TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 241 and a toxicology screen was negative for common street drugs, which could have led to the sudden change in behavior. In sum, there was no medical explanation for the change in behavior. Using the DSM-IV-TR , the psychiatrist diagnosed Saul with 295.30 schizophrenia, paranoid type . He cited evidence of a bizarre delusion, thus requiring only one symptom to meet criterion A. The psychiatrist noted paranoid type, which was appropriate given Saul’s preoccupation with the religious themes and the grandiose nature of the delusions. The psychiatrist prescribed an antipsychotic medication for Saul and encouraged him to follow up with a counselor and psychiatrist in the community for outpatient care. After discharge from the hospital, Saul received outpatient treatment from a licensed professional counselor and a psychiatrist. Saul took his medication each day with the assistance of his parents, who monitored his compliance. Saul was able to complete high school and started courses at a community college and worked part-time. However, when Saul was 20 years old, his psychiatrist noted a concern in his blood work, which was likely a side effect of the medication he was taking. Saul’s psychiatrist changed his medication because of this concern. Quickly, Saul’s preoccupation with his role as a messenger from God returned. Saul again began to have difficulty with course work and dropped out of school. He was fired from his job because his boss became frustrated that Saul was frequently late, took too long to complete tasks at work and appeared disengaged. There also were reports that he was scaring customers by asking about their religious faith and commitment to God. When Saul stopped showering, his parents requested that he be evaluated again and he was hospitalized for a second time. During his second hospitalization, Saul received another mental health evaluation from a psychiatrist. Saul continued to insist that he was a messenger from God and he perseverated on religious themes. Saul said he felt compelled to act on God’s commands, which he now heard as a deep male voice. The psychiatrist noted that Saul’s responses in session were delayed, he frequently asked for questions to be repeated and he seemed to be responding to his hallucinations. Using the DSM-5 , the psychiatrist diagnosed Saul with 295.90 schizophrenia, multiple episodes, currently in acute episode . There was evidence of at least two symptoms for criterion A: evidence of delusions, auditory hallucinations and diminished emotional expression. Saul reported feeling sad or down at times, but through Saul’s report and the treatment team’s observations, it appeared that this occurred less than half the time during an active psychotic phase, which ruled out schizoaffective disorder. Saul’s psychiatrist also completed a quantitative severity assessment using the Clinician-Rated Dimensions of Psychosis Symptom Severity from the DSM-5 (APA, 2013). Saul’s psychiatrist rated the impairment in the past seven days for the eight areas of functioning using a scale ranging from 0 ( no presence ) to 4 ( present and severe ). The psychiatrist rated hallucinations as 4 because Saul was frequently responding to voices, which limited his ability to track their conversation and impaired his functioning. Delusions were rated 3 because of pressure to follow God’s commands. This pressure caused Saul to isolate from others, research religious themes, neglect his personal hygiene and pester customers about their beliefs, which cost him his job. Disorganized speech was rated 0 as the psychiatrist noted Saul’s speech was normal. The psychiatrist did not observe any abnormal psychomotor behavior; therefore, it was scored 0 as well. Negative symptoms were rated 3 as Saul displayed moderate decrease in facial expressiveness. Impaired cognition was rated 3 as Saul was unable to take classes and concentrate at work. Thus his functioning was significantly below what would be expected from an individual of Saul’s age and socioeconomic status. Depression was rated as 1 because Saul reported feeling sad or down some of the time, but did not appear preoccupied with sadness. Mania was rated as 0 because there was no evidence of elevated or expansive mood.