Case study for Week 4 (Woody)
Woody is a 30-year-old male who presents in your office with a history of psychosis starting at age 21. He started becoming psychotic and paranoid while living with roommates in college. He was noted to withdraw and worry about the government spying on him. He decided that he could only eat white foods like cottage cheese, frozen yogurt, and vanilla ice cream. His roommates noticed that he began talking to himself, started hiding from others, and quit going to class so they called his mom who took him to the hospital and began getting his treatment and moved home with his mom.
He was started on olanzapine and did well for two years, but it was discontinued. He was then changed to an SGA which made it painful and hard to keep his legs still. He trialed another Second Generation Antipsychotic next that was dosed high very quickly and he began to experience gynecomastia. Some mood stabilizers were trialed, but one caused tremors and he became toxic when dehydrated. He was then hospitalized for malnutrition after he stopped eating. He claimed that he was chosen, and it was time to fast for the month. While inpatient, he was treated for dehydration and given Haldol which was effective for his psychosis, and he was discharged in stable condition. He remained on Haldol for a year and was able to work at the local grocery until he became to display some severe EPS making it difficult for him to continue bagging groceries at the store.
After losing his job he began to start withdrawing and refusing his medication. He began to start hiding from the mailman every day thinking that the government was spying on him. He said that the military was whispering in his ear telling him to kill himself to protect the world. He attempted to hang himself with his bedsheet, but his mom walked in and saved him. He was immediately admitted to the hospital. He continued to have suicidal ideations and whispered so that the government could not hear him.
Answer each of the following questions about this case:
- What is your working diagnosis? What are 2-3 most likely differential diagnoses? Why would you consider each differential for this case?
- Which labs would you want to order and why? (Think about what organic causes of psychosis you would want to rule out)
- What are the 5 components of a suicide risk assessment that need to be asked each shift until he no longer is suicidal? (See PowerPoint/Kaltura from Module1).
- What additional resources could be helpful for this patient and his family?
General Questions related to this case and similar cases where antipsychotic and mood-stabilizing medications are prescribed:
- Both delusions and hallucinations are part of the constellation of symptoms of psychosis. How are they different?
- What are some organic conditions that may present with symptoms of psychosis?
- What side effects of antipsychotic medications could be so troublesome that they get in the way of normal everyday activities?
- Which SGA is most likely to cause gynecomastia and why? What questions would you ask your patient to assess for this side effect and what lab would you order for monitoring?
- What are the indications for prescribing a Long-Acting Injectable (LAI) antipsychotic? What must occur prior to starting an LAI?
- What mood-stabilizing medication is most likely to cause tremors and dehydration? What special monitoring does this medication require?
- What is the Clozapine REMS? What are the serious side effects of clozapine? Explain the requirements for prescribing and patient monitoring, and what changes would you make depending on the results.
- Do you agree that Clozapine should be reserved for patients who have failed multiple previous trials of antipsychotic medications?
- What are the special considerations for each of the following frequently prescribed Second-Generation Antipsychotics? (For example which one is most likely to cause gynecomastia, which has been associated with akathisia, which is more highly associated with the chance for prolonged QTC interval in which an EKG may be helpful for a baseline, which is more weight neutral, which is more sedating, etc)
- Quetiapine XR: (What would be the advantage of the XR formulation? Disadvantage?)