[ANSWERED 2023] 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

Written By: Dan Palmer, RN

Psychotic disorders and schizophrenia are some of the most complicated and challenging

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

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

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.).

Transcript

00:00:00 TRANSCRIPT OF VIDEO FILE:

00:00:00______________________________________________________________________________

00:00:00 BEGIN TRANSCRIPT:

00:00:00[sil.]

00:00:15 OFF CAMERA Mr. Feldman? I understand you called us last week for an appointment.

00:00:20 MR. FELDMAN My parents.

00:00:25 OFF CAMERA Excuse me?

00:00:25 MR. FELDMAN My parents called for the appointment.

00:00:25 OFF CAMERA Oh. Do you know why your parents called for an appointment?

00:00:30 MR. FELDMAN No.

00:00:35 OFF CAMERA When your parents called me they said you were having some difficulty in school. Where are you in school?

00:00:50 MR. FELDMAN State College.

00:00:50 OFF CAMERA How long have you been at State College?

00:00:55 MR. FELDMAN My freshman year.

00:01:00 OFF CAMERA And how is it going?

00:01:05 MR. FELDMAN Fine.

00:01:10 OFF CAMERA What courses are you taking at State?

00:01:15 MR. FELDMAN In high school I took advanced placement courses. Theoretical physics, advanced calculus is what I’m taking now. Although I’m thinking about double majoring in philosophy and physics.

00:01:35 OFF CAMERA That’s an interesting combination.

00:01:35 MR. FELDMAN Yes, the mysteries of life. The courses are mysteries, and just when you think you’ve understood it, it’s gone.

00:01:45 OFF CAMERA Gone?

00:01:50 MR. FELDMAN The totality of life precludes us from repeating it. I mean what’s the point?

00:02:00 OFF CAMERA Do you have a roommate at state?

00:02:05 MR. FELDMAN You could call him that.

00:02:10 OFF CAMERA Can you tell me about him?

00:02:15 MR. FELDMAN Oh no.

00:02:15 OFF CAMERA Why not?

00:02:20 [sil.]

00:02:25 MR. FELDMAN He put a microwave in there, but I know what that means. But I won’t tell. Not a word..

00:02:35 OFF CAMERA A microwave oven?

00:02:40 MR. FELDMAN They had them in here too, in this building. But they’ll spare me, and they’ll spare you too, because you are with me, and what that’s about a bleeding degeneration of blood cells, bleeding the humanity from our rightful destiny… but this room spies on us.

00:03:05 OFF CAMERA I don’t understand what you mean.

00:03:10 MR. FELDMAN It’s in the eyes. You can hold of forever if you know how.

00:03:20 OFF CAMERA Mr. Feldman, did you come here with anyone else today?

00:03:25 [sil.]

00:03:30 MR. FELDMAN Sssshhhh.

00:03:35 OFF CAMERA Mr. Feldman, I think I may need to contact your parents.

00:03:45 SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com

00:03:45 END TRANSCRIPT

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

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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INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

  • Chief complaint
  • History of present illness (HPI)
  • Past psychiatric history
  • Medication trials and current medications
  • Psychotherapy or previous psychiatric diagnosis
  • Pertinent substance use, family psychiatric/substance use, social, and medical history
  • Allergies
  • ROS
  • Read rating descriptions to see the grading standards!

In the Objective section, provide:

  • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
  • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
  • Read rating descriptions to see the grading standards!

In the Assessment section, provide:

  • Results of the mental status examination, presented in paragraph form.
  • At least three differentials with supporting evidence. List them from top priority to least 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.
  • Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. 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.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas.

His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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