Schizophrenia: A Case Analysis
This essay will be discussing case scenario two. Omar is a 19-year-old university student who presents with problems of paranoia, suspicion of others, and stress. His behaviour leading up to his referral to counselling indicated a lack of appropriate sensible judgement or potential altered state of reality. During his counselling sessions, Omar noted a serious concern for his safety. His monotone voice and limited emotional expression further highlighted his disconnect from self.
Schizophrenia is diagnosed when a person presents with abnormalities of a psychotic nature. It affects about 1 in every 100 people (or 1.5%) in Australia (ReachOut, 2022; Garvan Institute of Medical Research, 2021) and is most likely genetic, though also can appear as a result of trauma, stress, or significant drug use. Two thirds of people diagnosed with schizophrenia will experience their first episode before the age of 25. Symptoms of schizophrenia include: delusions of fixed beliefs classified based on a variety of themes and plausibility, hallucinations of experiences which have no external stimulus but reported as clear and as vivid as normal perceptions not under voluntary control, disorganised thinking (speech) exhibited through communication effectiveness, grossly disorganised/abnormal motor behaviour characterised as situationally abnormal behaviour and this includes catatonia, that is, decreased reactivity to the environment. The final feature is negative symptoms which is also characterised in other psychotic disorders but diminished emotional expression (restricted emotional emphasis during communication) and avolition (decrease in motivation for personal activities) are particularly prominent in schizophrenia. It is important to note a person’s history of trauma when diagnosing for delusions as those who have experienced violence, torture or discrimination have intense fears of recurrence and may be misjudged as persecutory delusions (American Psychiatric Association, 2013).
Research shows an increased risk of schizophrenia based on environmental, genetic, physiological, culture-related and sex- and gender-related issues. Though most individuals diagnosed with schizophrenia have no family history of psychosis, complications during pregnancy and birth, prenatal and perinatal adversities and other medical conditions have been linked with schizophrenia (Brown, 2011). Socially oppressed groups, social deprivation, adversity, and socio-economic factors all contribute to the development of schizophrenia, especially in cases where ethnic and racialized groups live in areas with a small proportion of people from the same ethnicity or racialized group. This is due to higher levels of discrimination or fear of discrimination, less social support, more stigmatisation, and higher social isolation (Bourque et al. 2011; O’Donoghue et al. 2016; Pearce et al. 2019; Veling et al. 2015; Velthorst et al. 2012).
Omar is presenting with an augmented reality and is lacking sound judgement of his personal safety and the safety/reliability of others. By definition, the attributes of a person presenting with schizophrenia are met to some degree in Omar’s case. His personally stated truth suggests delusions both as persecutory delusions and nihilistic delusions as he believes he is under surveillance by the secret services and secondarily to this, he fears he will be murdered by secret agents as that is what he believes to have happened to his uncle. It may be inferred that his communicating with doves were hallucinations if he reports to actually hear them speaking rather than only ‘understanding’ them. Further inquiry would be required to certify this. This is the same for his paranoid behaviour where he is seemingly searching for something in the room. Omar also shows both diminished emotional expression and avolition, his voice remained monotone throughout the session and lacked emotional responsiveness. He was successful in completing his first year of university though since forming the belief that he is being tracked and monitored by secret agents, his grades of decreased and he has withdrawn from his studies. He has also disconnected from his peers due to this paranoia. There is also an increased risk of suicidal thoughts and behaviour and a significant social and occupational dysfunction.
5-P model Case Conceptualisation:
Presenting problems are factors which have brought the client to counselling. Omar believes the only safe places left are ledges. He reports a mistrust and suspicion of other people (that they are giving information about him to the secret services). He also distrusts technology and has delusions that he is under surveillance and secret agents are following him. Omar has recently moved out alone which has exacerbated his paranoia, he slowly reduced his social contacts to none, and his grades are now declining. He also described the uncle’s cause of death to be related to these secret service agents and his own conclusions are that he may “suffer the same fate” if he does not maintain his current behaviour.
The predisposing factors are the vulnerabilities relating to the case, meaning, the factors that have predisposed the client to have the presenting issue which often arise during childhood or early life. Schizophrenia can be hereditary (Tarrier & Berry 2020) and can appear after a person experiences difficult interferences in their life such as education or career stress, medication, illness, socio-economic downfall, and low familial/social support, but can also come on slowly with no external influence, mainly due to personality type, personal defence mechanism, coping strategies, level of self-esteem and cognition (APS, 2018) In Omar’s case, it seems his paranoia precedes his social and educational withdrawal though is likely grounded in the information he believes about his uncle.
The precipitating factors are the external or environmental factors which have contributed to the client’s problem. These are events or circumstances that are happening currently which impact the situation. Omar’s circumstances suggest he is having difficulty living in his own place and coping with the stressors of life at university. If his uncle has died, it is likely he is suffering with some grief. Though he identified having some friends at university, he has ceased contact with them because of his paranoia and subsequently has few supports. He denies any use of illicit substances which, if true, eliminates the possibility that this has been caused but such influence.
Perpetuating factors are behaviours or events that are currently occurring which are unhelpful to the situation and maintain the situation as an issue. Unfortunately, Omar’s delusions of being surveyed seem to have severely impacted his quality of life as he has put less importance into his grades and university experience (including his social circle) and spent more time involved in removing his online presence. His uncle’s death has clearly impacted him and has been used as evidence to support his delusions.
In each case, the protective factors are key to moving away from the presiding issue. These are factors that may help to mitigate the problem and aid in the person’s recovery. Prior to his onset schizophrenic symptoms, Omar was a part of a friendship circle at his university. The ability to enrol in classes and reengage with friends provide some structure to his life, which has become somewhat chaotic. His awareness of his uncle’s death and belief in his cause of death has deterred him from engaging in further harmful behaviour. He also denies any desire to end his life.
Diagnostic Tools and Intervention Plan
Diagnostic tools are used to identify whether a person presenting with symptoms of a particular mental health condition fits the criteria for diagnosis. It is also used to monitor the severity of symptoms and to track treatment for the supposed condition. Some newer scales for the diagnosis of schizophrenia include Clinical Assessment Interview for Negative Symptoms (CAINS) and the Brief Negative Symptom Scale (BNNS). However, the older scales such as the Positive and Negative Symptom Scale (PANSS), Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), Negative Symptom Assessment-16 (NSA-16) and the Clinical Global Impression Schizophrenia (CGI-SCH) carry a stronger foundation of supporting articles, though lack the reliability of new research in this area (Kumari et al., 2017).
Diagnosis is important to guide treatment options and predictions of outcomes (Macneil et al, 2012). It also assists with categorisation of individuals by disorder so to quantify outcomes and develop intervention strategies and aetiology. Though diagnosis is helpful in these areas, it also presents with ethical and professional challenges as it does not provide individualised experiences with disorders, or specific types of intervention. Some disorders, such as mood and personality disorders, carry such a broad range of contributing factors that it is unlikely to be encompassed in a categorical definition. Clinicians can, however, incorporate both diagnostic tools and personal experience into treatment plans.
Psychoeducation such as Supportive Psychodynamic Therapy (SPP), Metacognitive Therapy (MCT), and Acceptance and Commitment Therapy (ACT) have shown positive outcomes in areas such as functioning and mood, and a reduction in relapse, distressing symptoms, hospital stay duration and readmission for individuals experiencing schizophrenia or schizoaffective disorder (Andreou et al., 2017; Harder et al., 2014; Xia et al., 2013; Johns et al., 2016; Shawyer et al., 2017).
Initially, it would be beneficial for Omar to complete a series of diagnostic tools to gain further insight into his presenting issue. Given he is experiencing some personal hardships, it is recommended that he complete the Depression, Anxiety, and Stress Scale (DASS-21). This screening tool will identify symptoms of depression, anxiety, and stress and will assist with any further intervention (Black Dog Institute, n.d.). Proceeding this, more specific diagnostic tools such as the PANSS is recommended given Omar’s presenting symptoms. After these initial assessments, it is likely Omar’s intervention plan would involve a 60-minute session once a week over 12-weeks focusing on CBT and psychoeducation. This would also involve providing homework to reduce delusional symptoms, promote overall wellbeing, and to improve social functioning. CBT and psychoeducation have shown positive results for people diagnosed with schizophrenia as well as depression (Linde et al., 2015; Shawyer et al., 2017). Family Intervention (FI) is also recommended in level one intervention for psychotic disorders (APS, 2018; Miklowitz et al., 2014) but in this presenting case, it is not yet understood whether Omar has familial support for this to occur and is therefore unable to be recommended as a viable treatment option.
Meta-analyses indicate the efficacy of CBT in treatment for symptoms of schizophrenia and related psychosis (Xia, Merinder & Belgamwar, 2013; Tarrier & Berry, 2020). Though in some cases symptoms such as hallucination and delusions persist, CBT has still been effective at positive and general symptom management. The primary objective is to develop a strong therapeutic relationship with individualised goals. A formulised case management plan which identifies the symptoms of a psychotic experience for the patient and establishes associations with cognitive, behavioural and affects within the environmental context in response to the person’s experience. Treatment focuses on increasing autonomy and self-reliance by teaching the patient to identify their symptoms and learn methods and coping strategies to challenge hallucinatory and negative symptoms (Tarrier & Berry, 2020). It is important to continue to accept and justify the patient’s lived experience, but also challenge their paranoid thought patterns and teach them to challenge their own negative thought patterns. Through evaluation of whether a person’s fears are justified based on the nature of the trauma, the counsellor will have a clearer distinction between fears and delusions (American Psychiatric Association, 2013)
It is also necessary to present the ethical and professional challenges presenting in this case. Schizophrenia is a highly individualistic mental health disorder and requires intervention with the assistance of a highly skilled, experienced, and knowledgeable clinician (Tarrier & Berry, 2020). A strong alliance between practitioner and client is likely to yield positive results when organised steps are followed. There will continually be external stimuli which influences case management direction so adhering to the agreed upon coping mechanisms is integral. Suicide, suicidal ideation, and suicide attempts in people with schizophrenia are common due to the nature of the disorder (hallucinations, delusions, and depressive symptoms) and concern for the client’s safety is a priority throughout treatment (Hor & Taylor 2010). This would involve developing a safety plan in the case that this scenario may occur which may include the use of the Screening Tool for Assessing Risk of Suicide (STAR) which addresses risk factors, warning signs, and protective factors relating to suicide (Hawgood & De Leo, 2017).
In summary, it would be beneficial to explore the cause of Omar’s uncle’s death as well as the time of death to understand whether this event precedes the onset of Omar’s paranoia. It would also be necessary to gain a deeper understanding of Omar’s living conditions, income, and familial support and whether he is lacking in any of these areas. Though Omar was doing well and successfully completed his first year at university, moving into his own place may have added a significant amount of stress to his life, causing his cognitive decline. Omar stopped seeing his friends around the same time he moved into his own house and believes this to be the same time he felt the surveillance increased. Further exploration with Omar about his experience living alone may provide more insight into his behaviour. Omar’s age suggests a hereditary onset of schizophrenia (Velthorst et al., 2012) however, if through a more comprehensive interview it is discovered Omar has been using illicit drugs, this may need to be reconsidered. From the brief overview of behaviours and symptoms presented in Omar’s case, this is likely to be his diagnosis. It is, however, necessary to explore the above factors before providing a diagnosis to Omar.
For an intervention strategy, psychoeducation and CBT are strongly recommended for psychotic disorders and subsequently, for Omar (Harder et al., 2014; Xia et al., 2013). As indicated above, it is recommended he commit to one-on-one counselling where he attends a 60-minute session once a week for 12-weeks focusing on CBT and psychoeducation (Johns et al., 2016; Shawyer et al., 2017; Kumari et al., 2017; Tarrier & Berry, 2020).
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