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Week 7 Psychiatric Evaluation

NRNP 6635
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Week 7 Psychiatric Evaluation

Subjective:

CC (chief complaint): Mrs. Warren’s best friend called saying that the patient needed to come to

the emergency room due to paranoia.

HPI:

Mrs. Warren is a 33-year-old, Caucasian, female who was brought to the emergency

room by her best friend, Patty. The police responded to the patients’ house after she called 911

consistently and have been to her house five times. She was almost arrested for misuse of the 911

system, however, Patty told them she needs to go to the emergency room. The patient was

calling 911 because she believes that people are looking into her windows and watching her. She

believes that these people are waiting for her husband to come home so they may hurt him.

Presently, she complains of having an upset stomach. She believes that there is a snake in her

stomach, and she stopped eating two days ago because of this. She wants the snake removed.

Mrs. Warren has been to this emergency room three times and has had one psychiatric

admission two years ago. She denies self-harm behaviors. She has a history of being physically

aggressive towards others. She denies head injuries.

The patient has refused to allow her labs to be drawn and her vital signs taken. During the

assessment the patient appears to be on edge, anxious, and paranoid.

Past Psychiatric History:

 General Statement: The patient was admitted to inpatient psych two years ago.

 Caregivers (if applicable): None

 Hospitalizations: One psychiatric admission two years ago

 Medication trials: Unknown

 Psychotherapy or Previous Psychiatric Diagnosis: Unknown

o It is helpful to know the previous medications, psychotherapy, and psychiatric

diagnoses to provide the best care possible to the patient. Knowing this

information can save precious time. An example would be not trying a medication

that a patient has previously trialed and was not affective. Psychotherapy helps to

know because the success and compliance is higher when a patient attends

psychotherapy. Previous diagnoses give the provider an idea of where to start

when assessing the patient.

o Psychotherapy can help the patient by providing a safe place for them to discuss

their delusions and other symptoms while also providing them with safe coping

mechanisms and help with managing behavioral and psychological symptoms

(Cleveland Clinic, 2021). They can learn early warning signs, develop prevention

plans, and to control their symptoms (Bourgeois, 2017). Individual therapy can

help the patient “recognize and correct” distorted thinking (Bourgeois, 2017).

Cognitive-behavioral therapy helps the patient to recognize and learn patterns that

lead to their symptoms (Bourgeois, 2017). Family therapy helps them to

effectively contribute to the outcome of the patient (Bourgeois, 2017).

Substance Current Use and History: Denies substance abuse. Patient drinks alcohol

occasionally about once a month.

Family Psychiatric/Substance Use History: Father has had two previous inpatient admissions

for drug use in the 1970s for one week each time. Mother diagnosed with depression and treated

for many years. Paternal grandmother was state hospitalized for many years.
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Psychosocial History: Denies self-harm. Does have a history of physical aggression

towards others. Denies any traumatic experiences. However, Patty states that the patient losing

her patients was emotionally hard on the patient. Has never served in the military. No legal

issues.

She lives in Atlanta, GA. Her siblings include a sister of 10 years and both of her parents

have passed away in the last two years. She does not have children. She is married. Her husband

is currently out of town for work as a truck driver. She obtains SSDI. She states that she has been

sleeping about one to two hours before waking up throughout the night. She has a high school

diploma.

Medical History: Scoliosis. Denies Head injuries.

 Current Medications: Unknown

o Medications can cause the symptoms that the patient is experiencing and may

interact with any medications the provider may want to prescribe. It is imperative

to know what medications the patient is taking because of this.

 Allergies: Haloperidol

 Reproductive Hx: Does not have any children.

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose,

Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or

edema.
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RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No abdominal pain or blood. Has not

eaten for the past two days.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in

the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or

polydipsia.

Objective:

Physical exam: Refused Vitals

It is important to have vitals due to some psychiatric medications affecting the

cardiovascular system.

Diagnostic results: Labs are needed to rule out any medical causes for the delusions

(Manschreck, 2020).

1. CBC

2. CMP

3. Drug and Alcohol level test

4. LFT

5. Hep C

6. Hep B antigen
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7. HIV

8. Urinalysis

9. Pregnancy test for females

10. Kidney function panel

11. Lipid Panel

12. TSH

13. Rapid plasma reagent

(Wy & Saadabadi, 2021)

Assessment:

Mental Status Examination:

She is 33-year-old Caucasian Female who looks her stated age. She is alert and oriented

to person, place, and time. She is uncooperative with the interview and refuses to answer any

questions. She appears to be on edge, anxious, and paranoid. Her affect matches her mood. Her

facial expressions are appropriate for the situation. She is neatly groomed, clean, and dressed

appropriately. There are no signs of abnormal motor activity. Her speech is clear, coherent, and

normal in volume and tone. Her thought process is illogical. Her thought content includes

paranoia and delusions. Insight is poor. Judgement is fair. She denies suicidal or homicidal

ideation. Her concentration is intact. There is no evidence of looseness of association or flight of

ideas.

Differential Diagnoses:

1. Delusional Disorder Persecutory Type

Delusional disorder is typically seen later in age when compared to schizophrenia and

there is no gender preference (Joseph & Siddiqui, 2020). There are multiple types of delusions
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that are encountered. This patient is most likely experiencing persecutory delusions. These

delusions are characterized by the patient believed that someone or something is conspiring

against them, they are being harassed, or their being attacked (Joseph & Siddiqui, 2020).

Persecutory delusions are the most common type, and the patient can be seen showing signs of

anxiety, irritation, and aggression (Joseph & Siddiqui, 2020). It is possible for some patients to

be assaultive and litigious (Joseph & Siddiqui, 2020).

Patients will appear clean, groomed, and well dressed (Joseph & Siddiqui, 2020). They

can appear to be odd and suspicious (Joseph & Siddiqui, 2020). Patients will typically put their

trust in the clinician; however, the clinician must not accept their delusion because this can

confuse the patient's reality (Joseph & Siddiqui, 2020). Their mood will be congruent with the

delusion and mild depression symptoms will be present (Joseph & Siddiqui, 2020). They will not

typically have abnormal perceptions and auditory hallucinations may be present in some patients

(Joseph & Siddiqui, 2020). Their thought processes are the primary abnormality, and their

delusions are not bizarre, as in they are possible to happen (Joseph & Siddiqui, 2020). Bizarre

delusions are more congruent with schizophrenia (Joseph & Siddiqui, 2020). They will be alert

and oriented with their memory intact, unless the delusion is about a specific person, place or

time (Joseph & Siddiqui, 2020). Impulse control may be diminished; therefore, it is important to

assess the patient for suicidal or homicidal ideations (Joseph & Siddiqui, 2020). If the patient has

a history of being violent it may be pertinent to hospitalize them (Joseph & Siddiqui, 2020).

There are no labs or diagnostics to order to diagnose this disorder (Joseph & Siddiqui, 2020).

However, labs should be drawn to rule out any medical reasons for the delusions (Joseph &

Siddiqui, 2020). Prognosis is good when the patients are treated with medication (Joseph &
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Siddiqui, 2020). Around 50% of patients can have a full recovery and more than 20 % of patients

will have a decrease in symptoms (Joseph & Siddiqui, 2020).

DSM diagnostic criteria states that the delusion should not be bizarre and have at least

one delusion for at least a month (Substance Abuse and Mental Health Services Administration,

2016). The criteria A for schizophrenia has not been met, however, hallucinations may be

present only if they are related to the delusions theme (Substance Abuse and Mental Health

Services Administration, 2016). Criterion A for schizophrenia states that two or more of the

following symptoms must be present; delusions, hallucinations, disorganized speech, grossly

disorganized or catatonic behavior, and negative symptoms such as affective flattening

(Substance Abuse and Mental Health Services Administration, 2016). The patient's function is

not impaired, and their behavior is not overtly bizarre (Substance Abuse and Mental Health

Services Administration, 2016). Any mood episodes are short in duration when compared to the

length of the delusion. Finally, the delusion is not due to other substances or medical conditions

(Substance Abuse and Mental Health Services Administration, 2016).

It is very likely for this patient to have Delusional disorder persecutory type due to her

believing that someone is out to get her, and that people are looking into her windows at home.

During the interview she states that we are “out to get her” and when asked who, she responds,

“you know what you are doing” and turns away from the clinician. She appears anxious and

suspicious.

2. Bipolar Disorder with Psychotic Features

Bipolar disorder is one of the most common disabilities in the world (Jain & Mitra,

2021). It is a chronic and complex mood disorder that is distinguished by manic and major

depressive episodes (Jain & Mitra, 2021). There are seven specifications available, and these
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include rapid-cycling, psychotic features, mixed features, atypical features, with anxious distress,

has peripartum onset and seasonal pattern (Jain & Mitra, 2021). Mrs. Warren would fall under

the “with psychotic features” specification because she is having delusions. Psychotic features

include “delusions, phobias or paranoid thoughts, auditory, visual or other hallucinations” (Jain

& Mitra, 2021).

Patients with bipolar disorder with bipolar disorder will present as “hyperkinetic,

unpredictable, and erratic” (Jain & Mitra, 2021). They are usually disheveled, unaware of

boundaries, agitated or euphoric (Jain & Mitra, 2021). Their speech will be pressured and fast

when manic or soft and low in depressive episodes (Jain & Mitra, 2021). Their perceptions may

appear with delusions but will be congruent with their mood (Jain & Mitra, 2021). Patients will

be easily distracted, have little concentration capabilities, illogical thought processes, ideas of

grandiosity and flight of ideas (Jain & Mitra, 2021). They will be fully oriented; manic patients'

memory will be intact, whereas depressed patients may have some issues with cognition and

memory. Impulse control is extremely poor; depressed patients will show avolition and abulia

and manic patients will be aggressive (Jain & Mitra, 2021). Judgement and insight are impaired,

and they are unreliable (Jain & Mitra, 2021).

DSM criteria for bipolar disorder states that the criteria for a manic episode have been

met at least once and may be followed by a hypomanic or depressive episode (Substance Abuse

and Mental Health Services, 2016). The episodes cannot be better explained by another

psychotic disorder (Substance Abuse and Mental Health Services, 2016). The criteria for a manic

episode include there being a specific time of an abnormally high, expansive, or irritable mood

and the energy is always goal-directed, lasting at least a week and present throughout the day,

every day (Substance Abuse and Mental Health Services, 2016). During the manic episode at
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least three of the following symptoms must have occurred and are significant and noticeable

from their normal behavior (Substance Abuse and Mental Health Services, 2016). The symptoms

include having an inflated self-esteem, insomnia, talkative or pressured speech, flight of ideas,

easily distracted, increase in goal directed activity or psychomotor agitation, increase in

impulsiveness and risk-taking behaviors (Substance Abuse and Mental Health Services, 2016).

Criteria C states that the mood episode is severe enough that it causes a marked impairment in

social or occupational functioning and may need hospitalization if psychotic features are present

(Substance Abuse and Mental Health Services, 2016). The symptoms must not be better

explained by substance use or other medical conditions (Substance Abuse and Mental Health

Services, 2016).

Mrs. Warner does not have high energy, euphoria, or boundary issues. She is having

persecutory delusions. Her speech is normal in rate, rhythm, and volume. She does not have

issues with concentration, her memory is intact, and her impulse control is good. It is unlikely

that she has bipolar disorder because she does not have swings of emotions and her delusions are

not consistent with moods.

3. Schizoaffective Disorder

Schizoaffective disorder is one of the most misdiagnosed psychiatric disorder (Wy &

Saadabadi, 2021). DSM criteria for schizoaffective disorder states that criterion A for

schizophrenia is met and there is an uninterrupted period where the patient has either a major

depressive, manic or mixed episode (Substance Abuse and Mental Health Services

Administration, 2016). During this period the delusions or hallucinations must last at least two

weeks when there are no mood symptoms (Substance Abuse and Mental Health Services

Administration, 2016). Also, the symptoms of the mood episode are “present for a substantial
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portion of the total duration of the active and residual periods of the illness” (Substance Abuse

and Mental Health Services Administration, 2016). Finally, the symptoms must not be better

explained by substance use or a medical condition (Substance Abuse and Mental Health Services

Administration, 2016).

Mrs. Warner does not meet criterion A for schizophrenia. She does not have disorganized

speech, grossly disorganized behavior, or diminished emotional expression or avolition. Her

hallucinations have been present for more than two weeks in the absence of a mood episode. Her

delusions are not specific to a mood episode.

Reflections:

I learned in this case study that it is difficult to gain information from a delusional patient

who does not trust the provider. The patient in the video was very encompassed by her delusion

and would not answer questions. I also learned that many of the psychotic disorders are very

similar and have distinct small differences between them that make them different. I am not sure

that I would do anything differently from the interviewer because of the uncooperativeness of the

patient. The only thing to do is to ask the patient about their delusions and try to learn what their

current headspace is to help the patient.

Treating patients with delusions is full of ethical complications as the patient's insight and

judgement are lacking (Beck & Ballon, 2020). This means that their ability to meet the needed

requirements for informed consent, decision making, and voluntariness are impaired (Beck &

Ballon, 2020). However, a patient with delusions do not automatically lose their ability of

informed consent (Beck & Ballon, 2020). The patient's ability to make decisions becomes even

more impaired when it intersects with their delusions (Beck & Ballon, 2020). Providers always

try to do what is best for the patient and in patients with delusions the principles of beneficence
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and nonmaleficence collide with those of autonomy and being truthful (Beck & Ballon, 2020).

An example of this is not telling the patient the full truth, persuading them to involve their family

in their care and to take their medication (Beck & Ballon, 2020).

DSM-V estimates that the prevalence of delusional disorder is around 0.02 percent

(Bourgeois, 2017). This is substantially lower than the prevalence of schizophrenia which is at 1

percent and depressive disorders at 5 percent (Bourgeois, 2017). The female to male ratio varies

from 1.18 to 3:1 (Bourgeois, 2017). Men are more likely to develop paranoid delusions and

women are more likely to develop delusions of erotomania (Bourgeois, 2017). Associated factors

include being married, employed, recently immigrating, low socioeconomic status, and being

celibate in men and widowed in women (Bourgeois, 2017). The average age of onset is 40 years

old and can range from 18 to 90 years of age (Bourgeois, 2017). The etiology of delusional

disorder is not known and continues to be researched (Bourgeois, 2017). There is no way to

prevent this disorder, but early diagnoses and treatment may be able to diminish the disruption

caused to the patients’ life (Bourgeois, 2017). Complications include depression because of the

delusions, violence, or legal issues, stalking or harassing behaviors, alienation and damaging

relationships (Cleveland Clinic, 2021).

References

Beck & Ballon. (2020). Ethical issues in schizophrenia. Psychiatry Online.

https://doi.org/10.1176/appi.focus.20200030

Bourgeois (2017). Delusional disorder. Medscape.

https://emedicine.medscape.com/article/292991-overview

Cleveland Clinic. (2021). Delusional disorder. Cleveland Clinic.

https://my.clevelandclinic.org/health/diseases/9599-delusional-disorder

Jain & Mitra. (2021). Bipolar disorder. StatPearls.

https://www.ncbi.nlm.nih.gov/books/NBK558998/

Joseph, & Siddiqui. (2020). Delusional disorder. StatPearls.

https://www.ncbi.nlm.nih.gov/books/NBK539855/

Substance Abuse and Mental Health Services Administration. (2016). Impact of the DSM-IV to

DSM-5 changes on the national survey on drug use and health. Substance Abuse and

Mental Health Services Administration.

https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t20/.

Substance Abuse and Mental Health Services. (2016). DSM-5 changes: Implications for child

serious emotional disturbance. Substance Abuse and Mental Health Services

Administration. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t8/
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References

Joseph, & Siddiqui. (2020). Delusional disorder. StatPearls.

https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK539855/

Manschreck. (2020). Delusional disorder. UpToDate.

https://doi.org/https://www.uptodate.com/contents/delusional-disorder#H28688780

Wy, & Saadabadi. (2021). Schizoaffective disorder. StatPearls.

https://www.ncbi.nlm.nih.gov/books/NBK541012/