S.T. is a 57-year-old single male who presents for psychiatric evaluation at the request of his sister after the death of their mother, due to progressively worsening psychotic symptoms. According to S.T., his difficulties began several weeks ago and have intensified over time. He reports persistent persecutory beliefs that individuals sent by the government are monitoring him through his window, following him in public places, and spying on him through electronic devices such as the television. He also believes these individuals are intentionally attempting to poison his food, leading him to engage in protective behaviors such as locking food items in the refrigerator.
S.T. endorses ongoing auditory hallucinations, which he describes as loud voices and "heavy metal music" that occur throughout the day and night. These hallucinations significantly disrupt his sleep, with S.T. reporting that he is often unable to sleep for days at a time due to the intensity of the voices. He also reports visual disturbances, including seeing shadows and birds that others do not perceive. S.T. appears convinced these experiences are real and demonstrates limited insight into their pathological nature.
The patient reports that these symptoms have caused marked impairment in his daily functioning. He avoids leaving his home due to fear of being followed, does not shop for groceries, and has repeatedly contacted emergency services regarding perceived threats, resulting in warnings from authorities. Since the death of his mother three years ago, S.T. has become increasingly socially isolated and relies heavily on his sister for support. He is currently unemployed and reports minimal engagement in structured or recreational activities. He denies current or past suicidal ideation, homicidal ideation, or self-harm behaviors.
Current medication: Metformin, dosage not reported. Allergies: No known drug allergies (NKDA) reported.
S.T. is a 57-year-old African American male, born in the United States, raised by his mother and sister. His highest educational level is 10th grade. He is single, has never been married, has no children, and is unemployed. He reports smoking and drinking with no other hobbies or physical activities reported. He denies any trauma or sexual abuse but mentioned that his father was hard on the family until his death.
There is no diagnostic test for schizophrenia or schizoaffective disorder; the diagnosis is based on a comprehensive mental health assessment and ruling out medical causes. No vital signs were listed.
S.T. is a 57-year-old African American male who presented as disheveled and appeared his stated age. He was cooperative and appeared preoccupied with intrusive thoughts, demonstrating poor grooming and hygiene and maintaining limited eye contact. His speech was occasionally pressured and tangential, making redirection somewhat challenging. Mood was reported as "fine," but affect was constricted, suspicious, and incongruent with mood. Thought processes were disorganized and tangential, with prominent persecutory delusions involving government surveillance and poisoning. The patient reported auditory hallucinations in the form of voices and "heavy metal music," as well as visual hallucinations of shadows and birds. Insight was poor and judgment appeared impaired. Cognition showed mild deficits in attention and concentration. Orientation was intact for person and place, with partial orientation to time. There was no evidence of suicidal or homicidal ideation during the assessment.
1. Schizophrenia, paranoid type (F20.0) — primary diagnosis. Schizophrenia is the most likely diagnosis given S.T.'s clinical presentation, illness course and history. He demonstrates multiple core DSM-5-TR symptoms, including persistent persecutory delusions, prominent auditory hallucinations, possible visual hallucinations, and disorganized thought processes (Striebel, 2025). These symptoms have persisted for several weeks with clear functional decline — social isolation, unemployment, avoidance of public spaces, and repeated inappropriate calls to emergency services. His psychiatric history of multiple hospitalizations in early adulthood, together with a strong family history of schizophrenia (Kendler & Klee, 2022), further supports a chronic psychotic disorder rather than a mood- or substance-based condition.
2. Schizoaffective disorder (F25). Considered due to psychotic symptoms accompanied by sleep disturbance and the psychosocial stressor of bereavement. DSM-5-TR criteria require a major mood episode concurrent with schizophrenia symptoms, plus at least two weeks of psychotic symptoms in the absence of mood symptoms (Cardoso, 2022). S.T. does not display a sustained depressive episode — no pervasive low mood, anhedonia, worthlessness, or suicidal ideation — so this diagnosis is ruled out.
3. Delusional disorder, persecutory type (F22). Considered due to S.T.'s fixed beliefs of being watched and targeted. However, delusional disorder requires relatively preserved functioning without prominent hallucinations or disorganized behavior (American Psychiatric Association, 2023). S.T.'s prominent hallucinations, disorganized thought, and marked functional impairment exceed the diagnostic boundaries of delusional disorder, so it is ruled out as the primary diagnosis.
Based on the comprehensive psychiatric evaluation, clinical interview, mental status examination and diagnostic findings, S.T.'s presentation is most consistent with schizophrenia, paranoid presentation (DSM-5-TR: F20.9), with persistent persecutory delusions, prominent auditory hallucinations, possible visual misperceptions, disorganized thought processes, and markedly impaired insight and judgment, associated with significant functional deterioration.
If able to conduct this session again, earlier engagement strategies to build therapeutic rapport would be prioritized, given S.T.'s high level of paranoia and mistrust of authority figures (Ridenour et al., 2024). Grounding techniques and validating emotional experiences without reinforcing delusional content may reduce defensiveness and improve collaboration. Collateral information from his sister would also be sought sooner, to clarify symptom onset, medication adherence history, and baseline functioning.
A follow-up session would focus on assessing medication willingness through shared decision-making, given S.T.'s prior negative experiences with antipsychotics, including exploring long-acting injectable options. Risk would be assessed longitudinally, particularly the potential for self-neglect, victimization, or escalating paranoia leading to unsafe behavior.
From a legal and ethical standpoint, this case raises questions of decisional capacity, involuntary treatment criteria, and duty to protect. While S.T. currently denies suicidal or homicidal ideation, his impaired insight and reality testing may warrant careful monitoring for grave disability. Health promotion priorities include smoking cessation, metabolic monitoring, and linkage to community mental health resources.
The treatment plan focuses on symptom stabilization, relapse prevention, and improved functioning through a multimodal approach. Pharmacologic management is prioritized given symptom severity, with an atypical antipsychotic recommended through shared decision-making given S.T.'s history of adverse effects and mistrust of treatment. Given prior tolerance, quetiapine may be considered, starting low and titrating gradually. Long-acting injectable antipsychotics will be discussed as a future option if non-adherence becomes a concern. Baseline and ongoing metabolic monitoring — weight, A1C, lipid panel, and liver function — will be implemented given his diabetes, fatty liver history, and antipsychotic risk (Poojari et al., 2022).
Nonpharmacologic interventions include supportive psychotherapy focused on reality testing, coping skills and stress reduction, without reinforcing delusional beliefs, alongside psychoeducation on illness insight, medication purpose, and relapse warning signs. Case management referral is indicated for housing stability, benefits coordination, and connection to community mental health services. Follow-up is scheduled within two weeks to assess symptom response, medication tolerability, safety, and engagement in care.