pd psyche
TRANSCRIPT
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I. INTRODUCTION
Paranoid schizophrenia is the most common type of schizophrenia in most parts of the
world. The clinical picture is dominated by relatively stable, often paranoid, delusions,
usually accompanied by hallucinations, particularly of the auditory variety, and
perceptual disturbances. Disturbances of affect, volition, and speech, and catatonic
symptoms, are not prominent.
With paranoid schizophrenia, your ability to think and function in daily life may be better
than with other types of schizophrenia. You may not have as many problems with
memory, concentration or dulled emotions. Still, paranoid schizophrenia is a serious,
lifelong condition that can lead to many complications, including suicidal behavior.
(http://www.mayoclinic.com/health/paranoid-schizophrenia/DS00862)
Patients who have paranoid schizophrenia that has thought disorder may be obvious in
acute states, but if so it does not prevent the typical delusions or hallucinations from
being described clearly. Affect is usually less blunted than in other varieties of
schizophrenia, but a minor degree of incongruity is common, as are mood disturbances
such as irritability, sudden anger, fearfulness, and suspicion. "Negative" symptoms such
as blunting of affect and impaired volition are often present but do not dominate the
clinical picture.
The course of paranoid schizophrenia may be episodic, with partial or complete
remissions, or chronic. In chronic cases, the florid symptoms persist over years and it is
difficult to distinguish discrete episodes. The onset tends to be later than in the
hebephrenic and catatonic forms. (http://www.schizophrenia.com/szparanoid.htm)
According to the World Health Organization, It describes statistics about mental
disorders of year (2008). Schizophrenia is a severe form of mental illness affecting about
7 per thousand of the adult population, mostly in the age group 15-35 years. Though the
incidence is low (3-10,000), the prevalence is high due to chronicity. According to thefacts it reveals Schizophrenia affects about 24 million people worldwide.
Schizophrenia is a treatable disorder, treatment being more effective in its initial stages.
More than 50% of persons with schizophrenia are not receiving appropriate care.90% of
people with untreated schizophrenia are in developing countries. Care of persons with
schizophrenia can be provided at community level, with active family and community
involvement.
Schizophrenia affects men and women with equal frequency. Schizophrenia often first
appears in men in their late teens or early twenties. In contrast, women are generally
affected in their twenties or early thirties.
In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM-IV).
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(http://www.howstuffworks.com/framed.htm?parent=schizophrenia.htm&url=http://www
.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml)
In the Philippine setting, the disability survey done in 2000 by the National Statistics
Office (NSO) found out that mental illness was the 3rd most common form of disability
in the country. The prevalence rate of mental disorders was 88 cases per 100,000
population and was highest among the elderly group. This finding was supported by a
more recent data from the Social Weather Station Survey commissioned by DOH in
2004. It reveals that 0.7 percent of the total households have a family member afflicted
with mental disability. The Baseline Survey for the National Objectives for Health in
2000 stated that the more frequently reported symptoms of an underlying mental health
problem were sadness, confusion, forgetfulness, no control over the use of cigarettes and
alcohol, and delusions.
The most recent study on the prevalence of mental health problems was conducted by the
National Epidemiology Center (DOH-NEC) in 2006 which showed revealing results
though the target population was limited only to government employees from the 20
national agencies in Metro Manila. Among 327 respondents, 32 percent were found to
have experienced a mental health problem at least once in their lifetime. The three most
prevalent diagnoses were: specific phobias (15 %), alcohol abuse (10%), depression and
schizophrenia (6%). Mental health problems were significantly associated with the
following respondent characteristics: ages 20-29 years, those who have big families, and
those who had low educational attainment. The prevalence rate generated from the survey
was much higher than those that were previously reported by 17 percent.
Currently, there is no method for preventing schizophrenia and there is no cure.
Minimizing the impact of disease depends mainly on early diagnosis and, appropriate
pharmacological and psycho-social treatments. Hospitalization may be required to
stabilize ill persons during an acute episode. The need for hospitalization will depend on
the severity of the episode. Mild or moderate episodes may be appropriately addressed by
intense outpatient treatment. A person with schizophrenia should leave the hospital or
outpatient facility with a treatment plan that will minimize symptoms and maximize
quality of life.
This introduced psychiatric case was chosen primarily because it is the most interesting
amongst the cases that were encountered by the group members. It posts relevant
manifestations that are psychiatric in nature and the entire case is highly possible to be
studied comprehensively within the limited time available.
elderly population.
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RISK FACTORS:
Some formal psychotic disorders, like Schizophrenia, tend to run in families. If someone
has a psychotic disorder, it is quite likely that another member of his/her immediate or extended
family also has had a psychotic disorder. Generally, the first signs of most psychotic disorders
appear when a person is in his/her late teens, twenties, or thirties.
CAUSES
.
Causes are largely UNKNOWN
Patients with personality disorder may have biological or psychological vulnerability toward
the development of psychotic symptoms
One or more severe stress factors, such as traumatic events, family conflict, employment
problems, accidents, severe illness, death of a loved one, and uncertain immigration status, can
precipitate brief reactive psychosis.
Biological or genetic predisposition
Environmental factors may also play a role in their development, including stress, drug abuse,
and major life changes.
In addition, people with certain psychotic disorders may have an imbalance of certain
chemicals in the brain. They may be either very sensitive to or produce too much of a chemical
called dopamine. Dopamine is a neurotransmitter, a substance that helps nerve cells in the brain
send messages to each other. An imbalance of dopamine affects the way the brain reacts to
certain stimuli, such as sounds, smells, and sights, and can lead to hallucinations and delusions.
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SIGNS AND SYMPTOMS
Hallucination
Delusion
Disorganized or incoherent speech
Confused thinking
Strange, possibly dangerous behavior
Slowed or unusual movements
Loss of interest in personal hygiene
Loss of interest in activities
Problems at school or work and with relationships
Cold, detached manner with the inability to express emotion
Mood swings or other mood symptoms, such as depression or mania
PROGNOSIS
Many people who have been diagnosed with a psychotic disorder tend to lead productive
lives and function normally with the proper treatment. The prognosis for those with psychotic
disorders varies from person to person. For example, women tend to respond better to medication
than men. Those with a family history of illness have a lower prognosis than those without. The
number of negative symptoms also determines the individual prognosis as well as age; the older
the patient, the more promising prognosis. Another important factor in determining prognosis is
the individual’s support system. Most will never fully recover from or be cured of psychotic
disorders and will need to continue treatment for the duration of their lives. To maintain mental
and physical stability with the condition, it is important for patients to strictly follow the
treatment recommended by their healthcare providers.
COMPLICATIONS
Accidental injuries
suicide, or homicide can occur during a psychotic episode.
Loss of relationships or employment is common
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PREVENTION
In general, there is no known way to prevent most psychotic disorders, but many of therelated symptoms can be prevented with early detection and treatment.
Seeking help as soon as symptoms appear can help decrease the disruption to the person's
life, family, and friendships.
Avoiding drugs and alcohol can prevent psychotic disorders associated with these
substances.
II. OBJECTIVES
To commence rapport building and development of the therapeutic relationship
To introduce patient to the process of therapy and instill a sense of realistic hopefulness
about outcome
To know about differential diagnosis of psychotic episodes and relevant investigations.
To know about treatment including social, pharmacological and psychological.
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III. PATIENT’S PROFILE
Name: Macrina Dizon
Age: 39
Gender: Female
Address: Dayanki, Burgos Ilocos Sur
Occupation: Farmer/Housewife
Birhtdate: January 30, 1974
Birth Place: Ilocos Sur
Civil Status: Single
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: 04/16/2013 (April 16, 2013)
Time of Admission: 3:45PM
Diagnosis: Paranoid Schizophrenia
Attending Physician: Dr. Cayad
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IV. PSYCHIATRIC HISTORY
History of Present Illness
- Patient’s last admission was due to poor sleep and appétit, but still energetic during
the day, able to perform grooming and personal hygiene practices she also started to have
pressured speech, seen talking to self and always says, “Jehovah Ama”. She also started to
become verbally and physically assaultive toward husband and relatives. She also had visual
hallucinations of “red, black, and white dancing dumbles, and “witch nga agli ti bassit nga bato.”
She also had Auditory Hallucinations, “ag pakamatay kan”. The patient improved and discharged
after 18 hospital days, with home medications.
Patient discontinued her medications ever since her last admission. She takes it intermittently and
only whenever she likes to. She refuses to take it at night, complaining that it tastes bitter.
Patient was apparently coherent, responsive, and non-violent until two weeks PTA, patient
reportedly worked all day in the farm. She got exhausted and went home. When she arrived
home in the evening, there has been noticeable change in mood and affect. Patient had difficulty
in sleeping, was irritable, had a decrease in appetite and talked excessively.
She talks to herself in the kitchen, turns all the lights on and laughs all by herself. At the same
week, patient roamed around the plaza talking to herself and says, “Ama Jehovah” again. She
also spits on their neighbors.
Patient also manifests with auditory hallucinations saying that she hears non-existent voices
telling her, “Wala kang Silbi magpakamatay ka nalang” she also had visual hallucinations saying
that people around her have fangs.
6 days PTA, patient reportedly took her clothes off outside their house. When asked why she did
it she said that she felt hot and want to sun bathe. 3 days PTA patient threatened to hurt her
nephew One day PTA patient brought the foam of their bed outside their house. After a while she
was seen stepping on it with her clothes off. When asked why she did it patient verbalized “Bakit
ako mahihiya! Lahat naman tayo walang damit parang si Adan at si Eba” Symptoms persisted
and reportedly worsened hence admission in this institution on April 16, 2013
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Past Medical History
Patient has no known allergy to any drug, or food. She has had 4 past admissions in this
institution. She was diagnosed of Paranoid Schizophrenia, Undifferentiated, Chronic with acute
exacerbation on October 1989; Paranoid Schizophrenia, E with IERS on December 1998, July
2011 and July 2012. No other previous surgeries, history of trauma or accident and no known
other known medical conditions. She does not go for regular consultation, unless experiencing
Signs and Symptoms. She is a Non- Alcoholic and a Non- Smoker.
Family History
Father – Modesto – Deceased due to Old Age
Mother – Maria – 73 years old, with hip fracture
Siblings
- Fe – 58- married BSN Graduate
- Cecilia -55 Married Businesswoman
- Lenita- 54 married
- Susana 52 Married physician
- Corazon- 50 married commerce graduate
- Modesto Jr.- 29 unemployed
- Patient
No other family members of mental illness. All siblings are close to patient. Denies
heredofamilial diseases like cancer, asthma, Diabetes Mellitus
Personal Developmental, Social, and Environmental History.
Patient was born via NSD in, home delivery by a traditional birth attendant. Developmental
milestones at par with age. She is an average student during her school days but wasn’t able to
go to college due to financial constraints. She has a harmonious relationship with her family and
friends. She does not smoke nor drink alcohol at present she is a housewife and works as a
farmer in the morning. As for health care practices, she does not go for medical check up and
does not practice any form of alternative medicine.
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V. MENTAL HEALTH ASSESSMENT
PHYSICAL ASSESMENT
SENSATION
During the morning, it is scheduled that all patients must be taking their bath. Early in the
morning, the water is very cold and the weather is very windy and coldly. The patient knows about this
that’s why her significant other is requesting a hot water with water temperature at body temperature
just her for the patient not to refuse from taking a bath.
ELIMINATION
The patient is well voiding and eliminating with estimated urine and stool ratio of 2:6-8 per day.
LOCOMOTION
The patient is well moving around the room without pain noted during the movement.
FLUID
Patient is taking fluid without any difficulty and can drink water with an estimated intake of 1
liter.
POSTURE
Well ambulated and have acceptable social posture
AERATION
The patient is well breathing with no obstruction and difficult and having discharged patient has an
respiration rate of 18 breaths per minute
CIRCULATION
The patient has a normal cardiac rate with normal capillary refill from extremities and no abnormal
heart sound noted.
INTEGUMENTARY
The patient’s skin is well moisture warm to touch, with good skin. No Anomalies noted
NUTRITION
The patient eats all types of food and eats regularly (3x a day) During eating the patient doesn’t
experience any difficulty and obstruction
GENERAL APPEARANCE
The patient is neat , fairly groomed, coherent and not in reparatory distress.
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PSYCHOLOGICAL ASSESSMENT
GENERAL PRESENTATI ON
APPEARANCE
The patient had seen well groom and young. She dress appropriately according to age and
sex. She also had seen healthy and good posture and normal way walk or gait.
GENERAL BEHAVIOR
The patient does not show mannerism, combative actions, twitching, hand and feet
wringing and rubbing but she is clumsy and having psychomotor retardation (patient is less
moving and cooperative to the daily activities.
ATTITUDE TOWARDS THE EXAMINER
Attitude is a position of the body or manner of carrying oneself. It is a position or posture
of the body appropriate to or expressive of an action, emotion. The patient cooperates in the
whole duration of duty and was able to answers most of questions asked to her and can’t
participates in all activities. It was also observed that she was not going out with other patient
and student nurse.
STATE OF CONSCIOUSNESS
During my interaction to the patient I had observed that she is aware of the time date and
place of where she is.
Attention
As I observed to the patient, every time we interact, the patient focus during the
interaction is quite ineffective she’s having a flight of ideas during our conversation
SPEECH
During interaction with the patient, the patient is kept on silence and it seemed to be that
she’s afraid of something.
Orientation
The patient is aware to her name, age, and when she is born, the place and their home
address but when I asked her about the current time, she is not response and remained mute
following other questions.
Example conversation:
Nurse: Ano po pangalan mo?Patient: Macrina
Nurse: Ilan taon ka na?
Patient: 39 na
Nurse: san ka pinanganak?
Patient: Burgos Ilocos Sur
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Nurse: Galing naman, alam na alam ah..eh anong oras na ngayon at anong araw
ngayon?
Patient: Smiles, May 8, 2013
Mood and Affect
A severe reduction in emotional expressiveness. People with schizophrenia often show
flat affect. A person with schizophrenia may not show the signs of normal emotion, perhaps may
speak in a monotonous voice, have diminished facial expressions, and appear extremely
apathetic.
The patient sometimes shows flat affect during the whole interaction.
Form of Thought
As presented the example above, I think it is hard for me to determine the main idea that
she might poses to express because of the mute behavior of the patient the conversation but I
taught it is a form of thought (flight of idea), because I felt that she want to jump the topic from
another topic.
Thought Content
I observed to the patient that every time the door is open, she is always been near to the
door holding her things and also the mute behavior during interaction.
Perception
According to her husband, the patient displayed misperception to the sound. An auditoryhallucination that have been noted prior to hospitalization. The patient told “ wala kang silbi
magpakamatay ka na”.
JUDGEMENT
During the 3rd
day of conversation, I tried to remotivate the patient through helping to
increase self perception toward treatment. I told to her that:
Nurse: adding kong gusto mong gumaling at makalabas dito, sana makipagcooperate ka
lang, kasi sana sayo din yan nakasalalay, ang paggaling mo.
Patient: Sige po sir
Nurse: naiintindihan mo po ba ako? Tandaan mo, nasa sayo ang paraan para gumaling ka
Patient: Opo, Sir namimiss ko na po kasi sa bahay
These conversation might implied that the patient have good judgement because
she kept on talking and being restless staring and remember, commonly people, whey
they answer question like these, they will answer properly and accurately.
MEMORY
With Short Term Memory
INTELLECTUAL FUNCTIONING
The Patient is disoriented to 3 spheres
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VI. TREATMENT MODALITIES
Psychotherapy
Psychotherapy ("talk therapy") involves working with a trained therapist to figure out ways tosolve problems and cope with depression. It can be a powerful intervention, even producing
positive biochemical changes in the brain. Three major approaches are commonly used to treat
clinical depression. In general, these therapies take weeks to months to complete. Each has a goalof alleviating your symptoms. More intense psychotherapy may be needed for longer when
treating very severe depression or for depression with other psychiatricsymptoms.
Interpersonal therapy (IPT): This helps to alleviate depressive symptoms and helps you develop
more effective skills for coping with social and interpersonal relationships. IPT employs two
strategies to achieve these goals.
The first is education about the nature of depression. The therapist will emphasize thatdepression is a common illness and that most people can expect to get better with treatment.
The second is defining your problems (such as abnormal grief or interpersonal conflicts).
After the problems are defined, the therapist is able to help set realistic goals for solving these
problems. Together you will use various treatment techniques to reach these goals.
Cognitive behavioral therapy (CBT): This helps to alleviate depression and reduce the likelihoodit will come back by helping you change your way of thinking. In CBT, the therapist uses three
techniques to accomplish these goals.
Didactic component: This phase helps to set up positive expectations for therapy and promote
your cooperation. Cognitive component: This helps to identify the thoughts and assumptions that influence your
behaviors, particularly those that may predispose you to being depressed. Behavioral component: This employs behavior-modification techniques to teach you more
effective strategies for dealing with problems.
Behavioral therapy (BT): This helps to modify your depressive behaviors through highly
structured, goal-oriented therapy. BT uses three techniques to accomplish these goals.
Functional analysis of behavior: This helps to define the behaviors that will be targeted for
change.
Selection of specific techniques: Various techniques can be employed to help modify theselected behavior, including relaxation training, assertiveness training, role-playing, and time-
management tips.
Monitoring behavior: Progress and program effectiveness can be monitored by logs andrecords you keep.
General management and advice to patient and family
Remain optimistic and emphasize the patient’s strengths and abilities rather than deficits.
·Recovery often takes place in small steps and, for the patient, being engaged in an activity
that is meaningful to them might be as important as symptom control.
Support patient to function in the areas that are important to her (eg work, recreation,
relationships).
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It is important proactively to offer patients the same health promotion and prevention
measures as the general population (eg smoking cessation, weight control, screening for
diabetes and sexual health).
Psychological therapies for both the patient and family/carers might help prevent relapse,
promote recovery, and are increasingly available in local services.
Encourage the patient to engage with psychological therapies where available (eg cognitive
behavioural therapy, family therapy, problem-solving interventions).
Family interventions or problem-solving work might help improve patient and carer health.
Therapeutic alliances build on respect and feeling valued. Encourage the patient to build
relationships with key members of the practice team.
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