Bukidnon State University College of Nursing City of Malaybalay

A case presentation on:

Schizoaffective Disorder
Submitted by: Jangao, Jessel Dawn Ferrolino, Dhonabelle Serafin, Gunson Guel Estalane, Joan Oyao, Norah Belle Lamutay, Angelie Talose, Ariel Singsing, Elyvie Rosell Alcover, Hanah Jabon, Crystalline Laerin, Catherine Medado, Annie Lou Estrada, Jerah Mae Olila, Katreena Ness Silvosa, LA

Submitted to: Mrs. Ma. Algerica T. Cuenco, RN, MAN Mr. Zenas P. Paloma, RN, MN Mr. James Lim, RN, MN

I.

INTRODUCTION

Historically, schizophrenia has been classified as a major psychiatric brain disorder with a chronic, neurodevelopmental, severe, and disabling course. It is generally accepted that the underpinnings of schizophrenia are a complex and vast and are associated with genetic influences interacting with environmental insults that result in an assay of phenotypes in the schizophrenia spectrum. (Antai- Otong 2008) In 1911 Bleuler coined schizophrenia from Greek words schizein meaning split and phren meaning mind, because in schizophrenia, a major enduring split exists between the emotional and cognitive aspect of the personality. The persons mood is not congruent with his thoughts. (Sia 2008) Schizophrenia usually is diagnosed in late adolescent or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The prevalence of schizophrenia is estimated at about 1% of the total population. It is characterized by the weak ego. The common defense mechanisms used by the individual are aggression, projection, withdrawal and denial (Sia 2008) The exact cause of schizophrenia is not yet understood. However, studies implicate the interplay of genetic, biological, environmental, and psychological factors in the development of this psychiatric condition. There are four phases of schizophrenia and first is the schizoid personality. This is the premorbid phase. As a child, a person who later develop schizophrenia are often described by friends and family as loner and indifferent to social relationships, having a limited range of emotional experience and expression, physically clumsy and emotionally aloof. Second is the prodromal phase, this is the time when the person begins to experience a change in personality and a decline in academic functioning, avoids social interactions and isolates himself. The third phase is the psychotic break, the active phase when acute signs and symptoms are present. Signs and symptoms can be classified as positive symptoms or hard symptoms, which include delusions, hallucination, illusions, and grossly disorganized thinking, speech and behavior. And negative or soft symptoms, which include flat affect, lack of volition, and social withdrawal or discomfort. The fourth phase is the residual impairment, the period of remission when signs and symptoms are absent, minimal or can be controlled by the person. (Sia 2008) Schizoaffective disorder is a serious mental illness that has features of two different conditions, schizophrenia and an affective (mood) disorder, either major depression or bipolar disorder. A psychiatric diagnosis that describes a mental disorder characterized by recurring episodes of elevated or depressed mood, or of simultaneously elevated and depressed mood, that alternate with, or occur together with, distortions in perception

Schizoaffective disorder is a life-long illness that can impact all areas of daily living including work or school, social contacts and relationships. Most people with this illness have periodic episodes, called relapses, when their symptoms surface. While there is no cure for schizoaffective disorder, symptoms often can be controlled with proper treatment. A person with schizoaffective disorder has severe changes in mood and some of the psychotic symptoms of schizophrenia, such as hallucinations, delusions and disorganized thinking. While the exact cause of schizoaffective disorder is not known, researchers believe that genetic, biochemical and environmental factors are involved. Schizoaffective disorder usually begins in the late teen years or early adulthood, often between the ages of 16 and 30. It seems to occur slightly more often in women than in men and is rare in children. Because people with schizoaffective disorder have symptoms of two separate mental illnesses, it is often misdiagnosed. Some people may be misdiagnosed as having schizophrenia, and others may be misdiagnosed with a mood disorder. As a result, it is difficult to determine exactly how many people actually are affected by schizoaffective disorder. However, it is believed to be less common than either schizophrenia or affective disorder alone. Estimates suggest that about one in every 200 people (0.5%) develops schizoaffective disorder at some time during his or her life. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizoaffective disorder currently exists, though extensive evidence exists for abnormalities in the metabolism of tetrahydrobiopterin (BH4), dopamine, and glutamate in people with schizophrenia and schizoaffective disorders. People with schizoaffective disorder are likely to have comorbid conditions, including anxiety disorders and substance abuse. Social problems, such as long-term unemployment, poverty and homelessness, are common. The average life expectancy of people with the disorder is shorter than those without, due to increased physical health problems and a higher suicide rate. As a group, individuals with schizoaffective disorder have a more favorable prognosis than those with schizophrenia, but a worse prognosis than those with other mood disorders II. OBJECTIVES A. GENERAL OBJECTIVES At the end of 3 hours discussion about schizoaffective disorder, we will be able to discuss the topics properly, improve our knowledge and understanding about the process of the disorder, and reflect into it so that we could effectively apply our learning to the actual nursing practice, enhance our skills and techniques in dealing with mentally-ill clients, and develop the right attitude.

B. SPECIFIC OBJECTIVES At the end of 3 hours discussion of schizoaffective disorder, we will be able to:  Discuss various theories of the etiology of Schizoaffective disorder  Describe the symptoms of Schizoaffective disorder  Describe the functional and mental status assessment for a client with Schizoaffective disorder  Apply the nursing process to the care of a client with Schizoaffective disorder  Evaluate the effectiveness of antipsychotic medications for clients with Schizoaffective disorder.  Evaluate your own feelings, beliefs, and attitudes regarding clients with Schizoaffective disorder III. ANAMNESIS A. Demographic Data Name: Gandang Hari Age: 41 years old Complete Address: Purok 35, Kilometer 12, Cabantian, Buhangin, Davao City Birthday: May 21, 1970 Birthplace: Patindigin, Midsayap, North Cotabato Nationality: Filipino Status: Single Religion: Jehovas Witness Mother: Ms. J Father: Mr. P (deceased) Informants: Ms. J, Robin, Neighbor 1 & 2 Occupation: None Educational attainment: Grade 5 i. Maternal and Paternal Grand Lineages

Client claims that he is not sick and he never encountered any problems with his activities of daily living. He stated also that they have no family history of mental illnesses. Having no family history of mental disorder was also supported by his mother during our face-to-face interview, but his youngest brother who work as a construction worker at SM Mall, Davao bravely told us that they do have family history of mental illness. They inherited it, specifically, from their fathers side but he cant identify and name the persons involved because they were not that closed to his fathers family and they never get a chance also to get acquainted with them.

ii.

Father

In a good relationship and shares a close bond with his father than her mother. After he left the army, he resorted to farming to earn money for a living. He was truly a responsible man who prefers to spend his money to buy foods for his family. Client stated that his father was a kind and considerate man, not strict. This statement was, again, supported by his mother. But according to his youngest brother, their father was a very strict disciplinarian of the family. He agreed the fact that their father was truly a kind man, playful to their children but whenever they committed even small mistakes, heavy punishments immediately follows. And his brother believed that this type of corporal punishments also precipitated clients condition because he easily got depressed whenever their father scolded and punished him for his mistakes. His father also taught him how to farm at an early age that when he was still 15 years old, client started to work on a rice mill at their village. He became an active follower of their church due to his father because they often go together to other places professing their strong belief to God through their religion. When his father got stroke 11 years ago, it truly affected the client. He felt very frustrated because he cant find money to support his fathers medical expenses. Due to this, he attempted to offer his father a soup mixed with Marijuana because he thought it could help alleviate his fathers illness. At his fathers wake, he was unable to control his feelings and emotions and he got himself drunk due to depression. iii. Mother

Client states that his mother was a kind, hardworking woman but when client was still young, they were not that closed enough because his mother were always busy on her work as a businesswoman- buy and selling vegetables and fruits to different houses when they were still living at Midsayap. Her mother was a considerate woman. Whenever he and his brothers/sisters committed mistakes, she didnt scold them but rather talked to them in a soft-nonthreatening voice. He also remembered the time when his mother brought him a bike when he was still studying, he was very happy that time. He respected his mother so much but when there were times that he felt he begun losing himself, he was unable to control his feelings and emotions that he couldnt stop himself hurting his mother. This statement has been validated by his brother. Clients brother states that he has these worst hallucinations that he heard his mother telling and seducing him to have intercourse with him. Thats the reason why prior to the time of admission of the client at mental hospital, many of their neighbors saw him pointing sharp object to his mother while asking her, mama taka?!, mama taka?!. Client was unaware of this behavior of him because he always insisting that he didnt suffering from any mental illness while his mother, when we were having our personal interview with her, looks anxious and afraid everytime he saw his son.

iv.

Prenatal

Clients mother claimed that she never had any prenatal check-ups with a doctor or OB-Gyne from the past for her 7 children because she believed its not necessary at all and she have been very busy selling vegetables and fruits to different houses. She didnt have undergone any shots of vaccines intended for a pregnant client also because she thought its just a waste of time and money. But she confirmed on one of her statements that she decided not to consult a doctor or have vaccines because she did not know that time the significance or importance of this things and she just relied on a trained hilot. Even though shes pregnant with the client, she still kept on working to earned money for a living. Early in the morning at 5:00AM, she woke up to have her regular exercise like walking before she started her ADL. She likes to eat fruits and vegetables. v. Birth

Client was given birth at their house there in Midsayap last May 21, 1970 around 7:00-9:00 oclock in the evening by a trained hilot. Her mother was very happy delivering a child that was so healthy because he immediately cried-out after he got out. The delivery was normal, client was all in pink. vi. Infancy

During clients infantile period, clients mother stated that she always think for the best ways to provide clients needs. After she gives birth to the client, she rested from selling vegetables and fruits for a 2 month period so she could took care of her son. She used to breastfeed the client too but for a period of 5 months only because she has to go back to her business. When the mother was out, clients eldest sister Ester where held in-charge to watched for him. She added also that client have not taken any forms of vaccines in the past because she thought its not necessary at all. Her other children have experience the same thing too. She also verbalized that her son was a healthy baby, no problems experienced during this period. vii. Childhood

According to his mother, client was not used to talk to people during his childhood years and preferred to play with his brothers and sisters after school around their house. She added also that his son had attended school before but have only reached fifth grade because his son complained that his already tired and chose not to continue his studies. When he was still Grade 1, 7 years of age, he was an honored student but for the next consecutive years, he was unable to maintain his good academic performance. According to his brother, he loves to play taksi and piat-piat (lucky 9) when client was still young. As early as Grade 2, he got a huge crush to their teacher. Patient claimed

also that even though he shares a good bond with his brothers and sisters, he is not confident playing with them. viii. Siblings

They were 7 siblings in the family, he was the fourth child. Client verbalized that he was closed to his elder sister Ester, 46 years old and already married, because shes the one whom where he shared his problems and asked for advice but he loved most his younger sister Elizabeth who died at the very young age,14, due to unknown cause. According to his mother, they didnt exactly know the causes of her death but because dengue fever was very endemic that time and she manifested symptoms like high-fever and flushing of the skin, they immediately concluded that her sister died due to dengue. They didnt consult a doctor due to financial reasons. He had a sister named Myrna who also experiencing the same case as the client and her mother believed that the cause of her illness was precipitated by schistosomiasis. Now, she was already married and currently lives in Samal. According to her mother, when her children was still young, they used to have fun and play with each other because they didnt have any closed neighbor living nearby in their house their at Midsayap but after they have evacuated their home and transferred here in Davao in order to escape the war 8 years ago, his brothers and sisters became busy finding a work for a living. Their daily financial expenses were supported by his youngest brother Josua, 35 years old- not married, and the client currently stays with him. ix. Psychosexual/ psychosocial

Client stated that he had many girlfriends from the past but none of those relationships became successful. He said that none of them wants to have intercourse with him so he left them. Even his mother told us that he had many girlfriends before. His brother has known 2 of his previous girlfriends and according to him, his first relationship broke up due to his vices and the second one was due to religious factor, his girlfriend was known to be a muslim. He thought that if he continued their relationship, it would be a waste of time and money because marrying a muslim woman cost a lot. During adolescent period, client admitted that he have been under the influence of Marijuana and Shabu, a heavy smoker, and alcoholic. At first, it was purely due to curiosity but later on, became his habit. He is not married but claims to have many children. According to his brother, one of his frustrations in life was because, until now, he cant still find a girl that would accept his situation and marry him. All of his neighbors agreed that he is a kind and friendly man when in a calm and relax behavior. x. Religious/ social adaptability

When his father was still alive, he used to be an active member of their church because he always accompanied his father in traveling to other places, professing their

strong belief to God. Client shared also that he never experienced racing a flag or learning how to sing the national anthem because their church strictly prohibited this practice. After he learned about his fathers death 11 years ago, his behaviors started to change and his religious activities had stopped too. His brother related to us that the client had this delusion of religiosity. When he heard someone talking about God, he immediately got angry and shouted them. He believed that no one, and nothing is powerful than he himself. xi. Occupation

Client stated that he started farming and working on a rice mill at the age of 15. This data was validated by both his mother and brother. His brother verbalized that he loves working on a farm that it became one of his greatest frustrations when the land that the patient tills got pawned and half of the land they owned got sold. Client also experience working to Cebu from 1994-1997 as a stone carver- making figurines. xii. History of Past Illness

Year 2001, complete changes in clients behavior started to appear after his fathers death. He became very depressed, drinks and smokes heavily, and substance abuse becomes more apparent. He has been admitted several times in DMH and discharged again when he looks calm and relax with home medications but due to noncompliance of medications and excessive cigarette smoking, symptoms kept on returning that his family would delivered him immediately in Mental hospital when his starting to exhibit inappropriate behaviors again. Patient noted to have hostile behaviors, he shouts and hurts other people when his not in control of himself. -Psychiatric illness: Previously diagnosed with Schizophrenia, Paranoid (2001). Bipolar 1 Mood Disorder, Manic Phase, with Psychotic Features (June 17, 2003). Mood disorder, Bipolar 1, Manic Phase with Psychotic Features (December 11, 2004/ March 22, 2004/ march 29, 2004). Schizophrenia undifferentiated (April 20, 2005). Bipolar 1, Manic Phase, with Psychotic Features (September 4, 2007). Bipolar 1, Manic Phase with Psychotic Features (November 4, 2008). Schizophrenia undifferentiated (March 28, 2009). Schizophrenia Affective Disorder (October 4, 2009). Bipolar 1, Manic Phase with Psychotic Features (January 3, 2010). Schizophrenia Paranoid (January 28, 2010). xiii. History of Present Illness

One day prior to admission, clients mother states that her son kept on asking her money to buy cigarettes. His mother gives him 40php then he bought 1 pack of cigarette which he immediately consumed. Then he asked again for money to his mother. This

time, his mother refused to give him money. He got angry but he didnt show any signs of violence this time, he rather walked out of the house and went to their neighbors store. There he started laughing excessively, telling and shouting his neighbors that his the mighty one, and begun to talk boastfully. His closed neighbors saw him putting on make-up and polishing his nails, they also saw him cutting his hair with scissor. That night, according to his mother, he was unable to sleep and kept on roaming around the neighboring houses. At 6:00AM (August 4, 2011) he started to become violent, uncontrollable. His brother verbalized that the client had this hallucination that he heard his mother telling him to have sexual intercourse with her that he attempted to hurt their mother by pointing her sharp object. His brother immediately stops him that they really fought each other. Because the client had a big body than him, he restrained him by holding strongly his hands until the Police arrives, hand-cuffed him, and brought him to the Davao Mental Hospital. B. Informants: a. Ms. J Age: 74 years old Sex: Female Civil Status: Widowed Occupation: None Address: Same as patient Relationship to patient: Mother Length of time known to patient: since childhood When she was still pregnant with the client, she did not notice anything unusual to her body. Every day, early in the morning, she leaves home to sell vegetables and fruits from house-to-house, and goes home in the late afternoon. She was very busy that she didnt have any opportunity to have a prenatal check-up. All her children were born at home with the help of a trained hilot. She stated spent his childhood years working in the farm and playing with his brothers and sisters, iya rang mga igsoon ang pirme niya kadula kay mga lagyog balay man ang amu mga silingan. She admitted that the client was too naughty and decided to stop schooling by himself after Grade 5, bright mana siya pero perti ka bugoy mao nang dali ra gi sumhan og skuela,niundang human og grade 5 niya. He was 15 years old that time when he started working in the farm with his father after he stopped schooling. Client was only 19 years old that time when he left their place to work in Cebu as a stone carver in a stone craft factory for 3 years, which was from year 1994-1997. While he was there, his drug addiction becomes severe due to the influence of his

cousins. didto na jud siya nag sugod og kaadik og grabi kay mga drug pusher man tong mga ig-agaw niya nga naka-uban niya didto. They urge her son to returned home immediately after they received the bad news, but this time, there was a slight changes in clients behavior because her mother revealed to us that he burned there house in Midsayap for unknown reason. Last year 2001, his father got stroke. He became bedridden and very ill, this really affected the client. After about 10 days, his father died. nisamot iyang pagkapalahubog og paggamit anang marijuana og shabu, dli gapapugong, naapiktuhan jud siya sa mga panghitabo. His mother also added that when they evacuated their place and transferred to Davao in order to escape the war 8 years ago, he was accidentally left behind by their vehicle. He got lonely, angry, and depressed again. He stayed at Midsayap alone for almost 6 days before his brothers had returned to get him. b. Robin Age: 34 years old Sex: Male Civil Status: Single Occupation: Construction Worker at SM, Davao Address: Same as patient Relationship to patient: youngest brother Length of time known to patient: Since childhood According to Robin, they have familial tendencies to have mental illness on his fathers side. He admits that they have distant relative having mental illnesses. He said that four of his siblings had episodes of having mental illnesses. They are Manta, whom he said had an episode of mental illness but was already recovered. The other was Eliz whom he claimed also got mentally sick and died. pagsakit niya, kalit lang jud ang panghitabu, namatay na dayon siya. Gitabang pa jud to siya pero wala na jud naapas. There older brother Sunken2 also experienced the same case when he was still high school but was better now. The patient, according to his brother, spent his childhood at Patindigin, Midsayap, North Cotabato. He said that at an early age of about 11-14 years, the patient started smoking Marijuana. He added that the patient had a plot of land used for planting Marijuana, mga 20 metro kwadrado ang kaluag, Josua said. These later led the patient to use marijuana and even used intravenous drugs. According to Robin, the patient was very close to his father. The patient and his father were partners roaming around proclaiming their faith. The informant claimed also that their father was a veteran in world war. He was a strict disciplinarian and would not hesitate to punish his children if they did some wrong doings.

There was a closed siblings relationships. They played taksi and jolen when they were still young. Robin said also that the client was very friendly person even with their neighbors. problema lang jud, mahilig to mag sugal kay sige dulag piat-piat og lucky 9. He added that client wasnt that too close to his mother shes working far from their home and rarely took care of the patient but he said that their mother was very supportive and understanding to the patient. He also shared to us that the client learned farming at an early age of 15 and was very diligent to his work. In 1994- 1997, patient work at Cebu City as a stone carver- doing figurines for export. mahilig pud na siya manguyab. He said that he remembered his brother having 2 girlfriends-the first in 1994 and the second one was in 1998. He revealed that the patients behavior started to change in year. 2000, the year their father died due to stroke. He started getting violent at this time. A year later (August, 2001), the patient had his first admission in the Davao Mental Hospital. Robin believed that there may be several factors that led to his brothers illness. One of these was when the patient was left alone in Midsayap at an early age. He said that may be the patient got angry for being left alone. Another thing was about hereditary factors. He strongly believed that they have inherited the disorder at his fathers side. Patients history of substance abuse (marijuana and shabu). Lastly, the land that the patient tills got pawned and half of the land they owned got sold. c. Name: Neighbor 1 Age: 22 years old Sex: female Civil Status: Single Relationship to patient: Neighborhood Occupation: unemployed; stays at home Address: Same as patient Length of time known to patient: 4 months Neighbor 1 welcomes us openly during our first encounter. During the interview, she stated that, mayo og bootan man jud na siya sa among mga silingan niya basta dili lang jud siya motukar. She verbalized that she have been known the patient for 4 months and during this time, pirme ramana siya gapuyo sa ila basta normal og relax iyang paminaw, kugihan pud gani manlimpyo sa ilang balay. She added that they know already the signs whenever the patient started to exhibit the symptoms again because she kept on laughing and talking non-stop. bisag bawal sa iya manigarilyo, manigarilyo jud na siya labi nag wala iyang igsoon og mama ra niya iya kauban sa balay nga bilin.

apil-apilon pa jud na niya ang ubang bata diri basta manigarilyo na siya, as verbalized by the informant. She confirmed to us that client started to become disrespectful and shouting his mother whenever she cannot give him what he wanted. basta dili na siya matagaan sa iyang gusto, mag kuha dayon na siya og gunting dayon gunting-guntingon dayon niya iyang buhok. Mang lipstick dayon na siya og mag kutix sa iyang mga koko. She added also that whenever the situation gets worst, they immediately safeguard their children to protect them from him. basta grabi na gani kau iyang gabation, dili nana siya kapugong sa iyang kaugalingon. Hapit gani niya mapatay iyang kaugaligon inahan kay gatutukan na niyag sundang. Maau gani kay naawat sa amu mga silingan, napugngan pa siya, naka dagan og nakatago dayon iyang inahan. They immediately contacted his youngest brother and the police that time to stop the patient. She truly pitied the clients mother because she was truly afraid to his son, including his youngest brother who became the breadwinner of the family. She believed that the patient was already crazy because no normal person could do such things. d. Name: Neighbor 2 Age: 29 years old Sex: female Civil Status: Married Occupation: housewife Address: Same as patient Length of time known to patient: 5 years According to Neighbor 2, when the patient is not in manic phase, he just spends his time inside their house doing household chores and does not go out frequently. His relationship towards his neighbors are good, bootan mana siya kung dili sumpongon, makipagdula pa gani na siya sa mga bata. She said that there are several factors she noticed that triggers his situation. One was if the patient smokes excessively and noncompliance of his medications. When this happens, the patient exhibit several characteristics that warns them that his going to have, again, another attack. kung atakihon na siya mag sige na siya og katawa, mag make-up, mag sige baklay-baklay, dili makatulog, og mag kutix sa koko. pag naa na gani na nga mga simtomas, kabalo nami nga atakihon na siya og amu na dayon e-safety ang mga bata. Informant claimed that the patient doesnt hurt other people in their community. iya ramang mama og manghud ang iyang awayon, magdala na siya usahay og sundang o bunal. iya rang manghud ang makapugong sa iya, kwa-on dayon na siya sa pulis diri og pusasan kay mag-wild naman jud. According to her, she pitied the clients younger brother. looy kau na iyang manghud na si weweng (Josua). Siya pa gapangita kwarta unya gaproblema pa siya sa sitwasyon iyang igsoon. She thinks that Josua doesnt have any chance to

have his own family because he needs to work very hard to support the needs of her family. IV. COURSE IN THE HOSPITAL

A. Mental Status Examination 1. General description a. General appearance Patient is cleaned but mouth is dry; has nail polish; looks pale and restless b. Posture and Gait Patients Gait and Posture is normal c. Facial expression Patient was expressive, confident to answer our questions, facial expression is appropriate to his answers. d. Patient maintains direct eye contact to his interviewees 2. Behavioral/ activity The patient is conscious during the interview because he said that he hasnt brushed his teeth yet. He keeps on moving his hand and tends to look everywhere. Other than this hes cooperative throughout the interview. 3. Speech The patient answers the questions appropriately. He has a clear and loud voice during the interview. 4. Mood The patients mood is normal during the interview. He was responsive and euphoric. 5. Affect The patients affect is appropriate. 6. Range of affective expression Patients range of affective expressive is consistent and appropriate to the situation and feelings. 7. Perception The patient sated that he is ready to go home and claims that he does not have any mental illness.

8. Orientation The patient is oriented to the present date, time and place. 9. Memory The patient can recall recent and even remote past experiences. 10. Neuro -vegetative Functioning The patient claimed that he is having mild insomnia. 11. Elimination a. Bowel-patient usually defacate once a day. b. Bladder- the amount of urine he eliminates depends on the volume of water he ingests. 12. Abstract thinking ability- Intact ability 13. Judgement appropriate and considers his options to reach the best decisions 14. Ability to concentrate during the interview he was very attentive. 15. Roles and relationship - the patient was able to establish good relationship towards his family.

B. Progress Notes

C. Doctors Order with Rationale

DATE 08-04-2011 ORDERS  Please admit to CIU with watcher  Secure consent RATIONALE For further observation and treatment of the patient. It is designed to protect individuals participating in clinical trials. Client can take in whatever foods he desires but with the exemption of foods containing caffeine, too sweet foods, dark-colored foods, and alcoholic beverages. To monitor and determine any alterations of the clients vital signs

 DAT

 V/S every shift and record

 Meds: Carbamazepine 200mg/tab

Antipsychotic drugs are ordered to calm or sedate patients who are severely disturbed, agitated,

Chlorpromazine 200 mg 1tab tab now then tab a.m., 1 tab HS Biperiden 2mg 1 tab/tab, 1 tab BID, PRN  Flupentixoldec. 20 mg/amp. 1 amp IM now then every monthly.  Suicidal/homicidal/escape precaution please

hostile, or aggressive. They control the acute symptoms of mania (such as extreme overactivity, incoherence, and extravagant behaviour) and relieve acute positive symptoms of schizophrenia (such as disordered thinking, delusions, and hallucinations); long-term treatment is usually required for patients with schizophrenia in order to prevent relapses. Promotes safety

V.

PSYCHODYNAMICS

A. Tabular presentation on the predisposing and precipitating factors and justification. PRECIPITATING FACTORS Severe stress MANIFESTATIONS Client experiencing severe stress. According to his youngest brother Robin, Bb. Gandang Hari was very problematic; he was stress in thinking about their situation. During his childhood days he could say that his father was a kind man. His father is playful to them, but whenever they committed even a small mistake, punishment immediately follows. The patients brother stated that, their father was a very strict disciplinarian that Bb. Gandang Hari was not able to cope with it. JUSTIFICATION Stress is the wear and tear on the body caused by life and is the bodys nonspecific to demand in terms of potential disequilibrium (Selye, 1956 and 1976). Anxiety occurs when a person has difficulty dealing with life situations, problems and goals (Videbeck, 2001). Stress involves a reaction to a stressful event and circumstances that precipitated it. A stressor can be psychological or physiological and its source can be either internal or external (Antai-Otong, (2008). Stressful events are potential sources of crisis if they are not handled effectively (Antai-Otong,

1.

2.

Major Life Changes

3.

Substance Abuse

At the onset of Bb. Gandang Hari mental illness, the family moves to Davao because they were not able to pay the rent in their house. The patient was left in Midsayap, North Cotabato and work in their farm. At Midsayap, Bb. Gandang Hari became friendly to drug pushers as claimed by the mother. When his father died due to stock, patients behavioral changes noted. They experienced poverty since his father died and his youngest brother was the one who is sustaining their daily needs. He frequently asked money from his mother to bug cigarette but his mother refused because their budget is only intended for their daily needs. This made him angry and it came to a point that he hurts her mother. The patient stated that he started smoking and drinking alcohol at the age of 12 but his siblings was able to observe such thing to the patient when he was already 14 years old. During that year Bb. Gandang Hari began to work in a rice mill and tried using marijuana and shabu through the influence of his co-worker, in which in the succeeding years he became addicted to the said substances. In the year 1994-1997 Bb.

2008). Sullivan believed that ones personality involves more than individuals characteristics, particularly how one interacts with others. He thought that inadequate or nonsatisfying relationships produce anxiety, which he saw as the basis for all emotional problems and it interferes with social relationship (Videbeck, 2001).

Several substances have been used intentionally by people throughout recorded history and most likely before that time, for the purpose of altering their mind, bodies, perceptions, thoughts, and moods. For some individuals the intentional use of substances may be controlled and considered relatively harmless but many others, however, experience a loss of control over use of substances because of the combination

4.Emotional Trauma

Gandang Hari was in Cebu working in the stone craft and became more addicted since his cousins who were with him in Cebu were drug pushers. On 1998, his family moved to Davao City and Bb. Gandang Hari was left in Midsayap where he became a drug pusher. Patient claimed that he has been using marijuana and shabu as his outlet to forget his problems. At the year 2000, his mother and youngest brother observed the patient using shabu and there were behavioral changes seen. Patient was brought to MDS and was diagnosed as having Substance Induced Psychiatric Disorder. Presently, patient admitted that he smoke secretly whenever his brother and mother are not around. Patient claimed that he experienced a number of emotional problems in his life but among those, the death of his father brought him the biggest trauma in his life since he is so close to his father.

of biological, psychological, and environmental factors which often results in disruptive disorders (HoladayWorret, 2007)

5. Sleep Deprivation

Patient has insomnia since the onset of illness. He could not sleep well most especially if he cannot take his medication.

Anger, sadness and anxiety are the predominant emotional responses to loss. The grieving person may direct anger and resentment toward the dead person and his or her health practices, family members, or health care providers or institutions (Videbeck, 2006). Guilt over things not done or said in the lost relationship is another painful emotion (Zisook & Downs, 2000). Neuroanatomical studies also link sleep disorders to dysregulation in the hypothalamic-pituitaryadrenal (HPA) axis, which plays a role in cortisol

release (Otte et al., 2007). These data consistently indicate that low cortisol levels are found in posttrauma clients, whereas depressed clients are likely to have high cortisol levels (Otte et al., 2007). Sleep deprivation is associated with increased slow wave sleep, resulting in significant reduction in cortisol and growth hormone (GH) secretion the following day. Some researchers suggest that reduced cortisol levels arising from sleep deprivation may provide a temporary relief from depression (Antai-Otong, 2008).

PREDISPOSING FACTORS 1. Genetic Factors

JUSTIFICATION Most genetic studies have focused on immediate families (i.e., parents, siblings, offspring) to examine whether schizophrenia is genetically transmitted or inherited. Other important studies have shown that children with one biological parent with schizophrenia have a 15% risk; the risk rises of 35% if both biological parents have schizophrenia. Studies have indicated a genetic risk or tendency for schizophrenia, but genetics cannot be the only factor, identical twins have only a 50% risk even though their genes are 100% identical (Riley & Kendler, 2005). The research consistently shows decreased brain and abnormal brain function in the treatment and temporal

2. Neuro-Anatomic Factors

3. Neuro-Chemical Factors

areas of reasons with schizophrenia (Videbeck, 2006). People with schizophrenia have relatively less brain tissue and CFS than people who do not have schizophrenia (Flashman et. Al., 2000). This could represent a failure in development or a subsequent loss of tissue. Intrauterine influences such as poor nutrition, tobacco, alcohol and other drugs, and stress also are being studied as possible causes of the brain pathology found in people with schizophrenia (Bucharan and Carpenter, ) The most prominent neurochemical theories involve dopamine and serotonin. One permanent theory suggests excess dopamine as a cause. More recently, serotonin has been included among the leading neurochemical factors affecting schizophrenia. The theory regarding serotonin suggests that serotonin modulates and helps to control excess dopamine. Some believe that excess serotonin also contributes to the development of schizophrenia (Videbeck, 2006, 3rd edition).

VI.

LABORATORY AND DIAGNOSTICS EXAMS A. IDEAL

DIAGNOSTIC STUDIES

A.

B.

C.

D.

Usually done to rule out physical illness, which may cause reversible symptoms such as: toxic/deficiency states, infections, neurological disease, endocrine/metabolic disorders. CT Scan: May show subtle abnormalities of brain structures in some schizophrenics (e.g., atrophy of temporal lobes); enlarged ventricles with increased ventricle-brain ratio may correlate with degree of symptoms displayed. Positron Emission Tomography (PET) Scan: Measures the metabolic activity of specific areas of the brain and may reveal low metabolic activity in the frontal lobes, especially in the prefrontal area of the cerebral cortex. MRI: Provides a three-dimensional image of the brain; may reveal smaller than average frontal lobes, atrophy of left temporal lobe (specifically anterior hippocampus, parahippocampogyrus, and superior temporal gyrus). Regional Cerebral Blood Flow (RCBF): Maps blood flow and implies the intensity of activity in various brain regions.

E. Brain Electrical Activity Mapping (BEAM): Shows brain wave responses to various stimuli with delayed and decreased response noted, particularly in left temporal lobe and associated limbic system. F. Addiction Severity Index (ASI): Determines problems of addiction (substance abuse), which may be associated with mental illness, and indicates areas of treatment need. G. Psychological Testing (e.g., MMPI): Reveals impairment in one or more areas. Note: Paranoid type usually shows little or no impairment.

B. ACTUAL No actual diagnostic and laboratory exams performed to the client. VII.
I- Axis I II-Axis -II III- Axis-III IV-Axis-IV V-Axis- V

DIAGNOSIS STATISTICAL MANUAL

Schizoaffective disorder Bipolar 1 disorder Insomnia Environmental stressor 31 yrs. Old major impairment in several areas, such as work, school, family relations, judgement, thinking or mood

Justification Axis I Based on Bb. Gandang haris mental status examination he was diagnosed as schizoaffective disorder because he manifested the ff. signs and symptoms in psychotic schizophrenia (hallucinations, delusions) and in mood disturbance (difficulty sleeping, changes in appetite, feeling of sadness, hopelessness, and helplessness and in adequacy, irritability, mood changes, problem interacting with love ones). Axis II Bb. Gandang hari was attempting to burn their house and was trying to kill her mother. He also thinks that her mother will kill him. Axis III Bb. Gandang hari wasnt able to sleep. He claims that he wakes up during midnight and cant go back to sleep.

Axis IV The family of our patient belongs to the lower middle class. They live in a place where growing and using marijuana is rampant. Patient admits that he started using marijuana when he was 17 years old because of peer pressure.

Axis V Based on Global Assessment of Function Scale our patient belongs to code 3140 where in Bb. Gandang Hari quit school when he was in grade 5. He was not able to find a work because of his condition. He wasnt able to have a lifetime partner due also to his condition.

VIII.

PROGNOSIS

People with schizoaffective disorder have a greater chance of going back to their previous level of function than do people with most other psychotic disorders. However, long-term treatment is often needed, and results can vary from person to person. In the case of our patient, his prognosis is not good. Since his illness is said to non curable because as what we all know brain damage is irreversible. Though the patient had family support, he had poor compliance to his medication. The exact cause of schizoaffective disorder is unknown; this may consider as lifelong and non curable disorder. Changes in genes and chemicals in the brain may play a role. It is generally agreed that the prognosis for people living with schizoaffective disorder lies somewhere between that of people with schizophrenia and people with bipolar disorder. In other words, the prognosis appears to be better for patients with schizoaffective disorder than those with schizophrenia but worse than those with bipolar disorder. Because the condition is complicated and difficult to diagnose, it is also difficult for people living with this mental illness to get effective and timely treatment which will inevitably affect recovery outcomes. The justification for early and effective treatment is clear. As with schizophrenia and bipolar disorder, people living with schizoaffective disorder have higher mortality rates from suicide than the general population. IX. RECENT UPDATES

New indication for Invega: schizoaffective disorder

(29 March 2011, 1:59pm)

Invega (paliperidone) is now indicated for the treatment of psychotic or manic symptoms of schizoaffective disorder following a recent licence extension. The atypical antipsychotic is also indicated in the treatment of schizophrenia. The recommended dose for the new indication is 6mg once daily, adjusted according to response in 3mg increments at minimum four-day intervals up to a maximum of 12mg once daily. The dose should be reduced in renal impairment. Invega is not recommended for use in patients younger than 18 years and should be used with caution in severe hepatic impairment.

The efficacy of Invega in schizoaffective disorder was assessed in two six-week placebo-controlled trials involving adults with a Positive and Negative Syndrome Scale (PANSS) score of 60 and prominent mood symptoms (score of 16 on the Young Mania Rating Scale [YMRS] and/or Hamilton Rating Scale 21 for Depression). A dose range of 3-12mg daily was assessed in one study while two dose levels (12mg daily reducing to 9mg if required and 6mg daily reducing to 3mg if required) were assessed in the other.

Pooled data from the two studies showed that Invega improved psychotic and manic symptoms of schizoaffective disorder at the study endpoint relative to placebo when given as monotherapy or in combination with mood stabilisers and/or antidepressants. However, the overall magnitude of effect in terms of PANSS and YMRS scores was greatest when paliperidone was used as monotherapy.

X.

BIBLIOGRAPHY y http://en.wikipedia.org/wiki/Schizoaffective_disorder y http://emedicine.medscape.com/article/294763-overview y http://www.medicinenet.com/schizoaffective_disorder/article.htm y (http://www.medicinenet.com/schizoaffective_disorder/page2.htm) y http://www.drugs.com/enc/schizoaffective-disorder.html y http://www.nlm.nih.gov/medlineplus/ency/article/000930.htm#Expectations (prognosis) y http://www.mims.co.uk/more/LicenceChanges/rss/article/1061261/New-indicationInvega-schizoaffective-disorder/