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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

Mental Health Case Study: Schizoaffective Disorder

Allyson Jamison

Youngstown State University

NURS 4842: Mental Health Nursing

Professor Teresa Peck

November 1, 2021
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

Abstract

Schizoaffective disorder is a mental health condition that has characteristics of two different

disorders, schizophrenia, which is a thought disorder, and a mood disorder, usually either bipolar

or depression. “Schizo” pertains to the psychotic symptoms of schizophrenia. There is an

alteration in how a person, thinks, acts, expresses emotions, as well as affects how someone

perceives reality and relates to others. “Affective” refers to a mood disorder, or severe changes in

a person’s mood, energy, and behavior. An individual’s affect is the physical display of their

emotions, which can either be congruent or incongruent with their mood. Schizoaffective

disorder can further be broken down into two different types, bipolar disorder type and

depressive type. The main difference between the two types is that in bipolar disorder type, the

individual experiences cycles of depression and mania while in the depressive type there is only

the occurrence of depression. There is no real cure for schizoaffective disorder, but treatment can

help people manage symptoms and improve their quality of life. Throughout this paper, it will

discuss the struggles an individual faces with schizoaffective disorder, particularly bipolar

disorder type. It can be expected to read the characteristics of this patient’s behavior, the

discussion of schizoaffective disorder, how to evaluate this information, and how it is applicable

to nursing. It will discuss the importance of treating a patient with schizoaffective disorder due to

the complications it brings forth in their life.

Key words: Schizoaffective, Disorder, Affect, Schizophrenia, Bipolar, Depression, Mania,

Behaviors
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

Objective Data:

The patient is a biological 24-year-old female who is in the process of socially

transitioning towards the male gender, who will be referred to as “L.F.” throughout this paper.

The patient has the psychiatric diagnosis of schizoaffective disorder: bipolar type combined with

borderline personality disorder. They have other general medical disorders such as morbid

obesity, hypertension, and sleep apnea and their drug allergies consist of sodium phosphate,

citric acid, desmopressin, LORazepam, lurasidone. L.F. was admitted on October 26, 2021 for

reported worsening depression and suicidal ideations with a plan as well as an altered perception

of reality. It was recorded that they planned to kill themselves by either walking into traffic or

slitting their wrists, so it was deemed that they posed a risk to their own safety, and they were

admitted to a behavioral health facility. It should be noted that L.F. has an extensive list of

previous hospitalizations at multiple facilities for similar reasonings.

Throughout the interview process a substantial amount of information in regard to the

patient’s history and current situation was obtained. Although L.F. had stated to be socially

transitioning to the male gender, the only evidence of this would be through the use of a male

name in replacement of their birth name. They still wore feminine clothing, had long hair, and

painted nails. They stated that from a young age they knew that they were meant to be a boy but

just now got the courage to start the process. The transition of one gender to another is

recommended to extended over a period of about five years and is broken up into three distinct

stages: social transition, chemical transition, and surgical transition. The social transition

typically consists of picking a new name, dressing in the style of the opposite gender, and

publicly portraying the new gender. The chemical transition consists of a continuation of the

social transition with the introduction of hormones, which help to aid in the development of
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

secondary sex characteristics. Finally, the surgical transition pertains to the addition or removal

of body parts and a change in genitalia. When asked about familial and outside support through

their transition process, it was claimed that their mother had been supportive of most aspects of

their life up until this point and did not approve of them transitioning. L.F. did however report to

have a close friend in which they had sexual relations who was very supportive, and they

depended on this individual significantly.

Characteristics of the depressive aspect of schizoaffective disorder: bipolar type can

include a depressed mood, loss of interest in activities, a decrease or increase in appetite, either

insomnia or excessive sleeping, fatigue or energy loss, and thinking about, planning, or

attempting suicide. Through observation and report, L.F. projected a number of these qualities.

Most notably was the constricted affect they presented. A constricted affect is a diminished

variability and intensity with which emotions are expressed. Regardless of the topic, L.F. hardly

showed any emotion and briefly smiled on only one occasion throughout the interview.

Although L.F. had been expressing suicidal ideations on admission, during the interview they

expressed they no longer had the desire to harm themselves since being treated. This is thought

to have some relation to the cessation in nightmares that they expressed to be previously having.

The patient reported that prior to the previous night, they had not slept at all due to reoccurring

nightmares that they would have consistently every night. The nightmares displayed vivid scenes

of the patient killing themselves in multiple different ways. They claimed to think that these

nightmares had something to do with wanting to harm themselves while awake so badly that the

thoughts continued while they were sleeping. But similar to the suicidal thoughts, the nightmares

ceased once they began receiving treatment. Finally, the patient stated to be having an increase in

appetite and persisting bingeing. During the group therapy session, when L.F. was asked to
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

discuss some negative characteristics or coping skills that they wished to work on, they

mentioned their overindulgence in food. L.F. appears to have a hyper-fixation with food and

their body appearance as evidenced by the persistent discussions and multiple entries in their

journal of the topics.

Pertaining to the topic of body image, L.F. was displaying signs of having somatic

delusions. In their journal, they had an extensive list of intense exercises that they claimed to

have completed. When asked if these exercises had been done while in the mental facility, L.F.

said yes, and that they were done once they woke up. They claimed to on average workout six

hours a day. They also made comments that suggested they thought they were extremely fit and

in good shape when in reality, they weighed over three hundred pounds.

While speaking to L.F., they never held good eye contact and was as if they were looking

at something else. When asked if they saw something that was not actually there, they admitted

to having auditory and visual hallucinations which had been present for most of their life. They

claimed to see man eating plants as well as angels and demons which also spoke to them. The

hallucinations are always present, even when on medication. L.F. states that some of them are

friendly however most of them are displeasing to have and either contribute to the suicidal

thoughts and tell them to harm themselves or they make fun of him.

From a medical standpoint, he appeared to be unhealthy physically due to being morbidly

obese, but from a lab standpoint, all of the labs drawn were within normal range. Due to the

medications that he was taking, some important labs to note were his glucose level, which was

112, QTC, which was 416, and his hCG came back negative. Even though he identifies as a

male, he is still biologically a female and sexually active, so it is important to test if he is

pregnant or not. He also tested negative for both drugs and alcohol, however he does report
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

occasionally smoking marijuana, although has not done so recently. The current medication

regimen for patient L.F. consists of Abilify 30 mg, which is an atypical antipsychotic, used for

mood stabilization and treatment of hallucinations and delusions, propranolol 10 mg, which is a

beta blocker used for anxiety and also for the treatment of nightmares, and Zoloft 100 mg, which

is a selective serotonin reuptake inhibitor (SSRI), used to help manage depression. He also has

Vistaril 50 mg prescribed as needed for anxiety.

Discussion of Mental Illness:

To summarize schizoaffective disorder, it is a chronic mental health condition

characterized primarily by symptoms of schizophrenia and symptoms of a mood disorder, such

as mania and depression. There are primarily two types, bipolar type or depressive type, and in

the case of L.F., they experience occasions of both mania and depression, so he has been

diagnosed with bipolar type. According to the article, “Diagnosing Schizoaffective Disorder:

DSM-5 Criteria”, it explains that “the DSM-5 states that someone with schizoaffective disorder

meets the primary criteria for schizophrenia, which includes two or more of the following:

delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or

negative symptoms, which can consist of flat expressions, loss of pleasure, lack of motivation,

social withdrawal, and decreased sense of purpose. In addition to this, the individual must also

have a major mood episode, either major depression or mania, that lasts for an uninterrupted

period of time, delusions or hallucinations for two or more consecutive weeks without mood

symptoms sometime during the life of the illness, mood symptoms are present for the majority of

the illness, and the symptoms are not caused by substance use” (Peterson, 2018). Schizoaffective

disorder differs from schizophrenia in that while both contain symptoms of psychosis,

schizoaffective disorder in particular has the addition of mood symptoms. The prognosis for an
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

individual with schizoaffective disorder tends to be better compared to those with schizophrenia.

However, typically not all aspects of the disease are under control at the same time. If the bipolar

or depression aspect of the disease process is exacerbated, then the schizophrenia symptoms are

often aggravated as well.

The discussion of borderline personality disorder should be included in this paper as well

due to the contribution it has on the behaviors of the patient. Borderline personality disorder is

characterized by a pattern of intense and chaotic relationships with affective instability.

According to the article, “Diagnosing Borderline Personality Disorder”, “symptoms in

borderline personality disorder occur in 4 domains: affectivity, interpersonal functioning,

impulse control, and cognitive. The diagnosis requires that at least 5 of 9 specific criteria be met:

1.) frantic efforts to avoid real or imagined abandonment, 2.) a pattern of unstable and intense

interpersonal relationships characterized by alternating between extremes of idealization and

devaluation, 3.) identity disturbance: markedly and persistently unstable self-image or sense of

self, 4.) impulsivity in at least 2 areas that are potentially self-damaging, 5.) recurrent suicidal

behavior, gestures or threats, or self-mutilating behavior, 6.) affective instability due to a marked

reactivity of mood, 7.) chronic feelings of emptiness, 8.) inappropriate, intense anger or difficulty

controlling anger, and 9.) transient, stress-related paranoid ideation or severe dissociative

symptoms” (Biskin MD, Paris MD, 2012). An individual is at an increased risk of developing the

personality disorder if they report having a stressful childhood. Many of those diagnosed with

borderline report being sexually or physically abused or neglected while they were young.

Stressors and Behaviors:

L.F. had many stressors and presented a significant number of behaviors in his life that

could have potentially led him to his point of current hospitalization. L.F. reports being both
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

physically and sexually abused by his father and his paternal grandfather starting at the age of 3

years old. After this discovery was made, his parents got a divorce and he lived solely with his

mother. He does however still claim to communicate with his father from time to time. As

previously mentioned, his mother has been relatively supportive of him throughout his whole

life, except in regard to his transition from female to male.

Bullying has also played a substantial role in the life of the patient. L.F. reports being

severely bullied starting at around the third grade. He claims that he has never really had any

friends except his mother and now has the addition of one close friend in which he has casual

sexual relations. He also states that for most of his life he has been bullied because of his weight

and that is why he works out so much now and has become extremely fit. It was also mentioned

that L.F. had been routinely seeing a counselor up until recently. He claims that he revealed a

piece of traumatic information and became embarrassed so he would not be returning. This is

thought to have precipitated his recent depressive episode and hospitalization.

Recently, he claimed to have stop taking all of his medications, which has resulted in an

increase in his visual and auditory hallucinations. When asked the reasoning of the sudden

cessation he stated he did not need them anymore. He verbalized that he now realizes how much

they help him, and he will not do that again. However, it should be regarded that L.F. has a

history of noncompliance, especially since moving out of his mother’s apartment and into his

own. The hallucinations primarily manifest as angels and demons though he occasionally reports

seeing man eating plants, were repeatedly telling him to either kill or harm himself. His history

of abuse and bullying combined with the addition of more recent stressors may reflect his recent

behaviors and actions.

Patient and Family History of Mental Illness:

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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

The patient is single, although has a friend with benefits type of relationship, has no

children, and is unemployed. L.F. did complete high school and tried to attend college for a

semester but claimed it was too overwhelming and dropped out. Growing up he did not have the

best childhood, as his father who was diagnosed with bipolar disorder, repeatedly sexually and

physically abused him. When he was around the age of 7, he states that his mother took him and

his half-brother and left his father. He described his mother as being depressed most of the time,

and some days she would not get out of bed. Overall, though, she still had supported both him

and his brother.

Considering that both of his parents had histories with mental illnesses, his father with

bipolar disorder and his mother with what appears to be depression, it can be expected that

genetics play a role in the development of his mental illnesses. It is known that bipolar disorder

specifically does run in families, so that could explain why L.F. has the bipolar type of

schizoaffective disorder. In the article, “Family History in Patients with Bipolar Disorder”, it

states, “The familial transition of bipolar disorder is known by clinicians, patients, and their

families. The risk of prevalence in first-degree relatives of patients with bipolar disorder is

increased approximately 10-fold over the normal community” (Ozdemir, et. al 2016). Overall,

this familial history would make L.F. more susceptible to bipolar disorder in his life, which he

has presented traits of it through his behaviors and has been hospitalized over in the past.

Psychiatric Evidence Based Nursing Cared Provided:

After evaluation off the patient’s current state, orders were given in an effort to help him

get back to where he needs to be in terms of his mental health to optimally function. For now,

L.F. is prescribed Abilify 30 mg daily by mouth, propranolol 10 mg daily by mouth, and Zoloft

100 mg daily by mouth. L.F. also has Vistaril 50 mg ordered PRN with a maximum of 4 daily
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

doses for anxiety. All of these medications are necessary based on the data collected during the

interview.

There are also other orders such as activity as tolerated, meaning he can participate in any

activities going on, or do personal activities himself. L.F. was also placed on unit restrictions and

suicide precautions, meaning all of his belongings must be searched upon admission, and

anything that is potentially dangerous will be taken away. L.F. will be kept in a locked down

psychiatric institution and will not have access to his cell phone but will be permitted to use the

facility’s phone. His glucose will be closely monitored due to him having a high risk of

developing Type 2 Diabetes Mellitus from the combination of being morbidly obese and the

possibility of Abilify, Zoloft, and propranolol all raising his blood sugar. His QTC should also be

routinely monitored for the fact that Abilify and Vistaril can both possibly prolong the QT

interval. Lastly, L.F. has been placed on a regular diet, meaning he has no restrictions on what

he can or cannot eat in regard to the facility’s menu. However, the food will be served on a

safety tray, meaning the silverware must be plastic and there should not be anything on the tray

that can be used as a weapon.

Ethnic, Spiritual, and Cultural Influences:

L.F. did not describe much in terms of his ethnic or racial background but appeared to be

Caucasian. When asked about his spirituality, he said he believed in angels and devils, which can

be related back to his auditory and visual hallucinations but did not name any specific

denomination or religious affiliation. It was noted that he did have a pentagram tattoo on his left

shoulder. L.F. also claimed to occasionally smoke marijuana but has not done so recently. He

says the only time he ever really has access to it is when his friend offers to it. Other than that he

does not drink alcohol or participate in any other recreational drug use.
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

Evaluation of Patient Outcomes:

Upon admission the main goals of the patient were to prevent any harm to self and

promote sleep, which have since been successfully met. Moving forward, an ideal outcome

would be to work on increasing medication compliance. It is important for this patient to stay on

their medications in order to promote some mental stability and control hallucinations and

delusions as best as possible. Another expected outcome for this patient would be to promote a

proper sleep schedule and prevent any further nightmares. Since being hospitalized and

medicated, L.F. has finally gotten a full night’s rest without any nightmares. Hopefully, with the

continuation of medication, avoiding any caffeine before bedtime, and promoting a sleep routine,

the patient can continue to move forward with an adequate sleep schedule that offers a sufficient

amount of rest. One final outcome for the patient that should be prioritized is the management of

their weight through diet and exercise. Although the client claims to be fit and healthy, that is not

the reality. With the guidance of a nutritionist and both cognitive and behavioral therapy,

hopefully steps can be made in the right direction to reorient the patient to the reality of their

situation and get them on the right track.

Plans for Discharge:

It is set that patient L.F. will be returning home to his apartment on Monday November 1,

2021. It will be crucial in his discharge planning to include the importance of medication

compliance in order to maintain as much stability as possible. It must be made apparent to the

client the possible side effects of the medications he is on, the importance of taking the

medication as ordered, and not to abruptly stop taking their medications. It also should be

explained to report any adverse effects to his physician and when to seek medical attention. L.F.

should also be referred to outpatient treatment centers that will include individual therapy, along
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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

with group and family therapy. Even though the patient has stopped seeing their current

counselor, the possibility of seeing one should still be introduced and the benefits explained. All

of these forms of therapy can aide the client in pinpointing his strengths and weaknesses and

work on them individually, and collectively within a group. Family therapy could be beneficial

in working through the trauma with his father since he still has somewhat of a relationship and

remains in contact with him.

Prioritized List of Actual NANDA Diagnoses:

 Risk for suicide related to auditory hallucinations instructing patient to harm themselves

as evidenced by suicidal ideation with plan.

 Deficient knowledge related to medication noncompliance as evidenced by stopping his

medication when feeling better.

 Disturbed thought processes related to delusions and hallucinations as evidenced by

altered perception of body imaging, claiming to see and hear demons, angels, and man-

eating plants.

 Disturbed sleep pattern related to insomnia as evidenced by reoccurring nightmares of

killing himself preventing him from sleeping.

 Ineffective individual coping related to somatic delusions or stated self-image as being

extremely fit as evidenced by claiming he works out 6 hours a day when in reality he is

morbidly obese and does not work out.

 Overweight related to patient presenting as morbidly obese as evidenced by patient

persistently bingeing and hyper-fixation on food.

 Interrupted family processes related to unsupportive mother as evidenced by her

disapproval of the patient’s transition from female to male.

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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

List of Potential Nursing Diagnoses:

 Slow mental processes

 Disordered thoughts

 Anhedonia

 Fear of intensity of feelings

 Self-care deficit

Psychiatric-Mental Health Nursing (Videbeck, 2019)

Conclusion:

A number of factors can influence the development of psychiatric illnesses and an individual’s

current mental state. Schizoaffective disorder: bipolar type, is something to be taken seriously,

and can be truly detrimental in someone’s life. It is important to understand that in addition to the

symptoms of psychosis, individuals with this illness also present with a mood disorder as well.

So, it must be taken into consideration the occurrence of both mania and depression as well as

the signs and the triggers to their exacerbation. L.F. has taken the correct steps needed in order to

move forward and control his symptoms as best as possible with the use of medication regimen

prescribed by the treatment team. Following discharge, it is important for the patient to remain

compliant and seek outpatient treatment in order to maintain a healthy mental status and remain

independent outside a mental facility.

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MENTAL HEALTH CASE STUDE: SCHIZOAFFECTIVE DISORDER

References

Biskin RS, Paris J. Diagnosing borderline personality disorder. CMAJ. 2012;184(16):1789-1794.

doi:10.1503/cmaj.090618

Ozdemir, O., Coskun, S., Mutlu, E. A., Ozdemir, P. G., Atli, A., Yilmaz, E., & Keskin, S.

(2016). Family History in Patients with Bipolar Disorder. Archives of Neuropsychiatry,

53(3), 276+. https://link.gale.com/apps/doc/A521163774/AONE?

u=ohlink104&sid=bookmark-AONE&xid=395bd4e4

Peterson, T. (2018, March 28). Diagnosing Schizoaffective Disorder: DSM-5 Criteria,

HealthyPlace. Retrieved on 2021, November 9 from

https://www.healthyplace.com/thought-disorders/schizoaffective-disorder-information/

what-is-schizoaffective-disorder-dsm-5-criteria

Videbeck, S. L. (2019). Chapter 17: Mood Disorders and Suicide. In Psychiatric-Mental Health

Nursing (8th ed., p. 297). Lippincott Williams & Wilkiins.