Understanding Psychotic Disorders- Altered Reality Abnormal Thinking and Symptomatology

Understanding Psychotic Disorders- Altered Reality Abnormal Thinking and Symptomatology

Subjective:

CC (chief complaint): “I was forced to come in by my sister after my mom’s death because I have a persistent belief that government agents are surveilling me, disrupting my sleep, and attempting to poison my food.”

HPI: S.T., a 55-year-old Caucasian male, presents with a chief complaint of being compelled to seek psychiatric evaluation by his sister following their mother’s death. He describes persistent, distressing beliefs that government agents are surveilling him, disrupting his sleep, and attempting to poison his food. S.T. reports experiencing these symptoms for weeks, accompanied by auditory hallucinations and visual observations of shadowy figures outside his window. He links these phenomena to a government conspiracy aimed at inflating his taxes. Despite attempts to safeguard his well-being by locking up food, he perceives constant external threats. Sleep disturbance is evident, and S.T. expresses reluctance towards medications, citing adverse reactions to Haldol, Thorazine, and Risperidone in the past.

Substance Current Use: S.T. acknowledges daily caffeine consumption; however, the specific amount is not disclosed. He reports smoking heavily, amounting to three packs of cigarettes per day. While he admits to previous marijuana use, he claims abstinence from it since his mother’s passing three years ago. Alcohol intake consists of a daily 12-pack of beer supplied by his sister, with the last recorded consumption being yesterday. Despite this consistent use, S.T. denies any historical complications related to withdrawal, such as tremors, Delirium tremors, or seizures.

Medical History:

Current Medications: T. dislikes Haldol and Thorazine, citing a refusal to take them. Risperidone is rejected due to breast enlargement. However, Seroquel is acknowledged as tolerable. He, nevertheless, adamantly expresses skepticism about the medications, labeling them as “poison.” He denies the use of any over-the-counter or homeopathic products.

Allergies: No reported allergies to drugs, food, or environmental factors

Reproductive Hx: No reproductive history provided.

ROS:

GENERAL: Reports disrupted sleep patterns, feelings of constant surveillance, and paranoid delusions linked to external threats.

HEENT: Reports no headaches, head injuries, or discomfort. Denies visual disturbances, blurriness, or eye pain. No hearing loss, tinnitus, or ear pain was mentioned. No nasal congestion, sinus pain, or issues with smell were reported. Denies sore throat, difficulty swallowing, or voice changes.

SKIN: No skin abnormalities, rashes, or irritations were reported.

CARDIOVASCULAR: Denies chest pain, palpitations, or any cardiovascular symptoms.

RESPIRATORY: No respiratory difficulties, shortness of breath, or coughing reported.

GASTROINTESTINAL: No gastrointestinal issues or discomfort were mentioned.

GENITOURINARY: No specific genitourinary symptoms were disclosed.

NEUROLOGICAL: Reports auditory hallucinations, visual observations of shadowy figures, and delusional beliefs related to external surveillance.

MUSCULOSKELETAL: No musculoskeletal pain, joint complaints, or limitations in movement were reported.

HEMATOLOGIC: No excessive bleeding, easy bruising, or unusual fatigue.

LYMPHATICS: No swelling was reported.

ENDOCRINOLOGIC: Takes metformin for diabetes and mentions a fatty liver.

Objective:

Diagnostic results:

Metabolic Panel: To assess for metabolic imbalances or abnormalities contributing to psychiatric symptoms (Sadock et al., 2015).

Complete Blood Count (CBC): To evaluate for any hematologic conditions that could impact mental health (Sadock et al., 2015).

Liver Function Tests (LFTs): Given the reported use of metformin and the mention of a fatty liver, LFTs can help assess liver health (Sadock et al., 2015).

Thyroid Function Tests (TFTs): Thyroid dysfunction can manifest with psychiatric symptoms; TFTs aid in ruling out or identifying such conditions (Sadock et al., 2015).

Neuroimaging (MRI or C.T. Scan): To investigate potential structural brain abnormalities contributing to auditory hallucinations and delusions (Sadock et al., 2015).

Toxicology Screen: To identify any substance use that may be exacerbating or contributing to psychiatric symptoms (Sadock et al., 2015).

Psychiatric Assessment (DSM-5 Criteria): Comprehensive psychiatric evaluation based on DSM-5 criteria to determine the presence of specific mental health disorders (Nussbaum, 2022).

Assessment:

Mental Status Examination:

S.T., a 55-year-old Caucasian male, presents with a disheveled appearance and agitated demeanor. He exhibits poor eye contact and fidgets with his hands throughout the assessment. S.T. appears anxious, and his affect is constricted, displaying limited emotional expressiveness. His speech is rapid, pressured, and occasionally tangential, making it challenging to follow a coherent thought process. S.T. reports auditory hallucinations, describing shadowy figures surveilling him. He expresses paranoid delusions related to government conspiracies. Insight into his condition is limited, as he adamantly believes in the reality of these delusions. S.T. denies suicidal or homicidal ideation. Cognitively, he struggles with concentration and displays impaired short-term memory, often losing track of the conversation. Overall, S.T.’s mental status is indicative of severe psychosis with marked functional impairment.

Diagnostic Impression:

Schizophrenia Spectrum Disorder (SSD):

Supporting Evidence:T. displays prominent psychotic features, including auditory hallucinations, paranoid delusions, and impaired insight.

DSM-5 Criteria: Presence of two or more of the following: delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms (Cuthbert & Morris, 2021).

Rationale: T.’s symptoms align closely with the criteria for SSD, as evidenced by the severity of his psychotic symptoms and the impact on daily functioning.

Brief Psychotic Disorder:

Supporting Evidence: Acute onset of severe psychotic symptoms following a significant stressor (death of his mother).

DSM-5 Criteria: Presence of one or more of the following: delusions, hallucinations, disorganized thinking, or grossly disorganized or abnormal motor behavior lasting at least one day but less than one month (Nussbaum, 2022).

Rationale: A brief psychotic disorder may be considered due to the time-limited nature of S.T.’s symptoms following the death of his mother.

Substance-Induced Psychotic Disorder:

Supporting Evidence: Substance use history, including daily alcohol and tobacco use.

DSM-5 Criteria: Presence of prominent hallucinations or delusions that are judged to be directly attributable to substance use (Nussbaum, 2022).

Rationale: Considering S.T.’s substance use, it is essential to evaluate if the psychotic symptoms are substance-induced.

Diagnostic Impression Rationale:

The primary diagnostic impression is schizophrenia spectrum disorder (SSD) due to the persistence and severity of S.T.’s psychotic symptoms, lasting for weeks and significantly impacting his daily life. His symptoms align with the DSM-5 criteria for SSD, and the differential diagnosis process ruled out time-limited psychotic disorders and emphasized the necessity of exploring substance-induced causes. The absence of acute onset or clear substance-induced etiology, coupled with S.T.’s long-standing symptoms, supports the primary diagnosis of SSD. Pertinent positives include the presence of hallucinations, paranoid delusions, and impaired insight (Cuthbert  & Morris, 2021). Pertinent negatives include the absence of a clear substance-induced cause or a brief duration of symptoms post-stressor.

Reflections:

Reflecting on this case, I concur with the diagnostic impression of SSD. S.T.’s severe psychotic symptoms, including hallucinations and paranoid delusions, align with the DSM-5 criteria for SSD. The case underscores the importance of a comprehensive evaluation considering substance-induced causes and time-limited psychotic disorders. Learning from this case emphasizes the need for a nuanced approach, considering the interplay of psychiatric and medical factors (Nussbaum, 2022). I would emphasize collaboration with medical professionals for a more holistic understanding. Ethically, the case underscores the challenge of balancing autonomy with ensuring S.T.’s safety. Culturally competent care, recognizing the impact of social determinants, is crucial for a comprehensive treatment plan. This case reinforces the need for a patient-centered, interdisciplinary approach to mental health care.

Case Formulation and Treatment Plan:

Psychotherapy Plan:

Cognitive Behavioral Therapy (CBT): Implement CBT to address distorted thought patterns, particularly those contributing to paranoid delusions. Also, cognitive restructuring should be worked on to challenge and modify maladaptive beliefs (Zakhari, 2020).

Treatment and Management:

Pharmacologic Treatment: Initiate antipsychotic medication (Seroquel) to manage psychotic symptoms and improve overall functioning. Titrate dosage based on response and side effects (Sadock et al., 2015).

Nonpharmacologic Treatment: Engage in ongoing case management for psychosocial support, assistance with daily functioning, and community resources (Zakhari, 2020).

Alternative Therapies: Explore art or music therapy as complementary approaches to enhance self-expression and emotional regulation (Zakhari, 2020).

Rationale:

CBT: CBT is evidence-based for psychotic disorders, targeting cognitive distortions and improving coping strategies (Zakhari, 2020).

Pharmacologic Treatment: Antipsychotic medications are the mainstay for managing psychosis and addressing neurotransmitter imbalances (Sadock et al., 2015).

Case Management: Essential for ongoing support, ensuring access to resources, and promoting overall well-being (Zakhari, 2020).

Alternative Therapies: Offer additional avenues for emotional expression and therapeutic engagement (Sadock et al., 2015).

Health Promotion Activity:

Regular Exercise: Encourage S.T. to engage in regular physical activity, which impacts mental health by reducing stress and positively improving mood (Zakhari, 2020).

Patient Education Strategy:

Medication Adherence: Provide detailed education on the importance of medication adherence, potential side effects, and the need to report any adverse reactions promptly. Utilize visual aids and written materials to enhance understanding (Zakhari, 2020).

Follow-Up Parameters:

Regular psychiatric follow-up every two weeks initially, then monthly for medication monitoring and adjustment.

Bi-weekly psychotherapy sessions initially, transitioning to monthly sessions as symptoms stabilize.

 References

Cuthbert, B. N., & Morris, S. E. (2021). Evolving concepts of the schizophrenia spectrum: a research domain criteria perspective. Frontiers in psychiatry, 12, 641319. https://doi.org/10.3389/fpsyt.2021.641319

Nussbaum, A. M. (2022). The pocket guide to the DSM-5-TR™ diagnostic exam. American Psychiatric Pub.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.

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WK5 FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as a lack of emotion or withdrawal from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.

For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.
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TO PREPARE

• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Sherman Tremaine. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
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THE ASSIGNMENT
Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a 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, and list them 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 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.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also, one health promotion activity and one patient education strategy should be incorporated.
• Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. 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.).
• Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).