Delusional Disorders Essay Example

Incorporate the following into your responses in the template: Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Objective: What observations did you make during the psychiatric assessment?  Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Delusional Disorders Essay Example. Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Please include introduction and conclusion Reflection note the differential diagnosis should be at least three pages

Pakistani Female with Delusional Thought Processes

Introduction

The client is a 34-year-old Pakistan female who has lived in the United States since her later teens or about the early 20s. To understand her environment, the assessment focuses on her family and domestic setting. She is in an “arranged” marriage to a husband who was selected for her when she was 9 years old. After symptoms that persisted for less than a month, she was diagnosed as “brief psychotic disorder”. Before admission, the client reports having visions of Allah and in the course of the week, she believed to be prophet Mohammad. The patient’s condition was troubling to the extent that her husband became uncomfortable leaving her with their four children. It is during one of her episodes one evening that the got “out of control” that the police were called on her and she was subsequently admitted to an inpatient psych unit.

The patient has undergone assessments following her diagnosis in an attempt to find a proper treatment which will allow her to resume her normal life. in today’s assessment, the patient appears calm and believes that the incident leading to her commitment was blown out of proportion. She denies the claim that she believed herself to be prophet Mohammad and that her husband only sought to get her because he no longer loved her and now wanted an American wife.Delusional Disorders Essay Example.  She believes this to be true because the television is telling her so. The patient is five foot five and weighs 140lbs.

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The patient’s condition is Schizophrenia and she is classified as the paranoid type. In the in-patient treatment condition, the patient’s health needs will be focused on reversing the delusional condition and giving her psychological therapy to deal with her social condition. The background of the family indicates that the patient has possible insecurities in her marriage which began at a young age. The treatment process considers all these factors and involves continuous assessment and evaluation even after leaving the hospital. In this paper, the treatment procedure adopted for the patient is identified and reasons provided for the selection against the other alternatives. In this analysis, the progress of the patient is analyzed in a series of three decisions made after three assessments of the patient and how she responds to the medication at each step of the treatment process.

Decision #1

The patient is brought in with a diagnosis of Schizophrenia and is the paranoid type. Treatment begins with the administration of Invega Sustenna 234mg IM X1 followed by 156mg IM on day 4 and monthly thereafter. The selection of Invega Sustenna as the beginner drug is due to its moderate nature and the fact that it can easily be controlled by proper nutrition and exercise. Abilify Maintena is not a suitable first option because it is best applicable for someone who already has a positive response to Abilify oral. Abilify Maintena is less effective in some individuals and does not bind to the D2 receptor for long as well as Invega. The administration of Abilify Maintena requires prior administration of oral medication. It has the disadvantage that it requires a 2-week overlap of oral therapy because of effective blood levels lagging behind the induction dose.

After the administration of Invega Sustenna, the patient goes home and is required to return to the clinic after four weeks. After the four weeks, the patient reports a decrease in the PANSS score of 25 percent in positive symptoms. The medication is working well for the patient. The husband is supportive in her treatment process making sure she makes it for her appointments for injection; there has been one thus far. The patient has registered a weight gain of 2 pounds but it is not an issue of great concern for her. The patient has a complaint of pains in the site of injection. She says she has trouble sitting for hours after the administration of the injection and does not appreciate having to walk around for extended periods. Delusional Disorders Essay Example.

The physician has an ethical duty to ensure patient-centered care in the treatment of the patient. The patient complains of pains in the site of injection. Therefore, the physician has to find a solution to that problem. Most codes of medical ethics require doctors to protect and uphold the human dignity and rights of the patient. Since this is the first stage of assessment after the administration of medication, the doctor needs to ensure that there are no significant negative side effects on the patient due to the medication. The weight loss is still insignificant and has not troubled the patient at this point.

Decision Point Two

The PMHNP decides to continue with the same medication but instructing the nurse to begin injections into the deltoid as from this visit and onwards. The medication can be continued because there have been no significant side effects that will necessitate stopping the administration of this medication. There has been an improvement in the health of the patient who has reduced infections by 25 percent in the first month. The patient has reported a slight increase in weight which can be managed by moderate physical exercise. There is no need for change in medication. The purpose of continued medication is to try and achieve the same positive response in the patient in the subsequent four weeks. The patient’s concern for injury after the injection is taken to consideration and the nurse is advised to do injections from the deltoid.

After four weeks, the client returns to the clinic. The PANNS have reduced by a total of 50% in positive symptoms from the time of initiation of Invega Sustenna. The medication is working as expected since the PANNS have reduced in the same magnitude in the second period as the first. The patient’s concern about the injection-site pain is positive and she states that it is much better in the arm. The physician has to take into consideration the concern of the patient. Through open communication, the patient can communicate the discomfort she experienced with injection in the first period which has been solved at this stage. the doctor can discover that the patient is now concerned about her weight gain of plus 2.5 pounds; a total of 4.5 pounds in 2 months. The patient is bothered and is afraid that the husband, who is absent during this visit, might not like it. She likes how Invega Sustenna works but is wondering if there is an alternative drug that does not cause weight gain.

It is the ethical responsibility of the patient at this point is to ensure that the needs of the patient are considered even as the medication is working effectively. The patient has one concern which she explicitly makes known; there is a weight gain of another 2.5 pounds. Delusional Disorders Essay Example. At this point, she is concerned about the weight gain and asks whether there is an alternative drug. The doctor must consider their role to ensure effective recovery while still ensuring the comfort of the patient. The decision to be made must be in the best interest of the patient. The decision must be reached in consultation with the patient and the physician will make it known to her what is the best decision to ensure her recovery.

Decision Point Three

The physician decides to continue with the Invega Sustenna. Also, it is decided that the client should be counselled on the fact that the weight gain from Invega Sustenna is not as significant as what other drugs as efficient as Invega Sustenna can cause. A decision is made to make an appointment with the dietician and an exercise physiologist to work towards cutting the weight for the comfort of the client. The medication has worked well for the last two months and there are no severe side effects. The perceptions of the patient on the effect of medication on her weight are just an expression of her insecurities. Also, it is possible to manage the weight gain by proper dieting and exercising. Alternatives of Invega Sustenna are likely to cause much more weight gain compared to what the client is currently experiencing.

During this third decision point, the intention is to achieve a positive change in the mental health condition of the patient. The Invega Sustenna has proved to work effectively for the last two months and there are no significant side effects that can necessitate bringing the patient off the medication. In addition to the Invega Sustenna medication, the patient needs counselling to have a positive perception of their medication and drop the negative attitudes on her weight gain. Counselling is aimed at helping the client to deal with her feelings of self-doubt in her marriage. The medication at this stage also aims to manage the weight gain of the client by booking appointments with a dietitian and exercise physiologist. The doctor has to ensure the mental wellbeing of the patient, therefore, the concern about her weight must be addressed even though it appears to be a minor weight gain.

It is the ethical responsibility of the physician to ensure the all-round wellbeing of the patient. Any patient concerns, even those that are not medical ultimately lead to their wellbeing. Her concerns about weight gain must be addressed. The physician chooses to refer the patient for counselling to help her cope with the weight gain and address possible issues in her marriage. The counselling is not limited to the problem of Schizophrenia but to ensure that the patient has improved overall wellbeing.

Conclusion

The patient is diagnosed with Schizophrenia and is the paranoid type. The condition is “brief psychotic disorder” which has impaired her insight and judgement. She is brought to the hospital after incidences of delusion and paranoia. She believes that Allah sends her messages through the Television. Her mood in her description is euthymic and while she denies having visual or auditory hallucinations, it becomes apparent that she is paying attention and believing to get communication from something. The patient is brought to the hospital for treatment of the mental health issue. Delusional Disorders Essay Example.

The patient is administered with Invega Sustenna for three months across three assessment points. Invega Sustenna is suitable for treating mental disorders such as schizophrenia which our client has been diagnosed with. The medication is recommended against the other options which are less effective in treatment. Through the three months, the client reports no serious side effects associated with using the drug except for minor gain in weight.

In addition to Invega Sustenna, the client needs additional counselling for issues that manifest during the treatment period. The first issue is adding weight and the belief that her husband will not like the added weight. The husband has not made such an assertion but the belief that he will speak to the perception of the patient. The physician considers all the concerns of the patient and makes a reasonable effort to remedy them. For instance, her complaint on the injection-spot pain is addressed by changing the spot of injection to the hand. The physician decides to set an appointment with a dietician and exercise physiologist to help the client attain her desired body weight. The treatment procedure aims to offer the client the best medical help and look into any of her concerns to ensure recovery.

References

Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.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. Delusional Disorders Essay Example. doi:10.1093/schbul/13.2.261

https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

PANSS Scale. Available at: http://egret.psychol.cam.ac.uk/medicine/scales/PANSS

Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625–629. Retrieved from http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf

Introduction

The case under analysis involves a 34-year-old Pakistani female that has been presented to the facility after presenting symptoms of psychotic disorder in which she claimed that the television talks to her and it is from it that she receives messages from Allah. The woman is in the company of her husband, who unfortunately, she believes got things out of proportion when explaining about her condition, because he wants to poison her and marry an American woman. The subjective and objective data of the client demonstrates that she suffers from schizophrenia. Differential diagnosis will be carried out to help rule out the possibility of misdiagnosis with another psychotic or mental disorder.

Subjective Data

Chief Complaint (CC): The client believes that the television talks to her. She believes that Allah sends her messages through the TV.

History of Present Illness (HPI): A 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is presented 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. Before her hospitalization, 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. During the 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 says she knows this because the television is telling her so. Client reports that her mood is “good.” She denies auditory/visual hallucinations; she appears to be “listening” to something.  Insight and judgment are impaired. At times throughout the clinical interview, she becomes hostile towards you but then calms down.

Current Medications: Risperdal. She stopped taking the medication a week after leaving the hospital because she thought her husband is going to poison her so that he can marry an American woman.

Personal/Social History: Female Pakistani immigrant, 34 years old, married, 4 children

Objective Data

Vital signs:  She currently weighs 140 lbs., and she is 5’ 5

Mental Status Exam: The client is alert and 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 is constricted.

PANSS Scores: – 40 for the positive symptoms scale

-20 for the negative symptom scale

-60 for general psychopathology scale

Diagnosis: Schizophrenia, paranoid type

Assessment: Differential Diagnosis

Bipolar Disorder with Psychotic Features

Bipolar disorder with psychotic features is often misdiagnosed as schizophrenia, owing to some of the features that are common with the two disorders.Delusional Disorders Essay Example.  That is, manic episodes of bipolar disorder that have psychotic features resemble the positive symptoms of schizophrenia and they include paranoia, hallucinations, delusions of grandeur and disorganized speech. Depressive episode of bipolar disorder such as lack of affect, social isolation, low energy, and extreme emotional withdrawal can resemble negative symptoms of schizophrenia (Laidi, et al., 2015). Acute mania of bipolar disorder is treated with the same medication that treats schizophrenia. The key difference between the two disorders is that the onset of schizophrenia is more likely to be presented with symptoms of delusions that are bizarre; for instance, the client claiming to receive messages from Allah through the TV, while in the case of bipolar disorder depression and mania marks the onset of the disorder.

Delusion Disorder

Delusion disorder is a condition in which the patient presents diverse paranoid beliefs, but they need not be bizarre or even accompanied by symptoms of schizophrenia (Peralta & Cuesta, 2019). For instance, a person that has worked for a long time in an organization with the same colleagues might become unreasonably convinced that his colleagues are plotting against him so that he can get fired. In the case of the Pakistani female immigrant, the delusion she is having is that her husband, with whom she has four children is out to poison her so that he can marry an American woman; she claims she received this information from Allah who sends her messages through the TV. In a situation where this was the only symptom that she presented, then she would have been diagnosed with delusion disorder.

Schizoaffective Disorders

Schizoaffective disorder is characterized with recurring episodes of mood, psychotic and affective symptoms. The said mood symptoms can either be depressive or manic, and in some cases both depressive and manic. On the other hand, the psychotic symptoms might occur following the manic or depressive or even a mix of the same episodes. Schizoaffective disorders are thus, very difficult to diagnose because they present similar symptoms as a number of mental illnesses such as depression, bipolar disorder with psychotic features and schizophrenia. The only difference with the other mental disorders is that in schizoaffective disorder psychosis occurs during the periods the patient has no mood symptoms, which is not the case with the others including schizophrenia (Tavakoli-Ardakani, et al., 2018). The client’s husband decided to get her help after she got out of control, meaning she was not only a danger to herself, but also to the entire family. Delusional Disorders Essay Example.

Brief Psychotic Disorders

Patients that are diagnosed with brief psychotic disorders present one or more of the symptoms that are common in schizophrenia, which include hallucinations, delusions and disorganized speech, whereby it is often incoherent or marked with frequent derailment (Castagnini & Fusar-Poli, 2017). However, brief psychotic disorders episode often last for a single day, and if it lasts longer it is less than a month. After this the patient fully returns to his pre-morbid level of functioning.

Personality Disorders

There are a number of personality disorders that can misdiagnosed as schizophrenia; they include paranoid personal disorder, in which the patient becomes distrustful and is often suspicious of others; for instance, the client believes her husband wants to marry an American woman. However, the only difference with schizophrenia is that in paranoid personality disorder, there are no actual delusions presented, for instance the case of believing that she receives messages from Allah through the TV, which shows delusion. The other personality disorder that can be misdiagnosed as schizophrenia is schizotypal personality disorder, whose main characteristic is a pervasive pattern of discomfort when one is in close relationships with others (Kirchner, et al., 2018). The patient as well presents behaviors and thoughts that are very odd; although the difference with schizophrenia is that the oddness of behavior and thoughts in this case is not extreme as is the case with schizophrenia. Schizoid personality disorder is the other disorder that can be misdiagnosed as schizophrenia owing to its prime characteristic of lack of effect on the patient. In other words, the patients prefer solitary activities and lacks interest in establishing relationships with others due to lack of trust. For instance, the client’s affect is constricted.

Psychoses Not Otherwise Specified (NOS)

Psychoses NOS is a mental disorder in which the patient presents similar psychotic symptoms of those of schizophrenia and other mental disorders; however, this patient does not qualify for any of the identified categories of mental illnesses (Schultze-Lutter, et al., 2019). The notion is that the complexity and similarity of the symptoms to other mental disorders make it difficult to specify the disorder that the patient suffers.

Substance Abuse Disorder

Substance abuse disorder emanates from the abuse of substances such as hallucinogens, alcohol, cocaine, opiates, and other psychotic stimulants. These substances disrupt and disturb the thought, mood, behavior and perceptions of the individual and some such as those used by body builders that is anabolic steroids can result in psychotic symptoms (Messer, et al., 2017). For instance, the client’s insight and judgment are impaired. Individuals using anticholinergic drugs can as well show delirium symptoms in a situation where they abuse the medications. Other prescribed medications that can lead to psychotic symptoms similar to those of schizophrenia include Beta blockers used in the treatment of depressions; levodopa used to treat insomnia and hallucinations, sibutramine used to treat obesity and corticosteroids used to treat mania and psychosis (Basu, 2013).

Psychotic Depression

The other mental disorder that can be misdiagnosed as schizophrenia is psychotic depression, whose symptoms are similar to those of psychosis and depression. The disorder is also associated with mood congruent depression hallucinations and delusions, which are common in patients diagnosed with schizophrenia (Upthegrove, et al., 2017).Delusional Disorders Essay Example.  For instance, the client appears to be listening to something; aside from what she reports that she receives messages from Allah through the TV. The delusions and hallucinations can be said to be responsible for the false belief the client has that her husband wants to poison her through the medication that she was given after leaving the hospital so that he can marry an American woman.

Reflection Notes

The assessment of the possible mental disorder that the client suffers in line with the differential diagnosis shows that it is she suffers from schizophrenia. Schizophrenia is a mental disorder that is heterogeneous, complex and disabling disorder that impacts the perceptual, cognitive, behavioral and emotional functioning of an individual (Basu, 2013). The prevalence rate of the mental disorder across the globe is about 1%, which means that it is not a very common disorder; although it is often argued that this aligns with the fact that it is one of the most difficult to diagnose mental disorders owing to the close similarity of its symptoms with other mental disorders as illustrated by the differential diagnosis. The positive symptoms of schizophrenia include delusions in which an individual has false beliefs that do not align with reality; for instance, the client claim that her husband wants to poison her so that he can marry an American woman. Hallucinations, which involve hearing or even seeing things; the client appears to be listening to something and claims that she receives messages from Allah through the TV. Disorganized speech and thinking are the other symptom of schizophrenia, the client displays this through how slow speech, and impaired insight and judgment (Mayo Clinic, 2020). The patient might as well display symptoms of extreme disorganization or rather abnormal motor behavior for instance, the hostility that the client presents during the assessment. Schizophrenia is as well diagnosed through the observation of negative symptoms such as reduction in the ability to function normally such as neglect on self-care; however, the client presents very minimal negative symptoms as she is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics.

To further understand the client, I would ask questions such as; do you receive the messages from Allah through the TV while alone or even in the presence of other people? Do you have other family members that experience the same events as you do? When did you start receiving the messages from Allah through the TV? Has your husband shown interest on an American woman? I would ask this question to determine whether the client is having delusions or there is an event that occurred in her life that led her to believe that her husband wants to marry an American woman. Innately, the follow-up questions would help intensely in gaining insight concerning the whole situation and understanding the client better. Delusional Disorders Essay Example.  However, while doing this, I will be very careful in taking into consideration the legal and ethical considerations that align to the privacy, confidentiality and safety of the client. It will also be important to consider her ethical and religious standards, whereby being a Muslim woman, it is possible that she might be in the company of her husband or another family member or friend. In regard to the medication, I would advise the patient to continually take her medication as prescribed and, in a situation, where she is suspicious of her husband as the person that administers her medication, it would be appropriate that she suggests a person close to their home that she can trust with the process. The reason for this is that schizophrenia treatment is lifelong and, in a situation, where medication is not taken as prescribed then the possibility of recurring episodes is very high and, in this case, might as well be worse than previous ones. Additionally, since the effect of the client is constricted, it is only appropriate that she undergoes the medication administration with someone she trusts and one that she believes will not harm her.

Conclusion

This paper sought to examine a case of a 34-year-old Pakistani female who is married and has 4 children that was presented to the facility with symptoms that aligned with those of schizophrenia. Subjective and objective data were presented to assist in the diagnosis process of the client; as this presents the facts about the client and what is observed. Although the symptoms demonstrated that the client suffers from schizophrenia, differential diagnosis of several mental illnesses with similar symptoms as those of schizophrenia was carried out so as to rule out the possibility of a misdiagnosis of that would result in treatment error and thereby worsen the condition for the client. A reflection note that contained further questions that the client would be asked so as to set the plan for action in motion was written and it took into consideration legal and ethical issues that might arise during the treatment process of the patient, who most especially her religious background and culture needed to be taken into account.

References

Basu, S. (2013). Differential Diagnosis of Schizophrenia & Co-Morbid Psychiatric Conditions in Schizophrenia and their Management. The Singapore Family Physician, 39(1), 15-18.

Castagnini, A. C., & Fusar-Poli, P. (2017). Diagnostic validity of ICD-10 acute and transient psychotic disorders and DSM-5 brief psychotic disorder. European Psychiatry, 45, 104-113.

Kirchner, S. K., Roeh, A., Nolden, J., & Hasan, A. (2018). Diagnosis and treatment of schizotypal personality disorder: evidence from a systematic review. NPJ schizophrenia, 4(1), 1-18.

Laidi, C., d’Albis, M. A., Wessa, M., Linke, J., Phillips, M. L., Delavest, M., … & Houenou, J. (2015). Cerebellar volume in schizophrenia and bipolar I disorder with and without psychotic features. Acta Psychiatrica Scandinavica, 131(3), 223-233.

Mayo Clinic, (2020). Schizophrenia. <https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-20354443#:~:text=Schizophrenia%20is%20a%20serious%20mental,functioning%2C%20and%20can%20be%20disabling.>.

Messer, T., Lammers, G., Müller-Siecheneder, F., Schmidt, R. F., & Latifi, S. (2017). Substance abuse in patients with bipolar disorder: A systematic review and meta-analysis. Psychiatry research, 253, 338-350.

Peralta, V., & Cuesta, M. J. (2019). An empirical study of five sets of diagnostic criteria for delusional disorder. Schizophrenia research, 209, 164-170.

Schultze-Lutter, F., Nenadic, I., & Grant, P. (2019). Psychosis and schizophrenia-spectrum personality disorders require early detection on different symptom dimensions. Frontiers in psychiatry, 10, 476. Delusional Disorders Essay Example.

Tavakoli-Ardakani, M., Abbaspour, H., Nasab, A. F., Meibodi, A. M., & Kheradmand, A. (2018). Study of the effect of memantine on negative sign in patients with schizophrenia and schizoaffective disorders. Iranian Journal of Pharmaceutical Research: IJPR, 17(Suppl), 122.

Upthegrove, R., Marwaha, S., & Birchwood, M. (2017). Depression and schizophrenia: cause, consequence, or trans-diagnostic issue?. Schizophrenia Bulletin, 43(2), 240-244.

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 when she was 9 years old). She presents 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 says she knows this because the television is telling her so.

She currently weighs 140 lbs., and she is 5’ 5.

SUBJECTIVE

Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.

A review of her hospital records shows that she received a medical workup from 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 and 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 is 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.Delusional Disorders Essay Example.

You administer 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

PANSS Scale. Available at: http://egret.psychol.cam.ac.uk/medicine/scales/PANSS

• Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. doi:10.1093/schbul/13.2.261. Delusional Disorders Essay Example.

https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

• Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf

• Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625–629. Retrieved from http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf

Decision Point One

Select what you should do:

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME

Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks

A decrease in the PANSS score of 25% (in positive symtpoms) is noted at this visit

Client seems to be tolerating medication

Her husband has made sure she makes her appointments for injections (one thus far)

She has noted a 2-pound weight gain, but it does not seem to be an important point for her

She does, however, complain of injection-site pain, telling you that she has trouble sitting 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

Select what the PMHNP should do next: 

Continue same made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward

DC 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 IM qmonthly with oral Abilify 10 mg in the MORNING for 2 weeks. Delusional Disorders Essay Example.

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Her PANNS has been reduced by a total of 50% (in positive symptoms) from the initiation of Invega Sustenna

When questioned about injection-site pain, she states it is much better in the arm

Her weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2-month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself

She likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gain

Decision Point Three

Continue with the Invega Sustenna. Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one month 

Guidance to Student

Weight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.Delusional Disorders Essay Example.

Abilify Maintena is a good option for someone who has good response to Abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less effective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long-acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication before administering the first injection. Also a disadvantage to Abilify Maintena is that a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.

Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).

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PLEASE ADD A REGULAR INTRODUCTION AND CONCLUSION

Introduction to the case (1 page)

• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. Delusional Disorders Essay Example.