Diagnosis of Schizoid Personality Disorder
Schizoid Personality Disorder Diagnosis: Book Excerpts
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HALLUCINATIONS:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of drug or alcohol ingestion? Hallucinations are common during alcohol withdrawal but also may be noted in cocaine addiction, marijuana addiction, LSD intoxication, and PCP intoxication.
- Are the hallucinations primarily visual in nature? This would suggest an organic cause such as organic brain syndrome, epilepsy, brain tumor, etc.
- Are the hallucinations episodic? If the hallucinations occur in episodes with normal behavior in between, one should consider epilepsy or narcolepsy.
- Are the hallucinations associated with early stages of falling asleep or awakening? These types of hallucinations are called hypnogogic and are common in narcolepsy but may also be seen in normal people.
- Are the hallucinations primarily auditory in nature? This is the type of hallucination most commonly associated with schizophrenia.
DIAGNOSTIC WORKUP
A blood alcohol level and urine drug screen are essential at the outset. Most physicians will want to refer the patient to a psychiatrist if these studies are negative. However, the interested physician may proceed further with a wake-and-sleep EEG to identify psychomotor epilepsy, or a CT scan and MRI to identify brain tumors and other causes of organic brain syndrome. Remember, the MRI costs twice as much as a CT scan. A spinal tap will be helpful in diagnosing central nervous system lues. A sleep study will help diagnose narcolepsy. Psychometric testing will help identify schizophrenia and other psychiatric disorders.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hallucinations:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Delirium
–Develops over hours to days
–Fluctuates throughout the day
–Causes include dehydration, drug-induced, electrolyte imbalance, UTI, URI, hypoglycemia, and alcohol or drug withdrawal
–Occurs in 10–30% of hospital patients
–Drug-induced delirium (e.g., cocaine, β-blockers, alcohol, corticosteroids, pseudoephedrine, dopaminergic drugs)
- Alcohol withdrawal (delirium tremens)
–Often presents in hospitalized patients about 3 days after admission
–Commonly presents with tactile hallucinations (e.g., formication—the sense of insects crawling over body)
–May be accompanied by seizure activity
- Hallucinogenic syndromes (e.g., LSD, marijuana, mescaline, phencyclidine, mushrooms, amphetamines)
- Schizophrenia
–Auditory hallucinations are most frequent; visual hallucinations occur in about 50% of patients, tactile in 20%, olfactory in 6%
–Progresses to positive psychotic symptoms (e.g., hallucinations, delusions, thought disorder) and/or negative symptoms (e.g., anhedonia, poor concentration, flattened affect, poor social/personal function)
–1% incidence in the general population, males >females
-
Schizophreniform disorder
-
Schizoaffective disorder
-
Post-traumatic stress disorder
-
Dementia
-
Systemic lupus erythematosus
–Auditory hallucinations caused by corticosteroids; visual and tactile by lupus psychosis
-
Bipolar disorder
-
Psychotic depression
-
Postpartum major depression
-
Mass lesions
-
CNS infections/encephalitis
-
Seizures
-
Occipital lobe injury
-
Heavy metal ingestion
-
Lewy body dementia
Workup and Diagnosis
- History and physical examination
–In caring for patients with major psychiatric illness, follow three important principles: Know the patient's drug regimen, work with psychiatrist if changes are needed, and remember that chronic psychiatric patients have difficulty communicating medical history and needs
–Diagnosis of schizophrenia requires two positive or negative symptoms present for 1 month and signs continuing for at least 6 months (DSM-IV criteria)
–Assess for suicidal/homicidal ideations
–Note timing of hallucinations (e.g., following alcohol or drug use, at random, under stress)
-
Initial labs may include electrolytes, glucose, calcium, BUN/creatinine, albumin, liver function tests, alkaline phosphatase, magnesium, phosphate, CBC, ECG, pulse oximetry, urinalysis, toxicology screen, and drug levels
-
Chest X-ray may be indicated for infectious etiologies of delirium; lumbar puncture may be indicated
-
Further tests, if delirium is suspected, include vitamin B12 and folate levels, ANA, ammonia, and heavy metal screen
-
EEG may reveal slowing activity in delirium, low-voltage fast activity in alcohol withdrawal
-
Psychiatric consult after medical causes of psychosis are ruled out
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Hallucinations:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Hallucinogenic drugs
–LSD, “mushrooms,” mescaline, and PCP are primarily hallucinogens
–Amphetamines, cocaine, inhalants, and marijuana may also produce hallucinations
-
CNS acute events
–Trauma
–CNS infection
–Hypoxic events
- Psychosis
–Defined as a mental state with significant impairment in cognition, interpersonal relations, and reality testing
–Hallucinations may be a major or minor component
–Psychosis may be psychiatric or organic (secondary to CNS insult)
- Schizophrenia
–A disorder of impaired perception, cognition, interpersonal relations, and behavior with illogical and disordered thought content
–Hallucinations (most often auditory) and
delusions are common findings
–Onset is frequently in adolescence
–Frequently a positive family history
-
Seizure disorders
–Prominent auras may manifest as perceptual disturbances; visual and olfactory are the most common; tactile may also occur
-
Narcolepsy
–Hypnagogic hallucinations are hallucinations that occur while falling asleep; they may be visual or auditory
-
Medications
–Antipsychotics, anticholinergics, and
corticosteroids can rarely cause
hallucinations
Workup and Diagnosis
- History
–History of mental illness
–Recent behavioral patterns including relationships,
self-care, and school performance
–Medication and illicit drug use
–Trauma, CNS infection, hypoxic episodes
–Family history of mental illness
- Physical exam
–Vital signs: Hallucinogens, amphetamines, and cocaine may cause tachycardia, hypertension, and hyperthermia
–Hallucinogens, amphetamines, and cocaine may also cause pupillary changes, tremor, ataxia, arrhythmia, and hyperreflexia
-
Mental status exam
–Orientation and general appearance
–Long- and short-term memory
–Affect and behavior
–Thought processing and content
–Speech and language
-
Labs
–Urine and serum toxicologic screen
-
Studies
–Cranial imaging is most useful when there is a history
of head trauma
–EEG for patients in whom a seizure is suspected
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
HALLUCINATIONS:
Approach to Diagnosis
(Differential Diagnosis in Primary Care)
In the workup of hallucinations, it is essential to get a drug history from a relative or friend if not from the patient. Ask about a family history of epilepsy or head trauma. A drug screen should be ordered. If there is no mental deterioration, referral to a psychiatrist may be done but an EEG may still be indicated. With mental deterioration, a neurologist should be consulted. When there is doubt about mental deterioration, psychologic testing may be done. CT scans, EEGs, skull x-ray films, and arteriograms may be necessary in selected cases.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Psychotic behavior:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Because the patient’s behavior can
make it difficult — or potentially dangerous — to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and circumstances that may have precipitated it. Obtain a drug history, noting especially the use of an antipsychotic, and explore his use of alcohol and other drugs, such as cocaine, indicating duration of use and amount. Ask about recent illnesses or accidents.
As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?
Interview the patient’s family. Which family members does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has a family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.
Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Delusional disorders:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing delusional disorders, page 448. In addition, blood and urine tests, psychological tests, and neurologic evaluation can rule out organic causes of the delusions, such as amphetamine-induced psychoses and Alzheimer’s disease. Endocrine function tests rule out hyperadrenalism, pernicious anemia, and thyroid disorders.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Personality disorders:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing personality disorders.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Psychotic behavior:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Because the patient’s behavior can make it difficult—or potentially dangerous—to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and any circumstances that may have precipitated it. Obtain a drug history, noting especially use of an antipsychotic, and explore his use of alcohol and other drugs such as cocaine, indicating duration of use and amount. Ask about any recent illnesses or accidents.
As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?
Interview the patient’s family. Which family members does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has any family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.
Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Delirium/Hallucinations:
Differential Overview
(Field Guide to Bedside Diagnosis)
Systemic
❑ Drugs/toxins
❑ Sepsis
❑ Hypoglycemia
❑ Hypercalcemia
❑ Hyponatremia
❑ Shock
❑ Delirium tremens
❑ Vitamin B12 deficiency
❑ Hypoxia
❑ Hypercapnia
❑ Thyrotoxicosis
❑ Uremia
❑ Hepatic encephalopathy
❑ Thiamine deficiency
❑ Heat stroke
❑ Hypothermia
❑ Lead intoxication
❑ Carbon monoxide poisoning
Neurologic
❑ Concussion
❑ Hypertensive encephalopathy
❑ Subdural hematoma
❑ Postictal
❑ Transient global amnesia
❑ Meningitis
❑ Right parietal stroke
❑ Encephalitis
❑ Vasculitis
❑ Carcinomatous meningitis
Hallucinations
❑ Drugs
❑ Schizophrenia
❑ Temporal lobe epilepsy
Diagnostic Approach
Delirium is characterized by gross disorientation in the presence of alertness and vigilance, disorders of perception with vivid illusions, and psychomotor and autonomic hyperactivity. It usually develops over a short time and is associated
with fluctuating mental status, decreased attention, disorganized thinking as indicated by rambling, irrelevant, or incoherent speech, and a decreased level of consciousness. The most sensitive findings are variability in level of arousal, impaired short-term memory (e.g., digit span), and disorientation to time. Relatives or friends are helpful sources of information about the tempo and degree of impairment.
Fever, tachycardia, or hypertension should prompt a careful evaluation for a medical cause. Infection is a common cause in the elderly, especially pneumonia or urinary tract infection. Visual hallucinations are organic in origin, due to factors such as drugs, rather than due to schizophrenia.
Confusion Assessment1) Change in mental state (from baseline) that is acute and fluctuates. 2) Difficulty focusing attention or trouble keeping track of what is said. 3) Disorganized thinking (rambling or irrelevant conversation, unpredictable switching between subjects, illogical flow of ideas). 4) Altered level of consciousness (lethargy, stupor, or hyperalert). A positive test requires 1 and 2 positive, and either 3 or 4.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Delusional disorders:
Diagnosis
(Handbook of Diseases)
The DSM-IV-TR describes a characteristic set of behaviors that mark the patient with delusional disorder. (See Diagnosing delusional disorder, page 252.)
In addition, blood and urine tests, psychological tests, and neurologic evaluation can rule out organic causes of the delusions, such as amphetamine-induced psychoses and Alzheimer’s disease. Endocrine function tests rule out hyperadrenalism, pernicious anemia, and thyroid disorders such as “myxedema madness.”
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Personality disorders:
Diagnosis
(Handbook of Diseases)
For characteristic findings in patients with this condition, see Diagnosing personality disorders, pages 626 to 628.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Psychotic behavior:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Because the patient’s behavior can make it difficult — or potentially dangerous — to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and any circumstances that may have precipitated it. Obtain a drug history, noting especially use of an antipsychotic, and explore his use of alcohol and other drugs such as cocaine, indicating duration of use and amount. Ask about recent illnesses or accidents.
Interview the patient’s family. Which family member does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has any family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.
Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Psychotic behavior:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Because the patient's behavior can make it difficult—or potentially dangerous—to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and circumstances that may have precipitated it. Obtain a drug history, noting especially the use of an antipsychotic, and explore his use of alcohol and other drugs, such as cocaine, indicating duration of use and amount and when it was last taken. Ask about recent illnesses or accidents.
As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?
Interview the patient's family. Which family members does he seem closest to? How does the family describe the patient's relationships, communication patterns, and role? Has a family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient's compliance with his drug regimen.
Finally, evaluate the patient's environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
HALLUCINATIONS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
In the workup of hallucinations, it is essential to get a drug history
from a relative or friend if not from the patient. Ask about a family
history of epilepsy or head trauma. A drug screen should be ordered. If
there is no mental deterioration, referral to a psychiatrist may be done but
an electroencephalogram (EEG) may
still be indicated. With mental deterioration, a neurologist should be
consulted. When there is doubt about mental deterioration, psychologic
testing may be done. Computed tomography (CT) scans, EEGs, skull x-ray
films, and arteriograms may be necessary in selected cases.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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