Health Services

Troy University

Spring 2018

Introduction and Background

Schizophrenia is the most common psychotic disorder. It “is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves” (National Institute of Mental Health, 2016). The disorder can also cause “functional impairment in work, interpersonal relationships, and self-care” (Rosenberg, 2009, p. 10). Schizophrenia often causes an individual to lose touch with reality and, therefore, can be debilitating to not only the patient, but the patient’s family as well (NIMH, 2016). The disorder is characterized by an array of symptoms and has multiple methods of treatment but no cure. The lifetime risk for developing schizophrenia is about one percent; and the average age of onset for schizophrenia is eighteen to thirty years, although symptoms begin to appear in childhood (Hooley, Butcher, Nock, & Mineka, 2017). The disorder “tends to be more common and severe in men than women” (Hooley, Butcher, Nock, & Mineka, 2017, p. 4).

Signs and Symptoms

Regarding schizophrenia, the DSM-5 (Ciccarelli & White, 2014) states that the diagnostic criteria requires the persistence of two or more of the following symptoms, each lasting for a significant portion of at least a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms with the requirement of at least one of the two or more symptoms being delusions, hallucinations, or disorganized speech. Schizophrenia symptoms are categorized as positive, negative, or (the newest category) cognitive (Patel, Cherian, Gohil, & Atkinson, 2014). Positive symptoms include: delusions, hallucinations, thought disorders, and movement disorders (NIMH, 2016). Negative symptoms are ones that disrupt a patient’s emotions and behaviors and include: flat affect, reduced feelings of pleasure in everyday life, difficulty beginning and sustaining activities, and reduced speaking (NIMH, 2016). Cognitive symptoms are nonspecific and usually subtle so must be severe enough to notice and diagnose (Patel, Cherian, Gohil, & Atkinson, 2014).

Comorbidity can occur within patients with schizophrenia with substance-abuse disorders being the most common comorbid disorders (Patel, Cherian, Gohil, & Atkinson, 2014). The DSM-5 states that “over half of individuals with schizophrenia have tobacco use disorder and smoke cigarettes regularly” (Ciccarelli & White, 2014, p. 106). Comorbidity of schizophrenia with anxiety is becoming more prevalent, and “rates of obsessive-compulsive disorder and panic disorder are elevated in individuals with schizophrenia compared with the general population” (Ciccarelli & White, 2014, p. 106). Other symptoms and comorbidities that are more common with individuals who have schizophrenia than the general population are: weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary disease (Ciccarelli & White, 2014).

Suicide/ Homicide/ Substance Abuse

According to the DSM-5, “approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on one or more occasions, and many more have significant suicidal ideation” (Ciccarelli & White, 2014, p. 104). Suicide risk remains high for both males and females throughout their entire lifespan, but younger males with comorbid substance use may be at higher risk. (Ciccarelli & White, 2014).

Treatment

“The goals in treating schizophrenia include targeting symptoms, preventing relapse, and increasing adaptive functioning” (Patel, Cherian, Gohil, & Atkinson, 2014). In order to accomplish these goals, both pharmacological and nonpharmacological treatments must be employed: pharmacological for schizophrenia management and nonpharmacological for the treatment of residual symptoms (Patel, Cherian, Gohil, & Atkinson, 2014). The most common pharmacological treatment for schizophrenia is antipsychotic medication. “In most schizophrenia patients, it is difficult to implement effective rehabilitation programs without antipsychotic agents,” and today second generation antipsychotics are used most frequently as they cause less side effects than the first generation (Patel, Cherian, Gohil, & Atkinson, 2014). However, one first generation antipsychotic that is still sometimes used is Clozapine as it “is the treatment of choice for treatment-resistant schizophrenia” (Rosenberg, 2009, p. 11).

Nonpharmacological treatment consists of psychotherapy which may be individual, group, or cognitive behavioral (Patel, Cherian, Gohil, & Atkinson, 2014). Psychotherapy is an area known for emerging new concepts and evolution of past therapies; current “emerging psychotherapies include meta-cognitive training, narrative therapies, and mindfulness therapy” (Patel, Cherian, Gohil, & Atkinson, 2014). According to the NIMH (2016), “individuals who participate in regular psychosocial treatment are less likely to have relapses or be hospitalized,” however it is important to note that psychotherapy should be used in conjunction with pharmacological treatment and not instead of it (Patel, Cherian, Gohil, & Atkinson, 2014). “Most psychotherapies promote family involvement” as this method has been shown to also decrease re-hospitalization and to improve social functioning” (Patel, Cherian, Gohil, & Atkinson, 2014). According to Rosenberg (2009), other “components of schizophrenia treatment that have strong evidence for effectiveness are antipsychotic medications, family education, community treatment teams, supported employment and housing, psychosocial remedial therapies (organized peer support network, clubhouses, etc.), and case management” (p. 11).

Assessment

Social worker plans to video the client, Etta, during her session in order to be able to observe and better understand her symptoms, behavior, and words following the session. Etta has been diagnosed with schizophrenia and is living in an extended, uninterrupted period of psychosis. Etta’s disorganization of thinking is incredibly profound and makes it difficult to ask and talk about other symptoms. The social worker’s goal for this session is to uncover more of Etta’s symptoms.

S

Etta says that she has been hearing cracking sounds and has been made aware by Jesus that someone is going to break into her house. She believes that she is in danger of being shot because an eagle told her she would be if her house was broken into. When asked if there is a chance the eagle could hurt her, Etta replies with disorganized statements regarding a clock. She then reveals that the eagle would be the one doing the shooting if she answered the door or the phone. When asked about whether she had been seeing things, Etta believes that what she saw (a K-Mart bag floating down from her ceiling that Jesus wanted her to see) was normal and that it is odd that the social worker should regard it otherwise. Etta believes that Jesus is speaking to her at all times of day and night; when she hears a sound such as “dogs barking in the alley” she always gets up and looks at the clock and writes down what time it is to let Jesus know she is answering him. She also believes to hear messages from Jesus through the radio. When the social worker tries to uncover Etta’s mood, she replies in a disorganized manner about “answering Jesus’s message around the clock” that does not expose her true feelings or emotions. Etta eventually reveals some stressors that led to her first hospitalization in 1975: she had one child in school, a two-year-old child, and her in-laws had moved in with their family. When asked if she has felt depressed or if she has had fun in a while, Etta answers, “You really don’t have no fun when you got a shotgun behind your head.”

O

Etta’s dress and grooming is actually very fair. Her hair seems to be unwashed or ungroomed, but she is dressed in a nice outfit. Etta moves her hands in a repetitive and seemingly involuntary manner. She uses one hand to tap or stroke the other while the other taps her leg for an extended period of time. She does not show a visible change in mood or affect.

A

Etta has many delusions. She may or may not also experience hallucinations of the auditory and visual natures, but it is difficult to determine whether the things she hears and sees are real or hallucinated. Etta has a diminished ability to express her own emotions and seems to have no change in mood or affect. Her hand movements are indicative of tardive dyskinesia which is probably related to the antipsychotic medication she is taking.

P

The social worker plans to meet with Etta again in two weeks. During the next session, the social worker will aim to discover more about Etta’s emotional state while endeavoring to discern whether what Etta sees and hears is real or hallucinated.

Diagnosis

F-code and Axis 1-5 (Bio/Psycho/Social)

F-code- F-20

Axis I- schizophrenia

Axis II- N/A

Axis III- tardive dyskinesia

Axis IV- deceased husband

Axis V- 21-30

References

Ciccarelli, S. K., & White, J. N. (2014). Psychology: DSM 5. Boston: Pearson.

Hooley, J. M., Butcher, J. N., Nock, M. K., & Mineka, S. (2017). Chapter 13: Schizophrenia and

Other Psychotic Disorders. [PowerPoint slides]. Retrieved from Abnormal Psychology Chapter 13 Powerpoint.

National Institute of Mental Health. (2016). Schizophrenia. Retrieved February 12, 2018, from

https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: Overview and

Treatment Options. Pharmacy and Therapeutics, 39(9), 638–645.

Rosenberg, M. Diagnosis, Treatment Options, and Costs of Schizophrenia. (2009). Journal of

Managed Care Medicine, 12(3), 10-11. Retrieved February 12, 2018, from http://www.namcp.org/journals/jmcm/articles/12-3/schizophrenia.pdf