Subjective
CC (chief complaint): Ms. Jess Davies experiences depressive symptoms and delusions related to recent traumatic events.
HPI: J. D. is a 30-year-old White female who presents for psychiatric evaluation for depressive and psychotic symptoms due to the referral by her two roommates. She has stopped her medication, which was alprazolam 1mg twice daily, and allegedly experiences persecutory delusions and auditory hallucinations.
Past Psychiatric History
Ms. Jess Davies has a recent history of depression after the death of her aunt and brother. There are no additional specifications regarding the medical history of her parents.
- Caregivers: Ms. Jess Davies was raised by her aunt.
- Hospitalizations: There is no history of hospitalizations mentioned.
- Medication trials: Ms. Jess Davies has a history of taking alprazolam to relieve anxiety and depression symptoms for fifteen days, prescribed by her primary care provider.
- Psychotherapy or Previous Psychiatric Diagnosis: She has received treatment from her PCP; however, the details are omitted.
- Substance Current Use and History: Ms. Jess Davies has smoked cannabis since she was seventeen years old and drinks occasionally with her roommates.
- Family Psychiatric/Substance Use History: There is no history of family psychiatric or substance use.
Psychosocial History
Ms. Jess Davies was raised by her aunt and had a seemingly healthy relationship with her only sibling, her brother. Both of her closest relatives died in a short time, and she personally witnessed her brother being killed via a gunshot wound during a burglary. The patient does not talk to her parents or seek emotional help from them. The succession of traumatic events caused depressive symptoms and allegedly persecutory delusions. She currently lives with two roommates, works in a bakery, and has maladaptive nutrition (canned food exclusively) and sleep behaviors (~2 hours of sleep per day). There are no additional details regarding the patient’s education level, hobbies, legal history, or exposure to traumatic events.
Medical History
No specific information is available regarding the patient’s medical history.
- Current Medications: Ms. Jess Davies is currently not taking any medications.
- Allergies: Allergy to medical tape.
- Reproductive Hx: No specific information.
ROS
- GENERAL: Ms. Jess Davies does not report weight loss, fever, chills, weakness, or fatigue.
- HEENT:
- Eyes: Ms. Jess Davies does not report visual loss, blurred vision, double vision, or yellow sclerae.
- Ears, Nose, Throat: Ms. Jess Davies does not report hearing loss, sneezing, congestion, runny nose, or sore throat.
- SKIN: The patient does not report rash or itching.
- CARDIOVASCULAR: The patient does not report chest pain, chest pressure, chest discomfort, palpitations, or edema.
- RESPIRATORY: Ms. Jess Davies does not report shortness of breath, cough, or sputum.
- GASTROINTESTINAL: There are no indications of anorexia, nausea, vomiting, diarrhea, abdominal pain, or blood.
- GENITOURINARY: The patient does not report burning on urination, urgency, hesitancy, odor, or odd color.
- NEUROLOGICAL: The patient does not report headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.
- MUSCULOSKELETAL: The patient does not report muscle pain, back pain, joint pain, or stiffness.
- HEMATOLOGIC: No anemia, bleeding, or bruising.
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- ENDOCRINOLOGIC: The patient does not report sweating, cold, heat intolerance, polyuria, or polydipsia.
Objective
Physical exam: not applicable.
Diagnostic results: not applicable.
Assessment
Mental Status Examination
The patient, Ms. Jess Davies, is a 30-year-old White female who looks her age. She currently works in a bakery but demonstrates somewhat limited social competencies. She is uncooperative with the examiner, refusing to answer some questions and avoiding complicated topics. There are indications of misbehavior, emotional agitation, and noticeable suspicion towards the examiner. She is neatly dressed and groomed; however, her motor activity and non-verbal mechanisms are abnormal. Namely, during the interview, the patient constantly twitches, actively gesticulates, fiddles in the chair, and cannot maintain a stable body position for longer than 1-2 seconds.
The patient’s speech and expressions are clear and intelligible; however, her tone ranges from neutral to highly agitated, depending on her mood, which fluctuates during the interview. The thought process is mostly irrational, with notable symptoms of persecutory delusions – the patient believes that people around her have malicious intent towards her. She holds beliefs in conspiracy theories, including those involving Russian spies and secret government documents. There is an evident looseness and a presence of incomprehensible cognitive patterns.
Ms. Jess Davies cannot clearly explain why she undergoes a psychiatric evaluation and has trouble connecting rational ideas. Her facial expressions are emotionally appropriate to her mood; however, the periods of agitation are not based exclusively on the topic or conversation. The patient denies visual hallucinations but admits to hearing and knowing things that others cannot. The severity of delusions ranges from mild to severe, potentially significantly affecting her relationships with others. Ms. Jess Davies has recently stopped taking her medications, believing that they were harmful to her. She does not report headaches, paralysis, or ataxia, but her cognitive abilities seem to be severely affected by delusions and intrusive thoughts.
The patient has avoided the question about suicidal or homicidal ideations. Alternatively, it is possible that she has not fully understood the question due to cognitive patterns that are incomprehensible. Ms. Jess Davies does not seem mindful of relevant concerns, including the deaths of her relatives and potential relationship problems with her roommates. Instead, she primarily focuses on persecutory delusions, talking about her Russian neighbors (who are reportedly Spanish), and conspiracy theories. Therefore, the patient demonstrates a low level of cognitive awareness/alertness and a high severity of delusions. It is problematic to assess the patient’s memory due to her focus on delusions; however, she clearly remembers her roommates. Ms. Jess Davies appears to be concentrated during the conversation, but her insights are often interrupted by sudden emotional agitation and incomprehensible cognitive patterns.
Differential Diagnoses
Schizophreniform Disorder
Ms. Jess Davies demonstrates several symptoms commonly associated with schizophrenia spectrum disorders, including emotional agitation (grimacing, suscipision, outbursts, and mild symptoms of excited catatonia), disorganized thoughts, persecutory delusions, auditory hallucinations, incomprehensible cognitive patterns, and flawed insights/judgment (Boland et al., 2022). According to the present analysis, the most likely diagnosis is the schizophreniform disorder.
Namely, the DSM-5 criteria for the condition are mostly the same as for schizophrenia, including the required symptoms (≥2) of delusions, hallucinations, and disorganized thoughts (Boland et al., 2022). However, the differential factor is the duration, which is longer than six months for schizophrenia and between one and six months for schizophreniform disorder (Boland et al., 2022; Liu, 2022). According to the data, Ms. Jess Davies developed the symptoms recently after her aunt’s and brother’s deaths. Ultimately, the patient demonstrates common schizophrenia symptoms, but the duration of the condition is less than six months, suggesting that the main diagnosis is schizophreniform disorder.
Delusional Disorder (DD)
Despite the prevalence of schizophrenia symptoms in the patient, the manifestations are comparatively mild, implying the possibility of other diagnoses. For instance, Ms. Jess Davies is still capable of functional living, such as going out with her roommates or understanding/answering most examiners’ questions, which is unlikely in moderate-to-severe schizophrenia (González-Rodríguez & Seeman, 2022). Moreover, the most notable issue is the presence of persecutory delusions, which are highly prevalent in DD (González-Rodríguez & Seeman, 2022).
Nevertheless, according to DSM-5 criteria, DD is not associated with disorganized thoughts and incomprehensible cognitive patterns (Boland et al., 2022). Boland et al. (2022) state, “They (DD patients) also have generally normal cognition apart from their delusion,” which is not the case for Ms. Jess Davies since the state of her functional impairment resembles mild-to-moderate schizophrenia symptoms (p. 1035). Therefore, based on the examination, DD is a differential diagnosis.
Brief Psychotic Disorder (BPD)
BPD requires the presence of at least one schizophrenia symptom, maladaptive behavioral patterns, and a duration of the psychotic episode of less than one month (Boland et al., 2022). In other words, by the end of the first thirty days since the onset, the patient typically recovers with full remission. While the exact time period of the patient’s symptoms is unknown in the present case, it appears to be longer than one month.
Namely, Ms. Jess Davies developed her first symptoms after her aunt’s death (script), her brother was killed twelve days later (case details), and she was prescribed medication for fifteen more days. These inconsistencies in duration suggest that BPD is unlikely to be the main diagnosis. Moreover, according to DSM-5 criteria, BPD is typically associated with one major psychosis symptom, while Ms. Jess Davies experiences all schizophrenia manifestations to an extent (Boland et al., 2022). Hence, although more research is necessary to establish the exact condition, BPD is likely to be a differential diagnosis.
Schizoaffective Disorder
Schizoaffective disorder manifests via both psychotic and mood symptoms, meaning that the diagnosis requires an established bipolar, depressive, or anxiety disorder (Parker, 2019). Preferably, more information is necessary on the severity of Ms. Jess Davies’s depressive symptoms after her aunt’s death. However, it is clear that during the examination, psychotic manifestations are dominant in the patient. According to DSM-5 criteria, mood symptoms must be present throughout most of the disorder duration, which is not evident in the case details or interview (Boland et al., 2022; Parker, 2019). Therefore, schizoaffective disorder is unlikely to be the main diagnosis for Ms. Jess Davies.
Reflections
Based on the presented information, the most likely diagnosis is schizophreniform disorder due to the prevalence of all schizophrenia symptoms of mild-to-moderate severity and duration longer than one month. However, the details in the case are limited. If I were to conduct the session, I would focus on the patient’s family medical history, the duration of the condition, and the presence of mood symptoms. Ultimately, since there is no laboratory test for assessing schizophrenia spectrum disorders, a thorough mental health examination is paramount (Boland et al., 2022).
The patients’ and their families’ medical histories are critical as well because it is essential to evaluate psychotic symptoms over a prolonged period of time (more than one month) to establish an accurate diagnosis. Moreover, the research confirms that people who are exposed to schizophrenia in their first-degree relatives are more likely to develop the condition (Boland et al., 2022). Hence, I would preferably supplement the examination with semi-structured interviews with the patient’s roommates and parents to further understand Ms. Jess Davies’s past medical history (PMH).
Consequently, if I were to conduct the session, I would employ diagnostic questionnaires. For instance, the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS) can help assess the patient’s condition in greater detail (Boland et al., 2022). The tests are typically designed in a neutral tone to prevent emotional agitation, which is considered an ethical approach. Finally, the most critical factor to be identified during the examination is the onset and duration of the disorder. It is one of the primary differential metrics for schizophrenia spectrum disorders and is critical for the current case.
Although the mental health examination should be as thorough as possible and address the described issues, it is critical to adhere to the legal and ethical regulations of the profession. I recognize that Ms. Jess Davies might be incapable of providing comprehensive answers since patients with psychotic symptoms have “poor insight into the nature and severity of their disorder” (Boland et al., 2022, p. 1002). Moreover, the patient demonstrates emotional agitation at various stimuli, meaning that some questions might be detrimental to her mental health. Lastly, the examiner should not acknowledge persecutory delusions as the truth because this approach might further aggravate the patient’s condition and affirm their delusions (Boland et al., 2022). It is critical to follow these guidelines to ensure ethical decision-making during the mental health examination.
Finally, there are multiple patient and risk factors associated with schizophrenia spectrum disorders. For instance, patients who develop BPD frequently have the following demographic characteristics: young adults (20-30 years old) and females, which fit Ms. Jess Davies’s profile. Other critical risk factors include education, seasonality of birth, birth complications, childhood trauma, urban upbringing, cannabis consumption (highly relevant for Ms. Jess Davies), and cognitive deficits (Boland et al., 2022).
Although most of this information is unspecified in the present case, these characteristics are significant in determining the epidemiology of the disorder. There is non-extensive research on the impact of socioeconomic factors on schizophrenia specifically, but inadequate social determinants of health can aggravate depressive symptoms, which are prevalent in schizoaffective disorder (Parker, 2019). In summary, it is essential to conduct a thorough medical examination, especially focusing on condition onset/duration and PMH, to establish an accurate diagnosis.
References
Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini narrative review. World Journal of Psychiatry, 12(5), 683-692.
Liu, Y. (2022, December). New perspectives of schizophreniform disorder. In 2022 6th International Seminar on Education, Management and Social Sciences (ISEMSS 2022) (pp. 1964-1972). Atlantis Press.
Parker, G. (2019). How well does the DSM-5 capture schizoaffective disorder? The Canadian Journal of Psychiatry, 64(9), 607-610.