, and both parents were raised in San Francisco, California. She has a master’s degree in high school education and a Ph.D. in biology. She lives alone, single, without any children. She is currently in a new relationship after breaking up with her ex-boyfriend, Ryan. She drinks a couple of glasses of alcohol alone in her free time. She occasionally goes to social events with her friends. She is a high school teacher but does not currently enjoy her job. She denies any current or history of legal issues.

Medical History:

Current Medications: Unknown

Allergies: Unknown

Reproductive Hx: Heterosexual and sexually active. Not pregnant or lactating.

ROS:

GENERAL: Denies weight loss, fatigue, chills or fever

HEENT: Denies visual loss, blurred visions or yellow sclerae. Denies runny nose, nasal congestion, throat pain, hearing loss or sneezing.

SKIN: No itching or rash

CARDIOVASCULAR: Denies chest pain or chest discomfort. Denies peripheral edema or palpitations.

RESPIRATORY: Denies dyspnea, cough, or sputum

GASTROINTESTINAL: Denies appetite loss, nausea, vomiting or abdominal pain

GENITOURINARY: Denies urinary urgency, incontinence, or burning sensation on urination

NEUROLOGICAL: Denies syncope, ataxia, dizziness, numbness, paralysis, or headache.

MUSCULOSKELETAL: Denies muscle pain, joint pain, or back pain.

HEMATOLOGIC: Denies anemia or easy bruising

LYMPHATICS: Denies swollen lymph nodes.

ENDOCRINOLOGIC: Denies heat/cold intolerance, polyuria, polyphagia, or polydipsia

Physical exam:

Constitutional: The patient is A & O X3. She is appropriately dressed for the weather. She is not cooperative.

HEENT: Head is atraumatic and normocephalic. Eyes: Visual acuity: 20/20. PERRLA. Ears: Tympanic membrane is grey and intact. Nose: Nasal nares are patent. Throat: Oral mucosa is moist and pink

Cardiovascular: S1, S2 heard. Chest expansion is equal bilaterally. Capillary refill is less than three seconds.

Respiratory: No wheezes, crackles, or labored breathing noted.

Abdominal: Normal bowel sounds on auscultation. No masses were noted.

Lymphatics: No lymphadenopathy on palpation.

Skin: Skin is warm and moist to the touch. No tattoos noted.

Genitourinary: Deferred

Brest: Deferred

Diagnostic results:

The usual laboratory testing for alcohol in clinical settings is the blood alcohol content (BAC). BAC is estimated using a breathalyzer machine (Marienfeld, 2020). Other tests should also be conducted to rule out other medical conditions, such as macrocytic anemia, coagulopathies, elevated liver enzymes, and pancreatitis (Nehring & Freeman, 2021). These tests will include liver panel tests such as AST, ALTs, and glucuronide levels (Nehring & Freeman, 2021).

Assessment

Mental Status Examination:

The patient is a 48-year-old Asian female who looks clear of the stated age. She is not cooperative with the examiner. She is appropriately dressed for the weather. She is angry and irritable. She appears secretive and defensive. Her speech rate and volume are normal. Her language skills are intact. She denies suicidal or homicidal ideations. She denies auditory or visual hallucinations. She denies delusions. Her thought process is intact. Her associations are intact. There is evidence of grandiose ideas or looseness of association. Her cognitive functioning is intact and appropriate. She is alert and oriented to time, place, and person. Her insight and judgment are good. Her concentration during the assessment was good.

Differential Diagnoses:

Alcohol Use Disorder

According to the DSM-V diagnostic criteria, for an individual to be diagnosed with alcohol use disorder, the individual must have a problematic pattern of use resulting in clinically significant distress as manifested by at least two symptoms occurring in the last 12 months. The first symptom the patient presented with is recurrent alcohol use, leading to failure in fulfilling major obligations at work or school (Takahashi et al., 2017). The patient has been drinking alcohol since her college days. She drinks alcohol every day, and she has missed 22 days of work. There have been complaints from parents, colleagues, and students. This has led to the principal forcing her to go for an assessment. The second criterion is that alcohol is taken in large amounts (Takahashi et al., 2017). The patient takes about five glasses of wine and mixes it with beer every day.

Generalized Anxiety Disorder (GAD)

According to the DSM diagnostic criteria, the symptoms for GAD include worrying, restlessness, muscle tension, sleep disturbances, and irritability (Crocq, 2017). The patient only presents with irritability which rules out GAD as the presumptive diagnosis.

Major Depressive Disorder

This mood disorder presents emptiness, sadness, irritable mood, loss of interest in activities, weight changes, agitation, suicidal ideation, and worthlessness (Hasin et al., 2018). The patient is stressed because of accusations by her students and colleagues. She also does not love her job. She, however, does not meet all the DSM-V criteria, making this diagnosis unlikely.

Reflections:

I think the interviewer did a correct job during the psychiatric interview. The interviewer redirected the conversation back to the patient whenever she tried to avoid questions she did not want to answer. The patient was hostile and wanted to leave the office. The interviewer was, however, calm during the whole process. If I were in charge of the process, I would have interviewed the patient by an outside psychiatrist. This would have made the patient more cooperative since it would not have been her coworker. Culture is important in mental health issues. The interviewer must thus be culturally sensitive when interviewing the patient.

 References

Crocq M. A. (2017). The history of generalized anxiety disorder as a diagnostic category. Dialogues in clinical neuroscience, 19(2), 107–116. https://doi.org/10.31887/DCNS.2017.19.2/macrocq

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336. https://doi.org/10.1001/jamapsychiatry.2017.4602

Marienfeld, C. (2020). Absolute addiction psychiatry review: An essential board exam study guide. Springer Nature.

Nehring, S. M., & Freeman, A. M. (2021, April 16). Alcohol use disorder – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK436003/

Takahashi, T., Lapham, G., Chavez, L. J., Lee, A. K., Williams, E. C., Richards, J. E., Greenberg, D., Rubinsky, A., Berger, D., Hawkins, E. J., Merrill, J. O., & Bradley, K. A. (2017). Comparison of DSM-IV and DSM-5 criteria for alcohol use disorders in VA primary care patients with frequent heavy drinking enrolled in a trial. Addiction Science & Clinical Practice, 12(1). https://doi.org/10.1186/s13722-017-0082-0

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Psychotic disorders and schizophrenia are some of the most complicated and challenging diagnoses in the DSM. The symptoms of psychotic disorders may appear quite vivid in some patients; in others, symptoms may be barely observable. Additionally, symptoms may overlap among disorders. For example, specific symptoms, such as neurocognitive impairments, social problems, and illusions, may exist in patients with schizophrenia but are also contributing symptoms for other psychotic disorders.

For this Assignment, you will analyze a case study related to schizophrenia, another psychotic disorder, or a medication-induced movement disorder.

Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology 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 priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also, include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.