Case Conference Protocol on Delusional and Schizophreniform Disorders

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Table of Contents

Client Presentation (Presenting Problem)
Case Conceptualization (Diagnosis)
Comprehensive Treatment Planning (Intervention)
References

Dorothea Cabot is a 42-year old beautiful woman. She is a performing artist and is married to Cabot who is a well known Republican in the Province. He is good natured and kind and they loved each other. Out of their wed lock two children were born. When the children grew up the Cabot family was hesitant to continue living in the suburb though they owned a large house and farm in the country side. Dorothea preferred city life so that the children could get a good learning environment. Cabot could not say anything against her wish and without much ado they moved to a villa in the city. A nanny was put in charge of the whole household. With this, Cabot thought it would be a relief to Dorothea and that she could get enough time to move about meeting people in connection with her cultural activities.

The radiant Dorothea quickly earned her name in the societal circle being elite and influential rather than using her aesthetic caliber. Her emergence as a cultural volunteer was backed up by her childhood friend who was settled in the same locality where she lived. They were very much devoted and helpful to each other. Dorothy was proud of her fine body, and her health never put her down. While they spent their days planning things, it was known that there would be a cultural event in their locality in connection with the world premier show of a new ballet. Dorothea, who was inspired by the patronage from her friend, grabbed the responsibility of coordinating the event by utilizing her influential position. It was a sudden shift in her life, and to make things work quick, she undertook some construction jobs, and in that process she had to encounter some adverse situations.

Since she was supposed to prepare everything for the imminent stage show, she had to speed up the work, and in that effort she confronted certain construction problems and tools down strikes in the work site by the workers. To make matters worse, the set designer became volatile and threatened to walk out on the project if the stage properties were not delivered on time and the props were not fixed according to his meticulous specifications. Dorothea had a terrible time in calming him down. At this juncture, she was caught unawares by the disputes between the management and herself on the construction work she has undertaken. She was losing control of herself. She started feeling that more and more issues would come up to hamper the smooth finishing of her task and the successful inauguration of the show would become remote. The problems continued to escalate while time was running out and it was nearing the deadline. She was uncertain about the completion of the task. She felt everything has gone against her.

While these were happening her household problems also swelled and went out of control. Her nanny went on leave to visit her sick relative which resulted in the accumulation of domestic works, and that too fell upon her shoulders. In the midst of these difficulties, her best friend died in a car accident. Dorothea was heartbroken over the death of her friend. Her sudden demise affected her mental equilibrium and she started showing psychotic aberration. She was in the grip of uncontrollable agony. She was totally shrunk immediately after the funeral of her friend (Spitzer 2002).

Client Presentation (Presenting Problem)

Dorothea is now increasingly tense and jittery. Her sleep is limited 2 to 3 hours only during night. Two days after the funeral of her friend, Dorothea happened to see a woman who was driving a car just like the one her friend had driven. She was puzzled then. A few hours later she started to think that her friend is alive and that the accident has been staged. To her this is a part of a plot conceived along with the funeral. She firmly believes now that the plot is being directed toward her too and she is in grave danger. She no more trusts anyone except her dear husband. She fears that her phone is tapped and that the rooms are “bugged.” She pleads with her husband to save her from these dangers. She begins to hear a high-pitched, undulating sound, which she fears is an ultrasound beam aimed at her. She was in a state of sheer panic, gripping her husband’s arm in terror, when he brought her to the emergency room (Spitzer 2002).

Case Conceptualization (Diagnosis)

On seeing the delusional symptoms of Dorothea it was prima facie evident that she needed immediate medical attention. The previous case entries and the clinical data were studied keenly, but it was not possible to ascertain the real cause of the illness. It was because there was no report of a past case like this in the clinic to be leaned or referred to. The previous medical history of Dorothy as told by her husband proved she was in perfect health. The family traits were also checked. They were clean. The personal inquiries made to her husband Cabot could not dig out anything further that was conducive. What required now was the sort of cause and effect details to determine the form of diagnoses. Therefore, as a physician, it was necessary to go through the classifications and features elaborated in the DSM-IV-TR to assess the gravity of the illness before adopting a method of approach to diagnose the illness of Dorothea. Confidence was there, but to get substantial support was the need of the time.

In mental health analysis the term Diagnosis is said to be the bedrock of modern medicine. It is a concise denotation to give practical guidance in treatment, course and prognosis. It provides a real platform for prevention of illness and research. Diagnostic categories are reliable entities while they acknowledge the existence of imperfections. It ensures the liberty to take these imperfections as approximations, limited by the blank in current knowledge. However, it leaves no negation, and accelerates the presumption that knowledge will become perfect as science progresses while time passes on (Oken 2000).

DSM is an acronym for Diagnostic and Statistical Manual of Mental Disorders. It contains instructions for psychotic disorders which are referred to by the mental health professionals and practitioners in the United States. It is structured to cope with every diagnosing need in the health sector and it extends to all realms of occupation and rehabilitation. It is the designated tool for gathering and transacting precision public health statistics (DSM-IV Multiaxial System).

List of mental disorders are enlisted as diagnostic classification which is the authentic part of the DSM system. The selection and evaluation of the disorders from the classification reflecting the symptoms are known as DSM Diagnosis. Every disorder put into the DSM system has certain criteria that denotes the qualifying symptoms for diagnosis known as inclusion criteria. The disorders having no such explicit symptoms are categorized as exclusion criteria. This sort of inclusion and exclusion determine an individual’s qualifying nature to a particular diagnosis. Thus DSM gives compact and systematic description capsules of every mental disorder (DSM-IV Multiaxial System).

The nature of each disorder is explained and elaborated under several headings read from Diagnostic Features to Differential Diagnosis in DSM. It provides a firm empirical basis for executing modifications also (DSM-IV Multiaxial System).

It is stated in the DSM that while considering all these probabilities during diagnosis, the existence of an avoidant personality disorder must not be left unseen in patients with symptoms of SAD. Even if it is so, the diagnosis of avoidant personality disorders can mislead a physician as it is not yet clinically proven by recent studies. That is the reason why some researchers suggest removing avoidant personality disorder from the DSM as in the case of avoidant disorder of childhood or overanxious disorder in children and adolescents (EMEA 2006).

Therefore, in the diagnosis of the mental disorder of Dorothea the following symptoms are taken into consideration, as per the stipulations of DSM-IV-TR. They are: (1) persecutory delusions (2) auditory hallucinations (3) Intense tension and anxiety (Spitzer 2002).

In some patients, anxiety is seen associated with social situations of formal performances like presentation of a lecture or informal social interactions in the form of conversations, partying or dating. These are generic type of SAD. In a few other patients, anxiety occurs only when they are confronted with tasks like public speaking, or eating and drinking in public places, leading to a diagnosis of a non-generalized type of SAD. Exhibitory symptoms of anxiety in feared situations are shaky voice, clammy hands, trembling, sweating, palpitation, nausea and blushing. Associated attributes of SAD are hypersensitivity to criticism, allegation, subjection or rejection, lack of assertiveness, low self-esteem, morale etc. (EMEA 2006).

The ICD-10 diagnostic criteria are not at all strict in principle. It needs the presence of fear of social situation symptom or fear of humiliation symptom or avoidance symptom so as to make the diagnosis fruitful. Hence, the diagnostic criteria of SAD instituted by DSM IV-TR can be used for clinical trials. (EMEA 2006)

Differential diagnosis

Social anxiety is deeply connected with many other DSM-IV-TR disorders. It is seen that the disorders distinct from and other than specific phobia are linked with fear and avoidance of specific stimuli. Therefore, SAD should not be associated with common fear and anxiety on the basis of quantitative differences in the level of impairment. It can happen that at times other anxiety disorders may be left out or wrongly diagnosed as SAD. Panic disorder or generalized anxiety disorder is a fine example to this. It becomes necessary to determine which disorder is primary and which one is predominant when symptoms of depression and SAD exist in a patient at one time. Clinical reports reveal that a good number of patients with SAD develop severe depression. About one third of patients with primary major depression display symptoms of SAD (EMEA 2006).

Severity and Burden of Disease

Since SAD can set its roots in an early stage of one’s life, it will affect the learning process and social exemplary of adolescence. It can lessen the emotional health and work performance of the youth resulting in decreased employment and a troubled social life. Seclusion or loneliness, limited friendships, becoming single, divorced or separated, becoming prone to psychotropic medication, suicidal attempts, thoughts, money problems, seeking frequent medical attention and the feeling of having an unsatisfied life etc. are the results of it. SAD is generally linked to chronic psychosocial impairment and negative effect on the qualitative life of the patient (EMEA 2006).

Personality disorder is one of the most frequently reported disorders diagnosed in mental clinics, according to American Psychiatric Association (APA 2000). Vulnerability is very much associated with insecure styles or attachment styles. These styles are characterized by inconsistency or emotional unavailability of a patient (Ainsworth1978).

Personality disorder is seen more in women than in men. Therefore a study was conducted in this line also. In women it takes the form of submissiveness, while in men it is seen autocratic, leading to depression and anxiety. Personality disorders can be viewed as outcome of insecure working models that have become self confirmatory. These working models of self and other become comparatively rigid and shut to new information or awareness. Because of this the individual experiences distress in social, occupational, and relative functioning. Thus it is feasible to characterize the several disorders of the individuals in terms of their dimensional models (Sperry 2003).

Considering these with Marked Stressors as per the guidelines given on page 332 of DSM IV-TR diagnosis of Dorothea’s disorder was conducted. For eliciting accuracy in determining the disorder the diagnosis Provisional pending follow-up was adopted to ensure that she would return fully to her premorbid level of functioning. Rejecting the vague symptoms and behaviors, the clear and evident relationship between the stressor and the gradual origination and growth of the psychotic symptoms were focused. Since the predominant symptoms were persecutory delusions consisting of imagined themes like ‘ultrasound beams aiming at Dorothea’ which are termed as bizarre by certain clinical studies, it was decided to reject the possibilities of occurrence of Delusional Disorder and Schizophreniform Disorder. These diagnoses warrant the illness to prolong for at least one month. If the patient fails to recover, the possibility of Delusional Disorder of Persecutory Type could not have been ignored. This is because the delusional disorder involves the patient’s imagining bizarre themes like ultrasound beams. For, there is a reality of existence of ultrasound waves around us (Spitzer 2002).

John Briere and Catherine Scott, in their book ‘Principles of Trauma Therapy’ describe the symptomatic attributes to the disorder as: “With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person’s culture. Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person’s culture” (Briere & Scott 2006).

The main characteristics of Brief Psychotic Disorder is the sudden onset of any one of the positive psychotic symptoms such as delusions, hallucinations, disorganized speech or catatonic behavior. This disturbance may subside in one day or can continue to 1 month. The individual will get complete cure and will return to the premorbid level of functioning. The disturbance cannot be identified with a Mood Disorder With Psychotic Features or with Schizoaffective Disorder (Brief Psychotic Disorder).

The heavy psychosocial stressors in the form of severe confrontations in the work place and anxiety about non completion of the entrusted task and the inability to tackle the household problems paved the way to build the intense psychosocial stressor on her which is the death and funeral of her best friend given on Axis IV, caused the sudden outburst of Dorothea’s psychotic symptoms identifiable as persecutory delusions followed by auditory hallucinations. Dorothea’s case is an example of diagnosis under Axis I of Brief Psychotic Order (Spitzer 2002).

The findings that Dorothea had a good premorbid functioning really helped in arriving at a conclusion of ‘No Diagnosis’ on Axis II. In the same way it was also noted that as she had no major adverse medical condition prior to the admission to the clinic, it was needful to reject the possibility of putting a listing on Axis III. Axis IV called for the entries regarding her friend’s death, confrontations in the work place, and the absence of her nanny in the household. Thus it is decided to put the rate of 30 on Axis V towards her present functioning as her behavior is significantly influenced by her paranoid ideas (Spitzer 2002).

Multi axial Evaluation

After the detailed diagnosis, medication and observation the results were entered in the multi axial evaluation format as given below:

Axis I Clinical Disorders consisting of V-Codes, and conditions for Clinical attention : Brief Psychotic Disorder With Marked Stressors
Axis II Disorders & Mental Retardation: No Diagnosis
Axis III General Medical Conditions: Nil
Axis IV Psychosocial & Environmental issues: Death of the friend, work place obstacles, absence of nanny
Axis V Global Assessment of Functioning Scale = 30 (present) (Spitzer 2002).

Comprehensive Treatment Planning (Intervention)

Psychoanalytic Approach

The patient was examined on the basis of phenomenology, clinical research, and experimental neuropsychology. This was done assuming that the patient has mental illness. She experiences delusions and hallucinations which are pathological requirement for clinical treatment. Accordingly, drug compliance and illness symptoms were accepted as two separate entities. Neuropsychology was also chalked out because it has direct relation to the physiological mechanisms of insight. In order to assess these three dimensions of insight in psychosis of the patient, a printed questionnaire was created. Dorothea’s previous medical history was probed into and a check on her belongings including medical bills of the family were conducted (David 1990).

Cognitive-Behavioral Approach

During diagnosis it was found that there existed psychotic symptoms in the patient which could be resolved within one month. Since the disorder was supposed to be caused by a significant stressor, accounting it as an onset, and considering that she lacks a history of previous psychotic disorder, the following treatment was prescribed to the patient.

Aero medical disposition: NPQ/unfit (limited duty medical board). Waiver possible if there is significant precipitating stressor. It was presumed that the symptoms of the patient would disappear fully without recurrence and no psychotropic medications are required for her (Mittauer).

Since the patient has no hypertension or any other psychotic disorder previously, Aerospace Medical Disposition was advised, i.e., by giving NLP test consisting of monitoring the blood pressure in the morning and evening for three days. If 4/6 readings are less than 155/95 she will be qualified and no further treatment is required. If it is higher, it confirms the presence of hypertension due to any of precipitating stressor and in that case medication may require (Hypertension-Aero Medical Disposition, 2009)

Cognitive behavioral therapy (CBT) is made on the assumption that psychotic disorders are resulted from continuous perception by the patient that the world is a harmful place. This mal adaption to the physical environment creates intensification in anxiety of the patient. CBT replaces the non adaptive tendency with several adaptive coping responses which in due course will change the perception of the patient to go back to normalcy. By this method the patient is subjected to self-monitoring which includes relaxation training such as paced diaphragmatic breathing, meditation, cognitive restructuring etc. (Newman & Borkovec 1995).

Ethical considerations and Humanistic Approach

It is known that human dysfunctions are caused by a disrupted development process. These can happen due to immaturity and emotional disturbance. Considering this aspect together with the positive notion that there could be a return of the patient to the pre-morbid condition, as a physician in lieu of the professional ethics, proper interaction with the patient was initiated on time to allow her to come back to the former mainstream of normal life. In order to achieve it, a good rapport was built and extended to the patient (Dombeck 2006).

In addition to the above, during the course of treatment the patient was made to understand that she had a sort of very brief psychotic disorder and the physician was doing his best to cure it. The detailed analysis of the pre-medical history in relation to the patient’s background inspired the physician to take a pragmatic approach in the diagnosis as well as the treatment. This logical and ethical decision did marvels to get a quick recovery of the patient and her return to pre-morbid condition. The guidelines and principles of the American Medical Association on Medical Ethics were scrupulously followed in this regard (Ethics guidelines for the practice of forensic Psychiatry 2005).

The physician understood that primarily, he was bound by a duty to be fulfilled to the patient as well as to the society. In this attempt the ethical principles respecting persons, honesty, justice, and social responsibility were well observed. These involved the presenting of issues of confidentiality. Hence, effort was made to maintain the patient’s privacy and confidentiality. Moreover, the objective of the clinical examination was well informed to the patient’s spouse as the patient was not in a condition to receive the information (Ethics guidelines for the practice of forensic Psychiatry 2005).

Initially, during the course of evaluation formal notice was given about the nature and purpose of the evaluation. It was also made known of the limits of its confidentiality. To this effect, the consent of the spouse of the patient was obtained, since the patient was not at all fit and competent to give the consent at that time. Care was taken not to inform the patient explicitly that the physician was the ‘doctor’ at the beginning of admission of the patient at the clinic and during collection of data of her physical background and at the time of the clinical evaluation. The institutional policies attached to the psychiatrists were honestly put into practice (Ethics guidelines for the practice of forensic Psychiatry 2005).

The physician only applied his expertise in this clinical treatment of the patient and used only the knowledge, skills, training, and experience he has acquired in psychiatry. Apart from this, contingency fees that jeopardize honesty and objectivity were rejected while retainer fees which do not undermine these principles were accepted. In placing reports and opinions the qualifications of the physician were put precisely to reveal the areas of knowledge and expertise (Ethics guidelines for the practice of forensic Psychiatry 2005).

The physician asserts that there were no instances of leaving ethical implications in this diagnoses and treatment. He has imparted all possible assistance to the patient to build up a healthy and creative relationship. The positive steps and empathetic approach on the part of this physician had its impact upon her overall behavior and perception which constituted a speedy and involuntary return to her normalcy. The physician’s preferences or attitudes had in no way affected the treatment methods or his approach towards the patient. The patient was interactive with the physician and found happiness on seeing that she was well attended in getting her cured of her brief psychotic disorder.

References

Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Earlbaum.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR). Washington, DC: Author.

Brief Psychotic Disorder (n.d.). Armenian Medical Network. Web.

Briere, B., & Scott, C. (2006). Principles of Trauma Therapy: a guide to symptoms, evaluation, and treatment. Sage Publications, Inc. London

David, A.S. (1990). Insight and psychosis. Royal College of Psychiatrists (UK). Web.

Dombeck, M. (2006). Humanistic Psychotherapy. Web.

DSM-IV Multiaxial System. n.d. Web.

Ethics Guidelines for the Practice of Forensic Psychiatry (2005). American Academy of Psychiatry and the Law. Web.

European Medicines Agency. (2006). Evaluation of Medicines for Human Use. Web.

Hypertension-Aero Medical Disposition (2009). Web.

Mittauer, M. PPT on Psychotic and Anxiety Disorders. Web.

Newman, M. G., & Borkovec, T. D. (1995). Cognitive-behavioral treatment of generalized anxiety disorder. The Clinical Psychologist, 48(4), 5-7. Web.

Oken, D. (2000). Multiaxial Diagnosis and the Psychosomatic Model of Disease, Psychosomatic Medicine 62:171-175 American Psychosomatic Society. Web.

Sperry, L. (2003). Handbook of diagnosis and treatment of DSM-IV-TR personality Disorders. Brunner-Routledge, Taylor & Francis Group, New York. Web.

Spitzer, Robert, L., Gibbon, M., Skodel, A.E., B.W.Williams & Michael B. (2002). DSM-IV-TR casebook: a learning companion to the Diagnostic and statistical manual of disorders. 4^th Edition. American Psychiatric Pub. Washington, DC

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