A Case Study On

Schizophrenia

In Partial Fulfillment in
the Course Requirement in
Psychiatric Nursing

Submitted to:
The Faculty of the
Cebu Doctors’ University
College of Nursing

Submitted by:

September 1 , 2007
 INTRODUCTION
Schizophrenia, from the Greek roots schizein ("to split") and phren ("mind"), is a
psychiatric diagnosis that describes a mental illness characterized by impairments in the
perception or expression of reality. It is considered the most common and disabling of the
psychotic disorders. Although it is a mental disorder, it stems from a physiological
malfunctioning of the brain. Schizophrenia causes distorted and bizarre thoughts,
perceptions, emotions, movements, and behavior. It cannot be defined as a single illness;
rather, thought of as a syndrome or disease process with many different varieties and
symptoms.
According to DSM-IV-TR (Diagnostic and Statistical Manual of Mental
Disorders, Fourth edition, Text Revision), residual type of schizophrenia is classified as
having an absence of prominent delusions, hallucinations, disorganized speech and
grossly disorganized or catatonic behavior. There is a continuing evidence of, in
attenuated form, the presence of negative symptoms or two or more symptoms;
characterized by at least one previous, though not a current, episode; social withdrawal,
flat affect and looseness of associations.
The prevalence of schizophrenia is estimated at about 1% of the total population.
In the United States, which translates to nearly 3 million people who are, have been, or
will be affected by the disease. The incidence and the lifetime prevalence are roughly the
same throughout the world. (Buchanan & Carpenter,2005).
The researcher chose the subject Ms. Vasquez, Stephanie, 20 years old from
Tagbilaran, for the case study because she is responsive; she seems calm and relaxed,
although she was quite shy and withdrawn at first. The subject is also manageable, easy
to talk to because she understands simple statements and instructions and answers most
of the questions that the researcher asked her.
The researcher’s expectation in conducting this case study is to be able to gain
more knowledge about schizophrenia, its underlying causative factors, predisposing and
precipitating factors, its development and corresponding treatment and approaches. Most
importantly, the researcher wants to know how to manage and provide nursing care for
individuals with socially ineffective behavioral patterns, particularly schizophrenia, and
to impart this significant learning to others.
 LEVEL OF GROWTH AND DEVELOPMENT

I. NORMAL DEVELOPMENT AT PARTICULAR STAGE

PSYCHOSOCIAL
Erikson’s Psychosocial Theory
•Young Adulthood (19-40 yrs. old) stage: Intimacy vs. Isolation
Major developmental task for this stage is forming adult, loving relationships and
meaningful attachment to others. The positive behavior or resolution of a conflict by a
young adult include the following: Establishes mature relationship with a member of the
opposite sex, chooses a suitable marital partner, and performs work and social roles in
socially acceptable manner. A negative behavior or unresolved task results in self-
imposed isolation, emotionally jealous and being possessive.
The young adult is usually caught between wanting to prolong the irresponsibility of
adolescence and wanting to assume adult commitments.

COGNITIVE
The formal operational period is the fourth and final of the periods of cognitive
development in Piaget's theory. This stage, which follows the Concrete Operational stage,
commences at around 11 years of age (puberty) and continues into adulthood. It is
characterized by acquisition of the ability to think abstractly, reason logically and draw
conclusions from the information available. During this stage the young adult is able to
understand such things as love, "shades of gray", logical proofs, and values.
Critical thinking habits increase steadily through the young and middle adult years.
Formal and informal educational experiences, general life experiences, and occupational
opportunities dramatically increase the individual’s conceptual, problem-solving, and
motor skills. Because young adults are continually evolving and adjusting to changes in
the home, workplace, and personal lives, their decision-making processes should be
flexible. More secure young adults are in their roles, the more flexible and open they are
to change. Insecure persons tend to be more rigid in making decisions.
MORAL
Theory of Moral Development (Kohlberg)
Level III. Post-Conventional (can occur from adolescence onwards)
The person finds a balance between basic human rights and obligations and societal rules
and regulations in this level. Individuals move away from moral decisions based on
authority or conformity to groups to define their own moral values and principles.
Individuals at this stage start to look at what an ideal society would be like.
Stage 5: Social Contract Orientation. An individual may follow the societal law but
recognizes the possibility of changing the law to improve society. The individual also
recognizes that different social groups may have different values but believes that all
rational people would agree on basic rights, such as liberty and life.
Stage 6: Universal Ethical Principle Orientation. This stage defines “right” by the
decision of conscience in accord with self-chosen ethical principles. These principles are
abstract, like the Golden Rule, and appeal to logical comprehensiveness, universality, and
consistency. For example, the principles of justice would require the individual to treat
everyone in an impartial manner, respecting the basic dignity of all people, and would
guide the individual to base decisions on an equal respect for all.

SPIRITUAL
They usually question the existence of God and any religious practices they have been
taught. This questioning is natural part of forming a sense of identity and establishing a
value system at a time in life when they draw away from their families.

SEXUAL
Because of increasing exposure to and acceptance of premarital sexual relation in society,
more younger adult than ever before engage in sexual intercourse. This is also the time
for them to deal with the realization they are gay or lesbian. Although this orientation is
something they have been aware of for years, actually facing it and accepting it is another
step.
Physical development is accompanied by the ability to perform sexual acts. The young
adult usually has emotional maturity to complement the physical ability and is therefore
able to develop mature sexual relationships and establish intimacy. Young adults who
have failed to achieve the developmental task of personal integration may develop
relationships that are superficial and stereotyped.

PATHOPHYSIOLOGY AND RATIONALE

Normal ANATOMY AND PHYSIOLOGY of organ or system affected.

Central Nervous System

The CNS is composed of the brain, the spinal cord, and associated nerves that control
voluntary acts. Structurally, the brain is divided into the cerebrum, cerebellum, brainstem
and limbic system.

Cerebrum
The cerebrum is divided into two hemispheres. The corpus callosum is a pathway
connecting the two hemispheres and coordinating their functions. The left hemisphere
controls the right side of the body and is, the center for logical reasoning and analytical
functions such as reading, writing, and mathematical tasks. The right hemisphere controls
the left side of the body and is the center for creative thinking, intuition and artistic
abilities. The cerebral hemispheres are divided into four lobes: frontal, parietal, temporal,
and occipital. The frontal lobes control the organization of thought. body movement,
memories, emotions and moral behavior. The integration of all this information regulates
arousal, focuses attention. and enables problem solving and decision making. The parietal
lobes interpret sensations of taste and touch and assist in spatial orientation. The temporal
lobes are centers for the senses of smell and hearing and for memory and emotional
expression. The occipital lobes assist in coordinating language generation and visual
interpretations, such as depth perception.

Cerebellum
The cerebellum is located below the cerebrum and is the center for coordination of
movements and postural adjustments. The cerebellum receives and integragrates
information from all areas of the body, such as the muscles, joints, organs, and other
components of the CNS.
Limbic System is an area of the brain located above the brain stem that includes the
thalamus, hypothalamus, hippocampus and amygdale. The thalamus regulates activity,
sensation, and emotion. The hypothalamus is involved in temperature regulation, appetite
control, endocrine function, sexual drive, and impulsive behavior associated with feelings
of anger, rage, or excitement.

Neurotransmitters
Neurotransmitters are the chemical substance manufactured in the neuron that aid in
the transmission of information throughout the body. They either excite or stimulate an
action in the cells (excitatory) or inhibit or stop an action (inhibitory).
These neurotransmitters fit into specific receptor cells embedded in the membrane
of the dendrite, just like a certain key shape fits into a lock. After neurotransmitters are
released into the synapse and relay the message to the receptor cells, they are either
transported back from the synapse to the axon to be stored for later use (reuptake) or are
metabolized oxidase (MAO).
Dopamine, a neurotransmitter located primarily in the brain stem, has been found to be
involved in the control of complex movements, motivation, cognition and regulation of
emotional responses. Serotonin, a neurotransmitter found only in the brain, is derived from
trytophan, a dietary amino acid. the function of serotonin is mostly inhibitory, and it is
involved in the control of food intake, sleep and wakefulness, temperature regulation, pain
control, sexual behavior and regulation of emotions.

PSYCHOPATHOLOGY

>Diagnostic Criteria for Schizophrenia

In the most recent study of the Diagnostic and Statistical Manual of Mental
Disorders, the American Psychiatric Association (APA) made minor changes in the
behavioral indicators that must be present to justify a diagnosis of schizophrenia.
Five types of schizophrenia are characterized by a set of predominant symptoms.
The types of schizophrenia are:
1.) Paranoid Type – is characterized by preoccupation with one or more delusions of
frequent auditory hallucinations and that specific behaviors suggestive of the disorganized
or catatonic type are absent.
2.) Disorganized Type- is characterized by a marked regression to primitive, disinhibited,
and unorganized behavior and by the absence of symptoms that meet the criteria for the
catatonic type.
3.) Catatonic Type- the classic feature of the catatonic type is marked disturbance in motor
function; this disturbance may involve stupor, negativism, rigidity, excitement or
posturing. Associated features include stereotypies, mannerisms, and waxy flexibility.
4.) Undifferentiated Type – frequently, patients who are clearly schizophrenic cannot be
easily fitted into one or another type. DSM-IV classifies these patients as having
schizophrenia of the undifferentiated type.
5.) Residual Type – characterized by the presence of continuing evidence of the
schizophrenic disturbance in the absence of a complete set of active symptoms or of
sufficient symptoms to meet the diagnosis of another type of schizophrenia.
Emotional blunting, social withdrawal, eccentric behavior, illogical thinking and mild
loosening of association commonly appear in the residual type.
The course of the illness varies from client to client, and thus the APA has specified five
courses of the illness:

1.) Subchronic - the time from the beginning of the disturbance, when the person first
began to show signs of the disturbance (including prodromal, active and residual phases)
more or less continuously, is less than two years, but at least six months.
2.) Chronic – same as Subchronic, but more than two years
3.) Subchronic with Acute Exacerbation – reemergence of prominent psychotic
symptoms in a person with a subchronic course who has been in the residual phase of the
disturbance
4.) Chronic with Acute Exacerbation – reemergence of prominent psychotic symptoms in
a person with a chronic course who has been in the residual phase of the disturbance
5.) In Remission – when a person with a history of schizophrenia is free of all signs of the
disturbance (whether or not on medication), “in remission” should be
coded. Differentiating “schizophrenia in remission” from no mental disorder requires
consideration of overall level of functioning, length of time since the last episode of
disturbance, total duration of the disturbance, and whether prophylactic treatment is being
given.

Other disorders are related to but distinguished from schizophrenia in terms of presenting
symptoms and the duration or magnitude of impairment. The DSM-IV-TR (APA, 2000)
categorizes these disorders as follows:

1.) Schizophreniform disorder – The client exhibits the symptoms of schizophrenia but for
less than 6 months necessary to meet the diagnostic criteria for schizophrenia.
2.) Schizoaffective disorder – The client exhibits the symptoms of psychosis and at the
same time all features of a mood disorder either depression or mania.
3.) Delusional disorder – The client has one or more non-bizarre delusions – that is, the
focus fo the delusion is believable.
4.) Brief psychotic disorder – The client experiences the sudden onset of at least one
psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior,
which last from 1 day to 1 month.
5.) Shared psychotic disorder – Two people share a similar delusion.

>Nature of the Behavioral Disorder

Schizophrenia usually is diagnosed in late adolescence or early adulthood. Rarely
does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for
men and 25 to 35 years of age for women.
The symptoms of schizophrenia are divided into two major categories: positive or
hard symptoms/signs, which include delusions, hallucinations, and grossly disorganized
thinking, speech, and behavior, and negative symptoms or soft symptoms/signs, which
include flat affect, lack of volition, and social withdrawal or discomfort.
Medications can control the positive symptoms, but frequently the negative
symptoms persist after positive symptoms have abated. The persistence of these negative
symptoms over time presents a major barrier to recovery and improved functioning in the
client’s daily life.

>Development of the Schizophrenic Process

 Onset may be abrupt or insidious, but most clients slowly and gradually develop
signs and symptoms such as social withdrawal, unusual behavior, and loss of interest in
school or work, and neglected hygiene.

The initial acute episode ordinarily finds friends and relatives observing in the
individual a progressive indifference to normal interests, a blunting of the emotions, and
a sullen, suspicious attitude. Odd and unpredictable behavior, silly postures, and
excessive preoccupation with trivial things are common symptoms. Attempts to bring the
person back to a normal concern and interest in what is going about him may produce
inappropriate laughter, a stolid indifference, or a sudden and unexpected outburst of
violence.

In general, schizophrenia means a serious disintegration of personality, because

the symptoms appear to develop from a fundamental defect in the basic personality
structure.
Over time, the disease become less disruptive to the person’s life and easier to
manage, but rarely can the client overcome the effects of many years of dysfunction. In
later life, these clients may live independently or in a structured family-type setting and
may succeed at jobs with stable expectations and a supportive work environment.

SCHEMA ON THE PSYCHOPATHOLOGY OF THE DISEASE

Premorbid Personality
-the patient is shy and usually alone
-as a child, patient had few friends and no close friends
-can no longer function well in occupational, social and personal activities

PREDISPOSING FACTORS PRECIPITATING FACTORS

>Psychosocial: .
Family Systems Theory: Dysfunctional Family System
Schizophrenia evolves out of dysfunctional The patient is not visited by her family
family system ever since she was admitted because she
has no relatives here in Cebu.
Interpersonal Theory:
Psychotic person is the product of a parent-
child or spouse relationship fraught with
intense anxiety
Psychodynamic Theory:
Psychosis is a result of a weak ego,
development of which has been inhibited
by a cold, overprotective, and domineering
mother or father, husband or wife, friends
or relatives.

Behavioral Changes
-patient has blunted affect, social withdrawal, history of delusion and hallucination

Coping Behavior
-patient sleep during stress, repression and suppression, denial

Nursing Intervention
Care guide of patient with disease condition
1.) Be sincere and honest when communicating with the client. Avoid vague or evasive
remarks.
2.) Be consistent in setting expectations, enforcing rules, and so forth.
3.) Do not make promises that you cannot keep.
4.) Encourage the client to talk with you, but do not pry for information.
5.) Explain procedures, and try to be sure the client understands the procedures before
carrying them out.
6.) Give positive feedback for the client’s successes.
7.) Recognize the client’s delusions as the client’s perception of the environment.
8.) Initially, do not argue with the client or try to convince the client the delusions are false
or unreal.
9.) Interact with the client on the basis of real things; do not dwell on the delusional
material.
10.) Engage the client in one-to-one activities at first, then activities in small groups, and
gradually activities in larger groups.
11.) Recognize and support the client’s accomplishments (projects completed,
responsibilities fulfilled, interactions initiated).
12.) Show empathy regarding the client’s feelings; reassure the client of your presence and
acceptance.
 EVALUATION AND IMPLICATIONS

The study of Schizophrenia will make available the importance of knowing its
valuable information so that a nurse will know the basic care needed for the applicable
cure to be effective. It must be complete in such a way that a patient will gain the
confidence and trust of the caregiver and vice versa, the caregiver will also be
comfortable and sure of herself in extending needed care for the patient.
The education and training must also be comprehensive that the physician will
know that the patient is really in good and capable hands after treatment. There is also
that continuing research or update of knowledge that a nurse must do to make her
competitive and well versed and in order to obtain the goals of the nursing practice and
education in the field of mental health.
• Nursing Practice:
This case study of chronic schizophrenia is intended as a basic text for the
undergraduate and as a reference for professional registered nurses who are practicing in
psychiatric nursing. This case study will also serve as a guide for nurses who are
interested in specializing into psychiatric nursing and for those people who is caring for a
client with a psychiatric diagnosis. The authors of this case study presented the client’s
critical information, psychiatric clinical setting, the nursing care process and health
teaching resources as well. This can increase everyone’s knowledge and understanding
on the said matters and the avenues of psychotherapeutic interventions.
• Nursing Education:
The goal of psychiatric nursing education is geared towards the attainment of
knowledge, attitudes and skills in psychiatric nursing care. This study of nursing care in
schizophrenia will further strengthen the student’s learning foundation in the field of
psychiatric nursing care.
• Nursing Research:
More ongoing research is necessary in the effectiveness of psychiatric nursing
interventions and the various treatments and therapies of the disease. This case study
combines psychodynamics, psychosocial and psychobiological interventions in the case
of a schizophrenic patient. This case study will in a way help as a research tool in
psychiatric mental health care.