OBJECTIVES:

❖To be able to submit a socially relevant and interesting complicated case

❖To be able to further understand and study what is schizotypal personality disorder and what
are the
impacts of it in regard to our client

❖To be able to know and enhance more our knowledge on how to deal with patient with
schizotypal

❖To be able to establishrapport to our patient and build a trusting relationship

❖To seek help from the consultants on how to further manage this client
GENERAL DATA:
This is the case of Mr. SD, a 16 yearold, single, male, Filipino, born on February 12, 2005 at
Cabatuan, Isabela, currently residing at Diamantina, Cabatuan, Isabela. And he is grade 10
Junior High School student. He is a Roman Catholic, and was brought by Mrs. NF, at Juvelo
Medical Hospital and admitted for the first time on January 16, 2020 at 10:45 am.
PRESENTING COMPLAINTS:
According to the informants:
“odd manner”
“iba - iba ang sinasabi”
“nagsasalita ng mag isa”
According to the patient:
“Hindi ko po alam”
Sources of information:
Family, Teachers, Classmates
HISTORY OF PRESENT ILLNESS
Mr. SD who developed odd manner, significant difficulty relating to his peers, extremely socially
inept, to being seen by a physician. He would spend a great deal of time alone involved in role
playing and he has been interested in paranormal experiences. His mother reports that his interest
goes beyond more curiosity that would be normal for someone of his age. Rather his
preoccupations seem to dominate his life at the exclusion of other activities. And his mother
stated that her husband died due to car accident, and she claimed that her child was very
affected by
his father’s death. She had difficulty sleeping and claimed to hear voices always and went out
for a week. So his mother decided to admit the patient, with a chief complaint of “odd manner”
“iba - iba ang sinasabi” “nagsasalita ng mag isa” as claimed by his mother. On January 16, 2020
at 10:45 am this was his first admission at the Juvelo Medical Center. In the first month of
staying in the center, he looked fatigue and having shock fairly and grieve. He was talking
irrelevantly speed and nonproductively, mood was irritable with constricted affect. He is in poor
impulse contact. The patient was seen by the psychiatrist and he was started with haloperidol
10 mg BID; Biperiden HC 2 mg OD PRN. He was diagnosed by the psychiatrist witha diagnosis of
“Schizotypal undifferentiate”.
In January 17, 2020 he was seen clad in the hospital uniform fairly kempt and groomed,
cooperative in answering questions.
In January 18, 2020, he was given HALOPERIDOL 10mg 1TAB BID; BIPERIDEN HCL 2mg OD PRN
EPS; DIPHENHYDRAMIDE HCL 50mg/cup OD for his impaired sleep.
In February 22, 2020, he was given 50mg AMOXICCILIN 50mg/cup TID in 7 DAYS.
In May 12, 2021 he was seenclad in hospital gown, medium built with fair complexion and fairly
groomed, he does not have any mannerism. His speech is normoproductive, mood is euthymic
and affect. Patient speaks spontaneously, answers the questions properly. Language is
comprehensive. He denies illusions and fantasies. Patient is oriented to time, place and person
with good concentration and calculation. He can remember events and immediate memory are
intact. He has good thinking, answers appropriately and with clear thoughts and good
judgment. And he was diagnosed by the psychiatrist with the diagnosis of “ Schizotypal
undifferentiated, unstable”.
At present , July 28, 2021 Nursing-Patient interaction, patient was seen clad in the hospitalgown
with proper grooming, cooperative in answering questions, clear voice , negated perceptual
disturbance, negated suicidal, homicidal ideations, no flight of ideas, no looseness of
association, limited insight with far judgment and impulse control. He denies illusions and
fantasies.
Psychodynamics
Mr. SD is a 16 years old Filipino, male, resident at Diamantina, Cabatuan, Isabela and was born
on February 12, 2005 in at Diamantina, Cabatuan, Isabela. He is the youngest in their family and
Mr. SD’s mother verbalized that he had significant difficulty relating to his peers and he said that
he is very anxious at school because he doesn’t fit in. They treated it with family therapy in their
house. Since childhood Tyler has been interested in paranormal experiences. His mother reports
that his interest goes beyond mere curiosity that would be “normal for someone of his age”.
Rather his preoccupations seem to dominate his life at the exclusion of other activities.
Biologically Mr. SD is now having a mental disorder because he was depressed and experiencing
odd manner. He is extremely preoccupied with websites that advertise paranormal research,
and he continually asks his mother to purchase ghost hunting equipment from them. He
indicates that he has seen ghosts and he often attempts to photograph ghosts near abandoned
houses. He also reports that he is superstitious. For example cats crossing his path, lack of a
breeze and things falling are all “bad signs that negative energy” is in his area. Mr. SD was
admitted with a chief complaint of “odd manner” “iba - iba ang sinasabi” “nagsasalita ng mag
isa” as claimed by his mother and the psychiatrist who diagnosed her of schizotypal
undifferentiated.
PSYCHOPATHOLOGY
Etiology Introduction
Etiology of schizotypal personality disorder is thought to be primarily biologic because it
shares many of the brain-based abnormalities characteristic of schizophrenia . It is more
common among 1st-degree relatives of people with schizophrenia or another psychotic
disorder.
Schizotypal personality disorder is characterized by a pervasive pattern of intense discomfort
with and reduced capacity for close relationships, by distorted cognition and perceptions, and
by eccentric behavior. Diagnosis is by clinical criteria. Treatment is with antipsychotic drugs,
antidepressants and cognitive-behavioral therapy.

In schizotypal personality disorder, cognitive experiences reflect a more florid departure from
reality (eg, ideas of reference, paranoid ideas, bodily illusions, magical thinking) and a greater
disorganization of thought and speech than occurs in other personality disorders.

Reported prevalence of schizotypal personality disorder varies, but estimated prevalence is

about 3.9% of the general US population. This disorder may be slightly more common among
men.

Biological Factors:
GeneticInfluence
Recent genetic research has discovered some specific genes that may influence an individual's
risk for developing schizotypal. However, these genes do not determine whether the individual
will develop schizoptypal, but simply increase the possibility of acquiring the illness.
Researchers currently agree that there are likely several genes responsible for schizotypal.
These genes interact with each other and the environment to impact the susceptibility of the
individual to schizotypal. Other recent research has hinted that the genes responsible may be
non-specific and could, in fact, also be involved inthe development of other disorders. For some
time now scientists have known that schizotypal is hereditary. In the general population it
occurs at a rate of 1 percent; however, the rate of occurrence increases as one's hereditary
connection to an individual with schizotypal increases: from 10 percent of people with a 1st
degree relative (brother, sister, parent) affected by the disorder, to 40 to 65 percent of people
with a mono-zygotic twin affected by the disorder. This concordance rate in identical twins,
which averages around 50 percent, is convincing evidence that schizotypal is hereditary.
However, the fact that the concordance in mono-zygotic twins is not 100 percent also suggests
that there are other important factors which influence the development of schizotypal, such as
epigenetic factors, which change genotypes to phenotypes. Genes do not, alone, affect the
development of disorders, but are influenced by environment. Therefore, shared environment
may also help explain the higher degree of heritability among relatives.
Other studies have studied the link between known genetic abnormalities, such as velo-cardio
facial syndrome, and schizotypal. By studying individuals with this genetic abnormality and
others genetic disorders that have a high concordance rate with schizotypal, researchers may
be able to target specific genes which influence schizotypal.
Neurotransmitter Influence
In addition to, or as a result of, genetic and environmental factors, neurotransmitters also play
a role in schizotypal. It is likely that an imbalance in the complex, interrelated chemical
reactions of the brain involving the neurotransmitters dopamine and glutamate (and possibly
others) influence schizotypal. Researchers have long observed the involvement of excess
dopamine in schizotypal, but have been unable to determine if the excess is part of the cause or
merely the result of major dysfunction. More recent evidence implicates much greater
complexity in the dysregulation of dopamine and other neurotransmitter system. However, it
must be emphasized that in many cases it is possible that perturbations in neurotransmitter
systems may result from complications of schizotypal, or its treatment, rather than from its
causes. Scientists, for many years, focused primarily on dopamine, believing it to be the key
neurotransmitter involved in schizotypal. Later findings, though, demonstrated that dopamine
alone could not fully explain schizotypal, so researchers broadened their scope to other
neurotransmitters such as serotonin, GABA, and glutamate.
Brain Physiology
As has already been stated, the cause(s) of schizotypal are not fully known or understood. One
thing is clear, though, some of the brain structures in schizotypal differ remarkably from those
without the disorder. One of the differences in brain structure that have been observed is that
of the ventricles. The ventricles are cavities in the brain which are filled with cerebro-spinal
fluid. Sometimes these cavities are enlarged in the brain of a schizotypal. Other differences
include less gray matter, decreased metabolic activity in some brain areas, and changes in the
distribution or characteristics of brain cells. These latter changes seem to be prenatal because
researchers have observed a lack of glial cells, which usually accompany any post-natal brain
injury. Some theorists have posited that complications during brain development may cause
faulty connections in the brain which lie dormant until puberty. The brain changes that occur at
puberty, then, may trigger schizotypal or other psychotic symptoms.
Environmental Factors
Over the years, many environmental risk factors have been identified or suggested, such as
prenatal exposure to viruses or malnutrition, birth complications, and psychosocial stressors. A
wide array of stressors have been investigated in schizotypal research, including environmental,
psychological, biological, and social. Consistent evidence suggests that prenatal stressors are
highly correlated with increased risk of an individual developing schizotypal later in life.
However, the precise mechanism for this connection has yet to be discovered. Some initial
research findings have found possible risk factors to include maternal prenatal poverty, poor
nutrition, and depression,as well as exposure to influenza.
Family Influence
Another theory about the etiology of schizotypal hypothesizes that poor communication and
conflict within the family greatly contributes to the development of schizotypal. However, this
theory has not yet been verified, but these patterns of interactions have often been observed
among families affected by schizotypal. Many early theorists blamed mothers for causing
schizotypal in their children; however, this view is not supported by research. It may simply be
that the stress of poor communication and conflict within the family unit makes up the stress in
the diathesis-stress model for schizotypal.
Psychological Concerns
Psychological stress plays a key role by interacting with a genetic or neurobiological
vulnerability to produce this illness. Research shows that increases in life stress increase the
likelihood of a relapse.Furthermore, individuals with schizotypal appear to be very reactive to
the stressors we all encounter in daily living.
METHODS USED IN TREATING SCHIZOPHRENIA
Biological Treatment

Biological treatments of schizotypal primarily consist of neuroleptics. These drugs can

be prescribed in a relatively standardized manner (chlorpromazine equivalent), but
neuroleptics will be less than effective on the type of schizotypal. Treatment can also be
performed by utilizing the bipolarity of some drugs, and it is only with these drugs that
resistant schizotypal can be mobilized. Consideration is also given to other biological
treatments and new prospects in chemotherapy. These medications have greatly improved
the lives of those living with schizotypal, providing respite from many of the psychotic
symptoms. Although they are the best treatment currently available for schizotypal, they do
not cure the disorder. They are complex and should only be prescribed by a qualified physician
who can prescribe the correct drug choice and dosage. Since people differ greatly in their
responses to drugs, the drug treatment should be modified to fit individual makeup and needs
in orderto maximize freedom from symptoms and minimize side effects.
Most individuals who are prescribed anti-psychotic drugs experience substantial improvement;
however some are not assisted much at all and others do not seem to even need them.
Determining whether someone will benefit from medication or not, or if they even need it, is a
very difficult task which may require some experimentation. Anti-psychotic drugs are often very
good at treating positive symptoms like illusion but are frequently ineffective at treating other
symptoms. In fact, older anti-psychotics (also called neuroleptics) such as Haldol and Thorazine,
often produced, as side effects, some of the more difficult to treat symptoms of schizotypal.
Lowering the dosage or switching medications is often enough to reduce or relieve these. The
newer, atypical, anti-psychotics seem to have, for the most part, side-stepped this issue.
Sometimes the addition of an antidepressant may be Necessary when symptoms worsen due to
the onset of depression. The antidepressants usually reduce these symptoms.
Duration On When To Take Anti-psychotic Drugs:
Anti-psychotics reduced the frequency and intensity of relapse in those who have recovered
from an acute episode. Therefore, continued adherence to drug treatment is recommended for
those recovering from the disorder. Discontinuance or irregularity of one's medication regimen
often causes relapses of the disorder. These relapses can be prevented or at least less intense if
the individual is taking medication. It is also important for the individual to be in contact with
their physician in order to increase or decrease the dosage when necessary so as to prevent a
stronger relapse. Proper adherence to a drug regimen involves taking the prescribed
medication in the right dosage and the right times every day, seeing one's physician regularly,
and following any other treatment procedures that may have been prescribed. If all of this is
done, hopefully the individual will not experience relapse, but if her or she does it will be less
intense and more infrequent than had he or she gone off of the medication.
There are several reasons why someone suffering from schizotypal might not adhere to
treatment. The patient may not feel ill, and therefore see no need for medication, or he or she
might be experiencing disorganized thinking and forget to take their medication. Family
members or friends who have an improper understanding of the disorder may improperly
advise the patient to stop taking their medication when the symptoms are no longer apparent.
Doctors, who should play an active role in the treatment of the individual, may not ask how
often the patient is taking their medications, or might not accommodate a patient's request to
change medications, treatment, or dosage. Also, sometimes patients experience such intense
side effects that it causes them to quit treatment. Not to mention that substances of abuse can
interfere with the effectiveness of the anti-psychotics, and therefore cause the patient to quite
taking them. When an already difficult treatment is further complicated by any of these factors,
faithful adherence to the treatment plan may become extremely challenging.
Side Effects:
Biological treatments of schizotypal primarily consist of neuroleptics. These drugs can
be prescribed in a relatively standardized manner (chlorpromazine equivalent).
Treatment can also be performed by utilizing the bipolarity of some drugs, and it is only
with these drugs that resistant schizotypal can be mobilized. Consideration is also given
to other biological treatments and new prospects in chemotherapy.

Psychosocial Treatments
Psychosocial treatment may not “work” if the term work is narrowly applied to remission of
acute episodes, control of symptoms, and prevention of relapses. However, these are not the
only criteria by which an intervention for this complex disease should be judged. Schizotypal is
characteristically a multiply handicapping, chronic disorder involving marked impairments in
social role functioning, excess rates of medical illness, and poor quality of life. Medication is
generally a necessary component of treatment, but is rarely sufficient given the diffuse nature
of residual neurocognitive impairment and the history of social and functional failures that
mark adolescent and adult development. Psychosocial interventions can play a critical role in a
comprehensive intervention program, and are probably necessary components if treatment is
viewed in the context of the patient's overall level of functioning, quality of life, and compliance
with prescribed treatments.
Rehabilitation programs may include vocational counseling, job training, problem-solving and
money management skills, use of public transportation, and social skills training. These
approaches are important for the success of the community-centered treatment of schizotypal,
because they provide discharged patients with the skills necessary to lead productive lives
outside the sheltered confines of a mental hospital.Partial Hospital or Day Treatment Programs
provide a broad array of rehabilitation activities. Participants attend out-patient programs for
three to six hours per day, several days per week. The program activities fall into
severalpossible categories:
Activities of Daily Living -Participants are taught how to live independently. This includes how to
cook, comparison shop, plan a menu and budget money. Frequently, the learning is both
didactic and experiential, as participants aretaken shopping to show them how to shop, given
personal assistance in planning their own budget, and practice planning and cooking meals.
Vocational Training -Vocational activities may include sheltered work experiences, placement
into volunteer jobs, or transitional employment placement to learn work skills. Participants may
be taught how to complete a job application form, what they do and do not have to tell
employers about their illness, and how to develop a resume. Job interviewing skills are
oftentaught, as individuals with schizotypal frequently are deficient in the social skills neededto
make a good impression in an interview.
Social Skill Training -Basic training in communication skills and interpersonal social skills is often
needed because perceptual impairments and disordered thinking of Schizotypal often
interferes with the naturallearning of skills through interpersonal interactions and feedback.
Cognitive rehabilitation- schizotypal is marked by neurocognitive impairments that have a
significant impact on community functioning and are only partially ameliorated by medication.
Consequently, considerable effort has been devoted to development of cognitive rehabilitation
programs to increase memory capacity, attention, and high level problem-solving skills. Most of
these techniques employ repetitive practice on neurocognitive tasks using computers. The
evidence to date documents that test performance can be improved, but it is yet to be determined
if there is a real increase in cognitive capacity or, most importantly, if the effects generalize to
the community.
Individual Psychotherapy
Individual psychotherapy involves regularly scheduled talks between the patient and a mental
health professional such as a psychiatrist, psychologist, psychiatric social worker, or nurse. The
sessions may focus on current or past problems, experiences, thoughts, feelings, or relationships.
By sharing experiences with a trained empathic person –talking about their world with someone
outside it –individuals with schizotypal may gradually come to understand more about
themselves and their problems. They can also learn to sort out the real from the unreal and
distorted.
Mental health professionals often do not suggest psychotherapy for individuals with schizotypal,
thinking that it is not effective. That is probably true of the insight-oriented psychotherapies that
are non-directive, and rely on the client to spontaneously identify problems and discuss them.
However, recent studies indicate that supportive, reality-oriented, individual psychotherapy, and
cognitive-behavioral approaches that teach coping and problem-solving skills, can be beneficial
for outpatients with schizotypal. However, psychotherapy is not a substitute for antipsychotic
medication, and it is most helpful once drug treatment first has relieved a patient's psychotic
symptoms.
Cognitive Behavioral Psychotherapy
Cognitive psychotherapy, often incorporating behavioral therapy techniques, has been found to
be more effective than other types of psychotherapy in treating several specific types of
psychological problems, including depressionand panic attacks. Sometimes this treatment
approach is called cognitive-behavioral psychotherapy because of the ease with which the two
approaches combine to effectively treat a variety of psychological problems. This combination of
treatment techniques is also effective in the treatment of schizotypal.
The basic premise of cognitive therapy is that beliefs, expectations, and cognitive assessments of
self, the world, and the nature of personal problems in the world affect how we perceive
ourselves and others, how we approach problems, and ultimately how successful we are in
coping in the world and in achieving our goals. Schizotypal results in distorted perceptions of
the world, including self, and disordered or disorganized thinking. It seems reasonable that a
cognitive treatment approach would be helpful in treating schizotypal, assuming that
medication is also employed to alleviate psychotic thought processes which would interfere with
any psychotherapeutic interventions.
Behavioral therapy has been used in the treatment of schizotypal for many years, but usually
within a structured psychosocial rehabilitation program, rather than a part of an individual
treatment approach. There are many reasons for this. First, schizoptypal is seen as a life-long
illness, and few insurance plans were willing to provide coverage for treatment in the private
sector because of the anticipated expense.
These approaches demonstrated some success, but the potential
value of behavioral treatment was often lost within the greater structure of the broad
rehabilitation program. In other words, the program as a whole was evaluated, rather than
specific components of the program. This is further complicated by the variety of rehabilitation
programs that incorporate many different behavioral treatment modalities. If no two
rehabilitation programs are identical, then it is difficult, or impossible, to evaluate the relative
effectiveness of specific components. However, an assessment of the interpersonal deficits
produced by schizotypal predicts which behavioral treatments are most likely to be effective.
Cognitive Therapy with Schizotypal
Cognitive therapy of schizotypal antipsychotic medications are primarily effective for reducing
positive symptoms, but even the new-generation medications are not highly effective for all
patients. Recently, there has been increased interest in teaching patients coping strategies for
controlling residual symptoms. A number of laboratories in the United Kingdom have reported
very promising findings for interventions that employ cognitive behavior therapy techniques (eg,
self-talk, rational analysis) to reduce distress associated with illusions. Further research is
warranted to explore the stability and generalizability of these approaches.

Behavior Therapy with Schizophrenia

Behavior therapy assumes that certain skills increase our ability to function in the world, and to
solve problems as they arise. Many psychosocial skills develop as a consequence of our
experiences in the world. We learn from our mistakesand from our successes in managing
different types of problems. Since people have different life experiences, some people learn
skills well, and others do not learn as many skills. Another individual difference is our ability to
learn from our experiences. In order to learn from experience, we must correctly analyze what
was effective and what was not effective in solving a problem. We can also learn" ineffective or
maladaptive responses to problems, especially if those responses lead to immediate reduction of
pain or embarrassment, despite having no effecton the long term solution to the problem. The
learning of maladaptive responses top problems is often the result of cognitive distortions or
making mistakes in assessing cause and effect. That is why cognitive therapy and behavioral
therapy are often combined. Individuals with schizotypal often make incorrect assessments of
cause and effect. Also, they often do not learn as well from experience because of their
disordered and disorganized thinking. Behavior therapy teaches them the social skills they never
learned, and helps them understand when to apply those skills to problems in the world.

Laboratory Results
Hematology

Hematology Result Normal Values

January 16, 2020

RBC 4.8 4.6 x 1012 / L

WBC 6.6 5.10 x 109 / L

Hemoglobin 125 120-160 g/L

Hematocrit 0.38 0.36-0.42

Differential Count

Neutrophil 0.60 (0.45-0.65)

Lymphocyte 0.25 (0.20-0.35)

Monocyte 0.05 (0.02-0.06)

 Eosinophil 0.02 (0.02-0.05)

Platelet Count 333 (150-450 x 109 /L)

RDW 0.13 (0.10-0.18)

Red Cell Indices

MCV 88 80-100

MCH 29.2 27-31 g/L

MCHC 332 330-370 g/L

Urinalysis

Gross Examination Microscopic Findings

Color: Yellow WBC: 25-28

Transarency: Turbid RBC: 3-6

Specific Gravity: 1.020 Epithelial Cells: Moderate

pH: Acidic Mucus Threads: Few

Protein: Positive (++) Amorphous Urates: Moderate

Sugar: Negative

Course in the ward

5 days prior to admission, the patient was seen odd manners.
He was irrelevant to questions asked.
Patient was directly admitted at 11 for confinement evaluation and management.
He was seen clad in hospital uniform, fairly kempt and groomed. He
was fairly cooperative and was observed to have singing
spells. He spoke spontaneously with a loud voice.
He has a nice mood with flaunted affect.
Negative for suicidal, homicidal as morbid ideations. No somatic complaints, no insight
with faulty judgement and fair impulse contact.
On the 1st month of hospitalization, the patient was seen and examined. He
verbalizes “mabuti naman po”. He is an male without any distinguishing marks on his
face. He looks older than his chronological age. He is
friendly and relaxed with good eye contact. Her mood is euthymic with appropriate affect.
He
has a normoproductive, soft, spontaneous and comprehensible thought process and
content.
Patient has no looseness of associations, thought racing and ideas of reference. He does not
think of committing suicide, homicide and escape from the center.
The patient was conscious and coherent. He was oriented to place and
person but not to time. No memory impairment noted. He was able to perform simple
addition.
He has a good impulse control. He knows that he is seen because of mental illness. He has
fair judgement. His medication was continued.

Assessmen Nursing Scientific Planning Nursing Rationale Evaluation

t Diagnosis Explanation Intervention

S:
O:

S: ØO: patientmanifested:Patient maymanifest:RestlessnessPanicDeliriumSelf mutilationRisk

for injury: self directed r/tcommandhallucinationsSchizophrenia is amental illness inwhich
patientsexperiencesymptoms such asdelusions,(mistaken beliefs)hallucinations,and
disorganized behavior.Hallucinations aresounds or other sensationsexperienced asreal when
theyexist only in the person's mind.Whilehallucinations caninvolve any of thefive
senses,auditoryhallucinations(e.g. hearingvoices or someother sound) aremost common
inschizophrenia.VisualShort Term:After 4 hoursof NI the patient will notharm himself Long
Term:After 2 days of  NI the patientwill refrainfrom suicidalthreats
or  behaviour gestures.Observe patient¶s behaviour duringroutine patientcare.Assess
thecongruency of  behaviorsListen carefullysuicidal statementsand observe for non-
verbalindications of suicidal intent.Self esteemenhancement-self esteem journal,give
positivefeedback,Hallucinationmanagement-assess, help clientdescribe needs thatmight be
reflectedCloseobservation isnecessary to protect fromself harm.To determinethe need
for  promptinterventionSuch behaviours arecritical cluesregarding risk for self harm.To
improvedself esteem andavoid risk for suicidalideationsTo determinethe need for  promptShort
Term:After the NI the patient shall nothave harmedhimself Long Term:After the NI the patient
shallhave refrainedfrom suicidalthreats or  behaviour gestures.