Pakistani Woman with Delusional Thought Processes Decision Tree

Schizophrenia occurs from abnormal activities in dopamine receptor sites affecting dopamine pathways and neurotransmitters, including glutamate, dopamine, and serotonin (Patel et al. 2014). Schizophrenia is a mental illness where paranoia is one of the symptoms relating to how patients process their thoughts and respond to stimuli (Pinkham et al., 2016). Paranoia affects patients’ social cognition, causing impairments, including blaming others, hostility to others, lack of trust, and withdrawal with African American patients. It shows paranoid symptoms, agitation, and suspicious behaviors compared to other races (Pinkham et al., 2016).

Pakistani Woman with Delusional Thought Processes Decision Tree

According to Patel et al. (2014), Schizophrenia leads to disability in patients due to negative symptoms and lack of cognition, including altered working memory, attention deficit, and limited executive function. The authors noted that low dopamine levels cause negative symptoms and deficiency in comprehension with etiology of environment and social factors, genetics, and pregnancy complications.

A case of 34 years old female of Pakistani origin moved to the US in her late 20’s and is currently in arranged marriage with her husband when she was nine years old. She presents to the clinic following 21 days of hospitalization with a “brief psychotic disorder” (Laureate Education, 2020b). The hospital review indicated that she got medical work done by a physician reporting good health and labs were within the standard limit. Patient reports stopping to take prescribed Risperdal a week ago after hospital discharge because she thought the husband would poison her to marry an American woman (Laureate Education, 2020b).

Upon mental exam in the clinic, the patient is awake, alert, oriented, and dressed appropriately for time and weather. Her speech is slow and interrupted by periods of silence with self-report of euthymic mood, denies auditory and visual hallucinations, and appears to listen to something (Laureate Education, 2020b). Patient PANSS scores are 40 for positive symptoms, 20 for negative symptoms, 60 for general psychopathology, and diagnosis of Schizophrenia, paranoid type (Laureate Education, 2020b).

Decision # 1

I will order patient Invega sustenna 234 mg IM X1, followed by 156 mg IM on day 4 and monthly. After that, the patient has shown non-compliance with oral medication before and paranoia that the husband will poison her (Laureate Education, 2020b). According to Morris and Tarpada (2017), non-compliance in schizophrenia patients in treatment maintenance results in relapses, frequent hospitalization, raising healthcare costs, and a rising burden to patient families. The authors found that long-acting injections like Invega sustenna address the non-compliance issue by patient getting injection at the clinic rather than taking daily pills and injections with few side effects. The study found that patient who takes IM injections were more compliant, less neurological side effects, and fewer readmissions compared to a patient who took oral medications

I did not pick Zyprexa 10 mg and Abilify 10 mg orally because the patient has a history of non-compliance with oral medication and paranoia. The spouse is out to poison her to marry an American woman (Laureate Education, 2020b). According to Thomas et al. (2020), Zyprexa has adverse effects on dopamine blockage, including weight gain, metabolic instability, akathisia, tardive dyskinesia, and extrapyramidal symptoms, and neuroleptic malignant syndrome.

Moreover, Zyprexa needs continuous monitoring for the therapeutic range to prevent adverse reactions. Abilify has adverse effects of EPS symptoms, including akathisia, tremors, altered gait, tardive dyskinesia, acute dystonic, oculogyric crises, etc. agranulocytosis, uncontrollable urges to engage in sex, binge eating shopping, and opisthotonos (Gettu et al. (2020). Ability requires close monitoring for side effects and getting baseline inpatient weight, blood pressure, liver functions, CBC, and electrolytes (Gettu et al. (2020). After four weeks, the patient returns to the clinic with a decreased PANSS score of 25% in positive symptoms, tolerating medication, the appointment made for the next injection by the spouse, weight gain of 2 pounds but not crucial at this time (Laureate Education, 2020b).

Decision # 2

I decide to continue with Invega Sustenna IM but instruct the nurse to begin administering injections into deltoid at this visit and moving forward (Laureate Education, 2020b). I choose to continue with an injection because the patient has reduced positive symptoms by 25 %, and the patient is tolerating medication (Laureate Education, 2020b). The PANSS scale is a gold standard tool used in assessing Schizophrenia and other mental disorders for treatment with antipsychotic medications (Opler et al., 2017). Injection of Invega sustenna results in more stable serum levels of medication when administered on deltoid or gluteal IM addressing non-compliance with monthly injections (Morris & Tarpada, 2017). There is no need to increase the dose or change the dosage because symptoms have reduced to 25 % and no adverse effects were reported (Laureate Education, 2020b).

I did not change medication to ability and Zyprexa because of patient non-compliance with oral medicines, and Invega sustenna injection has shown to improve patent symptoms and PANSS score. No desires adverse or side effects were reported with the first injection apart from the weight of the side effects. Education on a diet can help in weight management (Laureate Education, 2020b). I hope that patient symptoms will reduce, and PANSS score improve. Weight gain is a side effect for long-acting injection Invega sustenna leading to comorbidities like diabetes, hypertension, cancer, arthritis, and hyperlipidemia. Referring patients to a dietician is highly recommended to prevent non-compliance (Sliwa et al., 2014).

After 4 weeks, the patient return to the clinic with PANSS score reduced to 50 % in positive symptoms from the first visit, less pain on the injection site but a weight gain of 4.5 pounds in two months period which is bothering the patient, and she is afraid that her husband does not like it (Laureate Education, 2020b).

Pakistani Woman with Delusional Thought Processes Decision Tree Decision # 3

I decide to continue the treatment with Invega sustenna, counsel the patient on the side effect of weight gain from the injection because other medications will have the same effects of weight gain, and refer the patient to a dietician and physiologist with a follow-up appointment in one month (Laureate Education, 2020b). I choose to continue with Invega sustenna because the injection is improving patient symptoms reducing PANSS score to 50 %, and weight gain can be controlled by exercises and poor nutrition (Laureate Education, 2020b). ). Controlling patient weight gain with a dietician and physiologist is a good idea before changing to a new medication when Invega sustenna is already showing effectiveness in inpatient treatments (Laureate Education, 2020b).

I did not choose Abilify maintena because it affected the patient who had good responses with oral medication and non-compliance, and Abilify IM did not bind with the D2 receptor for a great time like Invega sustenna and less useful to some patients (Laureate Education, 2020b).

Abilify maintena has the effects of akathisia, and when IM injections are given, the side effects can be worse and patient tolerance must be established with oral medication before providing injections (Laureate Education, 2020b). Abilify maintena IM has a disadvantage of two-week overlap with Abilify oral medication due to blood levels not being therapeutic (Laureate Education, 2020b).

I did not add Qsymia for weight loss to patient treatment because it is only prescribed for obesity. THE patients BMI is 28.9, meaning she is not obese and does not fit the criteria of getting Qsymia (Laureate Education, 2020b). The two wrong things with patient treatment with Qsymia are the recent adding of weight due to injection and weight gain but not actual obesity due to medication. Qsymia has toxicities to cardiovascular like elevated BP, increased workload, and HR on the heart (Laureate Education, 2020b). The dietician will help the patient with weight loss and maintenance by the next appointment, and the life coach will work with the patient in physical activities for weight loss. I will schedule the patient to follow up in 4 weeks while consulting with the dietician and life coach.

Ethical Consideration

The practitioners are bound not to harm, and maintaining sound decisions is vital for compassionate patient care while keeping boundaries ethical for patient safety (Noordsy 2016). Schizophrenia affects patients’ interpretation, perception, and decision-making, posing ethical challenges to providers in their daily work due to the need for consent and involuntary treatments (Noordsy 2016). Patients with Schizophrenia faces barriers in affordable health care, education, employment opportunities, and discrimination causes financial strains and lack of family support to many patients (Noordsy 2016). Patients’ early screening and detection in the community break the stigma of seeking mental health with families fearing the label of Schizophrenia and impact on their future finances and genetics (Noordsy 2016).

Pakistani Woman with Delusional Thought Processes

In conclusion, any mental disorder’s stigma is deep-rooted in middle eastern communities considered shame, weakness, and disgrace in public (Sewilam, et al., 2015). Community stigma towards mental health patients is surrounded by discrimination, prejudice, and stereotypes, increasing patients avoid and refusing psychiatric diagnosis ad treatments (Sewilam, et al., 2015). The recommendation includes community education on mental health issues, developing coping strategies to help patients, and promoting family support in mental health treatments (Sewilam, et al., 2015).

References for Pakistani Woman with Delusional Thought Processes Decision Tree

  • Gettu N, Saadabadi A. Aripiprazole. [Updated 2020 Oct 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547739/
  • Laureate Education. (2020b). Case study: Pakistani Woman with Delusional Thought Processes.  [Interactive media file]. Baltimore, MD: Author.
  • Morris, M. T., & Tarpada, S. P. (2017). Long-Acting Injectable Paliperidone Palmitate: A Review of Efficacy and Safety. Psychopharmacology bulletin, 47(2), 42–52.
  • Noordsy D. L. (2016). Ethical Issues in the Care of People With Schizophrenia. Focus (American Psychiatric Publishing), 14(3), 349–353. https://doi.org/10.1176/appi.focus.20160011
  • Opler, M., Yavorsky, C., & Daniel, D. G. (2017). Positive and Negative Syndrome Scale (PANSS) Training: Challenges, Solutions, and Future Directions. Innovations in clinical neuroscience, 14(11-12), 77–81.
  • Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: overview and treatment options. P & T : a peer-reviewed journal for formulary management, 39(9), 638–645.
  • Pinkham, A. E., Harvey, P. D., & Penn, D. L. (2016). Paranoid individuals with Schizophrenia show greater social cognitive bias and worse social functioning than non-paranoid individuals with Schizophrenia. Schizophrenia Research: Cognition, 3, 33-38.
  • Sewilam, A. M., Watson, A. M., Kassem, A. M., Clifton, S., McDonald, M. C., Lipski, R., Deshpande, S., Mansour, H., & Nimgaonkar, V. L. (2015). Suggested avenues to reduce the stigma of mental illness in the Middle East. The International journal of social psychiatry, 61(2), 111–120. https://doi.org/10.1177/0020764014537234
  • Sliwa, J. K., Fu, D. J., Bossie, C. A., Turkoz, I., & Alphs, L. (2014). Body mass index and metabolic parameters in patients with Schizophrenia during long-term treatment with paliperidone palmitate. BMC psychiatry, 14, 52. https://doi.org/10.1186/1471-244X-14-52
  • Thomas K, Saadabadi A. Olanzapine. [Updated 2020 Aug 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532903/