english thesis mark.docx

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CHAPTER 1

The Problem and Its Setting

Introduction

The problem focuses in interacting with patients that are mentally-ill, the proper ways on

handling and providing proper care they need. We know that this kind of patients are very

unpredictable, they can be dangerous in ways that will result to injuries on the health provider.

Schizophrenia is a mental illness. The first acute episode can be a devastating experience,

particularly as both the person experiencing the illness and those close to him will be

unprepared1. About one in a hundred people world-wide experience at least one such episode at

some time during their lives, although the highest incidence is in the late teens and early 20's.

About a quarter of people who develop schizophrenia recover within five years. Approximately

two-thirds of those who develop the condition experience fluctuating symptoms over many

years. About ten to fifteen percent experience severe long term incapacity. In about one quarter

of cases there is eventually a full recovery. The majority will have long periods of good

functioning, with occasional problems. The recent discovery of new forms of treatment may lead

to further improvement in rates of recovery, particularly if everyone involved, for instance, both

the person with schizophrenia and their family, learns to understand how to cope2.

In schizophrenia the activity of chemical messengers at certain nerve endings in the brain

is unusual and this may be a clue to the causes of the disorder. During what is sometimes


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referred to as "an acute episode" the mental processes of experiencing and thinking become

distorted. When severe this can lead to intense panic, anger, depression, elation or over activity,

perhaps punctuated by periods of withdrawal. It is not surprising that other people, particularly

family and friends, find the changes incomprehensible and are themselves devastated3.

One common misconception is that schizophrenia is the result of 'split personality'. In

fact 'multiple personality', the correct term, is very rare and has nothing to do with schizophrenia.

The mistake comes from the fact that the name 'schizophrenia' was coined from two Greek words

meaning 'split' and 'mind'. It was intended to represent the fact that processes of thought, feeling

and intention, guiding the person's actions, no longer interact to form a coherent whole4.

Statement of the Problem

The study aims to determine the causes, prevention, treatment and national response of

the growing cases of Schizophrenia. Specifically, answering and clearing the following

questions:

What is Schizophrenia? What caused Schizophrenia to spread specially in slums? What actions do the government has done to minimize the number of Schizophrenic

patients?

How to diagnose Schizophrenia? How can you acquire Schizophrenia? Who is at risk for developing Schizophrenia?


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Objective of the Study

The main objective of this study is to determine the causes, prevention, treatment and

national response of the increasing number of schizophrenic patients. It also aims in how can we

help and join in providing care for the victims of schizophrenia.

Interact with a Schizophrenic patient. Provide care for a Schizophrenic patient. Find the causes of Schizophrenia.

Who is at risk to develop Schizophrenia.

Understand what is Schizophrenia. Communicate with a Schizophrenic patient. Identify the cause of the problem on the patient. Minimize and eradicate the number of cases of schizophrenia. Recovery of a schizophrenic patient. Establish a cognitive stability of the patient.

Significance of the Study

The importance of this article is to enable us to be aware of the medicine and therapies

that may be helpful to the treatment of this depressive illness5. It makes us know the proper

interventions for the depressive patients6.


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For me as a future nurse, I will be able to know the drugs and therapies that are

appropriate for the treatment of a major and minor depressive illness. It also helped me to

understand the behavior of a mentally-ill patients7.

Definition of Terms

Depression. Is an illness that involves the body, mood, and thoughts, that affects the way

a person eats and sleeps, the way one feels about oneself, and the way one thinks about things8.

Illness. Is an abnormal process in which aspects of the social, physical, emotional, or

intellectual condition and function of a person are diminished or impaired compared with that

person's previous condition9.

Intervention. Is the act of intervening, interfering or interceding with the intent of

modifying the outcome10

.

Medication. Is the administration of a drug or medicine. (Note that "medication" does

not have the dangerous double meaning of "drug.")11.

Mental. Is intended for treatment of people affected with disorders of the mind12

.

Patient. Is one who receives medical attention, care, or treatment13

.

Schizophrenia. is a severe mental disorder characterized by delusions, hallucinations,

incoherence and physical agitation; it is classified as a "thought" disorder while Bipolar Disorder

is a "mood" disorder14

.

Therapy. Is a term that can be applied to any form of treatment for any illness or

disorder. For example, antacid is a form of therapy for heartburn, rehabilitation is a form of

therapy for addiction, and exercise is a form of therapy for obesity15

.


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ENDNOTES

14

thyear CEU Students, A Comprehensive Case Study on Schizophrenia and Psychiatric

Patients. 1992, pages 16-18.

2Dennis C. Daley. Dual disorders: mental illness. United States of America Hazelden

c1997.

3Vernon F. Jones. Creating effective programs for students with emotional and behavior

disordes. Borton,MA:Pearson/Allyn and Bacon, c2004.

4

Frederick J. Fuoco. Behavioral procedures for a psychiatric unit and hallway house. New

York van Nostrand Reinhold c1951.

5Andy K. Alazewski. Institutional Care and Mentally Handicapped. London Crown Helm

c1996.

6Jerome H. Rothstein. Mental Retardation: Reading and Resources. New York Rinehart.

and Winston c1971,2nd

ed.

7William C. Cockerham. Sociology of mental disorder/William cockerham. New Jersey

Prentice Hall, c1996,4th

ed.

8Richard M. Sanders, Behavioral Modification in a rehabilitation facility. Edwardsville

Southern Illinois University. C1975.

9Http://www.thefreedictionary.com/Depression.

10Http://www.thefreedictionary.com/Illness.

11Http://www.thefreedictionary.com/Intervention.

12Http://www.thefreedictionary.com/Medicaion.

13Http://www.thefreedictionary.com/Mental.


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14

Http://www.thefreedictionary.com/Patient.

15Http://www.thefreedictionary.com/Schizophrenia.


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CHAPTER 2

Review of Related Literature and Studies

This chapter includes discussion on related foreign and local studies which provide

relevant facts about Schizophrenia.

Foreign Literature

Drexer, Sharon M. in the book, A guide to nursing management of Psychiatric patients.

Provides information in dealing with psychiatric patients in terms of providing proper care and

intervention for their recovery.

Mendelson, Janice A. in A manual for the surgical management of the psychiatric patient.

Discussed the surgical ways in treating a psychiatric patient, its benefits, side effects, its progress

and the recovery of the patient.

Local Literature

Vargas, Josefina Q. in World Fellowship for Schizophrenia and Allied Disrorders: Visit

in Manila 2000. Destigmatisation: Promoting Partnerships among Families and Caregivers

Towards A Caring Community


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Foreign Studies

Comorbidity: Schizophrenia with Obsessive-Compulsive Disorder

The co-occurrence of obsessive-compulsive symptoms (OCS) and psychotic illness has been a

challenge for clinicians and investigators for more than a century1. Over the past decade, interest

in this area has burgeoned because of recognition of higher-than-chance comorbidity rates of

schizophrenia and obsessive-compulsive disorder (OCD), and observations of appearance or

exacerbation of OCS during treatment of schizophrenia with atypical antipsychotics. Emerging

neurobiological and genetic evidence suggests that persons with comorbid OCD and

schizophrenia may represent a special category of the schizophrenic population

2

.

The evidence for a putative schizo-obsessive disorder is examined and practical treatment

suggestions for this subgroup of patients are outlined in this article3.

Comorbidity between OCD and schizophrenia

The lifetime prevalence for schizophrenia is 1% and for OCD it is 2% to

3%.10

Comorbidity rates for OCD in the schizophrenia population are substantially higher than

what would be expected to occur randomly. In the schizophrenic population, the reported

prevalence of clinically significant OCS and of OCD ranges from 10% to 52% and from 7.8% to

26%, respectively3.

The higher-than-expected comorbidity rate for OCD and schizophre nia suggests a

nonrandom association and possibly an integral relation between these 2 conditions.The question

is whether this comorbid group with schizo-obsessive disorder represents a more severely ill

group with greater brain dysfunction that could, in part, be caused by common

neurodevelopmental predisposing factors, or whether the 2 conditions are part of a more complex


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syndrome that rep resents a distinct diagnostic entity. The answer could be clarified in part if

neurobiological studies were to demonstrate a distinct neuroanatomical substrate in this

comorbid group rather than the summation or superimposition of neurobiological lesions

observed in the separate disorders4.

Clinical and research challenges

Recent studies have aimed to reduce bias and confounding that were often inherent in

older studies. Newer studies have used such methods as randomization, prospective and cross-

sectional study designs, standardized diagnostic criteria, validated diagnostic tools, age-matched

control groups, and stratification of patient populations according to phase of illness to increase

the validity of study results5.

Notwithstanding these efforts to enhance diagnostic clarity and study validity, the

distinction between obsessions and delusions is often difficult to discern. Paradoxically,DSM-

IVallows for the OCD specifier with poor insight. This stands in contrast to the definition of

an obsession as being recognized by the individual as foreign to him or her (i.e., ego-dystonic),

and implies the presence of insight. Insel and Akiskalproposed that OCD represents a

psychopathological spectrum varying along a continuum of insight, and that this obsessional

delusion does not signify a schizophrenia diagnosis. Complicating the matter further is the

observation of perceptual disturbances that mimic various types of hallucinations or

pseudohallucinations in some persons with OCD.

Whether obsessions can be accurately detected in the presence of psychosis remains a

matter of debate. To date, there is no universally accepted method of detecting OCD in the


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presence of schizophrenia, although most contemporary study designs have used the Structured

Clinical Interview for DSM-IVAxis I psychiatric disorders and the Yale-Brown Obsessive-

Compulsive Scale (Y-BOCS).

In attempts to ascertain the reliability and validity of the Y-BOCS in this comorbid

subgroup, de Haan and colleaguesexamined the properties of this psychometric tool in patients

with recent-onset schizophrenia and comorbid OCS. These investigations found good internal

consistency and interrater reliability in this population. However, their findings concerning the

divergent validity against depressive and negative symptoms were inconsistent.

Although the phenomenological delineations between obsessions and delusions often

remain unclear, there is substantial evidence that OCS in schizophrenia represents more than just

an expression of enduring psychosis.This evidence includes observations that conventional

antipsychotic medications appear to be of limited use in the treatment of OCS in schizophrenia,

the persistence of OCS even after successful treatment of the psychotic symptoms, and the

effectiveness of serotonin reuptake inhibitors in the treatment of OCS in patients with

schizophrenia.

Clinical relevance of OCS in schizophrenia

Early investigators concluded that the presence of OCS confers protection against

cognitive deficits, functional impairment, and negative symptoms associated with

schizophrenia. Psychodynamic theories postulated that obsessions constitute a defense against

psychosis and prevent progression of the disease. However, more recent studies that used

rigorous methods have not tended to replicate these earlier findings.Instead, recent studies have


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found that this co-morbid group is burdened by a greater magnitude of cognitive deficits,

negative and positive symptoms, neurological soft signs, distress, dysfunction, hopelessness,

depression, suicidal ideation, and suicide attempts. A few studies have not replicated some of

these findings.

Pedigree and genetic studies

Pedigree and genetic studies have not found any familial relationship or shared etiology

between OCD and schizophrenia in their pure forms. However, specific genotypes of

polymorphisms of the same gene may differentially confer risk for the 2 disorders.

The catechol-O-methyltransferase (COMT) gene is a candidate gene for schizophrenia

because of its role in the breakdown of dopamine in the prefrontal cortex. Zinkstok and

colleagues found that the COMT high activity Val allele is associated with more OCS in young

patients with schizophrenia, whereas patients with the Met/Met genotype had the lowest Y-

BOCS scores. These results support the hypothesis that the COMT Val-Met polymorphism may

be a modifier gene for the symptoms of schizophrenia.

Poyurovsky and colleaguesexamined familial aggregation of schizophrenia spectrum

disorders and obsessive-compulsiveassociated disorders in schizophrenia probands with and

without OCD. They found that relatives of OCD-schizophrenia probands had significantly higher

morbid risks for OCD-schizophrenia and obsessive-compulsive personality disorder (OCPD);

they also found a trend toward higher morbid risk for OCD. When morbid risks for OCD,

OCPD, and OCD-schizophrenia were pooled, the significant between-group differences became


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robust. These data suggest a genetic contribution to the expression of OCS in individuals with

schizophrenia. In addition, they lend support for the validity of a putative schizo-obsessive

diagnostic entity.

Neurobiology of the schizo-obsessive subgroup

Considerable work has been done to reveal the neurobiological basis of both

schizophrenia and OCD.9 This research has focused primarily on elucidating key

neurotransmitter systems, structural and functional neuroanatomy, and neuropsychology.

However, there is very limited published research that focuses specifically on neurobiological

features unique to this putative schizo-obsessive subtype.

Neurotransmitter systems. There is a paucity of published research on unique

neurotransmitter involvement in the schizo-obsessive subtype group.

However, serotonin and dopamine have most consistently emerged as the principal

neurotransmitters of interest in both disorders. The dopamine hypothesis in schizophrenia has

long been regarded as the fundamental neurochemical premise; however, the superior efficacy of

the serotonin-dopamine receptor antagonists in the treatment of schizophrenia also supports the

importance of the serotonergic system in the pathophysiology of this disorder and may reflect the

modulation of dopaminergic systems by serotonin.

Conversely, in OCD a somewhat opposing picture has emerged with respect to neurotransmitter

involvement.The serotonin hypothesis of OCD is supported by successful treatment of the


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disorder with serotonin reuptake inhibitors, pharmacological challenge studies, and cerebrospinal

fluid neurotransmitter metabolite studies.However, several lines of evidence suggest that

serotonin is not the sole neurotransmitter involved in OCD. Considerable evidence supports the

additional role of the dopaminergic system in this disorder. Preclinical evidence of dopamines

reciprocal modulatory effects on the serotonin system and successful treatment of refractory

OCD with adjunctive dopamine receptor antagonists and serotonin-dopamine receptor

antagonists have provided support for the dopamine-serotonin hypothesis of OCD.

There is a lack of neurotransmitter data in the overlap group. However, one study

examined the differences in whole blood serotonin concentrations in healthy volunteers versus

patients with OCD, in persons with schizophrenia with and without OCS, and in clozapine-

treated schizophrenia in patients with and without clozapine-induced OCS. This study found that

the groups with OCD, schizophrenia with OCS, and clozapine-treated schizophrenia with OCS

had significantly lower levels of whole blood serotonin than did the healthy vol unteers and the

schizophrenia-only groups.

Neuroanatomy and neurocircuitry. In contrast to the abundance of neuroimaging studies

investigating structural brain abnormalities in persons with OCD and schizophrenia separately,

there is a dearth of such studies examining the comorbid subgroup. However, the considerable

overlap in the neurocircuitry and specific anatomical structures implicated in each disorder may

account for symptom coexpression in this subgroup of patient; the functional circuitry implicated

in the pathophysiology of OCD is generally believed to involve a cortico-striatal-thalamic-


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cortical circuit. Specific structures implicated in this pathway include the basal ganglia,

orbitofrontal cortex, and anterior cingulate cortex.

In schizophrenia, the dorsolateral prefrontal cortex circuit contains anatomical substrates

similar to those of the OCD orbitofrontal circuit. Thus, the specific neuroanatomical sites

identified by structural and functional neuroimaging studies performed in each of these disorders

independently show considerable over-lap in implicated structures, including the basal ganglia,

thalamus, anterior cingulum, orbitofrontal cortex, and regions of the temporal cortex, although

some of these findings are controversial.

Neuroimagin studies

Neuroimaging studies suggest the presence of specific neuroanatomical abnormalities in

the overlap group that may differ from what is observed in the individual disorders. One MRI

study of patients with juvenile-onset schizophrenia with OCS found significantly smaller left

hippocampi in this group than in schizophrenia-only and control groups. In addition, there was

an inverse correlation between illness duration and frontal lobe size in the comorbid group but

not in the schizophrenia-only group.

Another MRI study of patients with juvenile-onset schizophrenia demonstrated

significant enlargement of the anterior horn of the lateral ventricle and the third ventricle in

patients with OCS compared with patients who did not have OCS.64 In a different study of

patients with schizo phrenia and various degrees of OCS, functional MRI found that one


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subgroup exhibited a negative correlation between activation of the left dorsolateral prefrontal

cortex and OCS severity.

Taken together, these findings suggest greater neuroanatomical dysfunction in the

comorbid subgroup. Whether these findings reflect a specific pattern of dysfunction unique to

this comorbid subgroup or a more severe form of illness with greater brain dysfunction is thus far

unclear. The question warrants further study.

Neuropsychological testing

Several studies have compared the profiles of neurocognitive deficits in patients with

schizophrenia without OCS with those of the schizo-obsessive subgroup. Most, but not all, of

these studies have revealed more severe neuropsychological impairments in the comorbid

subgroup. Compared with their schizophrenia-only counterparts, the comorbid subgroup

demonstrated greater impairment in nonverbal memory, cognitive shifting abilities, visuospatial

skills, and executive function as measured by performance on the Wisconsin Card Sorting test6.

Local Studies

In the treatment of the depressed patient it is important for us to know the different ways

to treat this. In the medication of an anti-psychotic patient most of them will complain of

psychotic symptoms, auditory hallucinations, delusions, and often agitation. Commonly used anti

psychotic medication includes the tryfluorazine, haloperidol. Another therapy is the ECT or

(electro convulsive therapy) which has been found to elevate dramatically the mood of severely

depressed patients with few side effects. Psychological treatments as in the case of anxiety-


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related depressive reactions, there is now general acceptance of the role played by psychosocial

stressors in the precipitation of a major depressive illness. In accordance for inpatient care, the

biological symptoms such as: loss of appetite, weight, and hydration can be life threatening to

the aged and physically debilitated. For their rehabilitation in both the minor and major

depressive illness.

Rehabilitation unit may often be useful or necessary. Like in the cases of the suicidal

tendencies patients, we must give them proper attention so as to avoid the possibility of suicidal

attempt7.


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ENDNOTES

1Jerome H. Rothstein. Mental Retardation: Reading and Resources. New York Rinehart


ed.



ed.



ed.

4

http://www.psychiatrictimes.com/schizophrenia/content/article5http://www.psychiatrictimes.com/schizophrenia/content/article/10168/1402540?

6http://www.psychiatrictimes.com/schizophrenia/content/article/10168/1402540?pageNu

mber=2

74

thyear CEU Students. A Comprehensive case study on Schizophrenia and Psychiatric

Patients. 1992, pages 16,17,18.


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Chapter 3

Summary, Conclusion and Recommendation

Summary

This Chapter presents the findings of the study, the conclusion based on the data gathered

and the recommendation that may be valuable to future reference.

Epidemiological and biological data strongly suggest an integral relationship between

OCD and schizophrenia in the comorbid subgroup of patients. The epidemiological data strongly

suggest a unique relationship between these 2 disorders, given the marked degree of comorbidity

that has been consistently observed and which appears to represent more than just a spurious

association. Although pedigree and genetic studies of this overlap group are limited, preliminary

findings suggest intriguing genetic influences on comorbid symptom expression.

The neurobiological data on each disorder suggest the involvement of common brain regions and

neurotransmitter systems. However, more neuroimaging studies in the overlap group are required

to determine whether specific structural abnormalities unique to this putative subtype are present

Neuropsychological testing has generally revealed more severe impairment among patients in

this comorbid group, which suggests a specific and active interaction between these 2 disease

processes, but it has not identified a unique pattern of impairment.


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Conclusions

It is extremely important to recognize hidden suffering, loneliness and lack of self-esteem

as risk factors for violent and dangerous behavior in schizophrenic patients. Studying the

statements of violent schizophrenic patients sheds light on their striking and specific

vulnerability and emotional pain. More experimental psychopharmacological, neurofeedback and

combined psychotherapeutic research is needed to prevent and treat psychopathic behavior.

The current picture of the schizophrenic patients, which is reflected in the leading diagnostic

criteria of psychopathy offered by Cleckley and Hare, is incomplete because emotional suffering

and loneliness are ignored. When these aspects are considered, our conception of the psychopath

goes beyond the heartless and becomes more human.

Recommendations

Establish a good working communication with the schizophrenic patient Provide proper care for the schizophrenic patients. Health care providers must have patience and must control their feelings whenever

dealing with schizophrenic patients.

The treatment must be specific, time bounded, and realistic for the achievement of fullrecovery of the patient.

The Health Care Provider must explore new ways in interacting with their patients, theymust have new techniques in approaching the schizophrenic patient


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The Health Care Provider must be aware that a schizophrenic patient is unpredictable that

he/she may cause injuries both in the health care provider and to his/herself

Proper precautionary equipments and measures must be applied whenever interactingwith this patients.

The Health care provider must treat the patient with care, love and respect like his or wonrelative.

Proper medications must be administered for the continuous recovery of the patient.


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Bibliography

4th

year CEU Students, A Comprehensive Case Study on Schizophrenia and Psychiatric Patients.

1992, pages 16-18

Daley. Dennis C. Dual disorders: mental illness. United States of America Hazelden c1997

Jones, Vernon F. Creating effective programs for students with emotional and behavior

disordes. Borton,MA:Pearson/Allyn and Bacon, c2004

Fuoco,Frederick J. Behavioral procedures for a psychiatric unit and hallway house. New York

van Nostrand Reinhold c1951

Alazewski, Andy K. Institutional Care and Mentally Handicapped. London Crown Helm c1996

Rothstein, Jerome H. Mental Retardation: Reading and Resources. New York Rinehart and

Winston c1971,2nd

ed.

Cockerham, William C. Sociology of mental disorder/William cockerham. New Jersey Prentice

Hall, c1996,4th

ed.

Sanders, Richard M. Behavioral Modification in a rehabilitation facility. Edwardsville Southern

Illinois University. C1975.

Mendelson, Janice A. A manual for the surgical management of the psychiatric patient.

Springfield, III. Charles C. Thomas c1963

Livanainen, Matti C. A study on the origins of mental retardation. England Spastics International

Medical [c1974]

Poser, Charles M. Mental retardation:diagnosis and treatment. N.Y.: Harper and Row, [c1969]

Parr, Hester Q. Mental Health and Social space: towards inclusionary geographies

Http://www.thefreedictionary.com/Depression


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http://www.psychiatrictimes.com/schizophrenia/content/article

http://www.psychiatrictimes.com/schizophrenia/content/article/10168/1402540?

http://www.psychiatrictimes.com/schizophrenia/content/article/10168/1402540?pageNumber=2

Http://www.thefreedictionary.com/Depression

Http://www.thefreedictionary.com/Illness

Http://www.thefreedictionary.com/Intervention

Http://www.thefreedictionary.com/Medicaion

Http://www.thefreedictionary.com/Mental

Http://www.thefreedictionary.com/Patient

Http://www.thefreedictionary.com/Schizophrenia

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