Schizophrenia Spectrum and Other Psychotic Disorders; Medication-Induced Movement Disorders

Week 5: Schizophrenia Spectrum and Other Psychotic Disorders; Medication-Induced Movement Disorders

Subjective:

CC (chief complaint): The patient says, “ I was living and not bothering anyone, and those people, they just won’t leave me alone.”

HPI: S.T., a 55-year-old African American, comes to the clinic for psychiatric evaluation after her sister requested him to do so. He reports that he was living with his mother before she died 3 years ago. He says that he lived without bothering anyone and that some people would not leave him alone. He reports that there are people outside his window who keep watching him and that he can hear them as well as see their shadows. He says that the government sent them to keep watch on him. He indicates that his taxes are high in the sky. He reports that the same people watch him through his television screen. He says that the same people come inside his house to try to poison his food, but he locks everything up in his fridge. He illustrates seeing a bird and hearing metal music during the interview. He reports having difficulties falling asleep due to loud voices that keep him up for days. He indicates that he no longer goes to the grocery store since they play too loud heavy metal music and because they also follow him there. He says that he had been hospitalized 3 times when he was 20 years old. He reports having been prescribed Haldol, Thorazine, risperidone, and Seroquel, which he says are all poison; hence, he would not take them. He also indicates that he is on metformin for his diabetes and that he has a fatty liver. The patient was brought up by her mother and his sister. He reports that his father was rough on them when he was growing up before he died. He says that his father had been diagnosed with paranoid schizophrenia and that his mother had anxiety. The patient is currently not working and reports that he lives alone.

Substance Current Use: He has a history of smoking, alcohol consumption, and marijuana use. The patient reports that he smokes the entire day, around 3 packs in a day. He consumes alcohol around 12 packs in a weekend, and his last drink was yesterday. He says that he started using marijuana after his mother died 3 years ago.

Medical History:

• Current Medications: He is currently taking Haldol, Thorazine, risperidone, and Seroquel, all of which he does not take.
• Allergies: The patient has no known allergies.

• Reproductive Hx: No sexual concern was reported.

ROS:

• GENERAL: No loss or gain in weight reported. No weakness, fatigue, fever, or chills. No sweats or night sweats.
• HEENT: Hair present. No recent change in texture or hair loss. There is no history of severe headache, dizziness, or head injury. No difficulty with vision. No eye pain or double vision was reported. No swelling, redness, watering, or eye discharges were reported. No loss of hearing, earaches, or abnormal discharge. The patient reports no colds, nasal obstruction, sinus pain, allergies, nosebleeds, or changes in smell. He reports no mouth pain, bleeding gums, frequent sore throat, or difficulty swallowing. He has no changes in voice or altered taste.
• SKIN: The patient has no history of skin diseases, changes in skin color or pigment, excessive dryness or moisture, rash, bruising, or lesions.
• CARDIOVASCULAR: The patient has no chest pain, fullness, pressure, tightness, palpitation, cyanosis, or dyspnea on exertion. He has no history of hypertension, heart murmurs, or coronary heart disease.
• RESPIRATORY: No history of lung conditions. No chest pain during breathing, wheezing, noisy breathing, or dyspnea. No cough, sputum, or exposure to toxins or pollutants.
• GASTROINTESTINAL: No constipation or diarrhea. No black stools or rectal bleeding. No changes in appetite, dysphagia, heartburn, indigestion, or abdominal pain. No nausea or vomiting.
• GENITOURINARY: No urgency or frequency in urination. No nocturia, dysuria, polyuria, oliguria, or straining. No history of urinary disorders.
• NEUROLOGICAL: No history of seizures, fainting, or blackouts. There is no history of weakness, tic, or tremors. He has no paralysis or coordination issues. He has no numbness or tingling in the lower extremities.
• MUSCULOSKELETAL: No history of arthritis or gout. No joint pain or edema. No deformity or limited motion. No muscle discomfort, cramping, weakness, gait issues, or difficulty with coordinated activities. No back pain, stiffness, or restricted motion. No history of disk disease.
• HEMATOLOGIC: No excessive bleeding or bruising. No history of blood transfusions.
• LYMPHATICS: No lymph node swelling, No history of splenectomy.
• ENDOCRINOLOGIC: The patient has diabetes, and he is currently on metformin. No history of thyroid disease, changes in skin pigmentation, intolerance to heat and cold, or excessive sweating.

Objective:

Physical Examination

Skin—On inspection, there are no lesions or rashes. The skin is warm and dry and has good turgor on palpation.

HEENT:

• The head is atraumatic and normocephalic.
• Pupils are equal at 3 mm. They are round and responsive to light and accommodation.
• The extra-ocular muscles are intact.
• Negative for nystagmus
• No nasal discharge or nasal polyps
• The tympanic membranes are gray and shiny bilaterally; there is a minor accumulation of cerumen
• The mucous membranes are moist
• Throat clear without exudates or lesions

Neck and Lymph Nodes:

• The patient has non-palpable cervical, axillary, inguinal, and femoral lymph nodes
• He has a supple neck without jugular venous distension or thyromegaly

Cardiovascular:

• Has a normal sinus rhythm with no murmur. He has a normal S1 and S2. No gallops or rubs. Normal and non-displaced point of maximal impulse. The pulses in the carotid and femoral arteries are normal, and no bruits are present.

Chest/Lungs:

• There is no tachypnea or dyspnea. The lungs are clear to auscultation. There is a full chest excursion without tenderness.

Extremities: No deformities noted. They have a full range of motion. The Peripheral pulses 2+ through.

Neurological:

• Finger-to-nose normal and has negative Romberg. No localizing symptoms. The CNs II–XII are intact. Motor: 5/5 bilateral grip strength. The patient has a normal gait. Has feet sensitive to vibration, light touch, and pinpricks.

Diagnostic results:

Complete blood cell count- The low-grade inflammation associated with schizophrenia is critical in determining patient outcomes. White blood cell count, red cell distribution width, and total leukocytes are blood morphological components that can predict inflammatory processes (Bartoli, et al., 2021). A growing body of research indicates that understanding the neutrophil-to-lymphocyte ratio can help gain insights into pro- and anti-inflammatory homeostasis in psychosis (Juchnowicz et al., 2023). The monocyte-to-lymphocyte ratio (MLR) and the platelet-to-lymphocyte ratio (PLR) are other indicators showing inflammatory activities. An earlier study by Özdin & Böke (2019) illustrates that during the remission period, schizophrenia patients exhibited significantly higher MLR and PLR values compared to healthy individuals, which supports the inflammation hypothesis of the disease.

The blood chemistry panel includes electrolyte levels, renal function, liver function, and thyroid-stimulating hormone (TSH). TSH levels may be decreased in individuals with first-episode psychosis and increased in those with multiple-episode schizophrenia (Stańczykiewicz et al., 2021). Electrolyte abnormalities may lead to neurological manifestations. According to Mitra et al. (2021), hyponatremia can induce electrolyte imbalance and possibly account for psychotic symptoms.

Glucose levels- Patients with schizophrenia face an elevated risk of having metabolic disruptions as a result of their susceptibility to metabolic dysfunctions like insulin resistance, which can be exacerbated by the subsequent administration of antipsychotic medications (Kornetova et al., 2020).

Drug toxicology screen- This involves testing for drugs of abuse, including cannabis, alcohol, opioids, and cocaine. Patel et al. (2020) indicate that the presence of tetrahydrocannabinol in cannabis exacerbates symptoms of schizophrenia and psychosis, which contributes to increased rates of relapses and hospitalizations. The increased alcohol consumption has been linked to higher levels of general psychopathology (S. Chang et al., 2021). Cocaine enhances the release of striatal dopamine, which is considered a crucial mechanism in primary psychotic disorders (Sabe et al., 2021).

Brain imaging- to rule out tumors, cerebral abscesses, vasculitis, and subdural hematomas. Through magnetic resonance imaging, brain abnormalities associated with schizophrenia have been identified, including decreased white and gray matter volume and increased cerebrospinal fluid volume (Dabiri et al., 2022).

Electroencephalography—Disturbances in alpha, theta, and gamma activity, together with mismatch negativity and P300, have been associated with deficits in cognitive domains and executive functioning in the early stages, chronic phases, and at-risk mental states of schizophrenia spectrum disorders (Perrottelli et al., 2022).

Assessment:

Mental Status Examination:

The patient is a 55-year-old African American male who looks his stated age. His attitude towards the interviewer is appropriate. He has irregular eye contact. He is in an upright sitting position and keeps moving and shifting his hands. He shows unidentifiable distractions, such as seeing a bird. His speech is clear and normal in volume and tone. The patient’s thought process shows looseness of associations, and the interviewer cannot clearly follow the patient’s topic related to ‘those people.’ He also exhibits a tangential thought process; he talks about his high taxes when asked about people bothering him. The patient’s mood is euthymic, and affect is appropriate with the mood. There is evidence of visual and auditory hallucinations; she reports seeing a bird and hearing heavy metal music. Delusions are evident when he talks about people who keep watching him. He denies any suicidal ideation. The patient is oriented x 1; he is unable to give the approximate date and time of day as well as the place where he is. His recall, recent, and remote memory is fair. His concentration is fair. He lacks insight into his illness; he says that her sister made him come tha,t he was living alone without bothering anyone and that ‘those people’ would not leave him alone.

Diagnostic Impression:

Schizophrenia, multiple episodes, currently in acute episode 295.90 (F20.9)

The patient reports seeing a bird and hearing heavy metal music during the interview. This is a clear presentation of visual and auditory hallucinations. He has persecutory delusions, demonstrated by his belief that there are some people who keep watching him and want to poison his food. The patient shows looseness of associations as well as tangential thought processes. He meets criterion A of DSM-5-TR for the diagnosis of schizophrenia (American Psychiatric Association, 2022). The patient reports that he currently does not work, which shows that the disturbance has impaired his level of functioning. The patient says that his symptoms began 3 years ago after his mother died, which shows that the disturbance has persisted for more than six months. There are no manic or depressive episodes exhibited, which rules out mood disorders with psychotic features. The patient’s disturbance is not a result of a medical condition. The patient’s symptoms meet the DSM-5-TR diagnostic criteria for Schizophrenia, multiple episodes, currently in an acute episode, which makes the primary diagnosis (American Psychiatric Association, 2022).

Schizophreniform Disorder 295.40 (F20.81)

The patient’s symptoms display visual and auditory hallucinations, persecutory delusions as well as looseness of associations. He meets criterion A of schizophreniform disorder based on DSM-5-TR. The patient’s symptoms started 3 years ago after his mother passed away. This rules out the schizophreniform disorder, which requires the patient’s episodes to last for more than one month but less than 6 months, according to DSM-5-TR criteria (American Psychiatric Association, 2022).

Brief Psychotic Disorder 298.8 (F23)

In the patient’s case, there is the presence of hallucinations, delusions, and disorganized speech, hence meeting criterion A of brief psychotic disorder. However, the duration of the disturbance is more than one month, and the patient’s symptoms are better explained by schizophrenia, which rules out the disorder.

Delusional Disorder

The patient believes that there are people who keep watching him and aim to poison his food, which illustrates persecutory delusions. The disturbances have lasted for more than one month, thus meeting criterion A of delusional disorder based on DSM-5-TR. However, there is the presence of prominent hallucinations, and the patient’s symptoms are better explained by schizophrenia disorder (American Psychiatric Association, 2022).

Reflections:

The interviewer did exemplary well during the evaluation session. Schizophrenia, multiple episodes, currently in acute episode, is the primary diagnosis based on the patient’s data after a complete assessment. The differential diagnoses considered were appropriately ruled out based on symptom duration and presentation. This case reinforced the importance of a thorough history and mental status examination in diagnosing complex psychiatric conditions. Documenting specific examples of the patient’s symptoms and behaviors is essential in formulating the patient’s diagnosis. If I were to redo the evaluation, I would assess the patient’s capacity to make medical decisions, given his medication non-adherence status.

On legal/ethical considerations, the patient’s refusal of medications needs to be evaluated in light of their capacity to make informed decisions. However, respecting patients’ autonomy while ensuring they receive necessary treatment is a key ethical challenge. This would require involving his sister, who seems close to him, in the treatment process and the patient’s general well-being.

On social determinants of health, several factors may impact the patient’s health outcomes. According to Anglin (2023), Black Americans and Latinx are more likely to develop psychosis due to factors such as racial discrimination. The patient is currently unemployed, which may affect access to care and medication adherence. In addition, living alone and withdrawing from social activities may exacerbate symptoms and reduce support systems.

The patient has a family history of psychiatric disorders, including schizophrenia and anxiety, hence the need for health promotion and disease prevention. According to Le et al. (2020), individuals with a positive family history of schizophrenia have a greater risk of developing the disorder. Furthermore, the patient reports that his father used to be rough on them, which indicates childhood trauma. An earlier study by Jester et al. (2023) shows that childhood abuse increases the risk of getting schizophrenia later in life. Frequent evaluation and an effective support system would go a long way in reducing the risk of developing mental disorders. I would provide psychoeducation to the patient and family members to improve understanding of his condition as well as treatment adherence. Regular screening for diabetes complications and management of fatty liver disease would help prevent the worsening of his condition.

Case Formulation and Treatment Plan:

The evaluation reveals key symptoms appropriate for the diagnosis of schizophrenia, which include hallucinations, delusions, looseness of associations, tangentiality, duration over 6 months, functional impairment, and exclusion of other disorders. The patient has type 2 diabetes, which is managed with metformin. He has a history of hospital admissions and had previously been on antipsychotic medications, including Haldol, Thorazine, risperidone, and Seroquel.

I would involve the patient in the treatment plan and consider his previous medication response, side effects profile, and preferred route of administration. In addition, I would actively involve his family in treatment planning and implementation. The patient may have experienced a relapse due to medication non-adherence. In pharmacologic therapy, I would discuss with the patient and consider transitioning him to a long-acting injectable antipsychotic. I would consider risperidone 25 mg I.M. (Risperdal Consta) administered every 2 weeks. I would prescribe risperidone 2 mg taken orally every 24 hours along with the injection for the next 3 weeks to make sure adequate therapeutic plasma concentrations from Risperdal Consta are achieved. I would consider adding quetiapine 50 mg taken orally every 12 hours with a possible increase of its dosage up to 400 mg. Second-generation antipsychotics are known to have fewer extra-pyramidal side effects compared to first-generation antipsychotics, thus encouraging adherence. The patient should continue with metformin 1000 mg taken orally every 12 hours to enhance target cell insulin sensitivity and reduce G.I. glucose absorption. Weight gain and metabolic disturbances have been reported with the majority of antipsychotic drugs, hence the need to monitor fasting blood glucose and lipid profiles (Chang et al., 2021). I would advise the patient on smoking cessation and quitting alcohol consumption.

I would recommend individual psychotherapy, which is effective in helping the patient and therapist establish a therapeutic alliance. Patients with schizophrenia who have a strong therapeutic alliance are more likely to stick with their treatment plans, adhere to medications, and do well on 2-year follow-up assessments (Browne et al., 2021). Cognitive behavioral therapy (CBT) has been found to be beneficial in helping individuals with schizophrenia gain insight into their condition and reduce the likelihood of relapsing (Fei et al., 2021). Relapses may be less common with family-oriented therapies that educate the relatives and patients about schizophrenia and promote talking about psychotic episodes and the circumstances surrounding their emergence. Social skill training may help to enhance social skills, including eye contact. I would also advise the patient to join support groups such as the National Alliance on Mental Illness, which provides further education and resources for patients with psychiatric illnesses and their families. The patient may also benefit greatly from participation in community-based self-help and support organizations like Alcoholics Anonymous or Narcotics Anonymous during his recovery process. Patient education would involve teaching on the need to report any adverse effects associated with medications. I would educate the patient on the risks associated with taking over-the-counter medications along with prescribed drugs. The patient’s next follow-up clinic would be after 2 weeks.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Anglin, D. M. (2023). Racism and Social Determinants of Psychosis. Annual Review of Clinical Psychology, 19(1), 277–302. https://doi.org/10.1146/annurev-clinpsy-080921-074730

Browne, J., Wright, A. C., Berry, K., Mueser, K. T., Cather, C., Penn, D. L., & Kurtz, M. M. (2021). The alliance-outcome relationship in individual psychosocial treatment for schizophrenia and early psychosis: A meta-analysis. Schizophrenia Research, 231, 154–163. https://doi.org/10.1016/j.schres.2021.04.002

Chang, S., Jeyagurunathan, A., Lau, J. H., Shafie, S., Samari, E., Cetty, L., Mok, Y. M., Verma, S., & Subramaniam, M. (2021). Problematic Drug Use Among Outpatients With Schizophrenia and Related Psychoses. Frontiers in Psychiatry, 12, 762988. https://doi.org/10.3389/fpsyt.2021.762988

Chang, S.-C., Goh, K. K., & Lu, M.-L. (2021). Metabolic disturbances associated with antipsychotic drug treatment in patients with schizophrenia: State-of-the-art and future perspectives. World Journal of Psychiatry, 11(10), 696–710. https://doi.org/10.5498/wjp.v11.i10.696

Dabiri, M., Dehghani Firouzabadi, F., Yang, K., Barker, P. B., Lee, R. R., & Yousem, D. M. (2022). Neuroimaging in schizophrenia: A review article. Frontiers in Neuroscience, 16, 1042814. https://doi.org/10.3389/fnins.2022.1042814

Fei, X., Wang, S., Zheng, X., Liu, K., & Liang, X. (2021). Global research on cognitive behavioural therapy for schizophrenia from 2000 to 2019: A bibliometric analysis via CiteSpace. General Psychiatry, 34(1), e100327. https://doi.org/10.1136/gpsych-2020-100327

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