PRAC 6645 WEEK 4 Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
PRAC 6645 WEEK 4 Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Subjective:
CC (chief complaint): “I know I am pregnant but they think I am not”.
HPI: TK is a 40-year-old AA female referred by her psychiatrist. The patient was dx. with schizophrenia 14 years ago and reports she was in an altercation with her mother and ended up being admitted to the hospital. Hospital notes indicate the patient has been stalking the family of a man who died 15 years ago for about 2 years, saying she is 6 months pregnant with his baby and they are trying to prevent him from seeing her. She even claims to have spoken with him a week ago. When asked whether she had done a pregnancy test, she responds that all her pregnancies are never negative until she is over 6 months pregnant. The patient’s mother’s attempt to bring her to reality led to this altercation where the patient become uncontrollable and had to be hospitalized.
Past Psychiatric History:
- General Statement: The patient is a 40-year-old AA female who is convinced she is 6 months pregnant with the baby of a deceased man.
- Caregivers (if applicable): Currently lives with her aunt.
- Hospitalizations: The patient was diagnosed with schizophrenia 14 years ago and hospitalized in June 2022 for 5 days
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: schizophrenia, 2008
Substance Current Use and History: The patient reports smoking marijuana when she was in her 20s. Denies smoking tobacco or use of any other illicit drug of abuse.
Family Psychiatric/Substance Use History: The patient reports no family history of substance use or psychosis.
Psychosocial History: The patient is a single mother of 2 children aged 17 and 14 years who are
PRAC 6645 WEEK 4 Assignment 2 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
currently in the custody of her mother. The patient has not worked in over 2 years due to her disability and currently lives with her aunt. The patient reports that she only has one year of a college education. She was jailed for one 1 week in 2014.
Medical History: The patient has a history of a Benign cyst that was removed from her breast when she was 24 years of age.
- Current Medications: Haldol, Risperdal, Invega Sustenna
- Allergies: No allergies reported.
- Reproductive Hx: The patient is heterosexual with 2 children. She has a history of 2 Abortions. She reports her last monthly periods were 4 to 5 months ago.
ROS:
CONSTITUTIONAL: No fever, weight gain, weight loss, chills, fatigue, or general body weakness.
EYES: No changes in visual acuity or blurred vision. Puts on corrective lenses only when reading. Lat eye exam was done a year ago.
EARS, NOSE, THROAT: No hearing problems, tinnitus, or ear pain. No epistaxis. No bleeding gums, sore throat, or toothache.
CARDIOVASCULAR: No chest pain, palpitations abnormal heartbeat, or decreased exercise intolerance.
PRAC 6645 WEEK 4 Assignment 2 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
RESPIRATORY: No breathing difficulties or dyspnea. Denies coughing, congestions, or hemoptysis.
GASTROINTESTINAL: No constipation, diarrhea, hernia, or abdominal tenderness. Denies changes in bowel movement.
GENITOURINARY: Denies hesitation, polyuria, dysuria, oliguria, dribbling, or incontinence.
HEMATOLOGIC/LYMPHATIC: No anemia, easy bruising, or any other blood disorder.
ENDOCRINE: Denies heat or cold intolerance, sweating, changes in appetite, or hair loss.
NEUROLOGIC: No paralysis, syncope, dizziness, or headache.
PSYCHIATRIC: The patient has a compromised perception of reality. She believes to be pregnant with a dead man’s child.
Objective:
The patient is alert and oriented x 4, the abdomen is distended, respiration even and unlabored, pitting edema to BLE.
Diagnostic results:
Assessment:
Mental Status Examination: The patient is well-groomed and appropriately dressed for the weather. She is alert and maintains adequate eye contact in the interview but becomes evasive and defensive when asked about her pregnancy and the father of her baby. Speech is clear with normal tone, rate, and volume. The thought process becomes non-coherent and illogical as the interview progresses. The patient states she has been speaking to the father of her unborn baby, but cannot recall when she saw him last. No obsessions, compulsions, or hallucinations were noted, delusions of pregnancy need to be confirmed through a pregnancy test or ultrasound. She is oriented to person, place, and time. She demonstrates good abstract thought and judgment. Insight is present.
Differential Diagnoses:
- Pseudocyesis: Pseudocyesis is a condition in which the patient has all signs and symptoms of pregnancy except for the confirmation of the presence of a fetus. It is the conviction of a non-pregnant woman that she is pregnant Vazifdar & Gavali (2022). This is the most applicable primary diagnosis for the patient as she demonstrably presents with pregnancy signs such as menstrual disturbance, and abdominal swelling. However, the diagnosis of this disorder is based on ruling out a viable pregnancy by carrying out a pelvic examination, urine pregnancy test, or ultrasound.
- Delusion of pregnancy: Delusional pregnancy usually occurs among female patients during the state of psychosis. Delusions, a core symptom of psychosis, are false beliefs that are rigidly held with strong conviction despite contradictory evidence (Baker et al., 2019). In delusional pregnancy, there might be abdominal distension and menstrual period cessation, but with no additional outward signs just like the patient in the provided case study.
- Schizophrenia: This disorder occurs when an individual interprets reality abnormally. The patient presents with a previous diagnosis of schizophrenia, and continued use of antipsychotics in the management of this disorder. Antipsychotic medications act by inhibiting the secretion of dopamine hence raising prolactin levels which leads to amenorrhea, and breast tenderness in addition to the somatic experience of pregnancy (Seeman, 2014).
Reflections:
This was a very interesting and complex case. The patient presented as pregnant, her abdomen was distended, and her entire physiology presented as any 6-month pregnant woman would, but this case becomes complex as the patient is convinced, she is pregnant for a man who is confirmed to have been deceased for over 15 years. The patient has been under this illusion for about 2 years and it is consuming her entire life. The patient needs professional help to resolve her delusion preferably psychodynamic and supportive psychotherapy.
Case Formulation and Treatment Plan:
According to Vazifdar & Gavali (2022), the management of pseudocyesis is multidisciplinary, including psychiatrists, gynecologists, and psychologists. The goal of treatment is to help patients perceive the meaning of their symptoms and to help resolve the associated stressors. This patient has had her children taken away from her as she is not in a position to take care of them due to her mental illness. Feeling that she is pregnant and expecting a child may be a coping mechanism. On the other hand, Marzieh & Forouzan (2017), note that the available psychiatric literature on pseudocyesis is mostly associated with disorders such as schizophrenia, anxiety disorders, and mood disorders. A pregnancy test and more so an ultrasound needs to be done to confirm or rule out pregnancy and if negative, Psychiatric procedures that can be used in these patients include supportive, cognitive, behavioral, and psychoanalytical psychotherapy that focuses on problem-solving. Therapy might focus on helping the patient perceive the meaning of the symptoms and help resolve the stressors that were partly responsible for the condition’s onset (Marzieh & Forouzan, 2017).
Diagnostic studies: Pelvic examination, urine pregnancy test, or an ultrasound.
Referrals: Psychiatrists, gynecologists, and psychologists
Psychotherapy: Cognitive behavioral therapy
Pharmacotherapy: Advise the patient to continue taking Haldol, Risperdal, and Invega Sustenna for the management of previously diagnosed schizophrenia.
Education: Advise the patient to take an active role in therapy and stay compliant with the treatment regimen for a positive outcome.
Follow-up: The patient should report back to the clinic after one month for a review of the treatment outcome and adjustment of the care plan.
References
Baker, S. C., Konova, A. B., Daw, N. D., & Horga, G. (2019). A distinct inferential mechanism for delusions in schizophrenia. Brain: a journal of neurology, 142(6), 1797–1812. https://doi.org/10.1093/brain/awz051
Marzieh, A., & Forouzan, E. (2017). Biopsychosocial view to pseudocyesis: a narrative review. Pesquisa.bvsalud.org, 535–542. https://pesquisa.bvsalud.org/portal/resource/pt/emr-191450
Seeman, M. V. (2014). Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion. World Journal of Clinical Cases: WJCC, 2(8), 338. https://doi.org/10.12998/wjcc.v2.i8.328
Vazifdar, S., & Gavali, U. (2022). Impregnated With Delusion: A Case of Pseudocyesis. Indian Journal of Case Reports, 30–32. https://doi.org/10.32677/ijcr.v8i2.3257