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

Psychotic disorders are a spectrum of illnesses characterized by a loss of contact with reality. Persons with these illnesses will commonly manifest with delusions, hallucinations, disorganized thoughts, and a decrease in normal functioning. Some of the psychotic disorders recognized by DSM-V include Schizophrenia, brief psychotic disorder, schizophreniform disorder, delusional disorder, schizoaffective disorder, schizotypal disorder, and psychosis associated with substance use disorder (Lin & Lane, 2019). The purpose of this paper is to document an assessment and diagnosis of a 30-year-old female with a suspected psychotic illness.

Subjective:

CC (chief complaint): “My friends think I live in a movie. Maybe I am a movie.”

HPI: A 30-year-old female was brought to the clinic by her roommates with complaints of acting in a strange manner. She started acting strangely shortly after her aunt died and has been having and hearing things others could not hear. She thinks her new neighbors are Russians, uses code language to speak despite speaking in English, and believes they are terrorists. She also reports hearing the neighbors drilling.

Past Psychiatric History:

• General Statement: No reports of past mental health illnesses.
• Hospitalizations: No past hospitalizations.
• Medication trials: She was on unknown medications but stopped as she thinks the medications were part of the problem.
• Psychotherapy or Previous Psychiatric Diagnosis: She had issues with depression after her aunt died. The depression worsened after she witnessed her brother die of gunshot wounds in a gas station burglary.

Substance Current Use and History: She has been smoking cannabis daily since she was 17 and drinks a couple of beers whenever she goes out on weekends with friends.

Family Psychiatric/Substance Use History: No history of psychiatric illness in the family. His brother died of a gunshot wound during a gas station burglary.

Psychosocial History: The client lives with her two roommates, is estranged from her parents, and works in a bakery.

Other: The patient sleeps for only 2 hours.

Medical History:

• Current Medications: Alprazolam 2mg taken every 12 hours.
• Allergies: Medical tape

ROS:

• GENERAL: No reports of weight loss or weight gain.
• HEENT: Denies hearing or visual loss, nasal congestion or discharge, or difficulty swallowing.
• SKIN: Denies scars or any other skin lesions.
• CARDIOVASCULAR: No reports of palpitation.
• RESPIRATORY: No reports of wheezing, shortness of breath, or coughs.
• GASTROINTESTINAL: No reports of bowel movement inconsistencies or nausea.
• NEUROLOGICAL: The patient had depressive episodes after the loss of her aunt.
• MUSCULOSKELETAL: No reports of muscle or skeletal pain or joint swelling.
• HEMATOLOGIC: Denies unusual bleeding or anemia.
• LYMPHATICS: No reports of lymph node swelling.
• ENDOCRINOLOGIC: No reports of heat or cold intolerance.

Objective:

Vital signs: T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs

Physical exam:  

• Musculoskeletal: A musculoskeletal assessment is necessary to rule out muscle stiffness or any other movement mobilities that may suggest motor dysfunctionality. Psychotic symptoms have sometimes been associated with brain lesions and neurocognitive illness that manifests with mobility challenges (Eskelinen et al., 2020).
• Neurological: Neurological examination may be necessary to rule out organic causes of psychosis. Neurological disorders, such as Parkinson’s disease and dementia, sometimes demonstrate psychotic features and may be confused with other psychotic disorders (Eskelinen et al., 2020).

Diagnostic results: Schizophrenia is a clinical diagnosis made after a thorough history taking and assessment. No lab work or imaging is confirmatory of the disorder (Eskelinen et al., 2020). Quantitative rating scales such as the Positive and Negative Syndrome Scale (PANSS) can help measure symptom severity, aiding the diagnosis of schizophrenia and other psychotic disorders. However, a toxicological screen may be necessary to rule out substance abuse. Likewise, imaging in patients with a history of head traumas or the presence of a neurological pathology may rule out other causes of psychosis. A rapid plasma regin test may also rule out syphilis, as the disease may sometimes manifest with psychiatric symptoms (Orsolini et al., 2022).

Assessment:

Mental Status Examination: The patient is alert and responsive. She is oriented to place, time, and event. Her judgment is illogical, and her mood is labile and angry. She answers the interview questions inappropriately and is out of touch with reality. Her thought processes are disorganized, irregular, and dissociated. Her thought content is also disorganized. Her speech is incoherent. She is delusional and hears and sees things others do not hear or see.

Differential Diagnoses: 

• Major Depressive Disorder With Psychotic or Catatonic Features ICD-10 Code F23.3: The presence of hallucination and delusion during depressive disorders is often suggestive of major depressive disorder with psychotic features. This condition presents with the classical features of depression, such as depressed mood and anhedonia, along with psychotic manifestations (Wang et al., 2021). The patient in the case presented had psychotic symptoms. The psychotic manifestations followed a depression episode triggered by the death of the aunt. This warranted the inclusion of this differential.
• Schizophrenia ICD-10 Code F203: Schizophrenia is a psychiatric illness characterized by detachment from reality. As per the DSM-V criteria for diagnosing the disease, schizophrenia is marked by the presence of delusion, hallucinations, disorganized speech, catatonic behavior, and negative symptoms, such as diminished emotional expression (Orsolini et al., 2022). The presence of hallucinations, delusions, catatonic behavior, and disorganized speech warranted the inclusion of this differential. Further assessment to ensure the symptoms last for more than six months is necessitated to affirm the diagnosis.
• Substance-Induced Psychotic Disorder ICD-10 Code F19.150: Substance-induced psychotic disorder is a psychiatric illness where the onset of the psychotic episodes can be traced to the use of a substance of abuse (Fiorentini et al., 2021). Collaborative findings in the patient’s case revealed that she has been using cannabis every day since she was 17. this may have been the causal factor for the psychotic manifestation.

Reflections:

The interview captured many assessment aspects of schizophrenia and other psychotic disorders. One thing I would do differently is to incorporate quantitative scales for psychotic illnesses to help rule out other psychotic illnesses. An ethical consideration that applies to the case is beneficence. Beneficence requires that caregivers act in the best interest of their patients. In this case, caregivers tending to the patient must ensure they select appropriate and acceptable therapeutic interventions that will help manage the patient’s symptoms. Access to healthcare is a social determinant of health applicable to the case. Caregivers, in this respect, should recognize that the patients may have distorted perceptions of their wellness and, therefore, collaborate with the family members to ensure their wellness. As a point of health promotion for the client and the family, family members should be educated on the disease process and the significance of taking medications.

Conclusion

Psychotic disorders are a health concern. Comprehensive management of these illnesses requires thorough history taking and assessment to accurately diagnose the disorder and manage them. During management, caregivers should act in the best interests of the patient by selecting acceptable and effective therapeutic interventions for the clients diagnosed with psychotic illness. They should also involve the family members to ensure effective care.

References

Eskelinen, S., Suvisaari, J. V., & Suvisaari, J. M. (2020). Physical Health Examination in outpatients with schizophrenia: The cost effectiveness of laboratory screening tests. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00321-3

Fiorentini, A., Cantù, F., Crisanti, C., Cereda, G., Oldani, L., & Brambilla, P. (2021). Substance-induced psychoses: An updated literature review. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.694863

Lin, C.-H., & Lane, H.-Y. (2019). Early identification and intervention of schizophrenia: Insight from hypotheses of glutamate dysfunction and oxidative stress. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00093

Orsolini, L., Pompili, S., & Volpe, U. (2022). Schizophrenia: A narrative review of etiopathogenetic, Diagnostic and treatment aspects. Journal of Clinical Medicine, 11(17), 5040. https://doi.org/10.3390/jcm11175040

Wang, M., Wang, R., Hao, Y., Xiong, W., Han, L., Qiao, D., & He, J. (2021). Clinical characteristics and sociodemographic features of psychotic major depression. Annals of General Psychiatry, 20(1). https://doi.org/10.1186/s12991-021-00341-7

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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; with 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.

To Prepare:

• Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing psychotic disorders. Consider whether experiences of psychosis-related symptoms are always indicative of a diagnosis of schizophrenia. Think about alternative diagnoses for psychosis-related symptoms.
• Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Identify at least three possible differential diagnoses for the patient.
  

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

By Day 7 of Week 7
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

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-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.
• 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.).

submission information

• Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
• To submit your completed assignment, save your Assignment as WK7Assgn_LastName_Firstinitial

Resources:

• DSM-5-TR  text
• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). WoltersKluwer.
• Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.