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Psychosis Case Study - Everly Mann
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Introduction
Everly Mann, a 24-year-old African-American female, is presenting to the clinic with a chief
complaint of seeing lots of spiders crawling on her body, hands, and legs that no one else can
see. She also reports feeling them on her arms and legs, believing they are attracted to
hamburgers. Everly has a history of a first psychotic break a year ago, followed by a recent
return of auditory, visual, and tactile hallucinations. She has been experiencing three voices
talking to her, with the "mean voice" making derogatory comments. She denies command voices
but is suspicious that others can hear her thoughts when in public places. Everly becomes
agitated, chaotic, fearful, and yelled at strangers in public. She is poorly performing at work,
misses work, and has difficulty concentrating at home. A problem list includes auditory, visual,
and tactile hallucinations, suspiciousness, and difficulty functioning at work and home.
Differential Diagnosis List
1. Schizophrenia: Everly Mann's symptoms are consistent with a diagnosis of
schizophrenia, including auditory, visual, and tactile hallucinations, disorganized speech,
and paranoia.
2. Delusional disorder: Everly Mann's belief that spiders are attracted to hamburgers could
be considered a delusion, which is a key symptom of delusional disorder.
3. Substance-induced psychotic disorder: It is important to rule out the possibility that
Everly Mann's symptoms are due to drug or alcohol use, as substance-induced psychotic
disorder can mimic the symptoms of schizophrenia.
4. Mood disorder with psychotic features: While Everly Mann does not report significant
mood symptoms, it is important to consider the possibility that her psychotic symptoms
could be related to a mood disorder such as bipolar disorder with psychotic features.
Rationale; pertinent positives, pertinent negatives, and DSM-5
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The case of Everly Mann provides several pertinent positive and negative findings that can help
narrow down the diagnosis and select potential differentials. Firstly, her positive symptoms of
auditory, visual, and tactile hallucinations are consistent with a diagnosis of schizophrenia, which
is a key differential diagnosis. In addition, her belief that spiders are attracted to hamburgers
could be considered a delusion, another symptom of schizophrenia. Her tangential speech,
disheveled appearance, and flat affect are also consistent with schizophrenia.
On the other hand, there are some negative symptoms that may help rule out certain diagnoses.
For example, Everly Mann does not report significant mood symptoms, which makes it less
likely that her symptoms are related to a mood disorder with psychotic features. Additionally, she
denies command hallucinations, which are more commonly associated with certain types of
schizophrenia.
The DSM-5 criteria for schizophrenia include the presence of at least two of the following
symptoms for a significant portion of time during a one-month period (Edinoff et al., 2020):
delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and
negative symptoms (i.e., diminished emotional expression or avolition). The presence of these
symptoms must cause significant social or occupational dysfunction and must not be due to
substance use or another medical condition.
Delusional disorder is diagnosed when an individual has a persistent belief that is contrary to
reality, and this belief causes significant distress or functional impairment. The belief must
persist for at least one month and cannot be explained by another mental disorder.
Substance-induced psychotic disorder is diagnosed when an individual experiences psychotic
symptoms that are due to the effects of a substance, such as a drug of abuse or a medication.
Mood disorder with psychotic features is diagnosed when an individual experiences both mood
symptoms (such as depression or mania) and psychotic symptoms (Dubovsky et al., 2021). The
psychotic symptoms must occur only during mood episodes and cannot be explained by another
mental disorder.
Based on the case, the presence of auditory, visual, and tactile hallucinations, disorganized
speech, and paranoia suggest a diagnosis of schizophrenia. The lack of mood symptoms and
family history of psychotic disorders, as well as the duration and nature of the symptoms, help to
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rule out other differentials such as mood disorder with psychotic features or substance-induced
psychotic disorder. The presence of a specific delusion about spiders being attracted to
hamburgers suggests the possibility of delusional disorder, but the overall symptom presentation
is more consistent with schizophrenia.
Narrative Mental Status Exam
During the mental status exam, Everly appeared disheveled with unkempt hair and wearing
mismatched clothing. Her affect was flat with minimal facial expressions, and her speech was
tangential, often going off-topic. She reported auditory, visual, and tactile hallucinations daily,
with the tactile hallucinations being focused on spiders crawling on her body. Everly described
hearing three voices, one good, one mean, and one that is just blubber. She reported the mean
voice making derogatory comments. There were no perceptual distortions or illusions observed
during the exam. Everly appeared distracted and easily agitated, becoming fearful and yelling at
strangers in public. She denied suicidal or homicidal ideation but did express feeling paranoid
that others can hear her thoughts. Her insight and judgment were poor, and she had difficulty
with attention and concentration. Everly reported that she had previously taken Seroquel, which
worked well for almost a year, but stopped taking it when she felt well enough.
Variations from Normal and Monitoring Needs
The patient is experiencing hallucinations and delusions, which are not normal. There is also a
history of previous psychotic break and discontinuation of medication without medical advice.
The patient's disheveled appearance, flat affect, and tangential speech are also concerning. The
patient may require regular monitoring of their mental health and medication compliance. Labs
and vital signs appear normal based on the provided information. The patient's history of
medication non-compliance and potential drug interactions should be monitored.
Concerns:
Mental health monitoring
Medication compliance monitoring
Potential drug interactions
No concerns noted regarding labs and vital signs.
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Assessment
In order to confirm the diagnosis of psychosis, a comprehensive psychiatric evaluation is
necessary. This evaluation should include a clinical interview with the patient, a review of
medical records, and collateral information from family or other healthcare providers.
Additionally, the use of standardized tools and instruments can provide valuable information to
aid in the diagnostic process.
The Positive and Negative Syndrome Scale (PANSS) is a commonly used tool for assessing the
severity of symptoms in patients with psychosis (Buizza et al., 2022). It consists of 30 items that
assess positive symptoms (such as hallucinations and delusions), negative symptoms (such as
apathy and social withdrawal), and general psychopathology (such as anxiety and depression).
Each item is scored on a scale of 1 to 7, with higher scores indicating more severe symptoms. A
positive score on the PANSS would confirm the diagnosis of psychosis, as it measures the
presence and severity of positive symptoms such as hallucinations and delusions. A score of 4 or
above on the PANSS item for hallucinations would indicate the presence of significant auditory
or visual hallucinations. Similarly, a score of 4 or above on the PANSS item for delusions would
indicate the presence of significant delusional thinking.
Another instrument that may be useful in the assessment of psychosis is the Brief Psychiatric
Rating Scale (BPRS). This tool assesses a range of symptoms including hallucinations,
delusions, disorientation, and unusual behavior. Each item is scored on a scale of 1 to 7, with
higher scores indicating more severe symptoms. A positive score on the BPRS would also
confirm the diagnosis of psychosis, as it measures the presence and severity of a range of
symptoms commonly seen in patients with psychosis (Correll et al., 2018). A score of 4 or above
on the BPRS item for hallucinations would indicate the presence of significant auditory or visual
hallucinations. Similarly, a score of 4 or above on the BPRS item for delusions would indicate
the presence of significant delusional thinking.
Plan of Treatment and Rx
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Pharmacological Intervention and Rx:
• Quetiapine 300mg PO daily at bedtime
• Special instruction for the patient to take the medication at the same time every day
• Drug Class: Atypical Antipsychotic
• MOA: Quetiapine blocks dopamine and serotonin receptors in the brain, which helps to
decrease the symptoms of psychosis.
Neurotransmitters affected: Dopamine and serotonin
Enzymes involved: CYP3A4
Location for metabolism: Liver
• Correlation to Diagnosis: Quetiapine is indicated for the treatment of schizophrenia and acute
manic episodes of bipolar disorder. It targets the surplus of dopamine and serotonin receptors,
which can help to manage auditory and visual hallucinations, and other psychotic symptoms. The
medication is expected to reach a therapeutic level within 2-4 weeks after initiation.
• Lab Monitoring: No specific lab monitoring is required, but baseline metabolic panel,
complete blood count (CBC), and lipid panel should be obtained before starting the medication.
• FDA Approval: Yes, quetiapine is FDA approved for the treatment of schizophrenia and acute
manic episodes of bipolar disorder.
• Possible Side Effects: sedation, weight gain, dry mouth. The causes of these side effects are
due to the blocking of certain receptors in the brain.
• Contraindications or Interactions of Concern: Quetiapine can cause orthostatic hypotension
and should be used with caution in patients with cardiovascular disease. It also has the potential
for drug-to-drug interactions, and the patient’s current medication list should be reviewed for any
potential interactions. The patient should be monitored for any adverse reactions, especially
during the first few weeks of treatment.
Non-pharmacologic interventions
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Cognitive behavioral therapy (CBT) can help Everly learn to challenge and change her
thoughts and beliefs that may contribute to her hallucinations and paranoia. CBT can also
teach coping skills to manage the distress caused by her symptoms (Naeem et al., 2021).
Psychoeducation can be helpful in providing Everly with information about her illness,
treatment options, and ways to manage her symptoms.
Family therapy may also be beneficial to help Everly's loved ones understand and support
her during this challenging time.
Everly may require a more intensive approach such as assertive community treatment
(ACT). ACT is a team-based approach that provides individualized and comprehensive
care to patients with severe mental illness. This may involve home visits, assistance with
daily living activities, and social skills training (Swanson et al., 2022).
Frequency and duration of these interventions will depend on the patient's needs and
response to treatment. It is important to note that non-pharmacologic interventions should
be used in conjunction with medication management and under the guidance of a mental
health professional.
Patient Education
Mrs. Everly is experiencing symptoms of psychosis. This can be a challenging condition
to live with and can significantly impact her daily functioning. Psychosis affects about
3% of the population and can be caused by a variety of factors, including genetic
predisposition, substance abuse, and environmental stressors.
The course of illness for psychosis can vary from person to person, but it is often chronic
and requires ongoing management. Treatment typically involves a combination of
medication and therapy. It is essential that Mrs. Everly continues to take her prescribed
medication as directed to manage her symptoms effectively.
Common side effects of antipsychotic medication, like Seroquel, can include drowsiness,
dizziness, weight gain, and dry mouth. Mrs. Everly should contact her healthcare
provider immediately if she experiences any severe side effects like an irregular
heartbeat, muscle rigidity, or seizures.
Seroquel may interact with medications that affect the heart, liver, or kidneys, and it is
essential to discuss any new medication with her healthcare provider before starting it.
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Antipsychotic medication can pass through breast milk and affect the baby, and there may
be risks associated with taking medication during pregnancy.
There may also be conditions or medications that could contraindicate the use of
Seroquel. For example, patients with a history of seizures or liver or kidney disease may
be at risk of experiencing adverse reactions to the medication.
Finally, it is important to note that relief from symptoms may take time, and Mrs. Everly
should not stop taking her medication without discussing it with her healthcare provider.
It may take several weeks or even months to see an improvement in symptoms, and
continued therapy and medication management are essential for managing psychosis
effectively.
Safety Plan
I have asked about suicidal/homicidal ideation and the patient has said there is no such
ideas or thoughts that has closed her mind.
The patient has denied having access to weapons to any weapon that can cause harm to
her.
Seroquel, is not a controlled substance but does carry a black box warning.
The medications are currently kept at home in a shelf where only her and her adult family
members can access.
Mrs. Everly has been encouraged to be taking a walk every day which will help in
maintaining her health. In addition, visiting her friend and relatives will also boost her
value and hope.
One of the supportive person is her daughter who stays close to her home.
In case of emergency, Mrs Every has the hotline number that she can call to get help
which include 999, 911, and that of clinic which is indicated in her medication form.
Follow-up and outcomes
The level of care placed for Everly Mann is inpatient, given the severity and continuous nature of
her symptoms. She will follow-up in 2 weeks at the clinic for a medication evaluation and
therapy session.
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The outcomes of treatment plan on follow-up will be determined by both quantitative and
qualitative data. Quantitative data will include a reduction in frequency and severity of auditory,
visual, and tactile hallucinations, as well as improvement in work and social functioning.
Qualitative data will involve patient self-report on their overall experience with treatment and
their perceived improvement in symptoms.
Billing Code: The billing code for the initial intake is 90792, with additional codes for
psychotherapy (90834), patient education (98960), assessment testing (96101), and analysis
(96118) as needed.
Approach to care and clinical guidelines
The unique aspects of this case include the patient's auditory, visual, and tactile hallucinations, as
well as her belief that others can hear her thoughts and are talking about her. Additionally, the
patient has a history of stopping medication when she feels well, which is a common problem in
the treatment of psychosis.
An evidence-based guideline for the treatment of psychosis is the American Psychiatric
Association's Practice Guideline for the Treatment of Patients with Schizophrenia (Lopez et al.,
2022). This guideline recommends antipsychotic medication as the first-line treatment for
psychosis, with a preference for second-generation antipsychotics due to their lower risk of
extrapyramidal side effects. The guideline also recommends the use of cognitive-behavioral
therapy and family interventions as adjunctive treatments.
Based on this guideline, the approach to care for this patient would involve restarting
antipsychotic medication, specifically a second-generation antipsychotic such as risperidone or
olanzapine, to address her auditory, visual, and tactile hallucinations. The patient may also
benefit from cognitive-behavioral therapy to address her delusional beliefs about others being
able to hear her thoughts. Family interventions may also be helpful in improving her social
support and addressing any family dynamics that may be contributing to her symptoms. Close
monitoring for medication adherence and potential side effects is also essential.
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References
Buizza, C., Strozza, C., Sbravati, G., de Girolamo, G., Ferrari, C., Iozzino, L., ... & Candini, V.
(2022). Positive and negative syndrome scale in forensic patients with schizophrenia
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Psychiatry, 21(1), 1-17.
Correll, C. U., Galling, B., Pawar, A., Krivko, A., Bonetto, C., Ruggeri, M., ... & Kane, J. M.
(2018). Comparison of early intervention services vs treatment as usual for early-phase
psychosis: a systematic review, meta-analysis, and meta-regression. JAMA
psychiatry, 75(6), 555-565.
Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V. (2021). Psychotic depression:
diagnosis, differential diagnosis, and treatment. Psychotherapy and
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Edinoff, A., Wu, N., deBoisblanc, C., Feltner, C. O., Norder, M., Tzoneva, V., ... & Urits, I.
(2020). Lumateperone for the Treatment of Schizophrenia. Psychopharmacology
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Lopez-Morinigo, J. D., Leucht, S., & Arango, C. (2022). Pharmacological treatment of early-
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needs. Pharmacopsychiatry.
Naeem, F., Latif, M., Mukhtar, F., Kim, Y. R., Li, W., Butt, M. G., ... & Ng, R. (2021).
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