Schizophrenia Spectrum and Other Psychotic Disorders
Introduction
Schizophrenia spectrum and other psychotic disorders occur due to both environmental and hereditary factors. Schizophrenia spectrum is typified by positive symptoms like hallucinations and negative symptoms such as catatonia, disorganization, and alexithymia (Selwyn et al., 2017). On the other hand, psychotic disorders are typified by dissociation where the normal functions of memory, identity, perception, and consciousness are disrupted (Selwyn et al, 2017). Accordingly, the paper will provide an analysis regarding the treatment and management of an adult client with schizophrenia spectrum and other psychotic disorders. Schizophrenia Spectrum and Other Psychotic Disorders Essay Paper
HPI and Clinical Impression for the Client
The client, an 18-year-old male presented for a follow-up, three months after a diagnosis of ADHD, unspecified schizophrenia, and other psychotic disorders. The client presented with the mother. The mother reported that he had cut his hair using a sword as he wanted to be original. The client was also not adhering to the treatment regimen and at some point, the mother had to call the police as he had refused to take mediations and was not attending classes. His academic performance has significantly declined. The client calls himself “the god of sadness” and posts bizarre videos on his YouTube channel. The client was taking Latuda and it was recommended to change to Geodon 40 mg PO daily with food, to improve his adherence.
Assessment: The client looks healthy and appropriate weight for his age. He is appropriately dressed. He depicts a depressed mood and blunted affect. The client depicts an altered thought process. His judgment and insight are impaired. He denies any suicidal thoughts.
Clinical Impression: According to the DSM-5 diagnostic criteria in APA (2013), the diagnosis of this client is schizoaffective disorder versus schizophrenia and mood disorder.
Psychopharmacology
The healthcare provider recommended the medication change to Geodon 40 mg PO daily with food. Based on the diagnosis of this client, Geodon 40 mg PO daily is the recommended medication. Geodon is an atypical antipsychotic that is FDA recommended for the treatment of schizophrenia. Atypical antipsychotics are the preferred first-line treatment for schizophrenia because they effectively control both negative and positive symptoms of schizophrenia (Fellner, 2017). Also, atypical antipsychotics have a low risk of tardive dyskinesia and less extrapyramidal symptoms and this may improve the client’s adherence to the treatment regimen.
Carbamazepine will also be recommended for the client. This is because the client presents a depressed mood and carbamazepine will be used as a mood stabilizer for this client (Yogeswary, 2014). The client will need to be educated regarding the side effects associated with both medications.
The treatment goal is to help the client think more clearly and positively and also reduce hallucinations and delusional thoughts manifested by the client. It is also expected that the client’s mood will stabilize.
Psychotherapy
Family therapy and cognitive-behavioral therapy (CBT) will be the recommended psychotherapy choices for this client. Cognitive-behavioral therapy (CBT) will help make the client understand his condition and also helping him to adopt a more positive thinking pattern. Robinson et al (2015) provide that CBT improves both residual symptoms and psychotic symptoms in patients with schizophrenia. Family therapy will help the client and his family members. Using family therapy, family members will be enlightened about schizophrenia and how they can handle the client. The family will also be educated on the importance of understanding the client and providing the required social and emotional support (Robinson et al., 2015).
Medical Management
The client has not been adhering to the treatment regimen and thus this is an issue that needs to be monitored closely. According to Semahegn et al (2018), nonadherence to treatment is associated with poor health outcomes. It will also be important to discuss with the client about the relevance of taking baseline labs like hepatic panel, CMP, and kidney function test. The client will be monitored closely for any side effects.
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For community resources, the client will be linked with the local support groups so that he can meet and interact with other individuals experiencing similar mental health conditions. This may motivate him to adhere to the treatment regimen.
Follow -up Plan and Collaboration
The client and the mother will be instructed to come back for review after two weeks to monitor his adherence to treatment, and more importantly his response and tolerability to the prescribed medication. The client’s treatment regimen will be reviewed every four weeks. The client will be instructed to adhere to the recommended CBT and family therapy. It will be important to consult with the psychiatrist in case of any concern about the condition of this client. A social worker would help in monitoring the progress and adherence to treatment for this client while at home (Proctor, 2017).
Conclusion
An 18-year-old male presented for a follow-up, three months after a diagnosis of ADHD, Unspecified schizophrenia, and other psychotic disorder. From HIP and assessment, the diagnosis for this client is schizoaffective disorder versus schizophrenia and mood disorder. The pharmacological treatments for this client include Geodon and Carbamazepine. The recommended psychotherapy treatment includes CBT and family therapy. The client will need to be monitored for side effects and adherence to treatment.
Obsessive Compulsive Disorder (OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions (Sadock, Sadock, & Ruiz, 2014). These recurring obsessions or compulsions cause severe distress to the person. An obsession is a recurrent and intrusive thought while a compulsion is a conscious, standardized, recurrent behavior. The purpose of this paper is to explore management strategies of OCD in adult clients. As the PMHNP, I will discuss a case and recommend treatment modalities, medical management, follow-up plan and collaboration in the care of a client with OCD. Schizophrenia Spectrum and Other Psychotic Disorders Essay Paper
History of present illness (HPI) and Clinical Impression
HPI: K. K. a 22 yo CF referred for a psychiatric evaluation by her PCP. Karen reports a complaint of “I need help, I can’t keep a job because of these rituals I have.” She reports that she cannot maintain a job because of her rituals of checking locks. Karen has recurrent thoughts that she had left the door of her apartment and car unlocked. She reports leaving work several times daily to check the locks on both her car and apartment. Additionally, because she often had the thought that she had not locked the door to the car, it was difficult for her to leave the car or apartment until she had repeatedly checked that it was secured causing her to be late for work. She has been fired several times for tardiness and poor attendance however checking the locks decreases her anxiety about security. Karen denies any medical issues and is not currently taking any medications. She also denies the use of any alcohol, tobacco or illicit drugs. Reports a family history of depression in both maternal and paternal grandmothers. Karen recognizes that she is needs help and is eager to begin treatment.
Assessment: A healthy, well-groomed 22yo CF in no acute distress. A, A&Ox4, pleasant and appropriately dressed. Makes good eye contact however mood is depressed with a flat affect; recent and remoter memory are intact. Karen’s thoughts are circumstantial and preoccupied with obsessions and compulsions. Her insight and judgment are fair. Denies SI/HI/AVH.
Clinical Impression: Based on the diagnostic criteria in APA (2013), a diagnosis of OCD is made.
Psychopharmacology
If the patient’s symptoms cause a significant impairment in function or distress, treatment is recommended (Fenske and Petersen, 2015). Based on Karen’s report of losing several jobs because of tardiness and attendance, there is a significant impairment in social and home functionality. Karen also reports that her rituals cause her significant distress. The standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if the SSRI is not effective (Sadock, Sadock, & Ruiz, 2014). I will initiate Prozac 40mg oral daily as it is Food and Drug Administration (FDA) approved for treatment of OCD (Stahl, 2014). I will have the patient return to clinic in week to assess for tolerability and increase to the suggested 80mg oral daily. Higher dosages have often been necessary for a beneficial effect (Stahl, 2014). I prefer to initiate with an SSRI (Prozac) as opposed to tricyclic (Clomipramine) for the less troubling adverse effects associated with Clomipramine. Karen will be informed that she might experience sleep disturbances, nausea, diarrhea, headache and anxiety which are all adverse effects of SSRIs. The desired outcome of pharmacotherapy is to reduce the patient’s intrusive thoughts that cause the compulsions that interfere with her home and work life. Well controlled studies have found that pharmacotherapy, behavior therapy, or combination of both is effective in significantly reducing the symptoms of patients with OCD (Fenske and Petersen, 2015).
Psychotherapy
Some studies indicate that behavior therapy is as effective as pharmacotherapies in OCD and some indicate that the beneficial effects are longer lasting with behavior therapy (Sadock, Sadock, & Ruiz, 2014). Many clinicians consider behavior therapy the treatment of choice for OCD and also because it can be conducted in both outpatient and inpatient settings. With the prinicpal behavioral approaches being exposure and response prevention, patients must be committed to improvement as Karen is. Behavior therapy will be initiated the same week as pharmacotherapy. The goal of therapy is to change the client’s behavior to reduce dysfunction and to improve her quality of life. A psychotherapist will be consulted to intiate and manage therapy sessions.
Medical Management
I will consult with Karen’s PCP for updates and additional concerns. Since she has been with her PCP for more than 5 years, he has good insight into her life. We will discuss baseline labs such as CBC, CMP, TSH, hepatic panel. Since with SSRIs, nausea, headache dry mouth and diarrhea are common side effects, monitoring the patient’s electrolytes is important. I would also recommend an EKG for baseline and follow up after medication initiation as SSRIs can lengthen the OT interval in otherwise health people (Sadock, Sadock, & Ruiz, 2014). Community resources such as the local chapter of the OCD Foundation will be provided to Karen for support services.
Follow -up Plan and Collaboration
Karen was instructed to follow up in 1 week to monitor tolerability and compliance of medicaiton and dose adjustment. Subsequently, she will return every 4 weeks for medication management. She is also instructed to begin behavior therapy the same week as medication are initiated and to follow up weekly for therapy sessions. I will consult with the therapist weekly for updates and any concerns or questions. I will reiterate and reinforce to both the PCP and therapist the importance of monitoring for suicidal ideations as the patient is taking an antidepressant and abuptly stopping will increase risk of suicide. About one-third of patients with OCD have major depressive disorder, and suicide is a risk for all patients with OCD (Sadock, Sadock, & Ruiz, 2014). Schizophrenia Spectrum and Other Psychotic Disorders Essay Paper
Conclusion
A poor prognosis is indicated by Karen yielding to rather than resisting compulsion or the need for hospitalization. A good prognosis for Karen is indicated by good home, social and occupational adjustment. The importance of an interdisciplinary team including PCP, therapist and other ancillaries will benefit the client for a better quality of life.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Fenske, N. & Petersen, K. (2015). Obsessive-Compulsive Disorder: Diagnosis and Management. American Family Physician, 92(10): 896-903. Retrieved from http://www.aafp.org.afp
/2015/1115/p896.html
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer
Stahl, S.M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.
Patient information:
Visit information: Came in for 3 months medication follow up DSM-5 diagnosis: ADHD, Unspecified schizophrenia and other psychotic disorder
Treatment plan and note: 18-year-old male presents with stable vitals 119/61 pulse 75. He sits quietly in the chair with blunted affect, altered thought process, and depressed mood. He came in accompanied by his mother who he gave consent to be present during his visit.His mother reports that he cuts his hair with a sword because he wants to be original. The mother also states that he has not been compliant with his medications and she has not been able to convince him to take them. She endorses that she had to call the police last month after the patient missed two weeks in order to get him to attend his classes. He is failing all of his classes and will not be able to graduate. When asked why he is not compliant with his medications, he states” I have my reasons” I just want to be myself and I don’t have time to take medications.” The patient refers to himself as the God of sadness. He posts bizarre videos on his YouTube channel. His mother does not accept the diagnosis of schizophrenia and expressed that he has Bipolar disorder instead. The provider recommends changing the Latuda that the patient was not taking to Geodon 40 mg PO daily with food. The patient promised the providers that he will take this medication. Follow up in 1 month for reevaluation.
*** Patient has not medical issues.
To prepare for this Assignment:
- Select an adult or older adult client with a schizophrenia spectrum and other psychotic disorder you have seen in your practicum.
In 3–4 pages, write a treatment plan for your client in which you do the following:
- Describe the HPI and clinical impression for the client.
- Recommend psychopharmacologic treatments and describe specific and therapeutic endpoints for your psychopharmacologic agent. (This should relate to HPI and clinical impression.)
- Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
- Identify medical management needs, including primary care needs, specific to this client.
- Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
- Recommend a plan for follow-up intensity and frequency and collaboration with other providers.
Schizophrenia Spectrum and Other Psychotic Disorders Essay Paper