Psychiatric Diagnosis and Management in Adults
The Psychiatric-Mental Health Nurse Practitioner (PMHNP) is a Registered Nurse with a master’s degree in nursing specializing in psychiatric-mental health treatment for people of all ages. The PMHNP learns advanced health assessment abilities, including conducting screening history and physical exams, episodic assessments, forming initial physical diagnoses, and referring patients to primary care when necessary (Delaney & Vanderhoef, 2019).
The PMHNP develops advanced clinical skills and expertise in psychiatric-mental health diagnosis and treatment, including psychotropic drug prescription, case management, individual, group, and family psychotherapy, crisis intervention, and consulting.
Since its inception, the psychiatry field has struggled to categorize, investigate, and treat demonstrably severe diseases without being able to consistently and definitively distinguish the features of psychiatric illness from normal human behavior variations. However, exposure to different cases and learning standard criteria like the DSM V has prepared me to confidently see and manage psychiatric patients.
Significant Patient Interaction
One of the critical cases I interacted with was a 47-year-old woman brought to the psychiatric clinic by her sister. The patient was being followed up at our clinic and was on haloperidol at the time. According to the sister, the patient was suicidal and had left a message for them. She later found her in the garage, and the rope was already in position.
For the past three years, the patient has been hearing voices talking to her and seeing their faces, though unidentifiable. They show up now and then and always have a message for her. They sometimes tell her how she has been acting in an unchristian manner and laugh at how unattractive she is. They continue to playback her life experiences and display them on a screen.
As a result, the patient suffered from sleeplessness. On that fateful day, they had come for her, instructing her to end her life by hanging, as previous suicide attempts had failed. The patient began conversing with people who were not visible to us. She afterward looked in my direction and acted as if nothing had happened. Later, she became enraged and demanded why we were trapping her.
For 15 years, the lady used haloperidol to treat her schizophrenia. After the suicide attempts, she was admitted to the psychiatric hospital twice (2014 and 2021). She attends follow-up clinics at our facility. Insight was lacking. She was the firstborn of a family of three siblings, with two sisters in the family history. She is single and lives with her two younger sisters, both single. Both parents have passed away.
The father was a known schizophrenic patient and spent 15 years in a mental institution. Three years ago, the second-born sister was put on antipsychotic medication. She claims that the sisters are not employed in any capacity. As a result, she bears the brunt of the financial load.
On the Mental Health Assessment, she was an African-American woman who appeared to be her age. She went from clear to clouded consciousness before returning to clear consciousness. Her hair looked untidy, indicating that she had neglected her self-care. She had an excellent orientation to time, person, and place. Her speech was rapid, and she was occasionally deafeningly quiet.
She remarked that she felt hollow inside, and she appeared unhappy objectively. Her demeanor is appropriate for the situation. She sobs incessantly and sweats profusely. She cannot sit still on the chair and makes repeated, purposeless fidgeting movements. She believes that life is pointless. She has acted on impulses when she bursts out laughing loudly without any external stimulus.
She has an obsession with sin. Her hallucinations are both visual and auditory. She saw persons who tried to persuade her to commit suicide and replayed her deeds. Immediate, short-term, and long-term memory are all functioning well. Her intelligence was average, and she lacked insight. Medication adherence, on the other hand, is debatable.
The psychiatrist diagnosed Suicide in Chronic Schizophrenia based on the history and the Mental Status Assessment. For more than six months, positive symptoms such as hallucinations and Made impulses suggest schizophrenia. Negative symptoms of chronic schizophrenia include avolition (the patient skips work to sleep), poverty of speech, self-neglect, and a sense of emptiness. Suicide attempts are closely linked to the feeling of emptiness.
Patients with schizophrenia have a 10% suicide rate (Sher & Kahn, 2019). The patient also had a positive family history of schizophrenia, raising the question of heredity (McCutcheon et al., 2020). To rule out ‘folie a deux,’ the sister’s recent diagnosis should be probed. Medication adherence was questionable, and it was identified as a maintaining factor. The purposeless repetitive movements were noted to be choreo – athetoid movements. They occur as a side effect of long-term use of typical antipsychotics, causing extrapyramidal symptoms.
The doctor prescribed an antipsychotic for the treatment plan that helped lower suicidal risk and caused fewer extrapyramidal symptoms. Clozapine is the only antipsychotic licensed for lowering suicide risk in schizophrenic patients (Taipale et al., 2021). Furthermore, because clozapine is a second-generation antipsychotic, a change in management would reduce choreoathetosis.
The prescription was Clozapine 12.5 mg once a day for one month. Because clozapine is known to produce neutropenia, the patient was scheduled for weekly complete blood count tests. The patient was admitted and closely observed, and anti-suicide measures were placed because it was a psychiatric emergency.
Management was both pharmacological and non-pharmacological. Based on the patient’s improvement and consent, the likelihood of future Electroconvulsive Therapy was evaluated. Later, the patient was enrolled in therapy to enhance medication compliance and lower the suicidal risk.
Cognitive Behavior Therapy, Problem Solving Therapy, Group therapy, and Family therapy were the suggested forms of therapy once the patient gains insight (Byrne et al., 2018). The sister was assessed and isolated from the patient during family treatment. Positive signs disappeared after four months of separation from the primary case, confirming the diagnosis of “folie a Deux” in the sibling.
Impact of the Case on Roles Understanding
A PMHNP may work with a psychiatrist, but I may be the only one extending cost-effective mental health care in the rural setting. The case addressed most of my roles and how they should be executed (Chapman et al., 2018). The first role is eliciting signs and symptoms from the patient. I sharpened how to approach history taking from the case, especially for sensitive topics (Burgess et al., 2020).
Two important tools adopted were normalizing and exaggerating. For example, when inquiring about suicide, I should normalize by telling the patient that ” Normally, when patients are in a situation are in a situation like the one she is in currently, they tend to think about taking away their lives.”
The statement allows the patient to open up about her suicide attempts. Exaggeration is when I ask the patient if they take a crate of beer per day, then they laugh and say that they only take 12 bottles. Detailed history taking brings out predisposing and precipitating factors of the condition. Genetics was noted as a significant predisposing factor to the condition for this case.
The second role I learned was making the correct diagnosis of patients. The diagnosis must be rationalized by criteria such as DSM and for schizophrenia – Schneider First Rank symptoms. The criteria provide a timeline and a minimum number of symptoms allowing one to rule out borderline conditions.
Additionally, a diagnosis must be holistic by capturing organic, psychological, social, and mental aspects (Chapman et al., 2018). Based on these criteria, a diagnosis for the sister was established. It was made clear that it is my role to provide a continuum of care for the patients, especially the severely ill, and to have a continuous relationship that allows me to differentiate identifiable underlying diseases.
The case also informed my role in providing psychopharmacological management. The choice of drug is guided by the patient’s diagnosis, previous response to drugs, their choice, and current guidelines. The PMHNP must consider the patient’s co-morbidities, compliance issues, and side effects before settling for a drug.
The case also exposed me to the role of providing individual, group, and family psychotherapy. I learned how to schedule the sessions and the role of therapies in fully understanding the patient’s contest. The therapies are beneficial when a patient has the insight to follow through successfully.
Additionally, there is a role for a PMNHP to provide family–psychiatric mental health education because a psychiatric illness in one member may lead to mental health issues t another member. Lastly, one should focus on treatment and prevention by promoting mental health wellness. For this case, the sister who brought in the patient is also counseled and followed up to prevent the occurrence of a similar condition.
Case Application to Future Practice
The case reinforced my structure of history taking for psychiatry patients. The application of verbal and non-verbal cues learned will foster a therapeutic relationship with patients ( Burgess et al., 2020). I will ensure that the non–verbal cues match the words spoken to avoid confusing the patient. History taking will have events in chronological order to determine any temporal relationships between life events and the occurrence or precipitation of symptoms.
Thirdly, I will ensure that the diagnostic formulation includes organic, social, and psychological aspects for the holistic management of the patient. Each aspect will have a therapeutic approach. Diagnosis will always be based on the latest guidelines rather than best guesses, and evidence-based practice will inform management (Delaney & Vanderhoef, 2019).
The management will be inclusive of non-pharmacological techniques. The patient’s consent may be sought before management if stable, but if unstable, I may have a family member consent or act in the patient’s best interest. Lastly, I will ensure follow-up of my patients, including conducting home visits to improve their disease course ad outcomes.
Conclusion
A PMHNP must be able to conduct screening history and exams and examinations, construct initial physical diagnoses and refer patients to primary care as necessary. Additionally, they should have advanced psychiatric-mental health diagnosis and treatment skills, including psychotropic medication prescription, psychotherapy provision; case management; crisis intervention; and consultation. History taking and mental health examination in psychiatry require tact; diagnosis must have a rationale, and management is based on evidence-based practice.
References
Burgess, J., Costa, T., & Cousins, D. (2020). Clinical assessment and investigation in psychiatry. Medicine, 48(11), 686-693. https://doi.org/10.1016/j.mpmed.2020.08.009
Byrne, M., Jolley, S., & Peters, E. (2018). Cognitive behavior therapy for psychosis. Accessed 2nd June 2022 from https://psycnet.apa.org/record/2019-02032-010
Chapman, S. A., Phoenix, B. J., Hahn, T. E., & Strod, D. C. (2018). Utilization and economic contribution of psychiatric mental health nurse practitioners in public behavioral health services. American Journal of Preventive Medicine, 54(6), S243-S249. https://doi.org/10.1016/j.amepre.2018.01.045
Delaney, K. R., & Vanderhoef, D. (2019). The psychiatric mental health advanced practice registered nurse workforce: Charting the future. Journal of the American Psychiatric Nurses Association, 25(1), 11-18. https://doi.org/10.1177%2F1078390318806571
Lodha, P., & Sousa1, A. D. (2020). Female sexual dysfunction and schizophrenia: A clinical review. Journal of Psychosexual Health, 2(1), 44-55. https://doi.org/10.1177%2F2631831820916096
McCutcheon, R., Reis Marques, T., & Howes, O. (2020). Schizophrenia—An Overview. JAMA Psychiatry, 77(2), 201. https://doi.org/10.1001/jamapsychiatry.2019.3360
Sher, L., & Kahn, R. S. (2019). Suicide in schizophrenia: an educational overview. Medicine, 55(7), 361. https://doi.org/10.3390/medicina55070361
Taipale, H., Lähteenvuo, M., Tanskanen, A., Mittendorfer-Rutz, E., & Tiihonen, J. (2021). Comparative effectiveness of antipsychotics for risk of attempted or completed suicide among persons with schizophrenia. Schizophrenia Bulletin, 47(1), 23-30. https://doi.org/10.1093/schbul/sbaa111
Psychiatric Diagnosis and Management in Adults Instructions
Appendix A. Reflective Video Journal. #1, #2, #3, #4 each worth 25 points = 100 points
Assignment Steps
To complete this assignment:
A: Reflect on your practice as a Psychiatric mental health nurse practitioner-PMHNP I
B: What parts of the mental status exam are you most confident with?
C: What parts of the mental status exam are you least confident with?
D: What are your plans for shoring up your confidence with doing a mental status exam?
E: Summary/Conclusion
Assignment Evaluation
Each of these assignments will be evaluated according to the following rubric:
| Criteria | Points |
| Follows the prompt | 5 points |
| Is within time limits for the prompt | 5 points |
| Thoughtfully addresses the prompt | 15 points |
| Total | 25 points |