Examine Case Study: Pakistani Woman With Delusional Thought Processes

Schizophrenia Treatment Decision Tree

Introduction

This assignment is about a 34-year-old Pakistani female who presents with a brief psychotic disorder. She had been hospitalized for 21 days and given this diagnosis because her symptoms had only been available for less than a month. Her symptoms were hallucinations and delusions. She believed that she was prophet Mohammad and would report visons of Allah. She went out of control one evening and this made her husband concerned. During the assessment the patient appears calm and denies any of the hallucinations and delusions.

Examine Case Study: Pakistani Woman With Delusional Thought Processes

This shows that she has poor insight. The patient is in a good mood and occasionally becomes hostile during the interview. The patient reports to have stopped taking her medication. The PANSS score reveals that the patient has more positive symptoms. This is relevant as it may help decide the most appropriate treatment. A diagnosis of schizophrenia is made. After making a diagnosis, treatment needs to be commenced. In this paper, a series of decisions are made to help with the management of this patient.

Examine Case Study: Pakistani Woman With Delusional Thought Processes

Decision 1

My first decision was to start her on Zyprexa (olanzapine) 10 mg orally. It is a second (atypical) generation antipsychotic (SGA). SGAs are the recommended first line treatment for schizophrenia. SGAs are associated with fewer extrapyramidal side effects. Olanzapine exerts its action on the dopamine and serotonin receptors in the brain.  It is a dopamine D2 receptor antagonist. It binds loosely and easily dissociates from the receptor (Meftah et al., 2020).

This allows for normal dopamine neurotransmission its effect on D2 receptors decreases the positive symptoms of hallucination, delusion and disorganized thought. It also acts on serotonin 5HT2A receptors as an antagonist. This leads to a reduction in negative symptoms. There are associated adverse effects such as metabolic side effects like weight gain (Lord et al., 2017). Also, its effects on D2 receptors leads to dopaminergic blockade which can cause extrapyramidal effects. However, this risk is low because of its quick dissociation from D2 receptors.

I did not choose Invega Sustenna 234mg IM because it is a long acting injectable (LAI) antipsychotic agent (Johnston et al., 2019). It is recommended that before starting patients on LAI, the side effect profile be determined. This can be done by starting the patient on LAI, a short trial of the oral counterpart of the LAI to determine the tolerability. It is therefore not advisable to start LAIs before first determining tolerability.

Aripiprazole is also a good option for treatment of psychosis because it is an SGA. It is FDA approved for symptomatic management in schizophrenia patients. It acts as a partial agonist at the 5HT1A receptors and D2 receptors and antagonist at the 5HT2A receptors.  It has a high affinity for D2 receptors. However, it demonstrates functional selectivity.

Aripiprazole requires more than 90% occupancy rate at the D2 receptors to be clinically active (Ribeiro et al., 2018). This is advantageous in terms of tolerability. The downside of this is that it may require a long time before it can start working and this is not ideal when dealing with acute episodes. For this patient, it is likely that it might not be effective.

By giving olanzapine, I was hoping to achieve a reduction in the positive symptoms with a with a decrease in her PANSS score. The patient comes back for follow up four weeks later and reports an improvement in the PANSS score. A reduction by 25% in the positive symptoms is noted. She also reports to have hyperphagia and a weight gain of five pounds. This is an expected side effect of olanzapine. Among atypical antipsychotics, olanzapine has the most significant effect on metabolism. at this stage a second decision has to be made for the management of this patient.

Decision 2

The chosen second decision is to change the medication to Geodon (ziprasidone) 40 mg. Switching of medication when treating schizophrenia is a common practice in psychiatry. Ziprasidone is also an atypical antipsychotic. It has an affinity for dopaminergic adrenergic, histaminergic and serotonergic receptors.

The D2 antagonism produced by ziprasidone is efficacious in the treatment of positive symptoms. 5HT2A antagonism is helpful in the reduction of negative symptoms. The most common side effects are tardive dyskinesia and neuroleptic malignant syndrome. Also, it can cause hyperglycemia in diabetic patients and should therefore be used with caution (Vázquez-Bourgon et al., 2017).

I did not choose to reduce the dose Zyprexa to 7.5 mg because it will reduce the efficacy of the drug. The patient has shown improvement in symptoms at a dose of 10 mg and therefore a reduction in dosage would be counterproductive. Also, I did not choose to use Wellbutrin because it is mostly effective in the treatment of negative symptoms of schizophrenia (Azizi et al., 2018).

A majority of the patient’s symptoms are positive symptoms. This means that Wellbutrin would not be the most ideal drug of choice. Also, one of the side effects associated with the use of bupropion is psychosis. The risk/benefit ratio of using this drug would therefore not be beneficial for the patient.

By administering Geodon, I was hoping to achieve a further improvement in the patient symptoms. also, Ziprasidone has a lesser effect on metabolism compared to Olanzapine and therefore I was expecting a reduction in the patient’s weight. After four weeks, the patient returns to the clinic. She reports a significant improvement in her PANSS score.

Her positive symptoms are reduced by 40%. This is a sign as it shows that she is responding well to he medication. She doesn’t report any issues with tolerability. The only negative report she is problems with adherence. She admits to forgetting the second dose on several occasions. With this information, a third decision would be necessary.

Decision 3

The third decision would be to give a few test doses of Risperdal 1 mg orally to check for tolerance before stating her on Invega Sustenna. Invega Sustenna is an extended-release antipsychotic agent. It is given by IM injection. The essence of giving test doses of risperidone is to check for tolerability of the drug. Also test doses are necessary for checking the efficiency of the drug (Johnston et al., 2019). I did not choose to give Latuda because of the tolerability issues experienced with high doses. Patients usually complain of gastrointestinal side effects.

Geodon 80 mg was not taken as an option because it is recommended that doses are given twice daily if administered orally.  Once daily doses may interfere with the efficacy of the drug (Bouchette et al., 2017). The expected outcome of giving Invega Sustenna is that the patient will show an improvement in symptoms and live a normal life. Also, the patient will not have any problems with compliance as the drug is an extended release agent and therefore can be given only once a month once the loading dose has been given.

Ethical Considerations

For any patient, various ethical considerations have to be made. Some of the considerations include patient autonomy, beneficence, non-maleficence. The nurse should know that the patient is most sovereign when it comes to making decisions regarding their health. The nurse should make known all the available treatment options.  This would allow the patient to make an informed consent on the treatment option she is agreeing to.

Patients with schizophrenia often have an altered state of mind and therefore may have an impaired judgement. The nurse should take this into consideration and make sure that any treatment options agreed to by the patient are not harmful to them. In such scenario. The nurse should practice non-maleficence. The nurse should also practice beneficence by ensuring that the patient is considered when making all the decisions. In the event that the patient is incapacitated and cannot make an informed consent, the nurse should therefore consider talking to her family or next of kin to give consent.

Conclusion.

Schizophrenia is a chronic debilitating mental illness. Many treatment options have been developed over the years to help in managing this illness (McCutcheon et al., 2020). This paper discusses the case of a 34-year-old Pakistani woman who is diagnosed with schizophrenia.  A series of decisions are made to help with the management. The first decision was to start her on Zyprexa (olanzapine) 10 mg orally. This choice yielded a desired response with an improvement in symptoms. However, the patient presented with side effects such as hyperphagia and weight gain.

A second decision was made. A switch of medication was made to Geodon (ziprasidone) 40 mg. This yielded more improvement is symptoms. Also, the patient showed a reduction in weight. The patient however had compliance issues. A third decision was made to switch to Invega Sustenna IM. A test dose of Risperidone 1 mg had to be given first to test for tolerability. Finally, various ethical considerations were made. These ethical considerations include patient autonomy which also covers informed consent, beneficence and non-malevolence.

References

  • Azizi, H., Zeng, Y. H., Kallikkadan, J., Kahn, A., Olayinka, O., Popoola, O., Khan, T., Rimawi, D., Malik, A., Williams, S., Langdon, S., Obegolu, C. M., Nuthalapati, D., Alzear, R., Kalbouneh, H., Mahbub, A., Ojimba, C., Oyelakin, A., Kodjo, K., … Jolayemi, A. (2018). The use of stimulant augmentation of second-generation antipsychotics in the management of negative symptoms of schizophrenia: A case report. International Journal of Innovative Research in Medical Science, 3(08). https://doi.org/10.23958/ijirms/vol03-i08/08
  • Bouchette, D., Fariba, K., & Marwaha, R. (2017). Ziprasidone. Europe PMC. Retrieved October 17, 2021, from https://europepmc.org/article/nbk/nbk448157.
  • Johnston, K., Sliwa, J. K., Bossie, C. A., & Kim, E. (2019). Long-acting injectable antipsychotics. Journal of Psychosocial Nursing and Mental Health Services, 57(11), 5–5. https://doi.org/10.3928/02793695-20191016-02
  • Lord, C. C., Wyler, S. C., Wan, R., Castorena, C. M., Ahmed, N., Mathew, D., Lee, S., Liu, C., & Elmquist, J. K. (2017). The atypical antipsychotic olanzapine causes weight gain by targeting serotonin receptor 2C. Journal of Clinical Investigation, 127(9), 3402–3406. https://doi.org/10.1172/jci93362
  • Meftah, A. M., Deckler, E., Citrome, L., & Kantrowitz, J. T. (2020). New discoveries for an old drug: A review of recent Olanzapine Research. Postgraduate Medicine, 132(1), 80–90. https://doi.org/10.1080/00325481.2019.1701823
  • Ribeiro, E. L., de Mendonça Lima, T., Vieira, M. E., Storpirtis, S., & Aguiar, P. M. (2018). Efficacy and safety of Aripiprazole for the treatment of schizophrenia: An overview of Systematic Reviews. European Journal of Clinical Pharmacology, 74(10), 1215–1233. https://doi.org/10.1007/s00228-018-2498-1
  • Vázquez-Bourgon, J., Pérez-Iglesias, R., Ortiz-García de la Foz, V., Suárez Pinilla, P., Díaz Martínez, Á., & Crespo-Facorro, B. (2017). Long-term metabolic effects of aripiprazole, ziprasidone and Quetiapine: A pragmatic clinical trial in drug-naïve patients with a first-episode of non-affective psychosis. Psychopharmacology, 235(1), 245–255. https://doi.org/10.1007/s00213-017-4763-x