Critique the decision making of two of your peers in your response posts.
Critique the decision making of two of your peers in your response posts.
1. Do you agree/disagree with their medication choice? Why?
2. Is there anything else you recommend including?
3. 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.
Reply one:
1)Psychosis: Again, the diagnosis of schizophrenia is best made over time because repeated observations increase the reliability of the diagnosis. A diagnosis of schizophrenia is reached through an assessment of patient-specific signs and symptoms, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Schizophrenia presents with four symptom clusters: positive, negative, cognitive, and affective disturbances. Positive symptoms can include hallucinations, delusions, thought disorders/behaviors, and movement disorders. Negative symptoms include a flat affect, alogia, anhedonia, lack of self-motivation, social withdrawal. Cognitive symptoms include poor executive function, difficulty focusing, memory deficits. And finally, affective disturbances include odd expressions or actions, poor self-esteem, depression with an increased risk of suicide (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
The diagnostic criteria for schizophrenia include the persistence of two or more of the following active-phase symptoms, each lasting for a significant portion of at least a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. At least one of the qualifying symptoms must be delusions, hallucinations, or disorganized speech (DSM-5, 2013). Patient Andy presents with delusions, auditory/cenesthetic hallucinations, and increasing social withdrawal extending upon two months. As well, an estimated 80% of clients affected by a psychotic disorder experience their first episode between the ages of 16-30. In men, the symptoms tend to present between 18 and 25 years of age. In women, the onset of symptoms has two peaks, the first between 25 years of age and the mid-30s, and the second after 40 years of age (Holder & Wayhs, 2014). While continued clinical observation is necessary, this patient is presenting with psychosis along the disorder of schizophrenia.
Any patient presenting with such symptoms must be fully evaluated for underlying medical conditions. Consideration of substance abuse should be one of the primary differentials, and toxicology testing should be performed (Dunphy et al., 2011). Alcohol, opioids, cocaine, amphetamines, barbiturates, and hallucinogens are some of the most common offenders. Commonly prescribed medications such as anticholinergic agents, phenytoin, steroids, and anxiolytics may also produce similar symptoms. Our patient does admit to use of marijuana and speed; therefore, it is imperative to have the patient discontinue these substances. Other differentials to consider include delirium, in which the onset of symptoms occurs more rapidly and in which visual hallucinations are more common, versus schizophrenia in which symptoms occur over a longer time period and auditory hallucinations occur more frequently. Medical illness such as hepatic encephalopathy, hyponatremia, hypoglycemia, hypoxia, intracranial bleed, infection, meningitis, and so forth should be considered. A complete history and physical exam with attention to neurologic and mental status exam are essential. Laboratory evaluation should include CBC with differential, electrolytes, renal function, liver profile, thyroid function, drug and alcohol toxicology, and for woman, pregnancy (Dunphy et al., 2011).
Schizophrenia influences all aspects of life for patients and their families. Treatment goals should address reducing or eliminating symptoms, maximizing quality of life, improving function, and promoting and maintaining recovery. Pharmacologic intervention is the mainstay for treatment of schizophrenia (Patel, Cherian, Gohil, & Atkinson, 2014). Numerous studies have shown there is often a significant delay in initiating treatment for people affected by a psychotic disorder. These delays vary widely but the interval between onset of psychotic symptoms and commencement of appropriate treatment is often more than one year and as a consequence of these delays, significant disruption can occur at a critical developmental stage along with the formation of alarming secondary problems. The longer the period of untreated illness, the greater the risk for psychosocial disruption and secondary morbidity for the person and their family. Some evidence shows that long delays in treatment may cause psychotic symptoms to become less responsive to treatment (“Early Psychosis,” 2000).
Antipsychotic medications are the treatment of choice and patients should be offered such when they are suspected or initially diagnosed. Potential risks, benefits, adverse effects, and alternatives should be discussed with the patient. Antipsychotic medications include the typical or first-generation antipsychotics or the atypical or second-generation antipsychotics. Data suggest similar antipsychotic efficacy for both classes and a tendency for the second generation being better tolerated leading to enhance compliance (Papadakis & McPhee, 2017). It is essential to start any antipsychotic medication at very low doses to minimize side effects as these contribute to poor compliance. The start low and go-slow approach will bring around 60% of patients to full remission responding by 12 weeks and another 25% will respond more slowly (“Early Psychosis,” 2000).
For patient Andy, consideration should be given to the atypical antipsychotic risperidone. Risperidone works by blocking dopamine 2 receptors and can reduce positive symptoms of psychosis, sometimes within one week and then improve negative symptoms (Stahl, 2013). Andy can be started on a 2 mg dose administered as a single daily dose or 1 mg twice a day. If the dose is well tolerated, the dose can be increased to 3 mg on the second day and 4 mg on the third day. Risperidone 4 mg is in the therapeutic range for most patients, and should the patient continue this medication, he can stay at this dose for an additional two weeks before considering an increase. If he shows only minimal or no improvement, the dose can be increased up to 8 mg daily with careful monitoring for response and side effects, as doses of risperidone above 8 mg daily are associated with substantial side effects (Up To Date, 2018). Resolution of symptoms generally occurs over several days and may take as much as four to six weeks.
Side effects of risperidone can include increased heart rate, increased blood pressure, increased body mass index, increase weight gain, increased weight circumference, increased lipid panel, increased glucose level, and signs of movement disorder (i.e. extrapyramidal symptoms of akathisia, parkinsonism, dystonia or tardive dyskinesia of abnormal movements of the face, tongue, extremities, perioral areas) (Papadakis & McPhee, 2017). Prior to medication administration the clinician must obtain a thorough patient history as well as family history to know if it may include hypertension, obesity, diabetes, or dyslipidemia. It would also be feasible to obtain a CBC, electrolytes, fasting glucose, lipid profile, liver, renal, and thyroid function tests. Each visit should include a full set of vital signs and body mass index (Papadakis & McPhee, 2017). It is imperative to make patients aware of the adverse effects and to notify the clinician of any concerns. The patient should follow up in office in one week after starting medication for re-assessment and evaluation of adverse effects and clinical outcomes.
Recovery during the treatment of schizophrenia is defined both objectively and subjectively. Objective dimensions of recovery include the remission of symptoms and the patient’s return to full-time work or enrollment in college (Patel et al., 2014). Several tools are available for rating the progress of patients with schizophrenia. The Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS), for example, were developed as numerical indicators of improvement. Clinicians can also use quicker four-item instruments such as the Positive Symptom Rating Scale and the Brief Negative Symptom Assessment. Subjective dimensions of recovery are measured by the patient in terms of his or her life satisfaction, hope, knowledge about his or her mental illness, and empowerment (Patel et al., 2014).
2) Substance Use/Abuse: Predictors of a poor prognosis include the illicit use of amphetamines and other central nervous system stimulants, as well as alcohol and drug abuse. Several past studies have found that more frequent use of marijuana is associated with a higher risk of psychosis. In one particular study, researchers compared incidence of psychosis with the availability and use of marijuana in several different cities. The study found that three European cities, London, Paris and Amsterdam, had the highest rates of new diagnoses of psychosis at 45.7 per 100,000 person per year in London, 46.1 in Paris and 37.9 in Amsterdam. These are also cities where high-potency marijuana is most easily available and commonly used (Chatterjee, 2019). Other European cities in Spain, Italy and France were shown to have less marijuana use and also have lower rates of new psychosis diagnosis (Chatterjee, 2019). While it is reasonable to suggest that patient Andy discontinue his use of marijuana and speed as a first line treatment, if there is no immediate improvement in his presentation, the patient will need to start on psychopharmacologic therapy as the patient can end up a danger to self/others and an increased chance of acting out his suicidal…
