Running head: Schizophrenia

Schizophrenia
Alexis DeSantis
Mental Health
Youngstown State University
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Abstract
Schizophrenia is a complex disease that is determined to be a psychosis of the brain. It is

usually characterized by delusions, hallucinations, and disorganized thoughts and behaviors.

These symptoms are able to be categorized into two different symptoms: positive and negative

signs. A patient who was diagnosed with schizophrenia will be discussed in this paper, along

with some predisposing factors that may have led to this diagnoses and this specific acute

exacerbation. Schizophrenia can be treated by antipsychotic drugs, psychosocial therapies and

social support as well.

Schizophrenia

Objective Data

On 11.10.2018, a 30 year old female African American patient was admitted into the

emergency room at Trumbull Memorial Hospital. The patients initials were F.A. and this is how

she will be referred to for the rest of this paper. F.A. is diagnosed with schizophrenia, paranoid

type, and was currently having an acute exacerbation. The patient also had a history of cocaine

abuse. She was brought into the ER after walking into a police station very distraught while

looking for her missing cat. Once in the police station, the officers called the ambulance, and was

brought to the E.R. On admission, patient was stating that “a tornado was going to blow

everyone away” and that “they are going to cut my skin off my body”. At one point, patient had

said that there were “holes in my head and my brain is falling out”. She was also observed

talking to unseen others. After ​being medicated,​ she calmed down and the doctors were finally

able to perform a urinalysis and get labs.

The urinalysis ended up being positive for bacteria, as well as trichomonas. The white

blood cell count was elevated at ​12,900 mm3. This may have been caused by the white blood

cells trying to fight off the urinary tract infection as well as the trichomonas. F.A. also tested

positive on her cocaine screen. All other lab tests were within normal range. During initial

interview with patient, patient stated that she had been noncompliant with taking her Invega, and

had done cocaine for the first time in three years. She said she had lost her cat and her mind

“snapped” and that was how she had ended up at the police station.
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On the day of care, 11.15.2018, the patient’s behavior were much more calm than what

had been reported the day before. She was very willing to talk about her life and what had gotten

her onto the psychiatric floor. F.A. reported that the night before she was admitted into the

hospital, she had been at a party where she snorted cocaine for the first time in three years. When

she got home, she found out that her parents and identical twin sister (whom she was living with)

had found out about the drug use. Upon waking up the next morning, she realized that she could

not find her cat anywhere. After a lot of searching and waiting, F.A. had finally decided that

either someone had taken her car, or “something horrible” had happened to it. At this point, the

patient reported that her mind had “snapped” and that she decided to walk herself to the police

station before she acted upon hurting herself or others in anyway. After the police station, the

patient was unsure of what happened until she woke up on the psychiatric floor.

Throughout the interview with F.A., we were able to observe some of her behaviors.

Overall, the patient’s speech was very pressured and loud. She was talking very fast the entire

conversation, and it was sometimes hard to sneak a word in edgewise. The patient maintained

good eye contact throughout the conversation, as well as kept the conversation appropriate for

the setting we were in. The patient had stated that she had at least four past psychiatric

hospitalizations, and that her twin sister has schizophrenia as well. When asked about how her

mood had been lately, she responded with “depressed”. The reasoning behind this is that she

found out her sister had taken her cat, and even though it was in a safe place, she was still upset

that her sister would do that without telling her. She was also upset because her parents always

seem to be fighting. Patient stated that after leaving the hospital, she was planning on moving out

of her parent’s house and getting her own apartment where she will be able to get another cat and
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not have to worry about her family fighting. Her thoughts seemed to mostly focus on her cat, her

mind “snapping”, and on her father. She stated that her parents were both very religious, and

were disapproving of any type of illegal substances. The patient also stated that she had never

heard any voices or had any delusions, even though the chart says that she had somatic and

persecutory delusions upon admission, as well as auditory hallucinations.

The patient wasn’t sure how long she had stopped taking her medication for, but did state

that at one point, she did stop taking her Invega. The Invega was prescribed to treat her

schizophrenia episodes of paranoia. She stated that the medication had been giving her a

headache and was not taking it due to that and other side effects. The doctor decided to put her

on Cogentin in hopes that the Cogentin, an anti-parkinsonism drug, will cancel out any

extrapyramidal symptoms that the Invega may be causing. Overall, this patient was chronic

mentally ill, single, unemployed, lived with her parents and sister, was on SSDI (social security

disability), had a high school education, and was African American. These are many social,

ethnic, and cultural circumstances to consider when learning and studying this specific patient.

Psychiatric Diagnosis: Schizophrenia, paranoid type, acute exacerbation

Schizophrenia is defined as a “complex disorder, and it is not accepted that schizophrenia

is the result of neurobiological factors rather than due to some early psychological trauma”

(Pedersen, 2018). The onset of this disorder is usually from the late teens and the mid-twenties,

with the age usually being defined as from age 18-25. The diagnosis is equally prevalent in both

men and women as well. It is believed that schizophrenia is usually diagnosed at this age due to
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the high stress that college and becoming an independent adult brings. During this stressful time,

the patient will experience their first “psychotic break”.

There are both positive and negative signs of schizophrenia. The positive symptoms

include hallucinations, delusions, disorganized thought and nonsensical speech (such as echolalia

and word salad), and unusual behaviors. The positive symptoms our patient exhibited were

auditory hallucinations, as well as somatic and persecutory delusions. The negative symptoms of

schizophrenia are more difficult to diagnose, and effect more of the person’s behaviors and

mood. Some of these symptoms include a flat affect, anhedonia, catatonia, and reduced social

interaction. In the case of F.A., she mentioned having reduced social interaction in the past few

months. She also mentioned that the first few days on the psychiatric floor, she was very

depressed. These would all be negative symptoms of the schizophrenia, and they may have been

more difficult for her family to pick up on then the positive symptoms would be.

Identify the Predisposing Factors

A predisposing factor that may have put this patient at risk is something called the

downward drift hypothesis. This theory states that perhaps schizophrenia starts causing a spiral

of poor social conditions. In the case of F.A., she had had a job and was living on her own. After

losing the job, she had to move back in with her parents where her sister and her three nephews

were also living. This would be considered a change in social conditions for the patient, and it

definitely were not changes that would have a positive impact on her life. The night before her

psychotic break, she also had relapsed on her sobriety from cocaine. A consequence of this

ended up being her cat being taken from her possession. The hallucinations and delusions just
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happened to develop after all of this had occurred. Overall, these are all traumatizing events that

could have been caused due to the impending psychotic break.

Discuss Patient and Family History

The patient discussed living with her parents and her identical twin sister. Although the

parents had no history of mental illness, both her and her sister were diagnosed with

schizophrenia. This was interesting to learn due to the fact that mental illnesses have a tendency

to run in monozygotic (identical) twins. There have been many studies done on monozygotic

twins and the incidences of diagnoses of mental illness. This specific case study done by

O’Reilly, Torrey, Rao, and Singh in 2013 studied two monozygotic twins who were diagnosed

with mental illnesses twenty-two years apart. Twin A developed symptoms at age 26 while twin

B didn’t first exhibit symptoms until the age of 48 (O’Reilly, 2013). The conclusion of this study

mentioned that:

while it is never possible to be sure that any twin pair will remain discordant, follow‒up

studies of identical twins discordant for schizophrenia report that the majority of twins

who become concordant do so within five years following the onset of schizophrenia in

the first twin (O’Reilly, 2013).

Although this study had the twins diagnosed more than twenty years apart, that is not usually the

case with monozygotic twins. In the patient’s case, she was only 30 years old. Although they did

not have an official diagnosis date, both twins had been diagnosed by the age of 30. This article

also mentioned that “the heritability of schizophrenia has been calculated as approximately 80%

indicating that most of the variance is caused by genetic factors” (O’Reilly, 2013). Neither of the
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twins mentioned in the study had any traumatic events or head injuries that could have put them

at an inherent risk for schizophrenia.

Describing the psychiatric evidence based nursing care and milieu activities

While on the psychiatric floor, F.A. has attended multiple group therapies, plus has had

meetings with the doctors and the nurses. During the interview, we asked about how she had

been coping before the incident with the cocaine. She explained her coping mechanisms as

painting her nails and taking walks around the block with her cat by her side. She also really

enjoyed coloring while on the floor and while at home. She said that her coping skill for her most

recent “mind snap” was walking to the police station before she was able to hurt herself or

anyone else. She said that in the group therapies on the floor they had discussed more coping

strategies and that she plans to implement those as well. She also sees other people on the floor

who are having issues with hearing voices and speaking to unknown others, and she explained

that she does not feel as if those people are “crazy”. She mentioned that she believes the voices

that they are hearing must be real to the person, and she would be terrified if she ever

experienced voices like that (as she does not remember her admission very well).

We also saw that she was seen asking for her medications when she needed them, and

taking them compliantly on the floor. I believe this must be due to the fact that she had seen

other patients doing similar things. She was very happy to be on the floor due to the structure

that it brought back into her life, and also that she had a break from her sister, as well as her

parents constantly fighting. She was also happy to receive Cogentin to treat her EPS that was

originally caused by the atypical antipsychotic medication paliperidone (Invega). She was
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experiencing terrible headaches and was constantly restless. After being prescribed Cogentin,

she said that these side effects, for the most part, had subsided. She said the only lasting pain she

was experiencing was a headache type pain that ran down the front of her face. This just proves

that patients, no matter the age, can experience these movements that stem from antipsychotic

medications. In a study done by Saltz, Robinson, and Woerner in 2004, they said that “patients

receiving continual antipsychotic treatment should be advised of the risks associated with

antipsychotic agents and should be examined periodically to screen for early manifestations of

symptomatic movements (Saltz, 2004).

F.A. also reported that the reason for her noncompliance was the side effects that it was

causing. In the world today, we see many mentally ill patients being noncompliant with their

prescribed medications and self-medicating with alcohol and illicit substances.In a study done by

Swarts, Swanson, Hiday, Borum, Wagner, and Burns in 1998, they found that “​noncompliance

and substance abuse may be mutually reinforcing problems in that substance impairment

may impede medication adherence while noncompliance, in turn, may lead to

self-medicating with alcohol or illicit ​drugs” (Swarts, 1998). Although this is an older study, it

still applies to this patient, and many of the psychiatric patients today. F.A. used to self-medicate

with cocaine, and once becoming noncompliant with her medications a few months before

admission, had resorted to using cocaine again.

Analyze ethnic, spiritual, and cultural influences

Although living with parents who are very religious, F.A. had not recently been attending

any churches or participating in any religious activities. Upon being asked if she was religious,
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she responded with “no, but I would really like to start going back to church on Sunday

mornings”. I believe that she just did not want to attend the same church as her parents. No other

religious comments were made throughout the interview.

Evaluate the patient outcomes related to care

Overall, F.A. had met many of her outcomes when we had interviewed her. She was in

control of her emotions much more. What she was speaking about was congruent with her

emotions. The medication problem had been solved by collaboration with the nurses, doctor, and

patient. At first, they were unsure if putting the patient on Cogentin was the best option. After

careful consideration, they decided this was the best option, and the patient was very fortunate to

have responded as well as she did to the medication. She had also learned new coping techniques

at group, and was making plans for her future to move out into her own apartment to distance

herself from the stress that she experienced at home. She also understood her diagnoses to the

best of her ability.

Summarize the plans for Discharge

Although the nurses and doctors were unsure or when to discharge F.A., the plans for

after discharge had been established. In order to be discharged, the doctor wanted to make sure

the patient would remain compliant with medications. He established an increased chance of

compliance by putting the patient on Invega Sustenna, which is an IM injection that the patient

would receive every 30 days, rather than taking a daily dose. This increases compliance due to

the fact that the patient only has to worry about receiving the dose once a month, rather than

every day at a certain time. The patient also established trust with her family when she
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mentioned that she believes her sister put the cat in another safe home. She also believes in her

parents to put her into an effective rehabilitation program after discharge. After discharge, the

patient was planning on being admitted to a rehabilitation center outside of Cleveland. After

going through the rehabilitation program, the patient was planning on getting her own apartment

and a new cat which she could take care of.

Prioritized list of all actual diagnoses using individualized NANDA format

1. Disturbed sensory perception related to schizophrenia AEB to auditory hallucinations and

talking to unseen others

2. Risk for infection transmission related to trichomoniasis AEB contraction of the STI and

patient being sexually active

3. Ineffective health maintenance related to cocaine abuse as evidenced by patient reporting

snorting cocaine and cocaine toxicity screen testing positive.

4. Acute pain related to urinary tract infection as evidenced by pain when urinating and

positive urine bacteria.

List of potential nursing diagnoses

1. Impaired social interaction related to schizophrenia as evidenced by patient stating she

had lost contact with many of her friends and coworkers.

2. Dysfunctional grieving related to loss of familiar as evidenced by patient roaming the

streets, stating that her “mind snapped” and walking herself to the police station before

she could hurt herself or others.

3. Risk for infection transmission related to trichomoniasis AEB contraction of the STI and

patient being sexually active

4. Acute pain related to urinary tract infection as evidenced by pain when urinating and

positive urine bacteria.

5. Ineffective health maintenance related to cocaine abuse as evidenced by patient reporting

snorting cocaine and cocaine toxicity screen testing positive.

6. Ineffective coping related to substance abuse as evidenced by using cocaine at a party to

deal with her stressful home life.

7. Altered family process related to substance abuse as evidenced by patient stating her

mother and father did not approve of her use of cocaine.

8. Disturbed thought process related to schizophrenia as evidenced by persecutory delusions

upon admission.

Conclusion

Schizophrenia is a mental illness that most people never come back from. Although F.A.

had not have any positive symptoms of schizophrenia in the last year, one could see that the

negative signs were negatively affecting her life. F.A. and many others out their led normal lives

until their first psychotic break. Once the patient has their first, it is very hard to return back to

the full premorbid functioning. The onset may be abrupt, but it is important to treat the patient’s

symptoms as soon as possible. It is not only important to work with the patient, but to help work

with helping the family to understand the diagnoses. It is hard for a family to deal with those

who become mentally ill, but these patients need the social support to help get through the

devastating times they are going through. Even with therapy, medications, and support, the
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patient may never return back to the person they were before the psychotic break. As nurses, we

hope to see that they do return to full premorbid function, but it is always important to help along

those who never quite return to their full selves.

Reference Page

O'Reilly, R., Torrey, E. F., Rao, J., & Singh, S. (2013). Monozygotic twins with early-onset

schizophrenia and late-onset bipolar disorder: a case report. ​Journal of medical case

reports,​ ​7,​ 134. doi:10.1186/1752-1947-7-134

Pedersen, D. D. (2018). ​Psych notes: Clinical pocket guide​ (5th ed.). Philadelphia: F A Davis.

Saltz, B. L., Robinson, D. G., & Woerner, M. G. (2004). Recognizing and managing

antipsychotic drug treatment side effects in the elderly. ​Primary care companion to the

Journal of clinical psychiatry,​ ​6(​ Suppl 2), 14-9.

Swartz, M., Swanson, J., Hiday, V., Borum, R., Wagner, R., & Burns, B. (1999). The Role of

Co-Occurring Substance Abuse and Mental Illness in Violence. ​Violence and Severe

Mental Illness: The Effects of Substance Abuse and Nonadherence to Medication​.

doi:10.17226/9748