NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

Early Onset Schizophrenia: A Young Girl with Strange Behaviors Example

Schizophrenia is a devastating, pervasive, neuropsychiatric disorder characterized by an extreme behavioral, cognitive, and social functioning deficit. Studies show that schizophrenia occurs in 1% of the total world population. The onset of schizophrenia normally occurs between the age of 16 and 30 years, as the rate of onset increases with age, and peaks at 30 years.

NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

However, in some cases, the patient might start displaying symptoms before the age of 13 years. In such a case, the disorder is referred to as early-onset schizophrenia (EOS) (Dixon et al., 2018 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors). The diagnosis for this disorder is quite complex, however, different organizations have provided diagnostic criteria for this disorder among children above the age of 8 years and above. This paper will focus on examining the case of a 13 years old Caucasian female patient, make an appropriate differential, and formulate the best therapeutic interventions together with their outcome, in addition to legal and ethical considerations that might be encountered when taking care of this patient.

Decision #1: Differential Diagnosis

Selected Decision

Early-onset schizophrenia (EOS).

Reason for Selecting this Decision

Considering the available options, the patient is most likely suffering from Early-onset schizophrenia (EOS). According to the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters, the diagnostic criteria for EOS is similar to those used among adults, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-V-TR). The criteria require the patient to exhibit at least two of the following symptoms for at least one month; hallucinations, disorganized speech, delusion, negative symptoms, and grossly disorganized or catatonic behavior (Mohr et al., 2018 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors). The patient in the provided case study presents with most of these symptoms such as hallucinations, delusion, fixed false beliefs, and being grossly disorganized with her homework. The patient has been displaying these symptoms since the previous year, making it clear that she has satisfied all the diagnostic requirements as outline in DSM-V for EOS. On the other hand, the patient could not be diagnosed with schizoaffective disorder as she has not any signs of mood instability or manic episodes which are crucial when making this diagnosis. Lastly, she could not be diagnosed with Schizotypal personality disorder, as she did not display an unusual belief or fear affecting her interpersonal relationships.

Expected Outcome

Upon keen evaluation of the patient’s symptoms, in addition to mental status examination results, the patient is expected to meet the diagnostic criteria for EOS. Symptoms displayed by the patient suggesting that she is suffering from EOS include hallucinations, delusion, fixed false beliefs, and being grossly disorganized with her homework (Dixon et al., 2018 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors). The mental status examination results should also display symptoms relating to EOS.

Difference between the Expected and Actual Outcome

The expected outcome tallied with the actual diagnostic results based on the mental examination findings and patients presenting symptoms. The patient symptoms reached the DSM-5 threshold for the diagnosis of EOS. The mental status examination also revealed that the patient seemed preoccupied. She also sees and hear strange things, and believes that people on the television know her. All these affirm the EOS diagnosis for the patient (Dixon et al., 2018 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors).

Decision #2: Treatment Plan for Psychotherapy

Selected Decision

Refer the patient for psychological testing

Reason for Selecting this Decision

Several mental disorders share the same symptoms. As a result, it is important to carry out a comprehensive assessment, not limited to the patient’s symptom and mental examination results. As such, it is necessary to refer the patient to a psychiatrist for further psychological testing before initiating treatment therapy. There is no specific test that will be used to diagnose schizophrenia, however, through the results obtained from psychological tests, the clinician will be able to rule out other conditions such as obsessive-compulsive disorder, obsessive-compulsive disorder, and delusional disorders, behavioral/emotional disorders, and delusional disorders, which, might have otherwise be the reason behind the patient mental disorder (Taylor et al., 2020 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors). Consequently, studies indicate that in as much as psychological testing might not strictly be used to diagnosis schizophrenia among adolescents, it can, however, increase the diagnostic accuracy, which is very crucial in formulating the most appropriate treatment plan for the patient. Clozaril could not be initiated at this point, given the high dose that might be associated with side effects, in addition to inadequate information to make the most accurate diagnosis. psychotherapy can not also be used solely in the management of the mental disorder, but instead as an adjunct to pharmacotherapy.

Expected Outcome

Schizophrenia can not be diagnosed using any specific psychological tests. However, these tests help in enhancing the accuracy of the diagnosis made. As a result, it is expected that the patient will display results relating to and support the differential diagnosis for EOS (Gatsou et al., 2016). Consequently, the psychological test results are expected to display impairment in the patient’s cognitive and social functioning.

Difference between the Expected and Actual Outcome

The patient reported back to the clinic after 4 weeks. The psychiatrist report was quite comprehensive affirming the initial diagnosis for EOS. Based on the psychological test results, the patient’s social and intellectual functions have deteriorated just as anticipated. Other tests that were carried out include Personality Inventory; Rorschach test; Kaufman Adolescent and Adult Intelligence Test; the Millon Adolescent Clinical Inventory (MACI) Whitaker Index of Schizophrenic Thinking (WIST) test; and Wide Range Achievement Test – 4th Edition (WRAT- 4) (Taylor et al., 2020). The results for all these tests suggested that the patient is suffering from EOS.

Decision #3: Treatment Plan for Psychopharmacology

Selected Decision

Begin Lurasidone 40mg orally daily

Reason for Selecting this Decision

Lurasidone is used off-label in the treatment of schizophrenia among both children and adults. Lurasidone is a second-generation (atypical) antipsychotic agent that acts by altering both serotonin and dopamine receptors which are involved in schizophrenia symptoms. The recommended starting dose of the drug among adolescents is 40mg per day, which might be titrated upwards to a maximum dose of 80mg per day among this population depending on the patient’s symptoms (Gatsou et al., 2016 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors). Consequently, studies have shown a high therapeutic index for the drug with a desirable safety profile among the adolescent population. The drug displays mild side effects such as nausea and weight gain which can be managed. Clozapine is FDA approved for the management of resistant schizophrenia which is not the case as the patient had never received treatment for her condition in the past. Consequently, the dose indicated is too high and might lead to adverse effects, as the recommended starting dose for children should be 25mg per day. Psychotherapy, just as mentioned earlier can only be used as an adjunct to pharmacotherapy but not alone.

Expected Outcome

Given the therapeutic index of the drug among the young population, the patient is expected to display a positive outcome within two to four weeks. She should be able to watch television without believing that the presenters know her, or are speaking to her. Both her cognitive and intellectual functioning are also expected to normalize (Mohr et al., 2018). Her social interaction is also expected to improve. She might however face quite mild side effects such as nausea and weight gain.

Difference between the Expected and Actual Outcome

The patient came back to the hospital after 4 weeks with positive results. She is less involved with characters on the television. She claimed that the frequency of her hearing voices and seeing things that did not exist had also reduced just as expected (Giles, & Martini, 2016). Her social, cognitive, and intellectual functioning had also improved greatly just as expected.

Ethical Considerations

Handling psychiatric patients is quite challenging for the PMHNP, given the wide range of ethical considerations that must be observed. For starters, the law requires that parents and guardians be responsible for making health decisions concerning the health of their children. As such, the clinician is obliged to disclose all the relevant information concerning the patient’s health, including the available treatment options and the expected outcome (Paul, Maietta, & Allen, 2020 NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors). Consequently, the patient information must always be kept confidential unless the patient displays the possibility of breaking the law. The family members and patient teachers must also be educated on measures they can take to help improve the patient’s condition.

NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors References

Giles, L. L., & Martini, D. R. (2016). Challenges and promises of pediatric psychopharmacology. Academic Paediatrics, 16(6), 508-518. DOI: 10.1016/j.acap.2016.03.011

Paul, N. B., Maietta, J. E., & Allen, D. N. (February 09, 2020). Cultural Considerations for Schizophrenia Spectrum Disorders II: Assessment and Treatment. 381-401.

Mohr, P., Galderisi, S., Boyer, P., Wasserman, D., Arteel, P., Ieven, A., Karkkainen, H., … Gaebel, (September 01, 2018). Value of schizophrenia treatment I: The patient journey. European Psychiatry, 53, 107-115. https://doi.org/10.1016/j.eurpsy.2018.06.007

Gatsou, L., Yates, S., Hussain, S., Barrett, M., Gangavati, S., & Ghafoor, R. (February 10, 2016). Parental mental illness: Incidence, assessment, and practice. Mental Health Practice, 19, 5, 25-27. DOI: 10.7748/mhp.19.5.25.s18.

Dixon, L. B., Goldman, H. H., Srihari, V. H., & Kane, J. M. (January 01, 2018). Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative. Annual Review of Clinical Psychology, 14, 237-258. https://doi.org/10.1146/annurev-clinpsy-050817-084934

Taylor, J. H., Appel, S., Eli, M., Alexander-Bloch, A., Maayan, L., Gur, R. E., & Bloch, M. H. (July 01, 2020). Time to Clinical Response in the Treatment of Early Onset Schizophrenia Spectrum Disorders Study. Journal of Child and Adolescent Psychopharmacology. https://doi.org/10.1089/cap.2020.0030

Instructions – NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

Case #3
A young girl with strange behaviors
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.SUBJECTIVECarrie’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.” NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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.” NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

Early Onset Schizophrenia
Schizoaffective Disorder
Schizotypal Personality Disorder

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. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

Learning Objectives – NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

Students will:

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. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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? NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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? NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

medicat Schizoaffective disorder Schizophrenia
amisulpride
aripiprazole
asenapine
carbamazepine (adjunct)
chlorpromazine
clozapine
cyamemazine
flupenthixol
haloperidol
iloperidone
lamotrigine (adjunct)
l-methylfolate (adjunct)
loxapine
lurasidone
mesoridazine
molindone
olanzapine
paliperidone
perospirone
perphenazine
pipothiazine
quetiapine
risperidone
sertindole
sulpiride
thioridazine
thiothixene
trifluoperazine
valproate (divalproex) (adjunct)
ziprasidone
zotepine
zuclopenthixol

amisulpride
aripiprazole
asenapine
carbamazepine (adjunct)
chlorpromazine
clozapine
cyamemazine
flupenthixol
haloperidol
iloperidone
lamotrigine (adjunct)
l-methylfolate (adjunct)
loxapine
lurasidone
mesoridazine
molindone
olanzapine
paliperidone
perospirone
perphenazine
pipothiazine
quetiapine
risperidone
sertindole
sulpiride
thioridazine
thiothixene
trifluoperazine
valproate (divalproex) (adjunct)
ziprasidone
zotepine
zuclopenthixolions for schizophrenia. NURS 6660 Week 10 Case #3: A Young Girl with Strange Behaviors

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