The media presentation for this assignment is a case of young Carrie a 13-year-old Hispanic girl who came to the clinical office accompanied by her mother and father after she was referred by her primary provider for unmanageable behavioral issues.The young female presented with symptoms irritable mood, auditory and visual hallucination, delusional, poor academic performance and impaired social function. This paper explains the three decision that includes an appropriate diagnosis that I will make for the Carries symptoms, the choice of the treatment plan and the ethical review impacting the treatment decision concerning my young Hispanic patient. Week 10 Assignment 2: Practicum: Decision Tree
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Decision Point # 1: Differential Diagnosis
Patient’s Diagnosis: Early Onset Schizophrenia
The background information presented in the case study with my assessment and interview conducted, are the bases of my decision with the diagnosis of Early Onset Schizophrenia (EOS).
My Rationale: Schizophrenia is a problematic neurodevelopment chronic psychiatric disorder besetting 1% of the population worldwide, even though the early age of the illness is uncommon (Vyas & Gogtay,2012). According to study, the EOS is analyze as onset before 18 years of age. The characteristic features of the disorder according to DSM-5 or International Classification of Diseases are hallucinations, delusions, disorganized speech, disorganized or catatonic behavior, and negative symptoms such as flat affect (McClellan & Stock, 2013). Based on the criteria outlined by the DSM-5, it identify that two or more of the attribute symptoms of the disorder that is hallucinations, delusions, disorganized speech, disorganized or catatonic behavior, and negative symptoms, must be occurring for at least 1 to 6 month (APA, 2013). Week 10 Assignment 2: Practicum: Decision Tree
Carrie was already acting out the manifestation of auditory and visual hallucination features since she is responding to internal stimuli: that is the object she described as partially cat and human friends that converse with her in her head. She is delusional with the believed that some people in the TV have a personalized command task mainly for her. Her academic work is poorly written, unable to socialize with her peers. These changes have been going on for more than a year; she has passed from one class session to another even though her Teacher felt she should have to repeat the previous class (Laureate Education Producer, 2017b). All these information align with the criteria for the diagnosis of EOS according to DSM- 5, it concludes my diagnosis decision.
My Expectation and Difference: At this stage my main concern how to make Carrie’s parent understand the diagnosis of their child and the fact that family history might play a part in this since her paternal grandfather was known to have schizophrenia (Laureate Education Producer, 2017b).
Decision Point # 2: Refer to Psychological Testing
My Rationale: I decided on taking this step even though am aware that no lab study is required to diagnose a patient of Schizophrenia, but the parameter for effective treatment depends on identifying underlying medical, psychiatric and psychosocial risk factors. Another thing is that the disease is not common in children and it is accessible to diagnosis in adolescent than in children, so I believed a careful assessment and evaluation that including a screening question for psychosis are needed before diagnosing the young girl with the disorder (McClellan & Stock, 2013). Refer Carrie to psychological testing will allow Psychiatric detail assessments which are more subjective, together with a thorough examination of all areas of development and functioning of her life even though she appears to have a healthy growth with girls of her age. The assessment tools that can be used are the Schedule for Affective Disorders and Schizophrenia, the Positive and Negative Symptom Scale and the Premorbid Adjustment Scale. The negative symptom scale result might show the severity of the deficit in Carrie executive functioning, that is her memory, reasoning, problem-solving and planning. Which might explain her poor performance in school (Bartlett, 2014). The symptoms presented in Carrie are similar to the one known with the disorder such as ADHD, bipolar, ODD. The testing result will help me rule out these other diseases. It will also help to validate the diagnosis of EOS in my patient while preventing a misdiagnosis (McClellan & Stock, 2013).
My Expectation and Differences: My goal is to have an in-depth understanding of the manifestation of all the symptoms presented in the young lady and the prognosis for better treatment. Also, I want to be able to prepared Carrie parents to accept the diagnosis of their daughter, educate them on what to expect and the treatment plan, get their consent to begin treatment. Week 10 Assignment 2: Practicum: Decision Tree
There was no differences of diagnosis, the psychologist confirm the diagnosis of EOS even though they used some other different testing tool from mine.
Decision Point # 3: Begin Lurasidone 40 mg Orally Daily
My Rationale: I choose to begin my treatment plan with medical treatment after the disorder has been confirming, parent consent and proper documentation at this stage with lurasidone 40 mg orally daily because it is the appropriate option. Even though clozapine one of the FDA approved for the treatment of EOS in children the dosage of 100mg is not safe for a child of Carrie age, and family psychotherapy intervention will not treat the psychosis symptom (Sadock, Sadock, & Ruiz, 2014, Vyas & Gogtay, 2012).Lurasidone 40 mg is a Neuroscience-based Nomenclature: dopamine, serotonin receptor antagonist (DS-RAn), a second-generation antipsychotic, serotonin-dopamine antagonist, approved and widely Prescribed for the treatment of Schizophrenia disorder in children ages 13 and older. It treats the positive and negative symptoms presented in patient living with the illness (Stahl, 2013). The patient can start feeling the reduction in their symptoms within one week of beginning treatment. The goal of treatment with the drug is that Carrie experience a decrease in the trait of constricted affect that is making her isolative to self, she will be able to socialize and interact with the classmate. It will reduce the psychosis feature of auditory and visual hallucinations and delusional thoughts since she endorses responding to internal stimuli. And her cognition can improve that will enhance her academic performance. I also included in my discussion with my patient parents that she will enjoy the full efficacy therapy of the drug regarding her cognition and behavior if she continues taking them for up six months or more as long as its beneficiary to her. I also educate them that since Lurasidone is metabolized by cytochrome P450 (CYP) 3A4 it will be safe for Carrie to always take medication with food (Greenberg & Citrome, 2017).
My Expectation and Difference: I expect that while my patient continues on the drug, she will experience improvement in cognition, her behavior, and daily outcome without experience the side effect that come with taking antipsychotic such as working around like “Zombie” as the parent fear (Laureate Education Producer, 2017b). The student guidance result support the used of Lurasidone as the preferred antipsychotic, because it was the one that have the minimal impact on body weight and lipid profile of patient. As a PMHNP it is always good to let the parent be aware of how medication work and the possible side effect of medication before they give their consent (Laureate Education Producer, 2017b).
The Ethical and Legal issue Relating to the Pharmacotherapy Treatment of a Children and Adolescent with Schizophrenia
The significance of Nurse Practitioner use extreme caution in assessing and diagnosing EOS cannot be overemphasized. At the same time, it will be a wrong and endangerment not diagnose and give appropriate treatment to a child who meets the diagnostic criteria of this disorder due to a personal reason or to satisfy the child-parent (Bartlett, 2014). If proper diagnosis and treatment do not start as early as possible it put these children at risk of self-medication leading to substance abuse, Cannabis use to mask the symptoms of mental disorder will the individual after that become psychosis (McClellan & Stock, 2013). Once a diagnosis has been established, over the years, Antipsychotics have always been the first treatment of choice for childhood-onset schizophrenia. But the concern here in the use of Lurasidone and majorities of the antipsychotics are the metabolic side effects since this issue are more pronounced in youth than adults. The provider is responsible for educating patient, and the parent on how to active administer the medication to prevent the side effect of medicine, for safety and better outcome (Giles & Martini, 2016). Week 10 Assignment 2: Practicum: Decision Tree
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There is a lots complexity surrounding the diagnosis of EOS, but the certainty is that Psychiatric must demonstrate the ability for safe practice. They need to ensure that all necessary assessment and evaluation is done to prevent misdiagnosis and not to overlook this disorder in any child for any reason. This is when they can help the child to live a life with full potential, it will help the family to the with the emotional burden that come with the mental disorder and it will help the society at large.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Bartlett, J. (2014). Childhood-onset schizophrenia: what do we know? Health Psychology and
Behavioral Medicine, 2(1), 735–747. http://doi.org/10.1080/21642850.2014.927738
Greenberg, W. M., & Citrome, L. (2017). Pharmacokinetics and pharmacodynamics of
lurasidone hydrochloride, a second-generation antipsychotic: A systematic
review of the published literature. Clinical Pharmacokinetics, 56(5), 493-503.
Giles, L. L., & Martini, D. R. (2016). Challenges and promises of pediatric psychopharmacology.
Academic Pediatrics, 16(6), 508-518.
Laureate Education (Producer). (2017b). A young girl with strange behaviors [Multimedia
file]. Baltimore, MD: Author.
McClellan, J., & Stock, S. (2013). Practice parameter for the assessment and treatment of
children and adolescents with schizophrenia. Journal of the American Academy of
Child and Adolescent Psychiatry, 52(9), 976-990. doi: 10.1016/j.jaac.2013.02.008
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Vyas, N. S., & Gogtay, N. (2012). Treatment of early onset schizophrenia: Recent trends,
challenges and future considerations. Frontiers in Psychiatry, 3, 29.
Stahl, S. M. (2013). Prescriber’s guide: Stahl’s essential psychopharmacology. Cambridge
Week 10 Assignment 2: Practicum: Decision Tree
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