Silvia is a 23-year-old, single, Vietnamese-American female brought into the emergency department by her father and sister. Silvia states she feels "unsafe" and expresses a paranoid fear that a friend of hers wants to kill her. Additionally, Silvia discloses "people will come after me" and "people possess me because they want me." Silvia says "It feels like I have psychic dreams" and feels "something's been changing me." Silvia repeats the words "7 deadly sins" and states that people become possessed and angry at their insecurities when they don't get their way. They reportedly attacked Silvia and "take things out of my hands or make me forget things." Silvia also reports, "I feel I can communicate with spirits." Her father reports he is also concerned that Silvia has been "praying too much," spending significant amounts of time fixated on the words "7 deadly sins." He states his daughter is otherwise not religious. Her thought process is scattered and tangential, and she does not provide a clear history. She seems to indicate that she does not have a good memory of recent events. Silvia denies any suicidal or homicidal thoughts.

Silvia was born and raised in San Francisco and currently lives with her parents. She completed high school and received a bachelor's degree from UC Santa Barbara in Sociology. Her father is a retired professor, and her mother works in marketing.

Silvia discloses she "thinks" she is taking her medication. Her father and sister state Silvia has a history of medication noncompliance. Lab results indicate <0.2 lithium levels, suggesting Silvia stopped taking her lithium. It is unclear how long Silvia has not been adherent with her medication. She complains that psychiatric medications have dulled her emotions, and this may be why she discontinued lithium, though this is not entirely clear. Silvia endorses racing thoughts and distractibility. She is illogical. She makes reference to seeing "the devil in people's eyes." Her sister disclosed Silvia has not been sleeping or eating (1 meal a day at most), and is forgetful and easily confused. Her sister added Silvia is up at night, takes long showers, and blasts music to drown out her racing thoughts. The family is concerned about Silvia's bizarre behaviors. Her father added that Silvia is under recent, increased stress after graduating from college while unable to find employment, and increased isolation due to COVID-19. She has a history of 2 psychiatric hospitalizations, most recently 6 months ago.

Utox is positive for cannabis only. Silvia stated she smokes cannabis recreationally "on weekends." Silvia exhibits paranoid ideation and religious delusions as well as a decreased need for sleep and decreased food intake. Silvia endorses fixed beliefs that she can communicate with spirits and that people possess her and steal items from her hand or make her forgetful. Given Silvia's presentation, ER Dr. Reece D.O. paged psych to evaluate Silvia.

(40 points)

• • Consider possible diagnoses or co-morbidities.
  • Indicate whether any further assessment is necessary to support your conclusions.
  • Provide a diagnosis, in light of the currently available information about Silvia.
  • Utilize the axis system to structure Silvia's diagnosis(es).

1. (40 points)

• • Identify and explain potential treatments and/or evidence-based approaches for Silvia based on the presenting information provided.
  • What type of treatment(s) (short and long term), may Silvia benefit from, and why?
  • Does Silvia present a suicidal risk and/or is therefore in need of psychiatric hospitalization?
  • Draw a conclusion and make a clinical recommendation regarding the best treatment available for Silvia.

1. (20 points)

• • Identify any additional factors (i.e., cultural, medical, environmental, biological, etc.) that may complicate Silvia's diagnosis or success in treatment.