A CASE STUDY

In Partial Fulfillment of the Requirements in

NCM 102
(Related Learning Experience)

“Undifferentiated Schizophrenia”

Lorma Colleges, San Fernando, La Union

January 18 to February 10, 2010

Submitted By:

BSNIII-8
Group I Group IV
Alihuddin, Alnah D. Alcantara, Carlita
Avila, John Derrick Padilla, Aprille
Aquino, Donna Leah Rimas, Edelia
Balangue, Jesusa Rivera, Claire
Boado, Jasmin Sanchez, Virgie
Buen, Ailen Sevilla, Jezelle
Camacho, Florence Joy Sobrevilla, Kimberly
Cabusora, Athena Tan, Mary Ann
Dumpit, Jennifer Tejano, Rose Jane
Esguerra, Christopher Vera, Kervy June
Feraldo, Bennie Vic Verceles, Cresencio

Submitted to:
Mr. Jerry Abriam & Mr. Charles Rivera
Clinical Instructors
I. INTRODUCTION

Schizophrenia is characterized by a lack of grounding in reality, known as psychosis.

People in a state of psychosis can experience hallucinations, delusions, and other events in which
they break from reality. Individuals with schizophrenia experience psychosis and can also
develop symptoms such as disorganized speech, lack of interest in social interactions, a flat
affect, inappropriate emotional responses to situations, confusion, and disorganized thinking.

Patients with undifferentiated schizophrenia do not experience the paranoia associated

with paranoid schizophrenia, the catatonic state seen in patients with catatonic schizophrenia, or
the disorganized thought and expression observed in patients with disorganized schizophrenia.
However, they do experience psychosis and a variety of other symptoms associated with
schizophrenia, including behavioral changes which may be noticeable to family and friends.

This mental disorder is challenging to diagnose, and it can take weeks or months to
confirm a diagnosis of schizophrenia. During this process, other causes for the symptoms are
ruled out, and the patient is observed to collect information about changes in the patient's
personality, modes of expression, and mood. Family members and friends may also be
interviewed and asked for information with a goal of painting a more complete picture of what is
going on inside the patient's mind.

There are a number of treatment options available for undifferentiated schizophrenia.

Patients can discuss treatment options with their physicians, although it is important to be aware
that it can take time for treatment to be effective. Once patients start experiencing a change, they
may require periodic adjustments to their medications and treatment regimen to respond to
changes they experience over time. Undifferentiated schizophrenia cannot be cured, but it can be
managed with a cooperative effort.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement,

and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease
process with many different varieties and symptoms. It is usually 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 categorized into two major categories, the positive
symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and
behavior, and negative symptoms as flat affect, lack of volition, and social withdrawal or
discomfort. Medication treatment 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 the functioning of
client’s daily life.

The prevalence rate for schizophrenia is approximately 1.1% of the population over the
age of 18 or, in other words, at any one time as many as 51 million people worldwide suffer from
schizophrenia, including;
• 6 to 12 million people in China (a rough estimate based on the population)
• 4.3 to 8.7 million people in India (a rough estimate based on the population)
• 2.2 million people in USA
• 285,000 people in Australia
• Over 280,000 people in Canada
• Over 250,000 diagnosed cases in Britain

The number of people who will be diagnosed as having schizophrenia in a year is about 1
in 4,000, so about 1.5 million people will be diagnosed with schizophrenia this year, worldwide.
About 100,000 people in the United States will be diagnosed with schizophrenia this year.

Dr. Noel Reyes, a psychiatrist at the National Center for Mental Health in Mandaluyong
City, said that one of the most common brain diseases among Filipinos is schizophrenia, which
afflicts one percent of the total population. He said that it (cases of mental illness) increases as
the population increases. For example for schizophrenia, if the population now is 88 million,
expect that 880,000 of it are schizophrenic.
 In San Fernando City, La Union, there are 17 cases of schizophrenia. Seven of which are
diagnosed as paranoid schizophrenia and the rest have no specific diagnoses.

SPECIFIC OBJECTIVES

After 7 days of community visit:

PATIENT CENTERED OBJECTIVES:

1. The patient will be able to talk about her feelings in the context of a trusting, supportive
relationship
2. The patient will be able to verbalize her experience of delusions without engaging in power
struggle over the content or the entire reality of the delusions.
3. The patient will be able to identify behaviors that alienate significant others and family
members.
4. The patient will be able to socialize with her relatives and neighbors.

NURSE CENTERED OBJECTIVES:

1. The student nurses will be able to gain deeper understanding of Schizophrenia.
2. The student nurses will be able to gain awareness of several myths and facts about
Schizophrenia.
3. The student nurses will be able to demonstrate ability to identify signs and symptoms of
Schizophrenia.
4. The student nurses will be able to implement proper nursing interventions to the patient.
II. PATIENT’S HEALTH PROFILE

A. Biographic Data
Mrs. LF a 41 year old female, living at Upper Carcaramay, Bacnotan La Union. She was
born on September 19, 1968 via NSD. She is the 5th among the 8 siblings but two of them died
when they were still younger. She is married to CF and they have 2 children. She delivered her
children via NSD through her mother’s help. They are affiliated to the Roman Catholic Church.
She is a housekeeper and a store owner.

B. History of Present Illness

Mrs. LF’s signs and symptoms manifested on the month of December 2009. According to
her husband, she was worried about her sari-sari store. Her profits are depleting and her capital
has accumulated into debts incurred by their neighbor. According to Mrs. LF, an amount left in
her store was stolen but when her husband was asked there were no incident as such. Mrs. LF
became withdrawn. She refused to go out and just stayed in her store. Whenever somebody came
to buy, she did not respond nor looked at them. Her sleep patterns changed. She became
sleepless at nights. She lost her appetite which contributed to her big weight loss.

Her mental illness became prominent on January 05, 2010 after she watched news on
television about a sex video scandal the night before. On the night of January 4, 2010 she was
restless in front of the television and kept walking around the house while glancing on the T.V.
On that night she dreamed about the news but the ones performing the sexual act was her and her
husband. The morning after, January 5, 2010, she woke up doing bizarre things already
according to her husband. She was agitated even when asked softly and calmly. Her behaviors
turned aggressive and she stared angrily. She would yell at anyone whom she caught looking at
her. She exhibited ideas of reference. She accused her nephew to have manipulated the sex video
that was connected on their television. She became mistrustful of the people around her
especially those holding mobile phones. Her husband said that she taught that the camera of the
phone will be used against her that videos of her are being taken already. On that day, her
family decided to bring her to Baguio General Hospital and Medical Center. She was
uncooperative and resistant. According to her husband, it took 3 of her brothers and nephew have
to restraint and hold her in order to bring her to Lower Carcarmay to take the ride going to town
for a bus to Baguio City.
She was prescribed with the following medications: haloperidol 5 mg OD before
bedtime, olanzapine and biperiden 2mg OD.
During the initial interview, January 20, 2010 Mrs. LF was depressed and she repeatedly
asked “babalik pa kaya ang isip ko?”. She verbalized suspicion against her neighbors. She did
not go out of their house fearing that she might hear them mock her about her being “ nasisiraan
ng ulo” Due to her nervousness, the windows of their house facing her neighbors were closed
and she refused to have them opened.
According to her husband, she has experienced auditory hallucination. She kept hearing
voices at night, laughing at her and mocking her. When asked about the experience of being
mocked and being laughed at, she admitted the fear of experiencing it but she denied having
experienced it as what the husband has reported. She turned irritable when her husband shared
her experience without asking. She repeatedly say, “ nawala na…nawala na kasi pinakain ako ni
CF…nawala na…nawala na..inunahan na.” which is a manifestation of verbigeration
Mrs. LF’s was brought back to BGHMC for a follow-up check up last January 26, 2010
and she was prescribed with medications for one month. She was scheduled to go back on
February 17, 2010.

C. Past Health History

According to Mrs. LF’s mother the common diseases that she had during her childhood were
cough, colds and fever. She has not been vaccinated. According to her sister- in-law she suffered
from hair loss during her adolescence. Her family believed that it was caused the by bad spirits.

Mrs. LF verbalized to have taken medications for her heart disease, but she could not present
any prescriptions. She can no longer remember the name and type of drugs she has taken and
when was it taken. The husband of Mrs. LF knew hat her wife was into medications before but
has no idea if hat it was.
 Mrs. LF was diagnosed with goiter in 1989. She consulted various medical institutions
such as Bacnotan District Hospital and ITRMC to seek for treatment and for the management of
her disease. She reported to have high T3 and T4 when she undergone a test, but she could not
present the laboratory result which was already misplaced. According to her husband, her toxic
goiter made her eyes bulge (proptosis).

D. Family Health History

Mrs. LF’s father died four years ago after an abdominal surgery. Her sister-in-law
reported that he had a cancer. Her two siblings died when they were younger. The one died of
tetanus and the other from leukemia. Her youngest sister has toxic goiter too.

Mrs. LF’s mother denied of having a history of psychiatric illness. But when
interviewed if how they are related to a certain family in Lower Carcarmay, she acknowledged
them to be her husband’s brothers and relatives. These families have a family member with a
psychiatric illness.

E. Lifestyle and Health Practices

a. Description of Typical Activity

Most often Mrs. LF was alone in their house because her husband is working in a
cement factory. Her children are attending school. Sometimes her youngest sister accompanies
her and helps her with the house chores. She can cook rice but most of the household chores are
done by her husband. Her children’s needs are provided by her husband and mother.

b. Nutrition and Waste Management

The client’s typical food intake is composed of rice, fish and vegetables. The family
frequently has vegetable soup with their rice. Occasionally, the family eats fish with their
vegetables. Mrs. LF has a poor appetite and drinks less than 8 glasses a day.
 She used to defecate everyday but after she has taken her antipsychotic medications she
defecates once in every three days already.

c. Activity Level and Exercise

Mrs. LF has decreased physical mobility. She appears weak and is slow-paced when
changing positions like sitting, standing and walking. Before her mental illness, she could do
household chores which served as her regular exercise.

d. Sleep and Rest

Mrs. LF before her psychotic break out has difficulty sleeping already. She was up
until early morning, sleeps for a few hours and then wakes up again. Before her mental illness
she has a good sleeping pattern.

e. Medications
Mrs. LF’s current medications include haloperidol 5mg, 1 tab OD; biperiden (Akineton)
2mg 1 tab OD; diphenhydramine 50mg OD as needed. She has been injected with olanzapine
when she was brought to Baguio General Hospital and Medical Center. She has no history of
substance abuse.

f. Self Concept and Self-Care Responsibilities

She expresses concern and worry over not performing her responsibilities to both her
husband and children. She verbalizes of wanting to get well soon in order that she can resume
her former role as a mother and a wife. She is able of self care. She manages to take a bath and
maintain good hygiene except prior to and during her psychotic break out.

g. Social Activities
Mrs. LF’s being suspicious and mistrustful inhibits her to socialize. She has limited
time talking with her relatives and neighbors.
h. Values and Belief System
Mrs. LF is a family-oriented person. Despite of her inability to resume with her
ADLs, she verbalizes of wanting to take care of her children. She has an optimistic attitude as
manifested by her hope to be able to recover. Despite having suspicions and nervousness, she
accepted the student nurses in her home.
The family is affiliated to Roman Catholic. But they seldom go to church because
their home is situated in the mountainous part of the barangay.
The family believes in quack doctors. Prior to bringing Mrs. LF to BGHMC, she was
brought to an “albularyo” to determine if what was wrong with her. They believed that bad
spirits caused her illness.

i. Education and Work

Mrs. LF finished her elementary education at Lower Carcarmay Elementary School
and her secondary education at Quirino National High School. She took a vocational course in
dressmaking at Don Pacifico Leonzo School Foundatiuon in Hermosa, Bataan. She worked in
Bataan for several years ironing sewn clothes. It was in Bataan that she met her husband. Before
the onset of her disorder, she managed a small sari sari store as their source of income. Now, the
management of the store was transferred it to her brother.

III. DEVELOPMENTAL LEVEL

Erik Erikson’s Psychosocial Theory of Personality Development emphasizes the concept
of identity or an inner sense of sameness that perseveres through external changes, identity
crises, and identity confusion in the dynamics of personality development. Each stage has a
unique developmental task or dilemma that must be resolved wherein an individual is presented
with a crisis he must resolve.

TRUST vs. MISTRUST (birth to 18 mos)

The goal is to develop trust and trust is being developed from the inner feeling of self-
worth that is transmitted through maternal care. Patient LF was born via normal spontaneous
delivery. According to her mother, she was breastfed for 12 months and was well taken cared of.
She was cuddled, fondled and played with by her mother. Her needs were attended and were
adequately met, hence, the task in this developmental stage was achieved wherein trust has been
developed and she having a sense of the world as a safe and dependable place to live with.

AUTONOMY vs. SHAME and DOUBT (18 mos to 3 y/o)

The goal is to gain self-control and independence within the environment. Her mother
started to toilet train her at the age of 2 and she was able to master the task at 3 years old. As
stated by her mother, with patience, she constantly encouraged her to go to the toilet whenever
she feels so. With this, she was able to acquire sense of independence and competence.

INIATIVE vs. GUILT (3 – 5 y/o)

The goal is to develop a sense of purpose and the ability to initiate and direct one’s own
activities. According to the mother, patient LF loves to play with her siblings and with other
children in the neighborhood. She was given the freedom to play with others. Mental and motor
abilities were developed thus her sense of initiative was reinforced mastering this developmental
stage.

INDUSTRY vs. INFERIORITY (6-12 y/o)

The goal is to develop a sense of duty or to achieve a sense of self-confidence. Patient LF

feels unworthy whenever her efforts were not recognized. However, she is not afraid of failure as
she always tries to explore new things/activities. She has lots of female friends whom she
mingles and interacts with. She is close to her younger sister. In this stage, she develops some
gratification and the pleasure in the interaction and involvement with others.

IDENTITY vs. ROLE CONFUSION (12 – 18 y/o)

The goal is to develop sense of confidence, emotional stability and be able to view self as
a unique individual. Patient LF only attained high school level. Though she wanted to enter
college, she was not able to due to financial constraints. However, she went to vocational school
and taken up a short course in dressmaking in Bataan. She worked as a sewer and stayed with her
relatives thereat. It was manifested in this developmental task the patient LF was able to integrate
the task mastered in the previous stages into a secure sense of self.

INTIMACY vs. ISOLATION (19 – 40 y/o)

The goal is to perform an intense, lasting relationship or the ability to pledge a total
commitment to another. Patient LF is friendly and likes to socialize as she attends parties and
other events. During the stay of patient LF in Bataan, she met Charlie, and became her husband.
They are married for fourteen years now and were blessed with two children. They owned a sari-
sari store then, as a source of family income. Though they live a simple life, they are happy and
are living peacefully. She is not the type of person who easily gets jealous. She just remains
silent whenever conflict arises between her and her husband. She consults her husband’s
opinions whenever decisions are to be made in life. Patient LF was able to achieve this
developmental task as she was able to reach out and make contact with other people. She was
able to share with and care for another person without fear of losing oneself in the process.

GENERATIVITY vs. STAGNATION (41 – 64 y/o)

The goal is to achieve a sense of gratification from personal and professional

achievements and from meaningful contributions to others. Patient LF is classified under this
developmental stage as to her age. However, because of her illness, she cannot cope up with the
demands of the daily activities in life. She started to feel confuse and anxious. She cannot
perform parental, family and societal responsibilities. She gave up managing their sari-sari store.
She became unproductive and just stayed at home. In this stage, productivity, being constructive,
creative and active are the developmental tasks that patient LF failed to do, thus making her
stagnant. Nevertheless, patient LF is hopeful to get better and would soon resume most, if not all
of her daily chores and responsibilities for her family.
IV. GENOGRAM
V. PHYSICAL ASSESSMENT
Date: January 20, 2010
I. General survey
• Thin body built
• With erect and rigid posture
• Clean and without body odor
• Fairly good appetite
• Can eat without assistance
• Oriented to date, time, place, person; changes in alertness noted
II. Vital Signs
• BP- 150/70
• T-36.6°
• HR-83
• PR-82
• RR-22
• Weight-48 kg
• Height-5 feet 2 inches
III. Head-to-Toe Assessment
A. Head
a. Face
• Blunted affect
• Able to puff cheeks(CNVII)
• Able to frown(CNVII)
• Able to close eyes(CNVII)
• Able to smile but not fully (CNVII)
• Able to differentiate sensation such as touch and temperature
b. Eyes
• Able to read word/s from a distance of 6-7 feet
• (+) PERRLA
• (+) Corneal reflex (CNV)
 • (Both eyes coordinate and move in unison and with parallel alignment(upward,
downward and sideward) (CNIII,IV,VI)
• With pale pink conjunctiva
• With yellowish sclera
• Slight bulging eyes
c. Nose
• No secretions noted
• Able to differentiate the smell of coffee from soap (CNI)
d. Ears
• No abnormal secretions
• Able to hear normal voice tones
• Able to repeat words spoken by the examiner
• Able to hear whispered words
e. Mouth
• with dentures (two front upper teeth)
• Upper teeth-13, Lower teeth-12
• With cavities
• Salivating
• (+) gag reflex
• Able to swallow and masticate
• Buccal mucosa is pink
• Able to protrude tongue (CNXII)
• Able to purse lips (CNVII)
B. Neck
• Symmetrical carotid pulse
• No palpable lymph nodes
• Slightly enlarged thyroid
• Able to move head slowly from one side to another
• Able to hyperextend the head by 60°
 • Able to bend head forward
• Able to turn head slightly against a resistance
• Able to shrug shoulders slightly against a resistance
C. Chest and Back
a. Posterior thorax
• Skin intact
• With dry Skin
• Spinal column is straight; no deformities noted
• Back is straight
b. Anterior thorax
• Shallow respiration
• Skin intact and dry
• Heart murmurs noted
D. Upper Extremities
• (+)radial and brachial pulse
• Cold and clammy hands
• Capillary refill less than 2 seconds
• Able to feel light touch and pressure
• With full movement against gravity and against full resistance
• Bilateral fine tremors noted
E. Abdomen
• audible bowel sounds
• smooth and no tenderness noted
F. Genitals
• not assessed
G. Lower Extremities
• able to abduct, adduct, move forward and back
• With full movement against gravity and against full resistance
• Bilateral mild tremors noted
Date: February 3, 2010
I. General survey
• Thin body built
• With erect and rigid posture
• Clean and without body odor
• Fairly good appetite
• Can eat without assistance
• Oriented to date, place, person; changes in alertness noted
II. Vital Signs
• BP- 80/60
• T-36.6°
• HR-142
• PR-120
• RR-28
• Weight-48 kgs
• Height-5 feet 2 inches
III. Head-to-Toe Assessment
A. Head
a. Face
• Symmetric temporal pulse
• Unable to puff cheeks(CNVII)
• Able to frown(CNVII)
• Able to close eyes(CNVII)
• Able to smile but not fully (CNVII)
• Able to differentiate sensation like touch and pressure
b. Eyes
• Teary
 • Able to read word/s from a distance of 6-7 feet
• (+) PERRLA
• (+) Corneal reflex but reacted slowly(CNV)
• Both eyes coordinate and move in unison and with parallel alignment(upward,
downward and sideward) (CNIII,IV,VI)
• With pale pink conjunctiva
• With yellowish sclera
c. Nose
• No abnormal secretions noted
• Able to differentiate the smell of coffee and soap (CNI)
d. Ears
• No abnormal secretions found
• Able to hear normal voice tones
• Able to repeat words spoken by the examiner
• Able to hear whispered words
e. Mouth
• With dry lips
• With sticky saliva
• With dentures (two front upper teeth)
• Upper teeth-13, Lower teeth-12
• With cavities
• (+) Gag reflex
• Has difficulty swallowing
• Buccal mucosa is pink
• Unable to protrude tongue(CNXII)
• Able to purse lips but with difficulty (CNVII)
B. Neck
• Symmetrical carotid pulse
• No palpable lymph nodes
• Slightly enlarged thyroid
 • Able to hyperextend the head but with difficulty
• Able to bend head forward but with difficulty
• Able to turn head laterally but with difficulty
• Unable to turn head laterally against a resistance
• Able to shrug shoulders but with difficulty
• Unable to shrug shoulders against a resistance
C. Chest and Back
a. Posterior thorax
• skin intact and dry
• spinal column is straight; no deformities
b. Anterior thorax
• shallow respiration
• skin intact and dry
• Heart murmurs noted
D. Upper Extremities
• (+)radial and brachial pulse
• Cold and Clammy hands
• Capillary refill less than 2 seconds
• Able to feel light touch and pressure
• normal full movement against gravity and against full resistance
• bilateral fine tremors noted
E. Abdomen
• audible bowel sounds
• smooth and no tenderness noted
F. Genitals
• not assessed
G. Lower Extremities
• able to abduct, adduct, move forward and back
• Normal full movement against gravity and against full resistance
• Bilateral tremors noted
VI. PSYCHODYNAMICS

The causes of schizophrenia are unknown: while several possible causes exist, no single

cause explains all cases of schizophrenia. Genetics, birth defects, environmental triggers, and

imbalances of the neurotransmitter dopamine are all considered possible causes of schizophrenia.

Of all the schizophrenia sub types, Undifferentiated Schizophrenia is the one that does

not fall into the category of either, and is diagnosed when a schizophrenic patient does not

exhibit symptoms resembling any of the other types of schizophrenia.

In this schizophrenia type, the patient’s symptoms may fluctuate, or might stay

excessively stable, causing a doubt in placing it under any other sub type. The best schizophrenia

type’s definition for this type of schizophrenia is ‘mixed clinical condition’.

Genetical cause of Schizophrenia

Schizophrenia genetics have been well studied. Studies of identical twins have

established that genetics, if not the cause of schizophrenia, at least plays an important role in the

development of the illness. If one identical twin develops schizophrenia, the other twin has a

forty to fifty percent chance of developing the mental illness.

In addition to twin studies, schizophrenia genetics research has also studied parent/sibling

genetics. A person whose parent has schizophrenia has a ten percent chance of inheriting the

condition.
 Such studies indicate schizophrenia is influenced by genetics, but genetics alone cannot

be considered the root cause of schizophrenia. Too many schizophrenia patients have no family

history of the illness. Instead, genetics are thought to make certain people more susceptible to

schizophrenia. Other considerations, such as environmental factors, may combine with

schizophrenia genetics to trigger the disorder.

Environmental causes of Schizophrenia

Life stressors may trigger schizophrenia in people whose genetics leave them susceptible

to the illness. Ending relationships, leaving home, and other life stressors have been linked to

schizophrenia onset in some cases. Certain personality traits, while not causes of schizophrenia

themselves, may predispose individuals to the disease. Low levels of social competence and a

diminished ability to experience pleasure have been linked to schizophrenia, as have pre-existing

problems with cognitive and perception distortion.

Genetics and Environment: Multiple Schizophrenia Causes

Current schizophrenia theories suggest no single cause of schizophrenia exists. Instead,

schizophrenia genetics leave some people susceptible to the illness, which is triggered by

environmental factors. It is also worth noting that many schizophrenia experts believe

schizophrenia is actually more than one disorder, and that schizophrenia symptoms are actually

caused by several subtly different mental disorders. If true, finding a cause for schizophrenia

may be extremely complicated: many of the possible theories given above may be true for

different varieties of schizophrenia.

(http://www.psychiatric-disorders.com/articles/schizophrenia/schizophrenia-causes.php)
Brain Chemical Imbalances

There is evidence that chemical imbalances in certain neurotransmitters, proteins, and

amino acids play a role in causing schizophrenia.

 Dopamine — Dopamine is the primary brain chemical implicated in

schizophrenia. The dopamine hypothesis suggests that an excess of dopamine in the brain

contributes to schizophrenia.

 Glutamate — Glutamate is another important neurotransmitter implicated in

schizophrenia. Studies show an underactivity of glutamate in schizophrenic patients.

This supports the dopamine hypothesis, since dopamine receptors inhibit the

release of glutamate.

The Dopamine Hypothesis

Dopamine is a neurotransmitter that transports signals between nerve endings in the

brain. It is thought that the brains of people with schizophrenia and other psychotic disorders

produce too much dopamine. There is evidence that supports and counters the dopamine

hypothesis.

The main support for the theory that too much dopamine causes schizophrenia is the fact

that antipsychotic medications, which are used to treat schizophrenia, block dopamine receptors.

The medications are designed to bind to dopamine receptors in the brain, and their effects have

helped many people cope with symptoms. Secondly, drugs that increase levels of dopamine, like

amphetamines, often cause psychotic symptoms and a schizophrenic-like paranoid state.

Glutamatergic Activity in Schizophrenia

The glutamate hypothesis of schizophrenia posits that the function of the N-methyl-D-

aspartate (NMDA) receptor is compromised in this disease. NMDA receptors are a major

subtype of glutamate receptors and mediate slow excitatory postsynaptic potentials (EPSPs).

These slow EPSPs are considered critical for the proper expression of complex behaviors, such

as associative learning, working memory, behavioral flexibility, and attention, many of which are

impaired in schizophrenia. NMDA receptors also play an essential role in the development of

neural pathways, including pruning of cortical connections during adolescence, making them a

critical component of developmental processes whose malfunction may lead to schizophrenia.

Glutamate neurons regulate the function of other neurons that have been strongly

implicated in the pathophysiology of schizophrenia. These include GABA interneurons whose

morphology has been altered in schizophrenia (Lewis et al., 2005), and dopamine neurons, which

are the target of antipsychotic drugs. For example, bursting of dopamine neurons, which is

thought to be an integral component of their proper response to environmental stimuli, is

dependent on activation of NMDA receptors on these neurons (Johnson et al., 1992). Along the

same lines, it is noteworthy that two key pharmacological clues to the pathophysiology of

schizophrenia—clinical efficacy of D2 receptor antagonist and increased probability of

developing schizophrenia after cannabis use during adolescence—are consistent with deficient

NMDA receptor function in schizophrenia. Cannabinoid CB1 receptor and D2 receptors are

localized presynaptically on glutamate terminals and work to inhibit the release of glutamate.

Cannabis, therefore, reduces glutamate release, in particular in corticostriatal regions (Gerdeman

and Lovinger, 2001), leading to deficient activation of NMDA receptors, whereas reduced D2

receptor function produces modest increases in glutamate release (Cepeda et al.,

2001;Yamamoto and Davy, 1992).

Abnormal Brain Structure

In addition to abnormal brain chemistry, abnormalities in brain structure may also play a

role in schizophrenia. Enlarged brain ventricles are seen in some schizophrenics, indicating a

deficit in the volume of brain tissue. There is also evidence of abnormally low activity in the

frontal lobe, the area of the brain responsible for planning, reasoning, and decision-making.

Some studies also suggest that abnormalities in the temporal lobes, hippocampus, and amygdala

are connected to schizophrenia’s positive symptoms. But despite the evidence of brain

abnormalities, it is highly unlikely that schizophrenia is the result of any one problem in any one

region of the brain.

Thyroid Disease: Behavioral and Psychiatric Changes

Psychiatric symptoms in thyroid diseases such as Hashimoto's thyroiditis and

Graves' disease, are well known. In particular, patients with autoimmune thyroid disease

may develop psychoses that are nonspecific. This is expected because autoimmune thyroid

disorders typically cause a disorganization of the nervous system. This neurobiologic

disorganization is also a common feature of nonspecific psychoses, including bipolar

disorders. Cognitive dysfunction is also a common feature of hypothyroidism and this

symptom may confuse diagnoses of psychoses and other psychiatric illnesses.

Psychiatric Aspects of Hyperthyroidism and Hypothyroidism

The symptoms of hypothyroid psychoses are most pronounced in patients who suddenly

move from hyperthyroidism to hypothyroidism, including patients undergoing treatment for

hyperthyroidism with radioiodine ablation, excessively high doses of anti-thyroid drugs, and

surgery.

Hyperthyroidism itself causes multiple and varied neurobehavioral and psychological

changes including anxiety, dysphoria, emotional lability, insomnia, and occasionally episodes of

intellectual dysfunction. Concentration may be impaired, and patients may speak rapidly,

expressing disjointed thoughts.

(http://thyroid-disorders.suite101.com/article.cfm/thyroid_disease)
VII. MENTAL STATUS EXAMINATION

Date: January 20, 2010

I. General Appearance
A.1 Presenting Appearance
Mrs. LF is a 41- year old Filipino woman of average weight and height. She is brown-
skinned, has a shoulder length hair which was slightly disheveled and with an erect posture. She
looked older for her age.

A.2. Basic Grooming and Hygiene

During the interview (January 20, 2010), Mrs. LF was appropriately dressed. Her hair
was uncombed and her fingernails were not trimmed. Her skin was dry and her feet were dirty.

A.3. Gait and Motor Coordination

Mild tremors were observed from Mrs. LF during visitation. She was able to slightly turn
her neck from one side to another and to shrug her shoulders. She walked with upright posture
and steady gait in slow pace.
She was able to stand erect and slightly swayed when asked to stand with eyes open and
she moved her feet when asked to stand with eyes closed. She was found to have ataxic gait
when Romberg’s test was done.
She was able to repeatedly and rhythmically touch her nose when asked to do the Finger-
To-Nose test. She also was able to alternately supinate and pronate her hands in a little fast rate.

It was observed that Mrs. LF’s hands were trembling when she was asked to do draw.

B. Manner and Approach

B.1. Behavior
Mrs. LF was cooperative and slightly distant during the interview. She was easily
distracted by the noise and passersby. She was irritable when her husband butted in to the
conversation and shared information regarding her condition. She repeatedly blamed her husband
for forgetting what she was supposed to say. She drove away children who came in their house
and kept saying “bangad”.

B.2. Speech
Mrs. LF articulated herself in a slow manner during the course of interview. She spoke
softly throughout the conversation, particularly when mentioning about the unpaid debts her
neighbors have from her sari-sari store. She did not deviate from the topic but paused several
times before finishing her answers to the questions.

a. Expressive Language
Mrs. LF expressed herself with difficulty. She has difficulty finding words during
the conversations. She often paused and answered only when motivated. Her sentences
trailed off and do not finish them unless there was some motivation. Repetitions to what
she was saying were also noted.

b. Receptive Language
Mrs. LF was able to comprehend questions asked of her. She answered the
questions correctly and was related to the topic.
She was able to follow instructions like folding a paper into half, using crayons
instead of a pencil and determining shapes and sizes.

B.3. Eye Contact

Mrs. LF made a minimal eye contact during the interview, especially when recalling
experiences that made her anxious. She stared blankly when asked about her sari-sari store which
was closed and transferred to her brother’s house.

B.4. Recall and Memory

Mrs. LF was able to recall recent and past events. She was able to recall objects that were
asked for her to remember after 15 minutes of conversation. She was able to answer correctly
questions related to a storytelling test. She was able to recall the content of her breakfast and the
color of her children’s clothes leaving for school. These showed her capability for immediate
recollection
She was also able to recall experiences related to the pictures of her and her family when
she was younger. This manifested her capability in the recollection of her remote memories.

D. Orientation, Alertness and Thought Process

D.1. Orientation
Mrs. LF was able to answer accurately when asked if what day was it, what year, what
place she was in, who were interviewing her and what country she was in. She was able to
identify relatives that were present during the interview.

D.2. Alertness
Mrs. LF was alert, oriented and was able to answer questions.

D.3. Coherence
Mrs. LF responded with coherence and was easy to understand. She answered in simple
and concrete manner without unnecessary and overly details. Her answers to the questions were
associated and relevant.

D.4. Concentration and Attention

Mrs. LF was able to answer the serial 7s test. She was able to subtract 7 from 100, 93, 86,
79 but made more than 4 errors as the test progressed. She counted her fingers every time she
was asked to subtract.
She was able to recite the reverse of 87 and 649 without difficulty and had a difficulty
giving the reverse of the 4-digit number Normally, an average person can repeat 4-6 series of
numbers in reverse order.
She was able to follow instructions to draw a clock. This test was given to measure the
frustration tolerance which affects the concentration and attention of a person. Mrs. LF
successfully indicated the correct time but placed the numbers in slightly unequal gaps. She
placed the numbers on the edge/line of the clock and outside the face of it. This was a
manifestation of an alteration in the focus of attention of Mrs. LF. While doing the test, Mrs. LF
kept complaining that she did a wrong clock but her frustration was not enough to make her stop
what she has been instructed to do.

D.5. Thought Processes

Mrs. LF was able to recall information that was asked relevant to the storytelling. She verbalized
experience of depersonalization. She said that she was not like herself and that her real self is
separated from her body. Ideas of reference were also noted. She believed that the people in their
neighborhood were gossiping and making fun of her. She became suspicious, making her
withdrawn and not going out of their home to socialize. She also manifested nihilistic delusion.
She kept saying that her brain is missing and is not connected to her head anymore.

Stream
Mrs. LF’s thought stream was slow. She answered questions in a slow manner and
paused most of the time. Repetitions to what she was saying were evident.
Form
Mrs. LF was able to answer questions spontaneously and directly. She did not use any
new or created new words. She often paused during conversations but continue to speak in
relation to the topic.
Content
Mrs. LF was depressed and anxious about her health. She was obsessed with her
condition and was constantly asking about the rate and the possibility of her improvement and
recovery from her mental illness. Thoughts that her psychotic symptoms will not be cured
despite treatment were causing her anxiety. Mrs. LF was feeling guilty for not being able to care
for her children and husband since the onset of her psychotic manifestations. She denied having
hallucinations but her husband reported that his wife experienced hearing voices without him
hearing one. She was having suspicions that her neighbors and relatives were gossiping about her
being psychotic.

D.6. Hallucinations and Delusions

Mrs. LF experienced hallucination. She shared story of a dream which she did not really
knew if it was a dream. Her husband also reported that Mrs. LF complained of hearing voices, as
if mocking and laughing at her, but when she was asked directly if she has heard voices without
seeing who was talking, laughing or calling, she denied having experienced it. She insisted that
the windows must be closed all the time for the fear of seeing “those” people who were laughing
at her.
Mrs. LF manifested gustatory hallucination. She kept spitting during the conversation and
complained of sand in her tongue and something was stuck in her mouth but there was none
when checked.
Mrs. LF also experienced nihilistic delusion. She believed that her brain is missing and is
not connected to her body. She has also verbalized suspicion about her neighborhood making fun
of her and gossiping about her illness which was a manifestation of ideas of reference.

D.7. Judgment and Insight

When asked about her condition, Mrs. LF accepted the fact that she was ill and required
treatment. She was cooperative in going to the hospital for check up and was compliant with
management. She cooperated with the therapy and religiously took her medications. She was
hoping that she can be “stronger” again to pursue her role as a mother, a wife and a store owner.
She said that she pity her children because she has become useless for them.

D. 8. Intellectual Ability
Mrs. LF has an average intellectual ability. She was able to answer most of the questions
like: “What is the capital of the Philippines?”, “Name four countries in Asia”, “Who is the
Governor of La Union?”, and “Who is the president of the Philippines?”.
Her abstract skill was remarkable. She reacted with amazement when asked if what she
can say about the absurdity: “ May isang lalaki na naaksidente ng dalawang beses. Noong unang
nadisgrasya sya dahil nasagasaan nga sasakyan, ikinamatay nya. Ngunit ang pangalawang
aksidente, nahospital lamang siya.” She argued that the man could not be alive again because he
was already dead.
E. MOOD AND AFFECT
E.1. Mood and Affect
Mrs. LF during the interview usually has bland affect. She smiled minimally and often
stared blankly when asked if what made her happy. When her husband disclosed information
ahead of her, she irritably stared at him and got annoyed. Her expressions vary from being
tensed, relaxed, and then blank. When questions were asked related to sensitive information as
per reported by the husband, Mrs. LF only looked away and became tensed. She would only
speak when motivated.

E.2. Suicidal and Homicidal Ideation

Mrs. LF has not shown manifestations and has no ideation regarding suicide and harming
others.

E.3. Risk for Violence

Mr. CF has reported that Mrs. LF was difficult to manage during the onset of her illness.
She was withdrawn and never wanted to be held or touched. She needed to be held by several
persons in order to be brought to the hospital. She was acting violent and resisted in going to the
hospital for a check up.

E.4 Response to Failure on Test Items

Every time Mrs. LF was given an examination or a test, she was worried that all of her
answers were wrong. She also got frustrated and anxious when she thought that her response to
what was asked of her to do was wrong or a mistake.
Mental State Examination
Date: January 20 & 25, 2010
Name: Mrs. LF Age: 41 years old Is Patient alert? Yes
Level of Education: Secondary Maximum Score: 27=Mild Neurocognitive Disorder

Patient’s Score Questions:

1/1 What day is it?

1/1 What year is it?
1/1 What country are you in?

The examiner names five unrelated objects clearly and slowly, then asks the patient to
name all three of them. The patient’s response is used for scoring. The examiner repeats
them until patient learns all of them. (Mango, Dog, House, Cat, Pencil)

You have 50 pesos in your pocket, then you went to a store to buy Coke for 15 pesos and
a bread for 10 pesos.

1/1 How much did you spend?

2/2 How much money do you have left?

1/3 Please name as many animals as you can in one minute.

0=0-4 1=5-9 2=10-14 3=15 & above

5/5 Ask the patient if he or she can recall the five words you previously asked him or her
remember. Score the total number of correct answers (0-5).

1/2 Ask the patient to recite the numbers you will give in backwards manner.
0=87 1=649 2=8537
4/4 Give the patient a paper with a drawing of a circle. Let her assume that it is a clock face.
Instruct her to put hour markers in it and the time is 11:10.
2/2 Ask the patient to place an x in the triangle and a check to biggest shape among the three.

Ask the patient to listen to the story and inform him or her that questions will be ask later
after the story.
“Juana is a 21-year old woman who lives in Bacnotan. She works in the town’s municipal
building. Juana walks her way to work every day. She works as a clerk and she does good
in it. Juana loves to dress herself. Juana has no husband and no children yet”

2/2 What was the woman’s name in the story?

2/2 When does she go to work?
2/2 Where does she work?
2/2 What is her work?

Interpretation:

Result High School Less than High School Education

Normal 27-30 25-30

Mild Neurocognitive D/O 21-26 20-24
Severe cognitive Impairment 1-20 1-19
VIII. NURSE-PATIENT INTERACTION
IX. DRUG STUDY
X. EVALUATION

On the duration of the visitations and conversations with Mrs. LF, sufficient information
has been obtained regarding her psychiatric condition. It was learned that she has experienced
delusions, specifically ideas of reference and nihilistic delusion. She verbalized her suspicions
against her neighbor making fun of her and gossiping about her. She complained that her brain
was not attached to her head and that she was not herself. Her old self has wandered and has not
returned to her body. She shared a story about a dream which she was not sure if it was a dream
or a reality already. She said that there were voices laughing at her and mocking her being
psychotic. She has expressed her feelings of unworthiness. She thought of being worthless
because she could not look after her children’s and husband’s needs. By sharing these thoughts
and experiences, it manifested Mrs. LF’s trust and being able accept company especially those
who are not her immediate relatives..
After three weeks of therapy, the patient started mingling. She started socializing and
going to her siblings’ houses again.
On the last day of the visitation, February 3, 2010, the patient followed the student nurses
in the host family’s house and bid goodbye. She was thankful for what the group has shared and
for having helped her. With all these changes in Mrs. LF’s behavior, it is concluded that the
group’s patient centered objectives are met.
The student centered objectives were met. By understanding schizophrenia, the student
nurses were able to identify the patient’s signs and symptoms. Proper nursing interventions were
also formulated and implemented.