Genogram

The client is a 24-year-old female, single, African America active duty, service member (SM). SM who resides in the barracks medication, SM MOS is 25U, signal support specialist (IT), SM recently completed basic training and Advanced Individual Training (AIT), before enlisting SM worked as Computer Specialist.

Presenting Problem: I do not know why I am here; I do not need to be here.”

History of Present illness: She appears slightly disheveled, tired, and generally irritable both in the lobby, with nursing staff, and once in the room. She is accompanied by an escort who remains throughout the visit.

Past Psychiatric history: Insomnia.

Medical History: None

Substance use History: denies

Developmental History: She who appears older than stated age, the client is disheveled, with noted body odor

Family Psychiatric history: no familial history

Maternal grandmother marijuana user, paternal grandmother incarcerated no further history. Father Diabetes, Mother HTN, one sister HTN, 1 Brother HTN

Psychosocial History: She states she was homeless before joining the Army National Guard, difficulty to find a job. She wants to go to college for nursing or IT.

History of abuse/Trauma: She reports two episodes of sexual harassment in 2012 in 2013 with no sexual assault but declines to provide more information: no article 15s or negative counseling statements related to her behavior.

Review of Systems:

General: She is alert and oriented x 1 self only B/P 100/60 59, 24, 97.7, 99% room air. Pain 0/10, Weight 153.

HEENT: no discharge intact, moist

Skin: warm and dry

Cardiovascular: no palpitations

Respiratory: no cough or rales or expiratory wheezing was noted neither was any adventitious sounds heard.

GI: No nausea, no vomiting, and no abdominal pain..

Genitourinary: She denies any burning upon urination and dribbling. No obstetrics or gynecology symptoms LMP states 05/01/2019

Neurological: She denies headaches, dizziness, and tingling in all her extremities.

Musculoskeletal: FULL ROM to all extremities

Psychiatric:

Allergies: No known medication/ food allergies

Mental Status Examination

Orientation: Alert and oriented to person

Appearance: in uniform, disheveled, mild body odor

Musculoskeletal: gait and station intact

Behavioral: Irritable/cooperative

Motor activity: appropriate

Speech: pressured, frenzied

Mood: euthymic

Affect: Irritated Restless

Thought content: No suicidal ideation, no homicidal ideation

Perceptions: denies auditory/visual hallucination exaggerated sense of self

Thought Process: illogical and irrational

Attention and Concentration: distracted

Remote and Recent Memory: able to recall the last 5 minutes

Judgment: delayed

Insight and Judgment: fragmented

Differential Diagnosis:

Schizophrenia: a brain disorder that affects how a person reason, feel, and perceive. The hallmark symptom of schizophrenia is psychosis, such as experiencing auditory hallucinations (voices) and delusions (fixed false beliefs). Positive symptoms such as hallucinations auditory; delusions; disorganized speech and behavior. A visible alteration in behavior and a decrease in academic, social, and interpersonal functioning often occurring during middle-to-late puberty. Usually, 1–2 years pass between the onset of these vague symptoms and the initial visit to a mental health provider (Bertolucci, et al 2018). The first psychotic occurrence occurs between the late teenage years and the mid-twenties. Negative symptoms, include a decrease in emotional range, poverty of speech, and loss of interests and ambition; Cognitive symptoms, include neurocognitive deficits (i.e., deficits, with working memory and attention on executive functions, in the inability to organize thoughts; clients also find it problematic to recognize distinctions and restraints of interpersonal signals within relationships. Mood symptoms, clients, often seem cheerful or sad in a way that is difficult to understand;

Bipolar Disorder: is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania. Manic episodes are a feature at least one week of profound mood disturbance, characterized by elation, irritability, or prickly (Grande et al, 2016). One of these three symptoms may exhibit or overlap grandiosity, insomnia, excessive talking or pressured speech; a flight of idea; distracted; excessive pleasurable activities, often with painful consequences

Delusional Disorder; characterized by at least one month of delusions but no other psychotic symptoms, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, (APA, 2013). Delusions are categorized as persecutory (i.e., belief that one is going to be harmed by an individual, organization or group), referential (i.e., belief that gestures, comments, or environmental cues are directed at oneself), grandiose (i.e., belief that the individual has exceptional abilities, wealth, or fame), erotomanic (i.e., a false belief that another individual is in love with him/her), nihilistic (i.e., a conviction that a major catastrophe will occur), or somatic (i.e., beliefs focused on bodily function or sensation). Because cognitive organization and reality resting are otherwise intact in delusional disorder, it has been defined in the research as "partial psychosis” (Skelton,et al 2015).

Case Formulation: Reported by external sources client began having delusional behavior, accusing the president of conspiring against her. Client stopped coming to the formation and worked reporting; the MP’s were poisoning her food. SM was tested for illegal substances and alcohol (harmful) and place in Embedded Health Inpatient for further monitoring and medication regimen modification.

Treatment Plan: The objective to establish trust and encourage her to take medication to decrease the symptoms.

Schizophrenia

Treatment plan: Continue to see a LCSW or psychotherapist to assist in resurfacing symptoms and medication management.

References

 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Bertolucci, B., Pitta, J. C., Higuchi, C., Noto, C., Rocha, D., Joyce, D., ... & Gadelha, A. (2018). S129. Does Treatment Resistant Schizophrenia Present A Characteristic Symptomatic Signature?. Schizophrenia Bulletin, 44(suppl_1), S375-S376.

Detweiler, M. B., Chudhary, A. S., & Murphy, P. F. (2017). Screening for Schizophrenia in Recruits, Active Duty Soldiers and Veterans: Can we do a Better Job?. Neuropsychiatry, 7(5), 576-585.

Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572.

Howes, O. D., McCutcheon, R., Agid, O., De Bartolomeis, A., Van Beveren, N. J., Birnbaum, M. L., ... & Castle, D. J. (2016). Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. American Journal of Psychiatry, 174(3), 216-229.

Jauhar, S., Laws, K. R., & McKenna, P. J. (2019). CBT for schizophrenia: a critical viewpoint. Psychological medicine, 1-4.

Jennings, K. S., Zinzow, H. M., Britt, T. W., Cheung, J. H., & Pury, C. L. (2016). Correlates and reasons for mental health treatment dropout among active duty soldiers. Psychological services, 13(4), 356.

Skelton, M., Khokhar, W. A., & Thacker, S. P. (2015). Treatments for delusional disorder. Cochrane Database of Systematic Reviews, (5).

Brother

HTN

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Sister

HTN

Maternal Grandfather

Deceased

Deceased

D

Paternal

Deceased

Maternal

Grandmother

TMarijuana User

Paternal

Grandfather

Incarcerated

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Client

Schizophrenia

Client’s Mother

HTN

Father

DIabetes