INTRODUCTION
Clinical psychopharmacology has evolved over the past decade. The primary drive for its global adoption in the medical community stems from its unique objective of exploring the physiological influence of medications on the behavior of animals, and by extension humans. In addition, the number of psychopharmacological studies exploring the psychotropic nature of drugs and the possibilities of instituting the findings from these studies in primary care settings has doubled. This has birthed the emergence of a strong link between neurosciences and psychiatry, founded solidly on the biological knowledge of neuronal connectivity, neurotransmitter physiology, drug mechanism of action, neuronal circuitry, and psychotropic drug targets in the brain. Developing animal models of psychopathology and testing the new psychopharmacological inventions proved an invaluable tool for the medical community. More importantly, models like this have improved the general medical knowledge of the genetic, environmental, and pharmacological factors prompting characteristic symptomatic behaviors in patients with specific psychopathologies. Not only has this area of clinical intervention expanded medical care, it has also revolutionized how psychiatry can benefit from treatment regimens based on different psychotherapy options. Recently, the interest in psychopharmacology has shifted considerably to include an expanding frontier of new treatment models, conducting drug safety and compatibility studies, and designing ethical standards for psychopharmacology regimens. Case Study – Part I: Pedro’s Early Life Pedro started life like every other child in Monteiro, Brazil. He grew up playing beach soccer and idolizing famous soccer players with the grand dream of playing on the big stages someday. Born as the third male child in a family of seven, Pedro had the early luxuries of life: A bimonthly holiday in the countryside, a selection of the best Brazilian cuisines, and a close group of friends to play with. Everything that could be imagined started on the best note for Pedro. At an early age, he got enrolled in Montessori High, a public–private middle school available exclusively to Monteiro’s elite affluent families. In his early life, Pedro was shielded from social stressors and acute risk factors clinically implicated in the development of psychopathologies. However, it seems life had different plans. Once into his adolescent years, Pedro was a victim of a roadside robbery, an experience that would eventually begin a phase of trials and psychological crises in his life. Pedro was stabbed twice in the torso and robbed of all his valuables. He was admitted for a week at the municipal healthcare center and was discharged after his clinical symptoms had improved. However, Pedro wasn’t the young man he used to be - bubbling with life and always on a high social note. The incident scarred his memory, leaving him with several episodes of panic attacks and paranoia. For the rest of his adolescent years, he lived in perpetual fear of the unknown, became reclusive, and struggled with his grades. A few years later, Pedro was diagnosed with schizophrenia. He was started on separate trials of haloperidol, risperidone, and valproic acid. His response to the first-stage medication trials was erratic. On consultation, he was admitted to a regimen of fluphenazine decanoate, clozapine, lithium carbonate, benztropine, and trazodone. Pedro struggled to adhere to the medications and complained of different side effects. Maybe college would be different. At age 22 he headed off for college, leaving Monteiro behind to enroll in an Ivy League institution. In college, Pedro desperately struggled to leave his childhood crisis of paranoia and panic attacks. College life was different. Mixing and interacting with people from different parts of the world offered Pedro an unusual solace—a shelter he had desperately sought all his life. To become more integrated into the new life he found as an antidote to his early-life psychological crisis, Pedro fit effortlessly into this new
environment, attending college parties and becoming a member of a fraternity. In his third year of college, Pedro found a new savior, a faster way to deal with his recurrent flashbacks and “live in the moment.” The new savior was methamphetamine, a psychotropic substance available only to the affluent students. Case Study - Part II: Pedro’s Fling with Alcohol and Methamphetamine Getting involved with drugs and alcohol was easy for Pedro. He was a high-placed member of the college’s social circle. In this position, he commanded a huge reputation on the college campus. However, six months into his sojourn with drugs, tragedy struck. He overdosed on some drugs and was found unconscious in his room. He was subsequently rushed to the college clinic, where he was admitted to the emergency department. As he started to recover, Pedro was sluggish, weak, and incoherent, and he presented with an altered sense of place, people, and time. He was unable to follow through with simple commands and had a dampened response to painful stimuli. On physical evaluation, he had a fever of 38.7 °C (reference range 35.1 °C to 37.9 °C); tachycardia with a heart rate of 151 beats per minute (bpm; reference range 60 to 100 bpm); tachypnea with a respiratory rate of 32 breaths per minute (reference range 12 to 20 breaths per minute); blood pressure of 115/78 mmHg (reference range 90/60 to 130/80 mmHg); and hypoxemia with an oxygen saturation of 87% on room air (reference range 94%–100%). His laboratory workup indicated diabetic ketoacidosis (DKA), with glucose 1,700 mg/dL; anion gap 30 mmol/L (reference range 4 to 12 mmol/L); pH 7.04 (reference range 7.32 to 7.42); serum bicarbonate 6 mEq/L (reference range 20 to 24 mEq/L); beta-hydroxybutyrate 11.04 mmol/L (reference range 0 to 0.27 mmol/L); urine ketones, serum osmolality 407 mOsm/kg (reference range 280 to 300 mOsm/kg); and an elevated white blood cell count of 18.4 × 109/L (reference range 4.5 to 11.0 × 109/L). A computerized tomography (CT) scan of the head was negative for acute pathology. Imaging ruled out deep vein thrombosis, cardiac dysfunction, and stroke, but his CT chest scan was notable for bilateral lung infiltrates, which suggested aspiration pneumonia. Case Study - Part III: Pedro’s Clinical Evaluation O n psychiatric evaluation, a failed psychotropic regimen secondary to poor drug adherence was noted, and Pedro’s medications were withheld. His diagnosis was updated to diabetes complicated by DKA and poorly managed schizoaffective disorder. Despite the resolution of DKA on the third day of admission, Pedro remained altered and tachycardic. His clozapine, lithium, and benztropine regimen was restarted. The psychiatry team put Pedro on watchful observation and reserved IV haloperidol for agitation if needed. On the fifth day of admission, Pedro was transferred to the intensive care unit ICU with a fever (37.8 °C); tachycardia (120 bpm); tachypnea; withdrawal from painful stimuli; decreased reflexes; and muscle rigidity, including clenched jaw. The differential diagnosis drawn up by the ICU team included sepsis, meningitis, anoxic brain injury, and severe metabolic encephalopathy. He was subsequently started on an empirical antibiotic regimen that included ceftriaxone, vancomycin, and the antiviral acyclovir. On further examination, a lumber puncture ruled out the possibility of meningitis, and his antibiotic coverage was revised to only ampicillin-sulbactam. A magnetic resonance imaging (MRI) of the brain also ruled out acute stroke and anoxic brain injury, with an electroencephalogram (EEG) indicating no specific encephalopathy. However, a neurologic examination indicated flaccid paralysis and bilateral clonus. Combining observation from zero possibility of a central nervous system (CNS) infection and the subsequent evidence from the neurological examination, the psychiatry team reviewed Pedro’s differential diagnosis to include catatonia, serotonin syndrome, neuroleptic malignant syndrome, and autoimmune encephalitis.
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Book Code: PYFL4024
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