Training Title 134
Name: Mrs. Patricia Warren
Gender: female
Age: 42 years old
Background: Patricia was brought in under a emergency evaluation order after her best friend,
Felicia, after the police for Patricia locking herself in a closet and screaming loudly for over an
hour. EMS was able to calm her with a small dose of Ativan enroute to the emergency
department. This is Patricia’s third presentation to the emergency room in 2 weeks. She had one
psychiatric hospitalization around this same last year. No self-harm behaviors but has assaulted
other in the past. No hx of TBI. Sleeps 1–2-hour increments for total of 6 hrs. daily, refuses to
sleep at night. Refused vitals, wt., refuses labs, not cooperative. She obtains SSDI. She lives in
Cameron, Montana. She denies ever using any drugs and drinks one glass wine weekly. She has
a sister who is five years older, both parents deceased in the last three years. She has no children,
her husband is out of town, truck driver. Family history includes that her father had two previous
inpatient psychiatric hospitalizations for paranoia Mother had history of bipolar depression.
Paternal grandmother had “shock therapy”. Denies history of trauma experience, but her friend
reports parents death was extremely difficulty for Patricia. no current legal charges. dropped out
of high school in 11th grade, was pregnant and had abortion. allergies: Clozaril
Symptom Media. (Producer). (2018). Training title 134 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-134

NRNP 6635 Case History Report – Week 7: Schizophrenia and Other Psychotic Disorders; Medication‑Induced Movement Disorders
Training Title 134: Mrs. Patricia Warren
1. Introduction
Patient: Mrs. Patricia Warren, 42‑year‑old female.

Context: Case study from Symptom Media video (2018).

Clinical Focus: Schizophrenia spectrum disorders, psychotic features, and risk of medication‑induced movement disorders.

Importance: Demonstrates recurrent psychiatric presentations, family history of severe mental illness, and challenges with cooperation and adherence.

2. Demographics and Background
Age: 42 years old.

Gender: Female.

Residence: Cameron, Montana.

Family: Sister (five years older), husband (truck driver, often away), no children. Both parents deceased within last three years.

Education/Occupation: Dropped out of high school in 11th grade; receives SSDI.

Medical History: No traumatic brain injury; allergy to Clozaril (clozapine).

Psychiatric History:

One psychiatric hospitalization last year.

Current episode: third ER presentation in two weeks.

History of assaultive behavior, but no self‑harm.

Family Psychiatric History:

Father: paranoia, two psychiatric hospitalizations.

Mother: bipolar depression.

Paternal grandmother: “shock therapy.”

Substance Use: Denies illicit drugs; drinks one glass of wine weekly.

Trauma History: Denies trauma, but friend reports parental deaths were extremely difficult.

3. Psychosocial Stressors
Bereavement: Loss of both parents in past three years.

Marital Stress: Husband frequently absent due to work.

Social Isolation: Limited support, estranged from broader family.

Occupational/Educational Limitations: Dropped out of school, reliant on SSDI.

Repeated ER Visits: Suggests instability and poor outpatient follow‑up.

4. Clinical Presentation (Psychotic Features)
Reported Symptoms:

Locked herself in closet, screaming for over an hour.

Poor sleep (1–2 hour increments, total ~6 hours/day).

Refuses vitals, labs, weight.

Non‑cooperative with evaluation.

Behavioral Indicators:

Guarded, suspicious, paranoid.

Assaultive history.

Possible hallucinations or delusions (not explicitly stated, but suspected).

Risk Factors:

Strong family history of psychosis and mood disorders.

Bereavement stress.

Poor adherence and cooperation.

5. Mental Status Examination (MSE)
Appearance: Likely disheveled, uncooperative.

Behavior: Guarded, paranoid, non‑cooperative.

Speech: Loud screaming episodes, possible pressured or disorganized.

Mood: Anxious, irritable.

Affect: Labile, intense.

Thought Process: Disorganized, paranoid.

Thought Content: Possible delusions, paranoia.

Cognition: Alert, oriented but impaired judgment.

Insight/Judgment: Poor, refuses evaluation, history of assault.

6. Differential Diagnosis
Schizophrenia: Chronic psychotic disorder with paranoia, disorganized thought, functional decline.

Schizoaffective Disorder: Psychosis with mood episodes (family history of bipolar).

Brief Psychotic Disorder: Acute psychosis lasting <1 month, often triggered by stress.

Bipolar Disorder with Psychotic Features: Family history, mood instability possible.

Delusional Disorder: Persistent delusions without other psychotic features.

Medical Causes: Thyroid dysfunction, neurological illness (labs refused).

7. Diagnostic Considerations (DSM‑5)
Schizophrenia Criteria:

≥2 symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms).

Duration ≥6 months.

Impaired functioning.

Schizoaffective Disorder: Psychosis plus mood episodes.

Brief Psychotic Disorder: Symptoms lasting <1 month.

Patricia’s Case:

Recurrent episodes, paranoia, screaming, poor sleep, functional decline.

Likely schizophrenia spectrum disorder.

8. Medication‑Induced Movement Disorders
Antipsychotic Medications:

Typical (first‑generation): haloperidol, chlorpromazine.

Atypical (second‑generation): risperidone, olanzapine, quetiapine.

Movement Disorders:

Extrapyramidal Symptoms (EPS): Dystonia, akathisia, parkinsonism.

Tardive Dyskinesia (TD): Involuntary movements, often irreversible.

Neuroleptic Malignant Syndrome (NMS): Rare, life‑threatening.

Risk Factors:

Long‑term antipsychotic use.

Clozaril allergy limits treatment options.

Female gender, middle age increase TD risk.

9. Assessment Tools
PANSS (Positive and Negative Syndrome Scale): Measures schizophrenia symptoms.

AIMS (Abnormal Involuntary Movement Scale): Screens for tardive dyskinesia.

Barnes Akathisia Rating Scale: Measures akathisia.

Simpson‑Angus Scale: Assesses parkinsonism.

10. Treatment Plan
Pharmacological:

Antipsychotics:

Atypical preferred (lower EPS risk).

Clozaril contraindicated (allergy).

Adjunctive Medications:

Anticholinergics (benztropine) for EPS.

VMAT2 inhibitors (valbenazine) for tardive dyskinesia.

Benzodiazepines: Short‑term for agitation (Ativan used by EMS).

Psychotherapy:

CBT for psychosis.

Psychoeducation.

Grief counseling.

Lifestyle Interventions:

Structured routine.

Sleep hygiene.

Stress management.

Supportive Measures:

Family involvement (sister, husband).

Case management.

Community support services.

11. Monitoring and Follow‑Up
Regular psychiatric visits.

Medication monitoring (side effects, adherence).

Movement disorder screening (AIMS).

Suicide/violence risk reassessment.

Collaboration with family and healthcare team.

12. Challenges
Non‑cooperation: Refuses vitals, labs, weight.

Medication Limitations: Clozaril allergy.

Family Stress: Bereavement, limited support.

Functional Decline: SSDI, poor sleep, repeated ER visits.

Stigma: Mental health stigma in psychotic disorders.

13. Ethical and Cultural Considerations
Confidentiality: Respect patient privacy.

Consent: Informed consent for treatment.

Safety: Violence risk management.

Cultural Sensitivity: Address stigma, respect autonomy.

14. Case Summary
Mrs. Patricia Warren: 42‑year‑old female with recurrent psychotic episodes, paranoia, screaming, poor sleep, and non‑cooperation.

Likely Diagnosis: Schizophrenia spectrum disorder.

Treatment: Antipsychotics (excluding Clozaril), psychotherapy, lifestyle interventions, supportive care.

Outcome Goal: Symptom reduction, improved functioning, prevention of relapse, monitoring for movement disorders.

📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.

What is Patricia’s age? a) 40 b) 42 c) 44 d) 46

Where does Patricia live? a) Billings, MT b) Cameron, MT c) Helena, MT d) Missoula, MT

What triggered Patricia’s emergency evaluation? a) Assaulting someone b) Locking herself in a closet and screaming c) Suicide attempt d) Substance use

How many ER presentations has Patricia had in 2 weeks? a) 1 b) 2 c) 3 d) 4