Childhood psychosis is extremely rare

Childhood psychosis is extremely rare; however, children that present with psychosis must be carefully assessed and evaluated with appropriate interviewing of parent, child, and use of assessment tools.

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with early onset schizophrenia.

Learning Objectives
Students will:

Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
The Assignment:

Examine Case 3: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

Decision #1: Differential Diagnosis
Which Decision did you select?
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Running Head: Decision Tree 1

2

Decision Tree

Additional diagnostic tests that I would perform is a urine toxicology screen and possible imaging (CT/MRI). Before making a diagnosis, I would want to be confident in my decisions in making the diagnosis.

Decision # 1

From reviewing Case # 3 “A young girl with strange behaviors, I would Carrie, the client in the case study, the diagnosis of early onset schizophrenia. I give this diagnosis based upon symptoms that the client presents with. Carrie admits to hearing and seeing things. She states that the voices do not scare her and that “they come to see her from another world.” She presents with delusional thoughts, for example the television programs are played just for her. She, also, appears to have a constricted affect and provides minimal eye contact throughout the clinical interview.

Decision # 2

First, and possibly the most important step in the new diagnosis of any mental health disorder, is to set up psychotherapy for the client. Prescribing medication may be inevitable, but medications can only provide so much relief for the client. The client must attend counseling so she can work on any negative thinking she may have and distinguish what is real and what isn’t. Therapy should also involve family so they will be prepared to handle different situations and how to control any future strange behaviors.

Decision # 3

For decision three, I would choice to start the client Lurasidone 40 mg orally, also known as Latuda. This medication has been FDA-approved for use in children. Latuda is an atypical antipsychotic with high binding affinity for D2, 5-HTt2A, and 5-HT7 receptors (Goldman, 2017). In a placebo-controlled, short-term study, patients of the adolescent population were given 40 to 80 mg every day (Goldman, 2017). With this study the adolescent patients showed significant symptom improvements. Another important fact to consider when prescribing Latuda is that the client’s body weight and labs (lipids) should be monitored during treatment (Laureate, 2017). One important fact to inform clients and family when taking Latuda, the client should have a minimum of 350 calories with medication.

Ethical Considerations

There are a number of ethical considerations when treating clients with schizophrenia. In this case study I would explain the pros/cons of treatment with the parents involved. This should be one of the practitioner’s main concerns so the parents know enough about the treatment plan so they can make an informed consent.

Reference

American Nurses Association. (2014). Psychiatriic-mental health nursing: Scope and standards

of practiice (2nd ed.). Washingtton, DC: Author.

Golldman, R., Loebel, A., Cucchiarro, J., Deng, L, & Fiindling, R. (August 2017). Effiicacy

and Safety of Lurasiidone in Adollescents with Schiizophrenia: A 6-Week, Randomiized

Placebeo-Controlled Sttudy. Retrieved from https://www.cnbi.mllm.niih.gov/pmc/-

artiicles/PMC345569878017/.

Hall, S., & Beean, R. (2008). Familly Therapy and Chiildhood-Onset Schiizophrenia: Pursuing

Clinical and Bio/Psycho/Social Competence. Retrieved from htttps://link. Springer.com/-

article/10.1007/s10591-008-9061-7.

Laureatte Education (Producer). (2017b). A young girll with strange behaviors [Multiimedia

file]. Balltimore, MD: Autthor.

Sadock, B. J., Sadock, V. A., & Ruiiz, P. (2014). Kaplan & Sadock’s synopsiis of psychiiatry:

Behaviorall sciiences/cliinical psychiattry (11th ed.). Phiiladelphia, PA: Wolters Kluwer.

BACKGROUND

Carrie is a 13-year-old Hispanic female who is brought to your office today by her mother and father. They report that they were referred to you by their primary care provider after seeking her advice because Carrie’s behavior has been difficult to manage and they don’t know what to do.

SUBJECTIVE

Carrie’s parents report that they have concerns about her behavior, which they describe as sometimes “not normal for a 13-year-old.” They notice that she talks to people who aren’t real. Her behavior is calm and “passive.” Her parents noted that when she was younger, she was irritable at times, but have noticed that this has given way to passivity. Her parents state that they understand that it’s normal for younger children to have “imaginary friends,” but they feel that at Carrie’s age, she should have grown out of these behaviors. Carrie’s parents report that she has friends that are half-cat and half-human, and “spirits” who speak with her “in her head.” She also reports that the people on television know when she is home and that they have certain shows “just for her.”

Carrie’s parents report that they have taken her to her pediatrician who has given her a “clean bill of health.” Carrie’s parents note that they had some early concerns as she was lagging in meeting developmental milestones. Initially, when she first started school, Carrie managed to keep up with her peers in terms of academic performance, but she was noticed by her teachers to be isolative. It was also noted by her teachers and guidance counselor that Carrie’s social skills do not seem to match what they see in other children her age. Initially the school counselor suspected that Carrie may have been suffering from attention deficit hyperactivity disorder (primarily inattentive type), but now is not certain and has recommended a psychiatric evaluation. Her grades were “ok” in school up until last year when she left junior high school, and entered high school, where the academic demands began to increase. Carrie’s teachers had wanted to hold her back a grade, but her parents acknowledge that they were “insistent” that this did not happen. Now they are describing some regrets over this as Carrie seems “more lost than ever” in her schoolwork. Carrie’s mother produced a copy of a paper that Carrie had to submit as a homework assignment. You attempt to read the assignment, but there does not appear to be any clarity to the work, and it can best be described as a hodge-podge of thoughts and ideas.

Carrie’s parents want you to know that although they are concerned about Carrie, they are opposed to giving her medications that would turn her “into a zombie.” Carrie’s mother also confides that her husband’s grandfather spent “a few years in the nut house.” When you probe further, she began crying and said, “He was schizophrenic … what if Carrie is schizophrenic?”

During your interview with Carrie, she seems pleasant, but somewhat distant. When you ask her about her friends at school, she shrugs her shoulders and says, “I don’t really have any. I don’t like those people.” You inquire if she is sad or upset that she doesn’t like them, to which she states “no, why should I be? I guess they would be friends with me if I asked, but I’m not interested. I could make them be my friends if I wanted, but I don’t … but if I wanted them to, all that I have to do is make up my mind that they will be my friend and they would have to.” When you ask Carrie if she believes that she can control the thoughts of others with her mind, she puts her index finger up to her mouth and looks toward the door. “My mom gets upset when I talk about these things. I try not to think about them either because if she is close enough, she could read my thoughts and they upset her. She may think that I’m into witchcraft or something.”

When you ask Carrie about the homework assignment that you read, she explains that her teacher “is just miserable. She doesn’t understand how I think—I think high, she just can’t get it.”

OBJECTIVE

The client is a 13-year-old Hispanic female client who appears appropriately developed for her age. She is dressed appropriately for the current weather, and ambulates with a steady upright gait. She does not appear to be demonstrating any noteworthy mannerisms, gestures, or tics. No psychomotor agitation/retardation apparent.

MENTAL STATUS EXAM

Carries is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Carrie self-reports her mood as “good.” However, her affect does appear somewhat constricted. Her eye contact is minimal throughout the clinical interview and at times, Carrie seems preoccupied. Carrie is oriented to person, place, and time. She endorses hearing and seeing strange “things that I talk to. They don’t scare me; they come to see me from another world.” No overt paranoia is appreciated. She does report delusions of reference (she believes that the people on TV play programs “just for her” and at times, television commercials were designed to tell her what to do), as well as other delusional thoughts (as described above). Carrie denies any suicidal or homicidal ideation.

At this point, please discuss any additional diagnostic tests you would perform on Carrie.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO CARRIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Early Onset Schizophrenia

Schizoaffective Disorder

Schizotypal Personality Disorder

Decision Point One

Early Onset Schizophrenia

Decision Point Two

Refer for psychological testing

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Although there are no specific psychometric tests available for schizophrenia, the consulting psychologist administered a comprehensive psychological battery of tests in order to assess personality and cognitive functioning as well as to identify any underlying intellectual disabilities that could account for the difficulty Carrie is having in school. Tests administered included the Minnesota Multiphasic Personality Inventory; Kaufman Adolescent and Adult Intelligence Test; Rorschach test; Whitaker Index of Schizophrenic Thinking (WIST) test; Wide Range Achievement Test – 4th Edition (WRAT-4); and the Millon Adolescent Clinical Inventory (MACI). The consulting psychologist opined that early-onset schizophrenia was strongly suspected in this client.

Begin Celexa 20 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Decision Point Three

Increase Lurasidone to 60 mg orally daily

Guidance to Student

At this point, it should be noted that based on the initial presenting symptoms, Carrie’s condition is more consistent with schizophrenia. In order for schizoaffective disorder to be present, in addition to the psychotic features, the patient must meet the criteria for a mood disorder (depression or mania) concurrent with criterion A of schizophrenia. Nothing in the case description leads us to believe that Carrie is experiencing such a mood disorder.

This outcome is an excellent example of how at times, even with the lack of diagnostic clarity, psychotropic medications can serendipitously effectively treat a client’s condition. Clearly, Lurasidone is improving Carrie’s positive symptoms. Carrie seems to be having no side effects, which is another bonus. Although Lurasidone is not FDA-approved to treat schizophrenia in adolescents, it does not mean that the drug is unable to be prescribed, it means that the PMHNP must be certain to provide parents with a detailed explanation of risks versus benefits and obtain true informed consent. Since Carrie is experiencing a significant improvement in positive symptoms, the PMHNP could increase to 60 mg daily. It should be noted that it can take several weeks before full efficacy to be noted; therefore, maintaining the current dose is also an option.

Since Carrie does not have schizoaffective disorder, the addition of a selective serotonin reuptake inhibitor would be inappropriate.

Augmentation with psychotherapy to address residual symptoms would be useful, and while that can be started concurrently, the PMHNP should optimize the Lurasidone dose to treat positive symptoms.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Upon return to the office, Carrie’s parents state that she is no different than she was when she was last in your office. Carrie reports that she feels a little bit more “relaxed.” When assessed, Carrie continues to acknowledge auditory hallucinations and delusional thought processes.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Begin Clozapine 100 mg orally daily

Begin family interventions

Begin Lurasidone 40 mg orally daily

Decision Point Two

Begin Latuda 40 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Upon return to your office, Carrie’s parents report that Carrie appears less preoccupied. Carrie reports that she has felt “tired,” but no longer reports the ability to make people be her friend by mental force. She continues to report auditory hallucinations and no longer believes that some television shows are shown just for her, to which she says “no, I guess that was kind of silly of me to think, wasn’t it?”

Decision Point Three

Begin Clozapine 100 mg orally daily

Guidance to Student

It is not always necessary to procure a consult with a psychologist. However, psychologists by virtue of their advanced training and licensure are able to conduct comprehensive psychological testing on clients more advanced than those tests that could be conducted by the psychiatric/mental health nurse practitioner. In this case, we would like to know if the poor academic performance was the result of an intellectual disability, versus poor premorbid intellectual functioning that is often seen in schizophrenia.

In terms of treatment decisions, Clozapine is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). Clozapine 100 mg would most likely cause significant side effects that both the child and parents would find objectionable, thus making compliance an issue.

Although not FDA-approved for use in children, Lurasidone is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. Therefore, Lurasidone would be the best choice. Additionally, Lurasidone may be the preferred antipsychotic, as it appears to have the least impact on body weight and lipid profile.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Family interventions are important as well, as they do have a positive benefit on symptom relapse and admission/readmission to the hospital. Family interventions should include teaching about the disease, medications, and anticipatory guidance.

Begin Celexa 20 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Upon return to the office, Carrie’s parents state that she is no different than she was when she was last in your office. Carrie reports that she feels a little bit more “relaxed.” When assessed, Carrie continues to acknowledge auditory hallucinations and delusional thought processes.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Celexa to 40 mg orally daily

Add Seroquel 25 mg orally at bedtime

Reconsider Diagnosis

Decision Point Three

Increase Celexa to 40 mg orally daily

Guidance to Student

At this point, it should be noted that based on the initial presenting symptoms, Carrie’s condition is more consistent with schizophrenia. In order for schizoaffective disorder to be present, in addition to the psychotic features, the patient must meet the criteria for a mood disorder (depression or mania) concurrent with criterion A of schizophrenia. Nothing in the case description leads us to believe that Carrie is experiencing such a mood disorder.

Because of the diagnosis, increasing Celexa would be of minimal therapeutic benefit.

Based on the correct diagnosis of schizophrenia, Seroquel would be appropriate, as it is FDA-approved for treatment of schizophrenia in individuals aged 13 years and older, but not in addition to Celexa.

In this case, reconsideration of the diagnosis would be the most appropriate course of action.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Decision Point Two

Begin Risperdal 0.5 mg orally twice a day

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Upon return to your office, Carrie’s parents report that Carrie appears less preoccupied. Carrie reports that she has felt “tired,” but no longer reports the ability to make people be her friend by mental force. She continues to report auditory hallucinations and still believes that some television shows are shown just for her.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Risperdal to 1 mg orally twice a day

Add Paxil 10 mg orally daily to current regimen

Augment with psychotherapy

Decision Point Three

Add Paxil 10 mg orally daily to current regimen

Guidance to Student

At this point, it should be noted that based on the initial presenting symptoms, Carrie’s condition is more consistent with schizophrenia. In order for schizoaffective disorder to be present, in addition to the psychotic features, the patient must meet the criteria for a mood disorder (depression or mania) concurrent with criterion A of schizophrenia. Nothing in the case description leads us to believe that Carrie is experiencing such a mood disorder.

This outcome is an excellent example of how at times, even with the lack of diagnostic clarity, psychotropic medications can serendipitously effectively treat a client’s condition. Clearly, Risperdal is beginning to work in terms of resolution of psychotic symptoms, and a dose increase would be most appropriate. Carrie is feeling more “tired,” but this is most likely a consequence of Risperdal. The PMHNP should evaluate the tiredness to determine whether or not it is negatively impacting Carrie and if not, uptitrate the dose.

Since Carrie does not have schizoaffective disorder, the addition of a selective serotonin reuptake inhibitor would be inappropriate.

Augmentation with psychotherapy to address residual symptoms would be useful, and while that can be started concurrently, the PMHNP should optimize the Risperdal dose to treat positive symptoms.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Decision Point Three

Add Seroquel 25 mg orally at bedtime

Guidance to Student

At this point, it should be noted that based on the initial presenting symptoms, Carrie’s condition is more consistent with schizophrenia. In order for schizoaffective disorder to be present, in addition to the psychotic features, the patient must meet the criteria for a mood disorder (depression or mania) concurrent with criterion A of schizophrenia. Nothing in the case description leads us to believe that Carrie is experiencing such a mood disorder.

Because of the diagnosis, increasing Celexa would be of minimal therapeutic benefit.

Based on the correct diagnosis of schizophrenia, Seroquel would be appropriate, as it is FDA-approved for treatment of schizophrenia in individuals aged 13 years and older, but not in addition to Celexa.

In this case, reconsideration of the diagnosis would be the most appropriate course of action.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Decision Point Three

Augment with Armodafinil 150 mg orally daily

Guidance to Student

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly. In this case, beginning at 2 mg daily in the morning was probably too much of a dose, and the dose should have been administered at bedtime. Restarting it in the morning at the same dosage will most likely result in the same side effects, and discontinuation by the family.

Although not FDA-approved for use in children, Lurasidone (Latuda) is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label.” However, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. Therefore, Lurasidone would be the best choice. Additionally, Lurasidone may be the preferred antipsychotic as it appears to have the least impact on body weight and lipid profile, thus making this the optimal choice in this scenario.

As a rule of thumb, medications should not be added to the regimen to overcome the side effects of another medication (with some limited exceptions). Therefore, augmentation with Armodafinil would not be appropriate.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Tympanic Membrane And Thyroid Gland