Mental Health Consultation
John,
I appreciate you reaching out to me in regards to your patient. This is indeed a challenging situation you have been placed in, but we will work to get it resolved so that the patient can receive the care he clearly requires. Unfortunately, without the patient’s consent to a release of information, we are put in a position of using the information the patient IS providing to make a provisional diagnosis, or we need to try and find out if the patient has a family member that can provide the necessary background information. At this point in time, I would suggest asking the patient if he has anyone he would like for you to contact, and if this results in a dead-end or exacerbates his paranoid behaviors, you stick with the information and observations you have noted to make the diagnosis.
What do we know thus far? We know that the patient is a 38-year-old male, his appearance is unkempt and poorly groomed, he is paranoid about the police being after him and when asked about and prompted to release his medical history, the patient accused the on-duty psychologist of “being a cop.” The patient’s speech is noted to be pressured and indirect, and he exhibits signs of psychomotor agitation—this should be further specified—as well as an elevated body temperature (this also needs to be further explored). During this initial encounter with the patient, the patient revealed that he had been receiving psychiatric treatment “for years,” but would not provide his diagnosis or consent to a release of information regarding his medical history. In the event that this patient’s tox screen/toxicology report come back clean if acquired, the combination of symptoms leads to a seeming tentative diagnosis of undifferentiated schizophrenia.
The patient appears to be having a loss of control over the psyche, and therefore his grasp on reality, as seen through his paranoia. When evaluating the symptoms through a psychodynamic approach, we see there is a seeming disintegration with the ego. The ego is believed to have the position of keeping control of the id’s impulses and achieving a compromise between the demands of the id and the ethical and moral limitations of the superego. Freudians believe that abnormal upbringing, particularly with a rejecting, cold mother, can cause a fragile and weak ego, which then makes it extremely difficult to control the id’s desires (Sammons, n.d.). This can result in the ego being broken apart through its endeavors to suppress the id and the id gaining control of the psyche due to the disintegration of the ego. When this happens, the person loses touch with reality and regresses into a state of ‘primary narcissism’ wherein they revert back to animalistic instinct and are unable to manage their own behavior (Sammons, n.d.), which results in the slew of symptoms experienced in patients with this condition.
Schizophrenia is a disorder that is conceptualized to be a product of both genetic predispositions and environmental stressors (Burley, Stinnett, Goldsmith, Barrera, & Dobson, 2015). Thus, it will be imperative to garner as much background information about this patient as possible. Historically, acute anxiety was believe to be the primary etiologic component in the development of schizophrenia (McReynolds, 1960). However, behaviorists believed that it was a product of learned behavior through the processes of classical, operant, and social learning (Sammons, n.d.). However, it is important to note that this theory of orientation does not validly explain and/or account for principal characteristics like delusions, hallucinations, disorganized thinking, so on and so forth. It does, however, beg the question of whether or not this patient learned these sort of behaviors through his “years of psychiatric treatment.” To look at and evaluate this patient’s symptoms from a humanistic approach, it could be presumed that this patient has not achieved self-actualization, rather his mental illness “reflects distortions of the actualizing tendency, based upon faulty conditions of worth” (Olson, 2013, para 4). Society often dictates conditions of worth and those who do not measure up are often stigmatized and left to deal with these negatively distorted conditions of worth, which for the mentally ill, only exacerbates the adverse symptoms of their respective condition(s). There are so many ways to approach this patient and this situation; however, more time and assessment is needed in order to come to a sound diagnosis. In the meantime, a provisional diagnosis of undifferentiated schizophrenia would allow you to admit him to uphold the crisis house policy and buy you some more time to monitor and assess the patient as well as possibly getting his medical history.
On a final note, while diagnostic manuals like the DSM-5 are beneficial in helping to come to a definitive and/or differential diagnoses, additional manuals and/or handbooks would be useful in this situation. The primary reason it is imperative to consult other resources is so that we can identify patterns in symptomology in an effort to avoid misdiagnosis. In the event that the patient is suffering from schizophrenia and/or another psychotic disorders, two handbooks that might be useful to look over include: The (2011) “Handbook of Schizophrenia Spectrum Disorders” by Michael S. Ritsner and the (2007) “Clinical Handbook of Psychological Disorders, Fourth Edition” by David H. Barlow. I hope this information helps. Feel free to reach out to me again if you have any additional questions and/or concerns.
Respectfully,
Justine Nazworth
References
Barlow, D. H. (2007). Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual. The Guilford Press. New York, NY.
BURLEY, T., STINNETT, R., GOLDSMITH, S., BARRERA, K., & DOBSON, L. (2015). "Schizophrenia" Part IV: A Gestalt Conceptualization for Treating the Schizophrenic Patient. Gestalt Review, 19(1), 65-89.
McReynolds, P. (1960). Anxiety, Perception, and Schizophrenia. In D. D. Jackson, D. D. Jackson (Eds.), The etiology of schizophrenia (pp. 248-292). Oxford, England: Basic Books. doi:10.1037/10605-009
Olson, A. (2013). Humanistic Intervention in Psychosis. Retrieved from https://www.psychologytoday.com/blog/theory-and-psychopathology/201311/humanistic-intervention-in-psychosis
Ritsner, M. S. (2011). Handbook of Schizophrenia Spectrum Disorders, Volume 1. New York, NY. DOI 10.1007/978-94-007-0837-2. Retrieved from http://www.psychiatry.ru/siteconst/userfiles/file/englit/Michael%20S.%20Ritsner%20(Editor)%20-%20Handbook%20of%20Schizophrenia%20Spectrum%20Disorders,%20Volume%20I%20Conceptual%20Issues%20and%20Neurobiological%20Advances%201.pdf
Sammons, A. (n.d.). Schizophrenia: Psychodynamic explanations. Retrieved from http://www.psychlotron.org.uk/resources/abnormal/A2_AQB_abnormal_schizophreniaPsyBehActivity.pdf
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