NMHNP 6635 Week 7 Assignment: Psychopathology and Diagnostic Reasoning: Paranoid Schizophrenia in a 19 Year-Old European-American Male

NMHNP 6635 Week 7 Assignment: Psychopathology and Diagnostic Reasoning: Paranoid Schizophrenia in a 19 Year-Old European-American Male

NMHNP 6635 Week 7 Assignment: Psychopathology and Diagnostic Reasoning: Paranoid Schizophrenia in a 19 Year-Old European-American Male

Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Resources for NMHNP 6635 Week 7
American Psychiatric Association. (2013). Medication-induced movement disorders and other adverse effects of medication. In Diagnostic and statistical manual of mental disorders (5th ed., pp. 709–714). Author.
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

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Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
Chapter 7, Schizophrenia Spectrum and Other Psychotic Disorders
Chapter 29.2, Medication Induced-Movement Disorders
Chapter 31.15, Early-Onset Schizophrenia

YOU MUST USE THIS TRAINING TRANSCRIPT ONLY for the Comprehensive Psychiatric eval.
Training Title 29
Name: Mr. Jay Feldman Gender: male
Age:19 years old

T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs
Background: European-American male. He has two younger brothers, one with history of ADHD, the other with history of anxiety. His mother has anxiety; his father has paranoia schizophrenia. He is home for spring break. He has no previous medical problems. Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs since first going back to school in the fall. Jason has not acted this way before but did have a short trial of aripiprazole in the last six months of high school for mild paranoia. He stopped the medication after graduation as he could not tolerate due to side effects of akathisia. Jason has several friends but has not kept in touch with them since being back home. He has not been showering. Sleeping 4–5 hrs.
Training Title 134
Name: Mrs. Bunny Warren Gender: female
Age: 33 years old
Symptom Media. (Producer). (2016). Training title 29 [Video]. https://video-alexanderstreet-
com.ezp.waldenulibrary.org/watch/training-title-29
Training # 29
BEGIN TRANSCRIPT:
00:00:00
[sil.]
00:00:15
OFF CAMERA Mr. Feldman? I understand you called us last week for an appointment.
00:00:20
MR. FELDMAN My parents.
00:00:25
OFF CAMERA Excuse me?
00:00:25
MR. FELDMAN My parents called for the appointment.
00:00:25
OFF CAMERA Oh. Do you know why your parents called for an appointment?
00:00:30
MR. FELDMAN No.
00:00:35
OFF CAMERA When your parents called me they said you were having some difficulty in school. Where are you in school?
00:00:50
MR. FELDMAN State College.
00:00:50
OFF CAMERA How long have you been at State College?
00:00:55
MR. FELDMAN My freshman year.
00:01:00
OFF CAMERA And how is it going?
00:01:05
MR. FELDMAN Fine.
00:01:10
OFF CAMERA What courses are you taking at State?
00:01:15
MR. FELDMAN In high school I took advanced placement courses. Theoretical physics, advanced calculus is what I’m taking now. Although I’m thinking about double majoring in philosophy and physics.
00:01:35
OFF CAMERA That’s an interesting combination.
00:01:35
MR. FELDMAN Yes, the mysteries of life. The courses are mysteries, and just when you think you’ve understood it, it’s gone.
00:01:45
OFF CAMERA Gone?
00:01:50
MR. FELDMAN The totality of life precludes us from repeating it. I mean what’s the point?
00:02:00
OFF CAMERA Do you have a roommate at state?
00:02:05
MR. FELDMAN You could call him that.
00:02:10
OFF CAMERA Can you tell me about him?
00:02:15
MR. FELDMAN Oh no.
00:02:15
OFF CAMERA Why not?
00:02:20
[sil.]
00:02:25
MR. FELDMAN He put a microwave in there, but I know what that means. But I won’t tell. Not a word..
00:02:35
OFF CAMERA A microwave oven?
00:02:40
MR. FELDMAN They had them in here too, in this building. But they’ll spare me, and they’ll spare you too, because you are with me, and what that’s about a bleeding degeneration of blood cells, bleeding the humanity from our rightful destiny… but this room spies on us.
00:03:05
OFF CAMERA I don’t understand what you mean.
00:03:10
MR. FELDMAN It’s in the eyes. You can hold of forever if you know how.
00:03:20
OFF CAMERA Mr. Feldman, did you come here with anyone else today?
00:03:25
[sil.]
00:03:30
MR. FELDMAN Sssshhhh.
00:03:35
OFF CAMERA Mr. Feldman, I think I may need to contact your parents.
00:03:45
SymptomMedia Visual Learning for Behavioral Health
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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.).

https://content.waldenu.edu/content/dam/laureate/laureate-academics/wal/ms-nurs/nrnp-6635/week-03/NRNP%20PRAC%206635%20Comprehensive%20Psychiatric%20Evaluation%20Template.docx

—————————————————————————————————————————————-
RUBRIC
Write introduction of assignment/case with one to two paragraph.
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
Excellent
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
——————————————————————————————————————————————
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.
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.

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.

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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.

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%)
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity

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
Write one to two paragraphs of conclusion about assessing and diagnosing this psychiatric case evaluation.

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Psychopathology and Diagnostic Reasoning: Paranoid Schizophrenia in a 19 Year-Old European-American Male

            The patient in this case is a high school student with presents with clear hallucinations and delusions as well as other symptoms. These are indicative of a psychosis for which he has a family history on the side of the father. Schizophrenia is a psychotic illness that is characterized by symptoms that are designated as positive and negative. The positive symptoms include hallucinations and delusions and are considered additive. The negative ones are more sinister in terms of prognosis as they are considered subtractive. They include absence of motivation or avolition, anhedonia or lack of ability to experience pleasure, a poverty of speech, and apathy amongst others (APA, 2013; Sadock et al., 2015). This paper is about the psychopathology and diagnostic reasoning for this patient.    

Subjective:

CC (chief complaint): The 19 year-old who presents with complaints of insomnia, loss of weight, lack of appetite, anxiety, hallucinations, and paranoid delusions. The delusions are both referential (the belief that occurrences are directed at him) and persecutory (the belief that someone is out to harm him). For instance, he states during the psychiatric interview that “He put a microwave in there, but I know what that means. But I won’t tell.” He also says at another time that “… but this room spies on us.” When asked if he came with someone else, the patient says “Sssshhhh”. This is a clear indication that he is also hallucinating.

HPI: The patient is a 19 year-old European-American male who presets to the clinic with the above complaints. He denies a past history of the current symptoms although he has received some treatment before for paranoia. The onset of the current symptoms was some months ago and they bother his mind a lot; especially the delusions and hallucinations. The symptoms are constant and ever present in his mind and thought process. They are characteristically persistent and are aggravated by solitude. He feels somewhat relieved and reassured when he is with someone. These symptoms are present all day and night and the parents rate them at 7/10 in severity.   

Past Psychiatric History:

• General Statement: The patient has a significant history of past psychiatric illness and has even been treated with aripiprazole (Abilify) for mild paranoia. He stopped the treatment due to debilitating akathisia as a side effect.
• Caregivers (if applicable): He is not bathing and is therefore clearly dysfunctional in terms of personal care and interpersonal relations.
• Hospitalizations: He denies a history of hospitalization.
• Medication trials: He has been put on aripiprazole (Abilify) before for mild paranoia to which he did not adhere.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has had a previous diagnosis of mild paranoia made on him and he has been given pharmacotherapeutic treatment for the same.

Substance Current Use and History: The patient does not have a history of substance use either past or current.  

Family Psychiatric/Substance Use History: There is no substance use history in his family. However, the psychiatric history in the family is significant. His mother has a history of anxiety while his father was diagnosed with paranoid schizophrenia. He also has two siblings one of whom has a history of attention-deficit/ hyperactivity disorder or ADHD. The other one has a past diagnosis of anxiety.

Psychosocial History: The patient is the first born from a family of five and has two younger siblings. He just graduated from high school but during the time he is at home he is not seeking to see his friends. He typically keeps to himself and does not seem to have any hobbies at this particular time. He does not currently have a girlfriend.  

Medical History:

• Current Medications: He is currently not on any medications since he stopped the aripiprazole he had been prescribed for paranoia.
• Allergies: There are no known allergies affecting the patient.

• Reproductive Hx: He is a heterosexual male who does not have a girlfriend at present. He also has no children.

ROS:

• GENERAL: Negative for fever, chills, fatigue, weight loss, or headache.
• HEENT: Denies myopia, photophobia, tinnitus, otorrhea, hearing loss, sneezing, rhinorrhea, and sore throat.
• SKIN: Negative for rashes, pruritus, or eczema.
• CARDIOVASCULAR: Denies chest pains, palpitations, chest discomfort, or edema.
• RESPIRATORY: No shortness of breath, coughing, wheezing, or sputum production.
• GASTROINTESTINAL: Negative for nausea, diarrhea, vomiting, or changed bowel movements.
• GENITOURINARY: He denies frequency of urination, hesitancy, or incontinence.
• NEUROLOGICAL: He is negative for syncope, paraesthesia, loss of bladder and bowel control, or a tingling sensation.
• MUSCULOSKELETAL: He denies joint pains, muscle pains, or joint stiffness.
• HEMATOLOGIC: He is negative for blood or coagulation disorders.
• LYMPHATICS: Denies splenectomy or lymphadenopathy.
• ENDOCRINOLOGIC: He is negative for previous hormonal therapy, excessive thirst, or polydipsia.

Objective:

Physical exam:

Vital signs: T 98.4° F; BP 115/65 mmHg; HR 65; RR 15.

Diagnostic results: The patient shows no indication of any physical illness as per the normal laboratory results. The positive and negative symptom scale or PANSS indicated the presence of symptoms of psychosis; although positive symptoms were more than negative ones (Leucht et al., 2019). 

Assessment:

Mental Status Examination: The patient is a 19 year-old European-American male. He is oriented in place, space, person, event, and time but his speech is not goal-oriented. He looks unkempt and unhygienic with a characteristic sweaty odor. He is restless with clear psychomotor hyperactivity and the speech shows tangential thinking. There is word salad and flight of ideas. He has no mannerisms of tics of note. The self-reported mood is “anxious” but the observed affect is dysphoric showing incongruence. It is also clearly labile. There is no suicidal or homicidal ideation. Auditory hallucinations and persecutory/ referential delusions are also present. His insight and judgment are impaired. The diagnosis made is paranoid schizophrenia. Its DSM-5 diagnostic code is 295.90 (F25.0) (APA, 2013; Sadock et al., 2015).  

Differential Diagnoses:

1. Paranoid Schizophrenia – 295.90 (F25.0)

            This is the most likely primary diagnosis for this patient going by the symptomatic presentation. He fulfils most of the diagnostic criteria for schizophrenia such as having the positive symptoms of hallucinations and delusions. He is also dysfunctional in terms of self care and interpersonal relations. The fact that a first degree relative (his father) also has paranoid schizophrenia only solidifies the diagnosis (APA, 2013; Sadock et al., 2015).      

2. Substance-Induced Psychotic Disorder – 292.9 (F19.259)

            This is a possible differential diagnosis in the event that the patient had not been honest about his substance use history. The use of certain substances is associated with the development of psychotic symptoms. For instance, if he has been secretly using cannabis it may have been the reason he developed psychotic symptoms. The use of cannabis is linked to the development of schizophrenia after a period of time (APA, 2013; Sadock et al., 2015).   

3. Schizotypal Personality Disorder – 301.22 (F21)

            Schizotypal personality disorder is the third and last possible differential diagnosis in this case. The illness is distinguished from schizophrenia by the fact that the symptomatology does not fully match the DSM-5 diagnostic criteria for schizophrenia, as shown above. These clinical signs of schizotypal personality disorder are referred to be “sub-threshold” in diagnostic jargon. Another distinction is that schizotypal personality disorder is primarily a personality disorder that is only included here because it also includes psychosis (Sadock et al., 2015; APA, 2013).

Reflections: What I did with this patient is in conformity with the psychiatric interview protocol for patients with psychosis (Carlat, 2017). Given another chance I would still do the very same with this patient. The bioethical principles of beneficence, autonomy nonmaleficence, fidelity, and justice were all observed as was confidentiality (Haswell, 2019). The health education was focused on the importance of psychotherapy and adherence to medications prescribed. Also, the family was advised to take up the offer of family therapy to help them cope with the patient’s condition. If I had the opportunity to follow up with patient JF, my overall goal would be to assess his progress at each follow-up appointment after four weeks by conducting an evaluative PANSS test. This is what will tell me if the symptoms are becoming better or worse.

Conclusion

            This 19 year-old presented with a classic picture of psychosis; specifically schizophrenia. The positive symptoms of hallucinations and delusions coupled with the other symptoms are what clinched the DSM-5 diagnosis. The progress and evaluation going forward will depend on the scores he gets in the subsequent PANSS tests.

References

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

Carlat, D.J. (2017). The psychiatric interview, 4^th ed. Wolters Kluwer.

Leucht, S., Barabássy, Á., Laszlovszky, I, Szatmári, B., Acsai, K., Szalai, E., Harsányi, J., Earley, W., & Németh, G. (2019). Linking PANSS negative symptom scores with the Clinical Global Impressions Scale: Understanding negative symptom scores in schizophrenia. Neuropsychopharmacology, 44, 1589-1596. https://doi.org/10.1038/s41386-019-0363-2

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