IMust use American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Text citation: (American Psychiatric Association, 2013) for one of the citations
IDENTIFICATION: The patient is a 35-year-old Caucasian, English speaking, married male on permanent disability who lives with his wife and three children. He is being treated via telepsychiatry.
CHIEF COMPLAINT: Ive been having a lot of trouble with paranoia and anxiety.
HISTORY OF PRESENT ILLNESS: The patient has been in treatment at this community mental health agency continuously for the past several years. His primary complaints are auditory hallucinations, paranoia, and anxiety. The voices tell him he is worthless. They become more intense when he is alone. They bother him almost constantly, to the point that his wife can tell he is not present. He attempts to participate in the school activities of his children but admits that he can never stay for a full program because the voices tell him that someone there is going to hurt him. He has terrifying nightmares. The hallucinations and accompanying paranoia cause fears that others are talking about him, that his children may get hurt, etc. These fears precipitate panic attacks with rapid heart rate, difficulty breathing, tingling in hands and feet, upset stomach, and sweating. Due to the panic/fears he isolates himself. He also describes panic symptoms not triggered by any voices. However, he is trying to manage his anxiety by healthy activities such as walking over a mile a day.
PAST PSYCHIATRIC HISTORY: At age 9, the patient was hospitalized for behavior problems. He reports that he had dyslexia, attention deficit problems, and explosiveness. He has been in juvenile treatment centers. He has a history of suicide attempts at age 11 through overdose, at age 12 with shotgun. He had cutting behaviors. First auditory hallucinations occurred when he was around age 17. From age 17 he engaged heavily in drug use which included methamphetamines, heroin, cocaine, marijuana, and alcohol. He stopped using all substances at the age of 25 years when he almost died from an overdose. He was engaged in psychotherapy. He also received pharmacological treatment. Psychotropic medications have included lurasidone, buspirone, asenapine, lithium carbonate, quetiapine, and lorazepam. In the past 2 years, he has had two episodes of mania lasting 2 to 3 days, spaced about 6 months apart. His current medications are: lithium carbonate ER 300 mg in the AM and 900 mg at HS, quetiapine 300 mg at HS and 50 mg BID, lorazepam 1 mg TID PRN anxiety, and silenor 3 mg one at bedtime.
MEDICAL HISTORY: The patient has no known allergies. He has diabetes mellitus type 1, diabetic neuropathy, elevated liver enzymes, hyperlipidemia, hypertension (systemic), nonorganic sleep apnea, and osteoarthritis. His most recent hemoglobin A1c =8.7 (high). His weight is 304 lb. Body mass index (BMI) is 37.5. While taking olanzapine and then asenapine, his liver enzymes were elevated. His liver enzymes are currently normal. He is taking carvedilol 3.125 mg BID; Humalog KwikPen 25 units before meals, Lantus SoloSTAR 68 units at bedtime, atorvastatin 20 mg daily, lisinopril 2.5 mg daily, metformin 1,000 mg BID, ProAir HFA 108 two puffs every 4 hours PRN. Recently started on orlistat 120 mg daily. His sleep pattern has improved from only 3 to 4 hours nightly to 5 to 7 hours with the use of silenor.
HISTORY OF DRUG OR ALCOHOL ABUSE: The patient is a former cigarette smoker. He reports heavy drug and alcohol use from age 17 to 25. He acknowledges that his use was a form of self-medication for the hallucinations. He states, I used anything and everything: methamphetamines, heroin, cocaine, pot, and alcohol. He says he almost died at age 25 from overuse, which is what led to his decision to stop. He has not used substances since then. He no longer drinks alcohol due to the impact on his blood sugar. He achieved sobriety through participation in Alcoholics Anonymous meetings and the support of his church.
FAMILY HISTORY: The patient does not know if his biologic heritage includes any mental illness. He says that during his childhood, his father was violent and abusive, angry, yelling, and throwing objects. His father never received any diagnosis or treatment. His parents are alive and still married to each other, but the relationship is characterized by bitterness and fighting. The patient often feels pulled into the conflict and forced to take sides. He has two brothers and one sister. He feels close to his sister.
PERSONAL HISTORY
Perinatal history: No known complications.
Childhood: Was able to make friends and function academically in school. No known learning disabilities.
Adolescence: Completed high school.
Adulthood: After high school he left his family and moved out of state. He was in the Army briefly and was released due to mental health issues. He was married at age 20, and this ended in divorce with one child. He has been with his current spouse now for 10 years. They have two children. His child from his first marriage lives with them. He is on disability. He lives in an area that is underserved by psychiatric providers, so he is being treated via telepsychiatry.
TRAUMA/ABUSE HISTORY: The patient experienced abuse from his father. He does not elaborate on these details other than to say his own anger scares him because he does not want his children to live through what he did.
MENTAL STATUS EXAMINATION
Appearance: Neat, clean, appropriately dressed in casual wear, clean-shaven.
Behavior and psychomotor activity: Cooperative, pleasant, gait normal, posture upright, sits calmly in chair with no fidgeting, does not show or report any involuntary movements or tics.
Consciousness: Alert and oriented to person, time, and place.
Memory: Intact. Able to recall distant events of his life, recounts events from yesterday.
Concentration and attention: Able to do simple arithmetic, spell world backward. Stays on topic in conversation during sessions.
Visuospatial ability: Accurately draws clock-face and puts in stated time.
Abstract thought: Able to accurately explain proverbs People who live in glass houses shouldnt throw stones, and Dont cry over spilled milk.
Intellectual functioning: Average vocabulary and fund of general knowledge.
Speech and language: Good volume, calm rate of speech, fluid flow.
Perceptions: Auditory hallucinations of voices telling him he is worthless. No visual hallucinations reported.
Thought processes: Clear, linear, logical.
Thought content: Frequent thoughts that others are against him.
Suicidality/homicidality: No thoughts, intentions, or plans to hurt self or others.
Answer the following questions:
- Based off the above case presentation what is the most likely mental health diagnosis? (all diagnoses must be fully documented and coded (ICD-10) per the DSM-5; incomplete diagnoses will result in automatic points being deducted)
- What is your rationale for the diagnosis?
- What diagnostic testings or screening tools should be considered to help identify the correct diagnosis?
- What differential diagnosis should be considered and why?
- Describe your work-up and treatment plan for this client. Remember, this client is in the outpatient setting. Include a long-term plan for the management and monitoring of each psychotropic.
- What type of community supports or case-management services would this client benefit from? Make sure to cite EBP.