Case Study: Pakistani Woman With Delusional Thought Processes

Introduction
Schizophrenia is a mental disorder characterized by an abnormal social behavior and failure to recognize reality. Some of its common symptoms comprise wrong beliefs, uncertain or confused thinking, hearing voices that others fail to hear, decreased social engagement, and emotional expression, and a lack of stimulus (Konradi & Heckers, 2003). Kay, Fiszbein, and Opler (1987) report others symptoms of this ailments to be delusions, hallucinations, and disorganized thoughts. Many patients may also resist treatment arguing that nothing is wrong with them. In this case, the patient under study at one point went out of control and later diagnosed with schizophrenia, paranoid type, with the main focus being making three decisions regarding her medication.

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Decision Point One
Selected Decision
Start Zyprexa (olanzapine) 10 mg po orally at BEDTIME
Reason for Selection
The patient was diagnosed with Schizophrenia, paranoid type. Earlier on she had been diagnosed with brief psychotic disorder since her symptoms had only persisted for less than month. Olanzapine is normally used to treat mental and mood disorders like schizophrenia according to Laursen, Munk-Olsen, and Vestergaard (2012). Zyprexa medication could be so effective for decreasing hallucinations and helping a patient think more clearly and positively about herself, feel less disturbed, and take a more active role in day-to-day life.

Expected Results
It is expected that if an evaluation is conducted after four weeks, the patient’s PANSS should have decreased to a partial response. Moreover, increased social engagement is also anticipated with continued use of this medication. Fewer or no hallucinations and paranoid feelings should be experienced. We also expect the patient to start making right judgment and become relatively calm.

Difference between Expected Results and Actual Results
The patient re-visits after four weeks and though her PANSS has decreased to a partial response by 25%, she has reported weight gain of 5 pounds which implies further decreased social engagement. Additionally, she reveals that she can never seem to get full from her meals so she is snacking constantly throughout the day.

Decision Point Two
Selected Decision
Change medication to Geodon 40 mg orally BID with meals.
Reason for Selection
Changing to medication to Geodon 40 mg orally BID with meals is expected to continue reducing the patient’s PANSS and is also selected to increase her social engagement thus weight loss. Moreover, her hunger is can also be abated by this change of medication. Switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy.
Expected Results
It is expected that her PANSS will continue decreasing significantly while also experiencing increased social activity which is expected to bring about weight loss. Her hunger which was a side effect of first medication will also abate. This further means that her hallucinations will decline and her ability to think clearly will improve (Clozapine, 2015).

Difference between Expected Results and Actual Results
The only unexpected result with this change of medication to Geodon 40 mg orally BID with meals was the fact that the client could not remember the second dose and admits to missing afternoon doses on several occasions over the past month.

Decision Point Three
Selected Decision
Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose.
Reason for Selection
The patient should continue with Geodon and unlike the initial prescription which recommended using Latuda which is a medication that behaves much like Geodon but is taken only once daily (Ferri, 2010). This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing like the patient in this case. Tolerability can be an issue as doses are escalated (Hor & Taylor, 2010). Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients.

Expected Results
We expect the patient’s PANSS to continue decreasing because Latuda which is a medication that behaves much like Geodon and would produce the same results (Jones & Pilowsky, 2002). It is expected that the patient will still experience increased social activity which is expected to bring about weight loss. Her hunger which was a side effect of first medication will also disappear. This further means that her hallucinations will also decline and her ability to think clearly will improve.

Difference between Expected Results and Actual Results
The side effects of this drug include nausea, vomiting, and extrapyramidal (Laursen, Munk-Olsen & Vestergaard, 2012). Any of these side effects may show up while the patient is still on this medication.

Ethical Considerations
Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option this patient since who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability to this medication can be an issue as doses are escalated. Therefore, because of the side effects of nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients (Paz, Nalls & Ziv, 2011).

References


1. Clozapine, R. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
2. Ferri, F. F. (2010). Ferri's differential diagnosis: a practical guide to the differential diagnosis of symptoms, signs, and clinical disorders (2nd ed.). Philadelphia, PA: Elsevier/Mosby.
3. Hor, K. and Taylor, M. (2010). Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of psychopharmacology (Oxford, England), 24(4), 81–90.
4. Jones, H. M. and Pilowsky, L. S. (2002). Dopamine and antipsychotic drug action revisited. British Journal of Psychiatry, 181, 271–275.
5. Kay, S. R., Fiszbein, A. and Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
6. Konradi, C. and Heckers, S. (2003). Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment. Pharmacology and Therapeutics, 97(2), 153–179.
7. Laursen, T. M., Munk-Olsen, T., and Vestergaard, M. (2012). Life expectancy and cardiovascular mortality in persons with schizophrenia. Current Opinion in Psychiatry, 25(2), 83–8.
8. Paz, Z., Nalls, M. and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13, 625-629.

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