Psychotic disorder 

Psychotic disorder: The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her when she was 9 years old). She presents following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.

Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control,” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.

During today’s assessment, she appears quite calm and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She says she knows this because the television is telling her so.

She currently weighs 140 lbs., and she is 5’ 5.


Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.

A review of her hospital records shows that she received a medical workup from a physician, who reported her to be in overall good health. Lab studies were all within normal limits.

Client admits that she was tolerating her Risperdal well but stopped taking about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.


The client is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and, at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect is constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.

You administer the PANSS which reveals the following scores:

-40 for the positive symptoms scale

-20 for the negative symptom scale

-60 for general psychopathology scale

Diagnosis: Schizophrenia, paranoid type


PANSS Scale. Available at:

§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. doi:10.1093/schbul/13.2.261

§ Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from

§ Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625–629. Retrieved from

Decision Point One

Select what you should do:

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME

Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

Link to Case study:

Week 7 Three Point Decision Point on Schizophrenia
Mental health experts have a general consensus that women’s mental health and well-being are closely linked to their socio-economic status. According to Thara & Kamath (2015) aver that equality and economic empowerment have a positive impact while discrimination affects them negatively. Many women with serious mental disorders do not have access to adequate treatment, particularly those who live in low-income countries or neighborhoods. One of these serious psychiatric disorders is schizophrenia whose impact on the life of women patients extends to caregivers and their family members as well.
Schizophrenia is defined by its characteristic manifestations is believed to emanate from the interaction of inherited genetic polymorphisms and exposure to stressors within the environment at critical points of an individual’s life. Effective treatment requires to be customized in ways that meet a patient’s specific needs mainly focusing on gender, age, personal preferences, state of health, and family situation to offer optimal therapeutic interventions. Key among these interventions revolve around the decision-making process on the most appropriate medication to prescribe and the drug dosing (Seeman, 2018). Consequently, this essay purposes to present a three-point decision-making tree on the most suitable medication to administer to a woman diagnosed with schizophrenia, paranoid type. To achieve the goal, the selected case study is of a 34-year-old Pakistani female who migrated to the US in her late teens and is currently in an arranged marriage. The patient presented to the clinic following a three-week hospitalization for a brief psychotic disorder after she was out of control. Before admission to the inpatient psychiatric facility, she had reported visions of Allah and her believing she was the Prophet Muhammad with a mission to save the world from sin.
The following sections outline the 3 –decision points and their rationale.
Decision #1(DP#1) the Treatment Options Available
At decision point 1 (DP#1), the three treatment options available are to either initiate Olanzapine 10 mg PO at bedtime daily. Alternatively, the patient could start Invega Sustenna (Paliperidone) 234 Intramuscular extended-release followed by 156 mg IM on the fourth day and thereafter on a monthly basis. The third option was to start Abilify (aripiprazole ) 10 mg PO at bedtime every day.
The Choice of Starting Zyprexa (Olanzapine 10 mg PO at bedtime) and the Reason Why
At DP#1, I chose to start Olanzapine 10 mg PO daily at bedtime. In one study, a total of 376 subjects were randomly assigned 6 different antipsychotic medications. 55 participants were randomly assigned olanzapine group, 63 to the risperidone group, 56 to the haloperidol group, 78 to the aripiprazole group, 62 to the quetiapine group, and 62 to the Ziprasidone group. After a three-year period, the overall dropout rate was about 21% while treatment discontinuation rates also differed with olanzapine having 69, risperidone 71, aripiprazole 73, Ziprasidone 79 haloperidol 89, and quetiapine 96%. In conclusion. Olanzapine presented advantages for first-line treatment of psychosis in terms of effectiveness. Suffice it to say that the identification of discontinuation patterns can enhance treatment optimization selection after the FEP.
Why the Other Two Options were not selected
Although injectable long-acting paliperidone antipsychotic tic can help address of drug nonadherence, it was rejected because the patient does not have issues with nonadherence yet it has been found to have crippling side effects. For example, according to Al- Mahrouqi et al. (2021) a 20-year-old woman with schizophrenia on once a monthly dosage of LAI paliperidone presented to the ED with tarchydia, difficulties in breathing and swallowing among other adverse effects. Upon discontinuation of the PP injections and taking a treatment course with procyclidine, she achieved full recovery within 7 days. A rule of thumb when prescribing psychoactive drugs to women of productive age is to administer doses lower than those recommended for men. Aripiprazole was also rejected because its administration has been found by some studies to trigger sudden psychotic worsening in patients with schizophrenia. Takase et al (2015) report that after collecting medical records of in/outpatients for patients diagnosed with schizophrenia over a six-year course (2006-2012) they determined that aripiprazole has to be discontinued due to worsening positive symptoms.
Treatment Goals at DP#1
The treatment goals at DP#1 were to alleviate the symptoms, prevent relapse and increase adaptive functioning to ensure the patient integrated back into the society within the shortest time possible. In a study where 124 psychiatrists availed data on about 1200 patients decrease in symptoms was ranked the most important patient treatment goal (Fitzgerald et al,, 2021). Ethical concerns to consider in the treatment of schizophrenia are defining the at-risk population, false postils, and the impact of interventions on the individual client. I would have to communicate with the patient on how to overcome the stigma and loss of independence associated with a schizophrenia diagnosis. I would also communicate with the patient on the type of intervention regarded to be the best.
Results of Decision Point One
The actual outcome of DP#1 is that the client returns to the clinic in four weeks with her PANSS score having decreased partially with a specific decrease in positive symptoms by a quarter(from -40 to -30). This implies that the negative symptoms scale remains unchanged at -20 and -60 for the general psychopathology scale. She further reports an increase of 5 pounds due to her constantly snacking throughout the day.
Decision #2 (DP#2) Treatment options Available
At DP#2, the treatment options were to decrease olanzapine to 7.5 mg PO daily, switch to a new medication Geodon (Ziprasidone) 40 mg PO BID with meals, or add Wellbutrin(bupropion ) XL 150mg PO in the morning.
Selection of Switching To Geodon (Ziprasidone) 40 Mg PO BID With Meals
I opted to switch to Ziprasidone40 mg BID taken with meals. In four head–to–head RCTs comparing Ziprasidone and olanzapine, the former had a better profile in terms of weight gain and lipid profiles (Grootens et al., 2011). In an 8-week, double-blind parallel-group randomized, controlled multicenter trial, the effectiveness of Ziprasidonr 80-160mg/d) and olanzapine 10-20 mg was measured using PANSS amongst other scales. The mean weight gain was found to be higher in the olanzapine group while Ziprasidone was linked to lower-level triglycerides, cholesterol, and transaminases.
Why the other options were not selected
Decreasing Olanzapine to 7.5 mg PO daily is rejected because the patient’s symptoms marginally improved only in the positive symptoms with the other two realms of negative symptoms scale and general psychological scales remaining unchanged. Grootens et al. (2011) further note that Olanzapine is linked to increased weight gain with a mean weight gain of6.8 versus 0.1 kg. Similarly adding bupropion 150 mg XL daily was rejected because bupropion increases the risk of seizures in schizophrenic patients. Schmintz et al. ( 2021) posit that Bupropion can induce risk at 0.4% of the recommended doses. As such it is always advisable to use agents that do not elevate the seizure threshold should be used if possible.
Treatment Goals at DP#2
The treatment goals at DP#2 include preserving the gains made during the acute treatment, preventing worsening of symptoms, improving psychosocial functioning, and improving the patient’s quality of life (de Bartolomeis et al., 2016). These researchers observe that specific goals and outcomes of interventions in schizophrenia should be guided by the phase and severity of the condition. In the acute phase, the goal is to alleviate the psychotic symptoms.
Ethical Considerations and Impact on Communications with Patients
Ethical considerations at DP#2 include informing the patient that schizophrenia has the potential to have a negative effect on the quality of life prior to reaching long-term goals of treatment. There is a need to measure functional disability in this patient depending on the severity of impairment in her everyday living skills. As the symptoms alleviate, the patient will understand that her husband is not out to marry an American woman as currently claims and neither is she receiving visions from the television.
Outcome Results of DP#2
The patient returns to the clinic in four weeks. She reports she has complied and adhered to the prescribed medication. There was a marked reduction of between 40 and 60 % for all the three types of symptoms as per the PANSS. The positive outcomes have improved by 60% the negative symptoms scale now reads -10 as opposed to the previous 20, while the general psychological scale improvement has improved from-60 from -36. The client reports she has not gained any weight and has actually decreased by 3 pounds.

Decision #3 (DP#3)
The treatment options available at DP#3 are to increase the dose from 80 to 160 daily Ziprasidone dose and educate the patient on diet/ weight loss, increased fourfold the dosage of the current medication to 320 mg PO, or switch to Clozapine 12.5 PO BID.
Selection of Current Medication/ Dose (Ziprasidone to 160 Mg Daily PO plus Patient Education on Diet/Weight
I chose to retain the current dose and drug at Ziprasidone 80 mg PO daily in the morning and evening because in an eight-week double-blind, place controlled trial Ziprasidone 160mg for 3 weeks was identified as optimal treatment. (Goff et al, 2013). Recent studies have also recommended the use of cognitive-behavioral therapy (CBT) as an adjunctive to antipsychotic therapy s it helps alleviate the positive symptoms. Kart et al. (2021) also note that CBT helps resolved delusions. Negative symptoms and positive symptoms as well.
Why the Other Options Were Rejected
Goff et al (2013) reports that upon conducting an 8-week placebo-controlled, fixed dose-escalation comparing Ziprasidone 160 versus 320 mg /d in schizophrenia patients there was no symptomatic improvement at the high dose of 320 mg/d compared to the standard 160mg/d. Likewise, clozapine 12.5 mg PO BID is rejected because of its burden on adverse effects, the need for regular blood works yet it is not more effective than other medications in FEP patients.
Treatment Goals at DP#3
While the primary goal of DP#1is to alleviate psychotic symptoms, DP# 3 overriding goal is to achieve the stabilization phase so that the treatment is consolidated and relapse minimized.

Ethical Considerations at DP#3
At all times the provider must ensure they have adhered to the fundamental ethical principles of respect for persons, autonomy, beneficence, fidelity, and non-maleficence. Other ethical points are veracity, justice, and integrity (Beck et al., 2020). Incorporating all these ethical principles means I should have effective communication with the patient and her family caregiver the husband on the choices available to her and ensure they fully understand all the necessary information. I should also reason with the patient on the benefits and consequences of the option taken and those foregone.

Psychotic disorder

This three-point decision-making tree on pharmacological management of schizophrenia has established that this disorder is a complex mental illness that significantly affects both patients and their families. Its defining characteristics are positive symptoms like delusions, hallucinations, and jumbled speech while negative symptoms are decreased motivation and social withdrawal. General psychological symptoms include cognitive impairment. To effectively resolve these symptoms, the provider uses antidepressants and atypical antipsychotics to alleviate the symptoms (Ballester et al., 2016). With the exception of clozapine, second-generation antipsychotics have demonstrated their efficacy in treating and managing this disorder. Each of the medications has its fair share of side effects but these differ with the type of drug in context. For example, Gentile (2017) reports that data on olanzapine long-acting injection increases the risk of hyperprolactinemia, metabolic disturbances, and the risk of psychosis.
In the case of Ziprasidone, Bouchete et al. (2020) opine that patients treated with this drug are at risk of developing neuroleptic malignant syndrome commonly manifesting as muscle rigidity and high fever and altered mental status. Since every other medication has its own side effects, the use of the selected medications in this patient’s case should happen under the guidance and care of an interprofessional medical team to determine the applicable dosing and titration schedules.

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