Childhood Psychosis – A Yong Girl with Strange Behaviors

CASE #3

A young girl with strange behaviors

 

BACKGROUND

Carrie is a 13-year-old Hispanic female who is brought to your office today by her mother and father. They report that they were referred to you by their primary care provider after seeking her advice because Carrie’s behavior has been difficult to manage and they don’t know what to do.


SUBJECTIVE

Carrie’s parents report that they have concerns about her behavior, which they describe as sometimes “not normal for a 13-year-old.” They notice that she talks to people who aren’t real. Her behavior is calm and “passive.” Her parents noted that when she was younger, she was irritable at times, but have noticed that this has given way to passivity. Her parents state that they understand that it’s normal for younger children to have “imaginary friends,” but they feel that at Carrie’s age, she should have grown out of these behaviors. Carrie’s parents report that she has friends that are half-cat and half-human, and “spirits” who speak with her “in her head.” She also reports that the people on television know when she is home and that they have certain shows “just for her.”

Carrie’s parents report that they have taken her to her pediatrician who has given her a “clean bill of health.” Carrie’s parents note that they had some early concerns as she was lagging in meeting developmental milestones. Initially, when she first started school, Carrie managed to keep up with her peers in terms of academic performance, but she was noticed by her teachers to be isolative. It was also noted by her teachers and guidance counselor that Carrie’s social skills do not seem to match what they see in other children her age. Initially the school counselor suspected that Carrie may have been suffering from attention deficit hyperactivity disorder (primarily inattentive type), but now is not certain and has recommended a psychiatric evaluation. Her grades were “ok” in school up until last year when she left junior high school, and entered high school, where the academic demands began to increase. Carrie’s teachers had wanted to hold her back a grade, but her parents acknowledge that they were “insistent” that this did not happen. Now they are describing some regrets over this as Carrie seems “more lost than ever” in her schoolwork. Carrie’s mother produced a copy of a paper that Carrie had to submit as a homework assignment. You attempt to read the assignment, but there does not appear to be any clarity to the work, and it can best be described as a hodge-podge of thoughts and ideas.

Carrie’s parents want you to know that although they are concerned about Carrie, they are opposed to giving her medications that would turn her “into a zombie.” Carrie’s mother also confides that her husband’s grandfather spent “a few years in the nut house.” When you probe further, she began crying and said, “He was schizophrenic … what if Carrie is schizophrenic?”

During your interview with Carrie, she seems pleasant, but somewhat distant. When you ask her about her friends at school, she shrugs her shoulders and says, “I don’t really have any. I don’t like those people.” You inquire if she is sad or upset that she doesn’t like them, to which she states “no, why should I be? I guess they would be friends with me if I asked, but I’m not interested. I could make them be my friends if I wanted, but I don’t … but if I wanted them to, all that I have to do is make up my mind that they will be my friend and they would have to.” When you ask Carrie if she believes that she can control the thoughts of others with her mind, she puts her index finger up to her mouth and looks toward the door. “My mom gets upset when I talk about these things. I try not to think about them either because if she is close enough, she could read my thoughts and they upset her. She may think that I’m into witchcraft or something.”

When you ask Carrie about the homework assignment that you read, she explains that her teacher “is just miserable. She doesn’t understand how I think—I think high, she just can’t get it.”


OBJECTIVE

The client is a 13-year-old Hispanic female client who appears appropriately developed for her age. She is dressed appropriately for the current weather, and ambulates with a steady upright gait. She does not appear to be demonstrating any noteworthy mannerisms, gestures, or tics. No psychomotor agitation/retardation apparent.


MENTAL STATUS EXAM

Carries is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Carrie self-reports her mood as “good.” However, her affect does appear somewhat constricted. Her eye contact is minimal throughout the clinical interview and at times, Carrie seems preoccupied. Carrie is oriented to person, place, and time. She endorses hearing and seeing strange “things that I talk to. They don’t scare me; they come to see me from another world.” No overt paranoia is appreciated. She does report delusions of reference (she believes that the people on TV play programs “just for her” and at times, television commercials were designed to tell her what to do), as well as other delusional thoughts (as described above). Carrie denies any suicidal or homicidal ideation.

At this point, please discuss any additional diagnostic tests you would perform on Carrie.

Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO CARRIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
 Early Onset Schizophrenia
 Schizoaffective Disorder
 Schizotypal Personality Disorder. Childhood Psychosis - A Yong Girl with Strange Behaviors


Childhood psychosis is extremely rare; however, children that present with psychosis must be carefully assessed and evaluated with appropriate interviewing of parent, child, and use of assessment tools.

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 early onset schizophrenia.


Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders



The Assignment:

Examine Case 3: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:


Decision #1: Differential Diagnosis
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: Treatment Plan for Psychotherapy
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: Treatment Plan for Psychopharmacology
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 and their families.

Introduction

Childhood psychosis is rare, and children/adolescents with mental disorder interpret reality abnormally. The children present with impaired emotions and thinking, which cause loss of contact with reality. Due to early age, practitioners face challenges in diagnosing, treating, and educating them and their parents (Kendler, 2016). This paper case study involves Carrie, a 13-year-old Hispanic female, brought to the office today by her mother and father. Subjective data reveals that Carrie has delusion and hallucinations. She is isolative in school, and her performance is dropping. Objective data shows that Carrie has upright gait without mannerism and no apparent retardation. Her MSA reveals constricted affect, minimal eye contact, has delusions and has no suicidal or homicidal ideation. Decisions made regarding her differential diagnosis, psychopharmacology and psychotherapy will be made. Besides, a detailed description of ethical considerations, which impact treatment and communication, will be provided.Childhood Psychosis – A Yong Girl with Strange Behaviors

Decision #1: Differential Diagnosis

Decision Selected

Early Onset Schizophrenia.

Reason for Selecting This Decision

Based on the information presented, the psychiatric/mental nurse practitioner would diagnose Carrie with Early Onset Schizophrenia. Her symptoms are congruent to the DSM-5 criteria for schizophrenia. The five major symptoms in schizophrenic patients are hallucinations, delusions, disorganized speech, catatonic or grossly disorganized behavior and negative symptoms. According to it to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5), to diagnose one with schizophrenia, they should have at least two of these symptoms for a month. Besides, the person should have at least one symptoms among delusions, hallucination and disorganized speech (Kendler, 2016). Carrie has persistent hallucinations and delusions.

Carrie has referential delusions – she holds the belief that the TV programs are just for her and the television commercials are planned to inform her what to do. Her written assignment demonstrated disorganization in thought processes, a characteristic feature of schizotypal personality disorder- odd thinking or speech. She lacks close friends, a state caused by discomfort with either interpersonal relations or her classmates avoiding her due to manifesting odd behaviors. She has grandiose delusions, which are evident when she defends her assignment. Her assignment does not have any clarity, and it is merely a hodge-podge of ideas and thought. Carrie says that her teacher is miserable and cannot understand her high thinking. However, the diagnosis of schizotypal personality disorder cannot be confirmed because she has difficulties in interpersonal relationships (Kendler, 2016).

Expected Outcomes

The expected outcome is that her clinical manifestations meet the DSM-5 criteria schizophrenia. Following the assessment and diagnosis, Carrie should receive appropriate treatment- pharmacotherapy and psychotherapy to aid in remission of the symptoms. Study findings by Tolentino & McMahon (2020) reveal that integrating pharmacotherapy with psychotherapy such as CBT improves schizophrenic patients. The combined therapy prevents relapse, reduces symptoms and occurrence of adverse effects. Psychometric tests for early-onset schizophrenia are vital to determine the cognitive and personality functioning and intellectual disabilities, causing her to drop her school performance. Psychotherapy using a psychodynamic approach helps patients with schizophrenia, although it is not the first-line treatment.Childhood Psychosis – A Yong Girl with Strange Behaviors

Difference between Expected Outcome and Results of the Decision

Carrie met the DSM-V diagnostic criteria for Early Onset Schizophrenia that requires a patient to have at least one negative symptom. There was no difference seen between the actual and expected outcomes.

Decision #2: Treatment Plan for Psychotherapy

Decision Selected

Start psychotherapy, especially psychodynamic approach.

Reason for Selecting This Decision

Psychotherapy helps individuals with schizophrenia to avoid residual symptoms. Psychotherapy aims at exploring and positively influencing the past emotional memories of the client. For Carrie, Cognitive Behavioral Therapy will help work. Polese et al. (2019) highlight that psychodynamic psychotherapies reveal the schizophrenic client’s psyche’s unconscious thoughts and alleviate tension. Besides, the psychodynamic approach utilizes recalling, free association and dream interpretation. Cognitive-behavioral therapy shows efficacy against psychosis as well as group therapy for early signs of psychosis. CBT will ensure Carrie benefits from current cognitive development therapies and reveal potential barriers to her recovery.

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Expected Outcomes

The expected outcome is that Carrie returns to the office after four weeks with appreciable changes in her psychotic symptoms – dysfunctional behavioral patterns and thinking. She should have few and stable symptoms as well demonstrate the need to have friends at school. Besides, Carrie should demonstrate more the knowledge of potential barriers to her recovery and triggers of psychotic episodes. During the next visit, Carrie would report more reality to nature or environment- should not report hallucination or delusions of seeing herself better than others.

Difference between Expected Outcome and Results of the Decision

After four weeks, Carrie presented to the clinic with some psychotic features but with enthusiasm to meet the therapist. The difference between the decision’s results and the desired outcome is because the wrong choice of first-line therapy. Although not a first-line treatment modality for the disorder, psychotherapy can be useful in treating residual symptoms(Dana Muse, 2018). Therefore, use of this therapy as the first line has a high chance of failure.Childhood Psychosis – A Yong Girl with Strange Behaviors

Decision #3: Treatment Plan for Psychopharmacology

Decision Selected

Begin Lurasidone 40 mg PO daily.

Reason for Selecting This Decision

Psychopharmacology involves the use of drugs to affect behavior, cognition or mood. The drugs control neurotransmitter dopamine and cause antipsychotic features. Lurasidone is an effective off-label medication and an atypical antipsychotic for children. Though not FDA-approved, prescribing this medication does not attract legal action. The reason for selecting Lurasidone is that it has fewer effects on lipid profile and body weight than other antipsychotic drugs such as haloperidol (Channing et al., 2018).

Expected Outcomes 

Carrie returns to the psychiatric nurse office in four weeks with reduced symptoms of psychosis. The expectations were that Lurasidone would cause remission of the symptoms and prevent their relapse. Besides, Carrie’s physical and mental functioning will improve- she will start to have sustained ability to perform daily chores in the long term.

Difference between Expected Outcome and Results of the Decision

Carrie returned to the clinic in the company of her parents. The parents reported improved physical, mental and social functioning as well as reduced psychotic symptoms. However, Carrier had gained more weight. Weight gain is one of the side effects of Lurasidone. With any antipsychotic medication, practitioners should monitor weight, fasting triglycerides, blood pressure, plasma glucose levels, and BMI during treatment to balance efficacy and tolerance. Psychotherapy would effectively help reduce weight gain since the dose can be lowered to prevent more weight gain (Channing et al., 2018). Collaboration with a dietician would help health foodstuffs are chosen for Carrie while at home or school.Childhood Psychosis – A Yong Girl with Strange Behaviors

Ethical Considerations Impacting Treatment Plan and Communication

Ethical consideration will influence the treatment plan and communication with Carrie and her parents in several ways. The practitioners should seek informed consent before prescribing the management regimen to patients. Attention should be given to need for informed consent by the parents and Carrie. Since she is a minor, her parents decide since they are medically competent to choose between options for her. According to Carlsson et al. (2017), psychiatric/mental nurse practitioners should explain the pros and cons of treatment with children or adolescents. Besides, it is vital to inform the patients of goals or therapeutic endpoints of the treatment. Health education is essential in imparting all information the parents and patients to have informed consent.

Non-maleficence and beneficence are ethical principles, which guide the practitioner in prescribing the appropriate treatment or management. Beneficence guides a practitioner to balance the benefits and risks or costs involved in treatment. Non-maleficence requires practitioners to avoid causing harm. Several antipsychotic drugs are FDA approved for use in children with schizophrenia (Channing et al., 2018). Considering the patient’s risk factors for adverse drug reaction is vital in ensuring non-maleficence and beneficence.

Conclusion

Though childhood psychosis is rare, children who present with the disorder need careful assessment and evaluation aided by appropriate interviewing of a child, parent, and different assessment tools. Children diagnosed with schizophrenia experience physical, emotional, and social hardships. A correct diagnosis would likely lead to proper treatment with Lurasidone. Combination therapy of Lurasidone, an atypical antipsychotic, and CBT, a psychotherapeutic approach is the most appropriate for children with Early Onset Schizophrenia (Channing et al., 2018). Childhood Psychosis – A Yong Girl with Strange Behaviors 

References

Carlsson, I. M., Blomqvist, M., & Jormfeldt, H. (2017). Ethical and methodological issues in qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions: a critical review. International journal of qualitative studies on health and well-being, 12(sup2), 1368323.

Channing, J., Mitchell, M., & Cortese, S. (2018). Lurasidone in children and adolescents: systematic review and case report. Journal of child and adolescent psychopharmacology, 28(7), 428-436.

Dana Muse, M. (2018). Cognitive Behavioral Psychopharmacology. http://196.189.45.87/handle/123456789/5597

Kendler, K. S. (2016). Phenomenology of schizophrenia and the representativeness of modern diagnostic criteria. JAMA psychiatry, 73(10), 1082-1092.

Polese, D., Fornaro, M., Palermo, M., De Luca, V., & De Bartolomeis, A. (2019). Treatment-resistant to antipsychotics: a resistance to everything? Psychotherapy in treatment-resistant schizophrenia and nonaffective psychosis: a 25-year systematic review and exploratory meta-analysis. Frontiers in psychiatry, 10, 210.

Tolentino, R., & McMahon, A. (2020). The Integration of Olanzapine and Cognitive Behavioral Therapy for the Treatment of Schizophrenia: A Literature Review. Undergraduate Research in Natural and Clinical Science and Technology Journal, 1-8. Childhood Psychosis – A Yong Girl with Strange Behaviors