TABLE OF CONTENTS

I. INTRODUCTION

II. PATIENT’S DATA

 General Data

 Presenting Complaints

 Admitting Diagnosis

 History of Present Illness

 Past Medical History

 Past Psychiatric History

 Alcohol/Substance Abuse History

III. Family History

IV. Personal Development History

 Prenatal and Perinatal History

 Birth

 Infancy

 Early Childhood (Preschool age)

V. Childhood

 School age

 Further Personality Development

VI. Adolescent
 Personality change
VII. Adulthood
  Occupational history
 Marital and relationship history
 Educational history
 Habits
 Interest
 Personality and character structure
 Strength of client
VIII. Psychosocial History
IX. Environmental History
X. Mental status Examination
XI. Final Diagnosis
XII. Review of related literature (include anatomy)
XIII. Psychopathology
XIV. Drug study
XV. NCP
XVI. Discharge Plan
 I. GENERAL DATA

Name: Yabut Ryan Marmul

Age: 24 y/o

Birthday: June 1,1994

Civil Status: Single

Address: #1918 F. Munoz St. City of Manila – Malate

Hospital No.: 46012

Father: R.Y

Mother: N.Y

Educational Attainment: Grade II

Religion: Catholic

II. PRESENTING COMPLAINT OF THE PATIENT UPON ADMISSION

Informant Complain: Mother:“Naghahawak ng Kutsilyo”

“Nagbabantang Manakit”

“Naghahamon ng away”

According to the patient: “Wala akong sakit”

III. ADMITTING DIAGNOSIS

Undifferentiated Schizophrenia
IV. HISTORY OF PRESENT ILLNESS

This is a case of R.M.Y 24 years old male, born on June 1, 1994, Single, Catholic was

admitted for the 2nd time at NCMH with the presenting complaints of, “Naghahawak ng

kutsilyo” “Nagbabantang manakit” “Naghahamon ng away” as provided by the mother. He

was brought to the NCMH OPD for consultation. He was transferred to the ER and

subsequently was admitted.

3 days P.T.A the patient was noted to be restless and irritable. Patient had episode of

mumbling to self and become verbally threatening, frequently had a knife and assaulted his

relatives and neighbors. He was not sent by the relatives, but was restrained by the cousin.

According to the patient he was released from restrain when he is calm.

1 day P.T.A he had a drinking spree with his friend and they smoked marijuana. When

he was high he ran because he thought somebody is after him. He did not went home that

day. He just ran away from home. His relative looked for him but can’t find him.

November 12, 2017 He was found by his cousin walking aimlessly in the street of

Manila. He was found restless, irritable and mumbling to self and “Naghahawak ng kutsilyo”

“Nagbabantang manakit” “naghahamon ng away”, he was found by his cousin in that state

and he was brought by his cousin and other to NCMH for consultation. Seen and examined

an adult male with a slim built and average height, seemingly behave with some eye

contact. He spoke spontaneously and audibly. He had euthenics mood with blunted affect.

He denied having perceptual disturbances, racing thoughts and morbid ideation. He then

suddenly claimed that he can read often people’s thoughts and “May bumobulong sa akin
 na mangalmot ako ng tao” as verbalized by the patient . He was brought directly to the ER

and was admitted and brought to Pavilion 1.

V. PAST MEDICAL HISTORY

Based on patient’s medical history when he was a child, he was diagnosed of having

asthma. He couldn’t remember at what age he was diagnosed and unable to recall the name of

the hospital and the medication taken.

VI. PAST PSYCHIATRIC HISTORY

Patient has been mentally ill since 2003 with last admission on May to August 2016.

Admitted again on November 12, 2017.

VII. ALCOHOL AND SUBSTANCE ABUSE

Since 14 years old he was already drinking alcohol and using drugs.

VIII. FAMILY HISTORY

As stated by the patient, there was no history of mental illness in the family. The patient

is living with the family who is renting a house at Maisan Barangay 7124 Malate. The mother is

51 years old and working as a rug maker and selling it in the road, while the father is 52 years

old and selling a steering wheel cover together with the mother. He is the second among the

five sibling, three boys and two girls in the family. He has a good relationship with all the

members of the family but he is more close to his mother and to the youngest sister. However,
two of his brothers were in prison because of drugs, they were released last December 2017.

His sibling also works as a construction worker. He is helping at home by cooking and

sometimes washing their clothes. He give some of the money that he earn to the parents but

some of this he use to buy alcohol and marijuana and shabu with the friends. Due to the less

income of his parents, they are obliged to work to help all the needed expenses in their home.

PERSONAL DEVELOPMENT HISTORY

Birth to Infancy: He claimed that he was tiny when he was born. He was breast feed by her

mother when he was a baby. He did not remember much about his infancy.

Early childhood: 5-6 During his preschool age he is naughty but he is active in the school and he

has a lot of friends. He has experience being thrown by a board eraser by his teacher because

he is not listening during the lesson.

Childhood: When he was in the grade one he is also active and a lot of friend he got also a

perfect score during the activity, but he is usually absent and running away from school

because of this he returned a lot of times in this level until he stopped going to school.

Adolescent: He starts to drink alcohol and using solvent when he is only 14 years old. When he

returns to study he is big enough for that level but he did not finish the grade two because he is

so ashamed to go to school, when he went to school he spend more time in the street with the

friend playing and drinking alcohol. Sometimes he is with the friend working as a car washer

and construction worker. He experience to have his first girlfriend when he is 14 years old. He

spent more time outside with his friends and his girlfriend rather than staying at home. He was
imprisoned because of snatching a phone from someone just to earn money and buy

marijuana.

PSYCOSOCIAL ASSESSMENT

(UPON FIRST MEETING ON : FRIDAY JANUARY 12, 2018)

I. GENERAL ASSESSMENT AND MENTAL BEHAVIO

The patient was wearing blue mental hospital uniform, has a fair posture, clean and

neatly, cooperative and good eye contact but sometimes he is distracted with the other

patient who are surrounding him during the shift of conversation. The patient has the

tattoo in the right tip of lips. He said that he get that tattoo when he was in the prison.

II. MOOD AND AFFECT

The patient is euthymic.

III. THOUGHT PROCESS AND CONTENT

FANTASY: manifested in the patient as he verbalized that he is wishing to see the family

especially the two brothers who were released from the jail because of drug addiction

last December. He said also that he missed the family.

IV. SENSORIUM AND INTELLECTUAL PROCESS

The patient was able to recall the past memories and history that he was admitted to

the hospital when he was 1 year old because of asthma as he was told by the parents.at
 the age of 14 he start to take the cigarette and marijuana, at the same time he start to

work as a construction worker. The patient was able to verbalize the day and date of the

day (Thursday, January 25, 2018).therefore the patient has reaction formation.

V. SENSORY –PERCEPTUAL ASSOCIATION

The patient has a good sensory and associated with the environment. He was not

distracted by any visual or auditory sensory.

VI. JUDGMENT AND INSIGHT

VII. SELF CONCEPT

VIII. ROLES AND RELATIONSHIP

He was an active boy in the house because he is always helping the sisters and the

mother as soon as he got home or early in the morning for washing the plates, clothes

and even in cleaning. While in the hospital he is assisting other patient in taking the

meds and even in giving them bath. He is closed and friend with all.

IX. PSYCHOLOGICAL AND SELF-CARE CONSIDERATION

The patient can perform the daily living activities compliant with medication, sleeping

well at night and eating properly. He has a good care of himself.

 PSYCHOSOCIAL HISTORY

The patient socializes easily even with a strangers especially with the people in the early

twenties like him. According to him, he made a lot of friends not only in his hometown but also

in the different places he worked. Unfortunately not all his friends were good to him. In fact,

they introduced him to alcohol and drug specially marijuana. So he lived most of the time in the

street with his friends. His education was so erratic and low that he was able to reach the grade

two at 17 years old and got ashamed because he set his mind that he was too old to be just a

grade two student, so he skipped classes to hang out with his friends and all they did was drink

and use marijuana.

ENVIRONMENTAL HISTORY

Patient and family lived in a rented house in a Rural area. The place in which he grew up is a

dangerous squatter area used to all kinds of addictions such as smoking, gambling, and petty

crimes. It is a very polluted area not only by the dirty air to breath but also by the noise

pollution which made difficult at night to sleep and rest. There are plenty of karaokes around,

television and radios at full volume, people speaking loudly all the time. He stated that the

neighbors starts to drink alcohol and gambling even if it is early in the morning. In the

afternoon when his neighbors is already drunk there are situations that they start to fight

among themselves. He made friends in his neighborhood, he became very close to them which

caused him to use drugs and have a hobby of drinking alcohol every day.
 MENTAL STATUS EXAMINATION AND SOCIAL PROFILE

A. GENERAL APPEARANCE

The patient’s facial expression is calm, well grooming, with an appropriate clothing and the

motor activity is normal and is very cooperative. He is talkative and has a loud volume of voice,

rate and the quality of speech is normal. The patient’s mood is euthymic with irritable affect.

The patient’s mood and affect is appropriate.

He denies hallucinations of any kind.

F. THOUGHT PROCESSES

He was once talk about the suicide by someone whom he do not know, the patient is having

the auditory hallucination

Oriented in time, place and person

III. RELATED LITERATURE

Undifferentiated schizophrenia is mental illness is a brain disorder that makes it difficult for a

person to deference between real and false perceptions and beliefs. Symptoms can be severe.

They are normal ups and down that everyone goes through from time or time. Undifferentiated

schizophrenia symptoms can result in poor job or school performance and even suicide.

Limiting that everyday activities can be difficult to complete.

Cause:

Scientists have not been able to pinpoint an “exact” cause. There may be a number of

contributing factors that play role in the development of this debilitating disorder. These

contributing factors include: genetics, environment, brain chemistry, and brain structure.

GENETICS

The genetic, or hereditary, predisposition theory suggest that the risk of inheriting

schizophrenia is 10% to 20% in those who have one immediate family member with the

disease, and approximately 40% if the disease affects both parents or an identical twin.

Researchers have recently identified three patient groups considered to be at “ultra-high risk”

for the development of schizophrenia. The risk factors for one group include a family history of

psychosis, schizotypal personality disorder, and the presence of functional decline for at least 1

month and not longer than 5 years. The conversion rate for this group is considered to be 40%

to 60 %. Approximately 60% of people with schizophrenia have no close relatives with the

illness.

The first true etiology subtype of schizophrenia, the consequence of a chromosome deletion

referred to as the deletion syndrome, has been identified. Person with this syndrome have a

distinct facial appearance, abnormalities of the palate, heart defects, and immunologic deficits.

The risk of developing schizophrenia in the presence of this syndrome appears to be

approximately 25%.
Scientists also may be close to identifying genetic locations of schizophrenia, believed to be on

human chromosome 13 and 8. One study found that mothers of clients with schizophrenia had

a high incidence of the gene type H6A-B44.

The fact is that if a person has one or more parents with schizophrenia, the likelihood of that

individual developing schizophrenia increases drastically. When looking at severe disorders like

schizophrenia, there is typically a strong genetic 60% of individuals that develop schizophrenia

have no close relative with the illness.

This risk is lower than I would’ve suspected. I find that 10% risk is pretty low for having a first

degree relative with the disease, my estimations would’ve been greater.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and

behaviour. It cannot be defined as a single illness, rather thought as a syndrome or disease

process with many different varieties and symptoms. It is usually diagnosed in late adolescence

or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset 15 to 25

years of age for men and 25 to 35 years of age women.

Schizophrenia has been linked to violence. Violence among persons with psychotic disorders

include failure to take medication, drug, or alcohol abused, delusional thoughts, command

hallucinations or a history of violence. Approximately 50% of schizophrenia clients have a

substance-abuse disorder.

HISTORY

Written description of schizophrenia have been traced back to Egypt during the year 200 BC. At

that time, mental and physical illnesses were regarded as symptoms of the heart and the uterus
and thought to originate from blood vessels, fecal matter, a poison, or demons. Ancient Greek

and roman literature indicated that the general population had an awareness of schizophrenia.

Greek physicians blamed delusions and paranoia on an imbalance of bodily humours.

Hippocrates believed that insanity was caused by a morbid state of the liver. By the 18 th

century, an understanding about the relationship between nerves and organs increased, and it

was finally decided that disorders of the central nervous system were the cause of insanity.

Although the term schizophrenia (from the greek roots schizo [split] and phrene [mind] is less

than 100 years old, it was first described as a specific mental illness in 1887 by a psychiatrist,

Emil Kraepelin. Eugene Bleuler, a Swiss psychiatrist, coined the term in 1911. He was also the

first individual to describe the positive and negative symptoms of schizophrenia. Both kraepelin

and bleuler subdivided schizophrenia into three categories based on prominent symptoms and

prognoses: disorganized, catatonic, and paranoid. And then five classification originally

described by DSM-III in 1980: disorganized, catatonic, paranoid, residual, and undifferentiated.

The 19th century saw an explosion of information about the body and mind. Evidence was

mounting that mental illness was caused by disease in the brain. As a result of research during

the last two decades, the evidence that schizophrenia is biologically based has accumulated

rapidly.

Brain Structure and functioning

A. The neurologic system consists of two main divisions, the central nervous system (CNS) and

the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of

both central and peripheral elements.

1. The CNS is composed of the brain and spinal cord.

2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal

nerves.

3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in

the brain and spinal cord. Its peripheral division is made up of visceral efferent and afferent

nerve fibres as well as autonomic and sensory ganglia.

B. The brain is covered by three membranes.

1. The Dura mater is a fibrous, connective tissue

structure containing several blood vessels.

2. The arachnoid membrane is a delicate serous

membrane.

3. The pia mater is a vascular membrane.

C. The spinal cord extends from the medulla

oblongata to the lower border of the first lumbar vertebrae. It contains millions of nerve fibres,

and it consists of 31 nerves – 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral.

D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia mater.

It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of

Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and

the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the

subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is

absorbed by the arachnoid membrane.

II. Function

A. CNS

1. Brain

 The cerebrum is the center for consciousness, thought, memory, sensory input, and

motor activity; it consists of two hemispheres (left and right) and four lobes, each with

specific functions.

 The frontal lobe controls voluntary muscle movements and contains motor areas,

including the area for speech; it also contains the centers for personality, behavioural,

autonomic and intellectual functions and those for emotional and cardiac responses.
 The temporal lobe is the center for taste, hearing and smell, and in the brain’s dominant

hemisphere, the center for interpreting spoken language.

 The parietal lobe coordinates and interprets sensory information from the opposite side

of the body.

 The occipital lobe interprets visual stimuli.

 The thalamus further organizes cerebral function by transmitting impulses to and from

the cerebrum. It also is responsible for primitive emotional responses, such as fear, and

for distinguishing between pleasant and unpleasant stimuli.

 Lying beneath the thalamus, the hypothalamus is an automatic center that regulates

blood pressure, temperature, libido, appetite, breathing, sleeping patterns, and

peripheral nerve discharges associated with certain behaviour and emotional

expression. It also helps control pituitary secretion

and stress reactions.

 The cerebellum or hindbrain, controls smooth

muscle movements, coordinates sensory impulses

 with muscle activity, and maintains muscle tone and equilibrium.

 The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays

nerve impulses between the brain and spinal cord.

2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It

is also the reflex center for motor activities that do not involve brain control.

B. The PNS connects the CNS to remote body regions and conducts signals to and from these

areas and the spinal cord.

C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function.

Supervised chiefly by the hypothalamus, the ANS contains two divisions.

1. The sympathetic nervous system serves as an emergency preparedness system, the “flight-

for-fight” response. Sympathetic impulses increase greatly when the body is under physical or

emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood

vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased

peristalsis, and increased perspiration. Sympathetic stimuli are mediated by norepinephrine.

2. The parasympathetic nervous system is the dominant controller for most visceral effectors

for most of the time. Parasympathetic impulses are mediated by acetylcholine.

III. Differences in nervous system response. The nervous system is one of the first systems to

form in utero, but one of the last systems to develop during childhood.

A. Accuracy and completeness of the neurologic assessment is limited by the child’s

development.

B. The child’s brain constantly undergoes organization in function and myelination. Therefore,

the full impact of insult may not be immediately apparent and may take years to manifest.

C. The peripheral nerves are not fully myelinated at birth. As myelination progresses, so does

the child’s fine motor control and coordination.

D. Early signs of increased intracranial pressure (ICP) may not be apparent in infants because

open sutures and fontanelle compensate to a limited extent.

E. The development of handedness before 1 year of age may signify a neurologic lesion.

F. Several primitive reflexes are present at birth, disappearing by 1 year of age. Absence,

persistence, or asymmetry of reflexes may indicate pathology.

G. The spinal cord ends at 13 in the neonate, instead of L1-L2 where it terminates in the adult.

This affects the site of lumbar puncture.

H. Children have 65 to 140 ml of CSF compared to 90 to 150 ml in the adult.

BIOCHEMICAL AND NEUROSTRUCTURAL

The biochemical and neurostructural includes the dopamine hypothesis, that is, that an

excessive amount of the neurotransmitter dopamine allows nerve impulse to bombard the

mesolimbic pathway, the part of the brain normally involved in arousal and motivation. Normal
cell communication is disrupted, resulting in the development of hallucinations and delusions,

symptoms of schizophrenia.

The cause of the release of high level of dopamine has not yet been found, but the

administration of neuroleptic medication supposedly blocks the excessive release. Other

neurotransmitters or chemicals in the brain, such as the amino acids glycine and glutamate, and

proteins called SNAP-25 and a-fodrin, are also being studied. For example, glutamate is

considered to be the most prevalent excitatory neurotransmitter in the brain. Dysfunction of

glutamate receptors, which are likely present on every cell in the brain, may be the cause of

many neurologic and psychiatric disorder.

Abnormalities of neuro-circuitry or signals from neurons are being researched as well.

Supposedly, a neuronal circuit filters information entering the brain and sends the relevant

information to other parts of the brain for determining action. A defective circuit can result in

the bombardment of unfiltered information, possibly causing both negative and positive

symptoms. Overwhelmed, the mind makes errors in perception and hallucinates, draws

incorrect conclusion, and becomes delusional. To compensate for this barrage, the mind

withdraws and negative symptoms develop. Cognitive deficits, impairments of attention and

executive function, and certain types of memory deficits may be the result of abnormal circuitry

in the prefrontal cortex.

ORGANIC OR PATHOPHYSIOLOGY

Those who suggest the organic or pathophysiologic offer hope that schizophrenia is functional

deficit occurring in the brain, caused by stressors such as viral infection, toxins, trauma, or
abnormal substances. They also propose that schizophrenia may be a metabolic disorder.

Extensive research needs to be done, because the case for this theory rests mainly on

circumstantial evidence.

ENVIRONMENTAL

Proponents of environmental state that the person who develops schizophrenia has a faulty

reaction to the environment, being unable to responds selectively to numerous social stimuli.

Theorists also believe that persons who come from low socioeconomic areas or single-parents

homes in deprived areas are not exposed to situations in which they can achieve or become

successful in life. Thus they are at risk for developing schizophrenia. Statistics are likely to

reflect the alienating effects of this disease rather than any causal relationship or risk factor

associated with poverty or lifestyle.

PSYCHOLOGICAL

Although genetic and neurologic factors are believed to play major roles in the development of

schizophrenia, researchers also have found that the prefrontal lobes of the brain are extremely

responsive to stress. Individuals with schizophrenia experience stress when family members

and acquaintances respond negatively to the individual’s emotional needs. These negative

responses by the family members can intensity the individual’s already vulnerable neurologic

state, possibly triggering and exacerbating existing symptoms.

Stressors that have been thought to contribute to the onset of schizophrenia include poor

mother-child relationships, deeply disturbed family interpersonal relationship, impaired sexual

identity and body image, rigid concept of reality, and repeated exposure to double-bind

situations. A double-bind situation is a no-win experience, one in which there is no correct

choice. For example: a parent tells a child who is wearing new white tennis shoes that he may

go out to play in the park when it stops raining but that he is not to get his shoes dirty. At the

same time, the parent’s body language and facial expression convey the message that the

parent prefers that the child stay indoors. He child does not know which message to follow.

What is at risk?

Schizophrenia is a disorder that shows its symptoms in the late teens to early 20s. Hear voices,

see things that aren’t there, believe others are after you, which makes you paranoid.

Schizophrenia is a very serious disorder.

DIAGNOSTIC

A diagnosis of undifferentiated schizophrenia is given when a patient has been exhibiting

symptoms of schizophrenia, yet the symptoms don’t meet the criteria for disorganized,

catatonic, or paranoid schizophrenia.

A diagnosis of undifferentiated schizophrenia must meet the criteria for general schizophrenia,

but cannot match any of the three established types of schizophrenia: paranoid schizophrenia,

disorganized schizophrenia or catatonic schizophrenia.

Furthermore, undifferentiated schizophrenia must include psychotic symptoms. If psychotic

symptoms are not present or they cause only minimal problems, a diagnosis of residual

schizophrenia or post-schizophrenic depression may be the preferred diagnosis.

Symptoms of undifferentiated schizophrenia

According to the DSM, individuals with undifferentiated schizophrenia must exhibit symptoms

for a month or more that meet “criterion A” for schizophrenia. Criterion A is comprised of the

following.

Two or more of the following symptoms are present:

Hallucinations (e.g. hearing or seeing things that aren’t actually there)

Delusions (false, firmly held beliefs (despite evidence to the contrary) that aren’t typically held

by others – e.g. believing that one has superhuman powers or is constantly being watched via

hidden cameras everywhere)

Disorganized speech (e.g. gibberish or constantly jumping from one topic to another)

Catatonic or extremely disorganized behaviour (e.g. being in a stupor, staying in a rigid position

for a long period of time, echolalia, or wearing several layers of clothes on a hot summer day)

Negative symptoms (e.g. little or no display of emotion, inability to do simple, day-to-day tasks,

very brief and empty responses to questions)

A gradual worsening of “negative” symptoms often occurs in cases of undifferentiated

schizophrenia. Negative symptoms result from the loss of mental function. “Positive” symptoms

such as hallucinations or delusions result from excessive mental functioning.

Negative symptoms associated with undifferentiated schizophrenia include:

 Deadened or dulled emotions

 Improvised or impaired speech

  Inability to feel pleasure

 Loss of interest in activities

 Social withdrawal.

PARANOID TYPE

Paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory,

hallucinations. They also may exhibit behavioural changes such anger, hostility, or violent

behaviour. Clinical symptoms may pose a threat to the safety of self or others. Preoccupation

with one or more delusions or frequent auditory hallucinations, none of the following is

prominent: disorganized speech, disorganized or catatonic behaviour, or flat or inappropriate

affect. Prognosis is more favourable for this subtype of schizophrenia than for the other

subtypes of schizophrenia. Clients in whom schizophrenia occurs in their late twenties and

thirties usually have established a social life that may help them through their illness. In

addition, ego resources of paranoid clients are greater than those of clients with catatonic and

disorganized schizophrenia.

CATATONIC TYPE

Psychomotor disturbances, such as stupor, rigidity, excitement, or posturing, are the

prominent feature of catatonic schizophrenia. Echolalia (repeats all words or phrases heard),

the pathological parrot-like repetition of a word or phrase, and echopraxia (mimics actions of

others), the repetitive imitation of movements of another person, are also features of catatonic

schizophrenia. Clients are at risk medically because of extreme withdrawal, which can result in
a vegetative condition or excessive motor activity that could produce exhaustion or self-

inflicted injury. At least two of the following are present: motor immobility (rigidity), waxy

flexibility, or stupor, peculiarities of voluntary movement as evidenced by posturing,

stereotyped movements, prominent mannerisms or prominent grimacing.

DISORGANIZED TYPE

Disorganized schizophrenia are considered the most severe of all subtypes. The client

experience a disintegration of personality and is withdrawn, speech may be incoherent.

Behavioural is uninhibited, along with a lack of attention to personal hygiene and grooming,

prognosis is poor. All of the following are prominent and criteria are not met for catatonic type:

disorganized speech, disorganized behaviour, flat or inappropriate. Because most clients who

are diagnosed with schizophrenia disorder, disorganized type, are of a young age, student

nurses reaction may vary from shock to disbelief.

UNDIFFERENTIATED TYPE

Undifferentiated schizophrenia usually is characterized by typical symptoms that do not

meet the criteria for the subtypes of paranoid, catatonic, or disorganized schizophrenia. The

client may exhibit both positive and negative symptoms. Odd behaviour, delusion,

hallucinations, and incoherence may occur, prognosis is favourable if the onset of symptoms is

acute or sudden.

RESIDUAL TYPE
 Residual schizophrenia is the subtype used to describe client experiencing negative

symptoms following at least one acute episode of schizophrenia. Clinical symptoms may persist

overtime, or the client may experience a complete remission. Absence of prominent delusions,

hallucinations, disorganized speech, and grossly disorganized or catatonic behaviour.

TREATMENT

The treatment of undifferentiated schizophrenia symptoms is similar to general

schizophrenia treatment and faces the same challenges. Treatment options include

antipsychotic medication, therapy and, in severe cases, hospitalization.

The wide range of symptoms coupled with the fact that persons with undifferentiated

schizophrenia are only rarely aware that they need treatment complicates treatments plans for

undifferentiated schizophrenia.

MEDICATION

Antipsychotic drugs help to control almost all the positive symptoms of the disorder.

They have minimal effects on disorganized behaviour and negative symptoms. Between 60-70%

of schizophrenics will respond to antipsychotics. In the acute phase of the illness, patients are

usually given medications by mouth or intramuscular injection. After the patient has been

stabilized, the antipsychotic drug may be given in a long-acting form called a depot dose. Depot

medications last for two to four weeks, they have the advantage of protecting the patient

against the consequences of forgetting or skipping daily doses. Most people with schizophrenia
are kept indefinitely on antipsychotic medications during the maintenance phase of their

disorder to minimize the possibility of relapse.

DOPAMINE RECEPTOR ANTAGONIST

The dopamine antagonist include the antipsychotic (also called neuroleptic) drugs, such

as haloperidol (Haldol), chlorpromazine (Thorazine), and fluphenazine (Prolixin). These drugs

have two major drawbacks: it is often difficult to find the best dosage level for the individual

patient, and a dosage level high enough to control psychotic symptoms frequently produces

extrapyramidal side effects, or EPS, EPSs include Parkinsonism, in which the patient cannot walk

normally and usually develops a tremor, dystonia, or painful muscle spasms of the head,

tongue, or neck, and or restlessness. A type of long-term EPS

Thesedrugs have two major drawbacks: it is often difficult to find the best dosage level for the i

ndividual patient, and adosage level high enough to control psychotic symptoms frequently pro

duces extrapyramidal side effects, or EPS.EPSs include parkinsonism, in which the patient canno

t walk normally and usually develops a tremor; dystonia, orpainful muscle spasms of the head, t

ongue, or neck; and akathisia, or restlessness. A type of long-term EPS is called tardive

dyskinesia, which features slow, rhythmic, automatic movements, schizophrenics with AIDs are

especially vulnerable to developing EPS.

SEROTONIN DOPAMINE ANTAGONISTS

Also called atypical antipsychotics, are newer medications that include clozapine

(Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa). The SDAs have a better effect on
the negative symptoms of schizophrenia than do the elder drugs and are less likely to produce

EPS than the older compounds. The newer drugs are significantly more expensive in the short

term, although the SDAs may reduce long-term costs by reducing the need for hospitalization.

They are also presently unavailable in injectable forms. The SDAs are commonly used to treat

patients who respond poorly to the DAs.

NEWS DRUGS

Some newer antipsychotic drugs have been approved by the food and drug

administration in the early 2000s. These drugs are sometimes called second-generation

antipsychotics or SGAs. Aripiprazole (Abilify), which is classified as a partial dopaminergic

agonist.

PSYCHOTHERAPHY

Most schizophrenia can benefit from psychotherapy once their acute symptoms have

been brought under control by antipsychotic medication. Psychoanalytic approaches are not

recommended. Behaviour therapy, however, is often helpful in assisting patients to acquire

skills for daily living and social interaction. It can be combined with occupational therapy to

prepare the patient for eventual employment.

PSYCHOSOCIAL THERAPY

Social skills training, family- oriented therapy, case management, and assertive

community treatment are forms of psychosocial therapies provided for clients with the
diagnosis of schizophrenia. Social skills training focuses on stabilization of behaviour,

improvement of social performance within family and with peers, improvement of social

perception with the family, and the enhancement of extra familial relationship. Family oriented

therapy is usually a brief but intensive course that focuses on identifying and avoiding

potentially troublesome situations. If a problem does emerge with the client, the aim of the

therapy is resolve the problem quickly.

PROGNOSIS

One important prognostic sign is the patient’s age at onset of psychotic symptoms,

patients with early onset of schizophrenia are more often male, and have a lower level of

function prior to onset, a higher rate brain abnormalities, more noticeable negative symptoms,

and worse outcomes. Patient with later onset are more likely to be female, with fewer brain

abnormalities and though impairment, and more hopeful prognoses.

The average course and outcomes for schizophrenics are less favourable than those for most

other mental disorders, although as many as 30% of patient diagnosed with schizophrenia

recover completely and the majority experience some improvement. Two factors that influence

outcomes are stressful life events and a hostile or emotionally intense family environment.

Schizophrenia with a high number of stressful changes in their lives, or who have frequent

contacts with critical or emotionally over-involved family members are more likely to relapse.

Overall, the most important component of long-term care of schizophrenia patients is

complying with their regimen of antipsychotic medication.

EVALUATION

The purpose of evaluation is to compare the client’s current mental status with status

with stated desirable outcomes identified. If the outcomes have not been met, consider the

reason why. For example, outcomes may not be achieved because of the client’s lack of belief

in success, or unrealistic expectations regarding recovery. Lack of social support or income, or a

cognitive deficit that limits the clients insight regarding his or her illness, may also be factors.

Depression may occur because of a decline in dopamine level as the client ages. Additional

specific nursing intervention and changes in outcomes may be necessary.

PSYCHOPATHOLOGY

Schizophrenia is characterized by a broad range of behaviors marked by a loss of the

person’s sense of self, significant impairment in reality testing, and disturbances in feelings,thinking and
behavior. The individual is unable to distinguish the accuracy of their own perceptions and thoughts from external
reality

Stressors might contribute to the vulnerability-stressmodel of causation. Stressors as risk

factors, in the perinatal period include many circumstances that can be categorized as maternal
stressors: maternal prenatal poverty, poor nutrition, depression, exposure to influenza
outbreaks, war zone exposure, and Rh-factor incompatibility. Infants affected by these maternal
stressors may demonstrate conditions that create their own risk: low birth weight, short
gestation, and early developmental difficulties. In childhood, stressors may include central
nervous system infections caused by crowded living conditions and influenza. In general,
poverty and minority social status affect the life-time course of schizophrenia. Most people who
develop schizophrenia are diagnosed in late adolescence and early adulthood. Men diagnosed
earlier than women due to estrogen which play a protective role against the development of
schizophrenia that disappears as estrogen levels drop during menopause

There are several factors that cause schizophrenia when it comes to biologic theories .a First is the genetic factors
which states that when there is family history of schizophrenia there are 50% risk of schizophrenia in identical
twins, 15% risk in fraternal twins and if one biologic parents have history of the disorder there is a 15% risk and if
both parents has the history there is 35% risk. Second is the neuro anatomic and neuro chemical factors, findings
have demonstrated that people with schizophrenia have relatively less brain tissue and cerebro spinal fluid than
those who do not have schizophrenia, enlarged ventricles in brain and cortical atrophy can be seen through CT
scan. Glucose metabolism and oxygen are diminished in the frontal cortical structure of the brain seen through
PET scan and there is a decreased brain volume and abnormal function in the frontal and temporal alterations in
the neurotransmitter system in the brain. There is also excess dopamine and serotonin which contributes to the
development of the disorder. Third is the immuno virologic factor wherein alteration in brain physiology was
caused by exposure to a virus or the body’s immune response to a virus

In diagnosing schizophrenia, self-reported experiences by the person and abnormalities in

behavior reported by the family and friends are considered. In assessing patient; history,thought
process and content, general appearance, motor behavior, speech, mood and affect, sensorium
and intellectual process, judgment and insight, self-concept, roles and relationships,physiologic
and self-care considerations are important in the diagnosis of the disorder

There are two major categories of symptoms of schizophrenia: positive or hard symptoms and
negative or soft symptoms. The positive symptoms consists of ambivalence , associative
looseness, delusions, echopraxia, flight of ideas, hallucination, ideas of reference,perseveration.
The negative symptoms are not present in schizophrenia but are normally found in healthy
person, it includes alogia , anhedonia, apathy, blunted affect, catatonia, flat affect, and poor eye
contact

The patient was diagnosed with undifferentiated type schizophrenia. Patient with this type of
schizophrenia exhibit the major features of the disorder but have not met the full assessment
distinctions for paranoid, disorganized, or catatonic type.
Some individuals do not quite “fit” in to the previously reviewed subtypes. In other words, the person
has met all the basic criteria for schizophrenia, but has not met specific criteria for paranoid,disorganized, and
catatonic types of schizophrenia
 DISCHARGE PLAN

Medication
Advised to take his medication daily as prescribed by the doctor
 Haloperidol 5-10mg/tab twice a day
 Biperiden HCl 2mg/tab OD for 7 days
 Fluphenazine deconoate 25mg/cc 1cc ml every month with BP precaution

Explained to the client about the action and side effect of each drug that he takes

Exercise
Encouraged the patient to exercise regularly.
 Aerobic exercises, including jogging, walking, and gardening
 Help with house chores

Treatment
 Advised by the psychiatrist to visit NCMH – OPD 1 week after discharge
 Advised to undergo psychotherapy if needed

Hygiene
Pointed out the importance of hygiene
 Take a bath everyday
 Change clothes as needed
 Do oral care 3 times a day
 Wash hands as needed
 Advised to avoid straining during defecation, minimized coughing and cover mouth
 Encouraged patient to verbalize feelings to family and friends and let them constantly
orient patient to reality

Out-patient follow up
 Return to NCMH if progressive body weakness occurs, psychosis persist for more than a
week and bring to Psych-OPD if patient becomes weak and hostile
 Informed the patient about the importance of follow up check up and comply with the
schedule of his treatments and check up.

Diet
 Drink at least 8 glasses of water a day (about 2 liters) to prevent dehydration.
  A diet that relies on fruits, vegetables, nuts, whole grains, fish and unsaturated fats (like
olive oil).
 Should avoid sugary drinks and excessive amounts of caffeine; High-fat dairy, and fried,
refined and sugary foods, which have little nutritional value.

Spirituality
 Advised to go to church and attend mass every Sundays
 Encouraged the patient to have strong faith in God and do not lose hope regarding his
situation and always pray and thank Him for all the blessings he receives from Him.