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 since she was 9 years old). She presents to your office today 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 tells you that she knows this because the television is telling her so. Delusional Disorders Essay Paper

She currently weighs 140 lbs, and is 5’ 5”

SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down. You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. Client admits that she stopped taking her Risperdal 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, 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 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.

The PMHNP administers 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

Select what the PMHNP should do:
DECISION POINT ONE
Start Zyprexa 10 mg orally at BEDTIME
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
Start Abilify 10 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client\’s PANSS decreases to a partial response (25%)
Client comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals so she is snacking constantly throughout the day.
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
A decrease in PANSS score of 25% is noted at this visit
Client seems to be tolerating medication
Client\’s husband has made sure she makes her appointments for injections (one thus far)
Client has noted a 2 pound weight gain but it does not seem to be an important point for her
Client complains of injection site pain telling the PMHNP that she has trouble siting for a few hours after the injections and doesn’t like having to walk around for such a long period of time
Start Abilify (aripiprazole) 10 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night and has also been disrupting his sleep
Clientis unable to participate in the PANSS rating tool because she continually is nodding off (sleeping) during the appointment
The appointment is not productive for assessing how she is responding to the Abilify started 4-weeks ago
Decision Point Two
Select what the PMHNP should do next:

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Resources:
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.

Clozapine REMS. (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

Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.

Stanley R. Kay, Abraham Fiszbein, Lewis A. Opler, The Positive and Negative Syndrome Scale (PANSS) for Schizophrenia, Schizophrenia Bulletin, Volume 13, Issue 2, 1987, Pages 261–276, https://doi-org.ezp.waldenulibrary.org/10.1093/schbul/13.2.261

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi-org.ezp.waldenulibrary.org/10.2165/00023210-200923080-00002

 Delusional Disorders

Introduction

This paper focuses on a client with a diagnosis of schizophrenia, paranoid type. The client manifests impaired judgment, impaired insight, and a paranoid and delusional thought process. According to the PANSS, the client had -60 for general psychopathology; -40 for the positive symptoms; and -20 for the negative symptoms. The MSE revealed that she was oriented to event, place, time, and person. The client’s speech appeared slow and interrupted by moments of silence. This paper will thus involve making three decisions about the client’s treatment options.    Delusional Disorders Essay Paper

Decision Point One

The selection decision is for the client to begin Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter. This decision was chosen because an injection of Invega Sustenna will facilitate adherence to treatment since the client did not adhere to the oral Risperdal because of the delusional thought process (Fang et al., 2016). Invega Sustenna is effective in treating schizophrenia paranoid type (Helland & Olav, 2017). Zyprexa 10mg and Abilify were not selected because the client has shown non-adherence to oral medications. Moreover, the medications have numerous side effects like memory problems, constipation, dizziness, general weakness, etc. (Stahl, 2014).

By selecting Invega Sustenna IM, it is expected that the delusions, hallucinations, and paranoid feelings would significantly reduce. This is because the medication is an effective antipsychotic (Stahl, 2014). It is also expected she would tolerate the medication with no or minimal side effects (Fang et al., 2016).

As expected, the client manifested significant symptom improvement as indicated by decreased PANSS score (25% decrease). However, the client reported weight gain; this is a common side effect with Invega Sustenna (Safavi et al., 2016). The client also reported difficulties while sitting. This is due to the injury of the sciatic nerve because IM used the dorsogluteal region (Nakajima et al., 2017).

Decision Point Two

The second decision is to continue with Invega Sustenna IM but use the deltoid region to administer the medication. Invega Sustenna was maintained because it is an effective antipsychotic as indicated by the significant symptom reduction for this client (Safavi et al., 2016). The injection site changed to the deltoid region since the dorsogluteal region was painful for the client. According to Nakajima et al (2017), when the dorsogluteal muscle is used, the sciatic nerve may get injured, leading to pain for the patient. Discontinuing Invega Sustenna to start Haldol Decanoate and adding Abilify to Invega Sustenna were not selected because is no clinical reason to select these treatment options. Additionally, oral medications are not appropriate for this client because of psychotic and delusional symptoms (Helland & Olav, 2017).

The selection of this decision expected that the client would continue manifested symptom improvement. This is due to the efficacy of Invega Sustenna in treating psychotic symptoms (Helland & Olav, 2017). The second expectation is that the client would not have any discomfort since there is no risk of injuring the sciatic nerve when the deltoid site is used to administer the medication (Nakajima et al, 2017).

As it was expected, the symptoms further reduced as manifested by a 50% reduction of the PANNS score. This is due to the efficacy of Invega Sustenna in the treatment of psychotic symptoms.  Moreover, the client stopped experiencing pain at the injection site. Nonetheless, she reported additional weight gain. Weight gain is a common side effect of Invega Sustenna (Fang et al., 2016).

Decision Point Three

The third decision is for the client to continue taking Invega Sustenna, be educated about weight gain from the medication, and refer the client to an exercise physiologist and dietician. The rationale for choosing the decision is due to the efficacy of Invega Sustenna. Additionally, the other medications are associated with more weight gain than Invega Sustenna (Fang et al, 2016). The exercise physiologist and dietician will help the client through weight control to ensure that she loses some weight even as she continues being administered with Invega Sustenna.

Selecting the option expected that the client would continue manifesting symptom reduction, adhere to the treatment regimen, and prevent excess weight gain by adhering to the behavioral modifications suggested by the exercise physiologist and dietician.

Conclusion

The diagnosis of this client is Schizophrenia, paranoid type. The first decision is for the client to start Invega Sustenna 234 mg intramuscular. IM would facilitate the client’s adherence to treatment and also the medication is effective in treating psychotic symptoms. The client reported significant symptom improvement but reported weight gain and pain at the injection site. The second decision was thus to continue with Invega Sustenna IM but use the deltoid region to administer the medication. The symptom continued to reduce and thus the third decision was for the client to continue taking Invega Sustenna, be educated about weight gain from the medication, and refer the client to an exercise physiologist and dietician.

References

Fang L, Turkoz I & Fan. (2016). Efficacy and safety of once-monthly injection of paliperidone palmitate in hospitalized Asian patients with acute exacerbated schizophrenia: an open-label, prospective, noncomparative study. Neuropsychiatry Dis Treat, 1(12), 15–24.

Helland A & Olav S. (2017). Serum Concentrations of Paliperidone After Administration of the Long-Acting Injectable Formulation. Ther Drug Monit, 39(6), 659–662.

Nakajima Y, Mukai K, Kana T, Hirose T, Keiko M, Yuka Y, Urai T & Toshio N. (2017). Establishing a new appropriate intramuscular injection site in the deltoid muscle. Hum Vaccin Immunotherapy, 13(9), 2123–2129.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Safavi P, Ali H & Amir M. (2016). Comparison of risperidone and aripiprazole in the treatment of preschool children with a disruptive behavior disorder and attention deficit-hyperactivity disorder: A randomized clinical trial. J Adv Pharm Technol Res, 7(2), 43–47. Delusional Disorders Essay Paper