Psychosis Case Study

• PCOS diagnosed four years ago
• Obesity
• Lupus (diagnosed two years ago due to facial rash, no flare-up since)

• None

• PCOS
• Obesity
• Lupus

Inpatient and Outpatient Psychiatric/Mental Healthcare: Hospitalized at age 19 with initial psychotic break. Audio hallucinations and thought projection delusions. Inpatient hospitalization then for three weeks until symptoms resided. Followed up consistently for two years with outpatient visits and medication management. Good symptom control with Seroquel and CBT therapy. Follow-up with mental health counselor and psychiatrist decreased and became sporadic when client began full-time job. Patient felt symptoms were controlled enough that she may be cured and could stop medications.

Past Psych Diagnosis(es): Schizophreniform disorder

Treatments: Inpatient treatment, education of client and family

Current Psychotropic Medications: Seroquel 50 mg (1) tablet PO daily

Previous Medication Trials: Only Seroquel

Previous Therapy Trials: Individual CBT psychotherapy and social skills training

Outcomes of Previous Treatment: Substantial improvement of symptoms within five weeks on last admission and continued outpatient check-in monthly

• Birth history: Unknown
• Developmental delays: Unknown
• How were they managed? None identified.
• If any delays, what therapies were used, and did they help? N/A
• Substance Use: Denies any use of nonprescription medication, denies use of tobacco or ETOH.
• Trauma History: Denies any history of trauma.

H: Lives with parents. Four other siblings, ages 21, 18, 17, and 12 years old.

E: High school diploma

A: Secretary at local hotel

D: Non-smoker. Denies alcohol intake, denies any other substance use intake. Caffeine: two cups every morning.

S: Non-suicidality

S: Currently sexually active with one male partner x 1.5 years. No personal history of STD or exposure by partner. Last intercourse four nights ago. Uses OTC spermicide for BCP. Partner uses condoms.

Spirituality: Spiritual, no specifics.

• Father: alive, age 48, obese, recent MI at age 46
• Mother: alive, age 40, DM Type 2
• Grandparents: Unknown
• Family History of Psychiatric Mental Illness: Unknown
• Family History of Suicide: Denied

• Last immunization: Flu vaccine, two years ago
• No recent travel outside the U.S.

• Last gyn exam and Pap, ASCUS with negative HPV co-testing eight months ago at primary care provider.
• Follow-up Pap due in three years. Last PCP visit, eight months ago for possible contraception initiation to aid with PCOS symptoms.

Regularly wears seatbelt when riding as passenger.

No weapons in the home.

Reports usual health as “good.” Denies fever, chills, weight changes.

• Denies cough, dyspnea, or wheezing.
• Denies history of asthma, recurrent infections.

Denies chest pain, palpitations.

• Diagnosed with UTI three days ago. Nocturia, urinary frequency, and lower abdominal pain have resolved.
• Menarche age 15. Cycle usually q 35–55 days irregularly, duration eight days, flow moderate, mild dysmenorrhea, LMP three weeks ago. G0T0P0A0L0.
• Currently sexually active with one male partner x 1.5 years. No personal history of STD or exposure by partner. Last intercourse four nights ago. Uses OTC spermicide for BCP. Partner uses condoms.

• Denies polyuria, polydipsia, and polyphagia. Denies cold-heat intolerance, nervousness, change in appetite, weight gain, or change in skin.
• Reports history of PCOS, reports adherence to Metformin therapy but not sure why taking.

• Complains of increase in facial hair to chin and at side of face. Also complains of “acne” to cheeks and around nose.
• Lupus rash was present two years ago, no flare-up since.

• Denies coordination problems, numbness, tingling.
• Denies seizures or frequent headaches.
• Not aware of memory problems.
• Denies history of head injury.

Anhedonia, constricted affect, presence of significant stressors.

Hypersomnia, difficulty getting up in the morning, no middle-night awakening.

Inability to successfully carry out goal-directed behavior, social isolation.

Low self-esteem, anxious in public, lack of motivation, guilt over diagnosis.

No increased energy, feeling fatigued.

Difficulty concentrating when hearing voices.

No increased or decreased appetite.

Audio hallucinations, no command voices, voices are distracting. Sometimes unable to distinguish if hallucination or actual people around her. Afraid co-workers and family members can read her thoughts. Visual and tactile hallucinations now occurring daily—spiders or bugs crawling on arms and legs.

No self-inflicted injuries, no frequent thoughts of death, no suicidal thoughts, no suicidal intent, no past suicide attempts.

No homicidal thoughts, sometimes wants to “kill” the voices and spiders.

Withdrawn, poor work performance, limited interpersonal relationship problems. Stopped taking meds after getting new job and feeling like she was better.

A&O x 2 (person and place only). Disheveled appearance. No spontaneous speech, but answers questions when asked.

Cooperative, distracted, at times seems to be responding to internal stimuli (voices) by suspiciously looking about the room. No hostile nor disinterested attitude, no heightened startle, no hypervigilance.

No tremors or tics; normal gait and stance; no involuntary movements.

Minimal, slowed speech, normal volume.

Anhedonia, constricted affect, anxiety at times related to suspicions and voices.

Constricted.

No language abnormalities; speech fluent, but minimal, normal sentence structure.

Patient oriented x 2; no disorientation, short-term memory impairment, reduced abstraction ability, some cognitive functioning.

No deficiency on evaluation of connectedness, organized.

Audio hallucinations, paranoid ideations, thought insertion, no suicidal ideation, nor homicidal ideations.

Impaired insight, impaired judgment, poor problem-solving.