Case Study: Acute Psychosis and Suicidality

QUESTION

CC (chief complaint): Acute Psychosis and Suicidality

HPI: F.C. is a 48-year-old Caucasian male with a history of Schizoaffective, Bipolar disorder, Mild Intellectual disability, Delusional disorder, Depression, and Anxiety disorder. The patient was living with his mom and siblings brother called 911 for him to be brought in for a psychiatric evaluation; his concerns were about the patient’s suicidal thoughts, being off his medications, and concerns of decompensation of schizophrenia. F.C., who has not been on his treatment recently, which includes Clozapine and Depakote, is not behaving as his usual baseline behavior. The patient on assessment was quite disorganized and experienced loose associations, specifically with more complex questioning. He denied any acute distress or pain, appeared internally stimulated, and was impulsive and agitated. F.C. has hx of inpatient psychiatric hospitalizations; the most recent was at Southwest General Hospital Dec. 2022. The patient is connected to Signature Health for outpatient psychiatric services with an appointed guardian from Guardian Services. Medical record review showed that the patient’s dose of Clozapine was 150 mg and Depakote 100 mg at bedtime. Because of the patient’s nonadherence to treatment, Clozapine and Depakote would attempt to restart.

Past Psychiatric History: Multiple prior history of suicide attempts and inpatient psych hospitalization

• General Statement: The patient is alert, oriented with disorganized thoughts, and presented for psychiatric evaluation for suicidal and acute psychosis; diagnosed at an unknown age, he has been prescribed clozapine 25mg and Depakote 100 mg at bedtime in the past; the provider and PMHNP were unable to assess the patient on past last dose, due to bizarre patient behavior. The patient entered treatment years ago and stated in past medical records how many years of treatment are unknown. The patient has been in multiple inpatient facilities last inpatient facility Highland Spring in October/2022. The patient is connected to Signature Health for outpatient psychiatric services.
• Caregivers (if applicable): The primary patient caregiver is unknown and has a legally appointed guardian.
• Hospitalizations: F.C. has various inpatient psychiatric hospitalizations; The patient was recently in the inpatient psych at Southwest General Hospital in December. 2022.
• Medication trials: F.C. had previous psychotropic medications, Clozapine and Depakote; effectiveness is unknown. Current medication restarted Clozapine 25 mg at bedtime and Depakote 100 mg at bedtime.
• Psychotherapy or Previous Psychiatric Diagnosis: F.C.’s previous diagnosis was Schizoaffective, Bipolar, Mild intellectual, Depression, and Alcohol Disorder. Pt has multiple prior hospitalizations, the last admission on 4/22 at Windsor Laurelwood. Pt now in outpatient therapy at Signature Health Lakewood with an appointed guardian and case manager due to nonadherence to medication and multiple prior hospitalizations and was prescribed and treated with Clozapine 100mg, Depakote DR 1000 BID, Trazadone 50mg QHS, Haldol 5mg BID, Haldol Dec 200mg LAI, which he missed 10/18 dose, benztropine 1mg BID, hydroxyzine 50 mg P.O. q6H PRN anxiety which the patient was nonadherent to. Pt was unable to state if it was effective. Past psychiatric medications: Clozapine, Abilify, and Lithium. Pt has no hx of suicidal attempt, and pt has hx of head-banging behavior and hitting himself in the face. Pt has no hx trauma noted in his chart.

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?

Objective: What observations did you make during the interview and review of systems?

Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

Diagnostics/Labs/Psych screening tools: Please Discuss diagnostics and Psychiatric tools with evidence-based results.

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education considerations for this patient to improve health disparities and inequities in psychiatry and mental health? Demonstrate your critical thinking.

Please list 5 scholarly references and citations under five years old so I can further research.

I appreciate any help you can provide.

ANSWER

 Case Study: Acute Psychosis and Suicidality

Introduction

This case study focuses on the evaluation and assessment of F.C., a 48-year-old Caucasian male presenting with acute psychosis and suicidality. The subjective and objective data gathered during the evaluation will inform the differential diagnoses and help determine the primary diagnosis. Additionally, diagnostic tools and evidence-based approaches will be discussed, followed by reflection on the evaluation process and the impact of social determinants of health. Lastly, health promotion activities and patient education considerations will be explored to address health disparities and inequities in psychiatry and mental health.

Subjective

During the evaluation, F.C. provided information about his personal and medical history. He reported a history of Schizoaffective disorder, Bipolar disorder, Mild intellectual disability, Delusional disorder, Depression, and Anxiety disorder. The patient’s primary concern was his recent onset of acute psychosis symptoms and suicidal thoughts. The duration and severity of these symptoms were not clearly defined. F.C. expressed a decline in his baseline functioning, experiencing disorganized thoughts, impulsivity, agitation, and internal stimulation.

Objective

Objective observations during the interview and review of systems revealed disorganized thoughts and loose associations, particularly with complex questioning. F.C. appeared internally stimulated, impulsive, and agitated. No acute distress or pain was reported. The patient’s history indicated a previous pattern of nonadherence to medication and multiple psychiatric hospitalizations.

Assessment

Differential Diagnoses (listed from highest to lowest priority):
Schizoaffective Disorder: Given the patient’s history and presentation of disorganized thoughts, loose associations, and psychosis symptoms, Schizoaffective disorder is a primary consideration.
Bipolar Disorder with Psychotic Features: F.C.’s history of Bipolar disorder and the presence of acute psychosis suggests the possibility of Bipolar disorder with psychotic features.
Delusional Disorder: Delusional disorder is another potential diagnosis due to F.C.’s history of delusional symptoms and disorganized thoughts.

Primary Diagnosis: Schizoaffective Disorder

The primary diagnosis is Schizoaffective Disorder due to the combination of psychotic symptoms (disorganized thoughts, loose associations) and affective symptoms (depression and anxiety). This diagnosis aligns with the patient’s history, current symptoms, and the highest likelihood among the differential diagnoses.

Diagnostics/Labs/Psych Screening Tools

To support the assessment and diagnosis, the following diagnostics and psychiatric screening tools can be considered:
Comprehensive Psychiatric Evaluation: This evaluation includes a detailed history, mental status examination, and assessment of the patient’s symptoms, functioning, and past treatment history.
Standardized Psychiatric Rating Scales: Scales such as the Positive and Negative Syndrome Scale (PANSS) or the Brief Psychiatric Rating Scale (BPRS) can be used to measure the severity of symptoms and monitor treatment response.
Laboratory Tests: Blood tests may be ordered to assess general health, rule out medical causes of psychosis, and monitor medication levels.

Reflection Notes

In a similar patient evaluation, it would be important to ensure a thorough exploration of the patient’s adherence to medication and treatment recommendations. Additionally, assessing the patient’s social determinants of health, such as access to care, housing stability, and support systems, can provide valuable insights into potential barriers to treatment and support needs.

Social Determinant of Health: According to HealthyPeople 2030, socioeconomic status is a significant social determinant of mental health. In this case, understanding F.C.’s socioeconomic background and addressing any socioeconomic disparities can contribute to improved access to care and mental health outcomes.

Health Promotion Activity and Patient Education Considerations

Health Promotion Activity: Collaborate with community organizations and mental health agencies to provide mental health education and awareness programs, aiming to reduce stigma and increase knowledge about mental health conditions.
Patient Education Considerations: Provide psychoeducation to F.C. and his support system about the importance of medication adherence, early recognition of symptoms, and strategies for managing stressors. Encourage active involvement in therapy and support groups to enhance coping skills and promote self-care.