Delusional Disorders
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 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 a physician, who reported her to be in overall good health. Lab studies were all within normal limits.
Client admits that she was tolerating her Risperdal well but stopped taking 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.
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
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
Decision Point One
Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
· A decrease in the PANSS score of 25% (in positive symptoms) 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
Decision Point Two
Continue same made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward
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
Select what you should do next:
· 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
· DC Invega Sustenna and start Abilify Maintena (aripiprazole ) 400 mg IM monthly (after a few test doses of Abilify oral have been tried and tolerated) with overlapping oral Abilify 10 mg in the MORNING
· Continue Invega Sustenna and add on Qsymia (phentermine and topiramate) for weight loss
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.
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).
Delusional Disorders
Pakistani Female
with
Delusional Thought Processes
BACKGROUND
The client is a 34
–
year
–
old Pakistani female who moved to the Unite
d 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 give
n 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 fro
m 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 neve
r 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 ha
llucinations 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 a physician, who reported her to be in
overall good health. Lab studies were all within normal limits.
Client admits that she was tolerating her Risperdal well but stopped taking about a week after she got out of th
e
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 sil
ence. 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 im
paired. She is currently denying suicidal or homicidal ideation.
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: Schiz
ophrenia, paranoid type
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 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 a physician, who reported her to be in
overall good health. Lab studies were all within normal limits.
Client admits that she was tolerating her Risperdal well but stopped taking 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.
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
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