3

PREDISPOSING FACTORS
FAMILY SYSTEM THEORY
FST is a theory introduced by Dr. Murray
Brown that suggests that individuals cannot be
understood in isolation from one another, but rather
as a part of their family, as the family is an emotional
unit. Families are systems of interconnected and
interdependent individuals, none of whom can be
understood in isolation from the system.
The patient is under a strict family since she is
only the child in the family

She is dependent from the decision of her
parents. Given the fact that she is the only
child in the family and that her parents are
still the one who decides for her up to her
adult years, she might failed to achieve sense
of autonomy.

She experienced great frustrations when her
choice of place to practice her profession was
not accepted by her family. Her family was the
one who decided where she should work

Her parents are both busy in their work, her
father is a business man and her mother is a
teacher
PSYCHOPATHOLOGY

PSYCHOLOGICAL THEORY
Erikson's Psychosocial Development
Erikson believed that when a person reaches the age between 19 to 40 years old, the major conflict centers on forming
intimate, loving relationships with other people. For him, it is vital that people develop close, committed relationships with
other people because success in this stage leads to strong relationships, while failure results in loneliness and isolation.
So far, our client was not able to achieve the virtue of love during her current stage since at her age, this theory
proposes that she should have already achieved marital bond with a male partner.

Moreover, she kept on mentioning about her fixed marriage to an imaginary Spaniard which she believes was
planned by the "group of people" she says is controlling her. Significant other verbalized that she had a deep
admiration to her foreign-looking first-degree cousin whom she wants to get married with, but the man does not like
the client. She has not formed intimate relationships with other people probably because she had a poor sense of self
which had not developed from the prior stage of psychosocial development. (identity vs. confusion stage)
Sullivan's Interpersonal Theory
Sullivan emphasized that interpersonal socialization of human beings throughout their developmental stages. The mother
may be believed to be anxious, overprotective, or cold, and unfeeling; while the father was distant or overbearing. Some
theories described how a "schizophrenogenic" mother and other theories described how communicating in double messages
could "double blind" a person into developing schizophrenia.
The client is the only child in the family and both parents are protective to their only daughter. Interpersonal
relationship of the patient was focused on her mother, father, classmates, and friends. Significant other verbalized
that parents are strict towards the outgoings of the client.


SOCIO-CULTURAL & ENVIRONMENTAL THEORY
Social Model
Some theorists proposed that poverty, society, and cultural disharmony could cause
schizophrenia or that people chose to become schizophrenic to cope with the insanity of the
modern world. Others proposed that schizophrenia was caused by living in the city or living in
isolation in the country. Although accumulated stress related to sociocultural and environmental
factors is likely to be a contributing factor to the onset of schizophrenia and to relapses,
neurobiological findings point to other causes for the etiology of psychotic disorders.
The patient came from a middle class family. She was able to study college in a University
and finished a course in Psychology. She has not experienced significant or tremendous
societal conflicts nor cultural disharmony that we could look into as related to her
disorder. However, one factor is that she is withdrawn from society since she has no
friends until her college years

The client was able to graduate a psychology degree in college and was able to pass the
Philippine Board Exam for Teachers

She was not also abusing any substance.

She was unemployed since she graduated college.







Genetic
Studies have identified that certain genetic factors
may be involved in the development of a psychotic disorder.
Results have shown that individuals are at higher risk for the
disorder if there is familial pattern of involvement (parents,
siblings and other relatives)
The patients genetic predisposition is unknown. She
did not report anyone from her family that has a
mental disorder.
Biochemical
A biochemical theory suggests the involvement of
elevated levels of the neurotransmitter dopamine, which is
thought to produce the symptoms of overactivity and
fragmentation of associations that are commonly observed in
psychosis.
Neurobiology
Research suggests that the prefrontal cortex and the
limbic cortex may never fully develop in the brains of persons
with schizophrenia. The two most consistent neurobiological
research findings in schizophrenia are imaging studies
showing decreased brain volume and abnormal function, and
neurochemical studies showing alterations of numerous
neurotransmitter systems. This has been recently attributed
to faulty myelination occurring at about age 6 and again at
about 13.
The client was not tested with MRI nor CT scans,
hence neurobiology aspect was not assessed.
Dopamine is increased in client's mesolimbic area
while decreased in prefrontal mesocortical areas.


Neurotransmitter Studies
Dysregulation hypothesis of schizophrenia or the persistent
impairment in one or more neurotransmitter homeostatic
regulatory mechanisms causing unstable or erratic
neurotransmission which proposes that the mesolimbic areas has
overactive dopamine pathways, whereas the dopamine pathways
in the prefrontal mesocortical areas are hypoactive and that an
imbalance exists between dopamine and serotonin
neurotransmitter systems.
Neurodevelopment
This research suggests that some disruption in fetal neural
development may change the way the brain matures throughout
childhood and adolescence, affecting the myelination, migration,
and interconnections of young neurons as they mature in utero
and in the first few decades after birth and thus may contribute to
brain abnormalities common in schizophrenia.
Viral Theories
Mixed evidence indicates that prenatal exposure to the
influenza virus, particularly during the second trimester, may be
one of the factors in the etiology of schizophrenia in some people
but not in others.


BIOLOGIC THEORY






















PRECIPITATING FACTORS
Loss of Attachment/Life Events
Loss in adult life can precipitate depression. The loss may be real or imagined and may include of love, a person, physical functioning, status, or self-esteem. Many losses take on
importance because of their symbolic meaning which makes the reaction to them appear out of proportion to reality. In this sense, even an apparently pleasurable event, such as
moving to a new home, may involve the loss of friends, warm memories, and neighborhood associations.
The intensity of grief becomes meaningful only when the person understands earlier losses and separations. People reacting to a recent loss often behave as they did in previous
separations. The intensity of the present reaction therefore becomes more understandable with the realization that the reaction is to earlier lose as well. By definition loss is negative, a
deprivation. The ability to sustain, integrate, and recover from loss is a sign of personal maturity and growth.
(Give the explanation on the case of the patient)
Adverse life events are a potent factor in precipitating depression. Such events include loss of self-esteem, interpersonal discord, socially undesirable occurrences, and major
disruptions of life patterns. Events perceived as undesirable are most often the precipitants of depression.
(Give the explanation on the case of the patient)





Neurobiological Response Symptom Triggers
Precursors and stimuli, or combination of them, often precede a
new episode of the illness. The word trigger is used to describe these
stressors. Common triggers of neurobiological responses are related to
health, environment, attitudes, and behaviors.
Health
This includes poor nutrition, lack of sleep, out
of balance circadian rhythms, fatigue, infection, CNS
drugs, lack of exercise, barriers to accessing health
care.
She had no problems with regards to her
nutrition, sleep, past infection, lack of exercise
and she had no past experience of using CNS
drugs. Now that she is admitted to the
institution, we observed that our patient is
picky when it comes to food. She wont eat if
not in her food preferences. It is also stated in
her record that she had poor compliance of
her medications at home whenever she is
discharged.
Environment
The list composes the following: hostile/critical
environment, housing difficulties (unsatisfactory housing),
pressure to perform (loss of independent living). Changes in life
events, daily patterns of activity, interpersonal difficulties,
disruption in interpersonal relationships, social isolation, lack of
social support, job pressure (poor occupational skills),
stigmatization, poverty, lack of transportation (resources),
inability to get /keep job.
She experienced loss of her mother. It is stressful for her
since she is much close to her mother than her father.
She often shares her problems to her mother.
She also had problem with regards to her choice of
place for her work.
On her 2
nd
job, she claimed that she doesnt like her co-
workers for the reason that she is transferred from one
department to another
She also lacks social support for the fact that she is now
only living with her father.
Our patient has a problem with regards to establishing
interpersonal relationships to others including with her
opposite sex. She failed to establish an intimate
relationship with the opposite sex, given the fact that at
this age according to Erik Erikson, a person is expected
to achieve sense of intimacy.
Attitude/Behaviors
This compromise the following: Poor me (low self
concept), hopeless (lack of self confidence), Im a failure
(loss of motivation to use skills), Lack of control
(demoralization), feeling overpowered by symptoms, no
one likes me (unable to meet spiritual needs), looks/acts
different from others who are of the same age and culture,
poor social skills, aggressive behavior, poor medication
management, and poor system management.
The patient may have had a hopeless and poor
me attitude of her interpersonal difficulties since
she experience failure in her profession. She claimed
that she tried to apply in different works but failed
to be part of it. Her choice of profession is also
hindered by her parents.
She may also have felt lack of control because she
did not understand her symptoms and why they
were happening to her, she keeps on telling us that
that she is normal and it really hurts her to be placed
inside the rehabilitation even though she is not
psychotic.
On her record she has the following reason of
admission:
o Poor med compliance
o Stubborn behavior
o Relapses of incoherent speeches



APPRAISAL OF STRESSORS
COGNITIVE RESPONSE
Cognitive factors play a central role in adaptation. They account for the impact
of the stressful event; the choice of coping patterns used; and the persons emotional,
physiological, behavioral, and social reactions.
(Give the explanation on the case of the patient)

BEHAVIORAL RESPONSE
It is the result of emotional and physiological responses, as well as ones
cognitive analysis of the stressful situation.
(Give the explanation on the case of the patient)

SOCIAL RESPONSE
Search for meaning, in which people seek information about their problem.
Social attribution, in which the person tries to identify the factors that contributed to
the situation., in which people compares skills and capacities with those of others with
similar Social comparison problems.
(Give the explanation on the case of the patient)

AFFECTIVE RESPONSE
An affective response is the arousal of a feeling. In the appraisal of a stressor,
the major affective response is a nonspecific or generalized anxiety reaction, which
becomes expressed as emotions.
(Give the explanation on the case of the patient)



COGNITIVE / AFFECT PHYSIOLOGICAL BEHAVIORAL SUPPORT SYSTEM
According to Aaron Beck, schemata (persons
beliefs, values, and assumptions) shape
personality. Schemata influence people to
interpret certain life situations, explain their
own behavior, understand a sentence, do
arithmetic, solve intellectual problems,
reason, form opinions, and remember events.
These mental processes determine emotional,
behavioral, and physiological responses. The
higher the degree of earning the greater the
ability of the person to effectively develop and
use problem skills

Our client finished college in a
University with a degree of Bachelor
Science in Psychology. She took the
PRC Professional Teachers Board
Exam and had passed it in the year
2003. She had become a clerk at
Bayawan District Hospital but was not
contented so she quits. She was
applying for the work in their local
government but was not accepted.
She volunteered at Talay
Rehabilitation center for 6 months,
but was not given the job. Her level of
education serves her well in relating
life events and perhaps understanding
her own condition, insight.
According to Abraham Maslow, a basic need is
inactive or functionally absent in the healthy
person. If basic needs are not met, illness is
likely to occur and when basic needs are met,
health is a result. Needs are hierarchal, with
the lower level needs being critical to survival.
These physiologic needs are the biological
need for food, shelter, water, sleep, oxygen,
and sexual expression.

The patient is in a middle class family
wherein basic needs can be provided.
Both of her parents have job, her
father does a business man own a
store in their place and her mother is a
teacher.
Coping mechanisms are defined as the skills
used to reduce stress and they tend to be
learned from parents, individual experiences,
and social interaction.

When asked what are her stress
coping strategies she verbalized that
she pray to God.
She also verbalized Matulog ra, kay
stress gud, kapoi.
She is much close with her mother and
the one she confined with her
problems.
Client chooses the person she would
like to speak with, as verbalized by
significant other.

Coping skills tend to be learned from parents.
Parents are considered the number one
support system of children in times of crises.
Family resources such as parental and sibling
understanding of the illness, finances,
availability of time and energy, and ability to
provide ongoing support influence the course
of illness.

The patients family is her support
system. She is more close to her
mother compared to her father. She
verbalized that she talks to her mom
more often when she has problems so
when her mother died it really did
brought a great stress to her life and
we may say that her support system
at that moment collapsed. She
verbalized that her father is somewhat
busy with their business in their place.
She is visited by her father once a
month.


COPING RESOURCES



REACTION FORMATION DENIAL INTROJECTION INTELLECTUALIZATION
Acting the opposite of what one thinks and feels.

When talking about serious or
confidential topic such as the death of
her mother, she was observed to portray
the opposite of what should be expected
to feel; client was laughing and smiling
about the death of her mother and have
this delusions that her mother is still
alive.
Also, she verbalized that she doesnt
want to talk about sad events in her life;
instead she wants happy thoughts to be
discussed.
Failure to acknowledge an unbearable condition;
failure to admit the reality of a situation, or how
one enables the problem to continue.

When asked why she doesnt comply with
her medications she verbalized Mu
tumar ra man ko
She keeps on telling us that that she is
normal and it really hurts her to be
placed inside the rehabilitation even
though she is not psychotic.
She also believed that her mother is still
alive and is working in America.


Accepting another persons attitudes, beliefs,
and values as ones own.

The client verbalized that what she has
today came from her family and
relatives. She believes that they own
anting anting and it is passed on to
her and that it possesses great powers.
Excessive reasoning or logic is used to
avoid experiencing disturbing feelings.

She verbalized that she does
not want to take in her
psychotic medications because
she believed that it can cause
harm to her.

She verbalized , Ang meds kay
makacause ug harm sa body
unya normal ra man ko , di
man ko psychopathic so sakit
gyud kaayo ng patumaron ko
nila ug tambal

COPING MECHANISM

ADAPTIVE RESPONSES
SPIRITUAL GROWTH
Client always pray whenever confronted with problems. She prays that he father will
be always there with her or visit her most of the time.
SOCIALIZATION
Although she doesnt participate in most of the activities, she talks with people whom
she preferred to. She shares her life to the student nurses during the interaction but
only minimal information because she claimed that she doesnt talk confidential
things.
Fluphenazine Decanuate 1 cc
Chlorpromazine 110g tab OD
Akineton 20 mg 1 tab OD
Residon 2 mg tab 1 tab BID
PSYCHOSIS

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MALADAPTIVE RESPONSES
POSITIVE SYMPTOMS
Hallucinations
a. Auditory Hallucinations
- Verbalized Sulti an ra man ko unsa ako buhaton na sakto
b. Visual Hallucinations
- During one of our NPI, upon our arrival she verbalized Gimagic mo sa?, Nigawas ra lage mo kalit?. She believed that we came
from nowhere
Delusions/Thought Disorder
a. Grandiose
- Belief that one has exceptional powers, wealth, skill, influence, or destiny
- She believe that she possessed great powers and that they are related to the government officials (Arnaiz, Teves, Villegas).
- She strongly believed that her mom is still alive that it is possible for them to do everything they want because they [family]
believed that they possessed great power.
b. Persecutory
- The belief that one is being watched, ridiculed, harmed, or plotted against.
- Verbalized Mahadlok man ko dire kay patyon man nya ko. Dire sa mo ayaw sa mo lakaw

Dififculty maintaining attention (Distractibility)
- Distracted attention is impairment in the ability to pay attention, observe and concentrate on external reality.
- She is easily distracted with external stimuli, her attention is easily caught by what she hear and what she see.

Disorganized speech and behavior
- Client manifested lapses of incoherence as a positive formal thought disorder.

COGNITION
Be prepared to redirect
the patient back to the
task at hand
Assess and
document
patients
orientation.
Call patient by
name.
Spend time with
the client to talk
and encourage
verbalization of
feelings.
Be sincere and
honest when
communicating
with the client.
Be consistent
with the
interaction
Provide positive
feedback and
appropriate
behavior

NEGATIVE SYMPTOMS:
Difficulty processing emotions
- Problems of emotion: At times, client has flat and blunt affect and
does not emotionally respond while reporting her significant life
events. Client shared that she really feels sad and in sorrow about the
death of her mother but could not express crying. Significant other
claimed that the client did not cry during the wake of her mother 4
years ago. Sometimes she smiles and laughs with no apparent
reasons (silly).
Social isolation
- Asociality: Client was observed not talking to other person during the
excursion and culmination activity unless being approached first.
- Apathetic: She lacks interest towards people, activities and events, as
observed.
- Evasive: She gives a little information about her life. Claimed that she
doesnt want to talk about confidential things.
- Manipulation: She wishes the student nurses to play music for her.
She knows how to divert our attention whenever we dealt about
significant event in her life like the death of her mother. She often
change topics.
Impaired decision making
- Attentional impairment: Client could not maintain her focus and
sustain her attention during most of the nurse-client interaction. She
is also noted to be easily distracted from people passing by her cell
and also from what she hears.


Deterioration in Appearance and Lack of persistence:
Dirty Clothes
Unkempt Appearance
Poor Grooming
Personal Hygiene
o She doesnt take a bath regularly. She only takes a
bath depending on her own preference.
Slow Movements
Frequent Staring
Poor Eating Habits
o The client is picky when it comes to food. She wont
eat if its not her food preference.
Does not participate in some activities
o During the excursion closing program the client
doesnt want to participate in the games and also
doesnt want to answer the question during the
evaluation of the activity.

UNDIFFERENTIATED SCHIZOPRENIA
PHYSICAL
Assess the
clients ability
to do self care
Encourage and
assist client to
take a bath,
clean her teeth,
change clothes
and have well
grooming
Teach the
client the
importance of
good hygiene
Assist the client
in activities that
foster socially
acceptable
interactions with
others
Socialization
through planned
therapeutic
activities.