295.90 (F20.9) Schizophrenia, First episode; currently in acute episode and V60.89 (Z59.2) Discord with Neighbor, Lodger, or Landlord. Using the Clinician-Rated Dimensions of Psychosis Symptom Severity checklist: hallucinations and delusions are present and severe, meaning that the client exhibits severe pressure to respond to the voices, to act upon beliefs, and is very bothered by what she is hearing and believing; and negative symptoms and mania are both present and moderate due to the client’s lack of initiative with life activities and frequent periods of extensively elevated and expansive moods.
Based on my clinical judgement, I used a provisional diagnosis to reach the client’s subtype classification of schizophrenia, because the given narrative suggests, the client is experiencing ongoing symptoms that are evident to be progressive over time. During the concurrent time period, the client meets all symptoms of the criteria.
According to the diagnostic criteria of schizophrenia, section A, in order to meet criteria the client must present two or more symptoms with at least one exemplifying a positive symptom. The client is currently experiencing: delusions, hallucinations and negative symptoms. The client also meets criteria B by showing the decreased disturbances of functioning in major areas such as work and levels of self-care, both of which have been self-reported in WHODAS 2.0 assessment. Criteria C of schizophrenia suggests that the signs of disturbance has to persist for at least six months with at least one month of symptoms. The client has reported her “telepathic experiences” dating back the last two years with the past three months...
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...household, school, and work tasks, all of which she self-reported to be a difficulty for her in the WHODAS. Also, additional services such as career counseling would be in the client’s best interest due to her being out of the workforce. Career counseling could help her find jobs that will best suit her and her diagnosis.
Seligman & Reichenberg (2014) suggest people with schizophrenia in their first episode will make a complete remission, but then go on to say that, “nearly 50% of people hospitalized with this disorder will have a relapse within two years of the first episode” (p. 86). My clinical judgement suggest that the client maintain effective treatment throughout hospitalization and continue when released. Although it is unclear the exact course she may take, it is important to maintain treatment to eliminate further deterioration of the brain.
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