NU 643: Psychosis Case Study
Introduction and Differential Diagnoses
24-year-old Ms. Mann, an African American woman, is concerned about spiders crawling on her hands, legs, and body. It’s important to note that she is the only one who sees these spiders, and there are hypotheses that hamburgers attract them. Her psychiatric history reveals that she was first hospitalized at the age of 19 following an initial psychotic episode. About a year ago, she was diagnosed with a mental illness and began treatment. Recently, she has been experiencing auditory and tactile hallucinations, as well as visual disturbances. At work, Mann reports significant distractions and impaired performance, occasionally missing work altogether. She frequently exhibits outbursts, often in response to the voices she hears or as a result of suspicions she harbors about those around her. In addition, she expresses difficulty being in public spaces, primarily because she grows increasingly suspicious of those around her. Mann is concerned that others will listen to her thoughts and discuss them amongst themselves, resulting in chaos, agitation, fear, and confrontation. As part of her initial treatment, Ms. Mann was prescribed Seroquel in oral form, which proved to be effective. In spite of this, after taking the medication for a year, she decided to discontinue it because she thought she had recovered.
Differential Diagnosis List
- Schizophrenia
- Psychosis
- Delusional disorder
Rationale; Pertinent Positive, Negatives, DSM5 Criteria
- Schizophrenia– Patient symptoms include perturbed thoughts, hallucinations, delusions, distractions, confusion, social withdrawal, lack of motivation, extreme disorganization, and a flat affect. Note that the patient explicitly denied having suicidal thoughts or engaging in suicidal behavior (De Sousa et al., 2018).
- Psychosis – There are several symptoms present in the patient, including hallucinations, delusions, confusion, distractions, lack of motivation, perturbed thoughts, extreme disorganization, and changes in mood. This patient explicitly denied relapsing or extreme dependence (De Sousa et al., 2018).
- Delusional disorder – It is common for patients with this disorder to exhibit symptoms such as delusions, hallucinations, a tendency to react strongly when they perceive offenses, anger, low mood, irritability, and doubts about the trustworthiness of those around them (Muñoz-Negro, 2018). There was also an explicit denial of resentment and feeling exploited on the part of the patient.
Narrative Mental Status Exam
The physical appearance of Ms. Mann is typical, and she does not appear to have any hygiene issues. Based on her answers to questions, it appears that she is not impulsive. While she appears cooperative, her constant surveillance of the room indicates that she is also responding to internal stimuli, particularly voices. The volume of Ms. Mann’s voice is normal, but she speaks slowly. A number of features are notable, including anhedonia, limited emotional expression, and anxiety related to hearing voices and thinking suspicious thoughts. The content of her thoughts is significantly influenced by her consistent auditory hallucinations, thought insertion, and paranoid ideas, even though it is difficult to make a definitive diagnosis of confusion. As a result of compromised insight and judgment, the patient has difficulty solving problems.
Variations from Normal and Monitoring Needs
PCOS and obesity are significant concerns per the patient’s medical hx, monitoring is necessary.
Assessment
In order to enhance the quality of care across various levels, the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) supports the integration of psychometric tools into clinical practice. The utilization of rating scales by clinicians can enhance diagnostic precision and establish a reference point for monitoring the progression of a disorder over time or in response to specific interventions.
- Schizophrenia – The Positive and Negative Syndrome Scale (PANSS) is a valuable assessment instrument comprising up to 30 items, which evaluate the severity of symptoms across three subscales (Lim et al., 2021). A score of 110 or higher on this scale would indicate a diagnosis of severe schizophrenia.
- Psychosis – The Brief Psychiatric Rating Scale (BPRS) is a widely used tool for evaluating the intensity of psychosis in patients (Hofmann et al., 2022). The assessment encompasses 18 symptoms or behaviors associated with hallucinations, hostility, and disorientation (Hofmann et al., 2022). A cumulative score of 7 or above would indicate a diagnosis of severe psychosis.
- Delusional Disorders – The Delusion and its Origin Assessment Interview (DOAI) is a semi-structured interview protocol designed to explore the characteristics of delusional experiences and personality disorders, as well as potential factors that may have contributed to or influenced the development of delusions within the three months preceding the assessment (Hayashi et al., 2021). The DOAI consists of three sections: A. Delusional themes, B. Personality disorders, and C. Response and judgments (Hayashi et al., 2021).
Primary Diagnosis and Coding
- Schizophrenia (F20.9)
- Psychosis 8 (F23)
- Delusional disorder 297.1 (F22)
Plan of Treatment and Rx
Pharmacological Intervention and Rx
- Schizophrenia – The recommended treatment approach for schizophrenia involves the use of antipsychotic medications, such as oral Seroquel. To achieve the desired therapeutic outcome, a dosage ranging from 300-450 mg per day is appropriate (González-Rodríguez et al., 2022). This atypical antipsychotic aids in restoring the balance of neurotransmitters in the brain, thereby reducing hallucination, and enhancing concentration. In addition, it can reduce anxiety, promote positive self-perception, and increase engagement in daily activities. The medication is also expected to improve mood, energy levels, appetite, and sleep. However, it is important to note that certain side effects may occur, including lightheadedness, drowsiness, constipation, upset stomach, fatigue, dry mouth, blurred vision, and dizziness (Zhao et al., 2021). Considering the patient’s medical history, including obesity, it is crucial to monitor potential weight gain associated with the medication, as it may lead to unfavorable outcomes. Lastly, given the chronic nature of the condition, it may take between 6 months to 1 year to achieve the desired therapeutic effect.
- Psychosis – It is commonly understood that psychosis has fewer symptoms compared to schizophrenia, atypical antipsychotics are the preferred pharmacological treatment for both conditions (Faay et al., 2018). Therefore, I would still recommend resuming the use of Seroquel. A daily dosage of 300mg should be sufficient to achieve the desired therapeutic effect for psychosis. This atypical antipsychotic medication aids in restoring the balance of neurotransmitters in the brain, resulting in a reduction in hallucinations and improved concentration (Zhao et al., 2021). It can also contribute to fostering positive self-perception, reducing anxiety, and promoting increased engagement in daily activities. Additionally, it is known to increase sleep, enhance mood, increase energy level, and improve appetite, and sleep. However, it is important to be aware of potential side effects such as dry mouth, fatigue, upset stomach, blurred vision, constipation, lightheadedness, drowsiness, and dizziness. Monitoring is crucial, particularly considering the patient’s current medical conditions. For example, given her history of obesity, a medication that may lead to weight gain could have undesired consequences. The desired therapeutic effect for the diagnosis of psychosis should be achieved within a timeframe of approximately 6 months.
- Delusional disorder – A diagnosis of delusional disorder would also necessitate pharmacological treatment utilizing atypical antipsychotics (Muñoz-Negro et al., 2018). Considering the patient’s prior positive response, Seroquel PO remains the most suitable option. To commence treatment for the delusional disorder, a low dose of 300mg per day is recommended due to the condition’s comparatively fewer symptoms (Zhao et al., 2021). This medication is expected to effectively restore the balance of neurotransmitters in the brain, resulting in a reduction in hallucinations and improved concentration (Muñoz-Negro et al., 2018). Additionally, it may facilitate positive self-perception, reduce anxiety, and increase engagement in daily activities (Muñoz-Negro et al., 2018). Furthermore, it is known to improve mood, appetite, sleep, and energy levels. However, it is essential to be aware of potential side effects such as upset stomach, constipation, drowsiness, fatigue, blurred vision, lightheadedness, dizziness, and dry mouth (Zhao et al., 2021). Given the patient’s current medical issues, monitoring is crucial (Muñoz-Negro et al., 2018). Depending on the adjustments made throughout the course of treatment, such as gradual dosage increases, the desired therapeutic effect can typically be achieved within a timeframe of 3-9 months.
Non-Pharmacological Interventions
- Schizophrenia – Following a diagnosis of schizophrenia, the patient may explore various non-pharmacological treatment options such as cognitive-behavioral therapy (CBT), art therapy, talk therapy, or individual/family therapies (De Sousa et al., 2018). To initiate the treatment process, it is recommended to begin with 10-15 sessions lasting approximately 30 minutes each. The therapist will assess the patient’s needs and create an individualized treatment plan. The plan should be reviewed and updated regularly throughout the course of treatment. The patient should discuss any concerns or questions with the therapist.
- Psychosis – In line with schizophrenia, the treatment of a psychosis diagnosis may involve complementing medication with cognitive-behavioral therapy (CBT), art therapy, talk therapy, or individual/family therapies (Nelson et al., 2021). Additionally, the patient can initiate the treatment process with 10 sessions of 30 minutes each, with a reassessment of the need to continue treatment occurring during the final session.
- Delusional disorder – Cognitive-behavioral therapy (CBT) is considered the most effective non-pharmacological approach for treating delusional disorders (Diminich et al., 2020). To achieve the desired therapeutic outcomes, it is recommended to have 30-minute sessions at least twice a week during the initial month of treatment.
Patient Education
- Schizophrenia – The initial information conveyed to the patient should include the diagnosis, prevalence, expectations, and trajectory of the illness. It is important for the patient to understand that the prescribed medication may lead to certain side effects, such as constipation and weight gain. However, if these side effects persist or become severe, it is crucial for the patient to contact their doctor for further guidance. Additionally, it should be emphasized that engaging in regular exercise, spending time with family, and seeking social support are essential components that can complement the treatment of schizophrenia.
- Psychosis – Likewise, in the context of psychosis, it is important for the patient to comprehend that the prescribed medication may result in specific side effects such as blurry vision, weight gain, and constipation. However, if these side effects persist or become severe, it is essential for the patient to seek guidance from their doctor. Additionally, the significance of spending quality time with family, engaging in regular exercise, and seeking social support should be emphasized as crucial elements that can complement the treatment of psychosis.
- Delusional disorder – In addition to explaining the medication’s potential side effects, it is vital to place a strong emphasis on the importance of social support for patients diagnosed with delusional disorder. The central component of patient education should revolve around familiarizing them with various management techniques (Muñoz-Negro et al., 2018). Patients should comprehend that engaging in activities such as interacting with others, going for walks, or effectively responding to voices and hallucinations can play a crucial role in their treatment progress (Muñoz-Negro et al., 2018).
Safety Plan
- Schizophrenia – The initial steps of the safety plan should involve acknowledging the FDA warnings regarding Seroquel. Specifically, it is important to note that Seroquel is not approved for the treatment of individuals with dementia-related psychosis (Yunusa et al., 2022). Additionally, there have been documented cases of anaphylactic reactions in patients receiving Seroquel (Costa et al., 2021). It is also worth considering that certain side effects of the medication can increase the risk of fractures, falls, and other injuries. Furthermore, the patient’s current medical conditions and any known allergies, such as those related to drugs like penicillin, should be considered when formulating the safety plan. However, since the patient has previously used the medication without complications, these concerns may be limited. Nevertheless, it is crucial to consistently monitor any changes in the patient’s symptoms and their response to the treatment.
- Psychosis – Similar to schizophrenia, when creating a safety plan for psychosis, it is important to consider the FDA warnings, which include the lack of approval for treating individuals with dementia-related psychosis, the possibility of anaphylactic reactions, and the potential side effects that may increase the risk of falls, fractures, and other injuries (Yunusa et al., 2022). Additionally, it is crucial to ensure consistent monitoring of any changes in the patient’s symptoms and their response to the treatment as part of the implemented precautions (Costa et al., 2021).
- Delusional disorder – In developing a safety plan for a patient with delusional disorder, it is essential to consider whether the prescribed medication is a controlled substance and whether it carries a black box warning (Zhao et al., 2021). As previously mentioned, Seroquel is not approved for treating individuals with dementia-related psychosis, and there have been reported cases of anaphylactic reactions and side effects that may increase the risk of falls, fractures, and other injuries (Zhao et al., 2021). Therefore, the safety plan should incorporate strategies to mitigate these possibilities. Additionally, it is crucial to regularly evaluate any developments or changes in the patient’s symptoms and their response to the treatment, ensuring that these aspects are integrated into the safety planning process.
Follow-up and Outcomes
- Schizophrenia – The initial follow-up session should take place approximately one to two months after the diagnosis of schizophrenia. The main objective of this session should be to assess any progress resulting from the treatment, particularly in terms of reducing the core symptoms associated with schizophrenia. Any changes in medication should be discussed, and the patient should be monitored for any side effects. The session should also serve as an opportunity to address any questions or concerns the patient may have. Finally, the patient should be encouraged to continue to adhere to the treatment plan.
- Psychosis – The patient should schedule a follow-up session one month after receiving their psychosis diagnosis. During this session, the primary focus will be to evaluate whether the treatment has resulted in any improvements. This will include reducing the core symptoms associated with their psychosis. The patient will also be asked to provide feedback about the treatment and offer suggestions on how it can be improved. It is important for the patient to be open and honest about their experiences and provide as much information as possible. The session will also provide an opportunity for any additional questions to be answered.
- Delusional disorder – Following one month of treatment, it is recommended that the patient attends their initial follow-up session. During this session, the healthcare practitioner will evaluate the progress of the treatment. This will include its effectiveness in reducing the symptoms associated with delusional disorder. The healthcare practitioner may also adjust the treatment plan based on the results of the initial evaluation. If the treatment is deemed ineffective, alternative treatment options may be explored.
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Approach to Care and Clinical Guidelines
The case presents unique considerations about the patient that should guide the chosen approach to care, taking into account established clinical guidelines. Firstly, the patient has a lengthy history of mental illness, including a recent schizophrenia diagnosis. Secondly, although the prescribed medication proved effective following the diagnosis, the patient chose to discontinue it due to feeling better. These factors suggest a recurrence of the patient’s initial mental health issues, particularly given psychosis prevalence. Therefore, as highlighted by Hishimoto et al. (2022), it is crucial to recognize that the decision to stop taking the atypical antipsychotic contributes to the patient’s current challenges. Consequently, conducting a comprehensive assessment of the symptoms is imperative in developing an effective treatment plan, even if it involves resuming the previous medication prescription. Additionally, clinicians should also be mindful of how to best support the patient’s transition to the new treatment plan. Providing psychoeducation on the effects of the medication and creating an action plan that includes strategies to cope with the symptoms can help the patient to stay on track with the treatment.
References
Costa, A., Jesus, S., & Alcafache, J. (2021). Angioedema with haloperidol – case report. European Psychiatry: The Journal of the Association of European Psychiatrists, 64, S480–S481. https://doi.org/10.1192/j.eurpsy.2021.1284
De Sousa, A. E. F., Lepage, M., & Brodeur, M. (2018). T207. A review of predictors of responsiveness to CBT for psychosis. Schizophrenia Bulletin, 44(suppl_1), S197-S197. https://doi.org/10.1093/schbul/sby016.483
Diminich, E. D., Dickerson, F., Bello, I., Cather, C., Kingdon, D., Rakhshan Rouhakhtar, P. J., Hart, K. L., Li, C., Troxel, A. B., & Goff, D. C. (2020). D-cycloserine augmentation of cognitive behavioral therapy for delusions: A randomized clinical trial. Schizophrenia Research, 222, 145–152. https://doi.org/10.1016/j.schres.2020.06.015
Faay, M. D. M., Czobor, P., & Sommer, I. E. C. (2018). Efficacy of typical and atypical antipsychotic medication on hostility in patients with psychosis-spectrum disorders: a review and meta-analysis. Neuropsychopharmacology : Official Publication of the American College of Neuropsychopharmacology, 43(12), 2340–2349. https://doi.org/10.1038/s41386-018-0161-2
González-Rodríguez, A., Monreal, J. A., Natividad, M., & Seeman, M. V. (2022). Seventy years of treating delusional disorder with antipsychotics: A historical perspective. Biomedicines, 10(12), 3281. https://doi.org/10.3390/biomedicines10123281
Hayashi, N., Igarashi, Y., & Harima, H. (2021). Delusion progression process from the perspective of patients with psychoses: A descriptive study based on the primary delusion concept of Karl Jaspers. PLoS ONE, 16(4), 1–18. https://doi.org/10.1371/journal.pone.0250766
Hishimoto, A., Yasui-Furukori, N., Sekine, D., Matsukawa, M., & Yamada, S. (2022). treatment discontinuation among patients with schizophrenia treated with brexpiprazole and other oral atypical antipsychotics in Japan: A retrospective observational study. Advances in Therapy, 39(9), 4299. https://doi.org/10.1007/s12325-022-02252-9
Hofmann, A. B., Schmid, H. M., Jabat, M., Brackmann, N., Noboa, V., Bobes, J., Garcia-Portilla, M. P., Seifritz, E., Vetter, S., & Egger, S. T. (2022). Utility and validity of the Brief Psychiatric Rating Scale (BPRS) as a transdiagnostic scale. Psychiatry Research, 314. https://doi.org/10.1016/j.psychres.2022.114659
Lim, K., Peh, O.-H., Yang, Z., Rekhi, G., Rapisarda, A., See, Y.-M., Rashid, N. A. A., Ang, M.-S., Lee, S.-A., Sim, K., Huang, H., Lencz, T., Lee, J., & Lam, M. (2021). Large-scale evaluation of the Positive and Negative Syndrome Scale (PANSS) symptom architecture in schizophrenia. Asian Journal of Psychiatry, 62. https://doi.org/10.1016/j.ajp.2021.102732
Munikanan, T., Midin, M., Daud, T. I. M., Rahim, R. A., Bakar, A. K. A., Jaafar, N. R. N., Sidi, H., & Baharuddin, N. (2017). Association of social support and quality of life among people with schizophrenia receiving community psychiatric service: A cross-sectional study. Comprehensive Psychiatry, 75, 94–102. https://doi.org/10.1016/j.comppsych.2017.02.009
Muñoz-Negro, J. E., Ibáñez-Casas, I., de Portugal, E., Lozano-Gutiérrez, V., Martínez-Leal, R., & Cervilla, J. A. (2018). A psychopathological comparison between delusional disorder and schizophrenia. Canadian Journal of Psychiatry, 63(1), 12–19. https://doi.org/10.1177/0706743717706347
Nelson, B., Torregrossa, L., Thompson, A., Sass, L. A., Park, S., Hartmann, J. A., McGorry, P. D., & Alvarez-Jimenez, M. (2021). Improving treatments for psychotic disorders: beyond cognitive behaviour therapy for psychosis. Psychosis, 13(1), 78–84. https://doi.org/10.1080/17522439.2020.1742200
Yunusa, I., Rashid, N., Demos, G. N., Mahadik, B. S., Abler, V. C., & Rajagopalan, K. (2022). Comparative outcomes of commonly used off-label atypical antipsychotics in the treatment of dementia-related psychosis: A network meta-analysis. Advances in Therapy, 39(5), 1993. https://doi.org/10.1007/s12325-022-02075-8
Zhao, Y., Wen, S. W., Li, M., Sun, Z., Yuan, X., Retnakaran, R., Zhang, R., & Zhai, D. (2021). Dose-response association of acute-phase Quetiapine treatment with risk of new-onset hypothyroidism in schizophrenia patients. British Journal of Clinical Pharmacology, 87(12), 4823–4830. https://doi.org/10.1111/bcp.14928
NU 643: Psychosis Case Study
Week 8 Assignment 1: Psychosis Case Study
Value: 100 points
Due: Day 7
Gradebook Category: Assignments
Instructions
In this assignment, you will review the Psychosis Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.
Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.
For this assignment, you will
- Review the Case Study.
- Review the Comprehensive Case Study Content Exemplar (Word)to understand what is needed within your paper.
- Use the Comprehensive Case Study Paper Template (Word)to write the assignment in the proper format.
- Follow the requirements on the rubric and within the Content Exemplar.
- Interactive Comprehensive Case Studies should be 3- to 5-pages in length, excluding the title and reference pages.
- Interactive case studies should include a minimum of three evidence-based practice guidelines or articles.
- All papers should conform to the most recent APA standards.
Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.
When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up
Please refer to the Grading Rubric for details on how this activity will be graded.
