Assessing and Treating Clients With Psychosis and Schizophrenia
Delusional Disorders
Pakistani Female With Delusional Thought Processes
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1,#2,#3
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
CONCLUSION: Also include how ethical considerations might impact your treatment plan and communication with clients
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so. She currently weighs 140 lbs, and is 5’ 5”
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.
The PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Diagnosis: Schizophrenia, paranoid type
RESOURCES
§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
§ Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
§ Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.
Decision Point One
· Start Zyprexa 10 mg orally at BEDTIME
· Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
· Start Abilify 10 mg orally at BEDTIME
Decision Point Two
· Continue same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward
· Discontinue Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 months
· Continue Invega Sustenna. Begin injections into the deltoid and add on Abilify Maintena 300 mg intramuscular monthly with oral Abilify 10 mg in the MORNING for 2 weeks
Decision Point Three
· Instruct nurse give the client 50 mg intramuscular injection of Benadryl (diphenhydramine) and 1 mg IM Ativan (lorazepam). Discontinue Haldol and make a follow-up appointment for 2 weeks from today. Starts the client on a short course of Ativan 1 mg orally TID with Benadryl 25 mg orally TID for 1 week. Start oral Abilify 5 mg in the MORNING. Make a follow-up phone call to the home 4 days after this appointment
· Decrease Haldol Decanoate 25 mg IM q2weeks. Submit e-prescription to client’s pharmacy for Cogentin (benztropine )2 mg orally BID
· Discontinue Haldol. Start Abilify 2 mg orally daily and schedule a follow-up phone call 4 days from today’s appointment to check on client’s current symptoms. Also e-prescribe Cogentin 2 mg orally BID to treat the EPS
MY CHOICE MY CHOICE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Decision Point One
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
A decrease in PANSS score of 25% is noted at this visit
Client seems to be tolerating medication
Client’s husband has made sure she makes her appointments for injections (one thus far)
Client has noted a 2 pound weight gain but it does not seem to be an important point for her
Client complains of injection site pain telling the PMHNP that she has trouble siting for a few hours after the injections and doesn’t like having to walk around for such a long period of time
Decision Point Two
Discontinue Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 months
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client’s PANNS decreases by 10% since last visit (15% overall reduction from first visit)
When she walks into the office, the PMHNP notices an unusual movement in the trunk area of the client
When the client sits down, you note that her head is turned to the left and she is unable to move it. She continually smacks her lips and sticks her tongue out repeatedly during this interview session
Decision Point Three
Discontinue Haldol. Start Abilify 2 mg orally daily and schedule a follow-up phone call 4 days from today’s appointment to check on client’s current symptoms. Also e-prescribe Cogentin 2 mg orally BID to treat the EPS
Guidance to Student
Unusual Trunk movements, torticollis, and lip smacking/tongue thrusting are all cardinal signs of extra pyramidal effects and Tardive Dyskinesia [TD] (tongue thrusting). With continued treatment, TD can become persistent for years to decades and needs to be treated immediately. Since typical and atypical antipsychotics block D2 receptors in the substantia nigra, cholinergic effects “take over” and present with movement disorders. Treatment consists of anticholinergic therapy with or without benzodiazepine to control the movements. Since the client has been on long acting Haldol decanoate, it will take 4-5 half-lives to see complete removal of Haldol from her body. This translates into roughly 9 to 15 weeks (half-life of Haldol decanoate is around 3-weeks). It is always good clinical practice to start a client on oral therapy of Haldol and evaluate for efficacy and side effects (tolerability) before initiating long acting therapy such as in this case.
A reduction in the Haldol dose will not do anything for the immediate effects of the Haldol that being seen at today’s visit. It is a long acting medication and is going to take time to reduce the overall steady-concentration. This time frame is 9-15 weeks or 4-5 half-lives (half-life is roughly 3 weeks).
Discontinuation of Haldol is the most prudent option in this case due to her side effects and their effect on her quality of life. The decision to start at 2 mg of abilify or 5 mg of abilify is left to provider choice. This client, in any event, should be prescribed anticholinergic therapy with eight Cogentin, Artane, or Benadryl to control the EPS symptoms until which time the Haldol has been safely eliminated from her body. A follow-up phone call in 3-5 days is also in the best interest of the client to see if the EPS is lessening with the addition of anticholinergic therapy. Continued monitoring for these side effects should be considered at each follow-up visit until such time they can be deemed eliminated.
