Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study

Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study

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 is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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 is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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.” Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

 

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.
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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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.

Decision Point One
 Schizoaffective Disorder
Decision Point Two
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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.
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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

Decision Point One
 Schizotypal Personality Disorder
Decision Point Two
Begin cognitive behavioral therapy

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 enjoys being with her therapist because she is able to control her therapist’s mind, and makes her therapist “say whatever I want.” When assessed, Carrie continues to acknowledge auditory hallucinations and delusional thought processes are still apparent. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.
Decision Point Three
Reconsider diagnosis

Guidance to Student
Fluphenazine (Prolixin) Decanoate is not an appropriate choice as decanoate preparations should never be used until tolerability of the oral version of the drug has been established (you never want to give someone a depot drug that they are allergic to). Also, Prolixin and other first-generation antipsychotic drugs are generally considered to be second-line agents and should only be used after second-generation antipsychotics have been attempted/failed. Prolixin can also cause significant weight gain and alter lipid profiles significantly. Finally, if this truly were a personality disorder, there are no FDA-approved drugs to treat personality disorders, so Prolixin would probably not be appropriate in the absence of significant behavioral issues. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

Since this is neither a mood or anxiety disorder, Sertraline would be ineffective.

The most appropriate choice in this case is to reconsider the diagnosis. Although Carrie has several features that appear to approximate schizotypal personality disorder, the differences are important. For instance, she has delusions of reference, no ideas of reference. She also has more than “odd thinking or speech”—her written work demonstrated disorganized thought processes, much more severe than odd thinking or speech. She does lack close friends or confidants, but at this point, we have no way of knowing if it is because she has discomfort with interpersonal relationships or if it is because her classmates shun her due to her odd behaviors.

Finally, be cautious about making diagnoses of personality disorders in 13-year-old patients. During this time, personality is still forming. Schizotypal personality disorder may ultimately be what is wrong with Carrie, but we do not have enough information at this point. Personality disorders can be diagnosed in early adulthood. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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.

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/09/mm/decision_tree/index.html

 

Practicum: Decision Tree

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study 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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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? Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.
  • 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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.
    • 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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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. Carrie is a 13-year-old Hispanic female – A young girl with strange behaviors case study.

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