Jess is brought for evaluation

Running header: Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

1

Week 7 Assignment: Assessing and Diagnosing Patients with

Schizophrenia, Other Psychotic Disorders,

and Medication-Induced Movement Disorders

(Video: Training Title 24)

College of Nursing – PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

October 16, 2022

Subjective:

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 2

CC (chief complaint): Having thoughts and hearing things that others couldn’t hear

HPI: J.D. is a 30-year-old Caucasian female who was brought in for psychiatric evaluation by

her 2 roommates who are concerned with behaviors. The patient seemed fine, according to her

roommates Liz and Rachel, but soon after your aunt passed away, she began acting in a different,

slightly unusual manner. started hearing and thinking things that nobody else could. According to

the records, the patient had some depression after the death of her aunt, but her condition

deteriorated in the 12 days following her brother’s GSW death during a gas station robbery. She

only sleeps for two hours per day and only eats canned foods. She has used marijuana every day

since she was 17 and occasionally goes out during the week with her roommates to drink a few

beers. Her PCP prescribed her a 15-day supply of alprazolam 1mg twice day as needed. The PT

thinks she is in a movie

She claimed that the new neighbors are Russian men and whores who drill all night to

send information back, and that they are listening to their apartment from the one next door. She

also claimed that they don’t even speak English, that they secretly speak Russian. She added

that if she remained absolutely still, the Russians couldn’t decode her. The new neighbors

actually speak Spanish rather than Russian, according to her roommates. She stated that she

hears them talking when no one else can, clarifying that she did not mean her 2 roommates. The

reason she walked down to her car yesterday, according to her, was “because if I’m very, very

still, the Russians can’t code me.” She said that when the rest of the world learned that the

Russians were terrorists, it would be too late. She stated that she had stopped taking her

prescription drugs because, according to her, “the medications were part of the problem”. She

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 3

was tangential in her response as to whether or not she had suicide ideation or thoughts of

harming others.

Past Psychiatric History:

 General Statement: Patient brought in by roommates for psychiatric evaluation.

 Caregivers (if applicable): Not applicable

 Hospitalizations: None reported

 Medication trials: Alprazolam 1mg tab twice daily as needed for 15 days

 Psychotherapy or Previous Psychiatric Diagnosis: Depression.

Substance Current Use and History:

 Tobacco: smokes cannabis daily and has since she was 17.

 Alcohol: Two drinks of beers twice weekly.

Family Psychiatric/Substance Use History: Unknown.

Psychosocial History: She is estranged from her parents, and her lone sibling passed away after

being shot during a gas station robbery. She presently resides with Rachel and Liz, her two

roommates, who took her to the clinic for assessment. She has a full-time job at a bakery.

Although she admitted to having a difficult upbringing, she declined to go into further detail.

Medical History: Unknown

 Current Medications: Alprazolam 1mg tab twice daily as needed.

 Allergies: Medical tape

 Reproductive Hx: No children.

ROS:

 General: negative for – fever

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 4

 Respiratory: no cough, shortness of breath, or wheezing

 Cardiovascular: no chest pain or dyspnea on exertion

 Gastrointestinal: no abdominal pain, change in bowel habits, or black or bloody stools

 Musculoskeletal: negative for – muscle pain.

Objective:

Physical exam Vitals: Temp 98.6, Pulse 86, Resp 20, B/P 120/70, Height 5’2″, Weight 126

pounds, BMI 23

GEN: Alert, normal weight.

HEENT: sclera anicteric.

CV: Normal rate, regular rhythm. Normal S1/S2. No murmur, rub, or gallop.

PULM: Normal WOB on ambient air. Good respiratory effort with symmetric expansion. No

wheezes, rales, or rhonchi.

ABD: Soft, nondistended, nontender. No masses.

EXT: Warm and well perfused. No edema.

SKIN: Warm and dry. No wounds, lesions, rashes.

NEURO: Alert and oriented to self, place, recent events. No dysarthria. Moving all

extremities equally. Normal gait.

Diagnostic results:

 Labs – CBC, CMP, LFT, cholesterol, HgbA1c, complete toxicology screening,

 The Brief Clinical Assessment Scale for Schizophrenia (BCASS).

 Drug Use Disorder Identification Test (DUDIT)

 CT/MRI to rule out neurodegenerative disorder.

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 5

Assessment:

Mental Status Examination:

J.D. is alert, appropriately dressed, poorly groomed, maintains eye contact throughout the

evaluation. She is anxious and cooperative, paranoid several times throughout the evaluation.

Normal gait and station, no psychomotor agitation or retardation, no abnormal

movements. Slightly pressured speech, normal rhythm and tone. Thought process and

associations notable for being tangential, flight of ideas, and loosening of associations, includes

paranoid ideations of frank and suspicious delusions. She is positive for auditory hallucinations

and negative thoughts about the new neighbors. Her speech is slightly pressured, and

disorganized. Poor insight, poor judgement, average intelligence from vocabulary. She denies

suicidal and homicidal ideations. Her affect is constricted, and her mood is anxious.

Differential Diagnoses:

1) Schizoaffective Disorder, Bipolar type.

This is the priority diagnosis for this patient. The following are the DSM 5 criteria for

this diagnosis: A. An uninterrupted period of illness during which there is a significant mood

episode (major depressive or manic) contemporaneous with Criterion A of schizophrenia; B.

Delusions or hallucinations for at least two weeks without a major mood episode (depressive or

manic) throughout the course of the illness; C. The majority of the time during the active and

residual phases of the illness, symptoms that fulfill the criteria for a severe mood episode have

been present; D. The disturbance is not caused by the effects of a substance (such as a drug of

abuse or medicine) or another medical condition (Sadock et al., 2015). A mood episode and the

active-phase symptoms of schizophrenia co-occur in schizoaffective disorder when at least two

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 6

weeks of hallucinations or delusions without evident mood symptoms either before or followed

the mood episode (American Psychiatric Association, 2022). This patient meets the criteria for

this diagnosis because she has symptoms concerning for mania which include disorganization,

hallucinations, poor sleep, and delusions. Manic-depressive illness, or bipolar, is characterized

by mood fluctuations from depression to mania. These symptoms have been going for up to 2

weeks according to her roommates’ report. These mood swings may have an impact on an

individual’s behavior, capacity for rational thought, judgment, and ability to sleep (Carvalho &

Vieta, 2020).

2). Schizophrenia

The presence of two or more of the following for at least one month qualifies as the

diagnostic threshold for this condition (American Psychiatric Association, 2022). Delusions,

hallucinations, disordered speech, disordered conduct, and a lack of expressiveness or emotional

reactions. Schizophrenia can be diagnosed if there are delusions, hallucinations,

disorganized speech, and erratic behavior (Salvatore et al., 2021). Although it is uncertain if this

patient has had these symptoms for up to one month, the diagnoses is most suited for the

symptoms presented by this patient: disorganized though process, flight of ideas, delusions,

hallucinations, poor sleep, and poor appetite. This is a condition that comes with other mental

disorders making an individual lose contact with the reality.

Other psychotic symptoms, such as strong delusions, are also prevalent in this disorder. If

the delusions appear without the confused speech, disorganized conduct, loss in functioning, and

auditory hallucinations that are necessary for criterion A in schizophrenia, the provider may be

able to rule out this disorder. Given that this patient exhibits the symptoms listed, they may

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 7

indicate the presence of the condition. Although this patient exhibits at least 2 of these

symptoms which include hallucinations and disorganized speech, this disorder cannot be

conclusively accepted because of the uncertainty in the patient meeting all the criteria for the

diagnoses. At least two of these criteria have not been completely med, these are: Criteria D

which is that there have not been any severe manic or depressed episodes while the active-phase

symptoms have been present, and criteria B which is the disturbance’s ongoing symptoms

continue for at least six months. the duration of the patient’s symptoms should be determined,

and mania or major depressive episodes have to be ruled out.

3) Substance-Induced Disorder.

The existence of delusions or hallucinations, as well as indications of substance use

through laboratory tests, medical history, or physical examination, are diagnostic criteria for this

condition. Hallucinations and delusions are present in this patient, but laboratory tests are needed

to analyze whether there are any chemicals present that might be causing her symptoms.

(Klimkiewicz et al., 2020). Given the patient’s history of marijuana and alcohol use, it is also

necessary to perform the Drug Use Disorder Identification Test (DUDIT) screening test to

determine the chance that the patient has a drug use disorder that could be the cause of the

symptoms that are present (Klimkiewicz et al., 2020). It is not necessary for a patient to

experience hallucinations or delusions in order to be diagnosed with schizophrenia. Instead,

schizophrenia is diagnosed when a patient displays any two of the following symptoms:

delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior,

negative symptoms like diminished emotional expression or avolition (). (Sadock et al., 2015).

Reflections:

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 8

Recent traumatic events that this patient has experienced may have served as the initial

catalyst for this psychotic episode. Her regular marijuana use since the age of 17 was also

mentioned in the history, thus more investigation is required to rule out the possibility that this is

the cause of the symptoms. The patient had strange mannerisms as well as disorganized speech

throughout the conversation, appearing to follow no logical structure. Hallucinations, delusions,

and difficulty speaking and thinking coherently are some of these symptoms. In order to

accurately diagnose the patient, it is crucial to carry out necessary tests during a psychiatric

evaluation in order to rule out other conditions that may be responsible for the symptoms. For

patients who present with symptoms as in the case of this patient, it is important to determine the

risk factors for suicide or homicide potentials. The clinician must ensure the safety of their

patients and themselves.

Evaluating a patient with symptoms of delusions, hallucinations and disorganized speech

and thought process can present a major challenge, and so the clinician may rely on information

from her roommates and this may pose ethical dilemma It is important for nurse practitioners to

be aware of the difficulties they can encounter while evaluating a client who is unwilling to

cooperate since it can be quite challenging to gain information in this situation. The ethical

implications of treating a delusional patient must also be considered, and physicians must obtain

their agreement and involve them in decision-making (Ruderfer, et al 2018). Even if a patient has

poor judgement due to her current condition, the clinician should be aware that this does not

negate the responsibility to secure the patient’s permission.

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Assessing and Diagnosing Patients with Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders 9

References

American Psychiatric Association. (2022). Schizophrenia Spectrum and Other Psychotic

Disorders. Diagnostic and Statistical Manual of Mental Disorders.

https://doi.org/10.1176/appi.books.9780890425787.x02_schizophrenia_spectrum

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of

Medicine, 383(1), 58-66.

Klimkiewicz, A., Jakubczyk, A., Mach, A., Abramowska, M., Serafin, P., Szczypiński, J.,

Demkow, M., & Wojnar, M. (2020). Psychometric properties of the Polish version of the

drug-use disorders identification test. European Addiction Research, 26(3), 131–140.

https://doi.org/10.1159/000506156

Sadock, B. J., Sadock, V. A., & Pedro, R. M. (2015). Kaplan and Sadock’s synopsis of

psychiatry: Behavioral sciences/clinical psychiatry (Eleventh ed.). LWW.

Salvatore, P., Baldessarini, R. J., Khalsa, H. K., & Tohen, M. (2021). Prodromal features in

first psychotic episodes of major affective and schizoaffective disorders. Journal of

Affective Disorders, 295, 1251–1258. https://doi.org/10.1016/j.jad.2021.08.099

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