Clinical Manifestation, Diagnostic Criteria and Psychopathology of Schizophrenia - Case Study Example

CASE STUDY Mr. M is aged 38 years old. He is a single male morbidly obese, who is on disability pension. He lives at a community/shared housing and was diagnosed with schizophrenia in 2005. He presented with grandiose and persecutory delusions, auditory hallucinations, avolition and social withdrawal. Mr. M was homeless for many years before presented to crisis accommodation, and then admitted to psychiatric ward as an involuntary patient as his schizophrenia relapsed. It is believed that he was psychotic for several years prior to him seeking crisis accommodation. Mother to Mr. M died due to illness, when he was five years old and father’s hereabout is unknown. Mr. M has a history of polysubstance abuse from the age of seventeen. Since treatment in the psychiatric ward, Mr. M’s symptoms improved and thus been discharged to the community under Community Treatment Order (CTO) of Victorian Mental Health Act 1986. There are a team of health professionals working with him on a continuous basis including case manager, drug & alcohol specialist, nurse and project manager to assist with his needs. Although Mr. M reported positive symptoms have improved, but his negative symptoms are still present such as avolition and social withdrawal. There is evidence of lack of motivation for him to get up in the mornings as he sleeps most of the time during the day, poor personal hygiene, alcohol consumption at nights and social disconnection with others. He appears to be partially aware of his medical condition but remains to be non-adherent to medication. Despite his medical condition, he remains hopeful that one day he will be a barman riding a motorbike. Introduction Schizophrenia is a serious, complex and disabling mental illness associated with significant impairment in social and vocational functioning. MRI and post-mortem have identified psychopathology of people with schizophrenia as having structural brain deficits particularly frontotemporal volume reduction and ventricular enlargement . Statistics indicate that at least10% of the population will develop schizophrenic in their lifetime . Schizophrenia usually presents early in adulthood or late adolescence. Men have an earlier onset than women, and tend to experience more serious form of illness with long-term negative symptoms . The aetiology of schizophrenia is uncertain, but research indicates that abnormal genes and environmental factors combined to cause brain dysfunction. In addition, illicit substance have been found to contribute heavily to manifestation of psychotic symptoms, and also contribute greatly to the development and prevalence of schizophrenia. The effect of the illicit substances has been found to affect individuals found to be at high risk . Schizophrenic symptoms can be categorized into two groups: positive and negative. Positive symptoms are those that are seen in the acute psychotic state, which affect the functioning of the cognitive system. They include delusion, hallucinations often in the form of voices, and disorganised thinking, speech and behaviour. Negative symptoms are characterised by impairments in volition, poverty of thought and speech, poor self-care, flat affect, anhedonia, and social withdrawal. Besides mental illness, Mr. M has co-morbidities including obesity, hypercholesterolemia and hypertension. I have selected 37 year old Mr. M for my case study, because he is a young man who is suffering from schizophrenia for last 8 years. I want to learn how he will effectively integrate into the community and if there is any hope for him to achieve his dream. His case highlights the complexity of schizophrenia and the long term management and the commitment required from a team of professionals to meet his needs. I want to know how health professionals can assist him and perhaps motivate him to start taking little steps towards achieving his dream of becoming a ‘barman’. Mr. M has been diagnosed with delusional schizophrenia as defined by DSM-IV-TR diagnostic criteria as per Appendix A, outlining both: positive and negative symptoms. Positive symptoms of Mr. M are auditory hallucinations and delusions. Negative symptoms are social withdrawal and avolition. Mr. M. past medical history includes obesity, hypercholesterolemia and hypertension. The focus of case study is on Mr. M’s clinical manifestation, diagnostic criteria and psychopathology of schizophrenia. Furthermore, discussion about the patient management and pharmacological intervention is carried out. Finally, discussion of patient education and strategies put in place for the client’s current and future mental, physical and psychosocial healthcare requirements. This case study focuses on Mr. M’s clinical manifestation, diagnostic criteria and psychopathology of schizophrenia. Furthermore, discussion about the patient management and pharmacological intervention, addressing the implication of long term use of antipsychotics. Finally, discussion of patient education and strategies put in place for the client’s current and future mental, physical and psychosocial healthcare requirements. Clinical Manifestations and pathophysiology Auditory verbal hallucinations Mr. M suffers from auditory hallucinations, perception ideation with dangerous or violet themes, no visual or command hallucinations. Auditory hallucination occurs when an individual experiences problems to differentiate what is real and what is not real. Also, it is involves an individual having a lot of difficulties to think in a proper manner, have proper functioning emotions and fit well in social interactions experiences . Hallucinations are the main perceptual disturbances which are the result of dysfunction in the brain caused by the neurotransmitter dopamine . On most occasions, Mr. M will not discuss his auditory hallucinations. Patient history has indicated that in 2008, he presented to a crisis centre looking for accommodation exhibited bizarre bahviour, saw dead people, reported he had been abducted by aliens, and experienced hearing constant voices. He has reported of voices that were abusive and critical of him, such as ‘useless’, ‘hopeless’, ‘ugly devil’ that nobody wants him. However, in recent time during his interview with the case manager, he reported that hallucination still exist but less frequent and less intensive and refused to discuss any further. Mr. M never reported of any suicidal, violent themes, visual or command hallucinations. Delusions Mr. M’s delusions can be said to be largely persecutory in nature. Furthermore, he also experiences numerous instances of non-bizarre somatic delusions. These constitute delusions that Mr. M has exhibited in the past. For instance, Mr. M believes that police are responsible for hurting his mother. Subsequently, he tried to grab the gun from the police to protect his mother when the police arrived to take him to emergency department because someone rang the police when he was still homeless and behaving inappropriately on the street. A study by Steel, ascertains that in a number of cases, significant cognitive dysfunction and impairment is normally present just before schizophrenia become manifest . Besides, the study revealed that time-based measures adopted or developed over time when the disease is diagnosed appear to demonstrate deficits progress beyond what is normally expected with normal ageing. As a result, the cognitive deficits constitute primary characteristics of schizophrenia, which also may play a great role in affecting negatively the psychosocial functioning of a patient . Research has show that delusion is a condition that occurs in many ways, and there is no one particular way the condition can be described or understood. Over time, a different nature and characterization of delusion is likely to be evident in an individual suffering from schizophrenia . Furthermore, different factors are identified as having a role in precipitating the occurrence of delusions; examples of such factors include lack of belief flexibility and lacking rationality in arriving at conclusions . Avolition Mr. M was presented as obese, disheveled man, wearing a dirty striped t-shirt, long, unwashed hair with long beard. He was very dirt, not wearing shoes and thus feet were dirty. Nails on both hands and feet are long and dirty underneath. This can be interpreted to be outcomes of a frustrated individual, who is to a great extent de-motivated in many ways to a higher degree. Mr. M was found to lack motivation (avolition), which is a primary symptom that can be used to assess the functional capability of a schizophrenic patient like Mr. M. In addition, avolition has been found to have effect to the occurrence and persistence in neurocognitive dysfunction. This latter condition, which is always prevalent among schizophrenic patients, has been found to results into improper functioning of the brains, poor emotions, and frequent unconsciousness. All these symptoms manifest themselves in inability of a schizophrenic patient to appear disinterested in goal-directed behaviours that can enable him or her take care of his or her body Mr. M exhibits lack of ability to have motivation to take care of his body cleanliness, which is an important essential in achieving good body health. This is because he is not able to wake up and take shower there is significant correlations between his current conditions, working memory impairment, particularly for waking up, take shower, cut his hair and nails and stop scratching his eye with dirty hands. A state of inadequate motivation among schizophrenic patients is responsible to impairment in the ability of the patient to participate or appreciate productive actions . Social isolation Mr. M does not have relatives who can support him and also interact with by providing company to him. In most cases, the patient is forced to engage and interact with other people to make friends. He is withdrawn and isolated from people in general. For instance, he would in many instances sit on the floor in the court yard alone and sometimes appears to respond to internal stimuli. Social isolation is a concept that can be said to have close links with social cognition. It is a concept that underlies social behaviours that an individual experience from others. In most cases, individuals live dependent life in society, where their daily lives are largely and closely intertwined with lives of other members in society . Therefore, social interaction is the epicenter of social lives and continuity . Social isolation has to do with negative social perceptions that individuals may have against others; in most cases the negative social perceptions tend to disrupt interpersonal relationships, creating distances among individuals. Therefore, a socially isolated individual is the one that sees others as having little regard for him as far as social interaction is concerned. Such individuals may withdrawal socially when it becomes apparent that the quality of social interaction has declined. Accordingly, there is an association between negative symptoms that include tendency to conclude, whether right or wrong, what other people are thinking or up to. Other symptoms include inability to have or show compassion, feeling to have less worth, interpersonal self-concepts, and having beliefs that do not function properly or effectively . At the same time, inability to have proper social cognitive abilities by schizophrenic patients has in recent times been to be the primary catalyst precipitating poor functioning of the neurocognition system. Also, the problem has further been noted to affect the psychosocial rehabilitation. Studies show that the problem of social cognition is in most cases likely to be noted among patients suffering from schizophrenia. Subsequently, studies on impairments are widely available such as affect recognition , attribution bias and several others that tend to explore the perceived link that exist . Treatment & Management Schizophrenia is a medical condition that requires a detailed and holistic treatment and management plan as per appendix B. Besides having a holistic plan in place, it should be known that the treatment and management should be tailored to the patient’s need and circumstances. As a result, a holistic treatment and management plan should comprise implementation of clinical and psychosocial programmes to meet the patient’s needs. At the same time, it can be noted that combining antipsychotic drugs and specific psychosocial treatment are likely to provide better patient’s outcome. Consequently, literature shows that a relatively large number of those diagnosed with schizophrenia develops chronic form of the illness. When this happens, it forces adoption of measures to be implemented in order to provide a holistic care for the patient. Some of activities that may need to be implemented on a continuous process include regular follow-ups and creating a multi-disciplinary team to care for the patient . At the same time, proper and successful management of schizophrenia should involve implementation of bio-psychosocial programmes that are customised to the individual patient’s needs. Subsequently, an early plan is necessary, whereby, such plan helps to decrease continuing disability and increase resilience of the patients in the future. The idea for this is that chronic illness should be addressed through adopting a continuing approach to care, such as case management, which in nature should incorporate multi-disciplinary teams. Also, the idea of having community-focused treatment should not be ignored, since such kind of treatment has been found to provide successful measures of preventing crises and relapses, thereby, enriching the care process for the patient. Drawing from the advance pursued by the author, it can be noted that an effective treatment and management programme should be that is comprehensive and covers antipsychotic medication, education and support for the patient and the family, social skills training, rehabilitation to improve activities during the daily activities and vocational and recreational support Psychosocial treatment Psychosocial treatment for Mr. M aims to ensure the patient has reduced chances of developing morbidly conditions that may further lead to deterioration of his health. In this manner, the aim is to ensure the patient’s level of obese reduces or is managed properly, and also the instance of the patient to revert to alcohol and drug misuse is adequately managed. Therefore, psychosocial treatment programs include developing individualised interventional counseling programs to enable him overcome his dependence on alcohol as he reported consuming 4litres of alcohol on Thursday and Friday nights. Also they aim to ensure the patient embrace physical exercises, which means he has to wake up early and jog/walk around the block and improve his hygiene situation. Numerous evidence indicate that schizophrenia patients who were subjected to psychosocial treatment programs demonstrated to have a reduced number of clinical relapses, major incidents, positive and negative symptoms, and admissions to the hospital as well as improved social functioning and employment status . Peer support groups Peer support groups should largely be developed to ensure Mr. M receives adequate social support in terms of company and interaction with different people. Besides, the programs should ensure that Mr. M sleeps at night and up during the day. He has reported of hearig voices at night and sleeping at night might be helpful in conjunction with his medication. The interaction envisioned in this scenario is largely to help Mr. M reduce alcohol consumption and drug substance misuse. The programs have been found to be effective because patients in most cases are enrolled in a guided peer support group, and are able to experiences increase in social support, which results in significant improvements in self-efficacy and quality of life with less negative symptoms and distress . Modern community Mr. M may benefit from modern community services. The primary aim for implementation of these services is to provide treatment and adequate rehabilitation designing individualized care programme approach, as well as concrete community treatment services. When the agencies that provide this community care services, it is clear that the basic goal of the agencies is to provide necessary assistance to patients who have accommodation, work and employment, and education problems. Therefore, the ultimate goal is to provide necessary support to the patients . Cognitive-behavioural therapy (CBT). Another treatment program that can be applied in the case of Mr. M is the cognitive-behavioural therapy (CBT). This is a special treatment program that target to address the patients’ perception regarding their problems and treatment. To implement the program, the first step includes assessing and understanding Mr. M’s perspective with regard to treatment and management, examining evidence and further rolling with resistance (Velligan, 2010). The idea to pursue the rolling process is to ensure that given the situation that Mr. M is in at the moment, resistance to medication is likely. So, the idea is to understand the patient’s view regarding resistance to medication, and devise appropriate ways to help the patient change views about medication. In the case of Mr. M, this is a process carried out by spending relative time with the patient, asking his views about medication, asking him how he views the medication should be carried, and evaluating if the patient is comfortable with the medication procedure. The primary goal is largely to ensure that Mr. M is able to change any negative thoughts he may have about the medication or the treatment process (Velligan, 2010). Pharmacological interventions Pharmacological therapy for Mr. M includes the use of antipsychotic medications (dopamine receptor-blocking drugs) are used to treat schizophrenia and other psychotic conditions. The two main antipsychotic drugs are first-generation (typical) and second-generation (atypical) . Hallucinations can be minimized effectively using antipsychotic drug, about 8% of the patients who receive the medication experience mild, moderate or in some cases severe hallucinations adhering to medicine. The negative symptoms in most cases are likely to be continuous. Atypical drug has been developed and used widely since it produces less extrapyramydal side effect than typical drug . Mr. M had exhibited pill rolling tremor and thus close monitory for deterioration of this effect or any other side effect of medication is required as stipulated in Appendix 2, treatment plan. Mr. M previously responded poorly to Risperidone which is a very effective drug for minimizing hallucinations. While his treatment was resistant to psychotic symptoms, he was not trialled on clozapine because of his obesity and concerns about associated physical risks. Currenly, Mr. M is on three medications: 45mg of Aripiprazole tablet oral and 2mg of Benztropine tablet oral, both at mane. Flupenthixol is given intramuscular fortnightly (2/52) as depot. Aripiprazole Aripiprazole is a relatively new generation antipsychotic drug with with additional antidepressant properties. Aripiprazole is similar to typical antipsychotic drug in terms of efficacy but it represents an advantage over typical antipsychotic drug because of fewer extrapyramidal side effects, especially akathisia, hyperprolactinaemia . Due to obesity, Mr. M has been prescribed Aripiprazole which is less likely to cause weight gain unlike other antipsychotic atypical drugs, clozapine and olanzapine . Benzatropine Anticholinergic medication on one hand treast drug-induced extrapyramidal side effects like parkinsonism and dystonia (except tardive dyskinesia), but on the other hand produces side effects such as disoriendation, hallucinations, depression, toxic psychosis, confusion and memory impairment . During one of the debrief with health team, Mr. M presented with pill rolling tremor in his left hand and by taking benzatropine, Mr. M stated that the drug helps with his tremor. Flupenthixol An intramuscular long-acting injection administered to Mr. M every fortnight by the depot nurse because his compliance with oral medication is poor. Flupenthixol is used for long-term management of symptoms of moderate to severe schizophrenia with half-life of 17 days . This second-generation antipsychotic drug produces relatively non-sedative effect and can benefit the patient with flat or depressed affect like Mr. M and elevant his mood. Side effect of Flupenthixol include tremors, pseudoparkinsonism, dystonia, hypertonia, akathisia and tardive dyskinesia . Research has indicated depot has an advantage over oral medication as it has lower cases of relapse and thus lower cases for re-hospitalisation. Non-compliance or partial compliance is a barrier to optimal treatment . Psycho-educational programs After the evaluation of Mr. M’s earlier relapse, it was necessary recommend implementation of programmes such as continuous-but-monitored training, reinforcement and guidance so as to equip Mr. M with necessary skills that can enable him operate effectively in daily life situations so as to enable him overcome social isolation, adhere to medication and exercise more . The kind of psycho-educational programs used involves mental health education interventions as data continue to show the association between medications for schizophrenia (particularly atypical antipsychotics), obesity, and metabolic disorders. A strong correlation has been established between schizophrenia and the use of illegal substances. Subsequently, this association is found to contribute to the increase in the emergence of psychotic symptoms when the illegal substances are used continuously. In addition, the use of illegal substance abuse can come before, during or after the first case of psychotic symptom of schizophrenia is discovered. Distinguishing substance-induced psychosis from schizophrenia constitutes a challenging process that also constitutes a diagnostic dilemma, especially, during the first episode of psychosis in the context of substance use . Patient education Different individuals demonstrate different abilities to respond to the treatment plan for schizophrenia. As a result, there is need to create a patient centred approach that is conducted at a personal level, in order to address the present and likely future needs of the patient. In this way, it becomes possible to realize positive outcomes of any treatment plan. According to the situation of Mr. M, education program that is created addresses key pertinent areas. These are areas that are seen to be necessary in order to enable the patient realize success in the treatment and management process. First, education centres on personal hygiene such as bathing, washing and changing clothes, cutting nails, shaving and washing hands. This is important to increase the hygiene level of the patient as well as increase his chance of being acceptable by others. The patient has to know the dangers of substance use and how to reduce substances use. The education should involve creating activities, medication and supervision measures to ensure the patient gradually is divorced from the use substances. Conclusion The main goal of the study was to evaluate a case study of a schizophrenic patient. As a result, the objectives included to identify and outline clinical manifestation, diagnostic criteria and psychopathology of schizophrenia. Additionally, other objectives included discussing the patient management and pharmacological intervention, evaluating long-term impact of using antipsychotics, discussing patient education and strategies in place to deal with future issues related to mental, physical and psychosocial development. According to the study that is carried out, schizophrenia is a serious, complex and disabling mental illness that is associated with significant impairment in social and vocational functioning. About 20% of the population are said to have schizophrenia, and this population is faced with numerous challenges of mental, psychological, social and physical. Mr. M is used to analyse how schizophrenia impact on the lives of the people. Furthermore, from the positive conditions that the patient demonstrates, it becomes possible to identify and develop appropriate treatment and management strategies. A number of treatment strategies are found to be important in ensuring Mr. M undergoes through a gradual, but quality recovery process. From the review of literature and analysis of Mr. M condition, it becomes clear that an effective treatment and management programme should be the one that is comprehensive and covers antipsychotic medication, education and support for the patient and the family, social skills training, rehabilitation to improve activities during the daily activities and vocational and recreational support. At the same time, a treatment plan is developed to facilitate the recovery process for Mr. M. It should be noted that the treatment that is recommended for Mr. M is a result of detailed mental health assessment (MSE) process. What this means is that any recommended treatment procedure or plan for a schizophrenia patient should be asa result of a thorough and quality MSE. This makes it possible to develop individualized and appropriate treatment programs that address the needs of the patient adequately. Appendix A – DSM-IV Diagnostic criteria for Schizophrenia A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration: 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 two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). Subtypes 1. Paranoid Type A type of Schizophrenia in which the following criteria are met: A. Preoccupation with one or more delusions or frequent auditory hallucinations. B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. 2. Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following: motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor excessive motor activity (that is apparently purposeless and not influenced by external stimuli) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing echolalia or echopraxia 3. Disorganized Type A type of Schizophrenia in which the following criteria are met: A. All of the following are prominent: disorganized speech disorganized behaviour flat or inappropriate affect B. The criteria are not met for Catatonic Type. 4. Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type. 5. Residual Type A type of Schizophrenia in which the following criteria are met: A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or atatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). Reference: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR) Appendix B - TREATMENT PLAN Treatment for Mr. M is developed in a manner that it addresses the mental health needs, physical health needs, support needs as well as social needs. Monthly achedule of appointments and activities will be developed by the case manager along with other health professionals caring for Mr. M Type of treatment required Aim Treatment measures Mental health To ensure the mental health of Mr. M is stable Prevent the future relapse Decrease persistent psychotic symptoms Monitor adverse effects from antipsychotic medication Facilitate daily home visits by mobile support and treatment teams (MSTT) Supervise on a daily process medication adherence to increase compliance Frequently assess the mental state of Mr. M This is to ensure early detections are made regarding deterioration Create effective psycho-education strategies to deal with aspects like delusions. Physical health To manage the current alcohol and smoking tendency Manage obesity Treat chronic purulent bilateral conjunctivitis Management of hypercholesterolemia and hypertension Assist Mr M to make appointment to visit GP for routine check up Conducting occasional physical test to monitor the progress Advise on medication and physical exercises Started attending weight management group – need to monitor his progress Nurse from Royal District Nursing Services attends to Mr M’s daily cleaning/treatment of bilateral conjunctivitis Provide healthy and nutritious food Encourage exercise, may need to physically take him for a work Support needs Support to improve skills for daily living Help, advise and demonstrate to the patient on how to change clothes, bath, brush teach, cut nails and wash hands to improve personal hygiene Monitor and frequently praise the patient when he improves in acquiring the skills Home help services continues to prompt Mr M to get up & shower Case manager to arrange large print Webster pack labels & discuss medication with Mr. M Case manager has set aim for Mr M to start with personal hygiene and take small steps from there Case manager promised to help him write his resume Social needs Improve the ability of Mr. M to integrate in social activities so as to ensure no social exclusion Helping and advising Mr. M on the best way to keep friends Increasing his level of participation in group activities, e.g taking him to BBQ Making sure he is not lonely for a long time Facilitating his ability to access community organisations for social support. Started attending ‘coffee club’ in the local area Care team to assist him with moving to CCU & ensure psychosocial stresses are kept at minimal Appendix C - MENTAL HEALTH ASSESSMENT (MSE) A recent MSE was conducted on Mr. M as per follows:- Mr. M pleasant on approach and co-operative. Overweight and dishevelled man, wearing a dirty striped t-shirt with track suit pants and baseball cap. Hair was unwashed, shoulder length. Long beard. Chronic conjunctivitis. Malodorous ++ Speech mumbled, normal volume and rate Mood `down’, intermittent suicidal ideation with no plan or intent Affect restricted, blunted Thought – stream and form normal. Religious delusional system. Some persecutory ideation referenced. No dangerous or violent themes. Perception – auditory hallucinations, no command hallucinations Insight – partial. Recognises stressors that are affecting his mood; no insight into delusional system Chronic presentations – admits hearing voices at nights but not as frequent as usual, stated voices say “rubbish” that makes little sense, voices are now less distressing and denied any command hallucinations Mr. M states he has started attending coffee club fairly regularly and has recently joined a gym. He reports an improvement in this level of motivation. Impression – chronic positive and negative symptoms of schizophrenia persists, needing assertive outreach for personal care (Antony & Barlow, 2011). Need support and outreach in obtaining new accommodation. Risk/issues Physical health risks related to self care and weight Deterioration in mental status in setting of uncertain accommodation Social isolation Chronic positive (responds to internal stimuli) and negative symptoms (Antony & Barlow, 2011) No signs of physical or verbal suicidal risk or harm to others Ongoing issue of Mr. M staying up late drinking (reported 4 litres of alcohol) on some nights and having difficulty getting up in the morning. He also reported hearing voices at night. This issue is a concern to the health team as his symptoms may be precipitated and exacerbated by substance abuse (Antony & Barlow, 2011). References Read More