PREDISPOSING FACTORS

PSYCHOLOGICAL FACTORS Psychological theories believe that schizophrenia results in part from early interactions with primary caregivers who fail to provide warm emotional ties. Maladaptive parental responses increases stress, and this interaction in turn generates symptoms in the child. Intense frustration and distrust eventually culminate into regression that is often accompanied by social withdrawal of emotion investment or expectation of warmth or BIOLOGICAL a.) GENETICS It is widely agreed that both heredity and environment play an important role in severe mood disturbances. Affective illness has been the subject of considerable research on the relevance of hereditary factors. A genetic link has been suggested in numerous studies; however, no definitive mode of genetic transmission has yet to be demonstrated. b.) NEUROCHEMICAL THEORIES

FREUD Freud believed that family relationships were the basis of maladaptive responses. Distortions in the mother-child relationship brought about by anxious mothering makes the child unable to progress beyond dependence and affects the ego organization and interpretation of reality. In the case of our client, he grew up with a single mother only since his mother wouldnt want to marry the man who was supposed to be his father. Ever since from the start he was already an unwanted child since according to the watcher it was much more like an unwanted pregnancy. The mother didnt really like the man who got her pregnant for reasons not known by the watcher. His mother would always abuse him physically and

ERIKSON Erikson believed that a lack of meaningful relationships with primary caregivers generates profound frustration, conflict, fear and distrust of the world. Trust must be initially achieved by a person since it provides the foundation for the successful achievement of succeeding stages. The failure to resolve a stage may lead to psychological symptoms either in childhood or subsequently in late adolescence or adulthood. In the case of our client, he grew up with a single mother only since his mother wouldnt want to marry the man who was supposed to be his father. Ever since from the start he was already an unwanted child since according to the watcher it was much more like an unwanted pregnancy. When his mother found another man, she only brought his eldest half sister with her, leaving our client in the care of their relatives (sisters of his mother) and his grandmother. As claimed by his watcher, he was left even in the care of their relatives and his grandmother even though it was against their will. Since then, due to lack of to the caregivers interest and compassion, no one was able to take care of him well and his needs were

SULLIVAN Sullivan believed that childhood development is influenced by interpersonal relationships. Distortions in the interpersonal relations can affect ones personality development and chances for a normal and successful life. Sullivan believed that people acquire certain images of self and others throughout the developmental stages, and he referred to these subjective perceptions as personifications. Disapproval and neglect of the mother can develop the bad-me personification of the child, which grows from experiences of punishment and disapproval.

Neurochemical influences of neurotransmitters (chemical messengers) focus on serotonin and norepinephrine as the two major biogenic amines implicated in mood disorders. Serotonin has many roles in behavior: mood, activity, aggressiveness and irritability, cognition, pain, biorhythms, and neuroendocrine processes (i.e., growth hormone, cortisol, and prolactin levels are abnormal in depression Norepinephrine levels may be deficient in depression and increased in mania. This cathecolamine energizes ghe body to mobilize during stress and inhibits kindling. Kindling is the process by which seizure activity in specific area of the brain is initially stimulated by reaching a threshold of the cumulative effects of stress, low amounts of electric impulses. Dysregulation of acetylcholine and dopamine also is being studied in relation to mood disorders. The neurotransmitter problem may not be as simple as

As claimed by the watcher, his mother would always abuse him physically and emotionally as if projecting the mothers frustration and anger to him. He often isolates himself and rarely plays with his cousins and other children in their community during his toddlerhood. During his adolescence, he joined a fraternity yet due to

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PERSONALITY DISORDER Avoidant Personality Disorder It is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts. Afraid to commit mistakes hence they avoid gatherings which can then confirm their inadequacy. Ever since our client was still young, watcher claimed that he doesnt engage much in social relations with others. He often isolates himself with his cousins, neighbors and the society in general. However, the only pleasant significant relationship that he ever had was with his aunt who he considered to be his mothering one and his only consistent and constant support system. When he reached the adolescent stage where peer pressure is at its highest, he was able to find belongingness and acceptance with the fraternity: Kachinas. Unfortunately due to some conflicts regarding the hazing process he took it more as a sense of rejection, due to the fact that people with avoidant personality disorder are very hypersensitive to negative evaluation. In addition, throughout all the interactions that we had with him, we have observed that whenever he is asked with questions, he would usually pause for a while before answering the

PRECIPITATING FACTORS A. Sociocultural Stressors: Divorces are common. Mobility has broken up the extended family, depriving people of all ages of important support systems. The many stresses on the family have made it more difficult for family members to accomplish the developmental tasks related to intimacy. He grew up with a single mother only since his mother wouldnt want to marry the man who was supposed to be his father. Ever since from the start he was already an unwanted child since according to the watcher it was much more like an unwanted pregnancy. He wasnt able to receive the warm and accommodating love of his biological parents rather he grew up with his relatives. His mother would always abuse him physically and emotionally as if projecting the mothers frustration and anger to him. Since then, due to lack of to the caregivers interest and compassion, no one was able to take care of him well and his needs were not immediately gratified and that he didnt have any clear and consistent caregiver. We believe that the client was not able to

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B. Psychological Stressors: A combination of prolonged or intense anxiety with limited coping ability is believed to cause severe relationship problems. Ever since our client was still young, he was already vulnerable to stress and problems since he was abandoned by his family and had no constant support system. He also has limited coping abilities since he often keeps all his problems within him with no one to talk to. Thus, with all the stressors FACTORS that he has FAMILY experienced such starting from the problems within their family, aggravated by the death of his aunt and the hazing problems in his fraternity, this created prolonged and intense anxiety within him thus leading him to have problems with avoiding relationships. According to the family theory model of Bateson et. al. , the child is assumed to have been raised in an atmosphere of unhappiness and tension, which may not be apparent to others or even to the family members themselves. Families make great attempts to conceal or repress unhappiness resulting in psychological insensitivity. Several family patterns have been cited as being particularly damaging to the developing child. The first pattern is double-bind in which the child is forced between two unreasonable perceptions, thus, producing confusion, anxiety and fear in the childs mind. The second family pattern seen as destructive involves marital problems between parents. This pattern results in children being asked to support one parent against another. Such a situation causes guilt feelings in the children because of divided loyalties. In addition, the spouse is forced to submit may displace his/her anger onto the children. The third pattern arises from destructive expressed emotion (EE) within the family. At times there is a false agreement about family rules that is not communicated directly but produces explosive behavior when violated. There is also an air of pseudo hostility that forces some family members into emotional isolation. The constant criticism and hostility destroy the family functions to support and protection. In the case of our client, he grew up with a single mother only since his mother wouldnt want to marry the man who was supposed to be his father. Ever since from the start he was already an unwanted child since according to the watcher it was much more like an unwanted pregnancy. The mother didnt really like the man who got her pregnant for reasons not known by the watcher. His mother would always abuse him physically and emotionally as if projecting the mothers frustration and anger to him. When his mother found another man, she only brought his eldest half sister with her, leaving our client in the care of their relatives (sisters of his mother) and his grandmother. As claimed by his watcher, he was left even in the care of their relatives According to the family systems therapy by Murray Bowens, the family is a homeostatic system wherein balance is maintained while undergoing change. One concept of a family system is the family projection process. The projection of spouses problems onto one or more children is used in order to avoid tense emotional fusion between spouses. The process through which parental undifferentiation is transmitted to one or more of their children will also result to the child to become dysfunctional in later stages. In the case of our client, he grew up with a single mother only since his mother wouldnt want to marry the man who was supposed to be his father. Ever since from the start he was already an unwanted child since according to the watcher it was much more like an unwanted pregnancy. The mother didnt really like the man who got her pregnant for reasons not known by the watcher. His mother would always abuse him physically and emotionally as if projecting the mothers frustration and anger to him. Thus, with the mothers

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PRECIPITATING FACTORS
PSYCHOLOGICAL STRESSORS The stress-related theories believe that developmental and family stress, as well as other social, physiological or physical stress can play a significant role in the severity and course of schizophrenia. Any person is extremely sensitive to separation and loss. The vulnerable person continues to experience a profound sense of failure as reality becomes too painful and psychosis evolves as a defensive effort to protect oneself. However, there is no evidence that stress causes schizophrenia, although it may precipitate it in a vulnerable individual.

SOCIOCULTURAL STRESSORS Some theorists proposed that poverty, society, and cultural disharmony could cause schizophrenia or that people chose to become isolated to cope with the modern world. Although accumulated stress related to sociocultural and environmental factors is likely to be a contributing factor to the onset of schizophrenia. Due to less or absent constant support system, it became very difficult for our client to adjust to the entire moving process and he often isolates himself and rarely plays with his cousins and other children in their community. Due to his isolative behavior, the people started to view him as abnormal and different from that of the other children as claimed by his watcher. We believe that due to the stigma associated with him as being different and abnormal.

SYMPTOM TRIGGERS 1. Health Poor nutrition due to lack of appetite Lack of sleep 2. Environment Interpersonal difficulties, disruption in interpersonal relationships Lack of social support 3. Attitude/Behaviors Poor social skills Aggressive behavior Poor medication management As claimed, he has difficulty in sleeping at night due to the distressing auditory hallucinations that he often experience. We have observed that our client doesnt have a good appetite. Every time he is given food (e.g. bread), he wouldnt eat it and would often just throw it away. Also, as claimed by his watcher, he often doesnt want to eat and largely depends upon his mood. Whenever, he feels angry his facial expression appear vicious and terrifying. Moreover, as he feels angry or manifests aggression, the pitch and intensity of his voice immediately heightens. Whenever his emotions are provoked, he usually bangs the door, holds a tight grip on the rails and even attempts to destroy them. He doesnt join therapies because he is not allowed to go out of his cell and when we asked if ever he will be allowed to go out will he be willing to join the therapies he answered no. During the course of the whole interaction, we have

When he reached 4th year high school, his aunt died. Since then, he began to isolate himself again to the society and started to become easily disappointed and angry as his only consistent and clear support system was lost. Again, he felt the feeling of loneliness and abandonment that he had felt when he was a child. Due to his depression and feelings of emptiness, he decided to join the fraternity, Kachinas when he reached college. As claimed by the client, it was at that time wherein he received a sense of belonging and felt like he had a family. It was also the time that patient began to be engaged with alcoholism, cigarette smoking and use of illegal drugs

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APPRAISAL OF STRESSORS
COGNITIVE RESPONSE This mediates psychologically between the person and the environment in any stressful encounter; that is damage or potential damage is evaluated according to the persons understanding of the situations power to produce harm and the resources the person had available to neutralize or tolerate harm. People who are vulnerable and use passive, hostility, avoidant or self-defeating tactics, the source of stress is likely not to go away. The client views his problems in the family and with friends as a big stressor in his life to the point that he avoids and withdraws himself SOCIAL RESPONSES Search for meaning, social attribution and social comparison Client chooses to withdraw himself with the society and prefers to keep his problems within him. Moreover, he compares himself to other individuals who have a happy family and questions why he

LEARNING THEORY According to the learning theory, the irrational ways of handling situations, the distorted thinking and the deficient communication patterns of people with schizophrenia are a result of poor parental models in early childhood. Children learn what they are exposed to on a daily basis from parents who have their own significant problems, thus the child doesnt learn the skill in forming good interpersonal relationships. As claimed by the watcher, during the time that our clients mother was pregnant or was carrying our client in her womb, she was experiencing much stress and depression due to the continuous conflicts between the couple, hence, she submitted herself to use alcoholic beverages and smoking as a way of coping with her problems. This even continued as our client grew up since it was also the time that much of her problems escalated due to her separation from her husband. Hence was able to witness the vices of his mother. Thus, when he reached adolescence, he was able to engage himself with cigarette smoking, use of alcoholic beverages and illicit drugs. Moreover, since his mother constantly projects her strong emotions to other people, he was also able to learn from this behavior such that at present, we have observed throughout our

AFFECTIVE RESPONSE The affective response is the arousal of a feeling. The major affective response is a nonspecific or generalized anxiety reaction which becomes expressed as emotions such as anger, distrust, sorrow and fear. Client responds to problems through sadness and depression such as through crying. Also, client sometimes releases or faces his problems through anger and aggression. BEHAVIORAL These are the result of emotional, behavioral and psychological response. There are 4 phases. Phase 1 allows the individual to escape from the stressful environment. Phase 2 when client is able to change the external circumstances and their aftermath. Phase 3 includes intrapsychic behaviors that serve to defend against unpleasant emotional arousal. Phase 4 includes intrapsychic behavior that comes in terms with events and sequel of internal adjustment. Client chooses to separate himself with others and uses smoking, alcoholic drinking and use of illegal drugs as ways

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COPING RESORUCES
COGNITIVE The higher the degree of learning, the greater is the ability of the person to effectively develop and use problem-solving skills. According to Aaron Beck, schemata (persons beliefs, values, and assumptions) shape personality. Schemata influence people to interpret certain life situations, explain their own behavior, understand a sentence, do arithmetic, solve intellectual problems, reason, form opinions, and remember events. These mental processes determine emotional, behavioral, and physiological responses. In the case of our client, he was able to finish high school and reach college. With this knowledge, he was able interact during conversations although he may sometimes choose not to respond or speak. He was also PHYSIOLOGICAL This consists of basic resources like food, water, sleep, shelter, sexual expression, and freedom from pain. According to Abraham Maslow If basic needs are not met, illness is likely to occur and when basic needs are met, health is a result. Our client was not from a low socioeconomic class, hence, he was not deprived from his basic needs such as food, shelter, clothing and water. Moreover, in the facility, his grandmother is always with him to ensure that all his needs are met. SOCIAL Family resources such as parental and sibling understanding of the illness, finances, availability of time and energy, and ability to provide ongoing support influence the course of illness. Our clients grandmother is staying with him within the facility to ensure that all of his needs are met. Moreover, according the his grandmother, he is able to understand the clients condition and is willing to take care of him even if he will be discharged from the facility already.

PHYSICAL RESOURCES This includes clients over-all physical health. Presence of other comorbid medical illnesses may aggravate manifestations of psychosis. In the case of our client, he doesnt have any diseases such as cough, colds, and fever which can potentially aggravate clients ability to cope with the present situation or problem.

FINANCIAL RESOURCES Schizophrenia can best be managed through a combination of psychosocial and pharmacologic therapy. However, psychotropic drugs are mostly expensive which is needed for medication adherence and maintenance. Hence, financial resources may be a great help and support for people with schizophrenia. In the case of our client, hes admission is fully supported by his father in terms of financial needs. His father works in Europe, and he is the one who continuously sends money to the grandmother of our client to ensure that all his

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COPING MECHANISMS
EMOTION-FOCUSED MECHANISMS These are the mechanisms by which the patient is oriented to moderating emotional distress.

DISPLACEMENT Shift of emotion from a person or object to another, usually neutral or less dangerous, person or object.

DENIAL It is the avoidance of disagreeable realities by ignoring or refusing to recognize them.

Usually, whenever he cant He doesnt consider control his feelings of anger himself to be a patient in and aggression, he would the NOPH Psychiatric vent his emotions towards Extension and states that us even if we are not the dili ko pasyente. reason why he was REGRESSION provoked. This refers when an individual retreats from a behavior characteristic of an earlier level of development.

SUPPRESSION It is a conscious counterpart of repression which uses intentional exclusion of material from consciousness. At times, it may lead to repression.

Whenever, asked about what really happened during the time of the hazing activity, he would usually not respond and would usually shift the

WITHDRAWAL Social withdrawal related to establishing trust and preoccupation to internal experiences. Due to the problems that he has, he claimed that he isolates himself to the society. He is also fearful to show himself to others at times since he claims that someone or a group of people are trying to get and hurt him.

CATASTROPHIZING This refers when a person thinks the worst about people and events. Client always claims that he is not lucky since he is the only one who doesnt have any parents. Moreover, he always sees all people to be bad for not trying

Client was not able to resolve the developmental task of trust vs. mistrust during his infancy due to inconsistencies of the care that he has received, thus, at present, he is usually paranoid or suspicious of people around him and has difficulty forming trust with others. Moreover, based on Freuds psychosexual theory, he is fixated with the oral stage such that at present he engages himself with cigarette smoking. Moreover, Freud believed that more serious regressions resulted in serious emotional disorders. For example, in the case of our client, the psychosis of grandeur claiming that he is a famous individuals and is associated with other stars be considered as having regressed to a primary narcissism in which the boundaries between self and the external world are once again blurred. We have also observed a time when client was fighting with one of the facility staff member, he seemed to bully his enemy such as name calling and making faces similar to that of a preschooler.

PROJECTION It is attributing ones thoughts or impulses to another person. Through this process one can attribute intolerable wishes, emotional feelings, behaviors and motives. Client always projects his feelings of inadequacies to others such that he always claims people to be dumb.

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 NEUROBIOLOGICAL RESPONSES
ADAPTIVE ADAPTIVE MALADAPTIVE MALADAPTIVE
Emotions are consistent with experience and words Able to identify some nondestructive ways to deal with his anger Uses only social skills to satisfy his immediate gratification (e.g. REASON FOR ADMISSION: 1) Incoherent and disoriented 2) Self-talk & aggressive behaviors noted 3) Violent behavior noted at home (burned his things inside the house) MALADAPTIVE BEHAVIORS A. Schizophrenia Paranoid ideations Grandiose delusions Persecutory delusions Auditory hallucinations Social Isolation/ withdrawal Aggression and Violent behavior Acting-out Unusual behavior Flat affect Looseness of association Inattention, easily distracted Illogical and concrete thinking B. Avoidant PD Is preoccupied with being criticized or rejected in social situations 62 | P a g e Is inhibited in new interpersonal situations because of feelings of inadequacy

PARANOID SCHIZOPHRENIA
PRIORITY NURSING DIAGNOSES: 1. Disturbed thought process related to false beliefs, lack of reality orientation, inability to concentrate and disorganized thoughts 2. Altered sensory perceptions r/t false auditory perceptions that doesnt exist in reality 3. Impaired social interaction r/t poor judgment, grandiosity, intrusive behavior and short attention span or MEDICAL MANAGEMENT: Chlorpromazine (Thorazine) Biperidine (Akineton) Fluphenazine decanoate (Prolixin) NURSING INTERVENTIONS: Establish a therapeutic nurse-client relationship. - Maintain eye contact but not staring, a relaxed body posture, and facial expressions that convey genuine interest and concern and smiling in appropriate occasions. Providing for Safety - Presenting reality every time patient assumes delusions of persecution and delusions of grandeur. - Provide protection within the environment. - Maintaining straightforward communication and assist patient to learn assertive rather than manipulative, non-assertive/aggressive behavior - Conduct adjunctive therapies indicated for the client. Using Therapeutic Communication - Implementing the principles of effective and therapeutic communication skills that have been discussed in the classroom. To utilized space and minimize redundancy we would just name one: Use of open ended questions. The nurse should be calm when talking to the patient. Never reinforce hallucinations and delusions. Encourage client to participate in appropriate therapies/activities/exercise program. Allow verbalizations of feelings. Help client define alternatives to aggressive behaviors. Explore alternative coping strategies with the client - Client may have little or no knowledge of adaptive responses to stress and needs to learn other options for managing time, feelings, and relationships without drugs. Use of matter-of fact approach. Establish eye contact during interactions. Observe therapeutic distance especially during aggression and anger. Show passive friendliness. Never slip medications to food since the Nurse-Patient relationship is 63 a |Page trusting relationship between the nurse and the client and slipping medications would indicate that the nurse doesnt trust the patient and

RELAPSE Both clinical opinion and research studies support the observation that many patients with schizophrenia experience relapse and remission of symptoms throughout their illness. Persons most likely to suffer relapse are those exposed to stressors and those bit given antipsychotic medications (or not taking them if they were prescribed). As watcher claimed, after the first discharge of the client he still continues to drink alcoholic

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