DSM-5 and Paraphilic Disorders

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DSM-5 and Paraphilic Disorders

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.DSM-5 and Paraphilic Disorders

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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Introduction

The purpose of this paper is to provide an account and presentation of a   comprehensive psychiatric evaluation of a patient with  Schizotypal Personality Disorder. The author will utilize findings of the client’s history, mental status examination, and ROS to formulate differential diagnoses and make reflections on the learning points, ethical and legal considerations in assessing and diagnosing clients with personality disorders.

Demographic Data

Patient Initials: S.R.

Age:33            years old

Gender: Female

Race: Caucasian

Date:30/1/2021

CC (chief complaint): “I went to lunch… once… with some of them. I’ve been reading some very depressing books lately, and they can feel what I’m feeling. So when I think about the books, it ruins their meal. So I eat alone”.

HPI: S.R.  is a 33-year-old Caucasian female who reports that she was unable to maintain interpersonal and social relationships with her workmates. She admitted to having difficulties,  marked discomfort, and excess social anxiety with developing and maintaining social connections with her workmates and family members (sister). She attributed this difficulty and pronounced discomfort to negative thoughts that her workmates, friends, and sister harbored about her. Although she disagreed with her workmates and sister’s perspective of her behavior and thoughts as a pluto and ability to seeing more in the darkness, she admitted to feeling depressed to an extent of cutting herself off from her coworkers. S.R. also demonstrated odd beliefs and thinking patterns such as her ability to “see more in darkness as compared to others”, “sensing an evil presence in the room”, and “feeling that her college roommate was dead and in the same room as her” at the time/period of his death. She had an unusual bodily perception of a smelling an odor from within her which increased her worries and prompted her to take lots of showers. As a result, she had started to be conscious about being too close to people especially girls s well as avoiding contact with women.DSM-5 and Paraphilic Disorders

Past Psychiatric History:

  • General Statement: the client previously experienced the same situation once after she divorced her husband of 3 years. She was not able to consult with a counselor or psychologist but constant support and communication with her sister decreased her social anxiety. Since she hadn’t seen any counselor, psychologist, or primary care provider, she had no hospitalizations or medications. She also had no homicidal or suicidal ideations.
  • Caregivers (if applicable): N/A
  • Hospitalizations: none
  • Medication trials: none
  • Psychotherapy or Previous Psychiatric Diagnosis: N/A

Substance Current Use and History: the client denies  ETOH,   tobacco, or illicit drug use.  She admits to maintaining a healthy diet( three meals daily in-between snacks), exercises regularly, and performs her ADLs(Activities of Daily Life) independently.

Family Psychiatric/Substance Use History: She could not provide the psychiatric history of her maternal and paternal great grandparents. Her paternal grandfather had bipolar disorder.  Paternal grandmother abused  ETOH.  S.K.  denied having any psychiatric problems in the mother’s family although she was not 100% certain. Her elder brother had anxiety when he was laid off from work in 2010 and was managed with Paxil. She informs that both parents are healthy, although her father has mild cognitive issues. Her siblings (1 brother and  1 sister aged  38 and  35 respectively are all alive and healthy). Her paternal uncle was a heavy drinker and used to hallucinate.

Psychosocial History: The client was born in   Maryland,  Montgomery, the  3rd  of  3  children with  1 elder brother and 1 elder sister. Her father is a retired high school teacher and her other is presently working as a  sales officer at a local store. She described her relationship with her parents as warm and reports that she is at most times close to her mother.  She states that her mother was outgoing,  while her father is relatively shy, even though they have a very small circle of close friends. They are active in church (Baptist) and continue to be so.  She is however uncomfortable, anxious, and shy being around people like her father. When she is not at work,  she rather stays at home. She had little knowledge about her early childhood but believed that there was nothing remarkable about it. She interacts with two to three friends once in a while and her sister more often and is not outgoing. Her problems started with her marriage when she learned that her husband was having an extramarital affair with a young girl who was a  neighbor nearby.

Medical History:

  • Current Medications: none
  • Illnesses/Surgeries: recurrent tonsillitis, varicella at 2 years old, no major or minor  surgeries DSM-5 and Paraphilic Disorders
  • Allergies: none

Reproductive Hx: Menstrual History:

Menarche: 12 years old

LMP: 01/25/2021

Menstrual Pattern: a 30-day cycle

  • Duration of flow: 5 days
  • Amount of flow: Day 1 and  5-Light flow, and day 2, 3, and 4 moderate flow
  • Menstrual pain: Experiences mild to moderate cramps during menses
  • Intermenstrual bleeding: none
  • Menopause: not applicable

Contraception:

  • Present Satisfaction Method: presently, the client does not use oral,  IUD,  implants,  or injectable contraceptives.
  • Past method, complications, and reasons for discontinuation: the client reports no complications with past contraception methods. She reportedly stopped  using Mirena  IUD  in  2017
  • Cervical and Vaginal Cytology:
  1. Recent Pap: March of 2020
  2. History of abnormal pap smears: None (Last Pap had no abnormal findings)

Sexual History:

  • The client identifies as a heterosexual. She divorced her husband whom she was married to for three years.
  • No reports of past or current sexual assault.
  • No libido changes. The client states that currently she is not in a relationship and doesn’t engage in sexual intercourse.

ROS:

Constitutional: denies malaise,  abdominal pain, unintentional weight loss, chills, and fevers.

HEENT: head normocephalic, atraumatic, denies dysphagia dental carries,  and heartburn. Denies vision changes, and mouth ulcers. Denies loss of vision, double vision, and blurred vision.  Denies exudates and drainage in the ears.  Denies loss of hearing,  congestion, sneezing, sore throat, and runny nose.

Cardiovascular: denies  chest discomfort or  pressure, chest pain, palpitations, and  shortness of breath

Respiratory: denies  wheezing,  coughing,  and shortness  of breath

GI: denies vomiting,  anorexia,  protruding or superficial veins, and blood in stool.

Genitourinary: denies urinary frequency, dysuria change of urine color, urgency.

Skin: denies   moles,  lesions, and rashes

Neurological: denies continuous headache, syncope,  dizziness, ataxia, paralysis,   tingling, or numbness in the extremities.

Musculoskeletal: denies joint pain,  back pain,  and stiffness.

Lymphatics: denies  tenderness,  swelling, and drainage

Psychiatric: confirms  anxiety by denies depression

Endocrinologic: denies polydipsia polyuria,  night sweats, heat or cold intolerance.

Physical exam:

General Appearance and parent-child interaction: S.R. is a 33-year-old Caucasian female with an anxious appearance, a suspicious look, and poor eye contact.

Vital signs: Blood Pressure 125/75mmHg, Pulse 76, Weight 149pounds Height-5’7 DSM-5 and Paraphilic Disorders

  • Physical Assessment

HEENT:

  • Head: normocephalic with no bumps or scrapes with healthy growth of hair and a symmetrical face. Eyes: Normal vision –clear conjunctiva clear with no drainage. Ears: normal appearance of bilateral ears, no abnormal drainage, no swelling in the ear canal. Nose: patent, normal mucosa, the septum is midline and there is no sinus tenderness. Throat: pink and moist, no swelling, no drainage. Neck: supple, soft, no JVD (jugular venous distension)

Lymph nodes: non-palpable mass, non-tender.

Skin: no risk, pink,    minor lesions noted, the abdomen is warm to touch,  no cyanosis,  skin turgor;  less than 2seconds.

Gastrointestinal:  flat abdomen, no scars,  hyperactive bowel sounds on all abdominal quadrants,  there is a tympanic percussion throughout, liver span is  9 cm (right midclavicular line), smooth edges, and palpable from the right coastal margin 5cm. There is no splenic dullness, no CVA tenderness, no organomegaly, no inguinal adenopathy.

GU: bladder is at the normal position, not felt on palpation.

Assessment

Mental Status Examination: S.R.  is a 33-year-old Caucasian female appearing her stated age, she is dressed in oddly matched clothes. Her hair is neatly pulled to the sides, her face is pale with no make-up, she is cooperative but appears anxious and suspicious during the interview with occasional eye contact. Her speech is peculiar with an unusual and vague pattern. There were occasional blocking, hesitance, and latency in response. Affect is flat, and the mood is anxious.  She denies suicidal and homicidal ideations. Thought processes are eccentric and peculiar.  She denies delusions, and hallucinations but has ideas of reference,  thought withdrawal, and broadcast. Cognition: she is alert and oriented X4spheres( time, place, person, and situation). She can accurately do serial 7’s.  Her short-term, immediate,  and long-term memories are intact as evidenced by her ability to give history and remember three objects after five minutes. Fund of knowledge: she can name the president and the last four presidents. Her vocabulary aligns with her level of education.  Calculations:  she can accurately calculate 3 X 7=21, 3 X 3=9, 3 x 33 = 99, and 3 X 11 = 33. Perceptions: the client has illusions and unusual perceptions (sensing the presence of an absent person-college roommate). Insight: she has poor insight as she denies having any problems. Judgment is intact.

Differential Diagnoses:

Schizotypal Personality Disorder: The DSM V criteria of STPD involves a persistent pattern in interpersonal and social deficits primarily characterized by acute discomfort and a decreased capacity for close relations as well as eccentric behavior,   perceptual and cognitive distortions that start early in adulthood. Therefore clients present with at least five of the following symptoms;  abnormal perceptions,  ideas of reference,   magical thinking/ strange beliefs,   a constricted/inappropriate affect, a strange speech, lack of close friends, paranoid ideation or suspiciousness, and excess social anxiety (American Psychiatric Association, 2013).  Similarly,  S.K.’s major presenting complaint was that of inability to maintain close relationships with her family members as well as workmates. Even with increased familiarity with her workmates, she had excess social anxiety that did not diminish and was linked to paranoid fears rather than negative judgments about herself.  As a result, she lacked close friends. S.K.  had ideas of reference (her boss thinks she does not suit her current position from customer complaints)and magical thinking(she can see more darkness than others, ). She had a bodily illusion (smelling an odor that makes her take lots of showers) and during the interview, she was suspicious/had paranoid ideation (felt as if her dead college roommate was in the same room as her). Besides, her speech and thinking were vague (she had a disorganized speech whose were disconnected).DSM-5 and Paraphilic Disorders

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Paranoid Personality  Disorder(PPD): it involves continuous suspiciousness and distrust of the motives of other people. Individuals with PPD  respond with anger to threats on their autonomy, are hypersensitive, persistently seek confirmations of their doubts, bear grudges,  and are rigid in their beliefs and how they perceive others (Vyas & Khan, 2016).  Individuals with PPD  easily become fanatics of groups that promote their paranoid ideas or they can isolate themselves socially. In other instances, they can maintain steady employment but be excessively anxious, difficult, prejudicial, rigid, critical, or controlling with coworkers (Bates, 2018). S.R.  was excessively sensitive to setbacks such as small talk which she strongly believed could interfere with her performance at work. She was highly suspicious that her coworkers felt what she was feeling thus the avoidance to share meals. Besides, she felt some degree of self-righteousness when she acknowledged she didn’t use drugs or drink to save her public image. However, this client demonstrated no desire to control close friends and associates, neither did she have hallucinations, which is a  major feature in   SPD.

Schizoid Personality Disorder: individuals with schizoid personality disorder express a lack of desire to seek interpersonal relationships. Its main characteristic is

Detachment from social relations and at least four of the following symptoms; selecting solitary activities, non-desire for close relations, derives pleasure in very few to no activities, lacking confidants or close friends among 1st-degree relatives,  less interested in sexual experiences, and emotional detachment, coldness and a flat affect (Levi-Belz et al., 2019). S.R. expressed her lack of desire for close relations with her workmates She was less concerned about how she associated with her sister and how her sister perceived her thoughts and behaviors. Besides, she only expressed her interest in reading and didn’t mind her critics and cheerers especially in the work environment.

Reflections

After a thorough and careful evaluation of the client’s history, MSE, and assessment,  I agree with my preceptor’s assessment and diagnostic impression of Schizotypal Personality Disorder(SPD). Patients with SPD have a persistent pattern of cognitive-perceptual aberrations,   interpersonal deficits, and eccentric behavior which are primarily characterized by discomfort and a decreased ability to maintain close relationships as demonstrated by the patient in this case (Kirchner et al., 2018).  If I were to conduct this assessment and interview again, I would focus on asking the client directed questions on how she perceives her close associations and behaves while in other social settings as well as pay close attention to her language and expression. Fonseca-Pedrero et al., (2018) note that, clients with schizotypal personality disorder use words incorrectly,  they are unclear, and have stereotyped expressions that may not be to the point of incoherence and associative loosening.

A major concern that arises at the initial stages of a therapeutic relationship with mental health clients particularly clients with Schizotypal Personality Disorder is informing them about their diagnosis. Jurjako, Malatesti & Brazil (2019) partly attribute this to fear of the negative reactions by a client especially in instances where a client feels secluded and abandoned. A PMHNP   may feel that sharing this diagnosis, can result in stigma,  impair a  subsequent therapeutic relationship or even diminish a patient’s hope (Sheehan, Nieweglowski & Corrigan, 2016). However, currently, existing evidence reveals that it is necessary to share this diagnosis as it helps a client to make sense of her suffering, strengthens the  PMHNP-client therapeutic relationship, and improves success outcomes. For patients,  sharing this diagnosis can help to relieve their lifelong sense of shame, and guilt for having believed that what might have gone wrong in their relations is solely their fault.DSM-5 and Paraphilic Disorders

Another ethical consideration is discussing suicide risks. The findings of the study by Fonseca-Pedrero et al., (2018). reveal that patients with Schizotypal Personality Disorder are at a higher risk of committing suicide.  Therefore, asking a client if he/she has ever had suicidal/homicidal ideations during a psychiatric evaluation is not enough. Rather, the PMHNP  should inform clients with Schizotypal Personality Disorder about the increased risk of suicide with this mental disorder. From an ethical perspective,  sharing this information is a sign of respect to the patient and can increase the client’s trust (Bipeta, 2019).  On the contrary,   this disclosure can also be harmful to a  patient such that, it can become a  self-fulfilling prophecy or decrease the client’s hope for recovery. Despite all these challenges, a PMHNP must share this information with the client by making it clear that they want to face this risk together. The PMHNP should also express her fears about the negative impact of this information on the patient such as decreasing the patient’s hope. They can further proceed to sign an antisuicide contract.

References

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

Bates, C. (2018). Paranoid Personality Disorder.

Bipeta, Rajshekhar. (2019). Legal and Ethical Aspects of Mental Health Care. Indian Journal of Psychological Medicine. 41. 108. 10.4103/IJPSYM.IJPSYM_59_19.

Fonseca-Pedrero, E., Ortuño, J., Debbané, M., Chan, R. C., Cicero, D., Zhang, L. C., … & Fried, E. I. (2018). The network structure of schizotypal personality traits. Schizophrenia Bulletin, 44(suppl_2), S468-S479.

Fonseca-Pedrero, E., Ortuño, J., Debbané, M., Chan, R. C., Cicero, D., Zhang, L. C., … & Fried, E. I. (2018). The network structure of schizotypal personality traits. Schizophrenia Bulletin, 44(suppl_2), S468-S479.

Jurjako, M., Malatesti, L., & Brazil, I. A. (2019). Some ethical considerations about the use of biomarkers for the classification of adult antisocial individuals. International Journal of Forensic Mental Health, 18(3), 228-242.

Kirchner, S. K., Roeh, A., Nolden, J., & Hasan, A. (2018). Diagnosis and treatment of schizotypal personality disorder: evidence from a systematic review. NPJ Schizophrenia, 4(1), 1-18.

Levi-Belz, Y., Gvion, Y., Levi, U., & Apter, A. (2019). Beyond the mental pain: A case-control study on the contribution of schizoid personality disorder symptoms to medically serious suicide attempts. Comprehensive Psychiatry, 90, 102-109.

Sheehan, L., Nieweglowski, K., & Corrigan, P. (2016). The stigma of personality disorders. Current Psychiatry Reports, 18(1), 11.DSM-5 and Paraphilic Disorders