W4 Psychosis Case Study
Post#1 Psychosis Case Study by Edina Boros
This week's discussion will focus on a 21-year-old university student, who has been experiencing some disturbing symptoms suggesting psychosis. The discussion post will answer the questions regarding the assessment and treatment of Andy.
Identification of target symptoms/problems
1. What information, if any, would you like to know that was not included in the case?
- Family history of mental illness
- Any drug use around the time the symptoms first started
- Change in activities, assessing for anhedonia and avolition
- Change in grades
- Change in sleeping habits
- Any medication or food allergies
2. Which psychiatric symptoms are a treatment priority for this case?
Paranoia, auditory hallucinations, and persecutory delusions can all lead to situations when the patient is a safety risk to himself or others around him. Andy already has a knife and a baseball bat in his room, which he doesn’t intend to use. Still, these can be used as weapons causing bodily harm or even death if he feels threatened or his auditory hallucinations turn command in nature.
3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?
The American Psychiatric Association recommends a coordinated approach for patients diagnosed with schizophrenia, especially when they experience their first episode of psychosis. Their recommendation includes psychoeducation, Cognitive behavioral therapy (CBT). The proposals include employment services, family involvement in the treatment plan, and addressing social skills(Keepers et al., 2020). Andy is already showing signs of isolation, but thankfully he has his family to support him.
Another critical aspect of the case is addressing the physical side effects of antipsychotic medications. An intervention proposed early in the treatment should prevent possible weight gain due to antipsychotic regimens by lifestyle changes (Vancampfort et al., 2019).
In some cases, the medication does not completely eliminate auditory hallucinations. Using psychotherapy such as Cognitive Behavioral Therapy (CBT) can be a beneficial addition to treatment (Pandarakalam, 2016).
Medication Choice 1
4. List one medication that would be appropriate for this case. Include the name and starting dose.
Risperdal 1 mg twice a day. May increase dose by 1-2 mg a day after more than 24 hours. The recommended maximum dose is 4-6 mg/day. More than 6 mg daily dose have a higher risk for Extrapyramidal symptoms (EPS) without proven benefits (Puzantian & Carlat,
2016).
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 on which the medication is proposed to act on.
Andy experiences many positive symptoms of psychosis. Risperidone is an inexpensive first-line antipsychotic medication approved for schizophrenia. It is an atypical antipsychotic medication addressing the positive symptoms Andy experiencing with a moderate risk for weight gain and dyslipidemia. Risperidone is a dopamine (D2) and serotonin (5HT2A) receptor, antagonist. It is metabolized by the enzyme CYP2D6 (Puzantian & Carlat, 2016). Risperidone targets the mesolimbic and mesocortical pathways by inhibiting the D2 and 5HT2A receptors (DrugBankOnline, 2021).
6. What laboratory testing/monitoring is needed for safely prescribing this medication?
Monitoring weight gain and waist circumference are recommended for most atypical antipsychotics. Documenting the baseline measurements and monitoring periodically throughout the medication regimen is advised. Ordering fasting lipid levels at the beginning of treatment and monitoring after three months and then annually can alert the provider to the development of dyslipidemia. Monitoring blood glucose levels is recommended. Risperidone might cause elevated prolactin levels. Monitoring for symptoms is recommended (Haverkampf, 2016).
7. Are there any contraindications or safety issues associated with this medication?
Contraindications are known hypersensitivity to risperidone or its metabolite, paliperidone (McNeil et al., 2021).
References
Haverkampf, J. (2016). Recommended Monitoring for Atypical Antipsychotics.
Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., ... & (Systematic Review). (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-872.
McNeil, S. E. (2021, August 9). Risperidone. StatPearls [Internet]. Retrieved September 24, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459313/.
Pandarakalam, J. P. (2016). Pharmacological and non-pharmacological interventions for persistent auditory hallucinations in schizophrenia. Br J Med Pract, 9, a914.
Puzantian, T. & Carlat, D. (2016). Medication Fact Book for Psychiatric Practice (3rd Ed.). Newburport, MA: Carlat Publishing.
Risperidone. Uses, Interactions, Mechanism of Action | DrugBank Online. (2021, September 19). Retrieved September 24, 2021, from https://go.drugbank.com/drugs/DB00734.
Vancampfort, D., Firth, J., Correll, C. U., Solmi, M., Siskind, D., De Hert, M., ... & Stubbs, B. (2019). The impact of pharmacological and non‐pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta‐review of meta‐analyses of randomized controlled trials. World Psychiatry, 18(1), 53-66.