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Case Vignette Assignment 1 (10 points)

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Daniel

Daniel is 24 years old. He was a graduate student in Chemistry. In the last semester of his undergraduate studies his grades dropped. He began to have more problems with concentrating on work, getting his thinking to stick together, and he began to let his apartment and his appearance go. He was missing classes and seemed very distracted. This was all very untypical for him. He struggled, but graduated (in part due to his excellent performance throughout his undergrad prior to this semester). Over the summer his parents worried about him because he seemed sullen. He isolated from them and others more than usual and quit his job half way through the summer to that he could go on a camping trip to Idaho. This seemed odd to the family because he was going alone, had never been there before or talked about it, and had never liked camping before. They worried that he might be using drugs again.

In high school they discovered that he had been smoking marijuana. He has always been more anxious than most and started smoking marijuana to feel calmer. It actually made him more anxious. He stopped after experiences while high where he believed that spiritual entities were lurking in the shadows and following him to capture his mind. He also saw shadows move, change form and heard an unfamiliar, demonic sounding voice whispering to him. After that he stopped and has not smoked since and has not had these experiences since.

While in the first year of his master’s program (which has now been over a year ago) he began having odd physical symptoms where it seemed that a triangular shaped object was traveling through his circulatory system. Daniel became convinced that the device was placed in him by alien beings to keep him alive since they had removed his heart and spleen for experimentation. When brought into the ER Daniel is in dirty, ill-fitting clothes. On his shirt with a magic marker he has written “The 7th sphere protects the road”. He has been sleeping in a tent because if he sleeps in a house of wood or stone the aliens can use those materials to track him. He began to notice joggers near his tent and knew that one’s wearing black running attire reporting his movements, so he has been secluding himself further and further into the woods.

He reports hearing voices that he does not recognize. Most of the time these voices carry on about each action he takes, but occasionally they tell him to burn down his apartment so that the department of defense does not get his research. The interviewer has a hard time getting information because the information Daniel describes is all over the place. When asked a question he begins to answer but then goes off in another unrelated direction. His speech is slower and there are odd pauses and gaps in what he says. At times he seems to be in a trance and he keeps mumbling “When the short man extinguishes the light we will all be called to our

necessities.” The interviewer came back in the room at one point and Daniel was pacing back and forth beside his bed, almost like a military officer on patrol.

1. Based upon this vignette what is the likely diagnosis (list code number, diagnosis, and any applicable specifiers)

Diagnosis: F20.9 Schizophrenia, continous

2. How would you support or justify your diagnosis? What details support what criteria? Explain these in narrative form, meaning that each answer needs to be at least a paragraph or more (one to two sentences will not suffice) with attention to writing using complete sentences, appropriate grammar (spelling, punctuation) and clear organization and expression of content.

My diagnosis is supported by the following symptoms which appear to have been continuous for at least a year. This is evidenced because it has been over a year since he started his master’s program. Daniel is experiencing auditory hallucinations as shown by him hearing voices “carrying on about each action he takes” and “telling him to burn down his apartment so the department of defense does not get his research”. He is experiencing somatic hallucinations as evidenced by “odd physical symptoms where it seemed a triangular shaped object was traveling through his circulatory system.”

Daniel is also experiencing somatic delusions as shown by his belief that aliens removed his heart and spleen for experimentation. This delusion supports his somatic hallucinations of feeling the “triangular object moving through his circulatory system to get him alive”. He is also experiencing persecutory delusions as shown by his living in a tent and secluding himself further into the woods because if he sleeps in a building of wood or stone the aliens can track him as well as the “joggers wearing black running attire report his movements”.

Daniel is also exhibiting disorganized speech because the interview is having a hard time getting information from him because he “is all over the place” in his replies. He will also begin to answer a question then go off in another unrelated direction as well as being slower and having odd pauses or gaps in his replies. He is also exhibiting avolition and asociality by missing class, not taking care of himself or his home as well as being more sullen and withdrawn from others.

Michael

Michael is 24 years old. He recently started a new job at a large corporation. Michael is from a small town. Throughout childhood he had friends, but never many, preferring a smaller group of close friends. He often worried and believed that others were making fun of him. He comes from a good home and has never used any type of drugs other than having a beer or two once or twice a month at a small tavern in his neighborhood. He has always been physically and emotionally healthy and likes that he has never had to take any more medicine than an occasional aspirin for headache or antibiotic if he gets bronchitis.

He completed his undergraduate at a small, semi-private liberal arts college and recently completed his MBA program online while working for a company in his home town. In order to find better opportunity he moved away from home to a larger city. He lives alone and now has found his way around town.

Michael had actually worked at another company in this city first, and although he tried very hard he was let go. He started this position a few months ago. For the past several months he has felt more anxious than usual, which he attributed to the move and his new job. Since he has already been in the city for a while he feels settled there and used to his routine, he believed it was probably just the transition and wanting to do well at this new company. He has also had more difficulties sleeping, finding it hard to fall asleep at night.

When Michael first started and was going through orientation and training he felt more behind than the others, like he caught on more slowly. It seemed to him that everyone else was able to grasp everything immediately, whereas he felt lost. About eight weeks ago Michael became convinced that the other new trainees were talking about him pejoratively and conspiring to have him fail. He would see coworkers smile and believe they were secretly reviling in how they would get one over on him. When he lost some important files, he was sure that some of his coworkers had stolen them to ensure his failure. He has been hearing strange clicks on his office phone and is convinced that the firm has found a way to tap his phone to find a reason to let him go. When he sits in the cafeteria it always seems that someone sits behind him and to his left. He believes this positioning and angle allows them to surveille him so that they can use information about his movements to disrupt his work or report his mistakes to his boss.

When he goes home he often notices an unfamiliar vehicle across the street from him, and he is quite sure that his coworker Steve uses this vehicle in the evening to stalk him, switching it out with the car he drives to the office each day so as to try and throw Michael off. At night he does not turn his TV on and actually turns the screen towards the wall because his company is able to use cameras in the cable channels to watch him and he reports that his coworkers are using special code words in commercials to let him know that they are monitoring his house, such as “Like a good neighbor State Farm is there” and “You’re in good hands with Allstate.” Recently he worries that they might be plotting to kill him and that they think Michael will enjoy dying because he has heard the message “We all go, why not enjoy it.”

Michael continues to go to work each day and still gets out to the store, but he feels less comfortable being in public. He is able to engage in small talk with coworkers and his boss, hoping this will show them that he is an OK employee. He even volunteers for overtime believing that if they see he is a dedicated worker that they might no longer surveille him. When he presents for the assessment his appearance is kempt, he is wearing neat clothing, and while somewhat guarded and suspicious he interacts with the interviewer productively. He is able to convey and describe his experiences. He becomes very agitated with the interviewer when it seems to Michael that the interviewer is suggesting that he is not in danger and that all this is “just in his head”

1. Based upon this vignette what is the likely diagnosis (list code number, diagnosis, and any applicable specifiers)

Diagnosis: F22 Delusional Disorder, Persecutory Type, First Episode currently in acute episode

2. How would you support or justify your diagnosis? What details support what criteria? Explain these in narrative form, meaning that each answer needs to be at least a paragraph or more (one to two sentences will not suffice) with attention to writing using complete sentences, appropriate grammar (spelling, punctuation) and clear organization and expression of content.

My diagnosis is justified because Michael’s has never had any reported mental health issues in the past. The delusions started a few months ago. Michael has not had any marked reduction in functioning or impairment as shown by him presenting as well kempt and able to maintain his employment. His delusions are persecutory based on Michael thinking the other trainees are “talking about him and conspiring to have him fail”. Also when files went missing he believed that his coworkers took them to ensure he would fail, along with being surveilled in the cafeteria and though his TV by his coworkers using code words imbedded in commercials. Finally he also believes that his coworker Steve is stalking him and switching vehicles when surveilling him at home. Michael believes Steve is doing this to throw him off.