Schizophrenia. Case protocol slide share

CASE PROTOCOL

Profile of the Patient

Age: 36 years old

Sex: Female

Civil Status: Single

Religion: Roman Catholic

Educational Attainment:

College Undergraduate

Occupation: Unemployed

CHIEF COMPLAINT

CHIEF COMPLAINT:Patient: “May sakit daw ako.”Patient’s sister-in-law: “Ganun pa rin siya, laging takot, ayaw lumabas. Pero ngayon mas laging di mapakali at madaling mairita.”Patient’s sister: “Dapat for check-up lang sya. Pero ganun pa rin sya, laging takot.”

CHIEF COMPLAINT

MENTAL STATUS EXAMINATION

MSE Upon Admission

APPEARANCE: Fairly-groomed, with slightly disheveled hair, wearing shorts and T-shirt• Since we were not able to have first-hand encounter with the patient,

and the date when the mental status examination was conducted, we were not able to identify whether or not the patient was appropriately dresses as far as the weather is concerned; good hygiene is observed

BEHAVIOR: Good eye contact, (-)mannerisms• Maintaining good eye contact would probably mean that the patient

was emitting warm vibes and is more likely to be sincere and honest with the information being asked of her; no mannerisms were observed or the habitual facial expression or bodily movement

MSE Upon AdmissionATTITUDE: Cooperative• The patient answered the questions asked and most probably gave all

the information needed

SPEECH: Spontaneous, normoproductive, soft tone, normal rate and law volume• The patient had the tendency to blabber, say things which she really

did not mean. She also felt confident with what she said considering the rate of her speech

MOOD: Anxious• Perhaps the patient felt queasy talking about her unusual experiences

and being subject to such examination.AFFECT: Blunted• There was a reduction in the patient’s emotional response

MSE Upon AdmissionTHOUGHT CONTENT: (+) Paranoid persecutory delusions, (+) Ideas of Reference, (+) Suicidal Ideations, (-) Homicidal Ideations• 2 years prior to admission, patient was robbed off of her belongings

and that misfortune in her life made her believe that a particular person or a group of people are/actually going to harm her since then.

• The patient also avoided commuting fearing that something bad might happen to her. Occasionally, she would feel that her neighbors are always talking about her. Even she thinks that her sister-in-law, whose house is where she is residing, is talking bad about her to other people.

• She cut herself several times but not for the sole reason of wanting to die but to be able to kill her own self before anyone else could. Even with her suicidal thoughts, she had not thought to kill someone else (only herself)

MSE Upon AdmissionTHOUGHT PROCESS: Goal-directed process• The patient is still into completing certain tasks.

SENSORIUM: Awake, Alert• The patient is responsive to the questions asked was able to answer

them without difficulty.

ORIENTATION: Oriented to person, place and time• The patient knew who she was talking to, where she was what day it

was.JUDGMENT: Good. Q: "Ano ang gagawin no kapag may nakita kang batang nawawala?" A: "Tutulungan Kong hanapin magulang niya."• The patient's ability to make a sensible solution to a particular event is

satisfactory.

MSE Upon Admission

IMPULSIVITY: Good impulse control.• The patient's reactions and reflections were still acceptable. That is, a

forethought has been made before the act and its consequences have been put in to consideration.

INSIGHT: Level I. "May sakit saw ako. Pero totoo naman mga sinasabi ko, 'di lang sila naniniwala."• The patient is conscious on what was happening to her and was able

to tell the people around her what she was going through, though it seems that she still questions the state of her being since she had not consider herself sick just yet that time (May sakit DAW ako).

Latest MSEAPPEARANCE: Well-groomed, appropriately dressed, wearing t-shirt and shorts• The patient seemed to pay attention to the details of her outside

aspect. BEHAVIOR: Good eye contact, (-) mannerisms• Being able to main good eye contact means the patient has her self-

confidence intact and is more likely to be sincere to the answers she’s about to give; no signs of habitual facial and bodily movement

ATTITUDE: Cooperative• Complied with what she was asked to give answers to.

SPEECH: Spontaneous, normoproductive, normal rate and low volume.• The patient had the tendency to say things which she did not intend

to; had normal flow of speech.

Latest MSEMOOD: Euthymic• The patient showed a positive mood or she was in a balanced mood

stateAFFECT: Constricted• The patient seemed to hold back his real emotions and feelings.PERCEPTION: (-) Perceptual disturbances• Patient had disruptions in her perceptions (could be caused by her

current disorder and/or toxins) THOUGHT CONTENT: (+) Paranoid and persecutory delusions, (+) Ideas of reference, (-) Suicidal ideations / Homicidal Ideations• The thought that some people are still after her to harm or kill her still

persisted• She still thinks that everything that is happening around is about her• No desire to kill herself or other people

Latest MSE

THOUGHT PROCESS: Goal-directed thought process• The patient is still into completing certain tasksSENSORIUM: Awake, Alert• The patient was responsive to the questions asked and was able to

answer them without difficultyORIENTATION: Oriented to person, place and time• The patient knew who she was talking to, where she was, and what

day it wasJUDGMENT: Good. Q: “Kumain ka ng candy, tapos nais mo sana itapon yung basura ngunit walang basurahan, ano gagawin mo?” A: ”Ibubulsa ko muna.”• The patient was able to make a sensible solution to a particular event.

Latest MSE

IMPULSIVITY: Good impulse controlThe patient’s reactions and reflections were reasonably acceptable. That is, a forethought has been made before the act and its consequences have been put into consideration.

INSIGHT: Level V.”Meron akong Schizophrenia kasi meron akong naririnig na mga boses sa isip ko.”The patient has recognized and accepted the symptoms of the illness she has.

HISTORY OF PRESENT ILLNESS (HPI)

2 years PTA- patient was held up and robbed of her belongings

Preoccupied with that incidentextremely anxious when commutingoccasional flashbacks *********eventually resolved*************

quits job due to being stressed over the accounting responsibilities of her job.

1 year PTA- odd behavior and scared

•look around when outside•someone might be following her•neighbors might be talking bad about her•Works as part-time tutor

6 months PTA

•paranoid and persecutory delusions•auditory and olfactory hallucinations•silhouettes •anhedonia, •difficulty sleeping•poor appetite •suicidal ideations•storing blades •recurrent dreams •diary

5 months PTA- (sept 2015)

•Persecutory delusions and auditory hallucinations •Crying•If forced to go out -> extremely anxious and would be hyper vigilant, with complaints of palpitations, excessive sweating, trembling and cold sensation on upper extremities•depressed mood•Anhedonia•poor appetite and difficulty sleeping•BRIEF PSYCHOTIC DISORDER

2 months PTA

•auditory hallucinations and pseudo hallucinations•persecutory and paranoid delusions, •depressed mood, anhedonia, difficulty sleeping and decreased appetite•cutting herself•sought consult at OPD and was advised admission

2 weeks PTA

•pace up and down the house •refuse to sleep during the day•depressed mood •feelings of worthlessness and guilt. •verbalized wanting to live in Lucena •persecutory and paranoid delusions,• auditory hallucinations•difficulty sleeping•easily agitated and irritable

1 week PTA

•conflict with her sister •more irritable •psychomotor agitation and restlessness•Persecutory and paranoid delusions•auditory hallucinations

2 days PTA

•cutting her wrist again•episodes of restlessness and psychomotor agitation

•akyat-panaog sa hagdan •may kinakalikot na mga papel •nagbabasa lang ng paa sa CR lagi pag sinabihan na maligo.

Day of Admission

- Admitted due to persistence of symptoms, suicidal ideations, current parasuicidal behavior

SYMPTOMS

SYMPTOMSPhysical SymptomsPreoccupied about the incident; occasional flashbacks Agitation: the state of increased irritability and tension

Patient would feel extremely anxious when commuting; when forced to go out, patient would be extremely anxious and would be hypervigilant, with complaints of palpitations, excessive sweating, trembling and cold sensation on upper extremities. Patient started to become more restless than usual and would pace up and down the house and would refuse to sleep during the day.

Peeking outside the window and would become restless. Difficulty in sleeping Poor appetite Episodes of crying Psychomotor Agitation Deterioration of personal hygiene

SYMPTOMS

Clinical Symptoms:Auditory HallucinationsOlfactory HallucinationsDepressed moodPersecutory DelusionsAnhedoniaParanoid delusionsSuicidal ideations

SYMPTOMSPositive Symptoms: behavior changes that are added by the disorder, and which are not normally found in a healthy person.

Agitation: the state of increased irritability and tensionPatient would feel extremely anxious when commuting; when forced to go out, patient would be extremely anxious and would be hypervigilant, with complaints of palpitations, excessive sweating, trembling and cold sensation on upper extremities. Patient started to become more restless than usual and would pace up and down the house and would refuse to sleep during the day.Patient had a conflict with her sister that resulted for her to become more irritable than usual (at that time), with psychomotor agitation and restlessness.

Hallucinations: Including visual, auditory, olfactory, gustatory and tactile hallucinationsDisorganized Thinking: Persons with Schizophrenia lose the ability to keep track of their thoughts and conversationsDelusions: False and illogical but firmly-held beliefs because of inability to differentiate between real and unreal experiences

SYMPTOMSNegative Symptoms: the abilities that are lacking or missing in schizophrenic individuals, but are present in normal people.

Lack of Emotional Response: Lacking signs of emotions such as lack of facial expressions; or restricted or blank facial expressions, showing neither sadness nor happiness; monotone voice, and lack of eye contact

Patient had persisted feelings of anhedoniaSocial Withdrawal or Depression: Being unaware of their surroundings; and/or isolating themselves socially

Patient would consistently refuse to join the morning exercise and would just opt to stay inside the ward

Lack of Initiative or Drive: Lacking of self-care and motivationShe would only wet her feet every time she’s told to take a bath by her relatives

DIAGNOSTIC CRITERIA

Diagnostic Criteria

A. Two ( or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), (3):

1. Delusions•(1 year PTA) feeling that someone might be following her•(1 year PTA) neighbors might be talking bad about her•(6 months PTA) frequently afraid and verbalizing that someone might hurt her•(6 months PTA) silhouettes•(5 months PTA) she had episodes of crying, verbalizing that she doesn't feel safe when alone; refused to go outside and claimed that she might not get back home alive if she goes out

Diagnostic Criteria2. Hallucinations•(6 months PTA) auditory hallucinations - this symptom persisted until 2 days PTA •(6 months PTA) olfactory hallucinations of burnt candles and had recurrent dreams of people trying to hurt her

3. Disorganized speech (e.g., frequent derailment or incoherence)•(6 months PTA) the patient was noted to be frequently writing random things in her diary

4. Grossly disorganized or catatonic behavior•(2 days PTA) patient kept on going up and down the stairs and crumpling of papers

Diagnostic Criteria

5. Negative symptoms (diminished emotional expression or abolition)

•(6 months PTA), patient had difficulty speaking, poor appetite and suicidal ideations•(5 months PTA), when forced to go out, patient would be extremely anxious and hypervigilant, with complaints of palpitations, excessive sweating, trembling and cold sensation on upper extremities•(2 months PTA), patient started to cut herself•(1 week PTA), patient noted to be more irritable than usual

Diagnostic Criteria

B. For significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas of functioning, such as work, interpersonal relations, or self-care, is markedly below the level achieved before the onset.

•refused to go outside of their home alone or commute alone•Patient had a conflict with sister•lost appetite and episodes of restlessness have worsen over the course of time•started cutting herself

Diagnostic CriteriaC. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms.

5 months PTA, the patient was diagnosed with Brief Psychotic Disorder for two weeks preceded by schizophreniform disorder after a week

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

This was not applicable to the patient**

Diagnostic Criteria

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug abuse, a medication) or another medical condition


F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).


PROBLEMS AND CONFLICTS

Problems and Conflicts(Early Childhood)

1. Uninvolved Father2. Fear of Rejection3. Prefers to play by herself but

occasionally goes out to play with other young children

Problems and Conflicts(Middle Childhood)

1. Bullied2. Less Sociable

chechebureche

Problems and Conflicts(Later Childhood and adolescence)

1.Less Sociable2.No intimate relationship3.Reluctant to confide her problems

Problems and Conflicts(Adulthood)

1.Wasn’t able to pursue her dreams2.No intimate relationship3.Depression due to her mother’s death4.She was guilty to her mother’s death5.Feeling of insecurity to her siblings

DIAGNOSIS

Diagnosis

•Schizophrenia •Schizoid Personality Traits

WHY THE PATIENT BECOME SCHIZOPHRENIC?

Why the patient become Schizophrenic?

Biological Environmental

Hereditary

Family Work

Stressors

Why the patient become Schizophrenic? (BIOLOGICAL)

A. Biological Factors:According to them, the patient’s paternal uncle had an unknown psychiatric illness but this factor alone is relatively weak.

Why the patient become Schizophrenic? (environmental)

A.Family and Relationship


Their mother was the one who disciplined them since their father is always at work. The patient described her mother as a nagger, punitive and very strict who always scolded her.

During the patient's childhood, she reprimands them verbally and hit them with a stick whenever they made grave mistakes. Based on the research by Diana Baumrind, this kind of parenting style called as authoritarian produces an unsociable, unfriendly and withdrawn child. This is also one of the contributing factors for the schizoid personality traits of the patient. Moreover, this kind of hostility also makes the patient more vulnerable to stress.


A person fixated at the oral stage is unable to separate from her mother; therefore their identity never becomes secure. This could be supported by the patient’s claim that she only confides her problem to their mother and her constant shifting of course.

TRAUMATIC EXPERIENCEThe patient was robbed; this was the strongest stressor that triggered all the unresolved issues in the life of the patientIt was evident on the anamnesis that the patient has schizoid personality traits.


She preferred to play alone, had a few friends and admitted that she had a hard time establishing new friendship again when they moved to Lucena.

Her crushes and romantic relationships were ephemeral because she always lacks interest. She ignored her male classmates who called her chechebureche which further proved that she is indifferent to praise or criticism – a characteristic of a child having an uninvolved parent.


2 years prior to admission, the patient was robbed and claimed that everything was taken except for her employer’s money. Since she always keeps problems only to herself or her mom which is dead now her mind was overwhelmed

For the past years, a lot of problems and conflicts already happened in her life but the strongest stressor that marks the onset of schizophrenia was the robbery.

The patient cannot handle the fear and unable to express her anger towards the robber as well.

PSYCHODYNAMICSThe Psychodynamic Approach views Schizophrenia as the result of the disintegration of the ego. It is the Ego’s job to keep control of the Id’s impulses and strike a compromise between the demands of the Id and the moral restrictions of the Superego. Some types of abnormal upbringing can result in a weak and fragile ego, whose ability to contain the Id’s desires is limited. This can lead to the Ego being “broken apart” by its attempt to contain the Id, leaving the Id in overall control of the psyche. If this happened, the person loses contact with reality as they can no longer distinguish between themselves and others, their desires, fantasies and realities.

PSYCHODYNAMICSHer demented view of men as represented by her classmates who used to call her names could be the grounds on why she had auditory hallucinations of men threatening to harm and/or kill her since it was that kind of treatment that was programmed in her since she was a child.

Her constant symptoms of people from the outside world are threatening to kill her, or her neighbors talking bad about her, could have stemmed from what she experienced from her early interactions with significant figures.

PSYCHODYNAMICSFixation and regression mean that the ego is not fully developed and so the individual may be dominated by the id or superego, and because the ego is weak the individual will lack a sound basis in reality. The psychodynamics of schizophrenia may suggest that patients diagnosed had a very harsh childhood environments, often because their parents were cold and unsupportive (As in the case, the patient have an absent father and a nagging mother).

SUMMARYThe researchers conclude that the final diagnosis of the patient is Schizophrenia with Schizoid personality traits. This started when she was robbed while riding a public transportation. This event triggered all the unresolved issues of her life in the past. It was evident that the patient was apparently well and has no known co-morbidities until 2 year PTA this was the time when she was robbed while riding a jeepney. After the event, she had occasional flashbacks of the said event. 1 year PTA, she became scared. She often looked around when she was outside. She felt someone might be following her. 6 months PTA, she started having paranoid persecutory symptoms. She often told that there was someone who's going to kill her.

SUMMARY5 months PTA, she started became being withdrawn. She felt anxious and had continued persecutory delusions. 2 months PTA, she had persistent auditory hallucinations. She also started cutting her wrists. 2 weeks PTA, she became restless and she refused to sleep during the day. 1 week PTA, she had a verbal conflict with her sister. Her sister told her that she must come to her senses because a lot of money is now being spent for her medication and treatment. She became more irritable than usual. 2 days PTA, she started cutting herself again. On the day of admission due to persistent symptoms, suicidal ideations and parasuicidal behavior, it was advised that she was to be monitored closely and admitted at UERM psychiatric ward.

SUMMARYUpon admission she had mental status examination. It was found out that she has fairly groomed appearance, good eye contact, cooperative attitude, spontaneous speech, anxious mood, reduce emotional response, has auditory hallucinations and pseudohallucinations, thought process is goal directed, sensorium is awake and alert, is oriented to person, place and time, good concentration, good calculation, intact immediate, recent and remote memory, good abstract thinking and good impulse control. Her insight level is level 1. She insights that "May sakit daw ako, pero totoo naman mga sinasabi ko,'di lang sila naniniwala."

SUMMARYSymptoms of her condition included the following: Physical symptoms such as:Preoccupied about the incident; occasional flashbacks; agitation: the state of increased irritability and tension; patient would feel extremely anxious when commuting; when forced to go out, patient would be extremely anxious and would be hypervigilant, with complaints of palpitations, excessive sweating, trembling and cold sensation on upper extremities; patient started to become more restless than usual; peeking outside the window and would become restless ; difficulty in sleeping; poor appetite; episodes of crying; psychomotor agitation; deterioration of personal hygiene.

SUMMARYClinical symptoms include: Auditory hallucinations; olfactory hallucinations; depressed mood; persecutory delusions; anhedonia; paranoid delusions; suicidal ideations. The diagnostic criteria of the patient include, she had delusions, hallucinations, disorganized speech, grossly disorganized catatonic behavior, diminished emotional expression or abolition, and continued signs of disturbance that persisted for at least 6 months. The patient's problems and conflict include the following:

SUMMARYDuring her early childhood, she lacked father image and developed an fear of rejection. During her middle childhood, she was bullied. During her later childhood, she became less sociable, she had no intimate relationships, and became reluctant to confide her problems. During her adulthood, she wasn't able to pursue her dreams because she was not able to obtain a bachelor's degree. This developed into depression. She also have no intimate relationships. Her latest mental status examination findings were as follows: She had a well groomed appearance, she had good eye contact, she had cooperative attitude, had spontaneous speech, had a euthymic mood, had constricted emotions and feelings, had perceptual disturbances, she had paranoid and persecutory delusions, ideas of reference and suicidal/homicidal ideations.

SUMMARYShe had a goal-directed thought process, her sensorium is alert and awake, she is oriented to person, place and time, she had good concentration, good calculation, she has intact immediate, recent and remote memory, she is funs of knowledge and was able to name 3 presidents of the country, she has hood abstract thinking, good judgement, and good impulse control. Her insight level is level V which is "Meron akong schizophrenia kasi meron akong naririnig na nga boses sa isip ko." The patient has recognized and accepted the symptoms of the illness she has. This are the symptoms, background and findings which lead to the researchers to conclude of the patient's diagnosis.

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Schizophrenia. Case protocol slide share