Case study on mental health
Order Description

a case study which has to be done on a depression patient(Bipolar). you will need to write the scenario or case later. You can start from the Introduction. Evidence based guidelines are to be used which can be found in “australia newzealand college of psychology” or NICE. Important to know that The patient is currently under treatment and on ECT treatment. 6 ECTs done with some improvement and 6 more to go.Community service will be done by MAPS if you have to mention community services. The sample work is not of great quality and its for only an idea.
Example of clinical cases study (NUR5003)
1
Clinical Case Study: Paranoid Schizophrenia
1. Introduction
Schizophrenia is a serious and chronic mental health disorder, primarily characterized by psychotic
features such as significant disturbances in perception, thought content and processes, cognition,
social and occupational dysfunction (REF; REF). On average, schizophrenia affects approximately
1.5 % of the population world wide (REF; REF). The etiology of schizophrenia is not well
understood, but it appears that genetics and the combination of genes plus environmental
interaction account for around 80% of the probability of developing the disease (REF). The
experience of symptoms associated with this severe mental illness and the resultant effect that
physical, emotional and economic impairments have on ability to function in the community
presents a significant challenge to mental health agencies tasked with supporting these people to
remain well in the community and maximize their functional capacity and quality of life.
This paper presents the case study of a 54-year-old female, with a thirty-six year history and
primary diagnosis of continuous paranoid schizophrenia. For the purposes of the paper the case
subject will be referred to by the pseudonym of Mary. Mary is an informal (voluntary) patient who
lives alone in the community. Her last inpatient admission was five years ago. She is currently
managed by a Mobile Treatment and Support Team (MSTT) who supervises her medication daily
and assists Mary with weekly shopping and any other psychosocial issues. Mary’s relevant past
medical history includes morbid obesity; type two diabetes mellitus, hypercholesterolemia and
hypertension. The definition of Mary’s clinical diagnosis and the full DSM IV-TR diagnostic criterion
for continuous paranoid schizophrenia can be found in appendix 1. A detailed case description and
patient history is attached in appendix 2.
Example of clinical cases study (NUR5003)
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The case subject described above was selected for this case study to highlight complexities and
commitment required to effectively integrate and manage a client with chronic schizophrenia in the
community. This paper focuses on the case subject’s clinical presentation, diagnostic criteria, and
examines the clinical manifestations and pathophysiology of schizophrenia. It will describe and
discuss the case subject’s current and future treatment plan (in the context of GP medical case
management and the REF), pharmacological management in the context of current evidence
based practice, and will also address the long term implications associated with chronic use of
antipsychotics. Finally, it discusses patient education requirements and strategies required to
address the case subject’s current and future mental, physical and psychosocial healthcare needs.
2. Clinical manifestations and pathophysiology
The negative symptoms often experienced by those with schizophrenia have a demonstrable
impact on the person’s ability to maintain normal function. Anhedonia, avolition, affect restriction
and alogia account for significant disturbances to personal, social and occupational functioning
(REF). The clinical manifestations which Mary experiences secondary to these negative symptoms
are discussed below.
2.1 Disturbances in appearance – Mary appeared overweight, dishevelled, inappropriately
dressed for the weather and her clothes are stained and dirty. Her disheveled and matted and she
presents malodorous. The diagnostic criterion (B) of the DSM IV-TR for schizophrenia is
dysfunction in one or more significant areas of psychosocial functioning, including self care and
activities of daily living (ADL) (REF). Avolition in particular represents a loss of motivational drive to
participate in goal directed activities such as self-care, nutrition, ADL’s, physical exercise (REF;
REF, REF). In Mary’s case it is evident that both her ability to maintain personal care and
motivation for physical activity have been adversely affected.
2.2 Disturbances in mood – Mary subjectively reports she feels ‘a bit down’ especially in the
mornings, but this feeling usually self-resolves by lunchtime. Emotional impairments such as
anhedonia represent a common negative symptom of schizophrenia and are related to the loss of
interest or the experience of pleasure (REF). A randomized controlled trial conducted by REF
(2010) reported that MRI scans of individuals with high anhedonia ratings demonstrated reduced
Example of clinical cases study (NUR5003)
3
activation of the striatum and amaygdala in response to positive stimuli. The authors hypothesized
that this diminuted response may contribute to symptoms of anhedonia by failing to signal the
salience of positive events (REF).
2.3 Poverty of speech and thought – on examination Mary was noted to have slowed movement,
increased latency in speech and decreased rate. Alogia is typically manifests as poverty of speech,
characterised by short, laconic replies. Mary appeared to have a reduction of thoughts, which is
reflected in her diminished fluency and productivity of speech (REF).
2.4 Positive symptoms
2.4.1 Disturbances in thought processes
Mary exhibited a largely normal stream of thought, however in the course of the interview did
present the neologism ‘botonomy’ which she could not explain the meaning of to the interviewer.
Thought disorders may precipitate incoherent speech which is impossible to derive meaning from
and leaves the sufferer confused and makes communication very difficult (REF; REF).
2.4.2 Disturbances in thought content
Delusions: Mary’s delusions are predominantly paranoid and persecutory in nature, but she also
experiences a variety of non-bizarre somatic delusions. Whilst her delusions are multiple, her
sisters always relate the central theme to persecution. The REF states that the essential features
of paranoid schizophrenia are the prominence of persecutory and/or grandiose delusions with
hallucinations that are typically congruent with the delusional themes (REF). Mary’s cognitive
functioning only mildly impaired, she no longer demonstrates any significant behavioural response
to the psychotic symptoms, and she has some insight into her illness saying that she knows
something is not right and that has ‘retard syndrome’ and that her brain has gone ‘hard’ which is
why she can’t think straight. A recent study by REF (2010) contend that significant cognitive
dysfunction and impairment is present prior to the onset of schizophrenia, and time-based
measures across the span of the illness demonstrate deficits progress beyond what is expected
with normal ageing. These cognitive deficits are now becoming considered to be a primary
characteristic of schizophrenia and may contribute to the detrimental effect on psychosocial
Example of clinical cases study (NUR5003)
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function (REF).
2.5 Ideas of reference: Mary experiences delusions of reference from TV and radio. This a
common thought content disorder in schizophrenia, in which the person believes messages are
being conveyed to them through the media and that an insignificant event has a special personal
meaning to the individual (REF; REF).
2.6 Perceptual disturbances – Mary reports experiencing intermittent auditory, tactile and
olfactory hallucinations. These often appear to be congruent to the content of her delusions. She
also experiences persecutory and derogatory auditory hallucinations in the voices of her neighbors
and sisters. Hallucinations are sensory disturbances that occur in the absence of external stimuli
and may occur in any sensory modality, although auditory hallucinations are reported as the most
common type in schizophrenia (REF).
3. Patient management
The REF, details the legislative requirements for the treatment management of individuals with
mental illnesses (REF). Every patient treated under the ‘Act’ is required to have a treatment plan
by section 19A (REF). Whilst the Act doesn’t apply to those receiving mental health treatment on a
voluntary basis, both section 6A (j) of the Act and Standard 11.4.9 of the REF (1996), suggests
that best practice dictates that every consumer have a current individualised care plan which is
regularly reviewed and revised as necessary (REF). As mentioned previously, Mary’s legal status
under the Act is as an informal patient as she is able to give voluntary consent to treatment and is
cooperative and compliant. Accordingly, Mary’s current treatment plan (attached in Appendix 3) is
discussed below.
3.1 Current treatment and recovery plan:
Mary’s treatment and recovery plan is structured around four key areas:
1. Mental Health Needs
2. Other physical health needs
3. Support needs
4. Social needs
Example of clinical cases study (NUR5003)
5
1. Ongoing emotional and mental health treatment aims are to maintain Mary’s mental health and
prevent future relapse. Through intensive case management and daily home visits by the
Mobile Support and Treatment Team (MSTT), Mary’s medication is supervised daily to ensure
compliance, her mental state assessed to detect any deterioration, a risk assessment
completed as well as individual psycho education such as reality feedback and reassurance to
manage paranoid delusions and decrease associated distress. Assertive Community
Treatment models of care such as the MSTT team described above have been found to
significantly reduce relapse and improve accommodation stability (REF).
2. Physical health needs are addressed by a combined management approach between Mary’s
MSTT case manager and her GP who has provided an extended care plan and team care
arrangement. The primary current treatment goals are to effectively manage her diabetes
through strategy of GP medical management, and three visits per year from the Diabetes
Educator to provide Mary with education regarding medications, good nutrition, prevention of
diabetes complications and referral to podiatry and optometry services for foot and eye care if
required. MSTT staff takes Mary shopping weekly to assist her to buy and prepare health food,
and encourage fibrous food and fluid to prevent constipation.
Intervention and planning to prevent future deterioration or development of serious physical
health issues includes ensuring monthly clozapine reviews occur to monitor for adverse effects,
annual physical exams including ECG, echocardiogram, and pathology tests to monitor
glucose tolerance and lipid profile.
3. Support is required to assist Mary to improve her daily living skills. Current strategies to achieve
this are to encourage attendance to personal hygiene change clothes regularly, and give
positive reinforcement when she does. Mary has been provided council home help to assist in
maintaining a clean and habitable living environment.
4. Social needs are centered on the goal of improving Mary’s level of social inclusion and support
by suggesting strategies for Mary to maintain friendships, and increasing her participation in
group activities to promote inclusion and relieve loneliness and boredom. Linking her into
activities with community organisations such as Lantern and the Resource center will help
Example of clinical cases study (NUR5003)
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meet these social goals.
3.2 Future planning: crisis action and relapse prevention plan
Mary has an individualized, simple plan to recognize when she is becoming unwell, remind her of
the things she needs to do to stay well, and the MSTT and Psychiatry Triage phone numbers to
call in case of a crisis.
• _Green Light denotes a list of sign of wellness and things to build on such as keeping active,
regularly interacting in an acceptable and appropriate manner with case workers, family
and friends, taking medication and feeling happy.
• _Yellow light is the known sign and symptoms Mary is becoming unwell such as paranoia
about siblings, psychosomatic delusions and increased anxiety.
• _Red light is the indicators that Mary is unwell and needs to call immediately for crisis helpextreme
paranoia, aggression toward others.
3.3 Weaknesses in the current treatment plan suggestion for additional evidence based
treatment strategies.
Although antipsychotics have long been the cornerstone of treatment for schizophrenia,
approximately thirty percent of patients continue to experience chronic psychotic symptoms
despite medication compliance (REF). This highlights the need for a multifaceted approach to care
planning, with greater emphasis on providing concomitant psychosocial therapy to address
disabling disturbances in cognitive functioning, psychosocial issues and quality of life (REF; REF).
The growing body of evidence supporting psychotherapy approaches to schizophrenia
management is emerging. For example, a number of studies evaluating Acceptance and
Commitment Therapy have demonstrated that treatment with four hours of ACT resulted in a 50%
decrease in schizophrenia related hospital admissions over the following six months (REF).
Another feature absent in the current treatment plan is a more definite strategy and plan for weight
management. Encouraging Mary to eat healthy food has clearly not been effective as a
management strategy to prevent metabolic side effects and co-morbidities that have in part
Example of clinical cases study (NUR5003)
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occurred secondary to prolonged atypical antipsychotic treatment. Suggested evidence-based
patient education for weight management is detailed in section 5.
4. Pharmacological interventions
4.1 Current oral medication regime:
• _Clozapine; 350 mg nocte.
• _Diazepam; 5mg PRN.
• _Atorvastatin; 20mg mane.
• _Diabex XR(extended release) 500mg mane.
Clozapine is a second generation or ‘atypical’ antipsychotic agent which antagonises D1, D2, and
D4 dopamine receptors, and both the direct D2 blockade and inhibition of secondary depolarisation
appear to produce the antipsychotic action (REF; REF; REF). Clozapine’s primary indication for
use is refractory or treatment resistant schizophrenia, and current literature suggests that
clozapine has greater treatment efficacy than conventional neuroleptics (REF; REF). Whilst studies
making direct comparisons between different atypical antipsychotics (AAPs) show inconsistent
differences in acute efficacy, they do report evidence to indicate clozapine has superior efficacy
over other AAP’s in the 20-33 % of patients like Mary who have chronic schizophrenia (REF; REF;
REF; REF; REF).
Clozapine has a much weaker affinity for the D2 receptor, and is therefore less likely to produce
extra pyramidal side effects, hyperprolactaemia or tardive dyskinesia than the first generation
‘typical’ antipsychotics (REF; REF). However like other second generation antipsychotics,
clozapine comes with its own new set of risks. Adverse effects such as agranulocytosis, seizures,
metabolic syndrome (leading to increased risk of obesity, cardiovascular disease and diabetes),
and cardiomyopathy are potentially fatal (REF; REF; REF; REF).
Despite the introduction and use of both typical and atypical antipsychotics, the mortality rate for
those with schizophrenia compared to the normal population has continued to increase over the
past 20 years (REF). In a recent Cochrane review of clozapine efficacy, REF (2010) reported that
clozapine treatment substantially decreases the likelihood of relapse compared to those on typical
Example of clinical cases study (NUR5003)
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antipsychotic drugs, shows greater attenuation of symptoms, and had the greatest impact in
reducing the likelihood of suicide. However, despite these positive clinical effects, a systematic
review and randomised controlled trials have found there were no significant differences between
clozapine and other antipsychotics on cognitive impairments, mortality, occupational capacity or
psychosocial function (REF; REF; REF). In Mary’s case, although her MSE in Appendix 2.
demonstrates ongoing dysfunction, only treatment with clozapine has had a consistent effect on
attenuating positive symptoms and reducing the violence and aggression and disinhibition
associated with them. In the 38 years since Mary was diagnosed with schizophrenia, she has been
treated with multiple combinations of antipsychotics and had many admissions to psychiatric
facilities, without any significant improvement. The introduction of clozapine to her medication
regime six years ago has allowed her reach some stability in her illness, and with intensive mobile
support, live successfully on her own in the community for the first time in her life.
Diazepam is a benzodiazepine prescribed for its anxiolytic effects (REF; REF). Mary experiences
regular anxiety and distress secondary to her delusional content and PRN diazepam has an
effective short term sedating effect. An interventional review on benzodiazepines and
schizophrenia notes that evidence for augmentation of antipsychotics with benzodiazepines are
inconclusive, but the use of diazepam as an adjuvant agent has proven efficacy in targeting
anxiety, agitation and insomnia (REF; REF).
Finally, atorvastatin and diabex XR have been prescribed to manage Mary’s hypercholesterolemia
and diabetes which have occurred secondary to both lifestyle factors and the adverse effects of
weight gain and metabolic syndrome secondary to long term clozapine treatment.
4.1 Current and potential long term problems with current medications:
Clozapine has a high profile of serious adverse reactions (REF; REF; REF). Therefore as per the
treatment plan in section three, monthly clozapine reviews are required, including pathology to
monitor white cell count, neutrophils, LFT’s, blood glucose, haemoglobin and platelets. An ECG
and transthoracic echocardiogram are completed every 12 months to monitor cardiac function
(REF). Although there is potential to further increase Mary’s clozapine dose from the current
350mg, whilst this may provide more optimal symptom management, it must also be balanced
Example of clinical cases study (NUR5003)
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against the risk of further weight gain, increased insulin resistance and further exacerbation of her
diabetes. Diazepam has a long half-life which increases further with age and liver or kidney
disease. Therefore caution must be taken when titrating dose in this population, and the patient
must monitored for over-sedation and CNS depression. Other considerations include physical
dependency and withdrawal issues if prescribed for longer than 4 weeks, or withdrawn suddenly
(REF).
5. Patient education
In the same way that there is significant variation between individuals response to psychiatric drug
therapy, a patient centred approach to education should be done on an individual basis and
centred around the patients current, and likely future needs (REF). Key patient education areas
relevant to Mary’s current needs are:
• _Appearance and grooming; Mary’s experience of negative symptoms leads to poor self care.
Assisting and encouraging Mary to meet her personal hygiene needs to the best of her
ability is important both for diabetes management and it also decreases the likelihood that
she will experience further social rejection and isolation.
• _Social inclusion; negative symptoms and social isolation often combine to form a pervasive
feeling of loneliness and lowered mood. Encouraging Mary to attend purposeful ageappropriate
programs and activities provided though agencies like the Resource Centre,
Lantern and Impact will assist Mary to have some meaningful structure, socialisation and
support.
• _Weight management: Obesity is common co-morbidity for individuals with schizophrenia
(REF). A recent Cochrane review examining the efficacy of pharmacological versus nonpharmacological
interventions for weight management reported that modest short term
weight loss can be achieved with both selected pharmacological agents and diet and
exercise interventions (REF). The first consideration in managing weight gain should be
appraisal of the patient’s metabolic risk and balancing this with the need to prescribe
antipsychotics to achieve good control of psychotic symptoms (REF). Mary currently has a
GP extended care plan and team care arrangement, and could benefit greatly from some
Example of clinical cases study (NUR5003)
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Medicare funded consultations with an Exercise Physiologist who specialises in evidence
based exercise prescription for chronic disease management, and could also suggest
community exercise groups to link into.
• _Patient education surrounding the current plan for future relapse prevention and
management and monitoring of physiological issues, medication side effects and medical
conditions through the GP management plan is detailed in section 3; patient management.
6. Conclusion
Schizophrenia is an extremely complex mental illness which creating a wide variety of detrimental
symptoms. The 1.5 % of the population who suffer from it remains poorly understood and accepted
by the wider community. Approximately 20-33% of those with the disease have chronic
schizophrenia that is considered resistant to pharmacological treatment. There is currently no clear
evidence that antipsychotics as a mono-therapy have any meaningful effect on the person’s
cognition, social functioning or quality of life. Unfortunately, the pathological neural changes
associated with schizophrenia continue to progress, and despite treatment with antipsychotics, the
mortality rate amongst those like Mary with the disease remains disproportionate to the unaffected
population. A multi-modal approach to treatment and long term care is essential for those with
chronic schizophrenia. Assertive community treatment such as MSTT case management for this
population is congruent with current evidence based practice guidelines. High frequency of patient
contact is required to attend to medication compliance, and the complex behavioural, physical and
psychosocial issues that schizophrenia sufferers experience. More emphasis must be placed on
implementing evidenced based psychotherapy modalities to address the often-disabling
deterioration in cognition and psychosocial function.
Under the Mental Health Act, involuntary patients are not required to have a treatment plan,
although National Mental Health Service Standards suggest that best practice is that every
consumer should have an individualised care plan. Organised care pathways such as Mary’s
treatment and recovery plan has been shown to significantly enhance patient care by assisting
clinicians to implement evidence based treatment approaches and monitor patient outcomes.
Mary’s current management falls within current evidence based practice; however her prognosis
Example of clinical cases study (NUR5003)
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may be improved by the addition of psychotherapy approaches to her treatment plan. Whilst her
clozapine dose would ideally be increased above the current 350mg further attenuate psychotic
symptoms, this is necessarily balanced against her current cardiovascular risks and diabetes
management. In caring for patients with refractory schizophrenia, health care professionals must
balance treatment efficacy, prevention of disease progression, and adverse effects of medication
as they tailor the treatment plan to the individual.
Example of clinical cases study (NUR5003)
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References (removed)
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Example of clinical cases study (NUR5003)
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Appendix 1: DSM-IV definition of diagnosis
Primary Diagnosis: 295.30 – Paranoid schizophrenia
The DSM IV describes the presence of prominent auditory hallucinations or delusions in the
absence of cognitive dysfunction as being the defining feature of paranoid schizophrenia.
Diagnostic criteria for this sub-type is A) “preoccupation with one or more delusions or frequent
auditory hallucinations” and B) “None of the following behavior is prominent: disorganized speech,
disorganized or catatonic behavior, or flat or inappropriate affect” (DSM IV, p. 286).
According to the Diagnostic and Statistical Manual of Mental Disorders (4
the
edition), schizophrenia
can be described as a disturbance lasting at least six months including at least one month of
positive and/or negative symptoms (DSM IV, p. 286).
The diagnostic criterion for Schizophrenia requires assessment and evaluation in six key areas to
determine a clinical diagnosis.
A) Characteristic symptoms- including two or more of the following lasting at least one month;
delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behavior
and negative symptoms.
B) Social and/or occupational dysfunction – occurring for substantial length of time since onset
of illness and relating to disturbance in functioning at work, school, relationship or self-care.
C) Duration – disturbances last at least six months, including minimum of one month of
symptoms described in criterion A.
D) Exclude mood disorders- mood disorders with psychotic features and schizoaffective
disorder has been eliminated.
E) Exclude general medical conditions and substance abuse disorder – as cause of psychosis.
F) Secondary diagnosis with pervasive development disorders – additional diagnosis of
schizophrenia can only be formed if prominent psychotic symptoms last at least one month
(DSM IV, p. 286)
Example of clinical cases study (NUR5003)
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Appendix 2: case description and MSE
2.1 Case Description
For the purposes of this case study the case subject will be known as Mary, a 55 year old female
with a past history of chronic paranoid schizophrenia, and secondary co-morbidities of type 2
diabetes mellitus, morbid obesity, hypertension and hypercholesterolemia.
HOPC: Mary currently experiences chronic paranoid and persecutory delusions, mood is stable,
and she appears guarded and has little insight. She is visited daily by the Mobile Support and
Treatment Team to supervise her medication. Always consents to taking her medication but is
extremely unreliable if left to self supervise. Current medications are listed in section 4:
Pharmacological Interventions. Current detailed mental status examination is attached in appendix
2.2.
Past history Psychiatric – First diagnosis (1973) age 18: chronic schizophrenia with behavioural
disorder (sexual promiscuity) and low to average intellectual ability. First psychiatric inpatient
admission was in 1975 (duration 9 months). Most recent psychiatric inpatient admission was five
years ago. Current treatment status in the Mental Health Act (1986) is as an informal patient.
Social History – Mary lives alone in a unit privately owned by her family trust, is one of eleven
siblings, but over the years has estranged her self from all but one sister, who is supportive, and
rings her occasionally. She receives home help from the local council and her case manager
assists her with weekly shopping.
Family History: Mother deceased (unknown cause) in 1975 when Mary was 20. Long history of
violent and aggressive behavior toward family. They have subsequently cut off contact due to her
behavior. Otherwise socially isolated. Mary had a daughter at age 24, who was subsequently
adopted out, and is now married with children and refusing contact with her.
Example of clinical cases study (NUR5003)
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Appendix 2.2 Mental Status Examination
Appearance: Clothes dirty and stained, malodorous, hair un-brushed oily and matted. Overdressed
for the weather.
Behaviour: guarded, superficially warm and friendly, good eye contact. Slow but purposeful motor
movement.
Mood: ‘Depressed’ mood in mornings, usually resolves by lunchtime. Loss of interest and
dysphoric mood in Mary’s case results in the objective observation of a congruent blunted affect;
that is she appears to react spontaneously when spoken to, makes some eye contact but has an
empty emotional expression and a lack of animation in facial expression.
Affect: blunted affect congruent to mood.
Speech: Poverty of speech, increased latency and decreased rate. Short laconic responses.
Thought Form: Largely normal stream of thought although neologism “botonomy” expressed by
patient during interview and was unable to explain meaning.
Thought Content: Denies suicidal or homicidal ideation. Paranoid and persecutory delusions
regarding family and neighbours who want to kill/hurt her. One of Mary’s long held, fixed grandiose
and persecutory delusions is that her sisters are ‘jealous of her because she is moving up in the
world and getting special attention’ and because of this are going to come and ‘put a bullet in my
head’ Ideas of reference from TV and radio, believes they are telling her a gang is coming to hurt
her. Somatic delusions; olfactory, tactile and visual. Believes a girl from high school is putting
faeces on her which she can smell and feel on her skin. Mary has an ongoing conviction that she
regularly has chest pains from a recurring heart attack and bronchitis (which causes her significant
anxiety), stomach pains from constipation (somatic pain only, her bowel function is normal).
Perception: Auditory hallucinations – chronic derogatory and threatening voices of neighbours and
family. Grandiose delusions regarding self, and believes sisters are jealous of and persecuting her
because she is moving up in the world and getting special treatment.
Cognition: Mildly affected, some confusion and disorientation to day and year.
Insight: Limited insight into illness, aware that something is not right, states she has ‘retards
Example of clinical cases study (NUR5003)
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syndrome’.
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Appendix 3: Patient Management Plan
This has been removed from this example

Case study on mental health
Order Description

a case study which has to be done on a depression patient(Bipolar). you will need to write the scenario or case later. You can start from the Introduction. Evidence based guidelines are to be used which can be found in “australia newzealand college of psychology” or NICE. Important to know that The patient is currently under treatment and on ECT treatment. 6 ECTs done with some improvement and 6 more to go.Community service will be done by MAPS if you have to mention community services. The sample work is not of great quality and its for only an idea.
Example of clinical cases study (NUR5003)
1
Clinical Case Study: Paranoid Schizophrenia
1. Introduction
Schizophrenia is a serious and chronic mental health disorder, primarily characterized by psychotic
features such as significant disturbances in perception, thought content and processes, cognition,
social and occupational dysfunction (REF; REF). On average, schizophrenia affects approximately
1.5 % of the population world wide (REF; REF). The etiology of schizophrenia is not well
understood, but it appears that genetics and the combination of genes plus environmental
interaction account for around 80% of the probability of developing the disease (REF). The
experience of symptoms associated with this severe mental illness and the resultant effect that
physical, emotional and economic impairments have on ability to function in the community
presents a significant challenge to mental health agencies tasked with supporting these people to
remain well in the community and maximize their functional capacity and quality of life.
This paper presents the case study of a 54-year-old female, with a thirty-six year history and
primary diagnosis of continuous paranoid schizophrenia. For the purposes of the paper the case
subject will be referred to by the pseudonym of Mary. Mary is an informal (voluntary) patient who
lives alone in the community. Her last inpatient admission was five years ago. She is currently
managed by a Mobile Treatment and Support Team (MSTT) who supervises her medication daily
and assists Mary with weekly shopping and any other psychosocial issues. Mary’s relevant past
medical history includes morbid obesity; type two diabetes mellitus, hypercholesterolemia and
hypertension. The definition of Mary’s clinical diagnosis and the full DSM IV-TR diagnostic criterion
for continuous paranoid schizophrenia can be found in appendix 1. A detailed case description and
patient history is attached in appendix 2.
Example of clinical cases study (NUR5003)
2
The case subject described above was selected for this case study to highlight complexities and
commitment required to effectively integrate and manage a client with chronic schizophrenia in the
community. This paper focuses on the case subject’s clinical presentation, diagnostic criteria, and
examines the clinical manifestations and pathophysiology of schizophrenia. It will describe and
discuss the case subject’s current and future treatment plan (in the context of GP medical case
management and the REF), pharmacological management in the context of current evidence
based practice, and will also address the long term implications associated with chronic use of
antipsychotics. Finally, it discusses patient education requirements and strategies required to
address the case subject’s current and future mental, physical and psychosocial healthcare needs.
2. Clinical manifestations and pathophysiology
The negative symptoms often experienced by those with schizophrenia have a demonstrable
impact on the person’s ability to maintain normal function. Anhedonia, avolition, affect restriction
and alogia account for significant disturbances to personal, social and occupational functioning
(REF). The clinical manifestations which Mary experiences secondary to these negative symptoms
are discussed below.
2.1 Disturbances in appearance – Mary appeared overweight, dishevelled, inappropriately
dressed for the weather and her clothes are stained and dirty. Her disheveled and matted and she
presents malodorous. The diagnostic criterion (B) of the DSM IV-TR for schizophrenia is
dysfunction in one or more significant areas of psychosocial functioning, including self care and
activities of daily living (ADL) (REF). Avolition in particular represents a loss of motivational drive to
participate in goal directed activities such as self-care, nutrition, ADL’s, physical exercise (REF;
REF, REF). In Mary’s case it is evident that both her ability to maintain personal care and
motivation for physical activity have been adversely affected.
2.2 Disturbances in mood – Mary subjectively reports she feels ‘a bit down’ especially in the
mornings, but this feeling usually self-resolves by lunchtime. Emotional impairments such as
anhedonia represent a common negative symptom of schizophrenia and are related to the loss of
interest or the experience of pleasure (REF). A randomized controlled trial conducted by REF
(2010) reported that MRI scans of individuals with high anhedonia ratings demonstrated reduced
Example of clinical cases study (NUR5003)
3
activation of the striatum and amaygdala in response to positive stimuli. The authors hypothesized
that this diminuted response may contribute to symptoms of anhedonia by failing to signal the
salience of positive events (REF).
2.3 Poverty of speech and thought – on examination Mary was noted to have slowed movement,
increased latency in speech and decreased rate. Alogia is typically manifests as poverty of speech,
characterised by short, laconic replies. Mary appeared to have a reduction of thoughts, which is
reflected in her diminished fluency and productivity of speech (REF).
2.4 Positive symptoms
2.4.1 Disturbances in thought processes
Mary exhibited a largely normal stream of thought, however in the course of the interview did
present the neologism ‘botonomy’ which she could not explain the meaning of to the interviewer.
Thought disorders may precipitate incoherent speech which is impossible to derive meaning from
and leaves the sufferer confused and makes communication very difficult (REF; REF).
2.4.2 Disturbances in thought content
Delusions: Mary’s delusions are predominantly paranoid and persecutory in nature, but she also
experiences a variety of non-bizarre somatic delusions. Whilst her delusions are multiple, her
sisters always relate the central theme to persecution. The REF states that the essential features
of paranoid schizophrenia are the prominence of persecutory and/or grandiose delusions with
hallucinations that are typically congruent with the delusional themes (REF). Mary’s cognitive
functioning only mildly impaired, she no longer demonstrates any significant behavioural response
to the psychotic symptoms, and she has some insight into her illness saying that she knows
something is not right and that has ‘retard syndrome’ and that her brain has gone ‘hard’ which is
why she can’t think straight. A recent study by REF (2010) contend that significant cognitive
dysfunction and impairment is present prior to the onset of schizophrenia, and time-based
measures across the span of the illness demonstrate deficits progress beyond what is expected
with normal ageing. These cognitive deficits are now becoming considered to be a primary
characteristic of schizophrenia and may contribute to the detrimental effect on psychosocial
Example of clinical cases study (NUR5003)
4
function (REF).
2.5 Ideas of reference: Mary experiences delusions of reference from TV and radio. This a
common thought content disorder in schizophrenia, in which the person believes messages are
being conveyed to them through the media and that an insignificant event has a special personal
meaning to the individual (REF; REF).
2.6 Perceptual disturbances – Mary reports experiencing intermittent auditory, tactile and
olfactory hallucinations. These often appear to be congruent to the content of her delusions. She
also experiences persecutory and derogatory auditory hallucinations in the voices of her neighbors
and sisters. Hallucinations are sensory disturbances that occur in the absence of external stimuli
and may occur in any sensory modality, although auditory hallucinations are reported as the most
common type in schizophrenia (REF).
3. Patient management
The REF, details the legislative requirements for the treatment management of individuals with
mental illnesses (REF). Every patient treated under the ‘Act’ is required to have a treatment plan
by section 19A (REF). Whilst the Act doesn’t apply to those receiving mental health treatment on a
voluntary basis, both section 6A (j) of the Act and Standard 11.4.9 of the REF (1996), suggests
that best practice dictates that every consumer have a current individualised care plan which is
regularly reviewed and revised as necessary (REF). As mentioned previously, Mary’s legal status
under the Act is as an informal patient as she is able to give voluntary consent to treatment and is
cooperative and compliant. Accordingly, Mary’s current treatment plan (attached in Appendix 3) is
discussed below.
3.1 Current treatment and recovery plan:
Mary’s treatment and recovery plan is structured around four key areas:
1. Mental Health Needs
2. Other physical health needs
3. Support needs
4. Social needs
Example of clinical cases study (NUR5003)
5
1. Ongoing emotional and mental health treatment aims are to maintain Mary’s mental health and
prevent future relapse. Through intensive case management and daily home visits by the
Mobile Support and Treatment Team (MSTT), Mary’s medication is supervised daily to ensure
compliance, her mental state assessed to detect any deterioration, a risk assessment
completed as well as individual psycho education such as reality feedback and reassurance to
manage paranoid delusions and decrease associated distress. Assertive Community
Treatment models of care such as the MSTT team described above have been found to
significantly reduce relapse and improve accommodation stability (REF).
2. Physical health needs are addressed by a combined management approach between Mary’s
MSTT case manager and her GP who has provided an extended care plan and team care
arrangement. The primary current treatment goals are to effectively manage her diabetes
through strategy of GP medical management, and three visits per year from the Diabetes
Educator to provide Mary with education regarding medications, good nutrition, prevention of
diabetes complications and referral to podiatry and optometry services for foot and eye care if
required. MSTT staff takes Mary shopping weekly to assist her to buy and prepare health food,
and encourage fibrous food and fluid to prevent constipation.
Intervention and planning to prevent future deterioration or development of serious physical
health issues includes ensuring monthly clozapine reviews occur to monitor for adverse effects,
annual physical exams including ECG, echocardiogram, and pathology tests to monitor
glucose tolerance and lipid profile.
3. Support is required to assist Mary to improve her daily living skills. Current strategies to achieve
this are to encourage attendance to personal hygiene change clothes regularly, and give
positive reinforcement when she does. Mary has been provided council home help to assist in
maintaining a clean and habitable living environment.
4. Social needs are centered on the goal of improving Mary’s level of social inclusion and support
by suggesting strategies for Mary to maintain friendships, and increasing her participation in
group activities to promote inclusion and relieve loneliness and boredom. Linking her into
activities with community organisations such as Lantern and the Resource center will help
Example of clinical cases study (NUR5003)
6
meet these social goals.
3.2 Future planning: crisis action and relapse prevention plan
Mary has an individualized, simple plan to recognize when she is becoming unwell, remind her of
the things she needs to do to stay well, and the MSTT and Psychiatry Triage phone numbers to
call in case of a crisis.
• _Green Light denotes a list of sign of wellness and things to build on such as keeping active,
regularly interacting in an acceptable and appropriate manner with case workers, family
and friends, taking medication and feeling happy.
• _Yellow light is the known sign and symptoms Mary is becoming unwell such as paranoia
about siblings, psychosomatic delusions and increased anxiety.
• _Red light is the indicators that Mary is unwell and needs to call immediately for crisis helpextreme
paranoia, aggression toward others.
3.3 Weaknesses in the current treatment plan suggestion for additional evidence based
treatment strategies.
Although antipsychotics have long been the cornerstone of treatment for schizophrenia,
approximately thirty percent of patients continue to experience chronic psychotic symptoms
despite medication compliance (REF). This highlights the need for a multifaceted approach to care
planning, with greater emphasis on providing concomitant psychosocial therapy to address
disabling disturbances in cognitive functioning, psychosocial issues and quality of life (REF; REF).
The growing body of evidence supporting psychotherapy approaches to schizophrenia
management is emerging. For example, a number of studies evaluating Acceptance and
Commitment Therapy have demonstrated that treatment with four hours of ACT resulted in a 50%
decrease in schizophrenia related hospital admissions over the following six months (REF).
Another feature absent in the current treatment plan is a more definite strategy and plan for weight
management. Encouraging Mary to eat healthy food has clearly not been effective as a
management strategy to prevent metabolic side effects and co-morbidities that have in part
Example of clinical cases study (NUR5003)
7
occurred secondary to prolonged atypical antipsychotic treatment. Suggested evidence-based
patient education for weight management is detailed in section 5.
4. Pharmacological interventions
4.1 Current oral medication regime:
• _Clozapine; 350 mg nocte.
• _Diazepam; 5mg PRN.
• _Atorvastatin; 20mg mane.
• _Diabex XR(extended release) 500mg mane.
Clozapine is a second generation or ‘atypical’ antipsychotic agent which antagonises D1, D2, and
D4 dopamine receptors, and both the direct D2 blockade and inhibition of secondary depolarisation
appear to produce the antipsychotic action (REF; REF; REF). Clozapine’s primary indication for
use is refractory or treatment resistant schizophrenia, and current literature suggests that
clozapine has greater treatment efficacy than conventional neuroleptics (REF; REF). Whilst studies
making direct comparisons between different atypical antipsychotics (AAPs) show inconsistent
differences in acute efficacy, they do report evidence to indicate clozapine has superior efficacy
over other AAP’s in the 20-33 % of patients like Mary who have chronic schizophrenia (REF; REF;
REF; REF; REF).
Clozapine has a much weaker affinity for the D2 receptor, and is therefore less likely to produce
extra pyramidal side effects, hyperprolactaemia or tardive dyskinesia than the first generation
‘typical’ antipsychotics (REF; REF). However like other second generation antipsychotics,
clozapine comes with its own new set of risks. Adverse effects such as agranulocytosis, seizures,
metabolic syndrome (leading to increased risk of obesity, cardiovascular disease and diabetes),
and cardiomyopathy are potentially fatal (REF; REF; REF; REF).
Despite the introduction and use of both typical and atypical antipsychotics, the mortality rate for
those with schizophrenia compared to the normal population has continued to increase over the
past 20 years (REF). In a recent Cochrane review of clozapine efficacy, REF (2010) reported that
clozapine treatment substantially decreases the likelihood of relapse compared to those on typical
Example of clinical cases study (NUR5003)
8
antipsychotic drugs, shows greater attenuation of symptoms, and had the greatest impact in
reducing the likelihood of suicide. However, despite these positive clinical effects, a systematic
review and randomised controlled trials have found there were no significant differences between
clozapine and other antipsychotics on cognitive impairments, mortality, occupational capacity or
psychosocial function (REF; REF; REF). In Mary’s case, although her MSE in Appendix 2.
demonstrates ongoing dysfunction, only treatment with clozapine has had a consistent effect on
attenuating positive symptoms and reducing the violence and aggression and disinhibition
associated with them. In the 38 years since Mary was diagnosed with schizophrenia, she has been
treated with multiple combinations of antipsychotics and had many admissions to psychiatric
facilities, without any significant improvement. The introduction of clozapine to her medication
regime six years ago has allowed her reach some stability in her illness, and with intensive mobile
support, live successfully on her own in the community for the first time in her life.
Diazepam is a benzodiazepine prescribed for its anxiolytic effects (REF; REF). Mary experiences
regular anxiety and distress secondary to her delusional content and PRN diazepam has an
effective short term sedating effect. An interventional review on benzodiazepines and
schizophrenia notes that evidence for augmentation of antipsychotics with benzodiazepines are
inconclusive, but the use of diazepam as an adjuvant agent has proven efficacy in targeting
anxiety, agitation and insomnia (REF; REF).
Finally, atorvastatin and diabex XR have been prescribed to manage Mary’s hypercholesterolemia
and diabetes which have occurred secondary to both lifestyle factors and the adverse effects of
weight gain and metabolic syndrome secondary to long term clozapine treatment.
4.1 Current and potential long term problems with current medications:
Clozapine has a high profile of serious adverse reactions (REF; REF; REF). Therefore as per the
treatment plan in section three, monthly clozapine reviews are required, including pathology to
monitor white cell count, neutrophils, LFT’s, blood glucose, haemoglobin and platelets. An ECG
and transthoracic echocardiogram are completed every 12 months to monitor cardiac function
(REF). Although there is potential to further increase Mary’s clozapine dose from the current
350mg, whilst this may provide more optimal symptom management, it must also be balanced
Example of clinical cases study (NUR5003)
9
against the risk of further weight gain, increased insulin resistance and further exacerbation of her
diabetes. Diazepam has a long half-life which increases further with age and liver or kidney
disease. Therefore caution must be taken when titrating dose in this population, and the patient
must monitored for over-sedation and CNS depression. Other considerations include physical
dependency and withdrawal issues if prescribed for longer than 4 weeks, or withdrawn suddenly
(REF).
5. Patient education
In the same way that there is significant variation between individuals response to psychiatric drug
therapy, a patient centred approach to education should be done on an individual basis and
centred around the patients current, and likely future needs (REF). Key patient education areas
relevant to Mary’s current needs are:
• _Appearance and grooming; Mary’s experience of negative symptoms leads to poor self care.
Assisting and encouraging Mary to meet her personal hygiene needs to the best of her
ability is important both for diabetes management and it also decreases the likelihood that
she will experience further social rejection and isolation.
• _Social inclusion; negative symptoms and social isolation often combine to form a pervasive
feeling of loneliness and lowered mood. Encouraging Mary to attend purposeful ageappropriate
programs and activities provided though agencies like the Resource Centre,
Lantern and Impact will assist Mary to have some meaningful structure, socialisation and
support.
• _Weight management: Obesity is common co-morbidity for individuals with schizophrenia
(REF). A recent Cochrane review examining the efficacy of pharmacological versus nonpharmacological
interventions for weight management reported that modest short term
weight loss can be achieved with both selected pharmacological agents and diet and
exercise interventions (REF). The first consideration in managing weight gain should be
appraisal of the patient’s metabolic risk and balancing this with the need to prescribe
antipsychotics to achieve good control of psychotic symptoms (REF). Mary currently has a
GP extended care plan and team care arrangement, and could benefit greatly from some
Example of clinical cases study (NUR5003)
10
Medicare funded consultations with an Exercise Physiologist who specialises in evidence
based exercise prescription for chronic disease management, and could also suggest
community exercise groups to link into.
• _Patient education surrounding the current plan for future relapse prevention and
management and monitoring of physiological issues, medication side effects and medical
conditions through the GP management plan is detailed in section 3; patient management.
6. Conclusion
Schizophrenia is an extremely complex mental illness which creating a wide variety of detrimental
symptoms. The 1.5 % of the population who suffer from it remains poorly understood and accepted
by the wider community. Approximately 20-33% of those with the disease have chronic
schizophrenia that is considered resistant to pharmacological treatment. There is currently no clear
evidence that antipsychotics as a mono-therapy have any meaningful effect on the person’s
cognition, social functioning or quality of life. Unfortunately, the pathological neural changes
associated with schizophrenia continue to progress, and despite treatment with antipsychotics, the
mortality rate amongst those like Mary with the disease remains disproportionate to the unaffected
population. A multi-modal approach to treatment and long term care is essential for those with
chronic schizophrenia. Assertive community treatment such as MSTT case management for this
population is congruent with current evidence based practice guidelines. High frequency of patient
contact is required to attend to medication compliance, and the complex behavioural, physical and
psychosocial issues that schizophrenia sufferers experience. More emphasis must be placed on
implementing evidenced based psychotherapy modalities to address the often-disabling
deterioration in cognition and psychosocial function.
Under the Mental Health Act, involuntary patients are not required to have a treatment plan,
although National Mental Health Service Standards suggest that best practice is that every
consumer should have an individualised care plan. Organised care pathways such as Mary’s
treatment and recovery plan has been shown to significantly enhance patient care by assisting
clinicians to implement evidence based treatment approaches and monitor patient outcomes.
Mary’s current management falls within current evidence based practice; however her prognosis
Example of clinical cases study (NUR5003)
11
may be improved by the addition of psychotherapy approaches to her treatment plan. Whilst her
clozapine dose would ideally be increased above the current 350mg further attenuate psychotic
symptoms, this is necessarily balanced against her current cardiovascular risks and diabetes
management. In caring for patients with refractory schizophrenia, health care professionals must
balance treatment efficacy, prevention of disease progression, and adverse effects of medication
as they tailor the treatment plan to the individual.
Example of clinical cases study (NUR5003)
12
References (removed)
Example of clinical cases study (NUR5003)
13
Example of clinical cases study (NUR5003)
14
Appendix 1: DSM-IV definition of diagnosis
Primary Diagnosis: 295.30 – Paranoid schizophrenia
The DSM IV describes the presence of prominent auditory hallucinations or delusions in the
absence of cognitive dysfunction as being the defining feature of paranoid schizophrenia.
Diagnostic criteria for this sub-type is A) “preoccupation with one or more delusions or frequent
auditory hallucinations” and B) “None of the following behavior is prominent: disorganized speech,
disorganized or catatonic behavior, or flat or inappropriate affect” (DSM IV, p. 286).
According to the Diagnostic and Statistical Manual of Mental Disorders (4
the
edition), schizophrenia
can be described as a disturbance lasting at least six months including at least one month of
positive and/or negative symptoms (DSM IV, p. 286).
The diagnostic criterion for Schizophrenia requires assessment and evaluation in six key areas to
determine a clinical diagnosis.
A) Characteristic symptoms- including two or more of the following lasting at least one month;
delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behavior
and negative symptoms.
B) Social and/or occupational dysfunction – occurring for substantial length of time since onset
of illness and relating to disturbance in functioning at work, school, relationship or self-care.
C) Duration – disturbances last at least six months, including minimum of one month of
symptoms described in criterion A.
D) Exclude mood disorders- mood disorders with psychotic features and schizoaffective
disorder has been eliminated.
E) Exclude general medical conditions and substance abuse disorder – as cause of psychosis.
F) Secondary diagnosis with pervasive development disorders – additional diagnosis of
schizophrenia can only be formed if prominent psychotic symptoms last at least one month
(DSM IV, p. 286)
Example of clinical cases study (NUR5003)
15
Appendix 2: case description and MSE
2.1 Case Description
For the purposes of this case study the case subject will be known as Mary, a 55 year old female
with a past history of chronic paranoid schizophrenia, and secondary co-morbidities of type 2
diabetes mellitus, morbid obesity, hypertension and hypercholesterolemia.
HOPC: Mary currently experiences chronic paranoid and persecutory delusions, mood is stable,
and she appears guarded and has little insight. She is visited daily by the Mobile Support and
Treatment Team to supervise her medication. Always consents to taking her medication but is
extremely unreliable if left to self supervise. Current medications are listed in section 4:
Pharmacological Interventions. Current detailed mental status examination is attached in appendix
2.2.
Past history Psychiatric – First diagnosis (1973) age 18: chronic schizophrenia with behavioural
disorder (sexual promiscuity) and low to average intellectual ability. First psychiatric inpatient
admission was in 1975 (duration 9 months). Most recent psychiatric inpatient admission was five
years ago. Current treatment status in the Mental Health Act (1986) is as an informal patient.
Social History – Mary lives alone in a unit privately owned by her family trust, is one of eleven
siblings, but over the years has estranged her self from all but one sister, who is supportive, and
rings her occasionally. She receives home help from the local council and her case manager
assists her with weekly shopping.
Family History: Mother deceased (unknown cause) in 1975 when Mary was 20. Long history of
violent and aggressive behavior toward family. They have subsequently cut off contact due to her
behavior. Otherwise socially isolated. Mary had a daughter at age 24, who was subsequently
adopted out, and is now married with children and refusing contact with her.
Example of clinical cases study (NUR5003)
16
Appendix 2.2 Mental Status Examination
Appearance: Clothes dirty and stained, malodorous, hair un-brushed oily and matted. Overdressed
for the weather.
Behaviour: guarded, superficially warm and friendly, good eye contact. Slow but purposeful motor
movement.
Mood: ‘Depressed’ mood in mornings, usually resolves by lunchtime. Loss of interest and
dysphoric mood in Mary’s case results in the objective observation of a congruent blunted affect;
that is she appears to react spontaneously when spoken to, makes some eye contact but has an
empty emotional expression and a lack of animation in facial expression.
Affect: blunted affect congruent to mood.
Speech: Poverty of speech, increased latency and decreased rate. Short laconic responses.
Thought Form: Largely normal stream of thought although neologism “botonomy” expressed by
patient during interview and was unable to explain meaning.
Thought Content: Denies suicidal or homicidal ideation. Paranoid and persecutory delusions
regarding family and neighbours who want to kill/hurt her. One of Mary’s long held, fixed grandiose
and persecutory delusions is that her sisters are ‘jealous of her because she is moving up in the
world and getting special attention’ and because of this are going to come and ‘put a bullet in my
head’ Ideas of reference from TV and radio, believes they are telling her a gang is coming to hurt
her. Somatic delusions; olfactory, tactile and visual. Believes a girl from high school is putting
faeces on her which she can smell and feel on her skin. Mary has an ongoing conviction that she
regularly has chest pains from a recurring heart attack and bronchitis (which causes her significant
anxiety), stomach pains from constipation (somatic pain only, her bowel function is normal).
Perception: Auditory hallucinations – chronic derogatory and threatening voices of neighbours and
family. Grandiose delusions regarding self, and believes sisters are jealous of and persecuting her
because she is moving up in the world and getting special treatment.
Cognition: Mildly affected, some confusion and disorientation to day and year.
Insight: Limited insight into illness, aware that something is not right, states she has ‘retards
Example of clinical cases study (NUR5003)
17
syndrome’.
Example of clinical cases study (NUR5003)
18
Appendix 3: Patient Management Plan
This has been removed from this example

Case study on mental health
Order Description

a case study which has to be done on a depression patient(Bipolar). you will need to write the scenario or case later. You can start from the Introduction. Evidence based guidelines are to be used which can be found in “australia newzealand college of psychology” or NICE. Important to know that The patient is currently under treatment and on ECT treatment. 6 ECTs done with some improvement and 6 more to go.Community service will be done by MAPS if you have to mention community services. The sample work is not of great quality and its for only an idea.
Example of clinical cases study (NUR5003)
1
Clinical Case Study: Paranoid Schizophrenia
1. Introduction
Schizophrenia is a serious and chronic mental health disorder, primarily characterized by psychotic
features such as significant disturbances in perception, thought content and processes, cognition,
social and occupational dysfunction (REF; REF). On average, schizophrenia affects approximately
1.5 % of the population world wide (REF; REF). The etiology of schizophrenia is not well
understood, but it appears that genetics and the combination of genes plus environmental
interaction account for around 80% of the probability of developing the disease (REF). The
experience of symptoms associated with this severe mental illness and the resultant effect that
physical, emotional and economic impairments have on ability to function in the community
presents a significant challenge to mental health agencies tasked with supporting these people to
remain well in the community and maximize their functional capacity and quality of life.
This paper presents the case study of a 54-year-old female, with a thirty-six year history and
primary diagnosis of continuous paranoid schizophrenia. For the purposes of the paper the case
subject will be referred to by the pseudonym of Mary. Mary is an informal (voluntary) patient who
lives alone in the community. Her last inpatient admission was five years ago. She is currently
managed by a Mobile Treatment and Support Team (MSTT) who supervises her medication daily
and assists Mary with weekly shopping and any other psychosocial issues. Mary’s relevant past
medical history includes morbid obesity; type two diabetes mellitus, hypercholesterolemia and
hypertension. The definition of Mary’s clinical diagnosis and the full DSM IV-TR diagnostic criterion
for continuous paranoid schizophrenia can be found in appendix 1. A detailed case description and
patient history is attached in appendix 2.
Example of clinical cases study (NUR5003)
2
The case subject described above was selected for this case study to highlight complexities and
commitment required to effectively integrate and manage a client with chronic schizophrenia in the
community. This paper focuses on the case subject’s clinical presentation, diagnostic criteria, and
examines the clinical manifestations and pathophysiology of schizophrenia. It will describe and
discuss the case subject’s current and future treatment plan (in the context of GP medical case
management and the REF), pharmacological management in the context of current evidence
based practice, and will also address the long term implications associated with chronic use of
antipsychotics. Finally, it discusses patient education requirements and strategies required to
address the case subject’s current and future mental, physical and psychosocial healthcare needs.
2. Clinical manifestations and pathophysiology
The negative symptoms often experienced by those with schizophrenia have a demonstrable
impact on the person’s ability to maintain normal function. Anhedonia, avolition, affect restriction
and alogia account for significant disturbances to personal, social and occupational functioning
(REF). The clinical manifestations which Mary experiences secondary to these negative symptoms
are discussed below.
2.1 Disturbances in appearance – Mary appeared overweight, dishevelled, inappropriately
dressed for the weather and her clothes are stained and dirty. Her disheveled and matted and she
presents malodorous. The diagnostic criterion (B) of the DSM IV-TR for schizophrenia is
dysfunction in one or more significant areas of psychosocial functioning, including self care and
activities of daily living (ADL) (REF). Avolition in particular represents a loss of motivational drive to
participate in goal directed activities such as self-care, nutrition, ADL’s, physical exercise (REF;
REF, REF). In Mary’s case it is evident that both her ability to maintain personal care and
motivation for physical activity have been adversely affected.
2.2 Disturbances in mood – Mary subjectively reports she feels ‘a bit down’ especially in the
mornings, but this feeling usually self-resolves by lunchtime. Emotional impairments such as
anhedonia represent a common negative symptom of schizophrenia and are related to the loss of
interest or the experience of pleasure (REF). A randomized controlled trial conducted by REF
(2010) reported that MRI scans of individuals with high anhedonia ratings demonstrated reduced
Example of clinical cases study (NUR5003)
3
activation of the striatum and amaygdala in response to positive stimuli. The authors hypothesized
that this diminuted response may contribute to symptoms of anhedonia by failing to signal the
salience of positive events (REF).
2.3 Poverty of speech and thought – on examination Mary was noted to have slowed movement,
increased latency in speech and decreased rate. Alogia is typically manifests as poverty of speech,
characterised by short, laconic replies. Mary appeared to have a reduction of thoughts, which is
reflected in her diminished fluency and productivity of speech (REF).
2.4 Positive symptoms
2.4.1 Disturbances in thought processes
Mary exhibited a largely normal stream of thought, however in the course of the interview did
present the neologism ‘botonomy’ which she could not explain the meaning of to the interviewer.
Thought disorders may precipitate incoherent speech which is impossible to derive meaning from
and leaves the sufferer confused and makes communication very difficult (REF; REF).
2.4.2 Disturbances in thought content
Delusions: Mary’s delusions are predominantly paranoid and persecutory in nature, but she also
experiences a variety of non-bizarre somatic delusions. Whilst her delusions are multiple, her
sisters always relate the central theme to persecution. The REF states that the essential features
of paranoid schizophrenia are the prominence of persecutory and/or grandiose delusions with
hallucinations that are typically congruent with the delusional themes (REF). Mary’s cognitive
functioning only mildly impaired, she no longer demonstrates any significant behavioural response
to the psychotic symptoms, and she has some insight into her illness saying that she knows
something is not right and that has ‘retard syndrome’ and that her brain has gone ‘hard’ which is
why she can’t think straight. A recent study by REF (2010) contend that significant cognitive
dysfunction and impairment is present prior to the onset of schizophrenia, and time-based
measures across the span of the illness demonstrate deficits progress beyond what is expected
with normal ageing. These cognitive deficits are now becoming considered to be a primary
characteristic of schizophrenia and may contribute to the detrimental effect on psychosocial
Example of clinical cases study (NUR5003)
4
function (REF).
2.5 Ideas of reference: Mary experiences delusions of reference from TV and radio. This a
common thought content disorder in schizophrenia, in which the person believes messages are
being conveyed to them through the media and that an insignificant event has a special personal
meaning to the individual (REF; REF).
2.6 Perceptual disturbances – Mary reports experiencing intermittent auditory, tactile and
olfactory hallucinations. These often appear to be congruent to the content of her delusions. She
also experiences persecutory and derogatory auditory hallucinations in the voices of her neighbors
and sisters. Hallucinations are sensory disturbances that occur in the absence of external stimuli
and may occur in any sensory modality, although auditory hallucinations are reported as the most
common type in schizophrenia (REF).
3. Patient management
The REF, details the legislative requirements for the treatment management of individuals with
mental illnesses (REF). Every patient treated under the ‘Act’ is required to have a treatment plan
by section 19A (REF). Whilst the Act doesn’t apply to those receiving mental health treatment on a
voluntary basis, both section 6A (j) of the Act and Standard 11.4.9 of the REF (1996), suggests
that best practice dictates that every consumer have a current individualised care plan which is
regularly reviewed and revised as necessary (REF). As mentioned previously, Mary’s legal status
under the Act is as an informal patient as she is able to give voluntary consent to treatment and is
cooperative and compliant. Accordingly, Mary’s current treatment plan (attached in Appendix 3) is
discussed below.
3.1 Current treatment and recovery plan:
Mary’s treatment and recovery plan is structured around four key areas:
1. Mental Health Needs
2. Other physical health needs
3. Support needs
4. Social needs
Example of clinical cases study (NUR5003)
5
1. Ongoing emotional and mental health treatment aims are to maintain Mary’s mental health and
prevent future relapse. Through intensive case management and daily home visits by the
Mobile Support and Treatment Team (MSTT), Mary’s medication is supervised daily to ensure
compliance, her mental state assessed to detect any deterioration, a risk assessment
completed as well as individual psycho education such as reality feedback and reassurance to
manage paranoid delusions and decrease associated distress. Assertive Community
Treatment models of care such as the MSTT team described above have been found to
significantly reduce relapse and improve accommodation stability (REF).
2. Physical health needs are addressed by a combined management approach between Mary’s
MSTT case manager and her GP who has provided an extended care plan and team care
arrangement. The primary current treatment goals are to effectively manage her diabetes
through strategy of GP medical management, and three visits per year from the Diabetes
Educator to provide Mary with education regarding medications, good nutrition, prevention of
diabetes complications and referral to podiatry and optometry services for foot and eye care if
required. MSTT staff takes Mary shopping weekly to assist her to buy and prepare health food,
and encourage fibrous food and fluid to prevent constipation.
Intervention and planning to prevent future deterioration or development of serious physical
health issues includes ensuring monthly clozapine reviews occur to monitor for adverse effects,
annual physical exams including ECG, echocardiogram, and pathology tests to monitor
glucose tolerance and lipid profile.
3. Support is required to assist Mary to improve her daily living skills. Current strategies to achieve
this are to encourage attendance to personal hygiene change clothes regularly, and give
positive reinforcement when she does. Mary has been provided council home help to assist in
maintaining a clean and habitable living environment.
4. Social needs are centered on the goal of improving Mary’s level of social inclusion and support
by suggesting strategies for Mary to maintain friendships, and increasing her participation in
group activities to promote inclusion and relieve loneliness and boredom. Linking her into
activities with community organisations such as Lantern and the Resource center will help
Example of clinical cases study (NUR5003)
6
meet these social goals.
3.2 Future planning: crisis action and relapse prevention plan
Mary has an individualized, simple plan to recognize when she is becoming unwell, remind her of
the things she needs to do to stay well, and the MSTT and Psychiatry Triage phone numbers to
call in case of a crisis.
• _Green Light denotes a list of sign of wellness and things to build on such as keeping active,
regularly interacting in an acceptable and appropriate manner with case workers, family
and friends, taking medication and feeling happy.
• _Yellow light is the known sign and symptoms Mary is becoming unwell such as paranoia
about siblings, psychosomatic delusions and increased anxiety.
• _Red light is the indicators that Mary is unwell and needs to call immediately for crisis helpextreme
paranoia, aggression toward others.
3.3 Weaknesses in the current treatment plan suggestion for additional evidence based
treatment strategies.
Although antipsychotics have long been the cornerstone of treatment for schizophrenia,
approximately thirty percent of patients continue to experience chronic psychotic symptoms
despite medication compliance (REF). This highlights the need for a multifaceted approach to care
planning, with greater emphasis on providing concomitant psychosocial therapy to address
disabling disturbances in cognitive functioning, psychosocial issues and quality of life (REF; REF).
The growing body of evidence supporting psychotherapy approaches to schizophrenia
management is emerging. For example, a number of studies evaluating Acceptance and
Commitment Therapy have demonstrated that treatment with four hours of ACT resulted in a 50%
decrease in schizophrenia related hospital admissions over the following six months (REF).
Another feature absent in the current treatment plan is a more definite strategy and plan for weight
management. Encouraging Mary to eat healthy food has clearly not been effective as a
management strategy to prevent metabolic side effects and co-morbidities that have in part
Example of clinical cases study (NUR5003)
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occurred secondary to prolonged atypical antipsychotic treatment. Suggested evidence-based
patient education for weight management is detailed in section 5.
4. Pharmacological interventions
4.1 Current oral medication regime:
• _Clozapine; 350 mg nocte.
• _Diazepam; 5mg PRN.
• _Atorvastatin; 20mg mane.
• _Diabex XR(extended release) 500mg mane.
Clozapine is a second generation or ‘atypical’ antipsychotic agent which antagonises D1, D2, and
D4 dopamine receptors, and both the direct D2 blockade and inhibition of secondary depolarisation
appear to produce the antipsychotic action (REF; REF; REF). Clozapine’s primary indication for
use is refractory or treatment resistant schizophrenia, and current literature suggests that
clozapine has greater treatment efficacy than conventional neuroleptics (REF; REF). Whilst studies
making direct comparisons between different atypical antipsychotics (AAPs) show inconsistent
differences in acute efficacy, they do report evidence to indicate clozapine has superior efficacy
over other AAP’s in the 20-33 % of patients like Mary who have chronic schizophrenia (REF; REF;
REF; REF; REF).
Clozapine has a much weaker affinity for the D2 receptor, and is therefore less likely to produce
extra pyramidal side effects, hyperprolactaemia or tardive dyskinesia than the first generation
‘typical’ antipsychotics (REF; REF). However like other second generation antipsychotics,
clozapine comes with its own new set of risks. Adverse effects such as agranulocytosis, seizures,
metabolic syndrome (leading to increased risk of obesity, cardiovascular disease and diabetes),
and cardiomyopathy are potentially fatal (REF; REF; REF; REF).
Despite the introduction and use of both typical and atypical antipsychotics, the mortality rate for
those with schizophrenia compared to the normal population has continued to increase over the
past 20 years (REF). In a recent Cochrane review of clozapine efficacy, REF (2010) reported that
clozapine treatment substantially decreases the likelihood of relapse compared to those on typical
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antipsychotic drugs, shows greater attenuation of symptoms, and had the greatest impact in
reducing the likelihood of suicide. However, despite these positive clinical effects, a systematic
review and randomised controlled trials have found there were no significant differences between
clozapine and other antipsychotics on cognitive impairments, mortality, occupational capacity or
psychosocial function (REF; REF; REF). In Mary’s case, although her MSE in Appendix 2.
demonstrates ongoing dysfunction, only treatment with clozapine has had a consistent effect on
attenuating positive symptoms and reducing the violence and aggression and disinhibition
associated with them. In the 38 years since Mary was diagnosed with schizophrenia, she has been
treated with multiple combinations of antipsychotics and had many admissions to psychiatric
facilities, without any significant improvement. The introduction of clozapine to her medication
regime six years ago has allowed her reach some stability in her illness, and with intensive mobile
support, live successfully on her own in the community for the first time in her life.
Diazepam is a benzodiazepine prescribed for its anxiolytic effects (REF; REF). Mary experiences
regular anxiety and distress secondary to her delusional content and PRN diazepam has an
effective short term sedating effect. An interventional review on benzodiazepines and
schizophrenia notes that evidence for augmentation of antipsychotics with benzodiazepines are
inconclusive, but the use of diazepam as an adjuvant agent has proven efficacy in targeting
anxiety, agitation and insomnia (REF; REF).
Finally, atorvastatin and diabex XR have been prescribed to manage Mary’s hypercholesterolemia
and diabetes which have occurred secondary to both lifestyle factors and the adverse effects of
weight gain and metabolic syndrome secondary to long term clozapine treatment.
4.1 Current and potential long term problems with current medications:
Clozapine has a high profile of serious adverse reactions (REF; REF; REF). Therefore as per the
treatment plan in section three, monthly clozapine reviews are required, including pathology to
monitor white cell count, neutrophils, LFT’s, blood glucose, haemoglobin and platelets. An ECG
and transthoracic echocardiogram are completed every 12 months to monitor cardiac function
(REF). Although there is potential to further increase Mary’s clozapine dose from the current
350mg, whilst this may provide more optimal symptom management, it must also be balanced
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against the risk of further weight gain, increased insulin resistance and further exacerbation of her
diabetes. Diazepam has a long half-life which increases further with age and liver or kidney
disease. Therefore caution must be taken when titrating dose in this population, and the patient
must monitored for over-sedation and CNS depression. Other considerations include physical
dependency and withdrawal issues if prescribed for longer than 4 weeks, or withdrawn suddenly
(REF).
5. Patient education
In the same way that there is significant variation between individuals response to psychiatric drug
therapy, a patient centred approach to education should be done on an individual basis and
centred around the patients current, and likely future needs (REF). Key patient education areas
relevant to Mary’s current needs are:
• _Appearance and grooming; Mary’s experience of negative symptoms leads to poor self care.
Assisting and encouraging Mary to meet her personal hygiene needs to the best of her
ability is important both for diabetes management and it also decreases the likelihood that
she will experience further social rejection and isolation.
• _Social inclusion; negative symptoms and social isolation often combine to form a pervasive
feeling of loneliness and lowered mood. Encouraging Mary to attend purposeful ageappropriate
programs and activities provided though agencies like the Resource Centre,
Lantern and Impact will assist Mary to have some meaningful structure, socialisation and
support.
• _Weight management: Obesity is common co-morbidity for individuals with schizophrenia
(REF). A recent Cochrane review examining the efficacy of pharmacological versus nonpharmacological
interventions for weight management reported that modest short term
weight loss can be achieved with both selected pharmacological agents and diet and
exercise interventions (REF). The first consideration in managing weight gain should be
appraisal of the patient’s metabolic risk and balancing this with the need to prescribe
antipsychotics to achieve good control of psychotic symptoms (REF). Mary currently has a
GP extended care plan and team care arrangement, and could benefit greatly from some
Example of clinical cases study (NUR5003)
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Medicare funded consultations with an Exercise Physiologist who specialises in evidence
based exercise prescription for chronic disease management, and could also suggest
community exercise groups to link into.
• _Patient education surrounding the current plan for future relapse prevention and
management and monitoring of physiological issues, medication side effects and medical
conditions through the GP management plan is detailed in section 3; patient management.
6. Conclusion
Schizophrenia is an extremely complex mental illness which creating a wide variety of detrimental
symptoms. The 1.5 % of the population who suffer from it remains poorly understood and accepted
by the wider community. Approximately 20-33% of those with the disease have chronic
schizophrenia that is considered resistant to pharmacological treatment. There is currently no clear
evidence that antipsychotics as a mono-therapy have any meaningful effect on the person’s
cognition, social functioning or quality of life. Unfortunately, the pathological neural changes
associated with schizophrenia continue to progress, and despite treatment with antipsychotics, the
mortality rate amongst those like Mary with the disease remains disproportionate to the unaffected
population. A multi-modal approach to treatment and long term care is essential for those with
chronic schizophrenia. Assertive community treatment such as MSTT case management for this
population is congruent with current evidence based practice guidelines. High frequency of patient
contact is required to attend to medication compliance, and the complex behavioural, physical and
psychosocial issues that schizophrenia sufferers experience. More emphasis must be placed on
implementing evidenced based psychotherapy modalities to address the often-disabling
deterioration in cognition and psychosocial function.
Under the Mental Health Act, involuntary patients are not required to have a treatment plan,
although National Mental Health Service Standards suggest that best practice is that every
consumer should have an individualised care plan. Organised care pathways such as Mary’s
treatment and recovery plan has been shown to significantly enhance patient care by assisting
clinicians to implement evidence based treatment approaches and monitor patient outcomes.
Mary’s current management falls within current evidence based practice; however her prognosis
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may be improved by the addition of psychotherapy approaches to her treatment plan. Whilst her
clozapine dose would ideally be increased above the current 350mg further attenuate psychotic
symptoms, this is necessarily balanced against her current cardiovascular risks and diabetes
management. In caring for patients with refractory schizophrenia, health care professionals must
balance treatment efficacy, prevention of disease progression, and adverse effects of medication
as they tailor the treatment plan to the individual.
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References (removed)
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Appendix 1: DSM-IV definition of diagnosis
Primary Diagnosis: 295.30 – Paranoid schizophrenia
The DSM IV describes the presence of prominent auditory hallucinations or delusions in the
absence of cognitive dysfunction as being the defining feature of paranoid schizophrenia.
Diagnostic criteria for this sub-type is A) “preoccupation with one or more delusions or frequent
auditory hallucinations” and B) “None of the following behavior is prominent: disorganized speech,
disorganized or catatonic behavior, or flat or inappropriate affect” (DSM IV, p. 286).
According to the Diagnostic and Statistical Manual of Mental Disorders (4
the
edition), schizophrenia
can be described as a disturbance lasting at least six months including at least one month of
positive and/or negative symptoms (DSM IV, p. 286).
The diagnostic criterion for Schizophrenia requires assessment and evaluation in six key areas to
determine a clinical diagnosis.
A) Characteristic symptoms- including two or more of the following lasting at least one month;
delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behavior
and negative symptoms.
B) Social and/or occupational dysfunction – occurring for substantial length of time since onset
of illness and relating to disturbance in functioning at work, school, relationship or self-care.
C) Duration – disturbances last at least six months, including minimum of one month of
symptoms described in criterion A.
D) Exclude mood disorders- mood disorders with psychotic features and schizoaffective
disorder has been eliminated.
E) Exclude general medical conditions and substance abuse disorder – as cause of psychosis.
F) Secondary diagnosis with pervasive development disorders – additional diagnosis of
schizophrenia can only be formed if prominent psychotic symptoms last at least one month
(DSM IV, p. 286)
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Appendix 2: case description and MSE
2.1 Case Description
For the purposes of this case study the case subject will be known as Mary, a 55 year old female
with a past history of chronic paranoid schizophrenia, and secondary co-morbidities of type 2
diabetes mellitus, morbid obesity, hypertension and hypercholesterolemia.
HOPC: Mary currently experiences chronic paranoid and persecutory delusions, mood is stable,
and she appears guarded and has little insight. She is visited daily by the Mobile Support and
Treatment Team to supervise her medication. Always consents to taking her medication but is
extremely unreliable if left to self supervise. Current medications are listed in section 4:
Pharmacological Interventions. Current detailed mental status examination is attached in appendix
2.2.
Past history Psychiatric – First diagnosis (1973) age 18: chronic schizophrenia with behavioural
disorder (sexual promiscuity) and low to average intellectual ability. First psychiatric inpatient
admission was in 1975 (duration 9 months). Most recent psychiatric inpatient admission was five
years ago. Current treatment status in the Mental Health Act (1986) is as an informal patient.
Social History – Mary lives alone in a unit privately owned by her family trust, is one of eleven
siblings, but over the years has estranged her self from all but one sister, who is supportive, and
rings her occasionally. She receives home help from the local council and her case manager
assists her with weekly shopping.
Family History: Mother deceased (unknown cause) in 1975 when Mary was 20. Long history of
violent and aggressive behavior toward family. They have subsequently cut off contact due to her
behavior. Otherwise socially isolated. Mary had a daughter at age 24, who was subsequently
adopted out, and is now married with children and refusing contact with her.
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Appendix 2.2 Mental Status Examination
Appearance: Clothes dirty and stained, malodorous, hair un-brushed oily and matted. Overdressed
for the weather.
Behaviour: guarded, superficially warm and friendly, good eye contact. Slow but purposeful motor
movement.
Mood: ‘Depressed’ mood in mornings, usually resolves by lunchtime. Loss of interest and
dysphoric mood in Mary’s case results in the objective observation of a congruent blunted affect;
that is she appears to react spontaneously when spoken to, makes some eye contact but has an
empty emotional expression and a lack of animation in facial expression.
Affect: blunted affect congruent to mood.
Speech: Poverty of speech, increased latency and decreased rate. Short laconic responses.
Thought Form: Largely normal stream of thought although neologism “botonomy” expressed by
patient during interview and was unable to explain meaning.
Thought Content: Denies suicidal or homicidal ideation. Paranoid and persecutory delusions
regarding family and neighbours who want to kill/hurt her. One of Mary’s long held, fixed grandiose
and persecutory delusions is that her sisters are ‘jealous of her because she is moving up in the
world and getting special attention’ and because of this are going to come and ‘put a bullet in my
head’ Ideas of reference from TV and radio, believes they are telling her a gang is coming to hurt
her. Somatic delusions; olfactory, tactile and visual. Believes a girl from high school is putting
faeces on her which she can smell and feel on her skin. Mary has an ongoing conviction that she
regularly has chest pains from a recurring heart attack and bronchitis (which causes her significant
anxiety), stomach pains from constipation (somatic pain only, her bowel function is normal).
Perception: Auditory hallucinations – chronic derogatory and threatening voices of neighbours and
family. Grandiose delusions regarding self, and believes sisters are jealous of and persecuting her
because she is moving up in the world and getting special treatment.
Cognition: Mildly affected, some confusion and disorientation to day and year.
Insight: Limited insight into illness, aware that something is not right, states she has ‘retards
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syndrome’.
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Appendix 3: Patient Management Plan
This has been removed from this example