Case study

I. General Information
-Client name: Abdalrahem -Age: 38 -Marital status: not married - Diagnosis :
schizophrenia (delusion disorder ) . -Occupation : non employed -Educational
level : tawjihi
-Admission date : 15-7-2022 .

-Chief complaint:
- pt said my family brought me her and I don’t have any problems .

2. Present history :
-pt brought to the hospital forcedly with the assistance of police and parents , hence
dismantling the care again more than one time in order to prove that there is a spying
tools such as cameras .

3.Past history ( Medical/psychiatric history): pt said his father used to come back
from work drunk and beat his mother ,brothers and hurt him the most . this caused him
problems from a young age and the idea that his father does not love him also he
mentioned that he was using drugs in 2010, drinking alcohol and smoking weed in
2019 which made his relationship with his family worse associated with his excess
nervousness led him to insult, break tables and doors, and verbally threaten his mother
with murder .
- pt also said that he have been in al-Rashid privet hospital for 2 months in 2021
because his family didn’t believe him when he said that someone is spying at him and
to prove that he take of the car seats and other parts to show them that there is a
hidden camera or microphone.
-pt also had several suicidal attempts starting with his attempt to jump of his house ,
jumping from abdoun bridge and threatening to kill himself by pointing the knife on his
neck when the police tried to bring him her the last time
4. medical diagnosis:
- definition:

-Schizophrenia: sever psychotic disorder characterized by disturbance of thoughts

process and content and impairment in occupational, environmental and social function.
Sign and symptoms:

1-Positive Symptoms:
- Content of Thought

-Delusions
-Religiosity

-Paranoia
-Magical thinking

-Form of Thought
-Associative looseness

-Neologisms
-Concrete thinking
-Clang associations

-Word salad
-Circumstantiality

-Tangentiality
-Mutism
-Perseveration
-Perception
-Hallucinations

-Illusions
-Sense of Self
-Echolalia
-Echopraxia
-Identification and imitation

-Depersonalization
2-Negative Symptoms :

-Affect
-Inappropriate affect

-Bland or flat affect

-Apathy

-Volition
 -Inability to initiate goal-directed activity

-Emotional ambivalence
-Deteriorated appearance

-Interpersonal Functioning and Relationship to the

-External World

-Impaired social interaction

-Social isolation

-Psychomotor Behavior
-Anergia
-Waxy flexibility

-Posturing
-Pacing and rocking

-Associated Features
-Anhedonia
-Regression

3- Causes :

❖ Biological Influences

1. Genetics
• Studies show that relatives of individuals with schizophrenia have a much higher
probability of developing the disease than does the general population.
• How schizophrenia is inherited is uncertain.

• Some individuals have a strong genetic link to the illness,

whereas others may have only a weak genetic basis.

2. Twin Studies
• The rate of schizophrenia among monozygotic (identical) twins is four times that of
dizygotic (fraternal) twins and approximately 50 times that of the general population.
• Identical twins have the same rate of development of the illness

• one of a pair of monozygotic twins develops schizophrenia.

3. Adoption Studies : Children who were born to mothers with schizophrenia were more
likely to develop the illness than the comparison control groups . Children born to
nonschizophrenia parents, but reared by parents afflicted with the illness, do not seem
to suffer more often from schizophrenia than general controls.

❑ Biochemical Influences
1. The Dopamine Hypothesis
• This theory suggests that schizophrenia (or schizophrenia-like symptoms) may be
caused by an excess of dopamine-dependent neuronal activity in the brain.

• This excess activity may be related to:

A)increased production or release of dopamine at nerve terminals
B)increased receptor sensitivity
C)too many dopamine receptors

D)combination of these mechanisms

Amphetamines, which increase levels of dopamine, induce psychotomimetic symptoms.

The antipsychotics (e.g., chlorpromazine or haloperidol) lower brain levels of dopamine
by blocking dopamine receptors, thus reducing the schizophrenic symptoms, including
those induced by amphetamines.
Clients with acute manifestations(Positive sign) (e.g., delusions and hallucinations)
respond with greater efficacy to antipsychotic drugs than do clients with chronic
manifestations
The current position, in terms of the dopamine hypothesis, is that manifestations of
acute schizophrenia may be related to increased numbers of dopamine receptors in the
brain and respond to antipsychotic drugs that block these receptors. Manifestations of
chronic schizophrenia are probably unrelated to numbers of dopamine receptors, and
antipsychotic drugs are unlikely to be as effective in treating these chronic symptoms.

❑ Other Biochemical Hypotheses

•Abnormalities in the neurotransmitter's norepinephrine, serotonin, acetylcholine,

glutamate and gamma-aminobutyric acid and in the neuroregulatory, such as
prostaglandins and endorphins, have been suggested in schizophrenia.

•The N-methyl-D-aspartate (NMDA) receptor is the receptor that is activated by the

neurotransmitter's glutamate and glycine; Psychopharmacological studies have shown
that the drug class of glutamate antagonists (e.g., phencyclidine [PCP]; ketamine) can
produce schizophrenic-like symptoms in individuals without the disorder .

•In one recent study, participants who were experiencing ketamine-induced

schizophrenia-like psychotic symptoms were treated with a drug trial of a glycine
transporter-1 inhibitor.

•This medication was shown to reduce the effects induced by the NMDA receptor
antagonism of the ketamine. The researchers suggest that “enhancing glutamate
function by stimulating the glycine site of the NMDA receptor with glycine, D-serine, or
with drugs that inhibit glycine reuptake may have therapeutic potential in
schizophrenia” .Currently available conventional antipsychotic medications largely
target the dopamine receptors in the brain. Newer novel antipsychotics have strong
affinity for serotonergic receptors. The glutamate model of schizophrenia suggests
possibilities for new therapeutic target options, including NMDA agonists, glycine
transport inhibitors, and metabotropic glutamate receptor agonists.

Physiological Influences:

❑ Viral Infection
• Epidemiological data indicate a high incidence of
schizophrenia after prenatal exposure to influenza.

• Another study found an association between viral infections of the central nervous
system (CNS) during childhood and adult-onset schizophrenia .

❑ Anatomical Abnormalities ( with use neuroimaging technologies)

• Ventricular enlargement is the most consistent finding; however, sulci enlargement and
cerebellar atrophy .
Ventricular enlargement is associated with
A) poor premorbid functioning

B)negative symptoms
C)poor response to treatment

D)cognitive impairment.
• Studies with MRI have revealed a possible decrease in cerebral and intracranial size in
clients with schizophrenia.
• Studies have also revealed a decrease in frontal lobe size,but this has been less
consistently replicated.
• MRI has been used to explore possible abnormalities in specific subregions such as the
amygdala, hippocampus, temporal lobes, and basal ganglia in the brains of people with
schizophrenia.

❑ Histological Changes
• A “disordering” or disarray of the pyramidal cells in the area of the hippocampus has
been suggested.
•This disarray of cells has been compared to the normal alignment of the cells in the
brains of clients without the disorder.
•Some researchers have hypothesized that this alteration in hippocampal cells occurs
during the second trimester of pregnancy and may be related to an influenza virus
encountered by the mother during this period.

❑ Physical Conditions
• Some studies have reported a link between schizophrenia and epilepsy (particularly
temporal lobe), Huntington’s disease, birth trauma, head injury in adulthood, alcohol
abuse, cerebral tumor (particularly in the limbic system), cerebrovascular accidents,
systemic lupus erythematosus, myxedema, parkinsonism, and Wilson’s disease.

❖ Psychological Influences
• Early conceptualizations of schizophrenia focused on family relationship factors as
major influences in the development of the illness, probably in light of the conspicuous
absence of information related to a biological connection.

These early theories implicated :

A)Poor parent-child relationships
B)Dysfunctional family systems as the cause of schizophrenia, but they no longer hold
any credibility

❖ Environmental Influences

❑ Sociocultural Factors
• Indeed, epidemiological statistics have shown that greater numbers of individuals from
the lower socioeconomic classes experience symptoms associated with schizophrenia
than do those from the higher socioeconomic groups.

• Explanations for this occurrence include:

A)the conditions associated with living in poverty, such as congested housing
accommodations
B)inadequate nutrition

C)absence of prenatal care

D)few resources for dealing with stressful situations

E)feelings of hopelessness for changing one’s lifestyle of poverty.

❑ Stressful Life Events

• There is no scientific evidence to indicate that stress causes
schizophrenia.

• It is very probable, however, that stress may contribute to the severity and course of
the illness.

• It is known that extreme stress can precipitate psychotic episodes.

• Stress may indeed precipitate symptoms in an individual who possesses a genetic

vulnerability to schizophrenia.
• Stressful life events also may be associated with exacerbation of schizophrenic
symptoms and increased rates of relapse.
􏰀 Theoretical Integration

• No single theory or hypothesis has been postulated that substantiates a clear-cut

explanation for the disease.

• The most current theory seems to be that schizophrenia is a biologically based disease,
the onset of which is influenced by factors within the environment (either internal or
external)

•Degree of severity is determined by the level, number, and duration of psychotic signs
and symptoms

•Several of the disorders may carry the additional specification of with catatonic
features. Such as brief psychotic disorder, schizophreniform disorder, schizophrenia,
schizoaffective disorder, and substance-induced psychotic disorder, neurodevelopmental
disorder, major depressive disorder, and bipolar disorders I and II.

-DSM-5 criteria :
A. Two (or more) of the following, each present for a significant portion of time
during a 1-month period (or less if successfully treated). At least one of these
must be (1), (2) or (3) :

1)Delusions.
2)Hallucinations.
3)Disorganized speech (e.g., frequent derailment or incoherence.
4)Grossly disorganized or catatonic behavior.

5)Negative symptoms (i.e., diminished emotional expression or avolition)

B. Since the onset of the disturbance, level of functioning in one or more major
areas, such as work, interpersonal relations, or self-care, is markedly below
the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal,
academic, or occupational functioning)

C. Continuous signs of the disturbance persist for at least 6 months. This 6-

month period must include at least 1 month of symptoms (or less if successfully
treated) that meet Criterion A (i.e., active-phase symptoms) and may include
periods of prodromal or residual symptoms. During these prodromal or residual
periods, the signs of the disturbance may be manifested by only negative
symptoms or by two or more symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual perceptual experiences)
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic
features have been ruled out because either :
1)No major depressive episodes have occurred concurrently with the active-phase
symptoms.
2) If mood episodes have occurred during active-phase symptoms, they have
been present for a minority of the total duration of the active and residual periods of
the illness.(Stay to short period)

E. The disturbance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication
disorder childhood onset, the additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations, in addition to the other required
symptoms of schizophrenia, are also present for at least 1 month (or less if
successfully treated)

- MEDICATIONS :

SCIENTIFIC AND INDICATION SIDE EFFECTS NURSING

TRADE NAME : INTERVENTION

Quetiapine Schizophrenia Hypotension, 1. Ensure that

(Seroquel) Acute ,manic tachycardia, client does not
Antipsychotic episodes, dizziness, operate dangerous
Agitation, drowsiness, machinery or
aggression, headache, participate in
hallucinations, constipation, dry activities that
thought mouth. require alertness.
 disturbances, 2. Provide
wandering sugarless candy or
gum, ice, and
frequent sips of
water. Provide
foods high in fiber.
Encourage physical
activity and fluid if
not contraindicated.
3. Provide calorie-
controlled diet;
provide opportunity
for physical
exercise; provide
diet and exercise
instruction.
4. Monitor vital
signs. Observe for
symptoms of
dizziness,
palpitations,
syncope, or
weakness.
5. Monitor for
symptoms.
Administer prn
medications at first
sign. 6. Monitor
blood glucose
regularly. Observe
for the appearance
of symptoms of
polydipsia,
polyuria,
polyphagia, and
weakness at any
time during therapy
Fluoxetine -For the acute agitation -Assess for the
(Symbyax) treatment back or leg pains mentioned cautions
Antidepressant of depressive bleeding gums and
episodes blindness contraindications
associated with blistering, peeling, (e.g. drug allergies,
bipolar or loosening of the hepatorenal
I disorder in adults skin diseases, cardiac
- Treatment- bloating dysfunction, etc.) to
resistant blood in the urine or prevent any
depression stools untoward
bloody, black or complications.
tarry stools -Perform a thorough
physical
 blue-yellow color assessment to
blindness establish baseline
blurred vision data before drug
chest pain, therapy begins, to
discomfort, or determine the
tightness effectiveness of
clay-colored stools therapy, and to
constipation evaluate for the
continuing vomiting occurrence of any
cough or dry cough adverse effects
dark urine associated with
decreased interest drug therapy.
in sexual -Monitor results of
intercourse electrocardiogram
decreased urine and laboratory
output tests (e.g. renal and
decreased vision liver function tests)
to monitor the
effectiveness of the
therapy and
provide prompt
treatment to
developing
complications.

Assessment :
1- Physical dimension :

-Abdalrahem ,38 yrs male pt at the national center for mental health , his facial
expression was comfortable , sitting position with presence of mannerisms,
appropriate dressing for his ( gender , age , weather , place ) , normal motor activity
with symmetric balance gait ,no abnormal stereotypes ( echolalia , negativism ,etc)
and he was combative and friendly .

2- emotional dimension :
-affect : flat expressions
-mood: Upset
- (there is congruency between the mood and the affect )
-no euphoria and exaltation.
3-Intellectual dimension :

1- Perception :
- illusion : pt said that he had been seeing the car buttons pressed and the doors
were closed by its own .

-No record of hallucinations , depersonalization , derealization.

2- cognition :
1- form of thoughts :
-all normal

2- content of thought :
-Delusion : pt is having a persecutory delusion ( he said that his father is known
person that why there is someone powerful in the FBI is spying at him and
streaming his life live by hacking his phone and manipulating with every job he
worked or applied for ).

3- sensorium and cognitive ability :

1- memory :
-immediate : I asked him about his breakfast and he answered
-recent :I asked him about an event happen before 6 weeks and he told me what
he did in al adha eid .
-remote : asked him about his childhood and he answered .
2- orientation : pt is oriented by 3 ( time , place ,person )
3- Insight of illness : lack of insight ( he said that I don’t have any problems and
they put me here because they want to get rid of me ).
4- concentration : pt was focused and the prove of that was giving the same
answers that he said at the beginning of the interview .
5-social Judgmental : we asked the pt what would he do if he saw a crying baby
on the street ?
- He said that if the baby was 4 yrs or less he will buy him some candies and
then take him to the police , and if the baby was 7 yrs or more he will leave
him because there are many children got lost at this age also to learn him a
lesson .

6- capacity of abstract :
-we asked him about 2 proverbs :

. ‫ دنانير ال اكثر وال اقل‬10 ‫ دنانير بشتري ب‬10 ‫ فسره انه اذا معي‬: ‫ مد لحافك على قد رجليك‬-
. ‫ فسره انه شو ربنا كاتب رح يصير غير هيك بتكون متهكر زي حالتي‬: ‫ غير نصيبك ما يصيبك‬-
4- suicidal or homicidal idea :
- Pt had a previous suicide attempt but the police stopped him .
- Pt said ( when get out of here either my family will kill me or I’ll do ).

5- no records of obsessions ,paranoias, phobias, or magical thinking .

6- impulse control : he have Problems controlling his nervousness.

4- social dimension
1-ideal self : non
2-percived self: pt said ( I’m a good person trying to live a normal , quite
life
Maybe one day I’ll have my own family if any girl accept me ) .
3-self-esteem: objectively, from the pt position and manner of speech, he
has good and full self esteem .

5- spiritual dimension :
-Life philosophy : to be a good person not a consumer but also a producer .
-religion : Muslim
-hope or despair : He was hopeless, but he hoping for the best.
6-occupational dimension:
-pt is unemployed .
7- environmental dimension :
-he always felt like he’s being watched all the time .

Subjective data :
- pt said : I’m not crazy and I don’t make things up im sure that my life is
controlled and watched by someone in the FBI .
-pt said : when I get out of here I don’t know what to do especially with my
family maybe I’ll kill them or they kill me that how our problem will end .

-Nursing process :
1- nursing diagnosis :
- Risk for other-directed violence related to inability to trust AMB childhood
trauma , physical abuse and pt verbalized : when I get out of here I don’t
know what to do especially with my family maybe I’ll kill them or they kill
me that how our problem will end .

Goal :client will not harm others .

Objective : Within 3 days, pt will discuss and situations that precipitate hostility.

Interventions :
Actual Intervention :
1. Develop a trusting relationship with the client. Show empathy, concern, and
unconditional positive regard. Be honest and keep all promises.Rational: Trust is
the basis for a therapeutic relationship.
2. Remove all dangerous objects from client’s environment. Rational: Removal of
dangerous objects pre- vents client, in an agitated, confused state, from using
them to harm self or others.
3. Observe client’s behavior frequently. Do this while carrying out routine
activities. Rational: Observation during routine activities avoids creating
suspiciousness on the part of the client. Close observation is necessary so that
intervention can occur if required to ensure client (and others’) safety.
4. Maintain low level of stimuli in client’s environment (low lighting, few people,
simple decor, low noise level). Rational: Anxiety level rises in a stimulating
environment.(Stress-anxiety-anger-aggression-(suicide,violence))
5. Try to redirect the violent behavior with physical outlets for the client’s anxiety
(e.g., physical exercise). Physical exercise is a safe and effective way of relieving
pent-up tension.
Planned intervention:
1. Give medication as doctor order to restore balance of neurotransmitters and
prevent Progressive status of patient
2. educate the patient about relaxation technique such as deep breathing to
decrease stress and anxiety level
3. Use a calm and firm approach. rational: Provides structure and control for a
client who is out of control.
- evaluation : goal is partially met , evidenced by pt angry feelings and hostility
decreased
2-nusring diagnosis :
disturbed thought process related to abnormal brain activity AMB delusional
thinking : pt said : I’m not crazy and I don’t make things up I’m sure that my life
is controlled and watched by someone in the FBI .