Case #3
A young girl with strange behaviors

A young girl with strange behaviors

 

Decision Point One


 Schizotypal Personality Disorder
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:


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.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Add Fluphenazine Decanoate 12.5 mg every month
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.

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.

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.


Begin Sertraline 25 mg orally daily
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.

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.

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.


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.

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.

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.


Begin Olanzapine 5 mg orally at bedtime

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to the office, Carrie’s parents state that she is a little bit better in that she does not seem as preoccupied as she had been. They do notice that she has been tired more often.
  • They are also concerned that Carrie has gained 2 pounds in the last month.
  • Carrie tells you that she does feel tired, and asks you “what is this medicine supposed to be doing for me?” Carrie continues to acknowledge auditory hallucinations, but no longer thinks that she can control the minds of her friends. She still thinks that on occasion, television commercials were made just for her.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Increase Olanzapine to 10 mg orally at bedtime
Guidance to Student

If this truly were a personality disorder, there are no FDA-approved drugs to treat personality disorders, so Olanzapine would probably not be appropriate in the absence of significant behavioral issues. Because of the aforementioned information, psychodynamic psychotherapy would be the best choice. However, Carrie has schizophrenia and not schizotypal personality disorder. Therefore, although psychodynamic psychotherapy may help with residual symptoms, it is not a first-line treatment for schizophrenia.

Carrie’s delusional thought processes seem to be abating; however, Carrie is experiencing weight gain. Clearly, a weight gain of 2 pounds/month is not optimal. Therefore, a cross-titration to Lurasidone, which is purportedly more weight neutral, would be the most appropriate.

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.


Discontinue Olanzapine and begin psychodynamic psychotherapy
Guidance to Student

If this truly were a personality disorder, there are no FDA-approved drugs to treat personality disorders, so Olanzapine would probably not be appropriate in the absence of significant behavioral issues. Because of the aforementioned information, psychodynamic psychotherapy would be the best choice. However, Carrie has schizophrenia and not schizotypal personality disorder. Therefore, although psychodynamic psychotherapy may help with residual symptoms, it is not a first-line treatment for schizophrenia.

Carrie’s delusional thought processes seem to be abating; however, Carrie is experiencing weight gain. Clearly, a weight gain of 2 pounds/month is not optimal. Therefore, a cross-titration to Lurasidone, which is purportedly more weight neutral, would be the most appropriate.

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.


Change Carrie’s medication to Lurasidone 40 mg orally daily
Guidance to Student

If this truly were a personality disorder, there are no FDA-approved drugs to treat personality disorders, so Olanzapine would probably not be appropriate in the absence of significant behavioral issues. Because of the aforementioned information, psychodynamic psychotherapy would be the best choice. However, Carrie has schizophrenia and not schizotypal personality disorder. Therefore, although psychodynamic psychotherapy may help with residual symptoms, it is not a first-line treatment for schizophrenia.

Carrie’s delusional thought processes seem to be abating; however, Carrie is experiencing weight gain. Clearly, a weight gain of 2 pounds/month is not optimal. Therefore, a cross-titration to Lurasidone, which is purportedly more weight neutral, would be the most appropriate.

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.


Begin Haldol 2 mg orally every morning

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to your office, Carrie’s parents report that they stopped giving Carrie the medicine about 4 days after she started taking it. They explained that she would wake up, take the medicine, and be “falling over” by the time she was ready to leave for school. There have been no changes in Carrie’s symptoms.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Educate parents regarding the fact that the side-effects of Haldol are temporary and restart at 2 mg orally in the morning
Guidance to Student

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly. In this case, beginning at 2 mg daily in the morning was probably too much of a dose, and the dose should have been administered at bedtime. Restarting it in the morning at the same dosage will most likely result in the same side effects, and discontinuation by the family.

Although not FDA-approved for use in children, Lurasidone (Latuda) 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, thus making this the optimal choice in this scenario.

As a rule of thumb, medications should not be added to the regimen to overcome the side effects of another medication (with some limited exceptions). Therefore, augmentation with Armodafinil would not be appropriate.

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.


Begin Lurasidone 40 mg orally daily
Guidance to Student

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly. In this case, beginning at 2 mg daily in the morning was probably too much of a dose, and the dose should have been administered at bedtime. Restarting it in the morning at the same dosage will most likely result in the same side effects, and discontinuation by the family.

Although not FDA-approved for use in children, Lurasidone (Latuda) 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, thus making this the optimal choice in this scenario.

As a rule of thumb, medications should not be added to the regimen to overcome the side effects of another medication (with some limited exceptions). Therefore, augmentation with Armodafinil would not be appropriate.

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.


Augment with Armodafinil 150 mg orally daily
Guidance to Student

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly. In this case, beginning at 2 mg daily in the morning was probably too much of a dose, and the dose should have been administered at bedtime. Restarting it in the morning at the same dosage will most likely result in the same side effects, and discontinuation by the family.

Although not FDA-approved for use in children, Lurasidone (Latuda) 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, thus making this the optimal choice in this scenario.

As a rule of thumb, medications should not be added to the regimen to overcome the side effects of another medication (with some limited exceptions). Therefore, augmentation with Armodafinil would not be appropriate.

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.