Pakistani Female With Delusional Thought Processes

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Pakistani Female With Delusional Thought Processes

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Week 6: Antipsychotic Therapy

According to the National Alliance on Mental Illness, approximately 100,000 people experience psychosis in the United States each year (NAMI, 2016). In practice, clients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals. Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric mental health nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for clients.

This week, as you examine antipsychotic therapies, you explore the assessment and treatment of clients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.

Photo Credit: Ingram Publishing/Getty Images


Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia

Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.

Learning Objectives

Students will:
  • Assess client factors and history to develop personalized plans of antipsychotic therapy for clients
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
  • Evaluate efficacy of treatment plans
  • Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the
Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the
Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

  • Chapter 4, “Psychosis and Schizophrenia”
  • Chapter 5, “Antipsychotic Agents”

Stahl, S. M. (2014b).
The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on
The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

  • amisulpride
  • aripiprazole
  • asenapine
  • chlorpromazine
  • clozapine
  • flupenthixol
  • fluphenazine
  • haloperidol
  • iloperidone
  • loxapine
  • lurasidone
  • olanzapine
  • paliperidone
  • perphenazine
  • quetiapine
  • risperidone
  • sulpiride
  • thioridazine
  • thiothixene
  • trifluoperazine
  • ziprasidone

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…

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

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 week’s 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

To prepare for this Assignment:

  • Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.

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 client’s 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.

Delusional Disorders
Pakistani Female With Delusional Thought Processes

Hispanic male

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 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…

§ 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

Delusional Disorders
Pakistani Female With Delusional Thought Processes

Hispanic male

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

Select what the PMHNP should do next:

Decrease Zyprexa to 7.5 mg BEDTIME

Change medication to Geodon 40 mg orally BID with meals

Add-on Wellbutrin XL 150 mg orally in the MORNING



Delusional Disorders
Pakistani Female With Delusional Thought Processes

Hispanic male

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

Select what the PMHNP should do next:

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

Change the Geodon to 80 MG orally at bedtime daily and monitor for breakthrough symptoms throughout the day

Discontinue Geodon and start Latuda 40 mg orally Daily


Delusional Disorders
Pakistani Female With Delusional Thought Processes

Hispanic male

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

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

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.



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