Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study
Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study
| Age: 46 years old, Male |
| Occupation: Supervisor at Walmart. |
Chief Complaint (using patient’s words): The client appears at the facility for the initial psychiatric evaluation and complains that “there are always people outside my window who are intent on harming me. I can hear their voices clearly all the time even when they are whispering; and I believe that they have been sent by the state to kill me.” He believes that he has fund a secret cure for ageing and now “the government wants to kill me and steal my secret.” Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study
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| History of Present Illness: The patient is a 46-year-old African American male with a previous history of mental illness. He presents at the evaluation with unmistakable auditory hallucinations and delusions. The onset of the current symptoms was a few months ago and they specifically affect his thought content and processes. As is usual for him, his psychological manifestations are persistent and resistant in characteristic with a consistent duration. Being alone in the house is an aggravating factor; while being in the company of someone somewhat relieves the symptoms. The symptoms may manifest throughout the day or at night. He rates the symptom severity at 7/10. |
| Mania/Hypomania: He denies a history of mania ort hypomania. |
| Depressive symptoms: He has had some depressive episodes, but not too much to lead to a diagnosis of depression. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Suicidal Ideation/Intent/Plan: He denies ever having ideas about hurting himself or even killing himself. |
| Psychosis: The patient has an extensive history of psychosis, having shown in the past both positive and negative symptoms of schizophrenia. These include hallucinations, delusions, disordered thought processes, apathy, and anhedonia (Leucht et al., 2019; Wheeler, 2020). |
| Anxiety: There is an admission of episodes of anxiety in the patient, especially when the symptoms are at their height in severity. |
| Past Psychiatric History: |
| Hospitalizations: He has been hospitalized on three previous occasions under involuntary commitment due to homicidal ideation. Due to his hallucinations, he started revealing that he would attack all those that he thought were part of the plot to harm him. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Medication Trials: He has been tried on chlorpromazine (Thorazine) and haloperidol (Haldol). |
| Psychotherapy: He has previously been on individual cognitive behavioral therapy or CBT. |
| Suicide Attempts/gestures: None. |
| Violence (client past history, current risk): He has a worrying past history of violence and intent to harm others that he thinks “have been sent to harm him”. He also has a legal record with law enforcement regarding domestic violence. He used to batter his wife before they separated. |
| Abuse (sexual/physical/emotional): He narrates traumatic childhood experiences as an orphan; having been molested by the foster parents that raised him. The abuse was physical, sexual, and emotional. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Substance Use History: |
| Tobacco: He used to smoke and still smokes at least a pack of cigarettes in 24 hours. Cumulatively he has about 21 pack years of smoking. |
| Caffeine: He denies regularly taking drinks that have caffeine; only admitting to occasionally doing so. |
| Alcohol: He is a regular partaker of etoh, especially over the weekends which at times turn out to be binge drinking episodes. |
| CAGE: He denies any other history of substance abuse of the likes of cannabis, heroin, cocaine, hallucinogens, psychostimulants, methamphetamine, psychedelics, and so on. |
| Withdrawals: He does not have a history of withdrawal from any drugs of abuse or substances. |
| Adverse Consequences: He has never suffered from any adverse consequences of either drugs of abuse or prescription medications. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Last drink: The previous day (etoh). |
| Marijuana: Never smoked. |
| Cocaine/other stimulants: Never used. |
| Opiates: Never used. |
| Benzodiazepines: Never used. |
| Hallucinogens: Never tried. |
| Detox/Rehabilitation/other treatment: Never done. |
| Medical History |
| Drug Allergies: NKDA. |
| Primary Care Physician: He has one. |
| Current medications:
· Chlorpromazine (Thorazine) 25 mg orally three times a day. · Haloperidol (Haldol) 2 mg orally twice a day. · Metformin (Glucophage) 500 mg orally twice a day (for hyperglycemia). Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| OTC/herbal supplements: None at the moment. |
| Illnesses: Type 2 diabetes mellitus. |
| Surgeries: None. |
| Medical Review of Systems |
| General: Negative for fever, chills, weight changes, or fatigue. |
| Skin: Denies itching and/ or rashes. |
| Head, ears, eyes, nose, and throat: Negative for photophobia, otorrhea, rhinorrhea, or sore throat. |
| Cardiovascular and Respiratory: Denies chest pain/ tightness, coughing, sneezing, or dyspnea. |
| Gastrointestinal: Negative for N/D/V. |
| Genitourinary/Gyn: Denies urine retention or incontinence. Also negative for urethral discharge. |
| Neurological: Denies syncope, paraesthesia, dizziness, or a loss of control of the bowels and/ or bladder. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Family History: |
| Psychiatric: A history of schizophrenia exists in the family on both the mother’s and father’s sides. |
| Medical: There is a history of heart disease, hypertension, and diabetes on the mother’s side. |
| Substance use: There is a history of substance abuse as some of his uncles smoke cannabis and abuse opioids. |
| Suicides/homicides: His maternal grandfather was imprisoned for life for murder. He had paranoid schizophrenia and frequently had auditory and visual hallucinations that led him to commit homicide. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Social History |
| Background/Family of origin/Developmental History: He had a normal developmental period growing up. Disordered thought processes only started in his early adulthood. This is when his first psychiatric diagnosis of psychosis was made. |
| Marital Status: He was married but separated from his wife of ten years due to his mental illness. |
| Children: He has one daughter of 12 years whom the mother has custody of. |
| Employment: He works part-time as a supervisor at Walmart. This is a part-time employment position that cannot sustain all his needs. This is why he is on Medicaid to assist with his mental healthcare needs. |
| Hobbies/Interests: He likes watching movies, swimming, and cooking. |
| Education: He dropped out of school in high school. |
| Legal History: He has been booked before for intimate partner violence. |
| Spiritual: He goes to an evangelical church once in a while and is not very spiritual. |
| Mental Status Exam |
| General Appearance (include gait): The client appears disheveled and poorly groomed for the time of the day and the occasion. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Behavior (include motor movements): He is anxious and fidgety and does not maintain proper eye contact. |
| Attitude: He is cooperative and answers questions. |
| Speech: His speech is hardly coherent and goal-oriented. |
| Mood: His self-described mood is “anxious”. |
| Affect: This is dysphoric and hence mood-congruent. |
| Thought Content: He has delusions, hallucinations, illusions, ideas of reference, and derealization. |
| Thought Process: He displays tangential thinking and illogical shifting of thoughts. There is also circumstantial thinking, flight of ideas, and thought blocking. |
| Perceptions (hallucinations): Auditory hallucinations. |
| Judgment and Insight: Impaired. |
| Impulsivity (good, poor – examples): Impulsive, as when he does some things on the spur of the moment. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Cognition: |
| Orientation: He is oriented to time, space, place, person, and event. |
| Short term recall: Good. |
| Long-term recall: Poor. |
| Attention/Concentration: Poor. |
| MMSE score: 21 (possible cognitive impairment). |
| Diagnostic Impression: Paranoid Schizophrenia (APA, 2022; Boland et al., 2021). |
| Client strengths, protective factors, preferences: He has a strong social support system in his extended family of mother, father, and siblings. He is also resilient and adheres to treatment requirements. |
| Diagnosis |
| Primary DSM-5-TR Diagnosis: Paranoid Schizophrenia – 295.90 (F20.9)
A first degree relative of the patient suffered from paranoid schizophrenia; therefore there is a family history of mental illness. His complaints are likewise consistent with paranoid schizophrenia, according to the DSM-5-TR criteria. Delusions, hallucinations, catatonic behavior, and negative symptoms such as disorganized speech, anhedonia, and avolition are necessary for a person to be confirmed with schizophrenia (APA, 2022: Boland et al., 2021). Additionally, a level of functioning that has been severely compromised by the indications in at least one area must be evident. These are like in one’s occupation, relationships with others, and/ or self-care. Additionally, the manifestations must have lasted for at least half a year. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Differentials (rule-outs):
a. Substance-Induced Psychotic Disorder: 292.9 (F19.259) b. Schizotypal Personality Disorder: 301.22 (F21) |
| Plan |
| Pharmacological:
· To stop taking haloperidol and chlorpromazine and commence paliperidone (Invega Sustenna) 234 mg IM STAT. After that, to receive 156 mg IM on the fourth day following the first visit, then 156 mg IM every month thereafter (Stahl, 2020). Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study |
| Therapies:
· To start concurrently fourteen weeks of 45-minutes-per week cognitive behavioral group therapy or CBGT (Wheeler, 2020). |
Other needs, resources, referrals:
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References
American Psychiatric Association [APA] (2022). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-5-TR), 5th ed. Author.
Boland, R., Verdiun, M., & Ruiz, P. (Eds) (2021). Kaplan and Sadock’s synopsis of psychiatry, 12th ed. Wolters Kluwer.
Leucht, S., Barabássy, Á., Laszlovszky, I, Szatmári, B., Acsai, K., Szalai, E., Harsányi, J., Earley, W., & Németh, G. (2019). Linking PANSS negative symptom scores with the Clinical Global Impressions Scale: Understanding negative symptom scores in schizophrenia. Neuropsychopharmacology, 44, 1589-1596. https://doi.org/10.1038/s41386-019-0363-2
Stahl, S.M. (2020). Stahl’s essential psychopharmacology: Prescriber’s guide, 7th ed. Cambridge University Press.
Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice, 3rd ed. Springer Publishing Company, LLC. Psychiatric Evaluation of 46-Year-Old African American Male with Schizophrenia Case Study
