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Questions

1.The ability to see things others cannot or receive information through hearing or knowing, is a common belief or even gift in some cultural or spiritual practices. As a PMHNP, how do you provide an ethical and therapeutic treatment plan that supports and respects the patients cultural/religious/spiritual beliefs, and relieves symptoms that negatively affect or impair their quality of life

2. If you were interviewing a new client, how would you assess and educate the client on the difference between auditory hallucinations and intrusive thoughts?

3. What are some organizations and resources that assist individuals with schizophrenia related disorders, to live a better quality of life?

Subjective:

CC: “I hear voices that tell me to kill myself, I see shadows, I’m depressed, I don’t sleep for days

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

sometimes, and my drug use has gotten out of control”

HPI: Patient M.K. is a 28-year-old Caucasian male who is referred to Creekside from Greenville ED for psychiatric evaluation for suicidal ideation, depression, hallucinations, and methamphetamine use. He has a history of psychiatric treatment including a recent hospitalization one month ago for methamphetamine use at Woodridge. He has prior hospitalizations at Creekside with the last inpatient visit in February 2022, for hallucinations and methamphetamine use. He first received mental health services at age 15 for depression and anxiety. Previous diagnosis are Schizoaffective Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Post Traumatic Stress Disorder, and Attention Deficit Disorder.

He is not currently taking any psychiatric medications and has a history of noncompliance. He states that he attempted suicide one week ago by taking 20 Aleve tablets. He did not seek medical attention for the attempt. He continued to have suicidal ideation over the next week but denies plan. During this period, he reports his methamphetamine use became out of control, limiting his sleep to a few hours over a period of days. His depression worsened with a significant increase in irritability causing him to throw objects at times, he denies hurting others. He denies self-harming behaviors. Currently he denies SI/HI but reports having SI without a plan this morning. He reports command auditory hallucinations that tell him to kill himself or cut off his arm. He reports visual hallucinations of shadow like figures. His hallucinations began seven years ago and occur on a regular basis as does his depression. Depressive symptoms are described as intermittent. Patient states he will experience hallucinations without alterations in mood for months at a time before cycling back into depression.

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Past Psychiatric History: Schizoaffective, Generalized Anxiety Disorder, Major Depressive

Disorder. Post-Traumatic Stress Disorder, Attention Deficit Disorder. Recent hospitalization one month ago for methamphetamine use at Woodridge. He has prior hospitalizations at Creekside with the last inpatient visit in February 2022, for hallucinations and methamphetamine use. He first received mental health services at age 15 for depression and anxiety.

Medication Trials: Abilify- elevated anxiety, Seroquel- weight gain

Substance Current Use: He reports tobacco use via cigarettes one pack per day x 17 years, Methamphetamine use via snorting with daily use x 3-4 years- last use three days ago, Marijuana use daily x 15 years- last use three days ago, Heroin use via snorting 3 times per month x 1 year – last use three weeks ago. Social alcohol use once monthly, last use one month ago. His longest reported sobriety was 4 years.

Family Psychiatric/Substance Use:

Mother- Drug abuse and Depression

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Father- Drug abuse

Social History: Patient was born in Greenville, TN and raised by paternal grandmother. His biological parents were frequently incarcerated but intermittently present in his life. He is single, never married, and without children. He currently resides in Greenville, TN with three roommates whom he describes a good working relationship. He has one half-sister he describes a good relationship with. His sister is where he receives most of his emotional support. He reports good friendships that provide emotional support. He reports good appetite and poor sleep with difficulty falling asleep. He reports nightmares at times but does not experience them often. He also reports going days without sleep at times during methamphetamine use. His highest level of education is one year of college. He is unemployed. He reports a history of emotional abuse from his father and

physical and sexual abuse from his former boyfriend. He has no legal charges pending.

Medical History: HTN, Asthma as a child

Current Medications: None

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Allergies: NKDA, No food allergies, No seasonal allergies

Reproductive Hx: No suspected or reported concerns.

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: No visual loss, no blurred vision, double vision or yellowing of sclera, No hearing loss, No congestion, drainage, sneezing, or sore throat.

SKIN: No rashes, blisters, or growths.

CARDIOVASCULAR: No chest pain, pressure or shortness of breath, no palpitations, no peripheral edema

RESPIRATORY: No cough, shortness of breath, wheezing or productive sputum.

GASTROINTESTINAL: No N/V/D, no pain, no rebound tenderness, no blood in stools.

GENITOURINARY: No burning, urgency, frequency, or retention of urine. No odor

NEUROLOGICAL: No headache, dizziness, numbness or tingling in extremities, no loss of bowel, no loss of bladder, no syncope or paralysis.

MUSCULOSKELETAL: No muscle or joint pain, no stiffness.

HEMATOLOGIC: No bruising, bleeding, or anemia

LYMPHATICS: No enlarged nodes, no history of splenectomy, no recurrent infections

ENDOCRINOLOGIC: no heat or cold intolerance, no sweating, no polyuria or polydipsia

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Objective:

Diagnostic results:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

NEUROLOGICAL: No headache, dizziness, numbness or tingling in extremities, no loss of bowel, no loss of bladder, no syncope or paralysis.

The Clinical Global Impression-Schizophrenia Scale (CGI-SCH Scale)

CBC- Assess for anemia and get an overall picture of health

Chem10- electrolyte disorders

TSH- hypothyroidism (mimics depression)

UA/UDS- UTI, dehydration, ketones, blood, drug use

25 Hydroxyvitamin D- Evidence shows a deficiency is linked to Depression

EKG- To document baseline and monitor changes

Assessment:

Mental Status Examination: He is a 28-year-old Caucasian male who looks his stated age. He is cooperative with assessment with fair eye contact. He is poorly groomed, currently dressed in hospital scrubs. There is no psychomotor agitation present. His speech is clear, with low volume and soft tone. His mood is depressed, affect reflects mood. He endorses command auditory hallucinations that tell him to kill himself or cut off his arm. He endorses visual hallucinations of shadow figures. He does not appear to be responding to external stimuli. He denies current suicidal or homicidal ideation, but reports thoughts were present this morning upon waking with the absence of plan. Cognitively, he is alert and oriented to person, place, time, and event. His recent and remote memory are intact. His concentration is fair. His insight and judgement are poor.

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Diagnostic Impression:

Schizoaffective Disorder Depressive Type, Multiple Episodes Currently in Acute Episode F25.1 - Patient reports almost daily episodes of visual hallucinations of shadow like figures and command auditory hallucinations for the past two weeks. His hallucinations began seven years ago, varying in duration and intensity. He reports noncompliance with his medication with a secondary increase in his hallucinations. Poor hygiene and grooming noted. Poor insight, poor judgment, major depressive symptoms present as patient reports feelings of hopelessness, helplessness, worthlessness, and guilt. He has difficulty falling asleep due to depressed mood and hallucinations. He reports rumination about past abuse. He reports problems with energy and frequent fatigue. He reports problems with concentration as well as frequent suicidal ideation with recent OD attempt. His symptoms occur on most days with no ability to control the frequency or duration of those symptoms. Depressive symptoms are described as intermittent. Patient states he will experience hallucinations without alterations in mood for months at a time before cycling back into depression. His symptoms directly affect his ability to function in personal and social settings as well as employment and hinder his overall quality of life.

Major Depressive Disorder Moderate F32.1- Patient reports feelings of hopelessness, helplessness, worthlessness, and guilt. He has difficulty falling asleep due to depressed mood and rumination about past abuse. He reports problems with energy and frequent fatigue. He reports problems with concentration as well as frequent suicidal ideation with recent OD attempt. His symptoms began one week ago, occurring on most days with no

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

ability to control the frequency or duration of those symptoms. He reports the use of marijuana, heroin, and methamphetamine that he attributes to his depressed mood. His symptoms directly impact his ability to function in personal and social settings and hinder his overall quality of life.

Substance/Medication-Induced Sleep Disorder, Insomnia Type: with onset during Intoxication F12.288 F11.282 F15.282 F17.208 - Patient reports difficulty falling asleep on most night and at times, going days without sleep. The disturbance is not better explained by a sleep disorder that is not substance/medication induced. The lack of sleep causes clinically significant distress and impairment in social and personal functioning. Patient reports abusing methamphetamine, heroin, cannabis, and nicotine.

Additional Relevant Diagnosis:

Generalized Anxiety Disorder F41.1 He reports feeling anxious and restless frequently without cause. He reports loud noises, and watching the news increase his anxiety. His anxiety interferes with his ability to fall asleep at night. His anxiety is present on most days and affects his ability to function in social and personal settings.

Cannabis Use Disorder Severe F12.20 - Patient reports using marijuana daily since the age of 15. Most of his time is devoted to cannabis use with little to no ability to refrain from use. Cannabis use is continued despite known physical and psychological effects.

Opioid Use Disorder Mild F11.10 - Patient reports heroin use 2-3 times per month for the past year. Patient has been unsuccessful in stopping heroin use, continued opioid use despite having

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

persistent social and interpersonal problems exacerbated by the effects of opioids.

Stimulant Use Disorder Amphetamine-Type Substance Severe F15.20 - Patient reports daily methamphetamine use for the past 4-5 years and is often taken in larger amounts. There is a persistent desire with unsuccessful efforts to discontinue use. Amphetamine use is continued despite knowing physical and psychological risks, recurrent use in situations that are physically hazardous. Use persists despite its impact on social and personal functioning.

Tobacco Use Disorder Severe F17.200 - Patient reports daily tobacco use since the age of 15. He reports an increased need in amount to achieve the desired effects. A great deal of time is spent daily on smoking with strong cravings and continued use despite knowing the harmful effects of tobacco on the body.

Reflections: I agree with the diagnosis and treatment plan of the above patient. The frequency and intensity of his symptoms accompanied by the cycling of hallucinations and depression both together and consecutively, are consistent with a diagnosis of schizoaffective disorder. Through working with the patient, I learned how challenging it can be for a provider to decipher subjective information while considering history and disease progression, to formulate a treatment plan. The patient currently resides with three roommates that he reports having a good relationship with. Due to the nature of drug abuse by the patient, it would be beneficial to know if the roommates share the same habits. As drugs like methamphetamine and marijuana, are known to cause psychosis, the patient needs a stable home environment to support his recovery. The condition of the living space, the availability of food, medications, and hygiene products, as well as transportation to and from

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

appointments should be confirmed prior to discharge. Education on smoking cessation benefits and techniques should be discussed as well as safe sex practices and regular STD testing.

Ethically there is much to consider in the above case. As is the case with most mental health diagnosis, the matter of subjectivity always proves challenging. While labs and tools exist to assist a provider with the diagnostic process, there are no definitive tests or diagnostic images that factually determine if a patient has schizoaffective disorder or any of the related disorders. Attention to details that are conveyed through vocals, body language, mannerisms, and history, are imperative to an accurate and therapeutic treatment plan.

Hearing voices and seeing objects that are not witnessed and cannot be attested by others, is subjective at best. Without physical proof, time and consistency are necessary to build a case. One also must consider the circumstance where hearing and seeing things unseen and unheard by others, is a naturally occurring sense or gift. In some cultures, religions and spiritual communities, such phenomenon are normal and welcomed. As a provider, it is necessary to not only respect such beliefs but also manage and treat symptoms that impair their quality of life or threaten the safety of the patient or others.

Legally the provider must find a balance between patient confidentiality and safety. Schizoaffective disorder and related disorders are often accompanied by increased paranoia that can lead to aggressive or violent behavior. There may be times when a patient is required to have a Certificate of Need (CON), to ensure proper stabilization and treatment.

Case Formulation and Treatment Plan:

Schizoaffective Disorder Depressive Type, Major Depressive Disorder– Continue Risperidone 1mg oral BID. Monitor medication effects and behaviors daily while inpatient. Follow up with

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Psychiatrist after discharge

Educated on possible side effects: dizziness, hypotension, syncope, dystonia, akathisia, tardive dyskinesia, insomnia, anxiety, sedation, nausea, abdominal pain, weight gain, hyperglycemia, seizures, NMS, diabetic ketoacidosis, hyperprolactinemia.

Obtain weight, BMI, waist circumference, blood pressure, fasting plasma glucose, fasting lipids, CBC, prior to beginning medication and continue monitoring throughout treatment.

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture. Discussed benefits of smoking cessation and techniques to quit as well as safe sex practices and the importance of regular STD testing.

Client was encouraged to continue Cognitive Behavioral therapy services weekly and monthly visits with psychiatrist at Frontier Health

Client has emergency numbers: Emergency Services 911 Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

Records requested/reviewed from PCP

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agree to follow treatment regimen as discussed.

Follow up with PCP as needed for HTN

Labs ordered and/or reviewed:

The Clinical Global Impression-Schizophrenia Scale (CGI-SCH Scale)

CBC- Assess for anemia and get an overall picture of health

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Chem10- electrolyte disorders

TSH- hypothyroidism (mimics depression)

UA/UDS- UTI, dehydration, ketones, blood, drug use

25 Hydroxyvitamin D- Evidence shows a deficiency is linked to Depression

EKG- To document baseline and monitor changes as psychotropic medications can cause QT elevation.

Prior to beginning Risperidone and throughout treatment, monitor: weight, BMI, waist circumference, blood pressure, fasting plasma glucose, fasting lipids.

Return to clinic: Weekly for Cognitive Behavioral therapy services and continue monthly visits with psychiatrist at Frontier Health

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Carlat, D.J. (2017). The Psychiatric Interview (4th ed.). Wolter Kluwer

Gesi, C., Carmassi, C., Miniati, M., Benvenuti, A., Massimetti, G., & Dell’Osso, L. (2016). Psychotic spectrum symptoms across the lifespan are related to lifetime suicidality among 147 patients with bipolar I or major depressive disorder. Annals of General Psychiatry, 15, 1–7. https://doi.org/10.1186/s12991-016-0101-7

Halkitis, P. N. (2009). Treatment considerations for methamphetamine addiction. In Methamphetamine addiction: Biological foundations, psychological factors, and social consequences. (pp. 107–129). American Psychological Association. https://doi.org/10.1037/11883-007

Huhn, M., Leucht, C., Rothe, P., Dold, M., Heres, S., Bornschein, S., Schneider-Axmann, T., Hasan, A., & Leucht, S. (2021). Reducing antipsychotic drugs in stable patients with chronic schizophrenia or schizoaffective disorder: A randomized controlled pilot trial. European Archives of Psychiatry and Clinical Neuroscience, 271(2), 293–302. https://doi.org/10.1007/s00406-020-01109-y

Muenzenmaier, K. H., Seixas, A. A., Schneeberger, A. R., Castille, D. M., Battaglia, J., & Link, B. G. (2015). Cumulative effects of stressful childhood experiences on delusions and hallucinations. Journal of Trauma & Dissociation, 16(4), 442–462. https://doi.org/10.1080/15299732.2015.1018475

Noel, J. M., & Jackson, C. W. (2020). ASHP Therapeutic Position Statement on the Use of Antipsychotic Medications in the Treatment of Adults with Schizophrenia and Schizoaffective Disorder. American Journal of Health-System Pharmacy, 77(24), 2114 2132. https://doi.org/10.1093/ajhp/zxaa303

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Stahl, S.M., & Grady, M. M. (2020). Stahl’s essential psychopharmacology: The prescriber’s guild (7th ed.).