Comprehensive Psychiatric Evaluation of a 27 Year-Old Caucasian Male with Schizotypal Personality Disorder 

Personality disorders are recognized as distinct mental health conditions that have their specific diagnostic codes in the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. Schizoid personality disorder belongs to this diagnostic category of Personality Disorders in the DSM-5. To be specific, it belongs to what are referred to as ‘Cluster A Personality Disorders’ in the DSM-5. These are conditions that apart from schizotypal personality include paranoid personality disorder and schizoid personality disorder (Sadock et al., 2015; APA, 2013). The diagnostic code for schizotypal personality disorder in the DSM-5 is 301.22 (F21). This paper is a comprehensive psychiatric evaluation of a 27 year-old Caucasian male who has this diagnosis of schizotypal personality disorder.

CC (chief complaint): Patient LP presents with a chief complaint of smelling an odor that is “malicious and piercing”. He is also suspicious that his superior at work thinks that he is not qualified for his job at the library.  Caucasian Male with Schizotypal Personality Disorder Essay Paper

HPI: The patient is a 27 year-old Caucasian male who presents with odd beliefs, unusual perceptual experiences, and paranoid ideation. He claims to smell an odor that appears to be coming from his body. He denies any previous history of these symptoms but reports that their onset was about six months ago. All the symptoms are in his mind as he claims to feel and smell suspicious occurrences and stimuli. The symptoms are intermittent in duration and come and go. The odor is characteristically “piercing and malicious” according to the patient. The symptoms are aggravated by being close to workmates and other non-relatives and relieved by being at home or close to first-degree relatives. He claims to experience the symptoms especially during the day when he is at work. He rates their severity at 6/10.

Past Psychiatric History:

• General Statement: Patient LP is very superstitious and paranoid about almost everything and everyone at his workplace. He is not social and has difficulties forming and maintaining interpersonal relationships.
• Caregivers (if applicable): He is able to care for himself and does not require the help of caregivers.
• Hospitalizations: Patient LP has never been hospitalized for a psychiatric condition. He has however been hospitalized for malaria when he went for vacation in Africa and for pneumonia.
• Medication trials: He has not been involved in any medication trials or received any medications related to any mental illness.
• Psychotherapy or Previous Psychiatric Diagnosis: Because he does not have a psychiatric history, he has never attended any psychotherapy sessions. He has never been diagnosed with a psychiatric illness.

Substance Current Use and History: Patient LP denies using any banned substances or even smoking cigarettes. He however admits to taking etoh casually over the weekends with relatives at home.

Family Psychiatric/Substance Use History: There is no significant family history of psychiatric illness in patent LP’s family. There is also no history of drug or substance abuse in his family.

Psychosocial History: Patent LP lives alone. He had a girlfriend but they recently separated when she could no longer tolerate his paranoia and suspicion. He frequently sees his parents who do not live far from him, as well as his two siblings. He was born in Newark, Delaware and grew up there. That is also where he went to school and college. He does not have any children and currently works in a library. His hobbies include reading, bird watching, and watching movies. He does not have a criminal record and denies any history of violence or abuse in the family or outside.

Medical History:

• Current Medications: He is not currently on any medications.
• Allergies: NKDA, no food or environmental allergies.

• Reproductive Hx: He is heterosexual but does not have any children yet.

ROS:

• GENERAL: Denies malaise, weakness, fatigue, fever, or loss of weight.
• HEENT: Denies photophobia or diplopia. Negative for otorrhea or hearing loss. No rhinorrhea or sneezing. Denies a sore throat.
• SKIN: negative for rashes or itching.
• CARDIOVASCULAR: Denies chest pain, palpitations, or chest tightness.
• RESPIRATORY: denies coughing, producing sputum, or difficulty in breathing.
• GASTROINTESTINAL: Denies nausea, vomiting, loss of appetite, or diarrhea. Reports regular bowel movements.
• GENITOURINARY: Negative for urgency, frequency, or cloudiness. Also negative for polyuria. Denies any sexually transmitted infections.
• NEUROLOGICAL: Denies dizziness, tingling sensation, peripheral paraesthesia, numbness, or hemiparesis. Also denies loss of bladder or bowel control.
• MUSCULOSKELETAL: Negative for arthralgia and myalgia. Denies back pain or joint stiffness.
• HEMATOLOGIC: Denies a history of blood or clotting disorders in his family.
• LYMPHATICS: Negative for lymphadenopathy. Denies splenectomy in the past.
• ENDOCRINOLOGIC: Negative for polydipsia and polyphagia. Also negative for heat or cold intolerance as well as excessive diaphoresis.    Caucasian Male with Schizotypal Personality Disorder Essay Paper
  

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Physical exam:

Vital Signs: BP 110/60 regular cuff and sitting; P 78, regular; T 98.0°F; RR 16, non-labored; BMI 24.8 kg/m² (normal BMI).

General: Patent LP is alert and oriented in time, space, place, person, and event. His speech is coherent and goal-oriented. He appears well-dressed and appropriately for the time of the year and day.

HEENT: Head atraumatic and normocephalic. PERRLA. EOMI. No otorrhea and tympanic membranes intact bilaterally. Turbinates show no evidence of inflammation with no rhinorrhea. The throat shows no evidence of exudate or erythema.

Respiratory: Clear lung fields with no crepitations, rales, rhonchi, or wheezing.

CVS: Present S1 & S2 (RRR). No gallop, murmurs, bruit, or rub.

Diagnostic results:

1. Laboratory: No leucocytosis
2. Radiologic: Normal brain MRI

Assessment

Mental Status Examination:

The patient is a 27 year-old Caucasian male who is alert and oriented x 4. He is dressed appropriately for the weather and the time of the day. His speech is clear, goal-directed, and coherent. He maintains good eye contact during the interview but displays no notable tics, mannerisms, or gestures. Self-reported mood is “good”. Affect is euthymic and congruent to the mood. Thought process is loose and thought content shows ideas of reference, illusions, and hallucinations. He has no delusions. He also shows no homicidal or suicidal ideation. Insight is fair and judgment is good. Diagnosis: Schizotypal Personality Disorder – 301.22 (F21).

Differential Diagnoses:

1. Schizotypal Personality Disorder

A patient with this condition has difficulty creating and even maintaining social and interpersonal relationships. They are suspicious and paranoid as well as superstitious n their beliefs. They have odd beliefs that are real to them and make them not trust those who are not related to them. The critical thinking that went into arriving at this diagnosis was driven by a close comparison between the symptom profile of patient LP and the DSM-5 diagnostic criteria for schizotypal personality disorder.

According to the symptomatology exhibited by patient LP as indicated in the CC and HPI, he meets the DSM-5 diagnostic criteria of schizotypal personality disorder (Sadock et al., 2015; APA, 2013; Stahl, 2013). The criteria are: (A) Impaired social and interpersonal relations marked by five or more of (i) odd beliefs such as superstitiousness (ii) ideas of reference (iii) illusions (iv) odd thought processes such as circumstantial thinking (v) paranoid ideation (vi) inappropriate affect (vii) odd behavior (viii) excessive and inappropriate social anxiety, and (ix) not having everyday friends except close relatives. (B) The symptoms are not attributable to another psychiatric illness such as schizophrenia (APA, 2013).

2. Other mental disorder with psychotic symptoms (Schizophrenia)

The similarity in symptomatology between schizotypal personality disorder and schizophrenia is in the psychosis as seen in hallucinations. However, the difference is in the duration of the psychosis. In schizotypal personality disorder, the personality disorder was there even before the patent began showing psychotic symptoms like hallucinations. Also, when the psychotic symptoms undergo remission; the personality disorder still remains. This is not true with schizophrenia as in this condition; the psychosis is present from the beginning and is persistent (Sadock et al., 2015; APA, 2013).

To be diagnosed with schizophrenia as the other mental disorder with psychotic symptoms, the patient must show: (A) Two or more of: (1) Hallucinations (2) Delusions (3) Disorganized behavior (4) Impaired speech (5) A negative symptom such as anhedonia or poverty of speech. (B) Reduced level of functioning socially, occupationally, or in self-care (C) Continuous disturbance for six months (D) Other psychiatric disorders have been ruled out (E) the symptoms are not related to drug or substance abuse, and (F) There is a negative history of a communication disorder of childhood onset such as ADHD (APA, 2013).

3. Neurodevelopmental disorders (ADHD)

The most significant similarity between schizotypal personality disorder and ADHD (attention-deficit/ hyperactivity disorder) as a neurodevelopmental disorder is that in both there is social isolation. The patient cannot form interpersonal relationships and make them last. As a matter of fact, adults with ADHD cannot stay in one job for a long time specifically because of this. The critical thinking that went into this differential is that patient LP may be among the few ADHD patients whose symptoms have continued into adulthood. The only problem with this school of thought is that there is no mention by the patient in the subjective section of any learning difficulties as a child.

The critical thinking that went into putting this differential as the last and least probable is that the DSM-5 diagnostic criteria for ADHD requires amongst others (i) the presence of inattention and/ or hyperactivity and impulsivity, (ii) that these symptoms must have been present before age 12, (iii) and that schizophrenia and other psychotic disorders be excluded first.      Caucasian Male with Schizotypal Personality Disorder Essay Paper

Reflections:

If I were to be asked to carry out the comprehensive psychiatric evaluation again for patient LP, I would repeat exactly hay I have done. The reason for this is that the methodology followed is the best recommended and evidence-based (Ball et al., 2019; Bickley, 2017; LeBlond et al., 2014). While at it, I accorded the patient respect and allowed him to participate in decisions about his care in line with the ethical principle of autonomy. I also sought to deliberately give him the best and prevent harm to him psychologically or otherwise, as dictated by the principles of beneficence and nonmaleficence (Haswell, 2019; Entwistle, 2019; Santhirapala & Moonesinghe, 2016). On health promotion and education, I would advise and recommend that the patient attends cognitive behavioral therapy (CBT) sessions to remodel his thoughts (Corey, 2017). His family should likewise attend family therapy to help him make friends outside the family set-up.

Conclusion

This was a comprehensive psychiatric evaluation of patient LP, a 27 year-old Caucasian male diagnosed with schizotypal personality disorder. The evaluation was exhaustive and included collection of both subjective and objective information. The closest and most probable differential diagnoses for this patient have been found to be schizophrenia and ADHD.

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Entwistle, J.W.C. (2019). Noninformed consent and autonomy. The Annals of Thoracic Surgery, 108(6), 1610. https://doi.org/10.1016/j.athoracsur.2019.08.006

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

LeBlond, R.F., Brown, D.D., & DeGowin, R.L. (2014). DeGowin’s diagnostic examination, 10^th ed. McGraw Hill Medical.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Santhirapala, R., & Moonesinghe, R. (2016). Primum non nocere: Is shared decision-making the answer? Perioperative Medicine, 5(16), 1-5. https://doi.org/10.1186/s13741-016-0042-3

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4^th ed. Cambridge University Press.  Caucasian Male with Schizotypal Personality Disorder Essay Paper