Health

Schizophrenia: An Overview

Schizophrenia is a severe and chronic mental health disorder affecting about 20 million people in the world (Schizophrenia, 2020). It is characterised by hallucinations and delusions. Hallucinations refer to experiences of hearing, seeing and smelling things that are not there (Barrell et al., 2018). Delusions, on the other hand, are sets of beliefs that are false and cannot be explained by either their cultural or religious background (Alzheimer’s and Hallucinations, Delusions, and Paranoia, 2020). Schizophrenia is a serious mental health issue that affects all aspects of an individual’s life including their emotional, social, financial, and physical wellbeing. Their connection with others is impacted through loss of touch with reality and consequently this causes significant distress for the patient and people close to them (Ganguly et al., 2018). The exact cause of schizophrenia is largely unknown, studies however have indicate that schizophrenia can develop as a result of interactions between genetic and environmental factors (Kaskie et al., 2017). This care plan aims to maximise independence and to improve the quality of life through symptoms management, stress reduction and managing the factors related to the needs of the patient. The care plan will be developed in collaboration with the family and will change based on the current needs of the patient (Etiology of Schizophrenia, 2016).  

Case study

The patient was a 21-year-old Caucasian male, single, and lived in shared housing with friends. The patient was referred to the psychiatrist by the primary physician due to auditory hallucinations and paranoia. During the assessment the psychiatrist found the patient to be having persecutory delusions, third-person auditory hallucinations, running commentary, thought insertion and somatic hallucinations. The patient was having a psychotic disorder and the most likely diagnosis is schizophrenia.

Care Needs

        The nursing care plan goals for schizophrenia involves; recognising schizophrenia, establishing trust and rapport, maximising the level of functioning, assessing positive and negative symptoms, assessing medical history and evaluating support structures (Ganguly et al., 2018). The chief aim with this patient presenting with hallucinations and persecutorial delusions is safety. It is important to establish the contents of the auditory hallucinations, in some schizophrenia presentations, voices tell patients to either harm themselves or others. 

Auditory hallucinations are one of the most common symptoms of schizophrenia, hearing voices is varied, it can involve hearing one voice to hearing multiple voices. Most common in schizophrenia patients is that they hear multiple voices that are male, abusive, and repetitive (Hugdahl & Sommer, 2018). In this case, the patient has verbalised wanting to commit suicide by using medication but does not have the means to. Pharmacotherapy and hospitalisation are therefore warranted and must be discussed with the family as to ensure medication compliance and safety of the patient. 

            Individuals with schizophrenia lead a generally poor quality of life, this is due to poor medical attention, homelessness, unemployment, financial constraints, lack of education and poor social structures (Michalska da Rocha et al., 2018). Patients having persecutorial delusions will either attack the people they are suspicious of, or they will isolate themselves as a defence mechanism (Freeman, 2016). In this case, the patient will only go out of the room if the housemates have gone out, and this has been going on for over two months, suggesting the patient may be experiencing loneliness and possibly poor dietary intake. Loneliness is a very common experience for people with schizophrenia, theoretical models in the general population propose that loneliness is identical to the feeling of being unsafe. Loneliness is accompanied by enhanced environmental threat perceptions and can lead to poor physical, emotional and cognitive function (Eglit et al., 2018). The patient has been brought to the appointment by his mother, suggesting there is an element of trust between the mother and the patient. It may be beneficial in this case to explore the possibilities of the parents being the primary carers upon discharge.

        Secondly, although medications play a very important role in the management of schizophrenia, addressing nonpharmacological interventions such as financial management, regular exercise, living arrangements and friendship dynamics are essential in providing holistic care. It is important in this case to assess the financial situation of the parents and how they would cope with being full-time carers once the patient has been discharged (Fekadu et al., 2019). The financial and emotional burden on families is massive because they experience and endure most of the negative effects of the illness (Lippi, 2016). Taking in to account the welfare and safety of the parents by providing the correct support and resources is paramount to the recovery process. A social worker is required to work with the family on the various programmes they would benefit from, upon discharge. Furthermore, a diagnosis of schizophrenia is considered a disability, the social worker should discuss with the family their eligibility to receive government payments (Services Australia, 2020). 

Assessment

Assessment criteria
History of Presenting complaintPresented to the clinic with persecutory delusions, third-person auditory hallucination, running commentary, thought insertion and somatic hallucination
Biological History  Patient appears clinically healthy.
Social History  Regularly smokes cannabis and occasionally uses methamphetamines. Lives in shared housing with friends.
Psychiatric History  No evidence given of previous psychiatric history other than the presenting issues listed above.  The symptoms have been going on for over two months.
Appearance and behaviour  Presented well, normal work of breathing, alert and conversant. Appropriately dressed.  The patient appears underweight and older than actual age, skin appears dry.  
Mood and Affect (note congruence)Presents with a flat affect. Unsettled and appears suspicious. Patients is also anxious and keeps on looking around the room.
Thought Process and Content  The patient has prosecutorial delusions, thinks the British secret service have implanted a device in his brain and they are controlling his thoughts.
Sensorium and Cognition   While it is easy to understand the speech, and the content, the patient is unaware the voices are only in his head.  Patient appears alert to place and time.
Insight and Judgement  Patient is alert to place and time; patient is however suicidal and suspicious. Patients also appears to be having somatic hallucinations.
Self-concept and Self-care considerationsWould benefit from having an exercise regime to manage stress and outer act the effect of medication.  
Cultural considerations  N/A
Risk assessment  Has knife and is suspicious of his house mates. Stays in room and come out when his leave the house. Possible risk of self-harm or his house mates. Verbalised wanting to end his life, preferred choice is medications. The patient however does not have the means to.
MMSE score (if indicated)  NA
Clinical Formulation  Auditory hallucination, with no organic cause plus persecutorial delusions, running commentary with low affect. The patient also thought insertion and somatic hallucination. The patient’s is at risk of self-harm, has a knife and a baseball bat.  The symptoms are consistent with schizophrenia and warrants a review by the psychiatrist for pharmacotherapy and possible hospitalisation.  

Trauma and Psychosis

         The neural diathesis-stress model could explain the development of psychosis, the diathesis-stress model, posits that the development of mental health issues can be a mixture of environmental and genetic factors (Pruessner et al., 2017). Studies show that there is a link between trauma and development of psychosis (Popovic et al., 2019). This is not the case with this patient, there is no evidence of stress or past trauma, however the patient verbalised to being a heavy user of cannabis and methamphetamine. Important during the assessment process is to determine the reasons for use of illicit drugs. Some common reasons for the use of drugs include; stress, pain, abuse, and depression. This is essential for ongoing symptoms management, prevention of relapse, and eventual hospitalisation (National Institute on Drug and Abuse, 2020). For example, (Patel et al., 2020), found that individuals who are exposed or use cannabis are at increased risk of developing schizophrenia.  Evident by the fact that there is a high frequency of psychotic disorders with cannabis users. Cannabis-induced psychosis forms part of the schizophrenia spectrum that eventually convert to schizophrenia. People with the disorder have a higher tendency to use cannabis (Cuesta et al., 2017). Cannabis and schizophrenia have a close relationship primarily through the action of the Tetrahydro cannabinoid (THC) on the cannabinoid molecular system. This is especially in genetically predisposed individuals. THC also makes the psychosis worse and causes more relapses and hospitalisation (Zou & Kumar, 2018).

Care Plan

ProblemGoalPlanReview and Evaluation
Risk of self-harm related to the auditory hallucination, patient hearing voicesThe patient to stay safe and not act on the voices The patient will identify at least two stressful events that trigger hallucination.The patient will learn ways to refrain from responding to voicesExplore how the hallucinations are being experienced by the patient Consider environmental precautions. Find out if the patient has the means to self-harm. Evaluate the need for medication Evaluate the need for hospitalisation Help the client identify the times that the hallucinations are most prevalent     The patient will verbalise that they have not experienced any hallucinations.Will have no attempt at self-harm. Patient will socialise with friends.
Flat affectTo improve mood   For the patient to display appropriate emotions.   For patient to maintain social relationships  Cognitive behavioural therapy with the psychologist.   Needs medication to manage the mood.    The patient is displaying some level of satisfaction in daily tasks. The patient continues to attend cognitive behavioural therapy and complies with the medication regime. The patient will continue to perform physical activity.
Altered perception related to alteration in the brain chemistry. Either due to cannabis or methamphetamine use.The patient will express reality-based thoughts.   To take medication as prescribed   The patient to stop using cannabis.For Family to help the patient with medication compliance. Together with the family develop a plan to manage and minimise hallucinations through stress reduction Enrol in an addiction program Teach the family the positive and negative symptoms of schizophrenia and signs that the patient has stopped taking their medication. Clinical staff to assess if medication have reached therapeutic levels.Family will verbalise understanding of the positive and negative symptoms of schizophrenia. The patient will stop using illicit drugs.
Defensive coping related to paranoid and persecutorial delusionsPatient will state that they feel safe and in control with interactions with the environment, family, study and work.    Help the patient find ways to manage the anxiety and stress caused by the paranoia. Enrol patient in an addiction program to help manage drug dependence.The patient can interact with family and friends appropriately.The patient can apply various stress and anxiety reducing techniques. The patient will identify stress triggers to avoid further psychosisThe patients will demonstrate decreased suspicious behaviours with their interactions with others
Family role shift.The family will have access to support groups post discharge. The family will be helped financially  Teach the family and the client the warning signs of a relapse. Referral to the social worker.The patient and the family will understand a and verbalise the signs of relapse and when to seek help The family will verbalise the importance of taking medication. The family will have access to various government funded program for mental health. The family will have access to the financial help from the government

Collaborative Care

          Collaborative care planning values and prioritises the preferences of the person with lived experiences, there carers, families and kinship groups. Involvement of carers, families and kinship groups in the development, application and review of the care plan will often provide valuable nonclinical information to help personalise care which leads to improved outcomes (Morley & Cashell, 2017). Collaborative care is based on the current and perceived needs of the patient and must to be reviewed and amended whenever there is a change in the patient’s condition. Cost-effective studies also show that collaborative care practices lead to decreased cost to the health care system and improved overall quality of life. And while the overall cost of regular outpatient may be expensive, studies show that the cost of inpatient treatment was reduced (Camacho et al., 2016). CCP is a multidisciplinary approach to mental health and in this model of care patients have access to a psychologist, social workers and psychiatrist to help the patient manage the mental health. The goal may include, increasing exercise, finding a job, learning to manage stress and helping the patient manage substance abuse. The care plan review will be done every four to six weeks upon discharge, and whenever there is a change in the patient’s condition.  A successful care plan, in this case will be judged on how well the patient has integrated into the community.

         The framework used for this care plan is the Recovery-Oriented Practise framework. (Coffey et al., 2019) found that when recovery-focused care planning was high, the quality of care was also rated high among patients and families.  The recovery-oriented practise framework is a holistic and personalised plan that focuses on promoting the autonomy of the patient (Victoria State Government, 2020).  The main priorities of this care plan are safety, positive and negative symptom management and helping the client, together with the family, come up with strategies to manage the illness in the community. The management strategies are a mixture of pharmacological and non-pharmacological interventions. Non-pharmacological interventions proposed include stress reduction and cognitive behavioural therapies as studies show that stress hormones such as cortisol are elevated in most psychotic disorders .  Signs of high cortisol levels are; weight gain, irritability, anxiety, low libido, erectile dysfunction and headaches.  Other studies show that patient with acute schizophrenia had been exposed to stressful events in the preceding 3 months prior to the onset of symptoms (Karanikas & Garyfallos, 2015).

           Secondly, in dealing with the hallucinations, for safety reasons, it is essential to determine the content of the hallucination. The first-line treatment in the management of positive symptoms is medication; most positive symptoms can be managed with antipsychotics (Huhn et al., 2019). It is important to discuss with the family the possibility of having the patient hospitalised to make sure that the medication reaches therapeutic levels (Kaskie et al., 2017).  It is vital in this case to deal with the paranoia and hallucination for the non-pharmacological interventions to be effective. Antipsychotics are generally prescribed to manage and treat positive symptoms and not the root cause of schizophrenia. Most medications to manage schizophrenia deal with the hallucination and delusion, they work by reducing the positive symptoms by blocking dopamine receptors (Haddad & Correll, 2018).

            Finally, cognitive behavioural therapy (CBT) is a therapy technique that helps modify the undesirable mode of thinking, behaviours, and feelings.  CBT involves practical self-help strategies to reduce the positive symptoms of schizophrenia, it combines cognitive and behavioural techniques and the combination of these helps the patients gain healthy thoughts and behaviours (Carpenter et al., 2018). CBT involves establishing a collaborative relationship and developing a shared understanding of the problems. In this case, it is about helping the patient and the family come up with strategies to reduce and manage the symptoms of the illness at home non pharmacologically (Health Quality Ontario, 2018). The nurse needs to help the client come up with strategies for stress reduction themselves and some of the triggers of psychosis (Morley & Cashell, 2017).  This helps the client have some levels of control over their lives and in the long run, will promote independence.

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