Schizotypal Personality Disorder Essay

Comprehensive Psychiatric Evaluation of a 27 Year-Old Caucasian Male with Schizotypal Personality Disorder 

Personality disorders are recognized as distinct mental health conditions that have their specific diagnostic codes in the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. Schizoid personality disorder belongs to this diagnostic category of Personality Disorders in the DSM-5. To be specific, it belongs to what are referred to as ‘Cluster A Personality Disorders’ in the DSM-5. These are conditions that apart from schizotypal personality include paranoid personality disorder and schizoid personality disorder (Sadock et al., 2015; APA, 2013). The diagnostic code for schizotypal personality disorder in the DSM-5 is 301.22 (F21). This paper is a comprehensive psychiatric evaluation of a 27 year-old Caucasian male who has this diagnosis of schizotypal personality disorder.

CC (chief complaint): Patient LP presents with a chief complaint of smelling an odor that is “malicious and piercing”. He is also suspicious that his superior at work thinks that he is not qualified for his job at the library. Schizotypal Personality Disorder Essay.

HPI: The patient is a 27 year-old Caucasian male who presents with odd beliefs, unusual perceptual experiences, and paranoid ideation. He claims to smell an odor that appears to be coming from his body. He denies any previous history of these symptoms but reports that their onset was about six months ago. All the symptoms are in his mind as he claims to feel and smell suspicious occurrences and stimuli. The symptoms are intermittent in duration and come and go. The odor is characteristically “piercing and malicious” according to the patient. The symptoms are aggravated by being close to workmates and other non-relatives and relieved by being at home or close to first-degree relatives. He claims to experience the symptoms especially during the day when he is at work. He rates their severity at 6/10.

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Past Psychiatric History:

• General Statement: Patient LP is very superstitious and paranoid about almost everything and everyone at his workplace. He is not social and has difficulties forming and maintaining interpersonal relationships.
• Caregivers (if applicable): He is able to care for himself and does not require the help of caregivers.
• Hospitalizations: Patient LP has never been hospitalized for a psychiatric condition. He has however been hospitalized for malaria when he went for vacation in Africa and for pneumonia.
• Medication trials: He has not been involved in any medication trials or received any medications related to any mental illness.
• Psychotherapy or Previous Psychiatric Diagnosis: Because he does not have a psychiatric history, he has never attended any psychotherapy sessions. He has never been diagnosed with a psychiatric illness.

Substance Current Use and History: Patient LP denies using any banned substances or even smoking cigarettes. He however admits to taking etoh casually over the weekends with relatives at home.

Family Psychiatric/Substance Use History: There is no significant family history of psychiatric illness in patent LP’s family. There is also no history of drug or substance abuse in his family. Schizotypal Personality Disorder Essay.

Psychosocial History: Patent LP lives alone. He had a girlfriend but they recently separated when she could no longer tolerate his paranoia and suspicion. He frequently sees his parents who do not live far from him, as well as his two siblings. He was born in Newark, Delaware and grew up there. That is also where he went to school and college. He does not have any children and currently works in a library. His hobbies include reading, bird watching, and watching movies. He does not have a criminal record and denies any history of violence or abuse in the family or outside.

Medical History:

• Current Medications: He is not currently on any medications.
• Allergies: NKDA, no food or environmental allergies.

• Reproductive Hx: He is heterosexual but does not have any children yet.

ROS:

• GENERAL: Denies malaise, weakness, fatigue, fever, or loss of weight.
• HEENT: Denies photophobia or diplopia. Negative for otorrhea or hearing loss. No rhinorrhea or sneezing. Denies a sore throat.
• SKIN: negative for rashes or itching.
• CARDIOVASCULAR: Denies chest pain, palpitations, or chest tightness.
• RESPIRATORY: denies coughing, producing sputum, or difficulty in breathing.
• GASTROINTESTINAL: Denies nausea, vomiting, loss of appetite, or diarrhea. Reports regular bowel movements.
• GENITOURINARY: Negative for urgency, frequency, or cloudiness. Also negative for polyuria. Denies any sexually transmitted infections.
• NEUROLOGICAL: Denies dizziness, tingling sensation, peripheral paraesthesia, numbness, or hemiparesis. Also denies loss of bladder or bowel control.
• MUSCULOSKELETAL: Negative for arthralgia and myalgia. Denies back pain or joint stiffness.
• HEMATOLOGIC: Denies a history of blood or clotting disorders in his family.
• LYMPHATICS: Negative for lymphadenopathy. Denies splenectomy in the past.
• ENDOCRINOLOGIC: Negative for polydipsia and polyphagia. Also negative for heat or cold intolerance as well as excessive diaphoresis.

Physical exam:

Vital Signs: BP 110/60 regular cuff and sitting; P 78, regular; T 98.0°F; RR 16, non-labored; BMI 24.8 kg/m² (normal BMI).

General: Patent LP is alert and oriented in time, space, place, person, and event. Schizotypal Personality Disorder Essay. His speech is coherent and goal-oriented. He appears well-dressed and appropriately for the time of the year and day.

HEENT: Head atraumatic and normocephalic. PERRLA. EOMI. No otorrhea and tympanic membranes intact bilaterally. Turbinates show no evidence of inflammation with no rhinorrhea. The throat shows no evidence of exudate or erythema.

Respiratory: Clear lung fields with no crepitations, rales, rhonchi, or wheezing.

CVS: Present S1 & S2 (RRR). No gallop, murmurs, bruit, or rub.

Diagnostic results:

1. Laboratory: No leucocytosis
2. Radiologic: Normal brain MRI

Assessment

Mental Status Examination:

The patient is a 27 year-old Caucasian male who is alert and oriented x 4. He is dressed appropriately for the weather and the time of the day. His speech is clear, goal-directed, and coherent. He maintains good eye contact during the interview but displays no notable tics, mannerisms, or gestures. Self-reported mood is “good”. Affect is euthymic and congruent to the mood. Thought process is loose and thought content shows ideas of reference, illusions, and hallucinations. He has no delusions. He also shows no homicidal or suicidal ideation. Insight is fair and judgment is good. Diagnosis: Schizotypal Personality Disorder – 301.22 (F21).

Differential Diagnoses:

1. Schizotypal Personality Disorder

A patient with this condition has difficulty creating and even maintaining social and interpersonal relationships. They are suspicious and paranoid as well as superstitious n their beliefs. They have odd beliefs that are real to them and make them not trust those who are not related to them. The critical thinking that went into arriving at this diagnosis was driven by a close comparison between the symptom profile of patient LP and the DSM-5 diagnostic criteria for schizotypal personality disorder.

According to the symptomatology exhibited by patient LP as indicated in the CC and HPI, he meets the DSM-5 diagnostic criteria of schizotypal personality disorder (Sadock et al., 2015; APA, 2013; Stahl, 2013). The criteria are: (A) Impaired social and interpersonal relations marked by five or more of (i) odd beliefs such as superstitiousness (ii) ideas of reference (iii) illusions (iv) odd thought processes such as circumstantial thinking (v) paranoid ideation (vi) inappropriate affect (vii) odd behavior (viii) excessive and inappropriate social anxiety, and (ix) not having everyday friends except close relatives. (B) The symptoms are not attributable to another psychiatric illness such as schizophrenia (APA, 2013).      Schizotypal Personality Disorder Essay.

2. Other mental disorder with psychotic symptoms (Schizophrenia)

The similarity in symptomatology between schizotypal personality disorder and schizophrenia is in the psychosis as seen in hallucinations. However, the difference is in the duration of the psychosis. In schizotypal personality disorder, the personality disorder was there even before the patent began showing psychotic symptoms like hallucinations. Also, when the psychotic symptoms undergo remission; the personality disorder still remains. This is not true with schizophrenia as in this condition; the psychosis is present from the beginning and is persistent (Sadock et al., 2015; APA, 2013).

To be diagnosed with schizophrenia as the other mental disorder with psychotic symptoms, the patient must show: (A) Two or more of: (1) Hallucinations (2) Delusions (3) Disorganized behavior (4) Impaired speech (5) A negative symptom such as anhedonia or poverty of speech. (B) Reduced level of functioning socially, occupationally, or in self-care (C) Continuous disturbance for six months (D) Other psychiatric disorders have been ruled out (E) the symptoms are not related to drug or substance abuse, and (F) There is a negative history of a communication disorder of childhood onset such as ADHD (APA, 2013).

3. Neurodevelopmental disorders (ADHD)

The most significant similarity between schizotypal personality disorder and ADHD (attention-deficit/ hyperactivity disorder) as a neurodevelopmental disorder is that in both there is social isolation. The patient cannot form interpersonal relationships and make them last. As a matter of fact, adults with ADHD cannot stay in one job for a long time specifically because of this. The critical thinking that went into this differential is that patient LP may be among the few ADHD patients whose symptoms have continued into adulthood. The only problem with this school of thought is that there is no mention by the patient in the subjective section of any learning difficulties as a child.

The critical thinking that went into putting this differential as the last and least probable is that the DSM-5 diagnostic criteria for ADHD requires amongst others (i) the presence of inattention and/ or hyperactivity and impulsivity, (ii) that these symptoms must have been present before age 12, (iii) and that schizophrenia and other psychotic disorders be excluded first.

Reflections:

If I were to be asked to carry out the comprehensive psychiatric evaluation again for patient LP, I would repeat exactly hay I have done.  Schizotypal Personality Disorder Essay.The reason for this is that the methodology followed is the best recommended and evidence-based (Ball et al., 2019; Bickley, 2017; LeBlond et al., 2014). While at it, I accorded the patient respect and allowed him to participate in decisions about his care in line with the ethical principle of autonomy. I also sought to deliberately give him the best and prevent harm to him psychologically or otherwise, as dictated by the principles of beneficence and nonmaleficence (Haswell, 2019; Entwistle, 2019; Santhirapala & Moonesinghe, 2016). On health promotion and education, I would advise and recommend that the patient attends cognitive behavioral therapy (CBT) sessions to remodel his thoughts (Corey, 2017). His family should likewise attend family therapy to help him make friends outside the family set-up.

Conclusion

This was a comprehensive psychiatric evaluation of patient LP, a 27 year-old Caucasian male diagnosed with schizotypal personality disorder. The evaluation was exhaustive and included collection of both subjective and objective information. The closest and most probable differential diagnoses for this patient have been found to be schizophrenia and ADHD.

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Entwistle, J.W.C. (2019). Noninformed consent and autonomy. The Annals of Thoracic Surgery, 108(6), 1610. https://doi.org/10.1016/j.athoracsur.2019.08.006

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177. Schizotypal Personality Disorder Essay.

LeBlond, R.F., Brown, D.D., & DeGowin, R.L. (2014). DeGowin’s diagnostic examination, 10^th ed. McGraw Hill Medical.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Santhirapala, R., & Moonesinghe, R. (2016). Primum non nocere: Is shared decision-making the answer? Perioperative Medicine, 5(16), 1-5. https://doi.org/10.1186/s13741-016-0042-3

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4^th ed. Cambridge University Press.

Main Disorder: Schizotypal Personality Disorder

00:00:00TRANSCRIPT OF VIDEO FILE:

00:00:00______________________________________________________________________________

00:00:00BEGIN TRANSCRIPT:

00:00:00[sil.]

00:00:15OFF CAMERA I understand that you had a change in your work at the library. You moved recently from working in the back room to the front desk. Is that right?

00:00:25PATIENT Yes.

00:00:30OFF CAMERA What has that change been like for you?

00:00:35PATIENT Well… my supervisor is very busy and I don’t like to bother him. He already thinks I’m not suited for the position.

00:00:45OFF CAMERA He has said something to you about that?

00:00:50PATIENT No, not exactly, but when I’m with him I can sense that my customers have complained to him.

00:01:00OFF CAMERA How might that be?

00:01:05PATIENT When they ask me a question I answer them, but I don’t make small talk.

00:01:15[sil.]

00:01:20PATIENT I’ve always been… a pluto… out beyond the rest, circling, on the fringe, ever watching and, seeing more in the darkness than the rest.

00:01:40OFF CAMERA I talked to your sister, and she says she doesn’t think you’ve changed any over the years.  Schizotypal Personality Disorder Essay.

00:01:50PATIENT Constancy is a virtue.

00:01:55OFF CAMERA Are you friends with your coworkers?

00:02:00PATIENT 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.

00:02:30OFF CAMERA Have your fellow workers been helpful about his move to the front desk?

00:02:40PATIENT Well… we don’t talk.

00:02:40OFF CAMERA When you do want to talk, with whom do you talk?

00:02:50PATIENT I guess the last person would be my college roommate.

00:02:55OFF CAMERA In what way was he helpful to you?

00:03:00PATIENT I don’t think I understand your question.

00:03:05OFF CAMERA You said you used him to talk to him.

00:03:05PATIENT Not very much, and mainly about studies. We both worked very hard in school. I often knew what he was thinking so I knew when to leave him alone.

00:03:20OFF CAMERA Where is he?

00:03:25PATIENT He died.

00:03:25OFF CAMERA When was that?

00:03:30PATIENT A few years ago.

00:03:35OFF CAMERA How did that happen?

00:03:40PATIENT I don’t know. I read about it in the alumni magazine, but I remember receiving a feeling that something had happened to him before I read it. I felt he was dead and often felt as though he were in the room with me. So when I read about it in the magazine, I understood.

00:04:10OFF CAMERA What did you understand?

00:04:15PATIENT Well, I had thrown his photograph away the day before he died.

00:04:25OFF CAMERA Have you had any news or puzzling sensations recently?

00:04:30PATIENT Well, recently I started smelling an odor. I’m concerned that it’s coming from me. It worries me.

00:04:45OFF CAMERA What do you do about the odor?

00:04:50PATIENT I take a lot of showers, but it’s malicious, piercing.

00:05:00OFF CAMERA Does the odor hamper you in any way?

00:05:05PATIENT Well, recently, I’m quite conscious of being too near people at the desk, especially girls.

00:05:15OFF CAMERA What sort of contact do you have with women?

00:05:20PATIENT Well, uh… there’s a few that work at the desk from time… to time. I don’t like this room. I sense an evil presence here.  Schizotypal Personality Disorder Essay.

00:05:50OFF CAMERA What were you feeling just that minute?

00:05:55PATIENT OH… I guess I was just noticing the specks on the wall and how small they are in proportion to the rest of the wall. I was thinking about size, proportion, distance. I’m fascinated by outer space and the proportions one can see there… I was just there for a minute.

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00:06:30OFF CAMERA Uh huh. Have you ever talked with a psychiatrist, psychologist or counselor before today?

00:06:40PATIENT No.

00:06:45OFF CAMERA Do you ever see things or hear things that other people don’t see or hear?

00:06:50PATIENT Do I ever see things or hear… I don’t think so… No, no, no, no, no. Oh no, my uncle used to drink heavily and he would hallucinate, but I do not drink or use drugs. The director of public libraries sent me a letter saying that we should be conscious of our public image. I think he knows I’ve been reading D. H. Lawrence.

00:07:35OFF CAMERA Do you believe the director knows what you read?

00:07:40PATIENT No, not really. But I bet he wouldn’t approve!

00:07:45OFF CAMERA Did anyone else receive a letter from the director of city libraries?

00:07:55PATIENT I don’t know. But if working at the front desk is ruining the public library’s image, I’ll quit!

00:08:10SymptomMedia Visual Learning for Behavioral Health www.symptommedia.com

00:08:10END TRANSCRIPT

PLEASE INCLUDE INTRODUCTIONS AND CONCLUSION. DIFFERENTIAL DIAGNOSIS SHOULD BE AT LEAST TWO PARAGRAHS EACH. YOU CAN CUT OFF PAGES FROM OBJECTIVES IF YOU HAVE TO. BUT PLEASE DO A DECENT DIFFERENTIAL DIAGNOSIS

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?   Schizotypal Personality Disorder Essay.
• 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.). Schizotypal Personality Disorder Essay.