Psychiatric Inpatient Unit

Conduct a Comprehensive Psychiatric Evaluation(See template attached) on the patient presented (see case study attachment) using the template provided.

Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

CASE 51: IRRITABLE, AGGRESSIVE AND ON A MISSION

History

A 22-year-old young man is admitted to a psychiatric inpatient unit under involuntary admission. On admission, he is extremely agitated and hostile. He is very upset about having been admitted. He believes that he is of royal descent and is determined to punish those who are involved in ‘imprisoning’ him. It is reported by his family that he has no actual royal lineage, but that he sees himself as the person chosen to establish a new world government. He says he is on a mission. He has been angry and physically aggressive towards family members who contradict him. His grandmother banged the back of her head from when the man pushed her against a wall and has a bruised face. He refuses to allow a detailed mental status examination. He is pacing up and down the ward intimidating other patients. He is laughing out loud, talking to himself. He repeatedly makes threatening gestures at the ward staff. He lives with his grandmother. He has no contact with his father. His mother died of a drug overdose when he was 6 years old. He uses cannabis regularly spending £20 a week but does not abuse alcohol or any other drugs. He smokes 40 cigarettes a day. There is no significant previous medical or psychiatric history. He has been behaving strangely, according to his grandmother, for the past 2 weeks. She has observed him spending a lot of money and talking openly about his sexual exploits to her. He has hardly slept over the past week. Two days ago, he threatened her and pushed her when she tried to urge him to see the doctor. Since then, she has been feeling increasingly frightened of him. He was prescribed the antipsychotic medication olanzapine 5 mg nocte (at night), which he has taken a few nights. However, this morning, he hit her. She reported the matter to the police, which ultimately led to his admission.

Mental state examination

He appears dishevelled bearing 3-day-old stubble. He is pacing imperiously up and down the ward corridor, singing out loud. He also laughs and talks to himself. Any attempts to interview him result in him swearing, and when he does agree to temporarily come into the interview room he very quickly walks out slamming the door as he goes. He gives little eye contact and appears preoccupied with his own thoughts. It is not possible to discuss his thoughts or experiences with him. Physical examination He refuses a physical examination.

Comprehensive Psychiatric Evaluation

I. Identifying Information:

Patient’s Name: [Name]

Age: 22

Gender: Male

Date of Evaluation: [Date]

Setting: Psychiatric inpatient unit

Referral Source: Involuntary admission due to aggression and agitation

II. Chief Complaint:

The patient presents with extreme agitation, hostility, and aggressive behavior upon admission. He expresses upset about being admitted and believes he is of royal descent with a mission to establish a new world government. He has been physically aggressive towards family members, leading to his grandmother sustaining injuries. Additionally, he exhibits disorganized behavior, pacing, laughing out loud, and talking to himself. The patient refuses a detailed mental status examination and a physical examination.

III. History of Present Illness:

The patient’s family reports that he has been behaving strangely for the past 2 weeks. During this time, he has exhibited grandiose delusions of being of royal descent and has shown a fixed belief in his mission to punish those he perceives as imprisoning him. His behavior has escalated, with physical aggression towards family members who challenge his beliefs. He has also been observed spending money impulsively, engaging in sexual exploits, and experiencing a significant decrease in the need for sleep. There is a history of regular cannabis use and heavy smoking, but no reported history of alcohol or substance abuse. The patient has been prescribed olanzapine 5 mg nocte, but compliance has been inconsistent.

IV. Past Medical and Psychiatric History:

There is no significant previous medical or psychiatric history reported. The patient’s mother died of a drug overdose when he was 6 years old, and he has had no contact with his father.

V. Family History:

The patient’s mother had a history of drug abuse leading to her death. No other significant psychiatric or medical history is reported in the family.

VI. Substance Use History:

• Cannabis: Regular use, spending £20 a week.
• Alcohol: No reported history of abuse.
• Other drugs: No reported history of abuse.

VII. Mental State Examination:

Appearance: Disheveled with 3-day-old stubble.

Behavior: Pacing up and down the ward corridor, singing, laughing, and talking to himself. Hostile and swearing during interview attempts.

Mood: Appears irritable and preoccupied with his own thoughts.

Affect: Difficult to assess due to lack of cooperation.

Thought Process: Not assessable due to the patient’s lack of cooperation.

Thought Content: Presents grandiose delusions of royal descent and a mission to punish others.

Perceptions: No overt signs of hallucinations reported.

Insight: Poor insight into his current condition.

Judgment: Impaired judgment, as evidenced by aggressive behavior and lack of cooperation.

VIII. Assessment and Diagnostic Reasoning:

Based on the information provided in the case study and the observed mental state examination, the patient presents with symptoms suggestive of a severe psychiatric disorder. The prominent features include:

1. Grandiose Delusions: The patient firmly believes he is of royal descent and has been chosen for a mission to establish a new world government. This suggests the presence of grandiose delusions, which are often associated with psychotic disorders.
2. Aggression and Irritability: The patient’s extreme agitation, hostility, and aggression towards family members, coupled with his inability to control his emotions, may indicate an underlying psychiatric disorder.
3. Disorganized Behavior: The patient’s disheveled appearance, pacing, talking to himself, and laughing out loud indicate disorganized behavior, which is commonly seen in psychotic disorders.
4. Impaired Insight and Judgment: The patient’s inability to recognize the seriousness of his condition and aggressive actions demonstrate poor insight and impaired judgment.

Based on the symptomatology and the patient’s history, a provisional diagnosis of a psychotic disorder, possibly Schizophrenia, is warranted. Further evaluation is required to determine the specific subtype and severity.

IX. Differential Diagnosis:

1. Schizophrenia: The patient’s grandiose delusions, disorganized behavior, and impaired insight are consistent with the diagnostic criteria for schizophrenia.
2. Bipolar Disorder with Psychotic Features: The patient’s decreased need for sleep, irritability, and impulsivity could suggest a manic episode with psychotic features.
3. Substance-Induced Psychotic Disorder: Cannabis use may contribute to the development of psychosis in susceptible individuals. However, the symptoms described appear to extend beyond the effects of substance use alone.
4. Delusional Disorder: The patient’s grandiose delusions could be indicative of a delusional disorder, but the presence of disorganized behavior and agitation is not typical for this diagnosis.

X. Recommendations:

1. Complete Physical Examination: Despite the patient’s refusal, a thorough physical examination is necessary to rule out any organic causes contributing to his presentation.
2. Collaboration with Law Enforcement: Given the patient’s aggressive behavior and the reported incidents of violence, close collaboration with law enforcement is essential to ensure the safety of staff and other patients.
3. Continued Psychiatric Treatment: Initiate or continue treatment with antipsychotic medication, such as olanzapine, to manage psychotic symptoms and stabilize the patient’s condition.
4. Psychotherapy: Individual and/or group psychotherapy may be beneficial once the patient’s symptoms are stabilized to address underlying issues, improve coping skills, and enhance insight.
5. Substance Abuse Evaluation: Conduct a comprehensive assessment of the patient’s cannabis use and explore the possibility of a substance use disorder.
6. Family Involvement: Engage the patient’s grandmother in the treatment process, providing education and support to better manage the patient’s condition and promote safety.

Scholarly Resources:

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Andreasen, N. C. (1999). A unitary model of schizophrenia: Bleuler’s “fragmented phrene” as schizencephaly. Archives of General Psychiatry, 56(9), 781-787.
3. Mueser, K. T., & McGurk, S. R. (2004). Schizophrenia. The Lancet, 363(9426), 2063-2072.
4. Saha, S., Chant, D., Welham, J., & McGrath, J. (2005). A systematic review of the prevalence of schizophrenia. PLoS Medicine, 2(5), e141.
5. Tandon, R., Nasrallah, H. A., & Keshavan, M. S. (2009). Schizophrenia, “just the facts” 4. Clinical features and conceptualization. Schizophrenia Research, 110(1-3), 1-23.

Please note that this comprehensive psychiatric evaluation is based on the information provided in the case study and should not replace a formal evaluation by a qualified mental health professional. The diagnosis and treatment plan may vary based on further assessment and additional information.