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Delusional Thought Processes

Julie Thibeaux

NURS6630-13

Walden University

July 19, 2021

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Looking into the case this week, we are visited by a thirty-four-year-old woman of

Pakistani descent. This woman just moved here from Pakistan in her teen years or early twenties.

The patient expresses being married, one of which was arranged for her when she was only nine

years old. She has recently been hospitalized for twenty-one days and was diagnosed with

“brief” psychotic disorder. The patient explains she was given this diagnosis because her

symptoms have persisted for less than a month. The patient’s husband has reported he was afraid

to leave their children alone with the her because she was expressing visions of Allah while

believing she was the prophet Mohammad who could heal the world from sin. When the patient

showed signs of uncontrollable behavior the husband was forced to call the police on his wife

which resulted in her admission to the psychiatric unit. During the assessment of the patient, she

is quiet and calm, explaining that her husband has blown everything out of proportion. The

patient strongly believes that her husband does not truly love her and wishes she were American.

The reason she feels this way is because what she sees on television tells her so. She does report

today she is in a good mood, denying hallucinations, but does believe Allah is sending messages

through the television. There appears to be some hostility at times, but the patient manages to

calm down. Previous lab work and assessment from previous physicians prove to be normal. She

is alert, dressed appropriately and does not show any signs of hallucinations yet does appear to

be listening to something. The patient does deny thoughts of harm to self or others. Lim et al.

(2021) inform the positive and negative syndrome scale (PANSS) is a widely used 30-item

clinician-rated instrument developed to provide comprehensive assessment of schizophrenia

psychopathology. The goal for this patient is to achieve a pharmacotherapy level that is less than

fifty percent in symptoms as demonstrated with the PANSS score within two months.

Decision One

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My first decision for this patient is to start her on Abilify 10mg orally at bedtime.

Lertxundi et al. (2021) explains Abilify was the first dopamine 2 receptor partial agonist among

antipsychotics and was approved by the food and drug administration (FDA) for the treatment of

schizophrenia in 2002 and later approved for bipolar disorder. I chose this route first because I

felt the patient would see results in symptoms as she suffers from psychotic episodes and the

medication is only once at bedtime. The patient has expressed noncompliance before with

medication as she was prescribed Risperdal in the past. The other two options were Zyprexa

10mg orally at bedtime and Invega Sustenna 234mg intramuscular (IM) once then 156mg

intramuscular on the fourth day and monthly thereafter. The reason I did not choose these two

different options was because Zyprexa has been known to cause weight gain and this patient is a

thirty-four-year-old woman, so weight is still a concern for her. Gautam et al. (2016) note of

patients receiving Zyprexa, 66% had a weight gain of one to five pounds over a four-week

period. For this reason, I would not recommend this first for my young female patient. The

reason I did not choose the intramuscular injection was I would try all oral medications before

giving a patient an IM injection. Injections should always be thought to give as a last resort only

because patients do not usually want to stick themselves every day and with the dosing of

Sustenna changing, for a patient who has already shown medication noncompliance, I would not

start her on this first. I was hoping to achieve a 50% decrease in symptoms as well as an

improved PANNS score. Ethical considerations would be to teach the patient and the husband

about all medication options and possible side effects as well as the frequency of them to see

what works for them allowing them autonomy.

Decision Two

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The client has returned for her four-week visit looking disheveled. When questioned the

patient’s husband explains that she is not sleeping and is up and down all night, disrupting his

sleep too. The patients PANSS score could not be completed as the patient continues to doze off

asleep at her appointment and the appointment is not a productive one to assess the patient. My

next decision is to discontinue the Abilify and start the patient on Geodon 40mg orally twice a

day with meals. I chose to do this because when the patients husband expresses how the sleep

habits have been, this is a side effect that is common with this medication and rather than

continue the stress on the patient and her spouse, it is still early enough to try another medication

without major effects from this medication will occur. The U.S. Food & Drug Administration

(n.d.) inform to call a healthcare provider right away when there are symptoms of insomnia. The

other two decisions included Abilify which is why I did not choose either due to the symptoms

expressed by the spouse and the patient’s inability to complete her four-week assessment. By

making this decision I was hoping to see actual improvement, even if in the slightest to know the

patient is experiencing improved symptoms with her medication. Ethical considerations would

be to continue to explain all medication options to the patient and inform the husband it is what

the patient is comfortable with as she is the one whose autonomy is of concern, not his. While I

want to help him with the patient, their marriage is separate from the patients individualized

treatment and the patient comes first. With switching to Geodon, the patient has returned with a

40% decrease in her PANSS score and improved symptoms. Her weight is also down but does

complain that it is hard to remember her second dose and at times she is missing her second

dose.

Decision Three

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I thought it best to change her Geodon dose to 80mg orally at bedtime while monitoring

for breakthrough symptoms throughout the day. American Psychiatric Association (2019)

informs the FDA has required that a warning about QT prolongation be included with product

labeling for Geodon. With this, I would constantly monitor this with the patient, and I chose to

continue the same medication and increasing the dose in order for the patient to take it once a

day so that she would not forget to take a second dose. The patient has also shown signs of

improvement so it would not be wise to just discontinue the medication when there can be

adjustments made and monitor for more improvement for the patient. The other two selections

were to discontinue Geodon and start Latuda and to give Risperdal. I would not choose to begin

the patient on a medication where she has history of non-compliance so I would try other routes

before going back to Risperdal, a medication she has not had compliance with. Miller et al.

(2020) informs accumulating evidence has implicated insulin resistance and inflammation in the

pathophysiology of cognitive impairments associated with neuropsychiatric disorders while on

certain medications including Latuda. For this reason, I did not choose to switch a medication

that is already showing improvement for the patient to another medication such as Latuda that

could cause different side effects for the patient. I was hoping to achieve more improvement of

symptoms while continuing Geodon, while also motivating the patient that continuing her

medication and taking all doses, now especially that there is just one dose so that she can also see

improvement in her treatment plan. Ethical considerations for this patient are to inform her of all

the options, while encouraging her to remain on her treatment plan.

Conclusion

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When continuing to check on this patient at her four-week visits, the goal is to see a 50%

decrease in her symptom shown by the PANSS score and her symptoms. I am confident in the

decision to continue the Geodon once at bedtime as this can encourage the patient to continue to

take her medication and not miss doses or not be compliant completely. I would continue to

monitor this patient, especially since there are risks of non-compliance, side effects such as

extrapyramidal, and GI issues. I would also continue speaking with the patient and evaluating her

PANSS score while also speaking with her family who attends her appointments with her. It is

important to note that while her spouse attends with her and appears supportive, the patient has

expressed negative feelings toward him and their marriage so taking this into considerations is

important. Switching the patients’ medications early in her treatment plan are ok, but when the

patient has been on the medication for longer than two months that is when we could possibly

see more negative side effects in this patient. Barnsteiner (2021) informs medication

reconciliation is a formal process for creating the most complete an accurate list possible of a

patient’s current medications and comparing the list to those in the patient record or medication

orders. For this reason, it is important to speak with the patient about current medications,

complete medication compliance, and what to look for once the medication Geodon is started.

Ethical considerations are important to consider these patients beliefs, thought process, religion,

and ethical background in order to find the best treatment plan for them. Speaking with the

family is also important to understand the patients support system and teach them what to look

for when they are home with the patient and when to call the physician.

References

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American Psychiatric Association. (2019). Practice guideline for the treatment of patients with

schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical

%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

Barnsteiner, J. (2021). Medication reconciliation. Patient Safety and Quality: An Evidence-Based

Handbook for Nurses.

Gautam, S., Jain, S., & Bhargava, M. (2016). Weight gain with olanzapine: Drug, gender or age?

Indian Journal of Psychiatry, 48(1), 39. https://doi.org/10.4103/0019-5545.31617

Lertxundi, U., Hernandez, R., Medrano, J. (2021). Aripiprazole: Features and use in the aged.

Assessments, Treatments and Modeling in Aging and Neurological Disease, 355-365.

https://doi.org/10.1016/B978-0-12-818000-6.00032-9

Lim, K., Peh, O.-H., Yang, Z., Rekhi, G., Rapisarda, A., See, Y.-M., Rashid, N. A., Ang, M.-S.,

Lee, S.-A., Sim, K., Huang, H., Lencz, T., Lee, J., & Lam, M. (2020). Large-scale

evaluation of the positive and negative syndrome scale (PANSS) symptom architecture in

schizophrenia. https://doi.org/10.1101/2020.08.10.20170662

Miller, B. J., Pikalov, A., Siu, C. O., Tocco, M., Tsai, J., Harvey, P. D., Newcomer, J. W., &

Loebel, A. (2020). Association of C-reactive protein and metabolic risk with cognitive

effects of lurasidone in patients with schizophrenia. Comprehensive Psychiatry, 102,

152195. https://doi.org/10.1016/j.comppsych.2020.152195

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs.

https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

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