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

Subjective:

CC (chief complaint): “I hear people talking about me and think someone is spying on me.”

HPI: Acute psychotic symptoms were first seen by 30-year-old Jess Davies about a month and a half ago, following a tragic occurrence in which she saw her brother die during a gas station robbery. She describes her symptoms as progressively worsening, with increasing paranoia and auditory hallucinations. Jess reports hearing voices that others cannot, which she believes are connected to her neighbors, whom she suspects are spying on her and sending coded messages through “drilling noises” in the walls. She notes that her sleep patterns have been severely affected, with her only managing about 2 hours of sleep per night. Jess restricts her diet to canned foods due to fears of food contamination, leading to weight loss. She has a history of daily cannabis use since the age of 17, and she continues to smoke despite her symptoms. Although she denies any suicidal ideation or plans to harm others, she expresses significant distress and feels that she is losing control over her life. Her roommates, who became concerned about her increasingly bizarre behavior, encouraged her to seek help.

Past Psychiatric History: Jess claims that after her aunt passed away a few years ago, she went through a depressive phase, but she did not receive formal psychiatric treatment or counseling at the time. Previous mental hospitalizations or interventions are not documented.

• General Statement: The client has not engaged in any previous psychiatric treatment, and this is her first formal evaluation for mental health concerns.
• Caregivers (if applicable): Not relevant because Jess is an adult.
• Hospitalizations: No previous reports of psychiatric hospitalizations.
• Medication trials: She was recently prescribed alprazolam 1 mg twice daily by her primary care provider for anxiety; she stopped it after a few days, stating that it made her worse and that she has those problems now.
• Psychotherapy or Previous Psychiatric Diagnosis: Prior to the present presentation, Jess had no history of documented psychiatric diagnoses or participation in psychotherapy.

Substance Current Use and History: Jess reports using cannabis daily, having started at the age of 17. She consumes around one to two joints per day and occasionally drinks alcohol in social situations with her roommates. There is no history of other illicit drug use.

Family Psychiatric/Substance Use History: Mental disorders, abuse of substances, and suicide are not known to run in her direct family line. Her father and mother do not have a good relationship, and her aunt mostly brought her up.

Psychosocial History: Jess grew up in a household where her parents were frequently absent, so she was raised by an aunt who was the primary caregiver. She has had a strained relationship with her parents and is currently estranged from them. Her brother, who was recently killed, was her only close relative, and his death has deeply impacted her. Jess lives in an apartment with two roommates and works as an assistant in a bakery. While previously she was outgoing and doing fine, over the last year, her symptoms have greatly reduced the amount she socializes and negatively affected her performance at work.

Medical History: Jess has no major health issue, diseases or operations history to mention as well. Further, she does not have any past history of head injury, neurological disease or any chronic medical disease.

• Current Medications: None currently available yet.
• Allergies: She claims to have a medical tape allergy, which irritates her skin.

• Reproductive Hx: Jess has never been pregnant and experiences regular menstrual periods. She denies any history of sexually transmitted infections.

ROS:

• GENERAL: Reports significant fatigue due to poor sleep, along with recent weight loss attributed to restricted eating. No fever or chills.
• HEENT: Denies any visual disturbances or hearing loss. No history of head trauma or other ENT concerns.
• SKIN: No rashes, itching, or other skin conditions noted, apart from mild irritation from medical tape.
• CARDIOVASCULAR: No chest pain, palpitations, or history of cardiovascular disease.
• RESPIRATORY: Refutes experiencing a cough, breathlessness, or any other respiratory symptoms.
• GASTROINTESTINAL: No history of nausea, vomiting, or abdominal pain. Reports recent weight loss due to a restricted diet.
• GENITOURINARY: Denies experiencing any burning or pain when urinating and says she has never had a UTI.
• NEUROLOGICAL: Absence of history of seizures, dizziness, or fainting episodes. No reports of numbness, tingling, or other neurological symptoms.
• MUSCULOSKELETAL: Denies muscle or joint pain. No prior history of musculoskeletal injuries or fractures.
• HEMATOLOGIC: No history of anemia or bleeding problems.
• LYMPHATICS: Absence of prior splenectomy or expansion of lymph nodes.
• ENDOCRINOLOGIC: Rejects the presence of signs of thyroid disease, including intolerance to cold or heat.

Objective:

Physical exam:

• General: Jess looks messy and has seemingly neglected her personal hygiene. Her hair is disheveled, and her clothes are mismatched.
• Behavior: Shows timidity, is hesitant to interact at first, and makes poor eye contact. Jess occasionally loses her temper, and she seems easily upset.
• Speech: Jess’s speech is tense and off-topic, with frequent topic changes in the middle of her sentences. Her speech patterns make it challenging to have a meaningful conversation with her.

Diagnostic results: Imaging studies and lab data are not available at this time. A urine toxicology screen and basic blood work may be considered in light of the patient’s symptoms to rule out other possible causes of her symptoms.

Assessment:

Mental Status Examination:

Jess is a 30-year-old female, but she looks older than her stated age. She had poor hygienic care and looked quite disheveled. Her clothes were not matched, and her hair was unkempt. She is cooperative but guarded during the interview; eye contact is shot, and she may become irate if questioned about symptoms. Indeed, her behavior reflects great distress and paranoia. Further, the speech is pressured, tangential at times, and often incoherent. She frequently jumps from one topic to another and is not easily followed.

The mood can be described as labile, fluctuating from calm to angry or fearful. These changes tend to happen suddenly and for no apparent reason that might be observed from the outside world. Her affect is flattened, having minimal emotional range despite her high state of labile mood. Her facial expressions are generally unresponsive. Also, thoughts are disorganized, with frequent derailment and loose associations. Thought content reveals paranoid delusions of neighbors spying on her.

The patient describes hearing voices that talk about her and that others cannot hear. She denies any visual hallucinations or other disturbances of perception. She is oriented in terms of person, place, and time; however, she has poor concentration. She easily gets diverted during the interview. Additionally, her insight is severely impaired, as Jess does not recognize the abnormality of her experiences or the need for treatment. She attributes her experiences to external forces rather than acknowledging a mental health condition. Finally, judgment is compromised, as evidenced by her decision to discontinue medication without consulting a healthcare professional and her reluctance to seek help despite her deteriorating condition.

Differential Diagnoses:

• Schizophrenia (ICD-10: F20.9)

The DSM-5-TR criteria for schizophrenia are met by the presence of hallucinations, delusions, disordered speech, and severe functional impairment. This appears to be the main diagnosis based on the length and severity of the symptoms (M et al., 2020).

• Brief Psychotic Disorder (ICD-10: F23)

This disorder has been taken into consideration since symptoms from a stressful experience started to appear recently. However, schizophrenia is more likely when symptoms last more than a month (Stephen & Lui, 2021).

• Substance-Induced Psychotic Disorder (ICD-10: F12.259)

Regular cannabis usage may make psychotic symptoms worse. However, rather than being a result of drug-induced psychosis, the nature of the patient’s symptoms points to a primary psychotic condition (Fiorentini et al., 2021).

Paranoid schizophrenia was chosen as the primary diagnosis because Jess had before mentioned paranoid delusions, which are symptoms of paranoid schizophrenia, and she also experiences hallucinations, disorganization of speech and thinking, and a functional disability. The DSM-5-TR criteria for schizophrenia fully describes these symptoms, and their chronic nature rules out a more restrictive diagnosis of short psychotic disorder or drug- or substance-induced psychotic disorder. Other pertinent positives include paranoia, auditory command hallucinations, and functional deterioration. Pertinent negatives include a lack of mood episodes and symptoms related to substance use, as per Voss and Das (2024).

Reflections:

What Would Be Done Differently: Gathering more information from the client’s family or those close to her could provide further insight into her baseline functioning and any early symptoms. Using techniques to build rapport slowly could encourage Jess to share more about her experiences.

Legal/Ethical Considerations: If Jess’s symptoms worsen or if she becomes a danger to herself or others, involuntary hospitalization may be necessary. Addressing her cannabis use and its potential role in worsening her symptoms is also essential for a comprehensive treatment approach.

Health Promotion and Disease Prevention: Educating Jess on the risks associated with daily cannabis use and implementing harm-reduction strategies may help reduce her symptom severity (Caron et al., 2023). Additionally, providing guidance on sleep hygiene and incorporating behavioral interventions could improve her overall functioning.

References

Caron, R. M., Noel, K., Reed, R. N., Sibel, J., & Smith, H. J. (2023). Health promotion, health protection, and disease prevention: Challenges and opportunities in a dynamic landscape. AJPM Focus, 3(1), 100167–100167. https://doi.org/10.1016/j.focus.2023.100167

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

M, H., B, R., Y, A., & J, C. (2020, January 1). Schizophrenia. PubMed. https://pubmed.ncbi.nlm.nih.gov/30969686/

Stephen, A., & Lui, F. (2021). Brief psychotic disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30969734/

Voss, R. M., & Das, J. M. (2024). Mental status examination. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK546682/

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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. (See attached files)
• 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.).

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.