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.
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’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’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.”
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.”
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.
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.
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.
Case #3 A young girl with strange behaviors
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.
Decision Point Three
Begin Lurasidone 40mg 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.
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.
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.