PSYCHOPATHOLOGY

PREDISPOSING FACTORS
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

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 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.

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.

Neurotransmitter Studies 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.

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.

BIOLOGIC THEORY

PRECIPITATING FACTORS

Loss of Attachment/Life Events

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. (Give the explanation on the case of the patient) 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. (Give the explanation on the case of the patient)

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 coworkers 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: o Poor med compliance o Stubborn behavior o Relapses of incoherent speeches

APPRAISAL OF STRESSORS
COGNITIVE RESPONSE Cognitive factors play a central role in adaptation. They account for the impact of the stressful event; the choice of coping patterns used; and the persons emotional, physiological, behavioral, and social reactions. AFFECTIVE RESPONSE An affective response is the arousal of a feeling. In the appraisal of a stressor, the major affective response is a nonspecific or generalized anxiety reaction, which becomes expressed as emotions.

(Give the explanation on the case of the patient)

(Give the explanation on the case of the patient)

BEHAVIORAL RESPONSE It is the result of emotional and physiological responses, as well as ones cognitive analysis of the stressful situation.

SOCIAL RESPONSE Search for meaning, in which people seek information about their problem. Social attribution, in which the person tries to identify the factors that contributed to the situation., in which people compares skills and capacities with those of others with similar Social comparison problems.

(Give the explanation on the case of the patient)

(Give the explanation on the case of the patient)

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.

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, When asked what are her stress availability of time and energy, and ability to coping strategies she verbalized that provide ongoing support influence the course of illness. she pray to God. She also verbalized Matulog ra, kay The patients family is her support stress gud, kapoi. system. She is more close to her She is much close with her mother and mother compared to her father. She the one she confined with her verbalized that she talks to her mom problems. more often when she has problems so Client chooses the person she would when her mother died it really did like to speak with, as verbalized by brought a great stress to her life and significant other. 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
REACTION FORMATION
Acting the opposite of what one thinks and feels.

DENIAL

INTROJECTION

INTELLECTUALIZATION

Failure to acknowledge an unbearable condition; Accepting another persons attitudes, beliefs, Excessive reasoning or logic is used to failure to admit the reality of a situation, or how and values as ones own. avoid experiencing disturbing feelings. When talking about serious or one enables the problem to continue. confidential topic such as the death of The client verbalized that what she has She verbalized that she does her mother, she was observed to portray When asked why she doesnt comply with today came from her family and not want to take in her the opposite of what should be expected her medications she verbalized Mu relatives. She believes that they own psychotic medications because to feel; client was laughing and smiling tumar ra man ko anting anting and it is passed on to she believed that it can cause about the death of her mother and have her and that it possesses great powers. harm to her. She keeps on telling us that that she is this delusions that her mother is still normal and it really hurts her to be alive. placed inside the rehabilitation even She verbalized , Ang meds kay Also, she verbalized that she doesnt though she is not psychotic. makacause ug harm sa body want to talk about sad events in her life; unya normal ra man ko , di She also believed that her mother is still instead she wants happy thoughts to be man ko psychopathic so sakit alive and is working in America. discussed. gyud kaayo ng patumaron ko nila ug tambal

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.

o Be prepared to redirect the patient back to the task at hand

MALADAPTIVE RESPONSES
POSITIVE SYMPTOMS

COGNITION

Assess and document patients orientation. Call patient by name. Spend time with the client to talk and encourage verbalization of feelings. Be sincere and honest when communicating with the client. Be consistent with the interaction Provide positive feedback and appropriate behavior

Hallucinations a. Auditory Hallucinations - Verbalized Sulti an ra man ko unsa ako buhaton na sakto b. Visual Hallucinations - 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 a. Grandiose - 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. b. Persecutory - 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 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.

 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 Teach the client the importance of good hygiene

PHYSICAL
Deterioration in Appearance and Lack of persistence: Dirty Clothes Unkempt Appearance Poor Grooming Personal Hygiene o She doesnt take a bath regularly. She only takes a bath depending on her own preference. Slow Movements Frequent Staring Poor Eating Habits o The client is picky when it comes to food. She wont eat if its not her food preference. Does not participate in some activities o During 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.

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. - 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 change 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.

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

UNDIFFERENTIATED SCHIZOPRENIA