Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as a lack of emotion or withdrawal from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.
For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.
To Prepare: Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating schizophrenia spectrum, other psychotic, and medication-induced movement disorders.
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Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Sherman Tremaine. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
The Assignment: Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. 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, and list them in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule 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.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also, incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. 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.).
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).
Solution
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): The patient comes to the office with delusions and paranoia of alleged people who have been watching her.
HPI: The 53-year old comes to the office complaining of people watching her. She also claims that she has been hearing voices, loud and heavy music.
Substance Current Use: Uses tobacco, drinks alcohol, and has a history of taking marijuana
Medical History:
Current Medications: Metformin for diabetes
Allergies: None
Reproductive Hx: Not sexually active
ROS:
GENERAL: No significant weight gain or loss, no fatigue, no chills
HEENT: No eye pain or redness, no vision changes, no sneezing, no runny nose, or no congestion
SKIN: skin warm to touch, no itching, or redness, no eczema
CARDIOVASCULAR: no chest pressure, no palpations, no chest pressure pain or edema
RESPIRATORY: No wheezing, denies cough or sputum, no shortness of breath
GASTROINTESTINAL: no constipation, no anorexia, no burning sensation, no diarrhea
GENITOURINARY: no changes in the urinary pattern, no urgency, no incontinence
NEUROLOGICAL: no dizziness, no paralysis, denies tingling, no confusion
MUSCULOSKELETAL: no muscle weakness, pain, or stiffness
HEMATOLOGIC: no bruising, or bleeding, no history of anemia
PYSCHIATRY : History of schizophrenia and anxiety in the family
LYMPHATICS: no swollen lymphatics, no history of splenectomy
ENDOCRINOLOGIC: no cold or heat intolerance
Objective:
Vitals: Temp 96.2, pulse rate of 80. Respiration 18 non-labored, B/P 118/78
Diagnostic results:
The patient scored 6 on the Positive and Negative Syndrome Scale during a psychiatric examination which indicates that the patient’s symptoms are severe.
Assessment:
Mental Status Examination: The patient is a 53- year old Caucasian woman who appears her age. She is however not oriented to time and place. She is cooperative during the session. She is delusional during the interview and complains of hearing loud music which the therapist does not hear.
Diagnostic Impression: The diagnostic impression is Paranoid schizophrenia. The differential diagnoses are schizoaffective disorder, delusional disorder, brief psychotic disorder,
Paranoid schizophrenia
Paranoid schizophrenia is the diagnostic impression based on the patient’s clinical manifestations. The patient is delusional and unreasonably suspicious. Paranoid schizophrenia is a common type of mental illness where individuals are not in touch with reality. The disease affects a person’s behavior, way of thinking, and perceptions related to the immediate environment. Individuals suffering from the condition become unreasonably suspicious of others which makes it hard to maintain social relationships or even adhere to medications (Pinkham et al., 2016).
According to the DSM-5, two or more of the following must be present for one month. The symptoms are delusions, hallucinations, disorganized speech, negative symptoms like alogia, affective flattening, etc, and grossly disorganized or catatonic behavior. According to Krzystanek et al. (2016), 60 percent of schizophrenia patients tend to discontinue their treatment after 2 to 3 months without consulting their physicians which increases their vulnerability to a relapse of the symptoms. The patient’s father was also diagnosed with paranoid schizophrenia which justifies the diagnosis since the condition is hereditary.
Schizoaffective disorder
Schizoaffective disorder refers to a chronic mental illness that involves the symptoms of schizophrenia and mood disorders like depression and bipolar disorder. Symptoms may include delusions, depression symptoms, hallucinations, mania, problems with speech and communication, the lack of personal care, at work and school (Joshi et al., 2016). There are two types of schizoaffective disorder namely the bipolar type and the depressive type. The bipolar type includes episodes of mania and at times depression while the depressive type involves only major depressive episodes. Some of the causes of schizoaffective disorder include genetics, environment, brain chemistry, and structure as well as drug use.
Delusional Disorder
The diagnosis of delusional disorder is made from the prevalence of one or more delusions that occur for one month (Joseph & Siddiqui, 2019). The delusions result in the impairment of social and occupational problems. Delusions can be categorized into four groups namely bizarre, non-bizarre, mood-congruent, and mood neutral. Bizarre delusions are usually strange and implausible while non-bizarre delusions are possible but usually unlikely. Mood congruent delusions usually entail false beliefs which are in line with a person’s mood.
Brief psychotic disorder
Brief psychotic disorder refers to a psychotic condition that entails an onset of psychotic symptoms that lasts at least a day but less than a month. Symptoms include hallucinations, delusions, disorganized thinking, problems with memory, unusual behavior and dressing, speech or language that does not make sense, confusion and disorientation, poor decision making, and changes in eating and sleeping habits (Verinder & Baczynski, 2020).
Psychotherapy plan
The psychotherapy plan that would be the most suitable for this patient would be cognitive behavioral therapy. Cognitive-behavioral therapy is a type of therapy that modifies undesirable thinking, feelings, and behavior (Ganguly et al., 2018). One CBT technique that has been associated with schizophrenia is cognitive restructuring which entails challenging a patient to come up with evidence that their beliefs are real. The technique enables the patients to see that they have delusions. Patients exposed to this technique usually learn how to identify and change negative emotions, their faulty thoughts replacing them with realistic ones.
Alternative therapy that I would prescribe for the patient would be yoga therapy. Yoga reduces psychiatric symptoms, improves mental and physical life while at the same time reducing metabolic risk.
Case Formulation and Treatment Plan:
After the patient’s diagnosis with schizophrenia disorder, the treatment, and management plan was a combination of therapy and pharmacological agents. The patient was prescribed Risperdal 2 mg. Risperdal is a second-generation antipsychotic which are recommended or the management of schizophrenia (Gilbody et al., 2016). The initial dosage was 2 mg/daily with daily increments of 1 to 2 mg at intervals of 24 hours. After tolerability with PO risperidone, the patient can be put on Risperdal Consta based her history with non compliance with drugs. The medication will work by reducing the patient’s hallucinations and delusions.
The medication’s side effects however include anxiety, insomnia, nausea, weight gain, metabolic changes, hyperprolactinemia.
Reflection
If I were to see this patient again, I would try out a different therapy rather than cognitive-behavioral therapy. I would try out relaxation techniques like breathing exercises to enable the patient to gain control over her thought process (Škodlar & Henriksen, 2019).
The health promotion activity that I would carry out would be patient eduction on the importance of compliance with medication based on her medical history and a history of using drugs.
The patient education strategy that I would adopt would be the use of verbal instructions to instruct the patients about the condition and medication prescribed.
The history that would be important to collect from patients
- If there is another family member who presents with similar symptoms
- How the father coped with the disease
Interview questions
- How has your mental health issues affected your social life?
- Do you think you inherited the condition from your father based on his history of schizophrenia?
- Do you think if you are put on medication and therapy your life will improve?
- Do you feel safe at home or away from home?
Legal and ethical issues
Based on the patient’s history of non-compliance with drugs, the case study attracts ethical issues of non-compliance with drugs. It was necessary therefore for the patient to be educated on the need to comply with the treatment plan to minimize cases of relapse of symptoms. Similiarly, since the patient is not in any employment, she is likely to experience issues with affordability of the medication and therapy which communicates the need for open communication on how she can sustain her treatment.
The patient was educated on the need to seek medical attention in case of adverse events or allergic reactions.
The patient seemed to understand the discussion and at the same time agreed to follow the instructions as laid out throughout the session.
In case of an emergency, the patient should call 911.
The patient should return to the clinic after four weeks for follow up during which she will discuss with the physician any notable event or changes in health. The follow-up session will also ensure that the patient is coping well with the medication and therapy and there is a positive improvement in her symptoms.
Discussion Prompts
- Causes of schizophrenia
- Best psychotherapy for schizophrenia
- Pharmacological treatment for schizophrenia
References
Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic management of schizophrenia symptoms using pharmacological and non-pharmacological treatment. Frontiers in public health, 6, 166.
Gilbody, S., Bagnall, A. M., Duggan, L., & Tuunainen, A. (2016). WITHDRAWN: Risperidone versus other atypical antipsychotic medication for schizophrenia. The Cochrane database of systematic reviews, 9(9), CD002306. https://doi.org/10.1002/14651858.CD002306.pub2
Joseph, S. M., & Siddiqui, W. (2019). Delusional disorder.
Joshi, K., Lin, J., Lingohr-Smith, M., Fu, D. J., & Muser, E. (2016). Treatment patterns and antipsychotic medication adherence among commercially insured patients with schizoaffective disorder in the United States. Journal of clinical psychopharmacology, 36(5), 429.
Krzystanek, M., Krysta, K., & Skałacka, K. (2017). Treatment Compliance in the Long-Term Paranoid Schizophrenia Telemedicine Study. Journal of technology in behavioral science, 2(2), 84-87.
Pinkham, A. E., Harvey, P. D., & Penn, D. L. (2016). Paranoid individuals with schizophrenia show greater social cognitive bias and worse social functioning than non-paranoid individuals with schizophrenia. Schizophrenia Research: Cognition, 3, 33-38.
Škodlar, B., & Henriksen, M. G. (2019). Toward a phenomenological psychotherapy for schizophrenia. Psychopathology, 52(2), 117-125.
Verinder, S., & Baczynski, C. (2020). Clarifying the onset of brief psychotic disorder at childbirth. Archives of women’s mental health, 23(2), 221-221.