History A 24-year-old man presents to hospital having got into a fight as he thought he was being watched and felt threatened. He appears to have fractured his thumb but is reluctant to let you examine him or order an X-ray. He looks suspicious and wary. When asked about his concerns he says that over the last few months he has been carefully monitored by government agencies. He has been hearing a voice out loud giving a running commentary on his thoughts and these are being broadcast to the government. Any machine enables the government to get inside his head and the voice is telling him it would be unwise to face the X-ray machine. The voice is not one that he recognizes, and it is sometimes derogatory, telling him he is stupid for giving his thoughts away for free. Initially the voice came and went but over the last few weeks it is present almost constantly and he cannot always sleep because even when he sleeps the voice comments on what he is thinking. He is exhausted. The man is absolutely convinced that the government is after him but he cannot explain why. There is no previous history and he denies any substance use. Until a few weeks ago he had been working as a kitchen assistant but was sacked for leaving jobs unfinished. There is no family history of any psychiatric illness.
Mental state examination
The man looks unkempt. He is wary and looks quite frightened and agitated. His eye contact is fleeting and he constantly looks around him in a perplexed manner. His speech is rambling and he does not express himself coherently. He occasionally uses words that you have not heard before and repeats them as though they have some significance. He does not come across as depressed. He has delusions of persecution. He has auditory hallucinations that provide a running commentary on every aspect of his behaviour. He has thought broadcast and thought withdrawal. He is orientated in person, but unclear about the time. He seems aware that he is in hospital but not quite sure why
Conduct a Comprehensive Psychiatric Evaluation(See template attached) on the patient presented (see case study attachment) using the template provided in the Learning Resources.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning
Psychiatric Evaluation
Patient Name: [Insert Patient Name] Date of Evaluation: [Insert Date]
Chief Complaint: The patient presents with a complaint of feeling constantly monitored by government agencies and experiencing auditory hallucinations and delusions of persecution.
History of Present Illness: The patient, a 24-year-old male, reports that over the past few months, he has been under constant surveillance by government agencies. He believes that his thoughts are being broadcasted to the government through a voice he hears, which provides a running commentary on his behavior. The patient is convinced that any machine, including an X-ray machine, allows the government to access his thoughts, which is why he is reluctant to undergo an examination or order an X-ray. The voice is unfamiliar and sometimes derogatory, criticizing the patient for giving his thoughts away for free. Initially, the voice was intermittent, but it has become almost constant over the past few weeks, interfering with his ability to sleep. The patient appears exhausted and states that the voice comments on his thoughts even when he is asleep.
Past Psychiatric History: There is no previous history of psychiatric illness in the patient.
Substance Use History: The patient denies any substance use.
Personal and Social History: Until a few weeks ago, the patient worked as a kitchen assistant but was dismissed due to leaving jobs unfinished. There is no known family history of psychiatric illness.
Family History: There is no family history of psychiatric illness.
Medical History: No significant medical history reported.
Mental State Examination:
Appearance and Behavior: The patient appears unkempt, displaying signs of poor self-care. He exhibits an anxious and frightened demeanor, with fleeting eye contact. He appears agitated and constantly looks around in a perplexed manner.
Speech: The patient’s speech is rambling and lacks coherence. He occasionally uses unfamiliar words that he repeats, suggesting they hold some personal significance to him.
Mood: The patient’s mood is difficult to ascertain during the evaluation.
Affect: The patient’s affect is not specifically described in the case study.
Thought Process: The patient’s thought process is disorganized and lacks logical coherence. He experiences delusions of persecution, believing that government agencies are after him. The patient also reports thought broadcast and thought withdrawal.
Thought Content: The patient experiences auditory hallucinations, hearing a voice that provides a running commentary on his thoughts and behavior. The voice is unfamiliar, sometimes derogatory, and criticizes the patient for giving his thoughts away for free.
Perception: The patient’s perceptions are distorted due to auditory hallucinations.
Cognition: The patient is oriented to person but unclear about the time. He acknowledges being in the hospital but does not fully understand the reason for his presence.
Insight and Judgment: The patient’s insight appears impaired as he holds firm delusional beliefs about government surveillance. His judgment is difficult to assess based on the available information.
Diagnostic Impressions:
Based on the information provided, the patient presents with symptoms consistent with a primary psychotic disorder, specifically schizophrenia. The key features supporting this diagnosis include:
- Delusions of persecution: The patient firmly believes that government agencies are monitoring him.
- Auditory hallucinations: The patient experiences a voice that provides a running commentary on his thoughts and behavior.
- Disorganized thought process: The patient’s speech is rambling and lacks coherence.
- Impaired insight: The patient maintains his delusional beliefs despite evidence to the contrary.
- Social and occupational dysfunction: The patient was dismissed from his job due to unfinished tasks, suggesting impairment in daily functioning.
Differential Diagnosis:
It is important to consider other possible causes for the patient’s symptoms. The following differential diagnoses should be considered:
- Substance-induced psychosis: Although the patient denies substance use, it is important to rule out any substance-related causes for his symptoms through further history taking or laboratory investigations.
- Delusional disorder: This diagnosis could be considered if the patient’s symptoms are limited to delusions without the presence of prominent hallucinations or disorganized thinking.
- Other primary psychotic disorders: Conditions such as schizoaffective disorder or brief psychotic disorder may also need to be ruled out based on the patient’s clinical presentation.
Treatment Recommendations:
- Stabilization: The patient should be provided a safe and secure environment to address his immediate distress and agitation. Close monitoring for potential harm to self or others is necessary.
- Antipsychotic medication: Initiation of antipsychotic medication, such as a second-generation antipsychotic (SGA), is recommended to target the positive symptoms of psychosis and alleviate the auditory hallucinations and delusions. The choice of medication should consider potential side effects, tolerability, and the patient’s preferences.
- Psychotherapy: Individual therapy, such as cognitive-behavioral therapy for psychosis (CBTp), may be beneficial in improving the patient’s coping skills, addressing his delusional beliefs, and managing distressing symptoms.
- Social support: Involving the patient’s family or supportive individuals in the treatment process can help improve adherence to medication and provide a supportive network for the patient’s recovery.
- Ongoing monitoring: Regular follow-up appointments should be scheduled to assess treatment response, monitor medication side effects, and evaluate the patient’s overall progress.
References:
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- National Institute for Health and Care Excellence. (2014). Psychosis and schizophrenia in adults: Prevention and management. Clinical guideline [CG178]. Retrieved from https://www.nice.org.uk/guidance/cg178
- Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., & Dixon, L. B. (2010). The Schizophrenia Patient Outcomes Research Team (PORT): Updated Treatment Recommendations 2010. Schizophrenia Bulletin, 36(1), 94–103. doi: 10.1093/schbul/sbq109
- Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34(3), 523–537. doi: 10.1093/schbul/sbm114