HPI
A 48-year-old patient visited the health facility with complaints of poor vision and the inability to distinguish between different colors. He also stated that his life was in danger because many witches were after him. The patient had been diagnosed with type 2 diabetes five years ago, which had led to significant lifestyle changes for him. He attributed his misfortunes to the alleged school of witches who were focused on destroying him.
Psychosocial History
The patient had a history of depression. He was dejected by the fact that many people tried to avoid him. His wife had divorced him 10 years ago because she could no longer stand some of his strange ideations. The patient became withdrawn and unsociable, which led him to lose his job as a bookkeeper in a busy furniture shop. He had received antidepressants and psychotherapy, which had successfully alleviated his depressive symptoms.
However, his suspicions did not change. He currently works as a bookkeeper in a grocery store and his weird fixations and suspicious nature make it difficult for him to form and sustain new friendships. This factor also frustrates the patient. The patient has a 45-year-old brother who is alive and healthy without any notable problems. His parents are also alive and healthy. However, his paternal uncle has a history of unmanageable schizophrenia, thus compelling his family to confine him to a mental facility.
Medical History
The patient has a history of type 2 diabetes mellitus. Recently, his glycemic control has been poor because he forgets to take his medications, exercise, and measure his blood sugar levels regularly as advised. He has managed to avoid hypoglycemic incidents because he does not skip meals. Consequently, he has started developing diabetic complications such as diabetic retinopathy.
Medications
The major medication taken by the patient is metformin for the control of his blood sugar levels. The prescribed dose is 1000 mg of extended-release tablets to be taken once a day with evening meals.
Psychiatric Treatment History
The patient has a history of major depressive disorder and has been taking oral sertraline. The initial dose was 50 mg, which had been increased to 100 mg per day overtime. His depressive symptoms had subsided thus allowing him to secure another job. However, to rule out depression, he was screened using the Patient Health Questionnaire (PHQ-9), which has been recommended for the diagnosis and monitoring of patients with major depressive disorder (Manea, Gilbody, & McMillan, 2015; Mitchell, Yadegarfar, Gill, & Stubbs, 2016). An additional assessment was conducted using the schizotypal personality questionnaire (SPQ) for the evaluation of schizotypal personality disorder (Kirchner, Roeh, Nolden, & Hasan, 2018).
ROS (Review of Systems)
- General: The patient denies fever, fatigue, difficulties sleeping, decreased appetite, or unexplained weight changes.
- Eyes: The patient admits that he has blurred vision and trouble differentiating various related colors. He does not wear any glasses or contact lenses.
- Ears, nose, mouth, and throat: The patient denies any ear pain, sore throat, mouth lesions, or dental problems.
- Cardiovascular: No history of palpitation, heart murmur, dyspnea, chest pain, or edema.
- Respiratory: No notable symptoms.
- Gastrointestinal: The patient denies any vomiting, constipation, diarrhea, nausea, bloating, abdominal discomfort, or changes in bowel habits.
- Genitourinary: The patient denies any changes in urinary consistency. However, he admits that he passes urine more frequently.
- Musculoskeletal: The patient denies any joint pain, muscle aches, and neck stiffness.
- Integumentary: The patient denies any skin itchiness, rashes, or lesions.
- Neurologic: The patient denies any tingling, numbness, headaches, or seizures.
- Endocrine: The patient admits that he experiences excessive thirst, polyuria, and increased hunger.
- Hematologic/lymphatic: The patient denies any bleeding, easy bruising, or swollen lymph nodes.
- Allergic/immunologic: The patient does not have any food or drug allergies.
Assessment
Mental State Exam
- Appearance
- Demographics: Male, 38-year-old African American.
- Physique and hair: Average build, unkempt hair.
- Dressing: Brightly colored clothing.
- Cleanliness: Fairly clean, wrinkled shirt.
- Weight loss: Absence of unexplained weight loss.
- Behavior
- Rapport
- Attitude- Suspicious and guarded.
- Eye contact- Avoidant.
- Psychomotor activity: Agitation.
- Movement disorder
- Tics- Absent.
- Choreiform movements- Present.
- Dystonia- Absent.
- Signs of violence: Restlessness and pointing fingers, no intrusion into the interviewer’s personal space.
- Rapport
- Speech
- Quantity
- The pressure of speech- Rapid and difficult to comprehend.
- The poverty of speech- Absent.
- Quality
- Volume- Loud.
- Tone and fluency- Noncoherent.
- Spontaneity- Prompt responses.
- Quantity
- Mood or Affect
- Subjective mood- “I feel scared, the witches are out to finish me.”
- Objective mood.
- Nature of mood- Anxious.
- The constancy of mood- Mood changes during the interview from anxious to depressed.
- Congruity of mood- The patient’s mood is appropriate for the context.
- Thoughts
- Stream- Pressure of thought; the patient tries to convey many different thoughts at once.
- Form- Preservation; the patient repeatedly states that witches have been sent to harm him.
- Content- The patient is delusional and believes that all his problems are caused by witches who want to see him dead.
- Perceptions
- Altered sense of smell; the patient complains that flowers in the room have a pungent smell.
- Cognition
- Consciousness- Confusion.
- Orientation- The patient is aware of person, place, and time.
- Attention- Moderate.
- Memory
- Immediate- Good.
- Recent- Average.
- Long-term- Poor.
- Language- Good.
- Visio-spatial functioning- Good.
- Insight
- Moderate.
A diagnosis of schizophrenia or schizotypal personality disorder was made based on the patient’s presenting symptoms and the mental state exam. Positive distinguishing symptoms include discomfort in social settings, strange beliefs and preoccupations, odd appearance, anxiety, and paranoia (Kirchner et al., 2018). The patient’s paranoia and anxiety make it difficult to form and sustain new friendships, which has also been reported in patients with schizotypal personality disorder (Kirchner et al., 2018). A family history of schizophrenia also increases the likelihood of developing related disorders by close family members (Lu et al., 2018).
The patient has a paternal uncle who is institutionalized because of schizophrenia, which further points at this diagnosis. Besides, the patient’s SPQ score is indicative of schizotypal behavior. The SPQ scale is a self-report scale created based on initial DSM-III-R benchmarks for schizotypal personality disorder. It is a 74-item instrument that captures all the nine sub-traits of schizotypal characteristics (Fonseca-Pedrero et al., 2014).
Therefore, it is a reliable tool for the assessment of schizotypal behavior whose validity has been corroborated by various investigations (Fonseca-Pedrero et al., 2014; Tsaousis, Zouraraki, Karamaouna, Karagiannopoulou, & Giakoumaki, 2015). On the other hand, the PHQ-9 score for the patient is 2, which indicates a very mild case of depression. The patient’s eye symptoms are associated with mild diabetic retinopathy due to poor glycemic control.
Comorbid Condition
The identified comorbid conditions include diabetic retinopathy and mild depression as shown by the findings of the PHQ-9 test.
Plan
The patient was referred to an endocrinologist for additional help to manage his blood sugar levels, which would slow down the progression of diabetic retinopathy. Psychotherapy was recommended for the patient, particularly a cognitive-behavioral treatment approach (Bateman, Gunderson, & Mulder, 2015), to help him address his unusual preoccupation with witches.
Reflection
Personality is a blend of thoughts, feelings, and actions that make an individual stand out from others. It also refers to the way people perceive, comprehend, and interact with the outside world. Personality develops during childhood and is influenced by associations between heritable factors and environmental dynamics. Schizophrenia, on the other hand, is a mental disorder that is characterized by an impaired capacity to reason, feel, and act rationally. It is a serious mental disorder that causes affected patients to lose touch with reality, a phenomenon that is referred to as psychosis (Strik, Stegmayer, Walther, & Dierks, 2017).
A normal part of growth and development is learning to understand and act on social cues correctly. Schizophrenia interferes with this ability. However, in individuals who present with a schizotypal personality disorder, it is uncertain what goes wrong to cause the disorder. Nonetheless, it is hypothesized that genetics plays a role in the day-to-day operations of the brain.
Schizotypal personality disorder can be mistaken for schizophrenia. My encounter with this patient was an eye-opener that prompted me to find out the specific features of schizotypal personality disorder that distinguish it from other forms of schizophrenia. Even though short episodes of psychosis characterized by fallacies and illusions are witnessed in people with a schizotypal personality disorder, these occurrences are infrequent, short, and less intense than those in schizophrenic patients.
Another distinguishing feature of schizotypal personality disorder is that it causes strange behavior that often interferes with an individual’s capacity to form and sustain close interpersonal relationships. This problem is attributed to the inability to comprehend the impact of their strange behavior on other people as well as a wrongful construal of other people’s motives and actions, which breed mistrust.
Such problems result in excess anxiety and the propensity to avoid social settings given that people with a schizotypal personality disorder often hold strange beliefs or react tactlessly to social prompts. Nonetheless, handling a patient with a schizotypal personality disorder is easier than dealing with a schizophrenic person because the former can be helped to note the difference between their twisted thinking and reality. On the other hand, modifying the delusions of a schizophrenic person is virtually impossible.
In most cases, a schizotypal personality disorder is diagnosed in children. However, the patient in the note does not have a prior history of this disorder during his childhood. This observation is consistent with the findings reported by Volkert, Gablonski, and Rabung (2018) about the incidence of schizotypal personality disorder in adults. However, the patient has a positive family history of schizophrenia, which highlights the importance of conducting a detailed psychosocial evaluation of patients presenting with mental health problems.
A schizotypal personality disorder is often thought to be on a continuum with schizophrenia but as a less serious form of the ailment. Therefore, patients with a schizotypal personality disorder can still benefit from the same kinds of treatment that people with schizophrenia receive despite the differences in the manifestation and characteristics of the two mental problems. However, extra prompting from family members and friends may be needed to convince a person with a schizotypal personality disorder that they need medical help from a mental health expert.
Untreated schizotypal personality disorder elevates the risk of depression, personality syndromes, anxiety, suicidal ideations and attempts, abuse of drugs, and social problems at work or school. Extreme stress may trigger psychotic incidents, which further increase the risk of schizophrenia. Therefore, patients with identified schizotypal tendencies should receive appropriate care to prevent the progression of the symptoms to severe schizophrenia.
References
Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet, 385(9969), 735-743.
Fonseca-Pedrero, E., Fumero, A., Paino, M., de Miguel, A., Ortuño-Sierra, J., Lemos-Giráldez, S., & Muñiz, J. (2014). Schizotypal Personality Questionnaire: New sources of validity evidence in college students. Psychiatry Research, 219(1), 214-220.
Kirchner, S. K., Roeh, A., Nolden, J., & Hasan, A. (2018). Diagnosis and treatment of schizotypal personality disorder: Evidence from a systematic review. NPJ Schizophrenia, 4(1), 20. Web.
Lu, Y., Pouget, J. G., Andreassen, O. A., Djurovic, S., Esko, T., Hultman, C. M.,… Sullivan, P. F. (2018). Genetic risk scores and family history as predictors of schizophrenia in Nordic registers. Psychological Medicine, 48(7), 1201-1208.
Manea, L., Gilbody, S., & McMillan, D. (2015). A diagnostic meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. General Hospital Psychiatry, 37(1), 67-75.
Mitchell, A. J., Yadegarfar, M., Gill, J., & Stubbs, B. (2016). Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: A diagnostic meta-analysis of 40 studies. British Journal of Psychiatry Open, 2(2), 127-138.
Strik, W., Stegmayer, K., Walther, S., & Dierks, T. (2017). Systems Neuroscience of Psychosis: Mapping schizophrenia symptoms onto brain systems. Neuropsychobiology, 75(3), 100-116.
Tsaousis, I., Zouraraki, C., Karamaouna, P., Karagiannopoulou, L., & Giakoumaki, S. G. (2015). The validity of the Schizotypal Personality Questionnaire in a Greek sample: Tests of measurement invariance and latent mean differences. Comprehensive Psychiatry, 62, 51-62.
Volkert, J., Gablonski, T. C., & Rabung, S. (2018). Prevalence of personality disorders in the general adult population in Western countries: Systematic review and meta-analysis. The British Journal of Psychiatry, 213(6), 709-715.