5. Discuss the role of second-generation antipsychotics in the treatment of schizophrenia.

PATIENT PRESENTATION

Chief Complaint

“I want to see my lawyer.”

HPI

This is the first inpatient admission for Anita Gonzalez, a 32-year-old Hispanic woman who was brought to the psychiatric hospital by the police.
Earlier today she was brought to the crisis center by a friend in her apartment building after the landlord threatened to call the police since Anita
was creating a disturbance. At the crisis center, Anita became increasingly agitated and suspicious; the police were called; however, she left
before being evaluated by staff. The patient apparently has been delusional and believes people sneak into her room at night when she is
asleep and place a thousand worms inside her body. She also believes that she is being raped by passing men on the street. She is quite
preoccupied about having massive wealth. She claims to have bought some gold and left it at the grocery store. She believes that her ideas
have been given to a Cuban communist who has had plastic surgery to look like her and is using her identification to take possession of all of
her property. She states that she is having difficulty getting her property back.

Apparently, the precipitating event today that eventually resulted in her hospitalization was that she created a disturbance at a local fast-food
restaurant, claiming that she owned it. Because of the disturbance, police were called, and she subsequently was sent here on an order of
protective custody. According to the patient, she bought a hamburger and sat down to eat it, and for some reason, somebody called the police
and charged her with illegal trespassing. She claims that 6 years ago she was raped by a relative of a sister and broke her hip in the process.
She states that her feet were cut off because she would not do what her impostors wanted her to do, and her feet were subsequently sent back
to her from Central America and were reattached.

Her speech is quite rambling. She speaks of having been part of an experiment in Monterey, Mexico, in which 38 eggs were taken from her
body, and children were produced from them and then killed by the government. She claims that she has worms in her that are the type that kill
dogs and horses and says that they have been put there by the government. She also claims that at one time she had transmitters in her
backbone and that it took 3 years to have them taken out by the government. She claims to have had surgery in the past, and the surgeon did
not know what he was doing and took out her gallbladder and put it in the intestines where it exploded. The patient also states that on one
occasion, a physician was removing the snakes from her abdominal cavity, and the snakes killed the doctor and a nurse. She also claims that
she worked as a surgeon herself before 1963.

Past Psychiatric History

Denies any prior hospitalization for mental health problems

PMH

Gallbladder surgery (cholecystectomy) 2 months ago

Hypertension × 2 years

No record of her ever being raped or having a broken hip is found.

No further medical history is known.

Family Psychiatric History

The patient claims that her alleged family is not really her family and that she is not sure who her family is.
SH

Divorced; heterosexual; lives in an apartment alone; employment history unknown

Denies any illicit drug or alcohol use. Smokes two packs of cigarettes per day.

Meds

Lisinopril 20 mg PO once daily

All

Penicillin (rash)

Mental Status Examination

The patient is a woman of Hispanic ethnicity, modestly dressed, with some disarray. She is morbidly obese. Her hair is black and unwashed.
She is alert, oriented, and in no acute distress. Her speech is clear, constant, and pressured, with many grandiose delusions and illogical
thoughts. She is quite rambling, going from one subject to the other without interruption. Her affect is mood-congruent, her mood is euphoric,
and there is a marked degree of grandiosity. Her thought processes are quite illogical, with markedly delusional thinking. There is no current
evidence of auditory hallucinations, and she denies visual hallucinations. She denies any suicidal or homicidal ideation, but she is quite verbal
and pressured in her thought content, verbalizing a great deal about the things that have been taken away from her illegally by people
impersonating her. She has marked delusional symptoms with paranoid ideation prominent. Her memory (immediate, recent, and remote) is
fair. Her cognition and concentration are adequate. Her intellectual functioning is within the average range. Insight and judgment are markedly
impaired.

ROS

Reports occasional GI upset; complains that worms are inside her stomach; otherwise negative

PE

VS

BP 140/85 mm Hg, P 80 bpm, RR 17, T 37.1°C; Wt 97 kg; Ht 5′3″

Skin

Scratches on both hands

HEENT

PERRLA; EOMI; fundi benign; throat and ears clear; TMs intact

Neck

Supple, no nodes; normal thyroid

Lungs

CTA & P
CV

RRR, normal S1 and S2

Abd

(+) BS, nontender

Ext

Full ROM, pulses 2+ bilaterally

Neuro

A&O × 3; reflexes symmetric; toes downgoing; normal gait; normal strength; sensation intact; CNs II–XII intact

Labs

Laboratory Values

Na 140 mEq/L Hgb 14.6 g/dL WBC 11.0 × AST 34 IU/L Ca 9.6 mg/dL
103/mm3

K 3.9 mEq/L Hct 45.7% Neutros 66% ALT 22 IU/L Phos 5.1 mg/dL

Cl 104 mEq/L RBC 4.7 × Lymphs 24% Alk phos 89 IU/L TSH 4.5 μIU/mL
106/mm3

CO2 22 mEq/L MCV 90.2 μm3 Monos 8% GGT 38 IU/L RPR negative

BUN 19 mg/dL MCH 31 pg Eos 1% T. bili 0.9 mg/dL Serum alcohol <10
mg/dL

SCr 1.1 mg/dL MCHC 34.5 g/dL Basos 1% Alb 3.6 g/dL Urine pregnancy (–)

Glu 100 mg/dL Plt 232 × 103/mm3 T. chol 208 mg/dL

Urinalysis Urine drug screen

Color yellow Amphetamines (–)

Appearance slightly cloudy Barbiturates (–)

Glucose (–) Benzodiazepines (–)

Bilirubin (–) Cannabinoids (–)

Ketones, trace Cocaine (–)

SG 1.025 Opiates (–)

Blood (–) PCP (–)

pH 6.0 Oxycodone (–)

Protein (–)

Nitrites (–)

Leukocyte esterase (–)

Antipsychotic Treatment Recommendations

RecommendationAPA 2004 PORT 2009 NICE 2014

(commentary
2009)

First episode SGA SGA SGA, FGA

(except (in com‐
clozapine bination with
and psychological
olanzapine), interventions)
FGA

Second episode SGA, FGA, SGA, FGA SGA, FGA

clozapine (only if an
SGA has
already been
tried)

FGA = first-generation antipsychotics, SGA = second-

generation antipsychotics.

Recommended Monitoring Parameters for Patients Receiving SGA

Parameter Baseline 4 weeks 8 weeks 12 weeks QuarterlyAnnually

Personal/family history X

Weight (BMI) X X X X X

Blood Pressure X X X

Fasting plasma glucose X X X

Fasting lipid profile X X X

Waist circumference X X

Tardive dyskinesia evaluation X X

Hematologic profilea X X

CV statusb X X

a
Desirable for all SGA but required for clozapine according to a strict monitoring protocol.

bECG if > 40 years or h/o CV disease.

Assessment

1. Schizophrenia, acute episode

2. Hypertension

3. Obesity

4. Tobacco use disorder

QUESTIONS

Collect Information

1.a. What subjective and objective information indicates the presence of an acute episode of schizophrenia?

1.b. What additional information is needed to fully assess this patient’s schizophrenia?

Assess the Information

2.a. Assess the severity of the acute episode of schizophrenia based on the subjective and objective information available.

2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness,
safety, and patient adherence.

Develop a Care Plan

3.a. What are the goals of pharmacotherapy in this case?

3.b. What nondrug therapies might be useful for this patient’s schizophrenia?

3.c. What feasible pharmacotherapeutic alternatives are available for treating schizophrenia?

3.d. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient. Include specific drugs,
dosage forms, doses, schedules, and durations of therapy.

3.e. What alternatives would be appropriate if the initial care plan fails or cannot be used?

Implement the Care Plan

4.a. What information should be provided to the patient to enhance medication adherence, ensure successful therapy, and minimize adverse
effects?

4.b. Describe how care should be coordinated with other healthcare providers.

Follow-up: Monitor and Evaluate

5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of desired therapeutic outcome and to
detect or prevent adverse effects?

5.b. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.