HPI:A 53-year-old Dominican-American man, S.T., visited the clinic with his sister. He expressed distress over being followed by strangers and having his personal space invaded. S.T. is of Dominican descent and was raised in the United States. He mentioned living with his late mother until three years ago, after which he began perceiving the presence of spies observing him. Over the past few weeks, he claimed to see their shadows through glass and hear their conversations. According to S.T., he believes these individuals are government agents assigned to monitor him, leading him to suspect that his taxes are unreasonably high. He also mentioned hearing loud heavy metal music and seeing a bird in his room, although these observations were not evident during the assessment. S.T. believes the spies are trying to convince him that the music is not loud, but he insists that it disrupts his sleep and keeps him awake for extended periods. He mentioned using television to help with sleep problems but believes the spies are using it to monitor him. Additionally, he stated that the spies have broken into his home and contaminated his food, but he has managed to outsmart them by hiding everything in the refrigerator. Due to ongoing surveillance, he relies on his sister for grocery shopping, as he avoids going to the store. S.T. also expressed suspicion towards his sister, suspecting her involvement with the authorities and accusing her of placing a bug on his phone to combat his loneliness. Throughout the interview, he questioned if he could smoke and challenged the

diagnosis of fatty liver, suggesting that the doctors who made that diagnosis might have been influenced by aliens.

Mental Status Examination:

S.T., a 53-year-old male, appears to be his current age. He presents as alert, calm, and cooperative during the examination. His grooming and attire are wellmaintained and appropriate. He demonstrates orientation to place and person, although his orientation to time is slightly impaired. His speech is clear, audible, and of normal in tone and volume. He has a stable mood but exhibits some paranoia, but appropriately displays smiles. S.T’s thought process is logical, with no signs of dissociative symptoms such as depersonalization, or flight ideas. The client reports experiencing both visual and auditory hallucinations but denies other disturbances in perception. He didn’t show evidence of delusions. He does not express any current suicidal or self-harm ideation, nor does he indicate thoughts of harming others. S.T’s memory and concentration appear intact. Overall, his insight and judgment are deemed to be good.

Diagnostic Impression:

Schizophrenia

This is a complex mental disorder characterized by the altered interpretation of reality. Its primary symptoms include disordered thinking and speech, abnormal motor activities, primarily auditory hallucinations, delusions, neurocognitive deficits, depression, and persecutory delusions. According to the DSM-5 diagnostic criteria for schizophrenia, patients must exhibit at least two of these symptoms for over a month, accompanied by social dysfunction (APA, 2022). S.T.’s symptoms are consistent with schizophrenia as he has reported auditory and visual hallucinations, a belief in government spies, and disrupted sleep due to external influences, supporting this diagnosis.

Delusional Disorder

It is a distinct mental disorder separate from classical schizophrenia. The DSM-5 criteria for delusional disorder state that patients must have persistent false beliefs lasting at least a month without other signs of psychosis, and the symptoms should not meet the criteria for a diagnosis of schizophrenia (APA, 2022). Typical features include impaired concentration, hallucinations related to delusions, irrational or fervent beliefs or suspicions, social withdrawal, low/angry/irritable mood, and social difficulties. While the patient meets the criteria for a diagnosis of delusional disorder, it is not the primary diagnosis, as his symptoms align more closely with schizophrenia.

Schizophreniform Disorder

This is a psychotic disorder that affects an individual’s behavior, thought processes, and perception of reality. Symptoms include delusions, hallucinations, strange behavior, low energy, poor hygiene, lack of interest, and self-isolation. The DSM-5 diagnosis for schizophreniform disorder requires the presence of at least one of the mentioned symptoms for a period of up to six months (APA, 2022). Although the patient exhibits symptoms consistent with schizophreniform disorder, his symptoms have persisted for more than six months, indicating that it is only a differential diagnosis

Reflections:

If I could do the evaluation again with the patient, I would do numerous things differently to give proper care and intervention. First, I would order lab tests such as a CBC, metabolic panel, thyroid function tests, vitamin B12 levels, syphilis serology, and drug screening. These tests would rule out medical illnesses that induce psychotic symptoms or mimic psychiatric problems. To check for structural abnormalities or organic causes, I would have ordered a brain MRI or CT scan. I would then build a strong therapeutic alliance with the patient. Trust and rapport are essential to involve the patient in treatment and address his problems (Butt, 2021). I would affirm his experiences with government agents and gently challenge any delusions. He needs to understand his symptoms and how they may be related to schizophrenia. Psychoeducation on the illness, its causes, treatment options, and outcomes may help him cope and understand it. Respecting the patient’s autonomy and treatment decisions is ethical and legal. Involuntary treatment could be necessary to protect the patient and others because of his symptoms and beliefs. I would balance his autonomy with the need for adequate care and action by evaluating the circumstances and following relevant laws and regulations. The patient’s smoking habit will be addressed in health promotion and illness prevention, especially given his diabetes diagnosis. Smoking cessation resources, counseling, and support would improve his health and prevent diabetes and smoking-related problems (Long et al., 2023). Cultural sensitivity and knowledge are also needed to provide successful care and therapies that match the patient’s values and views as a Dominican-American. Assessing the patient’s socioeconomic variables and healthcare access, including drug and treatment costs, is also crucial.