Silliman University College of Nursing Dumaguete City

BEHAVIORAL ANALYSIS
ON PATIENT WITH SCHIZOPHRENIA
Prepared by: Maria Florita Gabales Mark Anthony Yabres

Name: Ms. Sweetie Status: Single Sex:Female Address: Boyco, Bayawan City, Negros Oriental Age: 34 yrs. old Date of Birth: September 13, 1977 Educational Attainment:College graduate Religion: Roman Catholic Nationality: Filipino Occupation: Office Clerk Room/Ward: Isolation C-3 Doctor in charge: Dr. Angelo Jesus V. Arias Admitting Nurse: Ms. Teresa Catacutan Date & Time of Admission: December 26, 2011 at 8:15 AM

Chief Complaint:

Poor noncompliance of medications at home , stubborn behavior and incoherent speeches.

History of Present Illness:

Prior to admission, client claimed that she keeps on shouting in front of the church and she dont whats the reason for shouting aloud. Client was then brought and admitted for the sixth time to Talay Mental Rehabilitation Center by her father together with the policemen. Clients psychiatrist is Dr. Angelo Jesus V. Arias. Presently, she is taking 4 medications: Fluphenazine Decanoate i cc, Chlorpromazine 110 mg tab OD, Akineton 20mg i tab BID, Risperidon 2mg tab i tab BID.

GENERAL IMPRESSION OF CLIENT

Client was alert, ambulatory and cooperative. She was verbally responsive and accommodating. Her speech was spontaneous although some thoughts were incoherent. She was sitting on her bed facing towards her student nurses during the whole duration of our nurse-patient interaction. Her clothing were soiled and nails were dirty on both hands and feet and hair is not well kept. She usually stares from afar and had a blank star at tmes and would just smile for no reason.

PAST MEDICAL HISTORY

According to her watcher, who is also their family friend, she was able to work at Talay Mental Rehabilitation Center for awhile until she was offered to become a permanent resident in the facility, but she was to be assigned in Bayawan City since her family wanted her to be close to them. She became so frustrated because she insisted to stay and work in Talay. And she has always have conflicts with her officmates in Bayawan District Hospital because she was a clerk there. To add to her frustration and stress her mother also passed away. In addition to that, she applied many times in Dumaguete and recently in Bayawan City Hall but she was rejected and she felt so helpless as claimed.
Client claimed to have been admitted to Talay Mental Rehabilitation Center six times. The first admission was on November 7, 2006, the other 3 admissions she couldnt remember, and then last April 14, 2010 as her 5th admission. She claimed that prior her first admission she was eating alone in their dinner table then she suddenly said to herself, Ako bana kay slave nako, not knowing that her father heard her, and she also tried to go to Cebu via Ceres without the knowledge of her family. Just as she arrived at the Ceres terminal she was handcuffed by the police and brought to Talay. Client was discharged on November 20, 2006, and the other 3 admissions client couldnt remember.

April 14, 2010, client was admitted to Talay Mental Rehabilitation Center accompanied by the police and her father. Client was not aware of the reason for her admission.
Recenly, December 26, 2011, client claimed that she keeps on shouting in front of the church and she doesnt know whats the reason for shouting aloud. Client was then brought and admitted for the sixth time to Talay Mental Rehabilitation Center by her father together with the policemen. Clients psychiatrist is Dr. Angelo Jesus V. Arias. Presently, she is taking 4 medications: Fluphenazine Decanoate i cc, Chlorpromazine 110 mg tab OD, Akineton 20mg i tab BID, Risperidon 2mg tab i tab BID.

Physical Development
Early adulthood or young adulthood ranges from 20 to 40 years old. It is also considered as the prime of life. During this time they are conscious in their physical appearance. They already reached their full size before 20 and reaches peak bone mass for both sexes up to 35 yrs old. Yet the rate of bone mass loss is greater and faster in women. They are at the peak of their strength, energy and endurance. Muscle strength is at peak at 25 yrs old and decline by 10% by 30-60 yrs old. By the middle twenties, most body functions are fully developed. This is the time in life when you can reach your peak physically. The growth spurt that came during puberty set the ground work for what you are capable of becoming as a young adult.Most of the senses are sharpest during young adulthood. Visual acuity is keenest from about age 20 to 40; and taste, smell, and sensitivity to pain and temperature generally remain undiminished until at least 45. However, gradual hearing loss, which typically begins during adolescence, becomes more apparent after 25, especially for very highpitched sounds.

Our patient is 34 years old, and according to the physical development of the young adult, she is still in her prime physical year. She is physically welldeveloped and coordinated as evidenced by her abilities. She has no problems with any of her body system, well developed. She has poor eating habits observed. She doesnt do any physical exercise and she has a big body build. However, she often feels tired because she doesnt want to be placed inside the cell, she always talks about freedom and is afraid of being alone as claimed.

Psychosocial Development
According to Erik Erikson, young adulthoods developmental task is intimacy vs. isolation (ages 20 40). Intimacy is the ability to relate well with other people, not only with members of the opposite sex but also with ones own sex to form long- lasting friendships. It is resolving conflicting demands of intimacy, competitiveness, and distance so as to enter into a loving heterosexual relationship with the ultimate aim of providing a nurturing environment for children. It is also achieving a sense of intimacy while avoiding isolation. There is an increase feeling of competency and self-esteem. The person is capable of trust, open to others leading to increase intimate relationship. People who achieve sense of intimacy are very cooperative, very accepting to different backgrounds, values and behaviors. A sense of intimacy grows out of earlier developmental tasks, because people need a strong sense of identity before they can reach out fully and offer deep friendship or love. Because there is always the risk of being rejected or hurt when offering love or friendship, individuals cannot offer it if they do not have confidence they can cope with rejection or if they did not develop a sense of trust as an infant.

Our patient has not been able to accomplish the developmental tasks of the young adult stage. She is still single and doesnt have an intimate relationship. She had not selected a life tim partner, lived with a partner, doesnt have a stable occupation, had not taken civic responsibility or found a congnial social group. She only have few friends as claimed. This may be because she is the only child and do the decision-making for her until she reached early adulthood. She doesnt have the chance to have a closer relationship with other people aside from her family, she is a type of person who is aloof and minimally reach out with other people. She dont have friends when she was young and she only stayed at home and she has a strict parents. She was able to finish her degree but was not given the chance to choose where to work and it was frustrating on her part as claimed by maam Marieta her watcher and a famiy friend.This contributes to her present condition and also the death of her mother few years ago that brought about a great crisis in her life. In the workplace, she most of the time have conflict with her officemates and she could not go along with them very well as claimed by the patient and she was moved to other depart because of the conflicts that arose. And when she worked in Talay Mental Rehabilitaion center, she would just smile for no reason as claimed by her co-worker.

Cognitive Development
During the young adulthood stage, the person is in the stage of formal operations (generating hypothesis) which characterize thinking throughout adulthood. Egocentrism also starts to decline. Also in this stage is a form of problem-finding stage which is characterized by creative thought in the form of discovered problems, relativistic thinking, the raising of questions from ill-defied problems, and the use of intuition, insight and hunches. The adult can easily think in abstract form and are able to comprehend and balance argument created by both logic and emotions.

Our patient does not show manifestations of formal thought disorder, she is a concrete thinker or she is unable to think abstractly. She shows looseness of association, neologism, tangentiality. Her perception of reality is somewhat altered.She experiences auditory hallucinations; she always tells us that she hears someone dictating her what to do or what is going to happen. She is also experiencing delusion of grandeur, she thinks that her family has an anting-anting that gives them power and her relatives are after it. Our patient experiences also broadcasting. She thinks that her mother can be seen on TV specifically in Fox news.

Moral Development
Moral development of children and adolescents, in Lawrence Kohlbergs influential theory, is a rational process accompanying cognitive maturation. Youngsters advance in moral judgment as they shed egocentric thought and become capable of abstract thought. In adulthood, however, moral judgments often seem more complex; experience and emotion play increasingly important role. According to Kohlberg, advancement to the third level of moral reasoning fully principled, post conventional morality is chiefly a function of experience. Most people do not reach this level until their twenties ever. Although cognitive awareness of higher moral principles often develops in adolescence, most people do not commit themselves to such until adulthood. Two experiences that spur moral development in young adults are encountering conflicting values away from home. Experience leads adults to reevaluate their criteria for what is right and fair. Some adults spontaneously offer personal experiences as reasons for their answers to moral dilemmas.

Our client has her own sense of judgment according to her own perceptions. Client believes that as long as she is not doing something

wrong that can harm others she is doing the right thing. Our client claimed
though most of the time she listens to the voices telling her what to do, if she sees it as wrong or against her moral values she refuses to follow it. She also claimd that there is somone who commands her father what to do.Client verbalized, Mutoo ko sa ako mind para makagawas na ko; kabalo ra man ko kung sakto or dili. Dili man ko mutoo sige, do what is right ra man.

Spiritual Development
The spiritual component of growth and development refers to individuals understanding of their relationship with the universe and their perceptions about the direction and meaning of life. The person during the young adulthood stage is in a paradoxical consolidative phase. This means that the person is aware of the truth from a variety of viewpoints. The religious teaching that the young adult had as a child now be accepted or redefined.

According to James Fowler, the individual enters the individuatingreflective period sometime after 18 years, a time where individual focuses on reality. A 27-year-old adult may ask philosophic questions regarding spirituality & may be self-conscious about spiritual matters. Religious teaching that the young adult had as a child may now be accepted or redefined.

Our patient is a Roman Catholic. She goes to church with her family before and verbalized Oo, tig church mi. Dili ra man, pero pasimbahon jud ko. Dili man mi kuyog tanan, basta pasimbahon ra. Pero kuyog mi sa ako mama. She believes that everything that she cant see at her first glance in a place and suddenly when she looks back at it again something has changed; she strongly believe that it is magic. She believes that her grandfather owns an anting-anting that has the power to do anything; it can make people fly, let the politicians win in every election. She also believes that it is her relatives using the anting-anting is the one who gave her problems in life including her condition.She believed that something existed because of magic and a person would just suddenly appear in front of her because of that.

Our patient is a Roman Catholic. She goes to church with her family before and verbalized Oo, tig church mi. Dili ra man, pero pasimbahon jud ko. Dili man mi kuyog tanan, basta pasimbahon ra. Pero kuyog mi sa ako mama. She believes that everything that she cant see at her first glance in a place and suddenly when she looks back at it again something has changed; she strongly believe that it is magic. She believes that her grandfather owns an anting-anting that has the power to do anything; it can make people fly, let the politicians win in every election. She also believes that it is her relatives using the anting-anting is the one who gave her problems in life including her condition.She believed that something existed because of magic and a person would just suddenly appear in front of her because of that.

PHYSICAL DOMAIN

Our client was always prepared for our interaction, she welcomed us in every interaction then she would the seat on her bed facing toards us. She dressed up accordingly and wears shorts and t-shirt most of the time. Her clothings were sometimes soiled. Her hair is is well combed most

of the time yet oily and has dandruffs, nits and lice. She has body odor, her
nails are not so long and dirty, she wore retainers but she does have tartars on her teeth (which only show that she fails to brush her teeth). She has a steady gait with erect posture, and when she is seated down on her bed while holding the grills during our interactions. She would always urinate many times during the interactions. She has reduced appetite when eating her meals but she has a big body build because she always eat

crackers, fudgee bar and so on more often. She is picky when it comes to
food. She wont eat if its not her food preference. She has a regular menstration.

INTELLECTUAL DOMAIN
Components include: perception, analyze, thinking, language, memory, problem solving, creativity and moral decisions (which includes: receptive functions, memory and learning, and cognition or thinking)

Genius is not spared; schizophrenia's victims span the full range of intelligence. In fact, one study reported that a higher than expected number of

people who develop schizophrenia had been intellectually gifted children.

Research suggests, however, that a decline in IQ scores during childhood may be a harbinger of psychotic symptoms in adults. One of the major characteristics of pathological mistrust is multiple difficulties in the process and character of thought. One hypothesis is that increasing stress accompanied by anxiety or fear reduces their ability to think clearly and logically. Hallucinations and perceptions of objects, sensations or images that have no basic reality; no stimulus exist. Yet, the individual perceives a stimulus and acts on it.

Our client was able to finish college with a degree of Bachelor in Science major in

Psychology and graduated in Silliman University and a member of the Blueberry Brain Institute.
She took the PRC Professional Teachers Board Exam and had passed it in the year 2003. She had become a clerk at Bayawan District Hospital but was not contented so she quits. She was applying for the work in their local government but was not accepted. She volunteered at Talay Rehabilitation center for 6 months, but was not given the job. Her level of education serves her well in relating life events and perhaps understanding her own condition, insight.With the influence her few friends, she then studied Bachelor of Science in Nursing for two years, when she had her pinning none of her parents attended the ceremony because they ar not in favor of her taking nursing but they just supported her financially she was really sad during that time as claimed by her watcher. She can understand and speak in English, Tagalog and Bisaya. She is fluent in speaking Bisaya but speaks in a monotonous voice. She pays attention and cooperates all throught our

interactions but sometimes manifest blocking episodes. She would be easily disturbed from external
stimuli especially when the neigboring cell would shout and bangs the grills. She easily forgets and thinks concretely. She loves to read magazines.

EMOTIONAL DOMAIN
This refers to the clients response to events; ones intrapersonal

relationship; self-concept; emotions, feelings, response to frustrations, self esteem,

self-discipline skills, identity and self-confidence.

Emotions refer to mood and affect that are connected to specific ideas. Emotions are generated from interplay of neural activity among the hypothalamus of neural activity among the hypothalamus. The hypothalamus, in addition to its hormonal functions, is the emotional coordinating center. People with schizophrenia

commonly have symptoms on hyperexpression and hypoexpression.

Some

patients perceive they no longer have any feelings. Problems in emotion usually observed in schizophrenia include anhedonia, anergia, apathy, flat affect, and a decreased ability to feel intimacy or closeness. In addition, people with schizophrenia can also have mood disorders. A major depression may develop.

During interactions, our client expresses her feelings and thoughts. She really anticipated us every Thursday and when saw us from a far she smiles, waves and call our names. And she is eager to converse with us. In most of our interactions, she always smiles but shows a flat affect sometimes and would just eventually showed a blank stare. She appears sad every time we talk about the death of her mother and would divert our topic into something else and if we would ask her about her problems that she had experienced before, she would just tell us that we should not talk about the sad memories only the happy things. Her watcher claimed that she had a crush on the guards in Talay and she would always call him. She also had a crush on one of her cousins in Bacong wherein, she would always go to Bacong and would always call her cousin I Love You. She would always tell us that she would be getting married to an American guy when she would be discharged as claimed.

She was so disappointed whn her father visited her but just for a few minutes just went home, she thought that someone else might be commanding his father not to visit her everyday as claimed by the client. She was teary eyed when we told her that we will end our working relationship ang our interaction ends during our terminations phase. She was very happy every time we have our interaction because she would be able to converse because she was bored staying alone in her cell and no one to talk to as claimed by the client. She claimed that she enjoyed the excursion therapy because she was able to stroll around and visit different places even though she went there before.

SOCIAL DOMAIN
This refers to the external responses to events; ones interpersonal relationships, social skills. Components include: affiliations, peer relations, play behaviors, status, communication, negotiation skills, social adaptation, roles, and social identity. This is the ability to form cooperative and interdependent relationships with others. Social problems are often the major source of concern to families and health care providers because these tangible effects of illness are often more prominent than the symptoms related to cognition and perception. Social problems may result from the illness directly or indirectly. Direct effects occur when symptoms prevent the person from socializing within accepted socio cultural norms or when motivation deteriorates. Regardless, the result is social withdrawal and isolation from lifes activities. Behaviors directly causing these problems include inability to communicate coherently, loss of drive and interest, deterioration of social skills, poor personal hygiene and paranoia. Indirect effects on socialization are secondary consequences of the illness. Specific problems in the development of relationships include social inappropriateness, disinterest in recreational activities, inappropriate sexual behavior, and stigmarelated withdrawal by friends, families, and peers.

Our client most often spent her time inside her cell. She is conversant and doesnt mingle with other patients but she only have few friends there. The fact that she says she had no friends since childhood could be a result of her inability to establish trust early in life and lack of socialization to other people for the reason of having a strict family. Yet she claimed that she has good relationship with the other patients. She always interrupt our interaction by

calling our clinical instructors especially when we are talking about her mother.
She is happy when she is assigned to student nurses because she would have someone to talk to. We had observed during the excursion therapy, she is not so cooperative during the games and during the culmination she did not cooperate in any game and she doesnt want to talk to anyone during that time. She stays inside her cell all the time. She is not close to her watcher.

SPIRITUAL DOMAIN
This refers to life force, soul, consciousness of existence, ones transcendental relationship. Components include commitment, verve / resiliency, ethics, survival instincts, faith, ability to love and be loved, purpose/ drive in life, integrity, hope, will. Spirituality involves the essence of a persons being and his or her beliefs about the meaning if life and the purpose for living. It may include belief in God or a higher power, the practice of religion, cultural behaviors and practices, and a relationship with the environment. Although many clients with mental disorders have disturbing religious delusions, for many in the general population, religion and spirituality are a source of comfort and help in times of stress or trauma. Studies have shown that spirituality is a genuine help to many mentally challenged adults, serving it as a primary coping device and a source of meaning and coherence in their lives or helping to provide a social network. Individuals experiencing pathological mistrust are cut off from opportunities to re establish a sense of being connected to a higher universe. The individual has lost the feeling of connectedness with significant others in his environment, so he no longer has access to resources critical for maintaining trust.

Our client is a Roman Catholic. She always went to church with her mother before when she was still in Bayawan and before her mother died as claimed. We observed her making signs of the cross during the time of our activities when we had

our opening prayer, and she is well focused during the prayer.
She always attend mass every Sunday in the facility.

PSYCHOPATHOLOGY
PREDISPOSING FACTORS

PSYCHOSOCIAL THEORY Failure to accomplish an early stage of psychosocial development could also lead to mental disorder. For example, infants inability to form a trusting relationship could lead to a lifetime intrapsychotic conflict. Schizophrenia was seen as the most severe example inability to cope with stress. Disturbances in identity, inability to attach to a love object, and inability to control basic drives also served as key theories. Given the fact that she is the only child in the family and that her parents are still the ones who decides for her up to adult years, she might failed to achieve sense of autonomy.

FAMILY SYSTEM THEORY FST is a theory introduced by Dr. Murray Brown that suggests that individuals cannot be understood in isolation from one another, but rather as a part of their family, as the family is an emotional unit. Families are systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. The patient is under a strict family since she is only the child in the family She is dependent from the decision of her parents. Given the fact that she is the only child in the family and that her parents are still the one who decides for her up to her adult years, she might failed to achieve sense of autonomy. She experienced great frustrations when her choice of place to practice her profession was not accepted by her family. Her family was the one who decided where she should work Her parents are both busy in their work, her father is a business man and her mother is a teacher

The fact that she says she had no friends since childhood could be a result of her inability to establish trust early in life and lack of socialization to other people for the reason of having a strict family

INTERPERSONAL THEORY Interpersonal theory relates that the psychotic is the product of a parent- child relationship fraught with intense anxiety. The child receives confusing and conflicting messages from the parent and is unable to established trust. High levels of anxiety are maintained and the childs concept of self is one of the ambiguity. A retreat in psychosis offers relief from anxiety and security from intimate relatedness. The fact that she says she had no friends since childhood could be a result of her inability to establish trust early in life and lack of socialization to other people for the reason of having a strict family.

PSYCHOLOGICAL THEORY Erikson's Psychosocial Development Erikson believed that when a person reaches the age between 19 to 40 years old, the major conflict centers on forming intimate, loving relationships with other people. For him, it is vital that people develop close, committed relationships with other people because success in this stage leads to strong relationships, while failure results in loneliness and isolation. So far, our client was not able to achieve the virtue of love during her current stage since at her age, this theory proposes that she should have already achieved marital bond with a male partner. Moreover, she kept on mentioning about her fixed marriage to an imaginary Spaniard which she believes was planned by the "group of people" she says is controlling her. Significant other verbalized that she had a deep admiration to her foreign-looking first-degree cousin whom she wants to get married with, but the man does not like the client. She has not formed intimate relationships with other people probably because she had a poor sense of self which had not developed from the prior stage of psychosocial development. (identity vs. confusion stage) Sullivan's Interpersonal Theory Sullivan emphasized that interpersonal socialization of human beings throughout their developmental stages. The mother may be believed to be anxious, overprotective, or cold, and unfeeling; while the father was distant or overbearing. Some theories described how a "schizophrenogenic" mother and other theories described how communicating in double messages could "double blind" a person into developing schizophrenia. The client is the only child in the family and both parents are protective to their only daughter. Interpersonal relationship of the patient was focused on her mother, father, classmates, and friends. Significant other verbalized that parents are not very strict towards the outgoings of the client.

SOCIO-CULTURAL & ENVIRONMENTAL THEORY Social Model Some theorists proposed that poverty, society, and cultural disharmony could cause schizophrenia or that people chose to become schizophrenic to cope with the insanity of the modern world. Others proposed that schizophrenia was caused by living in the city or living in isolation in the country. Although accumulated stress related to sociocultural and environmental factors is likely to be a contributing factor to the onset of schizophrenia and to relapses, neurobiological findings point to other causes for the etiology of psychotic disorders. The patient came from a middle class family. She was able to study college in a University and finished a course in Psychology. She has not experienced significant or tremendous societal conflicts nor cultural disharmony that we could look into as related to her disorder. However, one factor is that she is withdrawn from society since she has no friends until her college years

The client was able to graduate a psychology degree in college and was able to pass the Philippine Board Exam for Teachers
She was not also abusing any substance. She was unemployed since she graduated college. Double-bind Theory Double bind theory proposes that symptoms of schizophrenia are an expression of contradictory patterns of interaction in the family. Significant other verbalized that client's parents have less time together with their only child because of their hectic schedules in their work. Client's father was a businessman and her mother was a public school teacher.

BIOLOGIC THEORY
Neurotransmitter Studies Genetic Studies have identified that certain genetic factors may be involved in the development of a psychotic disorder. Results have shown that individuals are at higher risk for the disorder if there is familial pattern of involvement (parents, siblings and other relatives) The patients genetic predisposition is unknown. She did not report anyone from her family that has a mental disorder. Biochemical A biochemical theory suggests the involvement of elevated levels of the neurotransmitter dopamine, which is thought to produce the symptoms of overactivity and fragmentation of associations that are commonly observed in psychosis. Neurobiology Research suggests that the prefrontal cortex and the limbic cortex may never fully develop in the brains of persons with schizophrenia. The two most consistent neurobiological research findings in schizophrenia are imaging studies showing decreased brain volume and abnormal function, and neurochemical studies showing alterations of numerous neurotransmitter systems. This has been recently attributed to faulty myelination occurring at about age 6 and again at about 13. The client was not tested with MRI nor CT scans, hence neurobiology aspect was not assessed. Dopamine is increased in client's mesolimbic area while decreased in prefrontal mesocortical areas. Dysregulation hypothesis of schizophrenia or the persistent impairment in one or more neurotransmitter homeostatic regulatory mechanisms causing unstable or erratic neurotransmission which proposes that the mesolimbic areas has overactive dopamine pathways, whereas the dopamine pathways in the prefrontal mesocortical areas are hypoactive and that an imbalance exists between dopamine and serotonin neurotransmitter systems. Neurodevelopment This research suggests that some disruption in fetal neural development may change the way the brain matures throughout childhood and adolescence, affecting the myelination, migration, and interconnections of young neurons as they mature in utero and in the first few decades after birth and thus may contribute to brain abnormalities common in schizophrenia. Viral Theories Mixed evidence indicates that prenatal exposure to the influenza virus, particularly during the second trimester, may be one of the factors in the etiology of schizophrenia in some people but not in others.

Gender
Late-onset schizophrenia is more common in women and is more likely to be marked by paranoid delusions and hallucinations. It is less likely to include negative and disorganized symptoms. Our client is a female. Age The client is 34 years old.

PRECIPITATING FACTORS

Information-processing overload Interference in a brain feedback loop that regulates the amount of information that can be processed at a given time has been identified as one possible biological stressor. Normal information processing occurs in a predetermined series of neural activities. Visual and auditory stimuli are initially screened and filtered by the thalamus and sent for processing by the frontal lobe. If too much information is faulty, the frontal lobe sends an overload message to the basal ganglia. The basal ganglia, in turn, send a message to the thalamus to slow down transmissions to the frontal lobe. The decreased function of the frontal lobe impairs the ability of this feedback loop to perform. Less ability to regulate the basal ganglia is available, and ultimately, the message to slow down transmissions to the frontal lobe never occurs. This results to information-processing overload.

Abnormal gating mechanisms Another possible biological stressor is the abnormal gating mechanisms that may occur in schizophrenia. Gating is an electrical process involving electrolytes. It refers to inhibitory and excitatory nerve action potentials and the feedback occurring within the nervous system related to completed nerve transmissions. Decreased gating is demonstrated by a person's inability to selectively attend it stimuli.

Loss of Attachment/Life Events/Role Strain Loss in adult life can precipitate depression. The loss may be real or imagined and may include of love, a person, physical functioning, status, or self-esteem. Many losses take on importance because of their symbolic meaning which makes the reaction to them appear out of proportion to reality. In this sense, even an apparently pleasurable event, such as moving to a new home, may involve the loss of friends, warm memories, and neighborhood associations. The intensity of grief becomes meaningful only when the person understands earlier losses and separations. People reacting to a recent loss often behave as they did in previous separations. The intensity of the present reaction therefore becomes more understandable with the realization that the reaction is to earlier lose as well. By definition loss is negative, a deprivation. The ability to sustain, integrate, and recover from loss is a sign of personal maturity and growth. Adverse life events are a potent factor in precipitating depression. Such events include loss of self-esteem, interpersonal discord, socially undesirable occurrences, and major disruptions of life patterns. Events perceived as undesirable are most often the precipitants of depression. In analyzing social role, much of the literature focuses on women. This reflects the predominance of depression among women and the increasing interest in gender socialization processes and womens changing roles. Role strain in marriage emerges as a major stressor related to depression for both men and women.

Neurobiological Response Symptom Triggers Precursors and stimuli, or combination of them, often precede a new episode of the illness. The word trigger is used to describe these stressors. Common triggers of neurobiological responses are related to health, environment, attitudes, and behaviors.

Health This includes poor nutrition, lack of sleep, out of balance circadian rhythms, fatigue, infection, CNS drugs, lack of exercise, barriers to accessing health care. She had no problems with regards to her nutrition, sleep, past infection, lack of exercise and she had no past experience of using CNS drugs. Now that she is admitted to the institution, we observed that our patient is picky when it comes to food. She wont eat if not in her food preferences. It is also stated in her record that she had poor compliance of her medications at home whenever she is discharged.

Environment The list composes the following: hostile/critical environment, housing difficulties (unsatisfactory housing), pressure to perform (loss of independent living). Changes in life events, daily patterns of activity, interpersonal difficulties, disruption in interpersonal relationships, social isolation, lack of social support, job pressure (poor occupational skills), stigmatization, poverty, lack of transportation (resources), inability to get /keep job. She experienced loss of her mother. It is stressful for her since she is much close to her mother than her father. She often shares her problems to her mother.

She also had problem with regards to her choice of place for her work.
On her 2nd job, she claimed that she doesnt like her co-workers for the reason that she is transferred from one department to another She also lacks social support for the fact that she is now only living with her father. Our patient has a problem with regards to establishing interpersonal relationships to others including with her opposite sex. She failed to establish an intimate relationship with the opposite sex, given the fact that at this age according to Erik Erikson, a person is expected to achieve sense of intimacy.

Attitude/Behaviors
This compromise the following: Poor me (low self concept), hopeless (lack of self confidence), Im a failure (loss of motivation to use skills), Lack of control (demoralization), feeling overpowered by symptoms, no one likes me (unable to meet spiritual needs), looks/acts different from others who are of the same age and culture, poor social skills, aggressive behavior, poor medication management, and poor system management The patient may have had a hopeless and poor me attitude of her interpersonal difficulties since she experience failure in her profession. She claimed that she tried to apply in different works but failed to be part of it. Her choice of profession is also hindered by her parents. She may also have felt lack of control because she did not understand her symptoms and why they were happening to her, she keeps on telling us that that she is normal and it really hurts her to be placed inside the rehabilitation even though she is not psychotic. On her record she has the following reason of admission: oPoor med compliance oStubborn behavior oRelapses of incoherent speeches

APPRAISAL OF STRESSORS
STRESS DIATHESIS MODEL The model does assumes that the onset of a certain disorder (or at least episodes of a disorder) results from a combination of ones biological disposition towards the given disorder (or rather traits that may lead to disorders) and stressful events bring about the onset of a disorder. The reason why she developed delusions is probably because of her past experiences, intelligence, and personality: 1) She felt sudden loss of her mother who died of heart attack last 2007.

2) She had applied for so many jobs (clerk at Bayawan District Hospital, volunteer at Talay Rehabilitation center, teacher at Silliman University) after graduating college, but neither of them was she contented and did not stayed for more than 6 months.
3) She had passed the PRC Professional Teachers Board Exam last August 2003 but did not become a teacher. 4) She has a personality that chooses only the persons she would like to speak or talk to. 5) At the age of 30, she started to show manifestations of delusions and was admitted to psychiatric ward for 6 times due to poor medication compliance. She had escaped the ward for 2 times and can be found only outside the house of her first-degree cousin. During the interactions, the student nurses had noticed that all she want someone to talk to, someone who will listen, and someone who will stay beside her as she sleeps, and someone who can protect her all the time.

DSM IV - TR CRITERIA
The ICD-10 criteria are typically used in European countries, while the DSM-IV-TR criteria are used in the United States and the rest of the world, and are prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian first-rank symptoms. In practice, agreement between the two systems is high. According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met:[64] 1Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment). Delusions Hallucinations Disorganized speech, which is a manifestation of formal thought disorder Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior Negative symptoms: Blunted affect (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation) If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication. 2Social or occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset. 3Significant duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment). If signs of disturbance are present for more than a month but less than six months, the diagnosis of schizophreniform disorder is applied. Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder, and various conditions may be classed as psychotic disorder not otherwise specified. Schizophrenia cannot be diagnosed if symptoms of mood disorder are substantially present (although schizoaffective disorder could be diagnosed), or if symptoms of pervasive developmental disorder are present unless prominent delusions or hallucinations are also present, or if the symptoms are the direct physiological result of a general medical condition or a substance, such as abuse of a drug or medication.

Subtypes The DSM-IV-TR contains five sub-classifications of schizophrenia, although the developers of DSM-5 are recommending they be dropped from the new classification: Paranoid type: Delusions or auditory hallucinations are present, but thought disorder, disorganized behavior, or affective flattening are not. Delusions are persecutory and/or grandiose, but in addition to these, other themes such as jealousy, religiosity, or somatization may also be present. (DSM code 295.3/ICD code F20.0) Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1) Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code 295.2/ICD code F20.2) Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3) Residual type: Where positive symptoms are present at a low intensity only. (DSM code 295.6/ICD code F20.5)

Symptom clusters, Abnormal Behaviors and Movements in patients with Schizophrenia

POSITIVE SYMPTOMS Delusions Hallucinations Thought disorder Disorganized speech Bizarre behavior Inappropriate affect *Client has a firm belief that her mother really came back from death and is now working at America, despite being presented with reality. She hears "group of people" telling her what to do. Her speech is incoherently disorganized. She smiles at one time, and then becomes sad the next minute.

NEGATIVE SYMPTOMS Affective flattening Alogia Avolition Apathy Anhedonia Asociality Attentional deficit *Client is most of the time flat in affect, sometimes blunt and even inappropriate and does not socializes with other patients during therapies.

COGNITIVE SYMPTOMS Attention Memory Executive functions: abstraction. concept formation, problem solving, decision making. *Client is easily distracted by people passing by her cell and usually cannot focus or concentrate during interactions.

MOOD/AFFECTIVE SYMPTOMS Dysphoria Suicidality Hopelessness *Client sometimes show depression and is easily irritated during interaction.

BEHAVIORS Appearance Aggression/agitation/v iolence Repetitive or stereotyped behavior Avolition Lack of persistence at work or school *Client appears clean and neat but stinky odor is strongly noted. She always appears weak and is not interested in group activities.

MOVEMENTS Catatonia, waxy flexibility, posturing Extrapyramidal side effects of psychotropic medications Abnormal eye movements Grimacing Apraxia/echopraxi a Abnormal gait Mannerisms *Client has crouching posture when seated and could not stand erect well.

COPING RESOURCES

COGNITIVE / AFFECT 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. The higher the degree of earning the greater the ability of the person to effectively develop and use problem skills Our client finished college in a University with a degree of Bachelor Science in Psychology. She took the PRC Professional Teachers Board Exam and had passed it in the year 2003. She had become a clerk at Bayawan District Hospital but was not contented so she quits. She was applying for the work in their local government but was not accepted. She volunteered at Talay Rehabilitation center for 6 months, but was not given the job. Her level of education serves her well in relating life events and perhaps understanding her own condition, insight.

PHYSIOLOGICAL According to Abraham Maslow, a basic need is inactive or functionally absent in the healthy person. If basic needs are not met, illness is likely to occur and when basic needs are met, health is a result. Needs are hierarchal, with the lower level needs being critical to survival. These physiologic needs are the biological need for food, shelter, water, sleep, oxygen, and sexual expression. The patient is in a middle class family wherein basic needs can be provided. Both of her parents have job, her father does a business man own a store in their place and her mother is a teacher.

BEHAVIORAL Coping mechanisms are defined as the skills used to reduce stress and they tend to be learned from parents, individual experiences, and social interaction. When asked what are her stress coping strategies she verbalized that she pray to God. She also verbalized Matulog ra, kay stress gud, kapoi. She is much close with her mother and the one she confined with her problems. Client chooses the person she would like to speak with, as verbalized by significant other.

SUPPORT SYSTEM Coping skills tend to be learned from parents. Parents are considered the number one support system of children in times of crises. 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. The patients family is her support system. She is more close to her mother compared to her father. She verbalized that she talks to her mom more often when she has problems so when her mother died it really did brought a great stress to her life and we may say that her support system at that moment collapsed. She verbalized that her father is somewhat busy with their business in their place. She is visited by her father once a month.

COPING MECHANISM

SUPPRESION

REACTION FORMATION

DENIAL

INTROJECTION

PROJECTION

INTELLECTUALIZATIO N Excessive reasoning or logic is used to avoid experiencing disturbing feelings. She verbalized that she does not want to take in her psychotic medications because she believed that it can cause harm to her.

The conscious exclusion of Acting the opposite of what unacceptable thoughts and one thinks and feels. feelings from conscious When talking about awareness. serious or The patient stated confidential topic that she doesnt such as the death of want to think about her mother, she was her problems observed to portray because she wants the opposite of what to focus on how she should be expected could get out of the to feel; client was rehabilitation. laughing and smiling about the death of her mother and have this delusions that her mother is still alive. Also, she verbalized that she doesnt want to talk about sad events in her life; instead she wants happy thoughts to be discussed.

Failure to acknowledge an unbearable condition; failure to admit the reality of a situation, or how one enables the problem to continue. When asked why she doesnt comply with her medications she verbalized Mu tumar ra man ko She verbalized , Ang meds kay makacause ug harm sa body unya normal ra man ko , di man ko psychopathic so sakit gyud kaayo ng patumaron ko nila ug tambal She keeps on telling us that that she is normal and it really hurts her to be placed inside the rehabilitation even though she is not psychotic. She also believed that her mother is still alive and is working in America.

Accepting another persons attitudes, beliefs, and values as ones own. The client verbalized that what she has today came from her family and relatives. She believes that they own anting anting and it is passed on to her and that it possesses great powers.

Projection is an effort to explain confusing perceptions by assigning responsibility to someone or something. Client had verbalized that there is a "group of people" who manipulates her and controls her life that she blame them why she cannot decide for herself. She also strongly believes that her father is being dictated by someone that causes her father to change

Fluphenazine Decanuate 1 cc Chlorpromazine 110g tab OD Akineton 20 mg 1 tab OD Residon 2 mg tab 1 tab BID

PSYCHOSIS

ADAPTIVE RESPONSES
SPIRITUAL GROWTH Client always pray whenever confronted with problems. She prays that he father will be always there with her or visit her most of the time. SOCIALIZATION Although she doesnt participate in most of the activities, she talks with people whom she preferred to. She shares her life to the student nurses during the interaction but only minimal information because she claimed that she doesnt talk confidential things.

Deterioration in Appearance and Lack of persistence:

Assess the clients ability to do self care Encourage and assist client to take a bath, clean her teeth, change clothes and have well grooming

Dirty Clothes Unkempt Appearance Poor Grooming Personal Hygiene oShe doesnt take a bath regularly. She only takes a bath depending on her own preference. Slow Movements Frequent Staring Poor Eating Habits oThe client is picky when it comes to food. She wont eat if its not her food preference. Does not participate in some activities

Teach the client the importance of good hygiene

Assist the client in activities that foster socially acceptable interactions with others Socialization through planned therapeutic activities.

oDuring the excursion closing program the client doesnt want to participate in the games and also doesnt want to answer the question during the evaluation of the activity.

UNDIFFERENTIATED SCHIZOPRENIA

POSITIVE SYMPTOMS
Hallucinations
Be prepared to redirect the patient back to the task at hand aAuditory Hallucinations -Verbalized Sulti an ra man ko unsa ako buhaton na sakto bVisual Hallucinations

COGNITION

-During one of our NPI, upon our arrival she verbalized Gimagic mo sa?, Nigawas ra lage mo kalit?. She believed that we came from nowhere Delusions/Thought Disorder aGrandiose
Assess and document patients orientation. Call patient by name. Spend time with the client to talk and encourage verbalization of feelings.

-Belief that one has exceptional powers, wealth, skill, influence, or destiny -She believe that she possessed great powers and that they are related to the government officials (Arnaiz, Teves, Villegas). -She strongly believed that her mom is still alive that it is possible for them to do everything they want because they [family] believed that they possessed great power. bPersecutory -The belief that one is being watched, ridiculed, harmed, or plotted against. -Verbalized Mahadlok man ko dire kay patyon man nya ko. Dire sa mo ayaw sa mo lakaw

Be sincere and honest when communicating with the client.

Be consistent with the interaction Provide positive feedback and appropriate behavior

Dififculty maintaining attention (Distractibility)

-Distracted attention is impairment in the ability to pay attention, observe and concentrate on external reality. -She is easily distracted with external stimuli, her attention is easily caught by what she hear and what she see. Disorganized speech and behavior -Client manifested lapses of incoherence as a positive formal thought disorder.

NEGATIVE SYMPTOMS:
Difficulty processing emotions -Problems of emotion: At times, client has flat and blunt affect and does not emotionally respond while reporting her significant life events. Client shared that she really feels sad and in sorrow about the death of her mother but could not express crying. Significant other claimed that the client did not cry during the wake of her mother 4 years ago. Sometimes she smiles and laughs with no apparent reasons (silly). Social isolation -Asociality: Client was observed not talking to other person during the excursion and culmination activity unless being approached first. She only choose people whom she want to talk with. -Apathetic: She lacks interest towards people, activities and events, as observed. -Evasive: She gives a little information about her life. Claimed that she doesnt want to talk about confidential things. -Manipulation: She wishes the student nurses to play music for her. She knows how to divert our attention whenever we dealt about significant event in her life like the death of her mother. She often changes topics. Impaired decision making -Attentional impairment: Client could not maintain her focus and sustain her attention during most of the nurse-client interaction. She is also noted to be easily distracted from people passing by her cell and also from what she hears.

Chronic low self esteem related to

Situational Crisis (death of her mother; loss of

job

Fear related to feelings of lack of security

Ineffective coping related to maladaptive

responses to psychosocial stressors

Sensory alteration r/t presence of audiory

hallucinations

Altered family processes r/t manipulative

behavior

Impaired Social Interaction r/t manipulative

behavior, low sel esteem, and poor social skills.

Defensive coping mechanism r/t irrational

beliefs, assumptions and unrealistic

perception of self

Self care deficit r/t to lack of self concern

Risk for Altered nutrition: less than body

requirements r/t high preference in food