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Treatment of Resistant Schizophrenia

Question:

Discuss about the Treatment of Resistant Schizophrenia.

Answer:

Introduction:

The Chosen patient is Terry Oldie. He is 31 years old. He has been diagnosed with Schizophrenia, drug & alcohol abuse and acquired brain injury. There is no objective diagnostic test of Schizophrenia as of 2013 (American Psychiatric Association 2013). Diagnosis is entirely clinical and is based on symptoms of patient and his experiences which he tells to clinician. The diagnosis is also based on the behaviour of patient as described by friends and family members of patient (ibid). The diagnosis of Schizophrenia is often confused with, ‘Split Personality Disorder’ or ‘Multiple Personality Disorder’ (Picchioni and Murray 2007). But the two diseases are different, although they can co-morbid the same person (ibid). Drug and alcohol abuse is commonly present in patients of Schizophrenia (Gregg, Barrowclough & Haddock 2007). About 50 percent of patients with Schizophrenia indulge in drug & alcohol abuse (ibid). The patient has also acquired brain injury which is also associated with post-traumatic Psychosis (Fujii & Fujii 2012). Thus condition of patient is severe with the diagnosis of Scizophrenia, drug & alcohol abuse, and head injury. The patient is currently suffering from acute Psychosis and is under continuous medical observation.
 
The symptoms of Schizophrenia are often described in terms of positive and negative symptoms (Kneisl & Trigoboff 2009). Positive symptoms are those symptoms which are not present in healthy individuals but are present in Schizophrenia patients. It includes auditory hallucinations, delusions, disorganised thoughts & speech, abnormal social behaviour, and other manifestations of Psychosis (ibid). Negative symptoms are those which are deficits in patient with Schizophrenia as compared to normal healthy person. These include poor social skills, inability to form good relationships, difficulties in adjustment, inability to be happy and experience pleasure, poor speech, and lack of motivation in life (ibid). This particular patient is also showing similar symptoms. He is isolating himself in room, thus showing social withdrawal. He also has minimal engagement with staff. He is having auditory hallucinations which are telling him to kill people, and thus he is concealing bread and butter knives in his pockets. The person is also agitated and thus requesting Valium for relief. Thus patient is having most of the positive as well as negative symptoms of Schizophrenia. The symptoms may precede or pro-cede the diagnosed head injury in the patient. It means the condition of patient caused by Schizophrenia may have led to a behaviour causing head injury or the Schizophrenia like symptoms may have appeared after head injury. Whatever be the sequence, the symptoms have become worse due to head injury as well as due to substance abuse.
 
The legal status of the patient is CTO i.e. Community Treatment Orders. In such cases patient has to report to hospital for treatment irrespective of his consent for treatment (Ingram, Muirhead, & Harvey 2009). The consent of patient in such cases is not considered necessary as if untreated; the person may possess threat to himself or to others (ibid). The decision to admit the patient in hospital lies with the Mental Health Practitioner. The patient is then detained for a maximum of 72 hours, after which he may be released with the legal status of CTO itself, or the CTO may be revoked (ibid). In this particular patient CTO is very important as the patient already has auditory hallucinations to kill people. If discharged untreated, the patient may be a threat to society and it might have critically lethal consequences (Ingram, Muirhead, & Harvey 2009).
 
The patient has been prescribed Amisulpride 200mg BD. Amisulpride is used as a first line treatment in patients with acute Psychosis (Nuss, Hummer, Tessier 2007). Also it is a suitable treatment option in Schizophrenia patients with resistance to Clozapine (Solanki, Sing, & Munshi 2009). The very common side effects of Amisulpride include Extrapyramidal effects such as tremors (Rossi 2013). The other common side effects are nausea, vomiting, headache, anxiety, insomnia, hypersalivation and hyperactivity (ibid). Weight gain is also common (ibid).
 
Physical Well-being and future concerns are very important in this patient. The disease he is suffering from, is greatly associated with several risk factors such as sedentary lifestyle, obesity, smoking and poor diet (Laursen, Munk-Olsen, & Vestergaard 2012). Schizophrenia is also associated with increased rate of Suicides (Erlangsen et al. 2012). Antipsychotics are also associated with several risk factors such as obesity and thus make the prognosis of patient compromised. The chances of relapse are also high and thus require maintenance treatment even after clinical recovery (Smith, Weston, & Lieberman 2010). Thus the patient may have to continue the treatment for several years and the patient may develop other co-morbidities including cardiovascular diseases, diabetes and other chronic conditions precipitated by the medications taken by him (ibid). If he will not take the medications, the chances of relapse are high and the psychotic attack may precipitate which might be critically dangerous for the patient as well as others coming in his contact. Thus a maintenance treatment is always considered better irrespective of its side effects (ibid). Irrespective of high disability associated with Schizophrenia, most people recover completely and function well in society (Warner 2009).
 
There are two major risks. One is the well-being of patient himself. There may be chances of any suicidal attempts by the patient. The patient needs medical supervision till complete clinical recovery. Second major risk is the patient may possess threat to others including health staff as he is hiding weapons and getting aggressive. Thus legal status of patient also mandates Community Treatment Orders. The patient should be 24X7 under medical observation. There is a risk to the psychological well-being of patient after recovery. There is a need to keep the diagnosis of the patient confidential. The patient may face social stigma after getting clinically recovered and going back to his home and social circle. The patient may also face self-stigma as internalisation of stigma is very common in mental illness. The patient may not be able to lead a normal social life.
 
Schizophrenia is one of the most stigmatised human disorders (Mestdagh & Hansen 2014). There is generally negative emotional response among masses as a reaction to the word ‘Schizophrenia’ and the word is considered equivalent to being ‘mad’ or ‘insane’ (ibid). There is an additional stigma to this disease by associating ‘Violence’ with the disease (Jorm & Reavley 2014). People consider patients with Schizophrenia as being dangerous as they can become violent anytime (ibid). When people with Schizophrenia commit violent crimes, such a stigma gets reinforced (ibid). When treated properly, violence among Schizophrenics can be minimised or removed. Also the patients with Schizophrenia are considered incompetent and thus increase unemployment among them (Mestdagh & Hansen 2014). The patients are even stigmatised in a doctor-patient relationship. Whether a Schizophrenic patient complains pain in stomach or pain in back; the health personnel always consider it a pain in nerves. The other medical ailments of patients are generally overlooked by health personnels (ibid). The family and friends tend to avoid patients diagnosed with Schizophrenia. The patients are considered incapable of taking decisions. Thus patients diagnosed with Schizophrenia lost autonomy of their life, their self-respect, employability and self-esteem, which has a major impact on recovery from a serious mental illness as is Schizophrenia (Brennaman, & Lobo, 2011). The recovery is more than just absence of clinical symptoms of Schizophrenia (ibid). The disease shatters the life of patient completely socially and psychologically which needs to be recovered.
 
Social Welfare of patients with Schizophrenia is also compromised partly due to its symptoms, partly due to social stigma associated with it and partly due to unemployment caused by it (Rymaszewska, & Mazurek 2012). There is a tendency of social withdrawal among patients with Schizophrenia. The social world also desert them due to social stigma associated with the disease. The unemployability is also high among patients with Schizophrenia. The recovery in patients with Schizophrenia is generally limited to clinical recovery (Hopper 2007). The Social recovery of patients remains unaddressed. The recovery should be oriented towards social welfare, employability and complete well-being. In this particular patient, the main issue is social rehabilitation of patient even after clinical recovery. The patient may get rid of his psychosis due to medications but it will be required to put him on supportive therapy. There is a long journey ahead. Patient need to learn life-skills and employability skills. He needs to be employed and self-dependent to regain his self-confidence and self-esteem.
 
The role of a nurse is far beyond the biomedical model of nursing. It is more than just following physicians’ or supervisors’ clinical instructions. A nurse should have skills of clinical reasoning more than just clinical judgement (Levett-Jones 2013). Paradoxically the definition of recovery worldwide is limited to clinical recovery and job of a nurse ends with the ending of hallucinations (Barker, & Buchanan-Barker 2011). But ideally the nursing care should begin with the ending of hallucinations. The nursing care should aim towards complete physical, mental, social and spiritual well-being of patients (Swarbrick, 2012). It should enable the patient to stand on his own two feet with self-dignity and self-respect. The patient should be rehabilitated socially and economically in the society. In this journey, it is very important to take into account patients’ perspectives, his ideas and his choices (Drieta, Agrest, & Druetta, 2011). The patients’ perceptions about his life and about the world surrounding him become very important in shaping his recovery (ibid). The nurse should work with the patient in defining his recovery goals. The patient should be able to do his routine tasks first. When the routine tasks are easily managed by the patient, next level of recovery goals should be defined by the nurse in consultation with the patient. The patient should learn some recreational activity also. Recreation is very important even for a healthy person. It is critically important for patient with Schizophrenia. It is also important for self-expression. The patient may join music, dance, painting, art n craft, according to his interests. Next the nurse should work on defining some goals regarding learning life-skills, for example, routine management of finances, routine management of family tasks, some educational programmes, some diplomas, some certificate programmes. The patient may then learn some job-skills. Finally the task of a nurse will be accomplished, when the patient will be employed, self-reliant and self-sustained. Thus path to social recovery is a long journey for patient in which he needs nursing assistance and care.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

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Fujii, D., & Fujii, D. C. (2012). Psychotic disorder due to traumatic brain injury: analysis of case studies in the literature. The Journal of neuropsychiatry and clinical neurosciences, 24(3), 278-289.

Kneisl C. and Trigoboff E. (2009). Contemporary Psychiatric- Mental Health Nursing. 2nd edition. London: Pearson Prentice Ltd. p. 371.

Ingram, G., Muirhead, D., & Harvey, C. (2009). Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: changes in problem behaviours and social functioning. Australian and New Zealand Journal of Psychiatry, 43(11), 1077-1083.

Nuss, P.; Hummer, M.; Tessier, C. (2007). "The use of amisulpride in the treatment of acute psychosis". Therapeutics and Clinical Risk Management, 3 (1), 3–11. doi:10.2147/tcrm.2007.3.1.3.

Solanki, RK; Sing, P; Munshi, D. (2009). "Current perspectives in the treatment of resistant schizophrenia". Indian Journal of Psychiatry, 51(4), 254–60. doi:10.4103/0019-5545.58289.

Rossi, S, ed. (2013). Australian Medicines Handbook (2013 ed.). Adelaide: The Australian Medicines Handbook Unit Trust. ISBN 978-0-9805790-9-3.

Laursen TM, Munk-Olsen T, Vestergaard M. (2012). Life expectancy and cardiovascular mortality in persons with schizophrenia. Current opinion in psychiatry. 25 (2): 83–8. doi:10.1097/YCO.0b013e32835035ca.

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Mestdagh, A., & Hansen, B. (2014). Stigma in patients with schizophrenia receiving community mental health care: a review of qualitative studies. Social psychiatry and psychiatric epidemiology, 49(1), 79-87.

Jorm, A. F., & Reavley, N. J. (2014). Public belief that mentally ill people are violent: Is the USA exporting stigma to the rest of the world?. Australian & New Zealand Journal of Psychiatry, 48(3), 213-215.

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