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Question:

Choose one of the following cases. From your perspective as their psychiatric nurse practitioner, answer the following questions in a two- to three-page double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.

Write a summary statement about the case presentation, including potential DSM-5 diagnoses.
Is there a screening tool for this diagnosis? Would it be appropriate for this patient? If available online, include a link to the tool.
What assessment questions would you ask them to identify their eating disorders, triggers, and current coping skills?
What medication changes would you recommend, including doses and administration times? What precautions and interactions would you educate the patient about when prescribing your recommended medications or changes in medication?
Explain any other health professional referrals that would be significant in your patient’s treatment plan.

Transcript:

I’m so glad you could meet with us today. I’m Dylan, Jill’s father. We’re concerned about this odd habit she’s picked up lately. She’s been eating broken pieces of brick, little pebbles off the ground, and hand soap. So, we watch her carefully outside and try to make sure she doesn’t have access to bricks or little rocks. In the house, she’d just chew on the bar soap at the bathroom sink. We switched all the bar soap to liquid. But she still finds ways to eat this stuff maybe four or five times a week. We can’t watch her all the time, you know. She managed to chip away at a loose brick in the garden—I just can’t take down the whole retaining wall, can I?

We’ve noticed she becomes more anxious at night around bedtime and most notably by the weekend. Her main symptoms are restlessness, clenched jaws, and tense shoulders. Her teachers report that she’s on track with her IEP and has not had behavioral disturbances at school. Her teachers tell us that her anxiety is obvious by the end of each school day.

Before this appointment, her pediatrician ruled out organic causes and completed laboratory tests; additional blood serum iron, serum zinc, hemoglobin, stool, and urine tests showed unremarkable results. There has been no exposure to lead, so there is no test regarding lead concentration in her blood.

Jill’s Lab Results
Test Normal Levels Patient Test Result
Serum ferritin ng/ml 10–55 9
Serum zinc ug/10 ml 66–194 50
Hemoglobin g/dl Above 11.5 11.5
Calcium mf/dl 7.6–10.8 8.3

Answer:

Case Study on Eating Disorders

Eating disorders are popular across all age groups. In the case of Jill, his father is concerned about his odd habit of eating non-food items such as bricks, little pebbles, and hand soap. In addition, Jill becomes anxious at night around bedtime and presents other symptoms, including restlessness, tense shoulders, and clenched jaws. From a psychiatric nurse practitioner perspective and based on the DSM-5 diagnosis, Jill’s persistent and compulsive eating of non-food and non-nutritious items shows he has pica.

Screening Tool

According to Chansky et al. (2017), there is no validated screening tool or questionnaire for pica. Instead, a care provider relies on a patient’s clinical history to make a diagnosis. Usually, a provider will conduct a thorough medical history and interview close family members to obtain a clear picture of the situation. Here, McNaughten et al. (2017) suggest seeking information about the type of non-food items consumed, amount, duration of exposure, setting of occurrence, source of the substance, and any symptoms of toxicity. Additionally, a care provider should conduct a physical examination, although it is normal in most cases. However, it is important to identify any signs of poisoning or other underlying medical conditions such as dental, gastrointestinal, parasitic infestation, and toxic ingestion manifestations.

Laboratory tests are necessary for the evaluation of pica. However, no specific laboratory test exists to evaluate the presence of pica. In such situations, care providers conduct laboratory tests to determine the condition's impact based on the nature of non-food items consumed and the presenting medical condition. Any clinical findings and the specific ingested items will influence any further medical investigations. According to the American Academy of Pediatrics (2017), children living in areas where at least 27% of building existed before 1950 should receive regular screening for blood lead concentrations. In addition, if a care provider suspects that a child has ingested specific objects or presents with signs of gastrointestinal obstruction, then abdominal x-ray, upper GI endoscopy, and upper and lower GI barium examinations are critical.

Assessment Questions

As a psychiatric nurse practitioner, I would ask certain questions to identify any eating orders, triggers, and current coping skills. For eating disorders in children, I would rely on the pica tool kit for primary care providers that suggest asking parents questions such as;

  1. Does the child search the environment for items to place in the mouth? 

  2. Does your child hold non-edible items in the mouth? 

For current coping skills, I would ask questions such as; 

  1. How are you ensuring that your child does not consume non-food items? and, 

  2. Is your child under constant supervision at home and in school, or mostly alone? 

When evaluating for specific triggers, I would ask questions such as

  1. Does your child have cravings for a specific type of item?

  2. Is the eating of non-food items persistent at school or home?

  3. Is your child under stress or anxiety at home and school, and 

  4. Does your child eat a healthy balanced meal?

Medication

There exists no suggestion that Jill is under any medication, but he is under an individualized education plan (IEP). For his treatment, psychosocial and pharmacological interventions are necessary. The most effective psychosocial interventions include helping distinguish between edible and non-edible items, sensory reinforcement, self-protection devices that prohibit placing non-edible items in the mouth, and antecedent manipulation (Rajput et al., 2020). There are no specific or specifically approved medications on pharmacological interventions to treat pica (Al Nasser & Alsaad, 2018). However, anecdotal reports on antipsychotic use show that they help alleviate pica behaviors. In a study by Dobryakova (2015), pica leads to reduced dopaminergic neurotransmission, making drugs that enhance dopaminergic functioning useful. Some studies have suggested using olanzapine (antipsychotic agent) dosed from 2.5 to 20mg/day orally due to its serotoninergic, dopaminergic, adrenergic, and cholinergic effects (Fremaux et al., 2007). Others have suggested using medications such as Zyprexa, a medication ordinarily used among schizophrenia patients.

Precautions and Interactions

I would educate the parents on the impact of prescribing medications to treat pica. Firstly, I would let them know that despite the effectiveness of pharmacological interventions for pica, medications have serious side effects such as constipation and a condition called reaction with eosinophilia and systematic symptoms (DRESS) such as rash, hives, shortness of breath, and swelling of lips and tongue (Al Nasser & Alsaad, 2018). Secondly, I would inform the parents that pharmacological treatment is important but not a modality of choice since behavioral and psychosocial interventions alone offer a favorable outcome.

Health Professional Referrals

Treatment of pica requires an interprofessional team approach. The team should consist of a physician, psychiatrist/psychologist, behavioral therapist, social worker, and dietician (Al Nasser & Alsaad, 2018). Given Jill’s case presentation and considering that pica exists with other mental health disorders, I would refer Jill to a mental health specialist to understand what other conditions may be present and the best way to manage the symptoms. In his case, it is clear that Jill has another underlying mental health characterized by increased anxiety, restlessness, clenched jaws, and tense shoulders. In addition, although health professionals have implicated many factors in the etiology of pica, there is a lack of direct causality, which makes it important to refer Jill to a behavioral therapist to determine whether certain factors at home or in school could be the cause of his condition.

 

 

 

 

References

Al Nasser, Y., & Alsaad, A. J. (2018). Pica. https://www.ncbi.nlm.nih.gov/books/NBK532242/

American Academy of Pediatrics. (2017). Council on environmental health. Prevention of Childhood Lead Toxicity. Pediatrics. 2016; 38 (1): e20161493. Pediatrics, 140(2).

Chansky, M. C., King, M. R., Bialkowski, W., Bryant, B. J., Kiss, J. E., D'Andrea, P., ... & Mast, A. E. (2017). Qualitative assessment of pica experienced by frequent blood donors. Transfusion, 57(4), 946-951. https://doi.org/10.3389/fneur.2015.00052

Dobryakova, E., Genova, H. M., DeLuca, J., & Wylie, G. R. (2015). The dopamine imbalance hypothesis of fatigue in multiple sclerosis and other neurological disorders. Frontiers in neurology, 6, 52. https://doi.org/10.3389/fneur.2015.00052

Fremaux, T., Reymann, J. M., Chevreuil, C., & Bentue-Ferrer, D. (2007). Prescription de l’olanzapine chez l’enfant et l’adolescent. L'encephale, 33(2), 188-196. https://doi.org/10.1016/s0013-7006(07)91549-3

McNaughten, Ben, Thomas Bourke, and Andrew Thompson. "Fifteen-minute consultation: the child with pica." Archives of Disease in Childhood-Education and Practice 102.5 (2017): 226-229. https://doi.org/10.1136/archdischild-2016-312121

Rajput, N., Kumar, K., & Moudgil, K. (2020). Pica An Eating Disorder: An Overview. Pharmacophore, 11(4).