I.

INTRODUCTION Paranoid schizophrenia is the most common type of schizophrenia in most parts of the world. The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent.

With paranoid schizophrenia, your ability to think and function in daily life may be better than with other types of schizophrenia. You may not have as many problems with memory, concentration or dulled emotions. Still, paranoid schizophrenia is a serious, lifelong condition that can lead to many complications, including suicidal behavior. (http://www.mayoclinic.com/health/paranoid-schizophrenia/DS00862)

Patients who have paranoid schizophrenia that has thought disorder may be obvious in acute states, but if so it does not prevent the typical delusions or hallucinations from being described clearly. Affect is usually less blunted than in other varieties of schizophrenia, but a minor degree of incongruity is common, as are mood disturbances such as irritability, sudden anger, fearfulness, and suspicion. "Negative" symptoms such as blunting of affect and impaired volition are often present but do not dominate the clinical picture.

The course of paranoid schizophrenia may be episodic, with partial or complete remissions, or chronic. In chronic cases, the florid symptoms persist over years and it is difficult to distinguish discrete episodes. The onset tends to be later than in the hebephrenic and catatonic forms. (http://www.schizophrenia.com/szparanoid.htm)

According to the World Health Organization, It describes statistics about mental disorders of year (2008). Schizophrenia is a severe form of mental illness affecting about 7 per thousand of the adult population, mostly in the age group 15-35 years. Though the incidence is low (3-10,000), the prevalence is high due to chronicity. According to the facts it reveals Schizophrenia affects about 24 million people worldwide. Schizophrenia is a treatable disorder, treatment being more effective in its initial stages. More than 50% of persons with schizophrenia are not receiving appropriate care.90% of people with untreated schizophrenia are in developing countries. Care of persons with schizophrenia can be provided at community level, with active family and community involvement.

Schizophrenia affects men and women with equal frequency. Schizophrenia often first appears in men in their late teens or early twenties. In contrast, women are generally affected in their twenties or early thirties.

In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).

(http://www.howstuffworks.com/framed.htm?parent=schizophrenia.htm&url=http://www .nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml)

In the Philippine setting, the disability survey done in 2000 by the National Statistics Office (NSO) found out that mental illness was the 3rd most common form of disability in the country. The prevalence rate of mental disorders was 88 cases per 100,000 population and was highest among the elderly group. This finding was supported by a more recent data from the Social Weather Station Survey commissioned by DOH in 2004. It reveals that 0.7 percent of the total households have a family member afflicted with mental disability. The Baseline Survey for the National Objectives for Health in 2000 stated that the more frequently reported symptoms of an underlying mental health problem were sadness, confusion, forgetfulness, no control over the use of cigarettes and alcohol, and delusions.

The most recent study on the prevalence of mental health problems was conducted by the National Epidemiology Center (DOH-NEC) in 2006 which showed revealing results though the target population was limited only to government employees from the 20 national agencies in Metro Manila. Among 327 respondents, 32 percent were found to have experienced a mental health problem at least once in their lifetime. The three most prevalent diagnoses were: specific phobias (15 %), alcohol abuse (10%), depression and schizophrenia (6%). Mental health problems were significantly associated with the following respondent characteristics: ages 20-29 years, those who have big families, and those who had low educational attainment. The prevalence rate generated from the survey was much higher than those that were previously reported by 17 percent.

Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments. Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will minimize symptoms and maximize quality of life.

This introduced psychiatric case was chosen primarily because it is the most interesting amongst the cases that were encountered by the group members. It posts relevant manifestations that are psychiatric in nature and the entire case is highly possible to be studied comprehensively within the limited time available.

elderly population.

RISK FACTORS: Some formal psychotic disorders, like Schizophrenia, tend to run in families. If someone has a psychotic disorder, it is quite likely that another member of his/her immediate or extended family also has had a psychotic disorder. Generally, the first signs of most psychotic disorders appear when a person is in his/her late teens, twenties, or thirties.

CAUSES .

Causes are largely UNKNOWN Patients with personality disorder may have biological or psychological vulnerability toward the development of psychotic symptoms

One or more severe stress factors, such as traumatic events, family conflict, employment problems, accidents, severe illness, death of a loved one, and uncertain immigration status, can precipitate brief reactive psychosis.

Biological or genetic predisposition Environmental factors may also play a role in their development, including stress, drug abuse, and major life changes.

In addition, people with certain psychotic disorders may have an imbalance of certain chemicals in the brain. They may be either very sensitive to or produce too much of a chemical called dopamine. Dopamine is a neurotransmitter, a substance that helps nerve cells in the brain send messages to each other. An imbalance of dopamine affects the way the brain reacts to certain stimuli, such as sounds, smells, and sights, and can lead to hallucinations and delusions.

SIGNS AND SYMPTOMS

Hallucination Delusion Disorganized or incoherent speech Confused thinking Strange, possibly dangerous behavior Slowed or unusual movements Loss of interest in personal hygiene Loss of interest in activities Problems at school or work and with relationships Cold, detached manner with the inability to express emotion Mood swings or other mood symptoms, such as depression or mania

PROGNOSIS

Many people who have been diagnosed with a psychotic disorder tend to lead productive lives and function normally with the proper treatment. The prognosis for those with psychotic disorders varies from person to person. For example, women tend to respond better to medication than men. Those with a family history of illness have a lower prognosis than those without. The number of negative symptoms also determines the individual prognosis as well as age; the older the patient, the more promising prognosis. Another important factor in determining prognosis is the individuals support system. Most will never fully recover from or be cured of psychotic disorders and will need to continue treatment for the duration of their lives. To maintain mental and physical stability with the condition, it is important for patients to strictly follow the treatment recommended by their healthcare providers.

COMPLICATIONS

Accidental injuries suicide, or homicide can occur during a psychotic episode. Loss of relationships or employment is common

PREVENTION

In general, there is no known way to prevent most psychotic disorders, but many of the related symptoms can be prevented with early detection and treatment. Seeking help as soon as symptoms appear can help decrease the disruption to the person's life, family, and friendships. Avoiding drugs and alcohol can prevent psychotic disorders associated with these substances.

II.

OBJECTIVES

To commence rapport building and development of the therapeutic relationship To introduce patient to the process of therapy and instill a sense of realistic hopefulness about outcome To know about differential diagnosis of psychotic episodes and relevant investigations. To know about treatment including social, pharmacological and psychological.

III.

PATIENTS PROFILE

Name: Macrina Dizon Age: 39 Gender: Female Address: Dayanki, Burgos Ilocos Sur Occupation: Farmer/Housewife Birhtdate: January 30, 1974 Birth Place: Ilocos Sur Civil Status: Single Nationality: Filipino Religion: Roman Catholic Date of Admission: 04/16/2013 (April 16, 2013) Time of Admission: 3:45PM Diagnosis: Paranoid Schizophrenia Attending Physician: Dr. Cayad

IV.

PSYCHIATRIC HISTORY

History of Present Illness Patients last admission was due to poor sleep and apptit, but still energetic during

the day, able to perform grooming and personal hygiene practices she also started to have pressured speech, seen talking to self and always says, Jehovah Ama. She also started to become verbally and physically assaultive toward husband and relatives. She also had visual hallucinations of red, black, and white dancing dumbles, and witch nga agli ti bassit nga bato. She also had Auditory Hallucinations, ag pakamatay kan. The patient improved and discharged after 18 hospital days, with home medications. Patient discontinued her medications ever since her last admission. She takes it intermittently and only whenever she likes to. She refuses to take it at night, complaining that it tastes bitter. Patient was apparently coherent, responsive, and non-violent until two weeks PTA, patient reportedly worked all day in the farm. She got exhausted and went home. When she arrived home in the evening, there has been noticeable change in mood and affect. Patient had difficulty in sleeping, was irritable, had a decrease in appetite and talked excessively. She talks to herself in the kitchen, turns all the lights on and laughs all by herself. At the same week, patient roamed around the plaza talking to herself and says, Ama Jehovah again. She also spits on their neighbors. Patient also manifests with auditory hallucinations saying that she hears non-existent voices telling her, Wala kang Silbi magpakamatay ka nalang she also had visual hallucinations saying that people around her have fangs. 6 days PTA, patient reportedly took her clothes off outside their house. When asked why she did it she said that she felt hot and want to sun bathe. 3 days PTA patient threatened to hurt her nephew One day PTA patient brought the foam of their bed outside their house. After a while she was seen stepping on it with her clothes off. When asked why she did it patient verbalized Bakit ako mahihiya! Lahat naman tayo walang damit parang si Adan at si Eba Symptoms persisted and reportedly worsened hence admission in this institution on April 16, 2013

Past Medical History Patient has no known allergy to any drug, or food. She has had 4 past admissions in this institution. She was diagnosed of Paranoid Schizophrenia, Undifferentiated, Chronic with acute exacerbation on October 1989; Paranoid Schizophrenia, E with IERS on December 1998, July 2011 and July 2012. No other previous surgeries, history of trauma or accident and no known other known medical conditions. She does not go for regular consultation, unless experiencing Signs and Symptoms. She is a Non- Alcoholic and a Non- Smoker. Family History Father Modesto Deceased due to Old Age Mother Maria 73 years old, with hip fracture Siblings Fe 58- married BSN Graduate Cecilia -55 Married Businesswoman Lenita- 54 married Susana 52 Married physician Corazon- 50 married commerce graduate Modesto Jr.- 29 unemployed Patient

No other family members of mental illness. All siblings are close to patient. Denies heredofamilial diseases like cancer, asthma, Diabetes Mellitus

Personal Developmental, Social, and Environmental History. Patient was born via NSD in, home delivery by a traditional birth attendant. Developmental milestones at par with age. She is an average student during her school days but wasnt able to go to college due to financial constraints. She has a harmonious relationship with her family and friends. She does not smoke nor drink alcohol at present she is a housewife and works as a farmer in the morning. As for health care practices, she does not go for medical check up and does not practice any form of alternative medicine.

V.

MENTAL HEALTH ASSESSMENT

PHYSICAL ASSESMENT
SENSATION During the morning, it is scheduled that all patients must be taking their bath. Early in the morning, the water is very cold and the weather is very windy and coldly. The patient knows about this thats why her significant other is requesting a hot water with water temperature at body temperature just her for the patient not to refuse from taking a bath. ELIMINATION The patient is well voiding and eliminating with estimated urine and stool ratio of 2:6-8 per day. LOCOMOTION The patient is well moving around the room without pain noted during the movement. FLUID Patient is taking fluid without any difficulty and can drink water with an estimated intake of 1 liter. POSTURE Well ambulated and have acceptable social posture AERATION The patient is well breathing with no obstruction and difficult and having discharged patient has an respiration rate of 18 breaths per minute CIRCULATION The patient has a normal cardiac rate with normal capillary refill from extremities and no abnormal heart sound noted. INTEGUMENTARY The patients skin is well moisture warm to touch, with good skin. No Anomalies noted NUTRITION The patient eats all types of food and eats regularly (3x a day) During eating the patient doesnt experience any difficulty and obstruction GENERAL APPEARANCE The patient is neat , fairly groomed, coherent and not in reparatory distress.

 PSYCHOLOGICAL ASSESSMENT GENERAL PRESENTATION APPEARANCE The patient had seen well groom and young. She dress appropriately according to age and sex. She also had seen healthy and good posture and normal way walk or gait.

GENERAL BEHAVIOR The patient does not show mannerism, combative actions, twitching, hand and feet wringing and rubbing but she is clumsy and having psychomotor retardation (patient is less moving and cooperative to the daily activities. ATTITUDE TOWARDS THE EXAMINER Attitude is a position of the body or manner of carrying oneself. It is a position or posture of the body appropriate to or expressive of an action, emotion. The patient cooperates in the whole duration of duty and was able to answers most of questions asked to her and cant participates in all activities. It was also observed that she was not going out with other patient and student nurse. STATE OF CONSCIOUSNESS During my interaction to the patient I had observed that she is aware of the time date and place of where she is. Attention As I observed to the patient, every time we interact, the patient focus during the interaction is quite ineffective shes having a flight of ideas during our conversation SPEECH During interaction with the patient, the patient is kept on silence and it seemed to be that shes afraid of something. Orientation The patient is aware to her name, age, and when she is born, the place and their home address but when I asked her about the current time, she is not response and remained mute following other questions. Example conversation: Nurse: Ano po pangalan mo? Patient: Macrina Nurse: Ilan taon ka na? Patient: 39 na Nurse: san ka pinanganak? Patient: Burgos Ilocos Sur

Nurse: Galing naman, alam na alam ah..eh anong oras na ngayon at anong araw ngayon? Patient: Smiles, May 8, 2013 Mood and Affect A severe reduction in emotional expressiveness. People with schizophrenia often show flat affect. A person with schizophrenia may not show the signs of normal emotion, perhaps may speak in a monotonous voice, have diminished facial expressions, and appear extremely apathetic. The patient sometimes shows flat affect during the whole interaction. Form of Thought As presented the example above, I think it is hard for me to determine the main idea that she might poses to express because of the mute behavior of the patient the conversation but I taught it is a form of thought (flight of idea), because I felt that she want to jump the topic from another topic. Thought Content I observed to the patient that every time the door is open, she is always been near to the door holding her things and also the mute behavior during interaction. Perception According to her husband, the patient displayed misperception to the sound. An auditory hallucination that have been noted prior to hospitalization. The patient told wala kang silbi magpakamatay ka na. JUDGEMENT During the 3rd day of conversation, I tried to remotivate the patient through helping to increase self perception toward treatment. I told to her that: Nurse: adding kong gusto mong gumaling at makalabas dito, sana makipagcooperate ka lang, kasi sana sayo din yan nakasalalay, ang paggaling mo. Patient: Sige po sir Nurse: naiintindihan mo po ba ako? Tandaan mo, nasa sayo ang paraan para gumaling ka Patient: Opo, Sir namimiss ko na po kasi sa bahay These conversation might implied that the patient have good judgement because she kept on talking and being restless staring and remember, commonly people, whey they answer question like these, they will answer properly and accurately. MEMORY
With Short Term Memory

INTELLECTUAL FUNCTIONING
The Patient is disoriented to 3 spheres

VI.

TREATMENT MODALITIES

Psychotherapy Psychotherapy ("talk therapy") involves working with a trained therapist to figure out ways to solve problems and cope with depression. It can be a powerful intervention, even producing positive biochemical changes in the brain. Three major approaches are commonly used to treat clinical depression. In general, these therapies take weeks to months to complete. Each has a goal of alleviating your symptoms. More intense psychotherapy may be needed for longer when treating very severe depression or for depression with other psychiatricsymptoms. Interpersonal therapy (IPT): This helps to alleviate depressive symptoms and helps you develop more effective skills for coping with social and interpersonal relationships. IPT employs two strategies to achieve these goals.

The first is education about the nature of depression. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment. The second is defining your problems (such as abnormal grief or interpersonal conflicts). After the problems are defined, the therapist is able to help set realistic goals for solving these problems. Together you will use various treatment techniques to reach these goals. Cognitive behavioral therapy (CBT): This helps to alleviate depression and reduce the likelihood it will come back by helping you change your way of thinking. In CBT, the therapist uses three techniques to accomplish these goals.

Didactic component: This phase helps to set up positive expectations for therapy and promote your cooperation. Cognitive component: This helps to identify the thoughts and assumptions that influence your behaviors, particularly those that may predispose you to being depressed. Behavioral component: This employs behavior-modification techniques to teach you more effective strategies for dealing with problems. Behavioral therapy (BT): This helps to modify your depressive behaviors through highly structured, goal-oriented therapy. BT uses three techniques to accomplish these goals.

Functional analysis of behavior: This helps to define the behaviors that will be targeted for change. Selection of specific techniques: Various techniques can be employed to help modify the selected behavior, including relaxation training, assertiveness training, role-playing, and timemanagement tips. Monitoring behavior: Progress and program effectiveness can be monitored by logs and records you keep.
General management and advice to patient and family Remain optimistic and emphasize the patients strengths and abilities rather than deficits. Recovery often takes place in small steps and, for the patient, being engaged in an activity that is meaningful to them might be as important as symptom control. Support patient to function in the areas that are important to her (eg work, recreation,

relationships).

 It is important proactively to offer patients the same health promotion and prevention measures as the general population (eg smoking cessation, weight control, screening for diabetes and sexual health). Psychological therapies for both the patient and family/carers might help prevent relapse, promote recovery, and are increasingly available in local services. Encourage the patient to engage with psychological therapies where available (eg cognitive behavioural therapy, family therapy, problem-solving interventions). Family interventions or problem-solving work might help improve patient and carer health. Therapeutic alliances build on respect and feeling valued. Encourage the patient to build

relationships with key members of the practice team.

IX.

DISCHARGE PLANNING

M- Chlorpromazine 100mg tab; Oral; Once a Day Biperidine Haloperidol

E- Lower Class

T-Psychotherapy/Cognitive Behavioral Therapy and Medications (antipsychotic drugs)

H-Have a healthy, quiet and stress free environment Always have an adequate rest Verbalize and express your feelings to someone if you feel lonely and stress Always be optimistic Instruct patient to do some exercise that she can tolerate Comply on physicians order/teachings Support patient to function in the areas that are important to her work, recreation, relationships Never leave patient alone

O-The patient is advised to have a follow up check-up a week after she was discharged.

D-Diet as Tolerated