Diagnostic Case Conceptualization for Schizophrenia

Abstract

The Diagnostic Case Conceptualization Study intimately examines the schizophrenia spectrum and other psychotic disorders from symptoms to treatment plan as it attempts to extract the varied avenues of the psychotic disorder and their infamous abnormalities. The purpose of this written element is to understand how individuals, affected with a disorder on the schizophrenia Spectrum, suffer from symptoms beyond visibility. A thorough reflection of the cultural component and competency is also explored by connection of the ethnic and social impacts of the disorder. Concerning evidence-based treatment plans, this written component also attempts to keep abreast with current and effective treatment plans in the support of the annihilation of the notoriety of psychotic disorders and mental health illness.

Keywords:  Schizophrenia Spectrum, Treatment Plan

Diagnostic Case Conceptualization for Schizophrenia 

Diagnosis Coding:  295.90 (F20.9) Schizophrenia. According to the Diagnostic and statistical manual of mental disorders: DSM-5, 2013, “the defining attributes of a schizophrenia diagnosis are the commencement of two or more of the diagnostic criteria for a period of 30 days. The diagnostic criteria are: delusions, hallucinations, grossly disorganized speech or catatonic behavior, and negative symptoms.”

Diagnosis Justification

Hector, a 19-year-old Hispanic male, with no record of prior hospitalization or illicit substance or alcohol use, which was confirmed by a toxicology report. Hector has no known history of symptoms from the autism spectrum disorder. Hector has displayed several symptoms of Diagnostic Criteria of the Schizophrenia Spectrum and other Psychotic Disorders. Upon listing Hector’s symptoms, Hector has been given a temporary diagnosis of Schizophrenia, until further testing assessment of cognition, depression, and mania symptom is completed, these areas are necessary for differentiating between schizophrenia and other psychotic disorders. Hector has shown symptoms of abnormalities in the five domains, Delusions, hallucinations, grossly disorganized or abnormal motor behavior, and negative symptoms. Within the domain of delusions, Hector has experienced grandiose, persecutory, and erotomaniac delusions.

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Hector was suspended from his university after incident. It was reported Hector entered his class room hollering, “I am the Joker and I am looking for Batman.” Upon Hector’s refusal to depart the classroom, campus police were contacted. According to the Diagnostic and statistical manual of mental disorders: DSM-5, 2013, Diagnostic Criteria of Schizophrenia, Hector has satisfied one of the criteria, as he experienced grandiose delusions, delusions defined as an individual believing they are exceptionally affluent, possess larger than life capabilities, or excessive talent.

Hector had become progressively fixated with a female friend of the family living locally. Hector announced to his family the two were engaged to be married. It was discovered by Hector’s brother and confirmed by the female friend, the two were not affiliated in any way and Hector had written several unmailed letters. The DSM-5 describes erotomaniac type delusions as delusions that center to a person being in love with the individual. Hector has displayed romantic type delusions by insisting to his family that he was engaged to a stranger.The DSM-5 describes Persecutory type delusions as delusions involving belief that the individual is being maliciously plotted against. Hector displays paranoid delusions by alleging the hospital’s food was poisoned.  According to Hartley, Barrowclough & Haddock, “the evidence for an association of persecutory delusions with negative self-thoughts is convincing and is consistent with broader work showing links of negative emotion to positive symptoms of psychosis including paranoia.” Hector also suffers from Hallucinations.In another reported observation, which has satisfied criteria, Hector “stood on the roof of a house waving his arms as if he were “conducting a symphony.” He denied any intention of jumping from the roof or thoughts of self-harm, but claimed he felt liberated and in tune with the music when he was on the roof.”

According to Kerkar, “researchers have shown that many patients with schizophrenia have lesser levels of insight and judgmental abilities making it difficult for them to cope and deal with their situation”. Hector agreed “to sign himself into a psychiatric unit stating, “I don’t mind staying here, Anne will probably be here, so I can spend my time with her.” Patients often agonize from poor cognitive function and poor judgment. According to Cuesta & Peralta, “Poor insight is sometimes seen as just another symptom or manifestation of the disorder.” (Cuesta and Peralta, 1994).

After reading Hector’s evaluation and the notes of the LCSW, Hector was observed as being “a well-groomed young man who is uncooperative, appeared constricted, guarded, inattentive, and preoccupied. Hector was noted to have paranoid, grandiose, and romantic delusions. Hector also was internally preoccupied and refuted hallucinating. Hector described feeling “bad” but refused the thought of having depression. Hector self-reported no disturbance in sleep or appetite. He no longer sees his friend and spent most of his time lying in bed staring at the ceiling. He lived with several family members but rarely spoke to any of them. He was suspended from college because of nonattendance. His brother has seen him mumbling quietly.” According to The National Institute of Mental Health Measurement and Treatment Research to Improve Cognition in Schizophrenia consensus panel has outlined “five negative symptoms: minimized facial and emotional expression, decrease in oral articulacy, lack of participation in social relationships, declination in needs or objectives, an interactive reduction and incapability to encounter desire from encouraging inducements.

A history of mental illness is present inf the family. “Hector’s grandmother lived in a state psychiatric hospital for 15 years until her death, diagnosis unknown. Hector’s mother was reportedly “crazy.” According to Corcoran, Vinogradov, and Cadenhead, (n.d.) “Studies directed in the previous decade designates that schizophrenia is due to a genetic tendency and environmental stressors early in a child’s development”.

Rule Outs

Two diagnoses considered but ruled out were, based on Hector’s symptoms, are Schizophrenia Spectrum and Other Psychotic Disorders, Delusional Disorder Diagnostic Criteria 297.1 (F22) Mixed type. This was ruled out because “Criterion A for schizophrenia has been met, delusions and hallucinations. The second diagnosis that was considered but ruled out was Schizophreniform Disorder, Diagnostic Criteria 295.40 (F20-81), but catatonia did not present in Hector and Schizophreniform episodes last for at least 1 month but less than 6 months. Hector has been having episode for a year.

Treatment Plan

Goal #1: To improve overall mental health by participating in pharmacology therapy.

Objectives: Recognize medicines side effects disruptive to symptoms and cause harmful side effects. 

Strategies:  Hector will self-report symptoms by tracking side effects with a visual indicator.

Medication Necessary (Y/N): Y      Re-Evaluation Date _12/30/2018___

Type & Frequency of Service: Medication evaluation monthly

Goal #2: To prevent negative symptoms, delusions, and hallucinations.

Objectives:  To reduce hallucinations and delusions.

Strategies:  Hector will utilize his friends and family as a support system when he feels “bad”.

Goal #3:  Hector will keep all appointments.

Objectives:  Hector will improve overall mental health functioning by keeping all appointments. 

Strategies: Hector will be appointed a mentor.

Medicine Necessary (Y/N): Y       Deadline for Reevaluation: 12/15/2018  

Evidenced-Based Treatment.

Schizophrenia can be warded off with a combination of therapeutic efforts which involve, pharmacological involvements. This combination effort can diminish symptoms. decompensation. Many individuals suffering from schizophrenia find an effective strategy with the grouping of pharmacological and social intervention. According to Mueser, Deavers, Penn, & Cassisi, “Interventions targeting specific domains of functioning, age groups, stages of illness, and human service system gaps are classified as evidence-based practices or promising practices according to the extent to which their efficacy is currently supported by meta-analyses and individual randomized controlled trials.”

Diagnosis and Treatment Approach from a Biopsychosocial Model.

“The biopsychosocial model is an all-inclusive technique representing a natural and effective way for both understanding the connection of the treatment to the disease. Biopsychosocial model also represents schizophrenia as being somatic or relating to the person’s biological system. Even when prescribing medications, the serious side effects should be considered which could include EPS, extrapyramidal symptoms, symptoms consisting of akathisia, parkinsonism, and dystonia."

Cultural, Emotional, Mental, and Social Impacts

People suffering from Schizophrenia suffer from the loss of relationships, extreme emotional burdens, as they are often misunderstood and labeled “crazy”.  Being labeled and stigmatized, often many individuals are outcasted. This population will face a higher significance to suicide. It is key in considering the cultural implication of the mental health diagnosis, especially schizophrenia and its treatment are tremendously imperative. The ruthless truths of health disparities are a fact in the Hispanic community. Mental health must be made a priority.

References

• Andreasen NC. Symptoms, signs, and diagnosis of schizophrenia. Lancet. 1995 Aug 19;346(8973):477-81.
• Cuesta M.J., Peralta V. (1994). Lack of insight in schizophrenia. 359–366.
• Corcoran, C., Cadenhead, K., & Vinogradov, S. (n.d.). California. Retrieved November 23, 2018, from http://www.schizophrenia.com/earlypsychosis.htm#.
• Kerkar, P. (8, January/February). Insight judgement. Retrieved November 23, 2018, from https://www.keyword-suggest-tool.com/search/insight judgement mse/.
• Hartley, S., Barrowclough, C., Haddock, G. (2013). Anxiety, and depression in psychosis: a systematic review of associations with positive psychotic symptoms. 128(5):327-46. doi: 10.1111/acps.12080.
• Kirkpatrick B, Fenton WS, Carpenter WT, Jr, Marder SR. The NIMH-MATRICS consensus statement on negative symptoms. Schizophr Bull. 2006; 32:214–9.
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