Assessing and Treating Clients With Psychosis and Schizophrenia

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 in-patient psycho unit.

During todays 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 PMHNP administers 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
Select what the PMHNP should do:

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 One

Start Zyprexa (olanzapine) 10 mg po orally at BEDTIME
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client’s PANSS decreases to a partial response (25%)
Client comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals so she is snacking constantly throughout the day.
Decision Point Two

Change medication to Geodon 40 mg orally BID with meals
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this med
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month
Decision Point Three

Discontinue Geodon and start Latuda 40 mg orally Daily
Guidance to Student
Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the patient may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell and there information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in patients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Patients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

The Assignment

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 clients pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649-659. doi:10.2165/00023210-200923080-00002

Note: Retrieved from Walden Library databases.

Document: Midterm Exam Study Guide (PDF)

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.

Note: Retrieved from Walden Library databases.

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

Walden University. (2016). ASC success strategies: Studying for and taking a test. Retrieved from https://academicguides.waldenu.edu/ASCsuccess/ASCtesting

Required Media
Laureate Education. (2016j). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this weeks Assignment.

Optional Resources
Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., & … Miller, D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124-134. doi:10.3371/CSRP.5.3.2

Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728-738. doi:10.2146/ajhp130471

Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107-121. doi:10.1007/s11126-014-9326-2

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