Running head: PARANOID SCHIZOPHRENIA 1

Common Characteristics of Paranoid Schizophrenia and Schizoaffective Disorder

Mariah Snowden

Youngstown State University

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Abstract

On my date of care, I observed a thirty-one year old, Caucasian, male, whose diagnosis on the

DSM-IV-TR was paranoid schizophrenia and admitting diagnosis being schizoaffective

disorder. Based on my observation, a comparison was done from his date of admission to a few

days later on my date of care, to evaluate if any behavioral changes had occurred. Common

behaviors of those diagnosed with paranoid schizophrenia and schizoaffective disorder were

observed and summarized. Discussed are psychiatric medications and the reason they are

prescribed for these specific diagnoses. Safety and security measures that were provided for the

patient, staff, and other patients on the unit are included. Precipitating factors that may have

occurred prior to the patient's hospitalization, the patient's own history of mental illness, as well

as his family's history, and any current medical conditions that could be affecting him were

examined. Specific behavioral outcomes that are expected of the patient, short and long-term

goals, and plans for discharge are discussed as well.

Keywords: paranoid schizophrenia, behaviors, precipitating factors

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Objective Data

My patient, K.H., is a thirty-one year old, Caucasian, male. His current residence is with

his mother, whom assists him with some of his daily care needs. His date of admission was

9/25/2016. He was involuntarily admitted to the psychiatric intensive care unit, also referred to

as the PICU, due to the fact he was not only a harm to himself but to others as well.

Upon admission, the patient was displaying psychotic behaviors by frequently

responding to internal stimuli; demonstrating auditory and visual hallucinations. He arrived

with unkempt hair and numerous holes in his shirt. He was alert and oriented times one; to

person. K.H. was able to somewhat communicate superficial thoughts, feelings, and make his

needs known, but was frequently mumbling and making it difficult to obtain information at

times. He displayed feelings of agitation and irritability, believing that he was not in need of

any kind of psychiatric treatment. He also displayed preoccupation of thoughts that were

sexual, often making those thoughts known by frequently verbalizing inappropriate sexual

statements.

The psychiatric diagnosis of the patient using the DSM IV-TR, Axes I through V is as

follows: Axis I, identifies the patient's clinical disorder. His axis I is paranoid schizophrenia,

which he has a long-standing history of. Axis II, describes any personality disorder or any

evidence that the patient has mental retardation. This axis requires that the patient be seen over

a period of time, rather than just once by the psychiatrist. For this current hospitalization, the

primary focus is on the Axis I diagnosis, therefore, no diagnosis was given at this time for Axis

II, so it is labeled as deferred. Axis III, gives information about a patient pertaining to any

general medical conditions they are effected by. My patient has hypertension, diabetes, and

suffers from obesity.

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Axis IV, describes any environmental or psychosocial problems the patient may have, currently

he has social and environmental problems. He lives with his mother and at times she is unable

to care for him when his behaviors become overwhelming to her. When his behaviors reach that

point she no longer wants him at the home. Axis V, the Global Assessment of Functioning

Scale, gives a number that indicates the degree of occupational, psychological, and social

functioning a patient is capable of. The maximum score is 100; higher scores indicate higher

functioning. My patient received a score of 25, which is on the low end of the scale, meaning

he has significant difficulties in occupational, psychological, and social functioning.

Medical conditions he has include: diabetes, hypertension, and obesity. He is taking

metoprolol (Lopressor), a hypertension medication, to ensure his blood pressure stays in a

normal, safe range. Glipizide (Glucotrol) and insulin aspart (Novolog) are medications given

for his diabetes, to maintain a normal blood sugar level. Lastly, he is taking gemfibrozil (Lopid)

which is given to control his hyperlipidemia. His diet is being monitored not only due to him

being a diabetic, but also to assist him in losing weight.

The date of care was 9/27/2016. During my observation of K.H., I noticed he was still

extremely agitated and irritable. He was acting in a very aggressive manner, yelling, kicking,

and making verbal threats. He still was responding nonstop to internal stimuli, was still only

oriented to person, unaware of the nature of his illnesses, and not comprehending the

importance of medication compliance. The patient's behavior was labile. He was angry, tense,

and restless throughout the entire time I was on the unit. Most times the patient would just

ignore anyone trying to speak to him, but on occasion when a staff member attempted to

communicate with him he quickly became suspicious and hostile, seemed to be bothered, and

would give a quick, single word response. When he spoke to himself there was frequent
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mumbling, making it difficult to understand what he was trying to communicate. Interestingly,

every single remark said from his mouth that contained profanity, was clearly said with no

mumbling. His hair was unkempt and he still was wearing that same shirt with numerous holes

in it.

From my observation, I noticed he had a similar routine he followed throughout the

entire day. First, he would walk out of his room and begin pacing throughout the PICU with his

hands crossed, suddenly stop in the middle of the unit, put his hands in a triangle and begin

praying. Following his prayers, he began to pace again, would randomly stop and begin talking

to himself out loud. During these periods he was experiencing either a visual, auditory, or

command hallucination. He frequently made threats stating he would kill the nurses on the unit

and would swing his fists at them as well. Almost as if he was answering for, or to, the voices

in his head. During his pacing he happened to come around the corner as the doors of the unit

were shutting and quickly sprinted towards them in an attempt to get off the unit. As he

approached the doors one of the nurses yelled stop, and to my surprise, he listened and

immediately stopped. Suddenly, he began throwing himself against the doors and kicking them.

He walked back to his room and slammed the door. Every five minutes he came out of his

room, paced the unit, made threats to the staff, stared out of the windows of the doors, walked

back to his room, and slammed his door.

I also noticed his affect was inappropriate due to the fact that he would respond to

situations in unexpected ways. For example, he was given lorazepam (Ativan), for his moderate

level agitation. At first he was cooperative, complaint, and smiling. Within thirty seconds of

receiving the shot his demeanor changed and he became angry again, clearly began yelling

profanities at the nurse who administered the shot, reached over the desk and starting swinging
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his arms at her. He made several attempts to try and punch her. Soon after that, he walked up to

me, stared me down, and began swinging at me as well. Following that particular anger

outburst, every now and then the patient would yell loudly and grab his head or plug both of his

ears. He would make faces and stick out his tongue a lot, or lay on the floor and make choking

noises. He also started coughing up stuff from his throat to show the staff as well.

Safety and security measures maintained include, putting the patient in the psychiatric

intensive care unit due to the fact he was a harm to himself and others. Therefore, there was a

need to monitor him more closely to prevent any harm being done. Other measures maintained

were those pertaining to medication administration. Three checks were done prior to the patient

getting a medication and his arm band was scanned as well. This was done to ensure the right

patient is receiving a certain medication, the correct medication is being administered, and also

the correct dosage. Prior to giving K.H. his shot, it was discussed whether or not security

should be called just in a case an issue was to occur. Having security guards on the unit can

prevent harm from happening. It also can prevent situations from escalating to where they

become unsafe for those around the patient or for the patient himself. Making sure he is taking

all of the medications prescribed to him is also a major safety measure because they help

stabilize his mood and thought process, so he can return to his normal baseline level and no

longer be a harm to others or himself. Also, the medications he takes for his diabetes and

hypertension need to be given on schedule so his blood pressure and blood sugar are

maintained at safe ranges in order to prevent complications.

Psychiatric medications my patient is currently on are as follows: divalproex sodium

(Depakote), paliperidone (Invega), quetiapine (Seroquel), haloperidol (Haldol), and lorazepam

(Ativan). My patient is prescribed a five-hundred milligram tablet of Depakote, an

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anticonvulsant, to be taken twice a day, for mood stabilization. Nine milligrams, daily, of

Invega, an antipsychotic, for his diagnosis of paranoid schizophrenia, and three-hundred

milligrams of Seroquel, an antipscychotic, at bed time, which is taken for mood stabilization

and his schizophrenia. As needed he receives a two and a half milligram tablet or five

milligram intramuscular injection of Haldol, an antipsychotic, depending on the degree of

agitation and anxiety the patient is experiencing. Lastly, as needed the patient takes half a

milligram tablet or a two milligram intramuscular injection of lorazepam (Ativan), an

anxiolytic, which is given for anxiety, but also helps with decreasing mild agitation as well.

Psychiatric Diagnoses and Common Behaviors

The psychiatric diagnosis of schizophrenia is defined as, "a neurodevelopmental

disorder characterized by various combinations of delusions, hallucinations, disorganized

thoughts and behavior, cognitive impairment and movement disorders. The pathophysiology of

schizophrenia likely reflects genetic, developmental, and environmental factors" (Hirjak,

Hochlehnert, Thomann, Kubera, & Schnell, 2016, p.1). My patient frequently displayed

auditory, visual, and command hallucinations, believing he was hearing, seeing, or being told to

carry out an action by something or someone that was not really there. His schizophrenia was

further identified to be considered paranoid, due to his constant suspiciousness and obsessive

thoughts.

The admitting diagnosis of my patient was schizoaffective disorder, which is "a

continuous period of illness during which criteria for a major mood disorder (e.g. a major

depressive episode, a manic episode, or a mixed episode) coincide with the essential features of

schizophrenia (hallucinations or delusions)" (Kantrowtiz & Citrome, 2011, p.317). His mood
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during my observation was labile, meaning at any moment he could have a sudden mood shift,

going from one extreme to the other and had the hallucinations present as well.

"Outcome in diseases is a multidimensional construct consisting of several independent

domains, including clinical symptoms, their improvement, cognitive function, family burden,

quality of life and social functioning, especially the ability to relate to people and performance

at work" (Malik, Khan, Ataullah, & Rana, 2016, p. 579-580). Due to the possible

hallucinations, delusional thoughts, and mood swings it is difficult for those with schizophrenia

and schizoaffective disorder to behave in a way society views as normal, which can create

difficulties for them to find or keep employment, can cause stress amongst the family, and for

the patien. Patient's with these diagnoses may have feelings of loneliness due to difficulty with

social interactions.

Precipitating Behaviors

The behaviors that precipitated the current hospitalization began because the patient was

not being medication compliant at home. Shortly after him being admitted it was found that he

had severely high levels of divalproex sodium (Depakote), which was prescribed to him in

order to stabilize his moods, this was believed to be a contributing factor to his hospitalization .

On the day he was transported to the emergency room, the patient was witnessed playing in

traffic and lying in the middle of the road on a busy street, as well as repeatedly talking to

himself. The police were called and the patient, by court order, was subject to hospitalization.

Patient and Family History

Family history of mental illness was unknown. The patient has a long standing history

of mental illness, with the admission diagnosis stating schizoaffective disorder, a disorder

containing both mood and schizophrenic features. The DSM-IV-TR, Axes I though V, stating
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paranoid schizophrenia as the diagnosis. It was also believed K.H. may suffer from Asperger's

syndrome, due to some of the behaviors the patient engages in such as repetitiveness with

motions, his obsession of sexually inappropriate speech, and the fact he rarely makes eye

contact. When he makes eye contact it's as if he is looking in one's direction, not at them but

through them, and then he quickly shifts his eyes elsewhere. The patient has had prior

hospitalizations related to medication non-compliance. Prior to the last hospitalization the

patient displayed behavior that his mother determined was too much for her to handle,

including him breaking all of the mugs in the kitchen.

Psychiatric Nursing Care

The psychiatric nursing care provided to my patient included providing medication to

the patient at specified times to ensure he was receiving the proper medication necessary to

control his mental illnesses. Novolog was administered prior to breakfast to ensure the patient's

blood sugar was within the normal ranges. The nurse also at times redirected the patient from

his own internal stimuli to reorient him to reality. The nurses were constantly monitoring the

patient to ensure he did not cause harm to himself or others. He was encouraged to

communicate any of the needs he had to ensure all of his needs were being met. The

environment was calm and relaxed to decrease stimulation in order to prevent further agitation

and irritability for the patient.

Analysis of Patient's Spiritual Influences

It was stated that the patient believes in God. I frequently observed him randomly stop

in the middle of his pacing of the unit, put his hands in a triangle, and begin whispering what

sounding like a prayer. This seemed to help him calm down, possibly using prayer as a way to

momentarily cope with all of the stimulation, internal and external.

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On 10/11/16 the patient was still hospitalized, so I got the opportunity to observe him

again to see if there were any differences, in which there were many. The patient was on a trial

out, meaning he was allowed to live the PICU, which was a major difference from the last time

I was observed him. Throughout this observation, he was significantly more calm, not throwing

punches or constantly using profanity. He still was pacing but was able to sit still long enough

to eat his breakfast and for longer periods of time than previously. He still was talking to

himself but not as much, and he wasn't making verbal threats about killing anyone. He was

much more quiet and isolated himself in the television room at times. He did make attempts to

surround himself within a group, during breakfast he sat with everyone but talked to no one,

just himself. He seemed to have reached his baseline, the normal level of where he typically

behaves, if not, he was very close to that point. I did hear him once yell profanity at one of the

staff members.

Evaluation of Patient Outcomes

During my observation some of the short-term goals set for my patient included taking

his medications at the specific times and if possible he will communicate two desired effects of

that particular medication or possible side effects. Goals that were considered long-term goals

included not demonstrating auditory, visual, or command hallucinations. The second long-term

goal was to no longer allow the patient's response to internal stimuli to interrupt in his ability to

complete activities of daily learning. On my first day of observation these goals were not

achieved, but on my second observation these goals were closer to being met. The medication

compliance was helping significantly with getting him back to his baseline, his mood was not

as labile, he wasn't aggressive, and did not seem to be irritated at all. As I stated before, his

behavior was more controlled and he wasn't talking about harming anyone or himself. Due to
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his newly appropriate behavior he was permitted to leave the PICU. He appeared to no longer

have command hallucinations but still was talking to himself and hearing voices in his head.

Discharge Planning

Upon discharge, the patient will take prescribed medications, at the specified time, and

at the correct dosage amount, meaning no less or more then the prescribed dosage. The patient

will not be a harm to others or himself, will communicate to the best of his ability, and continue

to communicate when he is not feeling well or like he normally does. The patient's behavior

will reflect signs of mood stabilization, the patient's response to internal stimuli will be

decreased with a long-term goal of no longer demonstrating hallucinations of any kind, and the

patient will identify triggers that cause outbursts or shifts in mood.

Prioritized List of Actual Diagnoses

- Impaired verbal communication, related to developmental level, as evidenced by constant

mumbling and lack of understanding.

- Risk for injury, related to thought process, as evidenced by harmful command hallucinations.

- Ineffective impulse control, related to anger outbursts, as evidenced by swearing and making

threats.

- Risk for self directed violence, related to anger and agitation, as evidenced by throwing

himself into the door and kicking objects.

- Social isolation, related to behaving inappropriately, as evidenced by talking to himself,

making threats, and constant use of profanity.

-Disturbed thought process, related to hallucinations, as evidenced by talking to himself.

Potential Nursing Diagnoses

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- Anxiety related to change in normal environment

- Risk for unstable blood glucose level

- Risk for injury

- Risk for constipation

- Ineffective impulse control related to command hallucinations

- Risk for loneliness

- Noncompliance related to lack of understanding

- Impaired social interaction related to difficulty with communication

- Risk for other directed violence

- Risk for self-directed violence

References
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Ackely, B.J., Ladwig, G.B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights,

MO: Elsevier.

Hirjak, D., Hochlehnert, A., Thomann, P., Kubera, K.M., & Schnell, K. (2016). Evidence for

Distinguishable Treatment Costs among Paranoid Schizophrenia and Schizoaffective

Disorder. Plos ONE, 11(7), 1-10. doi:10.1371/journal.pone.0157635

Kantrowitz, J.T., & Citrome, L. (2011). Schizoaffective Disorder. CNS drugs, 25(4), 317-331.

Malik, M.A., Khan, S.M., Ataullah, Rana, M.H., & Khan, F.H. (2016). Long Term Outcome of

Schizophrenia - A Cross Sectional Study. Pakistan Armed Forces Medical Journal,

66(4), 579-585.