Schizophrenia and Other Psychotic Disorders; 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; with 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 for other psychotic disorders.
For individuals with disorders such as schizophrenia and other psychotic disorders, the development of mental disorder seldom occurs with a singular, defining symptom. Rather, many who experience such disorders show a range of unique symptoms. This range of symptoms may impede an individual’s ability to function in daily life. As a result, clinicians address a patient’s ability or inability to function in life.
For this Assignment, you will analyze a case study related to schizophrenia, another psychotic disorder, or a medication-induced movement disorder.
- Review the Learning Resources and consider the insights they provide about assessing and diagnosing psychotic disorders. Consider whether experiences of psychosis-related symptoms are always indicative of a diagnosis of schizophrenia. Think about alternative diagnoses for psychosis-related symptoms.
- Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
- video case study to use for this Assignment and “Case History Reports” document, keeping the requirements of the evaluation template in mind.
- Consider what history would be necessary to collect from this patient.
- Consider what interview questions you would need to ask this patient.
- Identify at least three possible differential diagnoses for the patient.
This assignment explores psychotic disorders, including schizophrenia. You also explore medication-induced movement disorders and formulate a diagnosis for a patient in a case study.
- Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
- Formulate differential diagnoses using DSM-5 criteria for patients with schizophrenia, other psychotic disorders, and medication-induced movement disorders across the life span
“Case History Reports”
Training Title 9
Name: Ms. Nijah Branning
Age: 25 years old T- 98.4 P- 80 R 18 128/78 Ht 5’0 Wt 120lbs
Background: Raised by parents, lives alone in Santa Monica, CA. Only child. Works in office supply sales, has a bachelor’s in business degree. Has medical history of hypothyroidism, currently treated with daily levothyroxine. Guarded and declined to discuss past psychiatric history. Denied family mental health issues, declined to allow you to speak to parents for collaborative information. Allergies: medical tape; menses regular Symptom Media. (Producer). (2016). Training title 9 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-9
TRANSCRIPT OF VIDEO FILE:
00:00:15OFF CAMERA Ms. Branning, Mr. Nehring asked suggested you see me. He said your having some issues at work.
00:00:20MS. BRANNING You could call them that.
00:00:20OFF CAMERA What kind of difficulty are you having at work?
00:00:25MS. BRANNING Well Mr. Nehring wants to fire me.
00:00:30OFF CAMERA Why do you think Mr. Nehring wants to fire you?
00:00:30MS. BRANNING Because Eric is in love with me. And it’s probably getting in the way. And he wants to fire me.
00:00:40OFF CAMERA Who is Eric?
00:00:40MS. BRANNING Eric is my supervisor.
00:00:45OFF CAMERA Are the two of you in a relationship?
00:00:45MS. BRANNING No! Eric has his own girlfriend, I have my own boyfriend. But Mr. Nehring got it in his head that this is my fault. And they’ve been ganging up against me.
00:01:00OFF CAMERA What happened to make you feel this way?
00:01:00MS. BRANNING Eric is lustful for me. Lust. Lustful.
00:01:10OFF CAMERA Well has Eric done anything inappropriate?
00:01:10MS. BRANNING No, he doesn’t have to.
00:01:15OFF CAMERA What do you mean?
00:01:15MS. BRANNING Well, he has this way of walking toward me and he gives me the easiest assignments to do and he asks me to voice my opinion a lot in our weekly meetings. And I’m beautiful. I mean, not to be boastful or anything but I’m a strong woman. And people are attracted to that. And others, like Mr. Nehring feel threatened by it. He probably feels I could replace him in a couple years. And I could.
00:01:45OFF CAMERA But there have been no instances of sexual harassment.
00:01:50MS. BRANNING No. And now they want to fire me, and it’s probably because they don’t want me to get in the way of their day. I’m probably a distraction or something.
00:02:00OFF CAMERA According to Mr. Nehring you haven’t made a sale in three weeks.
00:02:05MS. BRANNING Oh, it’s been a slow time period. I guess it wouldn’t be bad thing if they fired me. I mean after all of this, all the bad it’s done for my health. You know I should really sue for discrimination, you know the stress and the health problems.
00:02:25OFF CAMERA You’ve been having health problems?
00:02:25MS. BRANNING Yes. Yes. It keeps getting worse.
00:02:30OFF CAMERA Can you describe it for me?
00:02:30MS. BRANNING Well you know there’s this pain in my neck, it aches, it spreads to my back, I think there’s a lump, right here. I’m really worried.
00:02:55OFF CAMERA And what do you feel is the cause?
00:02:55MS. BRANNING I told you, pain, suffering, broken heart. I think it’s cancer.
00:03:05OFF CAMERA Have you been seen by a doctor?
00:03:10MS. BRANNING No. But it’s probably cancer. And it’s slowly killing me. And it’s all because of them. And Eric’s obsession with me.
00:03:20OFF CAMERA Ms Branning, I don’t think you have to worry, a broken heart can’t cause cancer.
00:03:25MS. BRANNING You never know until it happens.
Complete a Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a 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.).
SOAP NOTE for Schizophrenia
CC: The patient was referred to me by her boss Mr. Nehring because she has some issues at work.
HPI: Ms. Nijah Branning is a 25-years-old female of Palestinian origin working as a sales person in in office supply sales in one of the local sales companies. She came to my office after her boss Mr. Nehring suggested that she see me because she has some issues at work. She is not prescribed any psychotic medications at the moment. Branning says that her boss, Mr. Nehring wants to fire her because Eric her supervisor in in love with her and Mr. Nehring things that Eric is on the way. However, she says that Eric has a girlfriend. The patient says that Eric often walks towards her in a seductive manner. Her thinking is disorganized.
Past Psychiatric History:
- General Statement: The patient has refused to talk about her mental health history.
- Caregivers: The patient has no caregivers.
- Hospitalizations: The patient has never been hospitalized.
- Medication trials: The patient is under no medical trial at the moment.
- Psychotherapy: The patient has refused to discuss her past mental health history; thus it is hard to know whether she has had a prior mental health issue.
Substance Current Use and History: The patient denies using alcohol, tobacco, and illicit drugs.
Family Psychiatric/Substance Use History: The patient notes that there is not mental health problem among her family members. However, she says that her maternal uncle is an alcoholic.
Psychosocial History: The patient is the only child and was born in the US and raised by her parents. Currently, she lives alone in Santa Monica, CA. She is not married but has a boyfriend. The patient has a bachelor’s in business degree. She likes listening to music and having a walk in the park during weekends. She is currently employed as a sales person. She denies any legal issues. No history of trauma. Denies history of violence.
Medical History: The patient has hypothyroidism.
- Current Medications: She takes levothyroxine to treat hypothyroidism.
- Allergies: No allergies.
- Reproductive Hx: No reproductive concerns. Her menstrual cycle is up to date.
- GENERAL: No chills, weakness, fatigue, weight change, fever, or tiredness.
- HEENT: Eyes: No yellow sclera, visual loss, double vision, or blurred. Ears, Nose, Throat: No hearing problems, runny nose, sore throat, or sneezing.
- SKIN: No itching or rush.
- CARDIOVASCULAR: No edema, chest pressure, chest pain, palpitations, or chest discomfort.
- RESPIRATORY: No sputum or shortness of breath.
- GASTROINTESTINAL: No vomiting, nausea, diarrhea, or anorexia.
- GENITOURINARY: No urgency on urination or burning on urination.
- NEUROLOGICAL: No paralysis, numbness, headache, ataxia, or dizziness.
- MUSCULOSKELETAL: No musculoskeletal pain.
- HEMATOLOGIC: No bleeding, bruising, or anemia.
- LYMPHATICS: No enlarged nodes.
- ENDOCRINOLOGIC: No polyuria or reports of sweating, heart intolerance, or cold.
Physical exam: GENERAL: The patient is welled groomed and wears clothes relevant to the current weather and season of the year. She is also clean and looked like she was from the office. She answers questions correctly and maintains eye contact during the interview process.
Vital Signs: Temp 35.8, Ht. 5’7’’, Wt. 68kgs, HR 68, RR 17, B/P 112/89.
- HEENT: Head: Hair evenly distributed. No deformities Eyes: No abnormal discharge or redness observed. Sclera white and normal sensitivity to light. Ears: No discharge, TM intact, bilateral intact. Nose: Moist mucosa. Throat: No inflammation or swelling.
- Skin: No rash observed.
- Cardiovascular: Capillary refill <3 seconds, no murmurs, regular heart rate.
- Respiratory: Lungs clear. No cracks observed on the chest. No rales or wheezes.
- Neurological: Responds properly to temperature extremes.
- Musculoskeletal: Normal gait. No muscle swelling observed.
- CT Scan-pending
- 40 for the positive symptoms scale
- 20 for the negative symptom scale
- 60 for the general psychopathology scale
Mental Status Examination: The patient is oriented to place, event, person, and time. She is well groomed, appear as stated age, and maintains eye contact during interview. She has calm con concern attitude. Her behavior is cooperative. Speech is clear and within normal rate. Has candid rapport. Self-reported mood is “mild depressed” and affect is blunted. Goal-directed thought process. Delusional thinking noted in the thought content. Insight is fair and judgment is good. No suicidal and homicidal thoughts.
- Schizophrenia disorder: The primary diagnosis for this case is schizophrenia disorder. The symptoms of schizophrenia disorder include hallucinations, delusions, disorganized thinking, negative symptoms, abnormal or extremely disorganized motor behaviors (Gandal et al., 2018). The DSM-5 notes that for a patient to be diagnosed with schizophrenia disorder, the individual must have two of the five symptoms above. One of the two symptoms must be either disorganized speech, hallucinations, or delusions (American Psychiatric Association, 2013). This disorder is a primary disorder because the patient has delusions and hallucinations. She believes that her she has cancer. She confesses seeing Eric walking towards her in a seductive manner. The PANSS test results also shows that he has schizophrenia. According to Lim et al. (2021), PANSS can be used to diagnose people with schizophrenia.
- Schizoaffective disorder: This disease has been included in the study because it causes symptoms of schizophrenia (Archibald et al., 2019). However, the disorder is a secondary condition because patient does not have symptoms of mood disorder. According to DSM-5, a patient must have a schizophrenia symptom and a mood symptom for them to be diagnosed with schizoaffective disorder (APA, 2013).
- Delusional disorder: Delusion disorder has been included in the diagnosis because the patient has delusions (González-Rodríguez et al., 2019). She thinks that Eric and her boss are ganging up on her. She also thinks that she has cancer due to heartbreak. However, this disease has been included as a secondary diagnosis because the patient experiences hallucinations. Hallucinations are not among the symptoms of delusions.
One of the things I have learned in this case is the importance of good communication. The patient had refused to talk about her past mental health history because of poor communication between the patient and the person assessing her. If I was to work on the case again, I would apply communication skills that would help me built trust with the patient. I would show the patient that I am here to help her and not to judge her. An ethical consideration that I include in this case is therapeutic relationship. I will ensure that I have a good and professional relationship with the patient to improve her trust.
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
Archibald, L., Brunette, M. F., Wallin, D. J., & Green, A. I. (2019). Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder. Alcohol research : current reviews, 40(1), arcr.v40.1.06. https://doi.org/10.35946/arcr.v40.1.06
Gandal, M. J., Zhang, P., Hadjimichael, E., Walker, R. L., Chen, C., Liu, S., Won, H., van Bakel, H., Varghese, M., Wang, Y., Shieh, A. W., Haney, J., Parhami, S., Belmont, J., Kim, M., Moran Losada, P., Khan, Z., Mleczko, J., Xia, Y., Dai, R., … Geschwind, D. H. (2018). Transcriptome-wide isoform-level dysregulation in ASD, schizophrenia, and bipolar disorder. Science (New York, N.Y.), 362(6420), eaat8127. https://doi.org/10.1126/science.aat8127
González-Rodríguez, A., Esteve, M., Álvarez, A., Guardia, A., Monreal, J. A., Palao, D., & Labad, J. (2019). What we know and still need to know about gender aspects of delusional disorder: a narrative review of recent work. Journal of Psychiatry and Brain Science, 4(3). https://doi.org/10.20900/jpbs.20190009
Lim, K., Peh, O. H., Yang, Z., Rekhi, G., Rapisarda, A., See, Y. M., … & Lam, M. (2021). Large-scale evaluation of the Positive and Negative Syndrome Scale (PANSS) symptom architecture in schizophrenia. Asian Journal Of Psychiatry, 102732. https://doi.org/10.1016/j.ajp.2021.102732