Reply Posts
Critique the decision making of two of your peers in your response posts.
Do you agree/disagree with their medication choice? Why?
Is there anything else you recommend including?
Compare peer’s decision making to yours—what are the advantages and disadvantages of each?
Your response should include evidence of review of the course material through proper citations using APA format.
Please refer to the Grading Rubric for details on how this discussion will be graded. The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.
This is Ryan Perry post:
Psychosis Case Study
Purpose
The purpose of this discussion response is to initiate schoroly discussion between peers and colleagues in NU-643 Advanced Psychopharmacology. Using evidenced-based research and peer-reviewed articles in conjunction with required readings, we will evaluate the psychiatric inteeview o a patient with psychosis and identify target symptoms, treatment priorityes, non-phatmacological interventions, pharmacological interventions with evidenced-based reasoning, and clinician monitoring of both desired and undesired effects.
Identification of target symptoms/problems
1. What information, if any, would you like to know that was not included in the case?
Dr.Taylor does a very good job during the initial psychiatric interview assessing Andy, a young man referred urgently by his GP. According to (Carlat, 2016) , the four tasks of the initial interview include: Build a therapeutic alliance, obtain a psychiatric database, interview for diagnosis, and negotiate a treatment plan with your patient. During the film, Dr. Taylor elicits persecutory delusions related to Andy’s professor drafting his roommates into M15 and turning his roommates against him, third person auditory hallucinations without visual hallucinations in which he hears his three roommates talking about him from the other room, and running commentary with thought insertion of his UNI roommates always talking about him and that they are going to “sort me out” because he is aware of their involvement with M15.
According to (Association, 2013) , at least two of the following must be present for a significant portion of time during a one-month period: Delusion, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. According to (Stahl, 2013) , it is necessary to consider possible differentials of psychosis as not all psychotic episodes are schizophrenia. Dr. Taylor does not elicit a family history of psychiatric illness. Using the SOAP process of an initial psychiatric interview, we are missing the patient’s past medical history and the patient’s family past medical history. Additionally, Dr.Taylor does not assess for negative symptoms, such as asociality, anhedonia, or avolition. Additionally, Dr. Taylor used a closed-ended question when assessing Andy’s substance-abuse history including alcohol, cannabis, and speed. Instead of asking “I guess the reason I was checking, it is what you have picked up on, is that sometimes when people are having the kinds of experiences that you are, they find if take certain drugs, it can make things feel a lot worse. I just wanted to check that hadn’t been your experience” Understanding how using these drugs may have worsened his auditory hallucinations and if there was an addictive component to them. As described by (Stahl, 2013) , the mesolimbic cortical pathway of dopamine is also the pleasure center, in which it has been determined that patients with mesolimbic dysfunction of dopamine tend to use drugs such as nicotine to self-medicate.
Additional collateral information from Andy’s parents and his roommates might be helpful to rule out any other differential diagnosis such as drug-induced psychosis or other personality disorders such as borderline personality disorder or schizotypal personality disorder. Although, Dr. Taylor does elicit some answers when asking questions during the interview such as
2. Which psychiatric symptoms are a treatment priority for this case?
Assessment for risk of safety is the treatment priority. According to (Stahl, 2013) , between 25-50% of patients with schizophrenia attempt suicide with 10% of them eventually successful, with an overall mortality rate eight times greater than those without schizophrenia. The response elicited by Dr. Taylor of concern were related to suicidal and homicidal ideations. Andy replied “Well, I’ve got a knife, and I’ve got like a baseball bat. It is just in case they get in my room. I do not want to hurt anyone; I just feel like I have got to protect myself. It’s like cornering me to do this.” This statement response indicates risk of aggression related to fear, with a plan and access to weapons. Additional response of suicidal ideations indicated positive thoughts with a plan as evidenced by Andy’s response “I thought about getting some pills, but I couldn’t, I couldn’t leave the house so I didn’t get anything.” According to (Stahl, 2013) , the risk of suicide increases with somatic hallucinations. Andy described his somatic hallucinations when discussing the tracking device in his brain moving around.
3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?
One non-pharmacological issue noted in the case study is his lack of substantial nutritional intake. Andy’s suspicion and persecutory hallucinations lead him to believe his food is being poisoned and therefore not eating much at the moment leading to possible fluid and electrolyte imbalances as well as hypovolemia and other metabolic-related organ injuries.
Medication Choice 1
4. List one medication that would be appropriate for this case. Include the name and starting dose.
Olanzapine (Zyprexa) 10mg PO daily.
According to (Stahl, 2021) , Olanzapine is an atypical antipsychotic that is a dopamine and serotonin receptor antagonist
5. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.
According to (Stahl, 2021) , Olanzapine (Zyprexa) is an atypical antipsychotic that is a dopamine and serotonin receptor antagonist that has shown to reduce positive symptoms of psychosis and stabilizing affective symptoms through its dopamine 2 receptor blocking in the mesolimbic pathway. Additional benefits include serotonin 2A receptor blocking which results in an enhancement of dopamine release with a reduction in motor side effects (Stahl, 2021). An additional benefit of Olanzapine is it dosage forms: tablets, oral disintegrating tablets, Intramuscular formulation, and depot. According to (Komossa et al., 2018) , patients with schizophrenia and psychosis can be challenging with both medication compliance and emergency administration. The multiple dosage forms gives the clinician alternative routes of administration based on compliance, aggression, and rate of absorption. In the above case study, involuntary inpatient hospitalization is necessary based on risk of self-harm, poor insight, poor judgement, and persecutory hallucinations. In the event Andy was unwilling to take any oral medications in fear he was being poisoned, as referenced when he M15 poisoning his food and poor intake. According to (Stahl, 2021) , Olanzapine is a CYP450 1A2 and 2D6 substrate in which food does not affect absorption. According to (Komossa et al., 2018) , Olanzapine has a greater affinity for 5HT1A than D2, greater D2 than 5HT1B/D binding, greater 5HT2C than D2 binding, which make it a great choice for Andy’s acute psychotic crisis related to schizophrenia because of its 5HT2C antagonist properties and its H1 blocking properties for sedation.
6. What laboratory testing/monitoring is needed for safely prescribing this medication?
According to (Stahl, 2021) , the following laboratory information should be obtained prior to initiation of Olanzapine due to risk of metabolic syndrome:
· Initial Weight and BMI
· Waist Circumference
· Fasting Glucose
· Fasting Lipid Profile
· Vital signs including Blood pressure
7. Are there any contraindications or safety issues associated with this medication?
According to (Stahl, 2021) , Olanzapine’s H1 blocking can cause sedation, placing the patient at risk for injury. Additional adverse effects include metabolic syndrome including hypertension, weight gain and obesity, hyperlipidemia, insulin resistance resulting in possible diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic coma (Komossa et al., 2018) . Additional life-threatening adverse effects include neuroleptic malignant syndrome. According to (Komossa et al., 2018) , Olanzapine and other atypical antipsychotics are not recommended in seniors, 65 or older, due to increased risk of death when treating psychosis related to dementia.
Non pharmacologic Interventions
8. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complimentary and holistic therapies?
Cognitive Behavioral Therapy, cognitive remediation, and social cognition training could be considered for patients with schizophrenia to help develop better social and cognitive problem-solving skills. According to (Irfan et al., 2019) , CBT should be considered not during a time of psychosis, rather to lower the risk of relapse or to reduce the severity of symptoms (Irfan et al., 2019).
Safety Risk Assessment
9. What are the safety concerns, if any, associated with this case? How will you address safety?
Safety is a significant concern for Andy. Andy has persecutory hallucinations with paranoia. He has thought about suicide, and had a plan to overdose on pills but was too paranoid to leave his room. He also has report of fear and wanting to protect himself from his roommates with a plan, knife, and baseball bat. His poor insight and judgment would indicate the need for an involuntary inpatient hospitalization. I liked the fact that Dr. Taylor was able to provide Andy with reassurance that his privacy was going to be protected when he admitted to using drugs. Additionally, I like how Dr. Taylor did still ask for permission to involve Andy’s mother in the decision-making process to support Andy. However, according to Section 164.510(b)(3) of the HIPAA Privacy Rule, when a health care provider believes, based on professional judgment, that the patient does not have the capacity to agree or object to the sharing of personal health information at a particular time and that sharing the information is in the best interests of the patient at that time (“Hipaa Privacy Rule,” 2014).
10. When would you follow up with this patient?
I am recommending inpatient hospitalization for Andy. In recommending inpatient level of care, this would require daily visits by the PMHNP for consultation and collaboration with the patient and the nursing to staff to discuss response and any adverse effects. In the outpatient setting however, olanzapine can show improvement within one week, but it may take several weeks for full effect on behavior. Clinical recommendations, according to (Stahl, 2021) , to wait at least 4-6 weeks to determine efficacy of drug. In the outpatient setting, I would recommend follow-up in one week based on concern for worsening symptoms of schizophrenia.
References
Association, A. P. (2013). Diagnostic and statistical manual of mental disorders, fifth edition (dsm-5(tm)) (5th ed.). American Psychiatric Publishing.
Carlat, D. (2016). The psychiatric interview (4th ed.). LWW.
Hipaa privacy rule. (2014). In The practical guide to hipaa privacy and security compliance, second edition (pp. 69–70). Auerbach Publications. https://doi.org/10.1201/b17548-8
Irfan, M., Muzaffar, S., Kingdon, D., Rathod, S., & Naeem, F. (2019). Psychotherapy for schizophrenia and bipolar disorder. In Global mental health and psychotherapy (pp. 223–239). Elsevier. https://doi.org/10.1016/b978-0-12-814932-4.00010-0
Komossa, K., Rummel-Kluge, C., Hunger, H., Schmid, F., Schwarz, S., Duggan, L., Kissling, W., & Leucht, S. (2018). Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd006654.pub2
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.
Stahl, S. M. (2021). Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press.
