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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).

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Solution

 

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

Student Name

College of Nursing-PMHNP, Walden University NRNP 6635 Psychopathology and Diagnostic Reasoning

Week 7: Training Title 134

 

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

Subjective:

CC (chief complaint): “There’s nowhere that is safe. Don’t pretend like there is.”

HPI: B.W. is a 33-year-old Caucasian woman who comes in with her friend, Patty, for a mental examination. The patient states that she has called 9-1-1 many times because she believes that someone is monitoring her from her windows and awaiting her spouse to hurt him. She says a snake is in her belly, that she has a stomach upset, and that she hasn’t eaten for the last two days.

Past Psychiatric History:

•    General Statement: Psychiatric hospitalization for the patient occurred two years ago, according to her medical records.
•    Caregivers (if applicable): N/A
•    Hospitalizations: The patient has had three previous psychiatric hospitalizations, the most recent one being two years ago.
•    Medication trials: Unknown
•    Psychotherapy or Previous Psychiatric Diagnosis: Unknown

Psychotherapy, according to research, improves patient adherence and satisfaction while also providing the clinician with an insight into how to commence treatment with the patient (Tucci et al., 2017). A clinician’s knowledge of past drug trials may help him, or her determine which treatments are unhelpful. A thorough understanding of a patient’s history of psychotherapy, mental health diagnoses, and prior medications is essential to developing a successful treatment regimen.

Substance Current Use and History:

• Reports using alcohol intermittently.
• Denies smoking and using illicit substances.

 

Family Psychiatric/Substance Use History:

• In the 1970s, her father was admitted to the hospital for drug usage twice for one week each time.
• Mother has been diagnosed with depression and has received treatment for many years.
• In the past, her paternal grandmother spent several years in a state-run institution.

Psychosocial History:

Neither self-harm nor traumatic events are admitted by the client. A previous history of physical aggressiveness against others may be traced. According to Patty, the patient’s friend, the patient’s parents’ deaths in the previous two years have been extremely challenging for the client. There are no legal concerns with the patient. She presently resides in the city of Atlanta, Georgia. Her husband is a truck driver who is currently out of town. The patient’s younger sister is ten years old. She is a recipient of Social Security Disability Insurance (SSDI). She is a graduate of high school.

Medical History: Scoliosis.

•    Current Medications: The patient denies that he or she is presently taking any drugs. This detail is relevant to the mental examination in order to prevent negative outcomes (Hias et al., 2017).
•    Allergies: Haloperidol
•    Reproductive Hx: No children

ROS: There is no Review of Systems in this case. This ROS is derived from the information offered in the video and case narrative. ROS is an important element of the mental health assessment since it may assist the clinician in recommending particular diagnostic tests (Hendrickson et al., 2019).

• GENERAL: Denies weight loss, fever, fatigue, chills
• HEENT: Denies hearing loss, visual changes, breathing issues, and headaches.
• SKIN: Denies skin itching, hair loss, and rash

 

• CARDIOVASCULAR: Denies chest pain, palpitations, and edema
• RESPIRATORY: Denies shortness of breath, cough, sputum, and wheezing
• GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, and changes in bowel movement. Has not eaten in the past two days.
• GENITOURINARY: Denies dysuria, incontinence, urgency, and changes in frequency
• NEUROLOGICAL: Patient reports getting only 2 hours of sleep; denies headaches, dizziness, ataxia, numbness, and syncope.
• MUSCULOSKELETAL: Denies joint, and muscle pain or swelling
• HEMATOLOGIC: Denies bleeding and easy bruising
• LYMPHATICS: No enlarged nodes. Denies history of splenectomy
• ENDOCRINOLOGIC: Denies cold/heat intolerance, polyuria, polyphagia, and polydipsia

 

Objective: The patient refused to provide vital signs.

Physical exam: This case does not include the performance of a physical examination, which might discount the possibility of physiologic causes for their manifestation (Al-Huseini et al., 2016).

Diagnostic results: Using the 21-item Peters et al. delusions questionnaire, which highlights the multidimensional nature of delusions, comprising levels of anguish, obsession, and conviction, it is possible to diagnose and analyze delusional thoughts more effectively (Wang et al., 2017). In order to rule out substance-induced problems caused by the usage of numerous substances like marijuana, heroin, alcohol, and amphetamines, a urine drug test must be performed on the subject (Wilson et al., 2018). Neuroimaging investigations, like MRI scans, might be performed by healthcare professionals to rule out neurodegenerative illnesses.

 

Assessment:

Mental Status Examination Results:

Patient is a Caucasian female, 33 years old, who seems to be her claimed age. She declined to respond to the interviewer’s inquiries and is being difficult throughout. She is well-groomed and clothed properly for the occasion. Because she is distrustful of the interviewer and continually searches the room, she maintains hypervigilant eye contact with him. At the beginning of the interview, her tone is gentle and reserved, but it becomes louder as the interviewer inquires about her concerns. She seems to be in a flat and confined state of mind, with an agitated and angry demeanor. Owing to apparent thought blockage, her cognitive process seems to be irrational, as she suddenly stops speaking due to a loss of concentration and exhibits greater delay in responding to the interviewer’s inquiries, among other things. There are paranoid ideas of open suspiciousness delusions in her head, and she has delusions that she has a gang of individuals who are spying on her. Because she does not react to internal cues, there is no indication of distorted perception in this patient. Even though her sensorium is clear, her focus and attention are completely devoted to her delusions. The patient does not seem to have any significant memory problems. As seen by her assumption that she is being followed, the patient has a lack of awareness of her situation and poor judgment.

Differential Diagnoses:

1. Delusional Disorder Persecutory Type- This illness is characterized by the presence of at least one delusion that lasts for a minimum of one month. If a patient does not meet criterion A for schizophrenia, the practitioner may diagnose them with this disease (APA, 2013). Criteria C for delusional disorder is met in this case since the patient’s functionality has not been significantly disrupted. This patient has a greater chance of having this disease based on her presenting symptoms.
2. Schizophrenia- A hallmark of this condition is the presence of strong delusions, which is characteristic of psychosis. Disorderly speech, catatonic or excessively disordered conduct, a sudden deterioration in functionality, and significant visual or aural hallucinations are all signs that the patient is suffering from schizophrenia (APA, 2013). Based on his “hearing symphonies” occurring just during this episode, the patient may be ruled out for this illness.
3. Bipolar Disorder with Psychotic Features- This condition is characterized by delusions that occur only during mania or depression bouts (APA, 2013). Considering that there is no evidence of manic or depressed conduct, this diagnosis is most likely inaccurate.

Reflections

The difficulties that clinicians may have while questioning recalcitrant patients should be acknowledged since it may be challenging to get details from a delusional individual who is hesitant. The ethical implications for managing delusional individuals, such as obtaining consent and incorporating them in decision-making processes, should always be recognized by clinicians (Zettl & Sadler, 2020). Because of delusions, it is important for providers to understand that they are still responsible for obtaining their patient’s consent despite the fact that delusions may cloud their judgments (Beck & Ballon, 2020). In order to get informed consent from a patient, it is necessary to establish a bond with them. This indicates that they have faith in the clinician’s ability to deliver appropriate medical treatment.

References

Al-Huseini, S., Al-Madhani, A., Al-Shehhi, A., & Al-Sinawi, H. (2016). Physical examinations of psychiatric patients who presented at the emergency department of a tertiary-care hospital in Oman. Saudi journal of medicine & medical sciences, 4(3), 206. https://doi.org/10.4103/1658-631x.188248

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Beck, N. S., & Ballon, J. S. (2020). Ethical issues in schizophrenia. FOCUS, 18(4), 428-431. https://doi.org/10.1176/appi.focus.20200030

Hendrickson, M. A., Melton, G. B., & Pitt, M. B. (2019). The review of systems, the electronic health record, and billing. JAMA, 322(2), 115. https://doi.org/10.1001/jama.2019.5667

Hias, J., Van der Linden, L., Spriet, I., Vanbrabant, P., Willems, L., Tournoy, J., & De Winter, S. (2017). Predictors for unintentional medication reconciliation discrepancies in preadmission medication: A systematic review. European Journal of Clinical Pharmacology, 73(11), 1355-1377. https://doi.org/10.1007/s00228-017-2308-1

Tucci, V. T., Moukaddam, N., Alam, A., & Rachal, J. (2017). Emergency department medical clearance of patients with psychiatric or behavioral emergencies, Part 1. Psychiatric Clinics of North America, 40(3), 411-423. https://doi.org/10.1016/j.psc.2017.04.001

Wang, Y. Y., Shi, H. S., Liu, W. H., Yan, C., Wang, Y., So, S. H., … & Chan, R. C. (2017). Invariance of factor structure of the 21-item Peters et al. Delusions Inventory (PDI-21) over time and across samples. Psychiatry research, 254, 190-197.

Wilson, L., Szigeti, A., Kearney, A., & Clarke, M. (2018). Clinical characteristics of primary psychotic disorders with concurrent substance abuse and substance-induced psychotic disorders: A systematic review. Schizophrenia Research, 197, 78-86.

Zettl, R. E., & Sadler, J. Z. (2020). Psychiatric ethics. Landmark Papers in Psychiatry, 113, 329.