Diagnosis of Paranoid Schizophrenia - Case Study Example

Case Study: Paranoid Schizophrenia Name of Student: Student No: Date: Name of Supervisor: Introduction Schizophrenia is a devastating psychotic disorder characterised by disordered thoughts (also known as delusions); perceptions (or hallucinations); speech, affect and behaviour (Durand & Barlow, 2007). It is a complex disorder, and the signs and symptoms tend to vary. This makes it very complicated to diagnose due to is various symptoms, cognitive and emotional dysfunctions as well as the aetiology (cause of the disease). It usually manifests in the teenage years or early adulthood (Schizophrenia Symptoms, 2009). The DSM-IV categorizes schizophrenia as a mental disorder that has three main subtypes; paranoid, disorganised/ hebephrenic and catatonic. Paranoid schizophrenia presents with delusions of grandeur or persecution (Durand & Barlow, 2007). Paranoid schizophrenia is the most prevalent subtype and its most prominent symptoms are paranoid delusions that may also be accompanied by hallucinations, especially auditory hallucinations and disturbances in perception. Other common symptoms are persecution delusions, delusions of reference, exalted birth, having a special mission, bodily change perception or jealousy. The patient may hear voices that give commands or threaten the patients, or auditory hallucinations without words. There are also olfactory or taste, sexual or other bodily sensations, or visual hallucinations although these are not very common. Paranoid Schizophrenia may present in an episodic manner with remissions that may be partial or complete; or it may be chronic. In the latter case, the patient is symptomatic for years with difficulty in distinguishing discrete episodes. The symptoms tend to manifest later than other forms of schizophrenia (WHO, 1992). The DSM-IV-TR gives the following criteria to diagnose paranoid schizophrenia; the patient must display obsession with one or more delusions or must have recurrent auditory hallucinations. In addition, the patient must not prominently display disorganised speech, catatonic behaviour or flat or inappropriate affect that is, their emotions are flattened, they do not display any animation. Personal Data The patient’s name is Nick, and he is thirty-five years of age, a British male, single whose religion is undefined. He was born in Thurso in Scotland on 11th October 1976. His listed address is No. 4 Privet Drive and he lists his occupation as bartender. The patient is a high school graduate and he was admitted to this institution on the 6th of January 2011 at 2:30pm. He has previously been admitted to other institutions for durations of time. His first admission was on January 4th 1995 to 11th February 1999, in Scotland. He was again admitted to the same institution from 28th May 2001 to 30th December 2001. He then immigrated to London, England where he was admitted for the same complaint on 5th June 2004 to 6th September, 2005. Then again from 9th October 2008 to 7th April 2009. The patient is diagnosed as a paranoid schizophrenic by the attending physician, Dr. Lupin. For the last fifteen years, the patient has lived in Edinburgh, Scotland before moving to London England in 2001 where he currently resides. This information was provided by the patient’s mother. Chief Complaints The client was brought into the office by his mother because of a violent incident in which he attacked his brother, stating that he was the source of the whistling noises that had been disturbing him during the night. This is the patient’s first visit to my office and upon taking his history, he reported having had three episodes of psychosis within the last three years; is preoccupied with thoughts of being spied upon; has recently lost his bartending job and his family relations have become strained due to his suspicions that he was being betrayed by them to spies; he talks aloud to himself. In addition to this, the counsellor also noted that the patient displayed a marked lack of attention to hygiene. His breath was smelly, his teeth stained and he was generally unwashed. The patient was drunk and reeking of stale drink indicating excessive intake of alcohol; he displayed violent behaviour, beating up on his brother as well as pushing his mother within the clinic; the patient seems agitated and overanxious; his mother also reported that he has not been complying with his medication regimen. The patient meets the DSM-IV-TR criteria for paranoid schizophrenia with demonstrated delusions and auditory hallucinations. He also neither displays catatonia, disorganised speech nor flat affect. The episodic nature of his psychoses suggests that there are periods of lucidity in which patient can function fairly normally. The patient has held jobs on and off as a bartender for the last fifteen years and lives on his own. He has a history of alcohol abuse and lack of compliance with medications. Ego syntonic behaviour disorders imply that the patient is not aware of their symptoms. In cases of paranoid schizophrenia, it may take a while for the patient to accept their diagnosis. This is because they perceive the hallucinations and delusions as very real and not products of their imagination. They are unconvinced of their paranoia because they really believe someone is out to kill them (Schwartz, 2011). The fact that Nick is not compliant with his medication schedule and was brought in for beating up his brother for apparently making the whistling noises he was hearing suggests that he is not completely accepting of his diagnosis and therefore is ego syntonic. Coping Mechanisms Schizophrenics often present with five symptoms that are difficult for the patient and their families to cope with. These symptoms are paranoia, denial of illness, stigma, demoralisation and terror of being psychotic (Weiden and Havens, 1995). The patient, Nick, seems to display all except terror of being psychotic. His paranoia is displayed by his belief that his family is spying on him. The fact that he still has interaction with his mother, who brought him in to the clinic, and his brother who he beat up, may be source of hope because he has not completely isolated himself from his family. Weiden and Havens (1995) go on to state that stigma is something many patients will not admit to, because to admit to it would be tantamount to acknowledging that they have a mental illness. Stigma refers to the feeling of disgrace associated with having a mental disorder. This means that the presentation of stigma is usually indirect through refusal to access treatment such as Nick is doing by refusing to take his medication. Substance abuse is also usually a side effect of stigma, with the excuse that psychotic symptoms that manifest in the process of ‘getting high’ are a normal by-product of that process. This could be one reason for Nick’s alcohol abuse. According to Weiden and Havens (1995), demoralisation usually follows a psychotic episode and it is a by-product of the failure to meet familial or societal expectations, as well as personal expectations. For example, failure to obtain a college education may cause demoralisation in Nick’s life especially if he had to drop out due to the schizophrenia. Depression is a common side effect, aggravated by the patient’s disinclination to discuss his feelings. Nick could possibly be undergoing this experience as is displayed by his inattention to personal hygiene, his overconsumption of alcohol and the fact that he recently emerged from a psychotic episode. It is clear that Nick has the support of his family behind him to take care of him as he battles with his diagnosis. Unfortunately, the defence mechanisms he has employed to help him cope are negative in nature, including the alcohol abuse and the denial of illness. His strengths are that he has been able to curve out a livelihood for himself although he has lost his job. He has still been able to work on and off for fifteen years when he is not admitted for treatment. His hospital stays have also tended to not be prolonged, with the longest being his first admission from 1995-1999. This implies that in spite of his problems he is managing his condition in an outpatient capacity with some success. Probably due to help from his family. Achievement of Diagnosis The DSM-IV-TR gives the criteria for diagnosis of schizophrenia as follows; there must be two or more of these characteristic symptoms presenting for a substantial period of time in the course of a month. These symptoms are delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour or negative symptoms such as flat affect, alogia and avolition; in additional, social or occupational function should be impaired in the same substantial period following onset of symptoms. There should be a significant lowering of functionality at work, or in interpersonal interaction or ability to care for oneself as compared to the period before attack; the signs of disturbance must be persistent for a minimum of six months including the one-month period in which the above symptoms manifest. This may also include a stretch of time in which prodromal or residual symptoms are noted; In addition to these conditions, it is important to also exclude schizoaffective and mood disorders. This is done by ensuring that no major depressive, manic or mixed episodes are observed simultaneously with the active phase symptoms or that if mood episodes have occurred at this time, their duration has been short lived as compared to the active or residual phases; The symptoms displayed must not be due to substance ingestion or some other general medical condition; If some other pervasive developmental disorder or autistic disorder is present, hallucinations or prominent delusions must exist for a minimum of one month for Schizophrenia to be additionally diagnosed. In addition to these criteria to give the diagnosis of schizophrenia, additional differentiation into the sub type, paranoid schizophrenia demands that the patient displays obsession with one or more delusions or must have recurrent auditory hallucinations. In addition, flat affect, disordered speech or catatonia must not be present. In Nick’s case, he met all the criteria for paranoid schizophrenia due to his paranoia that he was being spied upon, by means of his family and his auditory hallucinations of whistling. In addition, his work life has been impaired since he lost his job, and his interpersonal relationships are also affected demonstrated by the fight with his brother. He has been in and out of facilities since he was 19 years old, which is the within the period of time that the disorder manifests. Although he has a history of alcohol abuse there is no evidence that it predates the disorder. He also suffers episodic psychotic attacks. Treatment Recommendations Psychotherapy The Mayo Clinic (2010) asserts that paranoid schizophrenics have better daily functioning in terms of memory, concentration and emotional response as compared to other forms of schizophrenia. The symptoms however, are still debilitating and according to the Merck Manual (2011), common treatment for paranoid schizophrenia is psychotherapy and medication. Psychotherapy assists with coping mechanisms, adaptation to the illness and obtaining empathy. Psychotherapy includes individual and family therapy. According to the Mayo Clinic (2010), individual psychotherapy using cognitive behaviour therapy is helpful in diminishing severity of symptoms and improving interpersonal interactions. Family psychotherapy is beneficial in assisting the patient’s family to cope with the paranoid schizophrenic. It also enhances communication between the patient and their family. The therapist assists the family to identify the triggers to symptoms and the patient to adhere to their treatment plan. Medications The most effective treatment for schizophrenia is antipsychotics. They alter the chemical balance of the brain that assists in controlling symptoms. Unfortunately, they have various side effects including sedation, dizziness, weight gain, increased chance of diabetes and cholesterol, irritability, sluggishness and tremors. Prolonged usage may cause tardive dyskinesia. Clozapine is the most effective anti-schizophrenic medication but it also has more side effects than antipsychotics. Medication must be taken for life as Schizophrenia is a chronic illness (Medline Plus, 2011). Support Programmes There are many supportive therapies that can be used to assist people with schizophrenia. These include social skills training, job training and relationship building classes. Community outreach and support programmes are helpful when family support is lacking. It is essential for the patient to learn how to stick to their medication regimen and manage side effects; be able to detect warning signs of a relapse and be aware of what to do; manage the symptoms that are not alleviated by medication through psychotherapy and other means; money management and how to use public transport (Medline Plus, 2011). Prognosis It is difficult to predict how a schizophrenic will turn out. Many patients see improvement with medication, but others are unable to function and risk repeat episodes especially early on with the disorder. It is inevitable that relapse will occur if medication is stopped. Complications There are several complications associated with paranoid schizophrenia including possible substance abuse exacerbating the risk of relapse; ill health resulting from inactivity and as a side effect of the medication and suicide due to depression (Medline Plus, 2011). References American Psychological Association. (2004). Diagnostic and statistical manual of mental Disorders. Washington DC: Author. Durand, V.M., and Barlow, D.H. (2007). Essentials of abnormal psychology (5th Ed.). Belmont, CA: Thomson Wadsworth. Mayo Clinic. (2010). Treatments and drugs. Mayo Foundation for Medical Education and Research Medline Plus. (2011). Schizophrenia. Bethesda, MD. U.S National Library of Medicine Merck Manual. (2011). Schizophrenia. Whitehouse Station, N.J. Merck Sharp & Dohme Corp. Schizophrenia Symptoms. (2009). Retrieved from http://www.schizophrenia.com/ Schwartz, A. (2011). Behaviour Disorders, Learning Your Diagnosis. Retrieved from http://www.mentalhelp.net Weiden, P and Havens, L. (1995). How to Manage 5 Common Symptoms of Schizophrenia. Ed. Jaffe, D.J Hospital and Community Psychiatry. World Health Organisation. (1992). The ICD clarification of mental and behavioural Disorders Read More

The fact that Nick is not compliant with his medication schedule and was brought in for beating up his brother for apparently making the whistling noises he was hearing suggests that he is not completely accepting of his diagnosis and therefore is ego syntonic. Coping Mechanisms Schizophrenics often present with five symptoms that are difficult for the patient and their families to cope with. These symptoms are paranoia, denial of illness, stigma, demoralisation and terror of being psychotic (Weiden and Havens, 1995).

The patient, Nick, seems to display all except terror of being psychotic. His paranoia is displayed by his belief that his family is spying on him. The fact that he still has interaction with his mother, who brought him in to the clinic, and his brother who he beat up, may be source of hope because he has not completely isolated himself from his family. Weiden and Havens (1995) go on to state that stigma is something many patients will not admit to, because to admit to it would be tantamount to acknowledging that they have a mental illness.

Stigma refers to the feeling of disgrace associated with having a mental disorder. This means that the presentation of stigma is usually indirect through refusal to access treatment such as Nick is doing by refusing to take his medication. Substance abuse is also usually a side effect of stigma, with the excuse that psychotic symptoms that manifest in the process of ‘getting high’ are a normal by-product of that process. This could be one reason for Nick’s alcohol abuse. According to Weiden and Havens (1995), demoralisation usually follows a psychotic episode and it is a by-product of the failure to meet familial or societal expectations, as well as personal expectations.

For example, failure to obtain a college education may cause demoralisation in Nick’s life especially if he had to drop out due to the schizophrenia. Depression is a common side effect, aggravated by the patient’s disinclination to discuss his feelings. Nick could possibly be undergoing this experience as is displayed by his inattention to personal hygiene, his overconsumption of alcohol and the fact that he recently emerged from a psychotic episode. It is clear that Nick has the support of his family behind him to take care of him as he battles with his diagnosis.

Unfortunately, the defence mechanisms he has employed to help him cope are negative in nature, including the alcohol abuse and the denial of illness. His strengths are that he has been able to curve out a livelihood for himself although he has lost his job. He has still been able to work on and off for fifteen years when he is not admitted for treatment. His hospital stays have also tended to not be prolonged, with the longest being his first admission from 1995-1999. This implies that in spite of his problems he is managing his condition in an outpatient capacity with some success.

Probably due to help from his family. Achievement of Diagnosis The DSM-IV-TR gives the criteria for diagnosis of schizophrenia as follows; there must be two or more of these characteristic symptoms presenting for a substantial period of time in the course of a month. These symptoms are delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour or negative symptoms such as flat affect, alogia and avolition; in additional, social or occupational function should be impaired in the same substantial period following onset of symptoms.

There should be a significant lowering of functionality at work, or in interpersonal interaction or ability to care for oneself as compared to the period before attack; the signs of disturbance must be persistent for a minimum of six months including the one-month period in which the above symptoms manifest. This may also include a stretch of time in which prodromal or residual symptoms are noted; In addition to these conditions, it is important to also exclude schizoaffective and mood disorders.

This is done by ensuring that no major depressive, manic or mixed episodes are observed simultaneously with the active phase symptoms or that if mood episodes have occurred at this time, their duration has been short lived as compared to the active or residual phases; The symptoms displayed must not be due to substance ingestion or some other general medical condition; If some other pervasive developmental disorder or autistic disorder is present, hallucinations or prominent delusions must exist for a minimum of one month for Schizophrenia to be additionally diagnosed.

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