Psychiatric Diagnoses: The Case Analysis Essay

Subjective

• CC (chief complaint): The patient seems to perceive the psychiatrist as one of the persons who interfere with her life decisions and make her behave in the way she does.
• HPI: PW is a 42-year-old female of Caucasian descent. She was brought by police officers who took PW out of a closet after she locked herself and screamed for over an hour. This is PW’s third visit to the emergency room over the course of the past two weeks. Approximately a year ago, PW was admitted to a psychiatric institution. Both PW’s parents are deceased. She is married to a truck driver who works out of town. They do not have children. The family history shows PW’s father having paranoia and her mother suffering from bipolar depression. There is also a history of the patient displaying assaultive behaviors against others. PW also has trouble sleeping during the night. The patient does not engage in self-harm or self-abusive behaviors. No history of legal charges is available for PW.

Past Psychiatric History

• General Statement: This is PW’s third visit to the emergency room. She was calmed down using Ativan. The patient still refuses to sleep at night. Both of PW’s parents were diagnosed with mental health disorders.
• Caregivers (if applicable): No caregiver.
• Hospitalizations: One hospitalization at a psychiatric hospital. Three visits to the emergency room during the past two weeks.
• Medication trials: No medication history is available except for allergy to Clozaril.
• Psychotherapy or Previous Psychiatric Diagnosis: None.

Substance Current Use and History

PW drinks one glass of wine per week and does not use nicotine, caffeine, or illicit substances.

Family Psychiatric/Substance Use History

PW’s father and mother had paranoia and bipolar depression, respectively. The patient’s grandmother received “shock therapy.”

Psychosocial History

PW was born in Cameron, MT. Together with the older sister, the patient was raised by both parents. PW is married but does not have children. There was a teenage pregnancy and an abortion. No legal issues on record. It was exceptionally hard for PW to overcome the death of her parents. No childhood trauma was reported.

• Medical History:
  • Current Medications: N/A
  • Allergies: Clozaril
  • Reproductive Hx: No children. Teenage pregnancy and abortion. No abnormalities were identified.
• ROS:
  • GENERAL: No fatigue, fever, or weakness
  • HEENT: No particular issues with eyes, ears, nose, and throat
  • SKIN: No itching or rashes
  • CARDIOVASCULAR: No palpitations or chest pains.
  • RESPIRATORY: No cough or shortness of breath
  • GASTROINTESTINAL: No abdominal pain, vomiting, or nausea
  • GENITOURINARY: Burning sensations during urination
  • NEUROLOGICAL: No headache, numbness, syncope, or changes in bladder control
  • MUSCULOSKELETAL: No particular issues
  • HEMATOLOGIC: No bruising or anemia
  • LYMPHATICS: No issues
  • ENDOCRINOLOGIC: No sweating, polydipsia/polyuria

Objective

• Physical exam: Refused lab tests and diagnostics; appears majorly uncooperative. Oriented and alert, well-developed. Does not have tremors or tics but displays restlessness and mild agitation.
• Diagnostic results: The patient refused to perform any lab tests or diagnostics.

Assessment

• Mental Status Examination:
  • PW is cantankerous and displays paranoid, restless behaviors. Eye contact is consistent; the patient is neatly groomed, and no abnormalities are identified in PW’s motor activity. Most of PW’s thoughts are oblique and illogical. No homicidal or suicidal ideations have been identified. PW is tangibly delusional and paranoid. She tends to accuse and display suspicions related to the interviewer, with seemingly little insight into the overall situation.
• Differential Diagnoses:
  • The first differential diagnosis is Delusional Disorder (297.1). There are one or more delusions that occurred over the course of the past month, and the patient also displayed no conspicuously strange or impaired behaviors (Peralta & Cuesta, 2019). There have been brief depressive episodes complemented by much longer delusional periods. Overall, the disturbance displayed by PW cannot be attributed to Delusional Disorder. Thus, the patient’s ability to function normally is impaired and making it impossible for PW to meet the criteria for this differential diagnosis. The second differential diagnosis is Paranoid Personality Disorder (301.0). This is a diagnosis that can be explained by a thorough exposure to suspiciousness and pervasive distrust toward others (Cheli et al., 2021). There have to be at least four symptoms met in order to diagnose a person with Paranoid Personality Disorder, but there are only three that are consistently displayed by PW: (1) she suspects almost everyone around of exploiting and harming her, (2) she is reluctant to engage in lab tests because she is affected by the fear that personal information would be utilized against her, and (3) displays irritation every time when she thinks that someone attacks her character or reputation. Other than these three criteria, the remaining symptoms cannot be associated with PW. The third differential diagnosis (the actual diagnosis) for PW is Paranoid Schizophrenia (295.30). Over the course of the past year, the patient displayed at least two of the behaviors included in the DSM-5 description of the mental health issue: (1) disorganized speech and (2) delusional thinking (Tonna et al., 2019). PW’s most recent mental health history reinforces the diagnosis as the frequency of delusions keeps increasing drastically.
• Reflections: I believe that the biggest challenge for me was to pick the correct diagnosis and ensure that all the required symptoms were present. The inability to access information regarding PW’s suspicions and the core of her irrational thinking became the key obstacles on the way to completing the evaluation process and developing a list of differential diagnoses. From the point of ethics, I think the best way would be to avoid misinterpretation and stigmatization because mental illness does not equal abandonment and disregard. Therefore, many patients with mental health issues represent an underserved population that deserves to be seen and heard.

References

Cheli, S., Cavalletti, V., Popolo, R., & Dimaggio, G. (2021). A case study on a severe paranoid personality disorder client treated with Metacognitive Interpersonal Therapy. Journal of Clinical Psychology, 77(8), 1807-1820.

Peralta, V., & Cuesta, M. J. (2019). An empirical study of five sets of diagnostic criteria for delusional disorder. Schizophrenia Research, 209, 164-170.

Tonna, M., Ossola, P., Marchesi, C., Bettini, E., Lasalvia, A., Bonetto, C.,… & GET UP Group. (2019). Dimensional structure of first episode psychosis.Early Intervention in Psychiatry, 13(6), 1431-1438.