Schizophrenia- A Case Study
Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality. Schizophrenia is often misunderstood as split personality by many people. It is a disease that markedly affects social and occupational functioning, interpersonal relationships, morbidity and mortality. A person suffering with it eventually loses his interest in basic needs of life. Symptoms of schizophrenia are divided into positive, negative and cognitive symptoms. Schizophrenia can be treated with antipsychotics which includes both typical and atypical antipsychotics. Along with the pharmacotherapy, psychosocial treatment is also done.
Introduction
Schizophrenia is a psychological illness which affects approximately 1% of the population. It is not just a single ailment but a family of disorders. The sufferer often lacks the connection with real world and lives in his own imaginary world. The exact cause is still unknown however, different theories are presented for Delusions Affective flattening Disorganized speech Hallucinations Alogia Thought disorder Combativeness Anhedonia Disorganized behavior Insomnia Apathy Poor attention Asocial behavior Table: Symptoms of Schizophrenia. A person who has at least two of the above symptoms for about one month will be diagnosed as a schizophrenic patient. The most common symptoms reported are hallucination and delusions [1].
understanding its pathophysiology. This includes: genetic theory, dopamine theory, non-developmental theory and psychosocial theory. Symptoms of Schizophrenia usually appear between the ages of 16 years to 30 years. They are categorized into positive, negative and disorganized symptoms.
Schizophrenia is divided into three further types, with each type having unique features. It includes: paranoid, catatonic and disorganized. Patients with paranoid type complains off hallucinations and delusions. Inappropriate
effect and disorganized speech patterns are the characteristics of disorganized type while catatonic schizophrenia displays strange and bizarre behavior [2].
As the exact pathophysiology of schizophrenia is still uncertain therefore the treatment mainly focuses on the elimination of symptoms. Pharmacotherapy as well as the psychotherapy are given to the patients. The goals of the therapy therefore emphasize on the removal of symptoms, relapse of disease and improving the quality of life. Antipsychotics are considered to be the cornerstone in the pharmacotherapy. They are further divided into two main classes: Typical antipsychotics and atypical antipsychotics, among which the atypical ones are new generation antipsychotics and have less side effects as compared to the conventional typical antipsychotics [3].
Case Presentation
A 22 years old girl was brought to the DHQ hospital Faisalabad by her parents with the presenting complaints that self-talk and self-laugh. They reported that their daughter suspects that somebody has casted a black magic on her. She even skips her meal with a suspiciousness that someone has poisoned her food. She was experiencing all the above complaints from at least past one year. On inquiring her no significant family history was found related to this disorder.
Past History
3 years ago she was brought to the DHQ hospital Faisalabad when antipsychotics were prescribed to her. But she stuck to the regimen just for one year and then showed noncompliance towards her medication.
General Examination
Weight: 46kg
B.P: 110/70
Temperature: 98 F
Pulse Rate: 63 beat per minute
Special Investigation
- Mental state examination (appreance, mood, behavior): neglected self-care, looking around, rapport and eye contact was not established. Non cooperative behavior throughout interview.
- Positive and Negative symptoms scale (PANSS): delusions, hallucination, poverty of speech, disorganized behavior.
Treatment
- Aripiprazole 15mg b.d
- Clonazepam 0.5mg h.s
- Psychotherapy session after every two weeks
Interventions
- As the patient’s history clearly shows that she has been non-compliant in the past so an alternative intramuscular therapy can be recommended such as Fluphenazine (25mg/ml) IM after every two weeks.
- Secondly the patient was prescribed a 10mg tablet which she was advised to take as one and half tablet at a time. Instead of it an alternative brand of Aripiprazole 15mg can be prescribed for resolving the compliance issue.
Outcomes and Follow-up
- The outcomes of the treatment achieving life milestones, feeling safe, improved physical activity, employment, a positive sense of self and psychosocial outcomes. Quality of life gets better and safety from harmful behaviors is achieved [4].
- The patient was advised to visit the psychiatrist for psychotherapy sessions.
Discussion
A medication regimen must be follow to get its beneficial effects. This particular concept is of great importance for patients who have schizophrenia as they often show poor adherence and for them leaving medication has serious results. There have been several studies related to the non-adherence to antipsychotic medications. The majority of these studies have used subjective measures of adherence that rely on patient, family member, or clinician reports, all of which have been shown repeatedly to overestimate adherence just few studies have used an objective method like electronic monitoring to assess adherence to oral antipsychotic medication in outpatients who have schizophrenia [5]. Remaining non-compliant to these medications leads to the worsening of clinical condition, relapse of psychotic episodes and hospitalization [6].
Patients who have a history of non-compliance or undergone frequent hospitalization need a long acting intramuscular antipsychotic medication. Currently three options exist: haloperidol deconate, fluphenazine deconate and long acting risperidone [1]. Among these haloperidol and fluphenazine are available in Pakistan in the intramuscular preparations .Therefore a depot preparation of Fluphenazine (25mg/ml) IM after every two weeks can be a suitable therapy for this patient. It is observed that patients on depot antipsychotics they have a low frequency of hospital admission. Interventions to improve adherence to antipsychotic medication in schizophrenia is emphasized [7].
Learning Points
- Schizophrenic patients often show non-compliance to their medication so a simplified dosage regimen must be designed for them
- In addition to the psychotherapy sessions of the patient, also educate the patient’s family to make sure that he/she taking the medication.
- If a patient is non-compliant, a depot intramuscular antipsychotic can be administered to prevent the relapse of psychotic episodes.
References
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Ayuk-Egbe PB, Hogue VW (2001) Comprehensive Pharmacy Review. American Journal of Pharmaceutical Education 65(3): p 303.
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https://www.nimh.nih.gov/health/topics/schizophre nia.
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http://www.mentalhealthamerica.net/conditions/sc hizophrenia.
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Lloyd J, Lloyd H, Fitzpatrick R, Peters M (2017) Treatment outcomes in schizophrenia: qualitative study of the views of family carers. BMC psychiatry 17(1): 266.
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Byerly MJ, Nakonezny PA, Lescouflair E (2007) Antipsychotic medication adherence in schizophrenia. Psychiatric Clinics of North America 30(3): 437-452.
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Eaddy M, Grogg A, Locklear J (2005) Assessment of compliance with antipsychotic treatment and resource utilization in a medicaid population. Clinical therapeutics 27(2): 263-272.
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Morken G, Widen JH, Grawe RW (2008) Non- adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC psychiatry 8(1): 32.
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