Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and 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 this Assignment you will analyze a case study related to schizophrenia, another psychotic disorder, or a medication-induced movement disorder.
To Prepare:
- Review this week’s 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.
- By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “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.
Training Title 24 Name: Ms. Jess Cunningham Gender: female Age: 28 years old T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs Background: Jess is brought for evaluation by her 2 roommates who are concerned with behaviors that began 12 days after Jess’s younger brother committed suicide in front of her via GSW after his girlfriend broke up with him. She is estranged from her parents and her brother was her only sibling. She is only sleeping 1–2 hours/24hrs; she will only canned foods. She smokes cannabis daily since she was 16, goes out on weekdays 2–3 times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. She works as a bartender. Symptom Media. (Producer). (2016). Training title 24 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-24
By Day 7 of Week 7
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.).
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NRNP_6635_Week7_Assignment_Rubric
| Excellent | Good | Fair | Poor | |||
| Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide: |
18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. |
16 (16%) – 17 (17%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. |
14 (14%) – 15 (15%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. |
0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing. |
||
| In the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. |
18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. |
16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. |
14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. |
0 (0%) – 13 (13%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing. |
||
| In the Assessment section, provide: • Results of the mental status examination, presented in paragraph form. • At least three differentials with supporting evidence. List them from top priority to least 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. |
23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. |
20 (20%) – 22 (22%)
The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. |
18 (18%) – 19 (19%)
The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy. |
0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing. |
||
| Reflect on this case. Discuss what you learned and what you might do differently. 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.). | 9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking. |
8 (8%) – 8 (8%)
Reflections demonstrate critical thinking. |
7 (7%) – 7 (7%)
Reflections are somewhat general or do not demonstrate critical thinking. |
0 (0%) – 6 (6%)
Reflections are incomplete, inaccurate, or missing. |
||
| Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). | 14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. |
12 (12%) – 13 (13%)
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. |
11 (11%) – 11 (11%)
Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. |
0 (0%) – 10 (10%)
Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based. |
||
| Written Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. |
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. |
3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. |
0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided. |
||
| Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors |
4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors |
3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors |
0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding |
||
| Total Points: 100 | ||||||
Name: NRNP_6635_Week7_Assignment_Rubric
Expert Answer and Explanation
Schizophrenia
Subjective:
CC (chief complaint): “Feldman has some difficulties in school.”
HPI: Mr. Jay Feldman is a 19-years-old European-American male presenting to the office for psychiatric evaluation. He was referred for evaluation by his parents. The patient’s parents complain that he has some problems in school. The parents note that his psychiatric problems started after he joined state college. Since joining college, he has been experiencing delusions that people are spying on him. He has lost 18lbs and has a poor appetite. His speech is disorganized and he is hallucinating. He has not been sleeping well, has not got in touch with his friends since he came for the spring holidays, and does not shower.
Past Psychiatric History:
- General Statement: He first entered aripiprazole treatment for mild paranoia six months ago.
- Caregivers (if applicable): Not applicable.
- Hospitalizations: Never hospitalized.
- Medication trials: He went through a short trial of aripiprazole but stopped because the medication caused a side effect of akathisia.
- Psychotherapy or Previous Psychiatric Diagnosis: He was diagnosed with mild paranoia six months ago.
Substance Current Use and History: He denies drug abuse and does not take alcohol or tobacco.
Family Psychiatric/Substance Use History: His family members have a history of mental health issues. His father was diagnosed with paranoid schizophrenia and his mother with anxiety. One of his younger brothers has a history of anxiety and the other ADHD. No family history of substance abuse.
Psychosocial History: The patient was born and raised by his parents in Alameda, California. He has two younger brothers. He lives with his roommate in the state college but is currently with his family for the spring holiday. He has no children and is single. He is a first-year student at a state college. He loves playing football. He is not working. He has no legal problems, history of violence, or history of violence.
Medical History: No previous medical issues. No surgeries.
- Current Medications: No medications.
- Allergies:No allergies.
- Reproductive Hx:He is sexually active. No reproductive problems.
ROS:
- GENERAL: Positive for weight change. No fever, fatigue, chills, or weaknesses.
- HEENT: No double vision or visual loss. No hearing abnormalities. No runny nose, sneezing, or congestion. No throat lesions or sore throat.
- SKIN: No inflammation.
- CARDIOVASCULAR: No chest pain, palpitations, edema, or chest pressure.
- RESPIRATORY: No respiratory problems. No shortness of breath.
- GASTROINTESTINAL: No diarrhea, nausea, abdominal problems, or vomiting.
- GENITOURINARY: He denies urinary tract diseases, urine urgency, or burning on urination.
- NEUROLOGICAL: No dizziness, headache, or ataxia.
- MUSCULOSKELETAL: No limited range of motions in all the muscles and joints. No pain in the muscles or joints.
- HEMATOLOGIC: No anemia.
- LYMPHATICS: No enlarged glands. No HIV/AIDS.
- ENDOCRINOLOGIC: No changes in the skin, polyuria, polydipsia, or polyphagia.
Objective:
Physical exam:
Vital Signs: T 98.3, Wt. 117lbs, BP 106/72, P 69, Ht. 5’7’’
HEENT: Head: Non-tender with no abnormalities. No scars. Eyes: Conjunctivae pink. Sclera white. PERRL pupils. Ears: External ears normal with no lesions. No redness or swelling. Hearing intact. Nose: Appears normal. The septum is midline and the nares are patent. Throat: No lesions or inflammation.
Skin: Appears normal with no vitiligo. No rashes.
Cardiovascular: Regular rhythm and rate. No rubs, murmurs, or gallops. Normal pulse in the carotid arteries. No edema.
Respiratory: Unlabored respirations. Clear lungs to auscultation. Chest clear and symmetric.
Diagnostic results:
- Structural MRI: According to Sadeghi et al. (2021), structural MRI can be used by psychiatrists to accurately detect schizophrenia. The test can show the abnormalities in the part of the brain responsible for memory, cognition, and mood. The test shows that the patient medical temporal region and prefrontal area are abnormal signaling the presence of schizophrenia.
- Scale for the Assessment of Negative Symptoms (SANS): Wójciak and Rybakowski (2018) note that SANS is a reliable tool that can be used to screen for schizophrenia disorder. The tool has 16-item questions used to screen for negative symptoms. The scores were high during screening.
Assessment:
Mental Status Examination: The patient is Mr. Jay Feldman a 19-year man who matches his age. Ne has a healthy weight, no tattoos, or scars. He was well-groomed and dressed according to the weather of the day. He has poor hygiene. He avoids eye contact and seems listening to voices. He looks disengaged. No unusual mannerisms or involuntary movements. Speech is slow and monotonous. He knows he is in my office and alert. The mood is low and affects flat. He has circumstantial thoughts. He has disorganized thoughts where he says things that are irrelevant to the interview. He experiences delusions and hears voices, but no sound is present. No suicidal thoughts. Insight and judgment are not intact. Cognition is grossly intact.
Differential Diagnoses:
- Schizophrenia Disorder (DSM-5 295.90 (F20.9)
- Schizoaffective Disorder DSM-5 295.70 (F25.0 or F25.1)
- Delusional Disorder (DSM-5 297.1 (F22)
Primary diagnosis. Comprehensive assessment and diagnostic tests show that the patient has schizophrenia disorder. Strauss et al. (2018) argue that schizophrenia causes hallucinations, disorganized thoughts, speech problems, and delusions. DSM-5 also highlights the signs of the disorder and they include hallucinations, delusions, negative symptoms, and disorganized thoughts or speech (APA, 2013). According to the document, schizophrenia should be diagnosed when a person has two symptoms highlighted for more than a month and one of the symptoms should be either hallucinations, delusions, or disorganized speech (APA, 2013). The patient in the case hears voices, yet the environment is quiet, and believes that the room is spying on him. His speech is also disorganized at some point during the interview.
The disease is a primary diagnosis because the patient meets all DSM-5 criteria. The diagnostic and screening results also confirm the diagnosis. The schizoaffective disorder also makes people experience symptoms of schizophrenia as highlighted by DSM-5. Hartman et al. (2019) argue that schizoaffective disorder causes manic episodes making it a second choice because the patient does not experience mania. The patient has delusions, and as a result, the diseased part of the diagnosis. However, the disease does not cause psychotic symptoms, such as disorganized speech or hallucinations making it a secondary diagnosis (González-Rodríguez et al., 2018).
Reflections:
If I could conduct the session again, I would screen the patient for anxiety. The patient might develop anxiety symptoms due to delusions and hallucinations he experiences about his roommate and around his environment. From an ethical perspective, the principle of truth-telling might conflict with nonmaleficence and beneficence when handling patients with schizophrenia. The patient might harm himself if he is told that he is delusional and hallucinating. Another concern is about patient autonomy. Patients with schizophrenia might not think properly, and this might make it hard for a psychiatrist to trust their decisions. For instance, a psychiatrist might find it hard to allow patient autonomy if a patient says he does not need to be treated at his current state. I would educate the patient’s family to spend more time with him and watch his condition. I would also recommend that he start treatment to improve his mental health.
References
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
González-Rodríguez, A., Estrada, F., Montalvo, I., Monreal, J. A., Palao, D., & Labad, J. (2018). F229. The biological underpinnings of treatment response in delusional disorder: A systematic review of qualitative evidence-to-date. Schizophrenia Bulletin, 44(suppl_1), S311-S311. https://doi.org/10.1093/schbul/sby017.761
Hartman, L. I., Heinrichs, R. W., & Mashhadi, F. (2019). The continuing story of schizophrenia and schizoaffective disorder: One condition or two?. Schizophrenia Research: Cognition, 16, 36-42. https://doi.org/10.1016/j.scog.2019.01.001
Sadeghi, D., Shoeibi, A., Ghassemi, N., Moridian, P., Khadem, A., Alizadehsani, R., … & Nahavandi, S. (2021). An Overview on artificial intelligence techniques for diagnosis of schizophrenia based on magnetic resonance imaging modalities: Methods, challenges, and future works. arXiv preprint arXiv:2103.03081. https://arxiv.org/pdf/2103.03081.pdf
Strauss, G. P., Nuñez, A., Ahmed, A. O., Barchard, K. A., Granholm, E., Kirkpatrick, B., Gold, J. M., & Allen, D. N. (2018). The Latent Structure of Negative Symptoms in Schizophrenia. JAMA Psychiatry, 75(12), 1271–1279. https://doi.org/10.1001/jamapsychiatry.2018.2475
Wójciak, P., & Rybakowski, J. (2018). Clinical picture, pathogenesis and psychometric assessment of negative symptoms of schizophrenia. Psychiatr. Pol, 52(2), 185-197. DOI: https://doi.org/10.12740/PP/70610
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