SCHIZOPHRENIA

Introduction:

Schizophrenia is a serious brain disorder that distorts the

way a person thinks, acts, expresses emotions, perceives reality,
and relates to others. The most chronic and disabling of the major
mental illnesses which often have problems functioning in society,
at work, at school, and in relationships. Schizophrenia can leave
its sufferer frightened and withdrawn. It is a life-long disease that
cannot be cured but usually can be controlled with proper
treatment.
Schizophrenia is not a split personality. Schizophrenia is a
psychosis, a type of mental illness in which a person cannot tell
what is real from what is imagined. People with psychotic
disorders lose touch with reality. The world may seem like a
jumble of confusing thoughts, images, and sounds. The behavior
of people with schizophrenia may be very strange and even
shocking. A sudden change in personality and behavior, which
occurs when schizophrenia sufferers lose touch with reality, is
called a psychotic episode.

Biographic Data:
Name: Ms. E
Address: c/o Capitol Security Agency, Capitol Drive,
Pasig City
Age: 47 years old
Birthday: December 30, 1969
Civil status: single
Date of Admission: September 8, 1991
Chief complaint: nagkakalat ng sinampay
Nagsusunog ng pwesto sa palengke
nambabato
Admitting physician: Dr. Loveria
Admitting diagnosis: Pschosis, to be classified;
unstable
Working diagnosis: AGE, improved, Schizophrenia,
Undifferentiated Chronic, unstable
Final diagnosis: Residual Schizophrenia, Stable

Body:
Schizophrenia varies in severity from person to person.
Some people have only one psychotic episode while others have
many episodes during a lifetime but lead relatively normal lives
between episodes. Still other individuals with this disorder may
experience a decline in their functioning over time with little
improvement
between
full
blown
psychotic
episodes.
Schizophrenia symptoms seem to worsen and improve in cycles
known as relapses and remissions.
There are several subtypes of schizophrenia based on their
symptoms. Paranoid schizophrenia are preoccupied with false
beliefs (delusions) about being persecuted or being punished by
someone. Their thinking, speech, and emotions, however, remains
normal. Disorganized schizophrenia are confused and incoherent
and have jumbled speech. Their outward behavior may be
emotionless or flat or inappropriate, even silly or childlike. They
have disorganized behavior that may disrupt their ability to
perform normal daily activities such as showering or preparing
meals. Catatonic schizophrenia are generally immobile and
unresponsive to the world around them. They often become very
rigid and stiff and unwilling to move. These people have peculiar
movements like grimacing or assume bizarre postures. They
might repeat a word or phrase just spoken by another
person. People with catatonic schizophrenia generally go back
and forth between more sedentary behaviors and the restless,
purposeless behaviors and are at increased risk of malnutrition,
exhaustion, or self-inflicted injury. Undifferentiated schizophrenia
is when the person's symptoms do not clearly represent one of
the other three subtypes.
My patients case is Residual Schizophrenia in which the
severity
of
schizophrenia
symptoms
has
decreased.
Hallucinations, delusions, or other symptoms may still be present
but are considerably less than when the schizophrenia was
originally diagnosed.
The word "schizophrenia" does mean "split mind," but it
refers to a disruption of the usual balance of emotions and
thinking. Schizophrenia is a chronic condition, requiring lifelong
treatment.
Schizophrenia involves a range of problems with thinking
(cognitive), behavior or emotions. Signs and symptoms may vary,
but they reflect an impaired ability to function. Symptoms are:

Delusions are false beliefs that are not based in reality. For
example, you're being harmed or harassed; certain gestures or
comments are directed at you; you have exceptional ability or
fame; another person is in love with you; a major catastrophe is
about to occur; or your body is not functioning properly.
Hallucinations involves seeing or hearing things that don't
exist. They have the full force and impact of a normal experience.
Hallucinations can be in any of the senses, but hearing voices is
the most common hallucination.
Disorganized thinking (speech) is inferred from disorganized
speech. Effective communication can be impaired, and answers to
questions may be partially or completely unrelated. Rarely,
speech may include putting together meaningless words that
can't be understood, sometimes known as word salad.
Extremely disorganized or abnormal motor behavior. This
may show in a number of ways, ranging from childlike silliness to
unpredictable agitation. Behavior is not focused on a goal, which
makes it hard to perform tasks. Abnormal motor behavior can
include resistance to instructions, inappropriate and bizarre
posture, a complete lack of response, or useless and excessive
movement.
Negative symptoms refers to reduced ability or lack of ability
to function normally. For example, the person appears to lack
emotion, such as not making eye contact, not changing facial
expressions, speaking without inflection or monotone, or not
adding hand or head movements that normally provide the
emotional emphasis in speech. The person may also have a
reduced ability to plan or carry out activities, such as decreased
talking and neglect of personal hygiene, or have a loss of interest
in everyday activities, social withdrawal or a lack of ability to
experience pleasure.
Schizophrenia symptoms in teenagers are similar to those in
adults, but the condition may be more difficult to recognize in this
age group. This may be in part because some of the early
symptoms of schizophrenia in teenagers are common for typical
development during teen years, such as Withdrawal from friends
and family, drop in performance at school, trouble sleeping,
irritability or depressed mood and lack of motivation.
Schizophrenia symptoms in teens may have less likely to have
delusions and more likely to have visual hallucinations. Suicidal
thoughts and behavior are common among people with
schizophrenia.

Onset of schizophrenia prior to adolescence is rare. The peak

age at onset for the first psychotic episode is in the early- to mid20s for males and in the late-20s for females. Though active
symptoms typically do not emerge until an individual is in their
20s, oftentimes prodromal symptoms will precede the first
psychotic episode, characterized by milder forms of hallucinations
or delusions. For example, individuals may express a variety of
unusual or odd beliefs that are not of delusional proportions
(ideas of reference or magical thinking); they may have unusual
perceptual experiences (sensing the presence of an unseen
person); their speech may be generally understandable but
vague; and their behavior may be unusual but not grossly
disorganized (mumbling in public).
Individuals with schizophrenia evidence large distress and
impairments in various life domains. Functioning in areas such as
work, interpersonal relations, or self-care must be markedly below
the level achieved prior to the onset of the symptoms to receive
the diagnosis (or when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal, academic, or
occupational achievement).
Schizoaffective Disorder and Mood Disorder with Psychotic
Features must be considered as alternative explanations for the
symptoms and have been ruled out. The disturbance must also
not be due to the direct physiological effects of use or abuse of a
substance (alcohol, drugs, and medications) or a general medical
condition.
The cause of Schizophrenia is unknown. But researchers
believe that a combination of genetics and environment
contributes to development of the disorder.
Problems with certain naturally occurring brain chemicals,
including neurotransmitters called dopamine and glutamate, also
may contribute to schizophrenia. Neuroimaging studies show
differences in the brain structure and central nervous system of
people with schizophrenia. While researchers aren't certain about
the significance of these changes, they support evidence that
schizophrenia is a brain disease.
Although the precise cause of schizophrenia isn't known,
certain factors seem to increase the risk of developing or
triggering schizophrenia, including having a family history of
schizophrenia, exposure to viruses, toxins or malnutrition while in
the womb, particularly in the first and second trimesters,
increased immune system activation, such as from inflammation
or autoimmune diseases, older age of the father and taking mind-

altering (psychoactive or psychotropic) drugs during teen years

and young adulthood.
When doctors suspect someone has schizophrenia, they
typically ask for medical and psychiatric histories, conduct a
physical exam, and run medical and psychological tests, including
Tests and screenings. These may include a lab test
called a complete blood count (CBC), other blood tests
that may help rule out conditions with similar
symptoms, and screening for alcohol and drugs. The
doctor may also request imaging studies, such as an
MRI or CT scan.
Psychological evaluation. A doctor or mental health
provider will check mental status by observing
appearance and demeanor and asking about thoughts,
moods, delusions, hallucinations, substance abuse, and
potential for violence or suicide.
Diagnostic criteria for schizophrenia

Diagnosis of schizophrenia involves ruling out other mental

health disorders and determining that symptoms aren't due to
substance abuse, medication or a medical condition. In addition, a
person must have at least two of the following symptoms most of
the time during a one-month period, with some level of
disturbance being present over six months:

Delusions
Hallucinations
Disorganized speech (indicating disorganized thinking)
Extremely disorganized behavior
Catatonic behavior, which can ranges from a coma-like
daze to bizarre, hyperactive behavior
Negative symptoms, which relate to reduced ability or
lack of ability to function normally
At least one of the symptoms must be delusions,
hallucinations or disorganized speech.
The person shows a significant decrease in the ability to
work, attend school or perform normal daily tasks most of the
time.
Residual schizophrenia is diagnosed when a person has a
history of prominent schizophrenic symptoms, but none of his/her

current symptoms dominate the clinical presentation. In other

words, s/he may still be experiencing delusions, hearing voices, or
showing some signs of disorganized speech or other positive
symptoms typical of schizophrenia, but the intensity has
decreased significantly. The symptoms are no longer as severe as
they were when s/he was acutely ill, but indicators of the disorder
are still evident.
Instead, the person may only be exhibiting some degree of
odd behavior, or his/her speech may be only mildly disorganized.
S/he may also have some strange beliefs. With residual
schizophrenia, if hallucinations or delusions are still part of the
picture, the person doesnt have any strong emotions associated
with them.
In this type of schizophrenia, some of the negative
symptoms of schizophrenia are still present. For example, s/he
may still have blunted emotions, have difficulties initiating or
carrying out tasks or show signs of impaired thought processes.
Additional Diagnostic Criteria
In order to meet the diagnosis of schizophrenia, regardless of
the type, these other criteria must also have been met prior to
the diagnosis of residual schizophrenia:
A marked decline in functioning, after the onset of
symptoms, in at least one of the primary aspects of the
persons life (e.g., work, school, relationships, self-care).
Signs of the disorder are present continuously for a
period of at least 6 months. For at least one month of
that time period (less if they subside due to effective
treatment), the active-phase symptoms (e.g. delusions,
hallucinations, extremely disorganized behavior, etc.)
must be present.
Schizoaffective disorder (a disorder similar to
schizophrenia but with prominent mood episodes) or
other mood disorder must have been ruled out.
With the residual type of schizophrenia, it may be a
transitional period which is occurring between an acute episode
and a full remission. In some cases, however, the person may
continue to meet the criteria for the residual type for a very long
time, even years.

Schizophrenia requires lifelong treatment, even when

symptoms have subsided. Treatment with medications and
psychosocial therapy can help manage the condition. During crisis
periods or times of severe symptoms, hospitalization may be
necessary to ensure safety, proper nutrition, adequate sleep and
basic hygiene.
A psychiatrist experienced in treating schizophrenia usually
guides treatment. The treatment team also may include a
psychologist, social worker, psychiatric nurse and possibly a case
manager to coordinate care. The full-team approach may be
available in clinics with expertise in schizophrenia treatment.
Medications
Medications are the cornerstone of schizophrenia treatment.
However, because medications for schizophrenia can cause
serious but rare side effects, people with schizophrenia may be
reluctant to take them.
Antipsychotic medications are the most commonly
prescribed drugs to treat schizophrenia. They're thought to
control symptoms by affecting the brain neurotransmitters
dopamine and serotonin.
Willingness to cooperate with treatment may affect
medication choice. Someone who is resistant to taking medication
consistently may need to be given injections instead of taking a
pill. Someone who is agitated may need to be calmed initially with
a benzodiazepine such as lorazepam (Ativan), which may be
combined with an antipsychotic.
Atypical antipsychotics
These newer, second-generation medications are generally
preferred because they pose a lower risk of serious side effects
than do conventional medications. They include:

Aripiprazole (Abilify)
Asenapine (Saphris)
Clozapine (Clozaril)
Iloperidone (Fanapt)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Quetiapine (Seroquel)

 Risperidone (Risperdal)
Conventional, or typical, antipsychotics
These first-generation medications have frequent and
potentially significant neurological side effects, including the
possibility of developing a movement disorder (tardive dyskinesia)
that may or may not be reversible. This group of medications
includes:

Chlorpromazine
Fluphenazine
Haloperidol (Haldol)
Perphenazine

These antipsychotics are often cheaper than newer

counterparts, especially the generic versions, which can be an
important consideration when long-term treatment is necessary.
It can take several weeks after first starting a medication to
notice an improvement in symptoms. In general, the goal of
treatment with antipsychotic medications is to effectively control
signs and symptoms at the lowest possible dosage. The
psychiatrist may try different medications, different dosages or
combinations over time to achieve the desired result. Other
medications also may help, such as antidepressants or antianxiety medications.
Psychosocial interventions
Once
psychosis
recedes,
psychological
and
social
(psychosocial) interventions are important in addition to
continuing on medication. These may include:
Individual therapy. Learning to cope with stress and
identify early warning signs of relapse can help people
with schizophrenia manage their illness.
Social skills training. This focuses on improving
communication and social interactions.
Family therapy. This provides support and education to
families dealing with schizophrenia.

 Vocational rehabilitation and supported employment.

This focuses on helping people with schizophrenia
prepare for, find and keep jobs.
Most individuals with schizophrenia require some form of
daily living support. Many communities have programs to help
people with schizophrenia with jobs, housing, self-help groups and
crisis situations. A case manager or someone on the treatment
team can help find resources. With appropriate treatment, most
people with schizophrenia can manage their condition.
There's no sure way to prevent schizophrenia. However,
early treatment may help get symptoms under control before
serious complications develop and may help improve the longterm outlook.
Sticking with the treatment plan can help prevent relapses or
worsening of schizophrenia symptoms. In addition, researchers
hope that learning more about risk factors for schizophrenia may
lead to earlier diagnosis and treatment.

Republic of the Philippines

University of Northern Philippines
Tamag, Vigan City

COLLEGE OF NURSING
A
CASE STUDY
ON

RESIDUAL SCHIZOPHRENIA

In partial fulfillment
Of the Requirements in
Related Learning Experience
(National Center for Mental Health)
Presented to:
Mrs. Jhal Espinosa, RN, MAN
Presented by:
Lyann Belle M. Quiocho
BSN-3

March 27, 2015