FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS

FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS

Focused SOAP Note for Schizophrenia Spectrum Disorders

Subjective:

Chief Complaint (CC):

“I was living, and not bothering anyone, and those people, those people, they just won’t leave me alone.”

History of Present Illness (HPI):

Sherman Tremaine (ST) is a 53-year-old male with a history of schizophrenia who presents for a mental health assessment at the request of a friend. ST reports feeling lonely since his mother’s death three years ago. He claims to have lived a solitary life without causing trouble but believes people constantly watch him from outside his window. ST reports hearing and seeing shadows of these individuals. He expresses paranoid thoughts about the government sending people to monitor him due to what he perceives as excessively high taxes.

ST says he had audio hallucinations from trying to change his senses of sight and sound. His hallucinations include loud metallic noises that keep him awake for days. He watches TV to survive but thinks others outside observe him through the screen. Since these people break into his residence and mess with his food, ST keeps it in the fridge to avoid contamination.

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ST initially claims to drink beer and smoke three cigarettes daily but later admits this is false. He discloses that he stopped using marijuana and began misusing cocaine after his mother’s death. ST denies any history of seizures or blackouts related to substance use. He dislikes psychiatric drugs, including Thorazine, Haldol, Seroquel, and Risperidone, as hazardous. ST denies considering self-harm or harming others.

Past Psychiatric History:

ST reports a history of mental illness, with three psychiatric hospitalizations at age 20. He is currently prescribed medications for his mental illness but is non-compliant due to his beliefs about their harmful nature.

Family Psychiatric History:

ST’s father was in an old state facility for mental illness. Mother allegedly had anxiousness.

Substance Use History:

ST admits to currently smoking three packs of cigarettes per day. He drinks alcohol weekly, with his most recent consumption being the previous day. His sister provides him with a 12-pack of beer weekly during grocery shopping. ST stopped using marijuana three years ago after his mother’s death but began misusing cocaine at that time. He denies any history of seizures or blackouts related to substance use.

Medical History:

ST has a diagnosis of diabetes, for which he takes Metformin regularly.

Current Medications:

  • Metformin (dosage not specified) for diabetes management
  • Prescribed but not taking: Thorazine, Haldol, Seroquel, and Risperidone for mental health management

Allergies:

No known allergies

Reproductive History:

ST is unmarried and has no children.

Psychosocial History:

ST is younger than his older sister. Their mother and sister were his primary caregivers. His mother died three years ago. ST lived with his father before moving in alone after his mother’s death.  He believes his sister is attempting to change their living arrangement. ST’s education is limited to the 10th grade, restricting his personal development opportunities. He has no history of legal troubles but has had encounters with law enforcement due to frequent calls about his hallucinations.

Review of Systems (ROS):

  • General: Denies fever, chills, weight changes, or sweating.
  • HEENT: Denies eyesight loss, impairment, swallowing issues, sore throat, or nasal blockage.
  • Skin: Denies markings, rashes, or itching.
  • Cardiovascular: No cardiac symptoms or palpitations confirmed.
  • Respiratory: Coughing, breathing difficulty, or sneezing denied.
  • Gastrointestinal: Refuses nausea, diarrhea, constipation, or vomiting.
  • Genitourinary: Denies urgency, urination pain, nocturia, or frequency changes.
  • Neurological: Denies headache, syncope, and localized neurological deficits.
  • Musculoskeletal: Denies joint and muscle pain and stiffness
  • Hematologic: Does not report bruises or anemia
  • Lymphatics: No leg swelling or discomfort, no lymphadenopathy noted.
  • Endocrinologic: Denies cold/heat intolerance, excess thirst/hunger, or thyroid disorders.

Objective:

Diagnostic Results: All baseline testing, including hormonal functioning tests, came back within normal limits.

Assessment:

Mental Status Examination: Sherman Tremaine, 53, appears his age. He is calm, alert, and helpful with the examiner. ST is appropriately clothed and groomed. Though oriented to people and places, he is disoriented by his current circumstances. He speaks coherently and at a regular volume. ST smiles appropriately but is anxious. His thought process is coherent and logical, without evidence of thought disorders such as dissociation or derealization. ST strongly denies any sensory disturbances in others despite reporting both auditory and visual hallucinations himself. There are no overt signs of delusions present during the examination. He denies any suicidal or homicidal ideation. ST’s memory and attention appear intact. His judgment and insight are assessed as fair.

Diagnostic Impression:

Primary Diagnosis: Schizophrenia Spectrum Disorder (F20.9)

Differential Diagnoses:

  1. Substance-Induced Psychotic Disorder (F19.959)
  2. Delusional Disorder (F22)

Rationale for Diagnoses

  1. Schizophrenia Spectrum Disorder (F20.9): ST’s presentation strongly aligns with the DSM-5-TR criteria for schizophrenia. He exhibits positive symptoms (auditory and visual hallucinations, paranoid thoughts) and negative symptoms (social withdrawal). The symptoms have persisted for an extended period, causing significant functional impairment. ST’s history of multiple psychiatric hospitalizations in his 20s and ongoing symptomatology support a chronic course of illness characteristic of schizophrenia. FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS

Key supporting evidence includes

  • Persistent auditory and visual hallucinations
  • Paranoid thoughts about being watched and monitored
  • Disorganized thinking (e.g., beliefs about high taxes reaching the sky)
  • Social withdrawal and functional impairment
  • Chronic course of illness with onset in early adulthood
  1. Substance-Induced Psychotic Disorder (F19.959): While ST’s cocaine use could potentially induce psychotic symptoms, this diagnosis is considered less likely than Schizophrenia Spectrum Disorder. The chronicity and nature of ST’s symptoms, along with his psychiatric history predating recent substance use, suggest that his psychotic symptoms are not solely attributable to substance use. However, substance use may be exacerbating his underlying psychotic Disorder.
  2. Delusional Disorder (F22): Although ST displays paranoid thoughts, the presence of prominent hallucinations and the broader range of symptoms he experiences make Delusional Disorder a less fitting diagnosis. Delusional Disorder typically involves non-bizarre delusions without the significant functional impairment and hallucinations seen in ST’s case.

Critical Thinking Process

The primary diagnosis of Schizophrenia Spectrum Disorder is supported by the long-standing nature of ST’s symptoms, their impact on his functioning, and his history of psychiatric hospitalizations. The presence of both positive and negative symptoms, along with disorganized thinking, aligns closely with the DSM-5-TR criteria for schizophrenia. While substance use is a complicating factor, the onset and persistence of symptoms beyond periods of intoxication or withdrawal suggest an underlying psychotic disorder rather than a purely substance-induced condition.

Pertinent positives include auditory and visual hallucinations, paranoid thoughts, social withdrawal, and a history of multiple psychiatric hospitalizations. Pertinent negatives include the absence of manic episodes, which helps rule out bipolar Disorder with psychotic features, and the presence of hallucinations, which is less common in Delusional Disorder.

Plan

The comprehensive treatment plan for ST encompasses pharmacotherapy, psychotherapy, substance use treatment, psychoeducation, family involvement, social support, health monitoring, safety planning, and regular follow-ups. The pharmacological approach involves restarting antipsychotic medication, specifically Risperidone, starting at 2 mg orally at bedtime and titrating up to 4 mg daily as tolerated. This choice is based on the efficacy of second-generation antipsychotics in treating both positive and negative symptoms of schizophrenia, with a relatively favorable side effect profile (Huhn et al., 2019). Concurrently, ST’s diabetes management will continue with Metformin, with the dosage to be confirmed with his primary care provider.

Psychotherapy, particularly Cognitive Behavioral Therapy for psychosis (CBTp), will be initiated with weekly sessions for 16 weeks. This approach can help ST manage his symptoms, challenge distorted thoughts, and develop coping strategies. Medication adherence and substance use will be addressed using motivational interviewing. ST’s concurrent substance use disorder requires a referral to a dual-diagnosis treatment facility that may use Motivational Enhancement Therapy (MET) to treat cocaine and alcohol.

Psychoeducation regarding schizophrenia, its symptoms, and treatment alternatives will be crucial to ST therapy. This instruction will stress medication adherence and substance use dangers. Antipsychotic side effects and management will be discussed, considering their metabolic and cardiovascular concerns (Correll et al., 2017; Stroup & Gray, 2018).

With ST’s approval, family engagement in treatment planning and family psychoeducation will be encouraged, especially his sister. Support and treatment outcomes can improve with this strategy. Social support and rehabilitation will include referrals to local schizophrenia support groups and vocational rehabilitation to address ST’s inadequate schooling and improve functional outcomes.

ST’s care plan must promote and monitor health. This includes setting baseline metabolic parameters, monitoring antipsychotic medication metabolic side effects, encouraging smoking cessation, and working with ST’s primary care provider to provide comprehensive diabetes and other physical health care. Given the higher mortality risk of psychiatric diseases like schizophrenia, this integrated strategy is crucial (Nemani et al., 2021).

With ST, a safety plan will include emergency contact numbers and symptom exacerbation management. Self-harm and other harm risk assessments will be done regularly. A first evaluation in 2 weeks will measure drug response and side effects, followed by monthly consultations for the first 3 months and further changes based on symptom stability. FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS

Reflection

This case example raises many challenges and lessons. Knowing his paranoia and pharmaceutical suspicions, rapport/trust would be managed more strongly if we had to encounter again. Inherent in a strong therapeutic alliance is the key to improvement in effect of treatment. I still would investigate ST’s drug use, especially when he switched from marijuana to cocaine after his mother’s death. Knowing how his feelings of sadness and loss affect his substance use and symptom exacerbation might help tailor treatment. ST’s case raises some of the most critical legal and ethical issues engaged in autonomy vs. beneficence. On the one hand, he can refuse medication, but on the other hand, the pathophysiology of his disease impairs his judgment. Respect for his autonomy and duty to provide adequate care require careful consideration and continuous monitoring. Capacity for informed care decisions will have to be treated cautiously and monitored over time. Health promotion and disease prevention will have to take into consideration ST’s physical health. This patient has an increased risk for developing cardiovascular disease and metabolic syndrome because of schizophrenia, hence his treatment plan should include lifestyle interventions and regular monitoring of the status of physical health. Low education and social isolation of ST will mandate specific interventions in health literacy and access to resources. Psycho-educational interventions attuned to his level of knowledge, with a rated community support services will aid in the effectiveness of treatment and enhance quality of life.

Again, holistic, person-centered care is driven home in this case. ST will not improve or recover long term until his social determinants of health are addressed, such as stability at home, social relationships, and meaningful daily activities, not just his psychotic symptoms. ST’s story underscores the mental illness problem entwined with substance use and psychosocial problems. It puts into light the complex multidisciplinary care involving psychiatric symptoms and problems in life. The case is a classic scenario where, as a professional, continuous learning, sensitivity, and adaptability are called for in mental healthcare.

References

Correll, C. U., Solmi, M., Veronese, N., Bortolato, B., Rosson, S., Santonastaso, P., Thapa‐Chhetri, N., Fornaro, M., Gallicchio, D., Collantoni, E., Pigato, G., Favaro, A., Monaco, F., Kohler, C., Vancampfort, D., Ward, P. B., Gaughran, F., Carvalho, A. F., & Stubbs, B. (2017). Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large‐scale meta‐analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry, 16(2), 163-180. https://doi.org/10.1002/wps.20420

Huhn, M., Nikolakopoulou, A., Schneider-Thoma, J., Krause, M., Samara, M., Peter, N., Arndt, T., Bäckers, L., Rothe, P., Cipriani, A., Davis, J., Salanti, G., & Leucht, S. (2019). Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. The Lancet, 394(10202), 939-951. https://doi.org/10.1016/s0140-6736(19)31135-3

Nemani, K., Li, C., Olfson, M., Blessing, E. M., Razavian, N., Chen, J., Petkova, E., & Goff, D. C. (2021). Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry, 78(4), 380-386. https://doi.org/10.1001/jamapsychiatry.2020.4442

Psychiatry Simplified – Dr Sanil Rege. (2017, April 24). Movement Disorders with Antipsychotic Medication – Conversations with Dr Stephen Stahl [Video]. YouTube. https://www.youtube.com/watch?v=ipW5AcbFzzE

Scissus Animus. (2020, March 19). Realistic schizophrenia simulation [Video]. YouTube. https://www.youtube.com/watch?v=63lHuGMbscU

Stroup, T. S., & Gray, N. (2018). Management of common adverse effects of antipsychotic medications. World Psychiatry, 17(3), 341–356. https://doi.org/10.1002/wps.20567 FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS