Question

Delusional Disorders
Pakistani Female With Delusional Thought Processes

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/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.

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.

Answer 1

The Positive and Negative Scale is medical scale used for measuring symptom severity of patients with schizophrenia.

Positive scale -    7 items ( minimum score= 7, maximum score = 49)

Negative scale - 7 items ( minimum score= 7, maximum score = 49)

General Psychopathology scale - 16 items (minimum score = 16, maximum score = 112)scores.

Scoring - As 1 rather than 0 is given as the lowest score for each item, a patient can not score lower than 30 for the total PANSS. Scores are often given seperately for the positive items, negative items, and general psychopathology.

Second - generation antipsychotics are generally preferred because they pose a lower risk of serious side effects than do first generation antipsychotics. e.g Risperidone ( Risperidal), Olanzipine (Zyprexa)

First- generation antipsychotics have frequent and potentially significant neurological side effects, including the possibilty of developing a movement disorder that may or may not be reversible. E.g. Chlorpromazine, Haloperidol

Long acting injectable antipsychotics can be given as an intramuscular or subcutaneous injection every two or four weeks. E.g Aripiprazole (Aristada), Paliperidone (Invega Sustenna, Invega Trinza)

Injection related adverse events compromise injection- site pain, a range of local injection site complications (sweating, induration, redness, nodules and occasionally abscesses), and post- injection syndrome. The first two problems can occur with any injectable antipsychotic, whereas post - injection syndrome is unique to OLAI.

Reference -1. Antipsychotic Long - acting Injections edited by Peter Haddad, Tim Lambert, John

2. Pharmacological treatment of mental disorders in primary health care (World Health Organization)

3. First- Generation Versus Second - Generation Antipsychotics in Adults, Comparative Effectiveness, Agency for Healthcare Research and Quality, U.S Department of Health and Human Services.

Some of the ethical considerations

1. Telling Half- Truth to Patients with Paranoid Schizophrenia
2. Supporting the Risky Ambitions of Patients with Schizophrenia
3. Asking a Patient with Schizophrenia whether he/ she wants to write Psychiatric Advance Directives
4. Persuading Patients with Schizophrenia to involve Their Family members
5. Prodromal Schizophrenia