DIAGNOSTIC AND TREATMENT APPLICATIONS

Case Example of Schizophrenia

By: SOPHIA F. DZIEGIELEWSKI

CASE OF JACOB

Jacob is a 58-year-old divorced White man. He is of large build and tall, with brown hair and brown eyes. He is unshaven, with long, greasy hair, and appears to care little about his personal hygiene, as evidenced by his dirty and disheveled appearance and layers of sloppy clothing. Jacob was recently released from jail after being arrested for vagrancy and resisting arrest. Currently, Jacob states he was evicted from his apartment by his landlord several weeks ago and has been homeless and living on the streets. Upon interviewing Jacob, he appeared guarded and suspicious of the police and his previous landlord.

While in jail, Jacob had gotten into a fight with another inmate and suffered a black eye and two broken ribs. Officers in the jail referred him for an evaluation, as he appeared to have limited insight and judgment. He also stated that the prisoner who beat him up was taking orders from the devil. When they did a drug screen, Jacob did not show positive for any substances, including marijuana.

Upon arrival at the crisis stabilization unit, Jacob displayed suspiciousness and refused to answer any questions that could reveal any personal information about himself or his behaviors. He appeared agitated, showed bizarre posturing, and appeared unpredictable in terms of his reactions and movement. Upon admission, Jacob was given a drug screen, for which he again tested negative, and a basic physical did not reveal any pending medical concerns that needed to be addressed.

When left alone for a few moments, Jacob was observed talking to himself. When he was finally able to talk, Jacob told the practitioner that he played as backup musician for Bob Dylan in the 1960s. Jacob stated that his being locked up in jail was a plot to keep him away from his real brother in music, Elvis, who was really not dead, as everyone thought. He also stated that he wished he could turn off the voices in his head. Once he started to feel more comfortable with the interviewer, he stated that he could hear two voices during the interview in particular, a man and a woman both telling him he was never going to be successful.

After permission was obtained from Jacob to call his family, his father related that Jacob had a long history of mental illness since age 25 and had been previously diagnosed using in DSM-IV criteria with schizophrenia, paranoid type, and it was chronic. Jacob had reportedly been in and out of the state mental hospital, the Veterans Administration hospital, his parents’ house, and various assisted living facilities for the past 15 years.

Recently, Jacob had been doing so much better that he was discharged from an assisted living facility and moved into his own apartment. According to his father, around this time Jacob started hanging around with the wrong crowd and sharing his cigarettes. It was also reported he would drink wine and smoke marijuana. His new friends would help him cash his disability check; they would buy wine and then drink the wine and smoke the cigarettes Jacob had bought.

According to his father, Jacob constantly reported that he could not sleep, as he often had nightmares of bombs exploding. Jacob’s father suspected that Jacob had stopped taking his antipsychotic medication shortly after he got into his apartment, but he could not be sure of exactly when. After Jacob failed to pay his rent, his landlord threw him out. This led to Jacob being on the street and his subsequent arrest for vagrancy. According to his father, Jacob had become quite paranoid and frightened in jail. Jacob had never had any legal problems prior to being arrested for vagrancy.

Jacob is a veteran who did not have direct combat experience but spent a great deal of time on tactical training maneuvers. His father insists that Jacob was fine until he was discharged from the military at age 21. After leaving the military, Jacob had gradually increasing symptoms, particularly hearing voices. Jacob told family and friends that he was discharged from the military because he was caught trying to help prisoners of war being held in the United States.

After the military discharge, he began to stay in his room all of the time, and his hygiene became very poor. Jacob began to express bizarre and paranoid thoughts. The family tried to ignore Jacob’s behavior until one night when he had a psychotic episode and threatened to stab his mother with a kitchen knife, while alternating between cries for help and fiendish ranting. After this incident, Jacob was hospitalized numerous times with delusions and hallucinations.

Jacob was married for 6 months to another patient he met during one of his hospitalizations. Jacob said they divorced after her parents protested the marriage. Between his times in the hospital, Jacob has usually lived with his parents or alone. He has no children. Jacob’s last hospitalization was 1 year ago.

His father states that Jacob feels overwhelmed and does not know what to do. Jacob’s father is elderly and legally blind, and he feels that he cannot handle Jacob anymore. He asked if permanent placement in the state hospital could be an option for Jacob because, if it was, then he would know that Jacob was safe.

After a 3-day course of antipsychotic medication, Jacob presents as friendlier and more cooperative, although his affect is flat and he complains of being sleepy. Jacob says that he knows he is a worry to his father but begs not to be put back in the state hospital. He wants to get his own apartment back and asserts that he goes off his medication because it has such terrible side effects, and then he smokes and drinks in an attempt to self-medicate.

Mental Status Description

Presentation

Appearance: Unkempt

Mood: Anxious

Attitude: Guarded

Affect: Blunted/flat Speech: Guarded

Motor Activity: Restless

Orientation: Fully oriented

Thought Form/Content

Thought Process: Disorganized and tangential

Delusions: Paranoid

Hallucinations: Auditory

Mental Functioning

Simple Calculations: Mostly accurate

Serial Sevens: Accurate

Immediate Memory: Intact

Remote Memory: Intact

General Knowledge: Mostly accurate

Proverb Interpretation: Refused

Similarities/Differences: Refused

Higher-Order Abilities

Judgment: Impulsive

Insight: Poor

Intelligence: Low to average

CASE APPLICATION OF THE DIAGNOSTIC ASSESSMENT

Given the behaviors that Jacob has exhibited and his past history, as well as the symptoms that he is now experiencing, Jacob’s diagnosis, according to the DSM-5, similar to DSM-IV, continues to be schizophrenia. Because the subtype paranoid type has been dropped, his principal diagnosis and reason for visit is now:

Schizophrenia (reason for visit) 295.90(ICD-9CM) or F20.9 (ICD-10CM)

Specify if: Multiple episodes, currently in acute phase

Specify if: Continuous

Clinician-Rated Dimensions of Severity Scale Rating:

Severe, hallucinations and delusions highest scores.

Problems Related to Crime or Interaction with the Legal System:

V62.5 (Z65.2) Problems Related to Other Legal Circumstances (Recent arrest for vagrancy, fighting, and resisting arrest)

Housing and Economic Problems:

(recent eviction) V60.0 (Z56.82) Homelessness
V60.1 (Z56.9) Other Problem Related to Employment

Economic Problems (inability to manage disability income)

V60.9 Unspecified Housing or Economic Problem  (Has difficulty managing his own funds and budgeting)

Jacob’s independent functioning and disability level, a global measure of disability, the WHO Disability Assessment Schedule (WHODAS, version 2.0)

WHODAS Score: Unable to Complete

SAMPLE TREATMENT PLAN 5.1

Sample Acute Care Goals and Intervention Provided

Goal

To stabilize Jacob for discharge to the least restrictive environment.

Objectives■ To help Jacob reduce agitation and paranoia.
■ To help Jacob get control of his behaviors and activities of daily living (ADL).
■ To help Jacob find an appropriate place to live upon discharge.
■ To help Jacob manage his own affairs and the course of the symptoms he is experiencing to the best of his ability.

Treatment Provided

■ Psychiatric evaluation and consultation.
■ Prescribed medication and monitoring for mental status and side effects. Nursing assessment and ongoing nursing care.
■ Contacts with clinician for counseling to address skill building.
■ Participation in therapeutic and psychoeducational group meetings as scheduled.
■ Observation and, as needed, other care by the treatment team.

Sample Application of Acute Plan

■ Medication compliance.
Objective: Monitor and evaluate medication effectiveness, side effects, and compliance, and report observations to social worker once a month.
Objective: Monitor and evaluate medication effectiveness, side effects, and compliance, and report observations to social worker once a month.

■ Stabilization of schizophrenia.
Objective: As client moves up the levels in the program, he will take progressively more responsibility for making sure that he takes his medication. Objective: As client moves up the levels in the program, he will take progressively more responsibility for making sure that he takes his medication.
Objective: During the next month, the client will phone a self-help group for individuals suffering from schizophrenia in the area and inquire about meetings. He will report back to the social worker on this task when they meet.

■ Development of a support system.
Objective: The client will phone and inquire about a day treatment program run by the facility and decide if he wants to participate in the program (1-month time frame).
Objective: The client will phone and inquire about a day treatment program run by the facility and decide if he wants to participate in the program (1-month time frame).

■ Education about medications.
Objective: The client will attend all psychoeducational group meetings at the facility and meet with his social worker once a month for counseling.
Objective: The client will be prepared to discuss with the social worker these objectives and the progress he has made during the month.
Objective: The client will attend all psychoeducational group meetings at the facility and meet with his social worker once a month for counseling.
Objective: The client will be prepared to discuss with the social worker these objectives and the progress he has made during the month.
■ Linkage with community resources.

Treatment Plan Development Topic: Schizophrenia

Definition: Two or more characteristic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or negative symptoms) with at least one of the first three required. The symptoms must persist for at least 6 months, 1 month of which must include the characteristic symptoms, and the person must experience a decline in two or more areas of functioning. Symptoms may not be associated with a general medical condition, schizoaffective, mood disorder, substance abuse, or withdrawal. If a pervasive developmental disorder exists, a diagnosis of schizophrenia can be made only if the symptoms are prominent and are present for at least 1 month (and last more than 6 months).
Signs and Symptoms
■ Delusions.
■ Hallucinations.
■ Disorganized speech.
■ Grossly disorganized behavior or catatonic behavior.
■ Negative symptoms (diminished emotional expression or avolition).
■ One or more areas of functioning are disturbed (self-care activities, work, social, and academic).
■ Inappropriate affect.
Goals
1. Client will not pose danger to self or others.
2. Client will independently perform self-care activities.
3. Client will maintain prescribed medication regimen after discharge.
4. Client will increase adaptive functioning.

Objectives	Interventions
1. Identify and control symptoms of psychosis (hallucinations, delusions, and disorganized speech), as measured by observations of psychiatric staff and self-reports by client, during the course of treatment and after release	Psychiatric staff to record behaviors associated with hallucinations or delusions in chart every day
2. Increase cooperation (with taking prescribed medications) from zero compliance before hospitalization (self and family reported) to full cooperation (taking medications as prescribed), as reported by hospital staff in client’s chart.	Client will take his medication as prescribed each day.
3. Increase performance of self-care activities from 0 per day to 5 per day, as measured by staff behavior count, by the end of treatment	Clinician to contract with client specific self-care behaviors to be learned and performed daily. Clinician to apply a cognitive-behavioral approach to teach/train client to perform self-care activities (brushing teeth, combing hair, bathing, dressing, etc.). Clinician will work with client and family of client to reinforce, maintain, and expand on self-care activities when client is released from the hospital
4. Maintain taking prescribed meds after discharge, as evidenced by record of full compliance in case management record and family reports (indefinitely).	Case manager will monitor client’s compliance with medication protocol through two times/week contact with client and family members.
5. Increase social functioning from a score of 15 at pre-test to a score of 55 by the end of treatment on the Social Adjustment Scale for Self-Report (SAS-SR).	Client will receive positive reinforcement from family members and clinician for behaving in a socially positive way. Client will participate in at least 12 weeks of social skills classes
6. Family members will show an increase in adaptive functioning, as measured by a score of 55 to a post-test score of 250 by the end of treatment on the Social Behavior and Adjustment Scale (SBAS).	Client’s family will participate in a 6-week educational program about schizophrenia. Client’s family will network with other families who share similar stressors.
Family of client will increase existing household income by $500/month through SS Disability to help care for client in the home, within 6 months.	Family of client will be assisted in filing for SS Disability for client’s special needs

References

SOPHIA F. DZIEGIELEWSK, 2015, DSM-5TM in Action, by John Wiley & Sons, Inc.

Read Also

Completing the Diagnostic Assessment

Other Conditions That May Be a Focus of Clinical Attention

The Psychiatric Evaluation

PRINCIPAL AND PROVISIONAL DIAGNOSIS

Diagnostic Principles
Documentation of diagnostic assessment of the mental health disorder
Importance Of Assessing For Medical Factors - Case Example
Puling It All Together in Completing the Diagnostic Assessment

The Comprehensive Diagnostic Assessment and Evaluation
WHODAS: Assessing Disability
Coding Medical Conditions