Schiz 7.V.35: Diagnosis of Mental Conditions

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.). PLEASE INCLUDE INTRODUCTION AND CONCLUSION. AT LEAST 2 PARAGRAPHS PER DIFFERENTIAL DIAGNOSIS. Schiz 7.V.35: Diagnosis of Mental Conditions

Introduction

Comprehensive mental assessment is used in the diagnosis of various mental conditions according to the cognitive, emotional, or behavioral symptoms. A comprehensive psychiatric evaluation of an individual is performed based on the presenting behaviors and symptoms in relation to the social, cognitive, environmental, emotional, functionality, and academic aspects that may be impacted by these behaviors and symptoms (Clark et al., 2017). It also involves collecting data about the patient’s past medical/psychiatric history, including family health/mental history. This paper will provide a discussion of a comprehensive psychiatric evaluation for a client named Jess who presented with both auditory and visual hallucinations such as “seeing Russians and terrorists”. She is also not aware that her favorite auntie who brought her up died. Schiz 7.V.35: Diagnosis of Mental Conditions

SUBJECTIVE DATA

CC(chief complaint):“I have been having thoughts and hearing things that others do not seem to hear. Sometimes people think I am crazy, but it is them who seem to be blind on deaf. For example, we are surrounded by terrorists and Russians in my neighborhood but my friends seem not to understand this….”

HPI: Jess is a 26-year-old African American woman who presents for assessment accompanied by her two friends. The friends report that ever since Jess’s favorite auntie died for the last 8 months, Jess has been acting strange and hearing strange things. Before this, her friends report that Jess was normal and conducted herself well. She also used to work well and performed exceptionally in her education. Jess is an orphan who was brought up by her auntie. When her parents died at the age of 17 years, she was diagnosed with major depressive disorder. However, she received pharmacological treatment (sertraline) and psychotherapy (cognitive-behavioral therapy), and after a year of treatment,she achieved full symptom remission. Her friends reported that Jess once confessed that she attempted suicide two times, six months aftershe lost her parents in a road accident. However, they have known her for the past 5 years but they have never noticed any abnormality, anxiety, or depression in her. They describe her as an outgoing person, who is dedicated to her work and really used to adore her auntie who took her in after she lost both her parents. However, things took a different turn for her after she lost her auntie. The friends report that she has started having episodes where she gets out of control and starts seeing or hearing things that others seem not to understand. She even reports that she receives messages through television about the plan Russians have about the world. Jess reports that she has Russians and terrorists within the neighborhood who pose a danger to her and other people. She states that the Russians are listening to everyone in their apartment and in the long-run, they will harm everyone. The friends were very concerned that they decided to bring her for a mental assessment. She does not believe that her auntie died. Jess also believes that strange people who she labels as Russians are listening and drilling information from everyone. She denies any visual or auditory hallucinations but still believes Russians and terrorists within the neighborhood seem to be hatching a plan, that everyone else seems not to understand. During the interview, she sometimes talks in whispers so that the “Russians” will not hear. Sometimes Jess does not go to work and stays locked in the house as she fears being attacked by the Russians. This has really affected her work. Schiz 7.V.35: Diagnosis of Mental Conditions

Past Psychiatric History

At 17-years old, Jess was diagnosed with major depressive disorder. This is after she lost her parents in a road accident. She was treated using sertraline for 6 months and psychotherapy (CBT). After about a year, she achieved complete symptom remission. She attempted suicide two times at the age of 18 years. The death of her parents really affected her.

Substance Use History

Jess does not drink alcohol, does not smoke tobacco, or take illegal drugs. However, when she lost her parents, she used to take so much alcohol but stopped drinking after she recovered from the depressive symptoms.

Family Psychiatric/Substance Use History

The mother had a history of bipolar type 1 disorder before she died. The father was diagnosed with schizoaffective disorder at the age of 41 years. Her paternal auntie was diagnosed with insomnia and compulsive-obsessive disorder at the age of 43 years. Her maternal uncle has a history of substance use disorder but recovered fully after rehabilitation. Schiz 7.V.35: Diagnosis of Mental Conditions

Social History

Miss. Jess was born in Mexico but during her childhood, they moved to Chicago when her parents secured employment in the US. Her parents were teachers, and thus she was brought up by a nanny. She is the only child to her parents but she interacted so much with her cousins in the US when she was growing up. Her parents died in a road accident when she was aged 17-years and her auntie who lives in the US took her in. She is currently not in a relationship. Even though she lives alone, her two best friends live within the neighborhood.

Her highest educational level is a college degree. She currently works in a nearby pharmaceutical firm. Her hobbies include watching television and reading. Jess does not have any history of violence or trauma. 

Medical History

Jess does not have any significant medical history, apart from the major depressive disorder when her parents died in a road crash.

Current Medications

She does not have any current treatment regimen. Schiz 7.V.35: Diagnosis of Mental Conditions

Allergies

No know allergy.

OBJECTIVE DATA

The mental status exam was performed. Jess is alert, and well oriented to person, event, time, and place. She appears well dressed for the time of the year and the weather and she is well-groomed. She manifests appropriate mannerisms, tics, or gestures. During the interview, Jess’s speech is slow and incoherent, but sometimes she appears to whisper to avoid “Russians” hearing what she is saying. Jess’ self-reported mood is euthymic, while her affect is flat and at times constricted. Even though she does not report auditory or visual hallucinations, she appears to be hallucinating as she expresses being watched by Russians and terrorists who are about to bring harm. She also has a delusional thought process as manifested by her report of strange Russians and does not know if her auntie is dead or not. Both her insight and judgment are significantly impaired. She does not have any homicidal or suicidal ideation. Schiz 7.V.35: Diagnosis of Mental Conditions

ASSESSMENT

Vital signs:

• Heart rate: 76 b/m
• Blood pressure 130/80 mm Hg
• Temperature 37⁰ C
• Respiration rate (RR): 16
• BMI 25
• Pain N/A

Differential Diagnoses

1. Schizophrenia spectrum disorder: This disorder is characterized by symptoms such as hallucinations, delusions, incoherence, catatonic behavior, and negative symptoms (Wright, 2020). Jess is incoherent, delusional, has a flat affect, and manifests hallucinations and therefore indicating the possibility of her having schizophrenia.
2. Bipolar I Disorder with psychotic features: This disorder is characterized by symptoms such as hallucinations, delusions of grandeur, paranoia, disorganized speech, among other symptoms (Fu-I et al., 2020). Jess exhibits some of these symptoms but does not manifest delusions of grandeur.
3. Schizoaffective disorders: This disorder is typified by recurring episodes of psychotic and affective/mood symptoms. mood symptoms can include depressive or manic symptoms, or both (Parker, 2019). Psychotic symptoms can occur prior, during, or after the manic/depressive episodes. However, the client is not manifesting any depressive symptoms.

Jess is administered with the Positive and Negative Syndrome Scale (PANSS) for schizophrenia which identifies the following scores:

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The PMHNP administers the PANSS which reveals the following scores:

• -20 score for the negative symptoms
• -38 score for the positive symptoms
• -58 score for general psychopathology.  Schiz 7.V.35: Diagnosis of Mental Conditions

DSM-5 Diagnostic Criteria

According to the DSM-5 diagnostic criteria, symptoms of schizophrenia include hallucinations, disorganized speech, or delusions for at least a month. Other symptoms include diminished emotional expression and gross disorganization (Citrome et al., 2019). For the diagnosis of schizophrenia to be confirmed, the symptoms must have affected the functionality of an individual and interpersonal relationships; symptoms of the disturbance should have lasted for a minimum of 6 months; other mental disorders are ruled out, and the disturbance should not be as a result of a medical condition or substance abuse (Gaebel&Zielasek, 2015).

Jess is having both visual and auditory hallucinations, as well as delusions as she believes and reports that there are “Russians and terrorists” are within the neighborhood and seem to be plotting bad things against everyone. She also does not seem to know that her auntie died. Jess exhibits diminished emotional expression and gross disorganization as indicated by the flat and constricted affect. The symptoms started over 8 months ago and the symptoms have also affected her interpersonal relationship and her work. Therefore, the symptoms the client presents match the DSM-5 diagnostic criteria of schizophrenia.

The findings from the PANSS and DSM-5 diagnostic criteria confirm the diagnosis of schizophrenia spectrum disorder for this client.

Diagnosis

Schizophrenia spectrum disorder

Reflection

The comprehensive evaluation for this patient facilitated the collection of comprehensive patient information in order to inform the diagnosis for this patient and come up with the correct diagnosis. By collecting the data, it was discovered that there is a family history of various mental disorders for Jess and that the death of Jess’s guardian (auntie) was a trigger for the mental disorder. It was also discovered that the patient does not drink alcohol or take illegal drugs and hence substance abuse is not the cause of the mental disorder for Jess. The patient presented with psychotic symptoms as manifested by the delusions and the hallucinations. The DSM-5 criteria and PANSS were the diagnostic tools used to confirm the diagnosis for this client.Schiz 7.V.35: Diagnosis of Mental Conditions

Given another opportunity, I would still use PANSS and DSM-5 diagnostic criteria to confirm or rule out any mental disorder. However, I would consult widely from the latest available evidence, before coming up with the list of differential diagnosis.

The various legal and ethical considerations for this client. First, the psychotic symptoms may make the client uncooperative during the assessment and may also lead to resistance to treatment (McCutcheon,2020). This brings in the legal issue of forceful treatment and the ethical issue of respecting the patient’s autonomy. Moreover, it would be important to ensure informed consent is sought from the client before the comprehensive mental evaluation. The confidentiality of the patient’s information should be protected and her diagnosis should not be revealed to anyone else, without her consent (Deshpande et al., 2020).

Conclusion

The findings from the PANSS and DSM-5 diagnostic criteria and the collected patient information helped to confirm the diagnosis for this patient as a schizophrenia spectrum disorder. Schizophrenia spectrum disorder is characterized by symptoms such as delusions, hallucinations, flat mood, disorganized speech, among other symptoms. The recommended treatment choice for the patient is Invega Sustenna 234 mg IMs”. The medication rebalances the level of dopamine and serotonin in the brain and hence treats symptoms such as delusions and hallucinations. By using the medication, the social functioning of the patient will also improve and this will be demonstrated by improved social interactions and the patient resuming to work effectively. Schiz 7.V.35: Diagnosis of Mental Conditions

References

Citrome, L., McEvoy, J. P., Todtenkopf, M. S., McDonnell, D., &Weiden, P. J. (2019). A commentary on the efficacy of olanzapine for the treatment of schizophrenia: the past, present, and future. Neuropsychiatric disease and treatment, 15, 2559–2569. https://doi.org/10.2147/NDT.S209284

Clark, L. A., Cuthbert, B., Lewis-Fernández, R., Narrow, W. E., & Reed, G. M. (2017). Three approaches to understanding and classifying mental disorders: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC). Psychological Science in the Public Interest, 18(2), 72-145.

Deshpande, S. N., Mishra, N. N., Bhatia, T., Jakhar, K., Goyal, S., Sharma, S., Sachdeva, A., Choudhary, M., Shah, G. D., Lewis-Fernandez, R., & Jadhav, S. (2020). Informed consent in psychiatry outpatients. The Indian journal of medical research, 151(1), 35–41. https://doi.org/10.4103/ijmr.IJMR_1036_18

Fu-I, L., Gurgel, W. S., Caetano, S. C., Machado-Vieira, R., & Wang, Y. P. (2020). Psychotic and affective symptoms of early-onset bipolar disorder: an observational study of patients in the first manic episode. RevistaBrasileira de psiquiatria (Sao Paulo, Brazil: 1999), 42(2), 168–174. https://doi.org/10.1590/1516-4446-2019-0455

Gaebel, W., &Zielasek, J. (2015). Schizophrenia in 2020: Trends in diagnosis and therapy. Psychiatry and clinical neurosciences, 69(11), 661-673.

McCutcheon, R. A. (2020). Disentangling relapse and adherence in psychosis. Lancet Psychiatry, 722-723.

Parker, G. (2019). How Well Does the DSM-5 Capture Schizoaffective Disorder?The Canadian Journal of Psychiatry, 64(9), 607-610.

Wright, M. (2020). Schizophrenia and schizophrenia spectrum disorders. Journal of the American Academy of PAs, 33(6), 46-47. Schiz 7.V.35: Diagnosis of Mental Conditions