Discussion Questions / Prompts:

Week 4: Grand Rounds Discussion: Complex Case Study Presentation

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Graduate Studies

Date:

At the end of the presentation, the audience will understand the objectives below.

Objectives for this presentation:

1. The audience will be able to summarize the defining characteristics of paranoid personality disorder as identified in the DSM 5 manual.

2. The audience will understand how to diagnose paranoid personality disorder accurately.

3. The audience will gain insight into possible pharmacological management of paranoid personality disorder

4. The audience will be able to identify nonpharmacological management of paranoid personality disorder.

Subjective:

CC (chief complaint): “ I suspect my neighbors want to hurt me”.

HPI: R.H is a 46-year-old African American female who presents for follow-up with a concern of feeling suspicious of her neighbors. She reported feelings of suspicion, which began when she was about 22 years old. She explained that she suspects her neighbor is conspiring to hurt her, but she cannot justify her suspicion. She explained that her neighbor insulted her, which led her to bear grudges toward her neighbor. This incident resulted in her paying her friend to have the windscreen of her neighbor's car shot. She reported that her friend took her money and did not shoot the neighbor's car windscreen resulting in her developing homicidal thoughts towards her friend. She narrated going to a psychiatric hospital for homicidal ideation towards the said friend and got hospitalized for two days. She reported explaining to the hospital that she was under the influence of drugs when she thought of having her neighbor's windscreen shot. The hospital then signed a duty to warn against her. She highlighted that after being discharged from the hospital, she was free of homicidal thoughts toward her friend and attempted to apologize to her neighbor for the intention to have her car windscreen shot. But her neighbor had a peace order issued against her.

She reported that she constantly grudges against people and is unforgiving of insults. She highlighted feeling afraid to confide in anyone to prevent such information from being maliciously used against her. She also reported another incident with a different friend who plans to ruin her reputation. She explained that this new friend deceived her into allowing her to walk with her dog, and afterward, the dog bit the friend. She said she doubts her friends and close associates as everyone seems to be plotting ways to indict her. She highlighted that her suspicions make her react very angrily in most situations causing recurrent fights and altercations. She reported feeling irritable and angry as she quickly reads meanings into people's remarks that she feels are designed to hurt her. She also highlighted her need for assistance to relocate from her present house to a different home to avoid her neighbors and friends. She also reported hearing voices that are non-commanding. She further explained that she does not think anything is wrong with her and does not take her medications every day. She is prescribed paroxetine 30mg p.o daily, buspirone 10mg p.o tid, prazosin 1mg nightly, and depakote 750 mg p.o daily.

Substance Current Use: The patient denies substance/ illicit drug current use.

Substance Use History: Previous marijuana (cannabis) use.

Previous Psychiatric Hospitalization: The patient reported one-time psychiatric hospitalization.

Family Psychiatric History/Substance Use: The patient reports autism (son) and denies family suicide attempts and substance use.

Medical History: seizure disorder, hypothyroidism.

Current Medications: paroxetine (paxil) 30mg p.o daily (depression), buspirone 10mg p.o tid ( anxiety), prazosin 1mg nightly (nightmares), 750 mg deparkote p.o daily (seizures / mood stabilization), Synthroid 50mcg p.o daily (hypothyroidism).

Medication Trial: Abilify 5mg p.o daily, risperidone 2mg p.o.daily.

Psychotherapy or Previous Psychiatric Diagnosis: The patient is non-compliance with individual psychotherapy. Previous psychiatric diagnoses include post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder.

Allergies: medication reaction, Abilify ( causes seizures per patient), risperidone (causes rashes).

Reproductive Hx: heterosexual (sexually active), denies pregnancy and lactation.

Social History: The patient was raised in Maryland by her mother. She is single, unemployed, and lives in Maryland with her nine-year-old autistic son. She has one elder sister. Her highest level of education is a high school diploma. She reported childhood sexual and emotional abuse and multiple legal histories.

ROS:

GENERAL: patient appears anxious, with no complaints of weight loss.

HEENT: No complaints of visual loss or double vision. Ears, Nose, Throat: No complaints of hearing loss, sneezing, congestion, and sore throat.

SKIN: No complaints of rashes or itching on the skin.

CARDIOVASCULAR: No complain of chest pain, and palpitations.

RESPIRATORY: No complaints of shortness of breath and cough.

GASTROINTESTINAL: Patient reported feeling a little nauseous.

GENITOURINARY: No complaints of burning on urination or urgency.

NEUROLOGICAL: The patient reports slight headache, but denied syncope and recent seizures.

MUSCULOSKELETAL: No complaints of muscle pain, and joint pain.

HEMATOLOGIC: Denies complaint of anemia, and bruising.

LYMPHATICS: No complaints of enlarged nodes.

ENDOCRINOLOGIC: The patient denies sweating, cold, polyuria, or polydipsia.

Objective:

Diagnostic results: Review of patient's labs revealed.,

Urine Drug Screening (UDS): Normal.

Comprehensive metabolic panel (CMP): Normal.

Complete Bood Count (CBC): Normal

Liver Function Test: Normal.

Thyroid Function Test: Normal.

Ammonia Level: Normal. Performed to assess the possibility of hepatic encephalopathy.

Alcohol Level: Normal.

Deparkote (Valproic acid) Level: 20mcg/ml. This indicates medication noncompliance.

Pregnancy Test: Negative.

Assessment:

Mental Status Examination:

R.H is a 46-year-old African American female who appeared appropriately dressed. She was calm, attentive and intermittently avoided eye contact. She did not reveal signs of psychomotor retardation but had a crying episode during the interview. The speech was coherent, fluent, and normal in rate, rhythm, and articulation. Language skills were average. The mood was depressed, affect was anxious and irritable. Orientation to self, place and time was accurate. She was appropriately oriented to the right time, place, and person. Her thought process was normal, with no signs of delusions. The patient showed some lack of insight into her present condition and impaired judgment. Her recent and remote memory were slightly impaired. She reported hearing noncommanding auditory hallucination sometimes but denied visual hallucination, self harm, suicidal and homicidal thoughts.

Diagnostic Impression:

Paranoid Personality Disorder: 301.0 (F60.0)- Primary Diagnosis

Paranoid Personality disorder is associated with a pattern of enormous distrust and suspicion towards people, which results in impairment in the misinterpretation of others' intentions causing violent and criminal behaviors (Doustkam etal., 2017). Paranoid personality is known to begin in early childhood, and the patient confirmed her symptoms started when she was about 22 years old. Symptoms linked with this disorder include suspecting people of harm without enough evidence, unjustified doubts of trustworthiness and reliability of companions, reading frightening meanings into friendly comments, and always bearing grudges towards other people, difficulty confiding in others due to the fear of the information being spitefully used and the perception that attacks are directed to their character or reputation that are not directed towards others and quick anger. The patient reported all the above symptoms which led to my selecting paranoid personality disorder as my primary disorder.

Borderline Personality Disorder: 301.83 (F60.3)

A borderline personality disorder is linked with an extensive pattern of unpredictable interpersonal relationships, self-image, and affect with noticeable impulsivity, which begins in early adulthood ( American Psychiatric Association, 2013). Symptoms of borderline personality disorder include averting thoughts of abandonment, constant feelings of emptiness, unstable interpersonal relationship with intense idealization and devaluation, identity disturbance, repeated suicidal behaviors or threats, affective instability such as intense anxiety or irritability lasting for some hours, disproportionate excessive / consistent anger causing frequent fights and short-term stress-related paranoid ideations. I choose borderline personality disorder as a differential diagnosis due to symptoms of anger and the onset of early adulthood like paranoid personality disorder. But the patient did not report other symptoms of borderline personality disorder. Therefore the symptoms presented by this patient do not meet the full criteria to make borderline personality disorder my primary diagnosis. Borderline personality disorder is a psychological disorder characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image ( Miller etal., 2022).

Delusional Disorder Persecutory Type: 297.1 (F22)

Delusional disorder is characterized by one or more delusions occurring within 1 month or more ( American Psychiatric Association, 2013). Symptoms of Persecutory delusional disorder include the belief that there is a conspiracy against the individual, feelings of being cheated, spied upon, spitefully maligned or followed. People with persecutory delusion are usually infuriated, angry and violent towards the individuals they believe may be hurting them. This individual reported conspiracy thoughts, suspicion of harm, and quick/uncontrolled anger, which caused fights that began when she was 22. The individual deliberately engaged in the altercations because there was no evidence of delusion to justify the diagnosis of a persecutory delusional disorder. Delusional ideations may evolve from personality disorders, with paranoid traits and paranoid personality disorder being the strongest predictor of delusional severity (Tonna etal., 2018).

Reflections:

R.H is a 46-year-old African American female who reports feelings of suspicion towards her neighbors. This patient said that her anger and distrust has caused several fights. She also reported noncompliance to her medications and intermittent non commanding auditory hallucinations.

Firstly, obtaining the patient's consent and right to confidentiality of care is essential. Furthermore, educating the patient and her family on medication compliance; involving her family members (mother and sister) with her consent in her care will help remind her to take her medications and adhere to the treatment plan. Non-adherence to psychotropic medications can result in increased illness, reduced treatment effectiveness, re-hospitalization, poor quality of life, relapse of symptoms, increased co-morbid medical conditions, and suicide attempts (Semahegn etal., 2020).

Due to previous medication allergies, the patient was encouraged to undergo gene testing to dictate which medication would be most effective for her. Starting the patient on Haldol ( first-generation antipsychotic) 5mg p.o to target auditory hallucination as the patient is allergic to abilify, and risperidone (second-generation antipsychotic) will enhance management of this patient. Since I cannot follow up with this patient, I will plan to switch to Haloperidol decanoate IM if the patient tolerates Haldol p.o over time to encourage medication compliance.

Educating the patient on the need for cognitive behavioral therapy is vital to help change dysfunctional thoughts, beliefs, and negative behaviors and aid appropriate thinking patterns, behavior, and mood adjustment. Cognitive-behavioral therapy (CBT) assists individuals in removing avoidant and safety-seeking behaviors that hinder self-correction of faulty beliefs, reduce stress-related disorders and enhance mental health (Nakao etal.,2021).

Based on the patient's low socioeconomic status and History of marijuana use, the patient was educated against associating with individuals and events that cause drug use. This is because drug use increases impaired judgment and hinders the treatment plan. Substance use has been shown to impact the ongoing stagnation of life expectancy in the United States, which is more evident in lower socioeconomic strata than higher socioeconomic strata (Rehm & Probst, 2018).

Case Formulation and Treatment Plan:

Continue paroxetine (paxil) 30mg p.o daily (depression), buspirone 10mg p.o tid (anxiety), prazosin 1mg p.o nightly (nightmares), 750 mg deparkote p.o daily (seizures / mood stabilization).

Start Haldol 5mg p.o daily for psychotic symptoms. The patient is allergic to abilify, and risperidone. The patient is willing to be compliant with Haldol 5mg p.o daily.

The benefit of the medication was reviewed with the patient. Possible side effects / life-threatening side effects of Haldol and her other prescribed medications were reviewed with the patient. Side effects of Haldol include akathisia, tardive dyskinesia, sedation, dizziness, dry mouth, hypotension, neuroleptic malignant syndrome.

The patient was educated against suddenly stopping the medications without professional advice from the provider. The patient was made aware to contact the office immediately with any questions or proceed to the ER with life-threatening side effects. The patient verbalized understanding. The patient was advised to avoid over the counter drugs, illicit drugs without seeking professional advise.

Initiation:

Start Haldol 5mg p.o daily for psychotic symptoms.

Referral:

Therapist: Recommend individual cognitive-behavioral therapy.

Social worker: to determine if the patient qualifies for Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) to encourage adherence to the medications and plan of care, assist with better coping skills, and provide resources to enhance better living.

Alternative Therapy :

Mindfulness Meditation: helps reduce stress, depression, anxiety, and feelings of paranoia.

Art therapy: helps to serve as a source of distraction from disturbing or paranoid thoughts.

Health Promotion: I reviewed medical /psychiatric histories with the patient and educated the patient on the need for medication compliance to prevent decompensation, possible seizure activity, and life-threatening symptoms which may lead to inpatient hospitalization. The patient was also encouraged to set phone reminders to promote medication compliance. I enlightened the patient to give about 4 – 6 weeks to experience the maximum effect of the medications.

· Encouraged the patient to engage in physical activities/exercise to improve mood, sense of control, coping ability, and overall self-esteem.

· Encouraged the patient to eat a balanced diet and sleep hygiene such as consistent sleep time and avoiding noise at bedtime.

· Abstinence from marijuana or any illicit drug use and social events that will encourage use.

· The patient was encouraged to contract to safety to call 911, or the Baltimore Crisis Line at 410 433 5175 with active self-harm, suicidal and/or homicidal thoughts.

Phone calls: Called mother and sister to encourage patient's medication compliance.

Time spent: about 15 minutes was set aside for the patient for questions and answers.

Labs reviewed include: CMP, CBC, UDS, Pregnancy, Liver function test, thyroid function test, alcohol level, and ammonia.

Order placed: Gene testing to identify which medication will be most effective for the patient.

Return to clinic: in 1 week.

To evaluate the patient's response to new medication, Haldol 5mg p.o daily, medication compliance, and attitude towards the treatment plan/recommendations.

Suppose the patient continues to comply with Haldol 5mg p.o daily and can tolerate the drug over time. The plan will be to switch Haldol p.o to Haloperidol decanoate IM ( 10 – 20 times the p.o dosage), following all relevant safety protocols to manage this patient and further ensure medication compliance.

Discussion Questions / Prompts:

1. Identify other ways to encourage medication compliance in a patient with a paranoid personality disorder.

2. Identify other alternative therapies that will be beneficial in managing an individual with a paranoid personality disorder.

3. Identify one other type of psychotherapy that will effectively manage paranoid personality disorder.

References

American Psychiatric Association. (2013). Personality disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, V: Author.

American Psychiatric Association. (2013). Delusional Disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, V: Author.

Doustkam,M., Pourheidari, S., Mansouri, A. (2017). Interpretation bias towards vague faces in individuals with paranoid personality disorder traits. Journal of Fundamentals of Mental Health, 19(6), 441–450. https://doi.org/10.22038/jfmh.2017.9550

Mendez-Miller, M., Naccarato, J., Radico, J. (2022). Borderline Personality Disorder. American Family Physician, 105(2), 156–161.

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w

Rehm, J., Probst, C. (2018). Decreases of life expectancy despite decreases in non- communicable disease mortality: The role of substance use and socioeconomic status. European Addiction Research, 24(2), 53–59. https://doi.org/10.1159/000488328

Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020). Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Systematic Reviews, 9(1), 1–18. https://doi.org/10.1186/s13643-020-1274-3

Tonna, M., Paglia, F., Ottoni, R., Ossola, P., De Panfilis, C., Marchesi, C. (2018). Delusional disorder: The role of personality and emotions on delusional ideation. Comprehensive Psychiatry, 85, 78–83. https://doi.org/10.1016/j.comppsych.2018.07.002