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

History of Present Illness (HPI): P.W. is a 42-year-old Caucasian female admitted to the emergency department after a psychotic episode. P.W.’s best friend, Felicia, called the police because P.W. had intentionally locked herself in the closet for an hour and was screaming. The police arrived, and P.W. was calmed down with a dose of Ativan as they headed to the hospital. P.W. has been reported to the police in the past for assaulting others, including strangers. She accuses the people she assaults, including Felicia, of spying on her. P.W. believes the spies are all over and she is not safe anywhere, including her house; therefore, she takes protective measures such as locking herself in the closet and assaulting any suspected spy. Felicia highlights that P.W. does not sleep at night because she fears being watched. She periodically sleeps during the day for about one hour per episode. P.W. does not believe that she has a mental condition and gets angry whenever Felicia suggests visiting the hospital for a mental examination.

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 Past Psychiatric History: P.W. was admitted to the psychiatric hospital exactly one year ago. She has been admitted to the emergency department after a psychotic episode thrice in the past two weeks. A dose of lorazepam (Ativan) injection is usually very effective when administered during P.W.’s psychotic episodes. Previous treatment using clozapine (Clozaril) led to severe adverse reactions and was withdrawn.

Substance Use History: P.W. drinks one glass of wine per week. She does not use any illicit drugs.

Family Psychiatric/Substance Use History: P.W.’s father has a psychiatric history of two inpatient psychiatric hospitalizations due to paranoia. Her mother suffered from bipolar depression. P.W.’s paternal grandmother underwent treatment using shock therapy.

Social History: P.W. was born in Cameron, Montana. Her mother and father brought her up. P.W. has a 47-year-old sister. Her parents died in the last three years. P.W. currently lives with her best friend, Felicia, in a two-bedroom apartment. She is married to her husband, who works as a truck driver. She does not have any children. She has been pregnant once but underwent an abortion for medical reasons. P.W. dropped out of school in the 11^th grade and has never had a stable job. She obtains Social Security Disability Insurance. Felicia highlights that the death of her parents traumatized her. P.W. has no current legal charges. She has, however, been reported a few times for assaulting others. She has no history of self-harm.

Past Medical History (PMH): P.W. was pregnant and underwent an abortion. Her immunization status is up to date. She received two doses of the AstraZeneca vaccine for COVID-19.

Current Medications: No medications.

Allergies: Allergic to clozapine. No known food allergy.

Reproductive history: The last menstrual period was two weeks ago. Heterosexual. Not pregnant. Not lactating. Uses condoms as a contraceptive method.

ROS:

General: Reports daytime sleepiness. Denies chills, fever, headache, day sweats, fatigue, weight loss, or weight gain.

HEENT/Neck: Denies difficulty swallowing and rhinorrhea. Denies double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Denies changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. Denies dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion.

Skin: Denies rashes and itching.

Cardiovascular: Denies lightheadedness when standing, paroxysmal nocturnal dyspnea, leg edema, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies painful urination, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine. Her last monthly period was two weeks ago.

Neurological: Denies headache, changes in memory, loss of consciousness, seizures, confusion, difficulty balancing, numbness, memory loss, tingling sensation, spells of blindness, or dizziness.

Musculoskeletal: Denies muscle pain, back pain, stiffness, or joint pain.

Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.

Lymphatics: Denies swollen lymph nodes or splenectomy.

Endocrinology: Denies weight gain, hair loss, weight loss, and frequent urination.

Psychiatric: Reports history of psychiatric hospitalizations and psychotic episodes. P.W. has been admitted with a psychotic episode thrice in the past two weeks. She was admitted to the psychiatric hospital exactly one year ago. Reports change in sleeping pattern. P.W. does not sleep at night and periodically sleeps during the day. Denies self-harm and suicidal thoughts.

Objective:

Physical Exam:

Vital signs: Not conducted.

General: The patient is uncooperative, angry, and violent. She is demanding to be released from the hospital. Her hair and clothes are unkempt. She positively identifies the date, day of the week, time, and year.

HEENT: Clear or nasopharynx, PERRLA, normocephalic head, no visual acuity issues.

Neck: The neck has a full range of motion in all directions, normal symmetry, normal length, and no palpable lymph nodes.

Respiratory: On palpation, no tenderness or palpable mass. On auscultation, normal breathing sounds without wheezing or audible breathing sounds. No chest deformities.

Heart/Peripheral Vascular: On palpation, normal heart size, and normal heart location. On auscultation, normal heart rate, normal rhythm, and no murmurs. Normal extremities.

Abdomen: Denies abdominal pain on palpation. The liver and spleen are of normal size, tenderness, and consistency.

Genital/Rectal: This exam was not conducted.

Lymphatic: No swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Psychiatric: She is disoriented and delusional.

Skin: Her skin tone is appropriate to her ethnicity.

Diagnostic results:

The patient was uncooperative and declined any laboratory tests.

Assessment:

Mental Status Examination: The patient is a forty-two-year-old Caucasian female who looks her stated age. She is uncooperative and does not want to describe why she is at the facility. Her best friend accompanies her. Her clothes are untidy and unclean. P.W. has a history of mental conditions. She was admitted to a psychiatric hospital exactly one year ago. In the past two weeks, she has been admitted twice to the emergency department for a psychotic episode. The recent admission to the emergency department is because P.W. locked herself in the closet for more than an hour and was screaming. The patient is delusional and believes she is being spied on. She believes the spies are everywhere, including her house and the hospital.

Differential Diagnosis (DDx):

Schizophrenia: The hallmark symptom of schizophrenia is psychosis, such as delusions (Hany et al., 2022). Delusions are fixed false beliefs. According to DSM 5 diagnostic criteria, patients diagnosed with schizophrenia must present with at least two of the following: disorganized speech, negative symptoms, delusions, disorganized behavior, and hallucinations. One of the symptoms must be delusions, disorganized speech, or hallucinations. The symptoms should be present for at least six months and at least one month actively (Hany et al., 2022). Schizophrenia is a primary diagnosis because P.W. presents with delusions, disorganized speech, and cognitive symptoms. Her delusions are whereby she believes that she is being spied on. She is currently admitted with psychosis which is the hallmark symptom of schizophrenia. P.W. was admitted to the psychiatric hospital exactly one year ago, showing that her symptoms have lasted more than six months. Her cognitive symptoms manifest when she has been reported for assaulting others and cannot maintain healthy friendships.

Schizoaffective disorder: According to DSM 5 criteria, patients with schizoaffective disorder have schizophrenia and a mood disorder (Wy & Saadabadi, 2022). Although P.W. has signs and symptoms of schizophrenia, she does not have any signs and symptoms of a mood disorder.

Delusional disorder: According to DSM 5 criteria, patients diagnosed with delusional disorder present with at least one month of delusions and no other psychotic symptoms (Joseph & Siddiqui, 2022). Although P.W. presents with delusions, she also has disorganized speech, as seen during her interview.

Reflections:  I concur with P.W.’s assessment and diagnostic impression. The patient was uncooperative; therefore, I would also not conduct laboratory tests and assess the vital signs. P.W. was admitted to the psychiatric hospital exactly one year ago, thrice in the past two weeks; therefore, I would manage the patient through non-pharmacological interventions such as psychotherapy and pharmacological interventions such as antipsychotic medications. The patient has SSD insurance benefits; therefore, it is crucial to determine if the benefits are adequate for the patient to obtain quality medical care. Further, I learned the importance of having a loved one, caregiver, or friend describe a patient’s situation in a case where a patient is unable to give accurate information. The patient’s legal rights were respected. Her decision against having laboratory tests and her vital signs checked was respected. Her best friend, who accompanied her to the hospital, was informed about her treatment plan and diagnosis.

References

Hany, M., Rehman, B., Azhar, Y., et al. (2022). Schizophrenia. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/.

Joseph, S. M., & Siddiqui, W. (2022). Delusional Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

Wy, T. J. P., & Saadabadi, A. (2022). Schizoaffective Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/.

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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.

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.

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.).