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[ANSWERED] Psychotic disorders and schizophrenia are some of the most complicated and challenging diagnoses in the DSM.

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 of other psychotic disorders.

To Prepare:

  • Consider whether experiences of psychosis-related symptoms are always indicative of a diagnosis of schizophrenia. Think about alternative diagnoses for psychosis-related symptoms.

Complete your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.

THE QUESTION

Subjective: 

Ø What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis?

Ø What is the duration and severity of their symptoms?

Ø How are their symptoms impacting their functioning in life?

Objective: 

Ø What observations did you make during the psychiatric assessment?

Assessment:

Ø Discuss the patient’s mental status examination results.

Ø What were your differential diagnoses?

Ø Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority.

Ø 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.

Ø 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:

Ø What would you do differently with this client if you could conduct the session over?

Ø Include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!).

Ø Also include 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.).

Expert Answer and Explanation

Schizophrenia

Subjective:

CC (chief complaint): “Feldman has some difficulties in school.”

HPI: Mr. Jay Feldman is a 19-years-old European-American male presenting to the office for psychiatric evaluation. He was referred for evaluation by his parents. The patient’s parents complain that he has some problems in school. The parents note that his psychiatric problems started after he joined state college. Since joining college, he has been experiencing delusions that people are spying on him. He has lost 18lbs and has a poor appetite. His speech is disorganized and he is hallucinating. He has not been sleeping well, has not got in touch with his friends since he came for the spring holidays, and does not shower.

Past Psychiatric History:

  • General Statement: He first entered aripiprazole treatment for mild paranoia six months ago.
  • Caregivers (if applicable): Not applicable.
  • Hospitalizations: Never hospitalized.
  • Medication trials: He went through a short trial of aripiprazole but stopped because the medication caused a side effect of akathisia.
  • Psychotherapy or Previous Psychiatric Diagnosis: He was diagnosed with mild paranoia six months ago.

Substance Current Use and History: He denies drug abuse and does not take alcohol or tobacco.

Family Psychiatric/Substance Use History: His family members have a history of mental health issues. His father was diagnosed with paranoid schizophrenia and his mother with anxiety. One of his younger brothers has a history of anxiety and the other ADHD. No family history of substance abuse.

Psychosocial History: The patient was born and raised by his parents in Alameda, California. He has two younger brothers. He lives with his roommate in the state college but is currently with his family for the spring holiday. He has no children and is single. He is a first-year student at a state college. He loves playing football. He is not working. He has no legal problems, history of violence, or history of violence.

Medical History: No previous medical issues. No surgeries.

  • Current Medications: No medications.
  • Allergies: No allergies.
  • Reproductive Hx: He is sexually active. No reproductive problems.

ROS:

  • GENERAL: Positive for weight change. No fever, fatigue, chills, or weaknesses.
  • HEENT: No double vision or visual loss. No hearing abnormalities. No runny nose, sneezing, or congestion. No throat lesions or sore throat.
  • SKIN: No inflammation.
  • CARDIOVASCULAR: No chest pain, palpitations, edema, or chest pressure.
  • RESPIRATORY: No respiratory problems. No shortness of breath.
  • GASTROINTESTINAL: No diarrhea, nausea, abdominal problems, or vomiting.
  • GENITOURINARY: He denies urinary tract diseases, urine urgency, or burning on urination.
  • NEUROLOGICAL: No dizziness, headache, or ataxia.
  • MUSCULOSKELETAL: No limited range of motions in all the muscles and joints. No pain in the muscles or joints.
  • HEMATOLOGIC: No anemia.
  • LYMPHATICS: No enlarged glands. No HIV/AIDS.
  • ENDOCRINOLOGIC: No changes in the skin, polyuria, polydipsia, or polyphagia.

Objective:

Physical exam:

Vital Signs: T 98.3, Wt. 117lbs, BP 106/72, P 69, Ht. 5’7’’

HEENT: Head: Non-tender with no abnormalities. No scars. Eyes: Conjunctivae pink. Sclera white. PERRL pupils. Ears: External ears normal with no lesions. No redness or swelling. Hearing intact. Nose: Appears normal. The septum is midline and the nares are patent. Throat: No lesions or inflammation.

Skin: Appears normal with no vitiligo. No rashes.

Cardiovascular: Regular rhythm and rate. No rubs, murmurs, or gallops. Normal pulse in the carotid arteries. No edema.

Respiratory: Unlabored respirations. Clear lungs to auscultation. Chest clear and symmetric.

Diagnostic results:

  1. Structural MRI: According to Sadeghi et al. (2021), structural MRI can be used by psychiatrists to accurately detect schizophrenia. The test can show the abnormalities in the part of the brain responsible for memory, cognition, and mood. The test shows that the patient medical temporal region and prefrontal area are abnormal signaling the presence of schizophrenia.
  2. Scale for the Assessment of Negative Symptoms (SANS): Wójciak and Rybakowski (2018) note that SANS is a reliable tool that can be used to screen for schizophrenia disorder. The tool has 16-item questions used to screen for negative symptoms. The scores were high during screening.

Assessment:

Mental Status Examination: The patient is Mr. Jay Feldman a 19-year man who matches his age. Ne has a healthy weight, no tattoos, or scars. He was well-groomed and dressed according to the weather of the day. He has poor hygiene. He avoids eye contact and seems listening to voices. He looks disengaged. No unusual mannerisms or involuntary movements. Speech is slow and monotonous. He knows he is in my office and alert. The mood is low and affects flat. He has circumstantial thoughts. He has disorganized thoughts where he says things that are irrelevant to the interview. He experiences delusions and hears voices, but no sound is present. No suicidal thoughts. Insight and judgment are not intact. Cognition is grossly intact.

Differential Diagnoses: 

  1. Schizophrenia Disorder (DSM-5 295.90 (F20.9)
  2. Schizoaffective Disorder DSM-5 295.70 (F25.0 or F25.1)
  3. Delusional Disorder (DSM-5 297.1 (F22)

Primary diagnosis. Comprehensive assessment and diagnostic tests show that the patient has schizophrenia disorder. Strauss et al. (2018) argue that schizophrenia causes hallucinations, disorganized thoughts, speech problems, and delusions. DSM-5 also highlights the signs of the disorder and they include hallucinations, delusions, negative symptoms, and disorganized thoughts or speech (APA, 2013). According to the document, schizophrenia should be diagnosed when a person has two symptoms highlighted for more than a month and one of the symptoms should be either hallucinations, delusions, or disorganized speech (APA, 2013). The patient in the case hears voices, yet the environment is quiet, and believes that the room is spying on him. His speech is also disorganized at some point during the interview.

The disease is a primary diagnosis because the patient meets all DSM-5 criteria. The diagnostic and screening results also confirm the diagnosis. The schizoaffective disorder also makes people experience symptoms of schizophrenia as highlighted by DSM-5. Hartman et al. (2019) argue that schizoaffective disorder causes manic episodes making it a second choice because the patient does not experience mania. The patient has delusions, and as a result, the diseased part of the diagnosis. However, the disease does not cause psychotic symptoms, such as disorganized speech or hallucinations making it a secondary diagnosis (González-Rodríguez et al., 2018).

Reflections:

If I could conduct the session again, I would screen the patient for anxiety. The patient might develop anxiety symptoms due to delusions and hallucinations he experiences about his roommate and around his environment. From an ethical perspective, the principle of truth-telling might conflict with nonmaleficence and beneficence when handling patients with schizophrenia. The patient might harm himself if he is told that he is delusional and hallucinating. Another concern is about patient autonomy. Patients with schizophrenia might not think properly, and this might make it hard for a psychiatrist to trust their decisions. For instance, a psychiatrist might find it hard to allow patient autonomy if a patient says he does not need to be treated at his current state. I would educate the patient’s family to spend more time with him and watch his condition. I would also recommend that he start treatment to improve his mental health.

References

American Psychiatric Association. (2013). Schizophrenia spectrum and other psychotic disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm02

González-Rodríguez, A., Estrada, F., Montalvo, I., Monreal, J. A., Palao, D., & Labad, J. (2018). F229. The biological underpinnings of treatment response in delusional disorder: A systematic review of qualitative evidence-to-date. Schizophrenia Bulletin, 44(suppl_1), S311-S311. https://doi.org/10.1093/schbul/sby017.761

Hartman, L. I., Heinrichs, R. W., & Mashhadi, F. (2019). The continuing story of schizophrenia and schizoaffective disorder: One condition or two?. Schizophrenia Research: Cognition, 16, 36-42. https://doi.org/10.1016/j.scog.2019.01.001

Sadeghi, D., Shoeibi, A., Ghassemi, N., Moridian, P., Khadem, A., Alizadehsani, R., … & Nahavandi, S. (2021). An Overview on artificial intelligence techniques for diagnosis of schizophrenia based on magnetic resonance imaging modalities: Methods, challenges, and future works. arXiv preprint arXiv:2103.03081. https://arxiv.org/pdf/2103.03081.pdf

Strauss, G. P., Nuñez, A., Ahmed, A. O., Barchard, K. A., Granholm, E., Kirkpatrick, B., Gold, J. M., & Allen, D. N. (2018). The Latent Structure of Negative Symptoms in Schizophrenia. JAMA Psychiatry, 75(12), 1271–1279. https://doi.org/10.1001/jamapsychiatry.2018.2475

Wójciak, P., & Rybakowski, J. (2018). Clinical picture, pathogenesis and psychometric assessment of negative symptoms of schizophrenia. Psychiatr. Pol, 52(2), 185-197. DOI: https://doi.org/10.12740/PP/70610

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