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September 10, 2012

Nina: A Case Study of Schizophrenia

Nina: A Case Study of Schizophrenia

The following is a case study of a client being treated for schizophrenia by an Assertive Community Treatment team in Michigan. This client will be given the pseudonym, Nina, for purposes of privacy and confidentiality.

Schizophrenia

According to the DSM IV-TR (2000), schizophrenia is a psychotic disorder characterized by at least two of the following five symptoms: hallucinations, delusions, disorganized speech, disorganized behavior, and negative symptoms (anhedonia, avolition, alogia, and flat affect). Symptoms also must impair social or occupational functioning, last longer than six months, must not be due to substance use or a general medical condition, and there must not have been any mood episodes (manic, depressive, or mixed). Schizophrenia is prevalent in roughly 1% of the population and can be one of the most costly disorders due to need of repeated hospitalizations because of suicidal or homicidal behavior. Schizophrenia is also one of the most deteriorative disorders, and once there has been one episode, clients most often do not return to baseline and decompensate more and more as the disorder progresses.

Nina, who is a 45 year old African American female, exhibits many of DSM IV-TR criteria for Schizophrenia. Nina experiences tactile hallucinations, as she believes that snakes are in her stomach and she can feel them crawl up her throat, and “they eat the medicine”. The feeling of snakes inside her is greatly distressing to her and causes her to vomit most evenings. Nina also has persistent delusions that she has “spirit babies” that live both inside of her and in Highland Park. Nina often desires to return to Highland Park to find her “spirit babies” and “the spirit man who [she] fornicated with”. Nina reports having up to 20 children but says she does not know their names. She reports that some of them “be crackin” and try to convince her to consume drugs for them to eat. Nina currently takes Vicodin and Klonopin for arthritis in her knees, but says she rarely feels relief because the spirits will steal these substances.

Nina also has delusional beliefs that she has psychic abilities and knows when a crime is about to take place. Nina reports that she often calls the police to warn them of future crimes. However, she says they do not listen to her, and when she watches the news and sees that the crime occurred, she feels guilty. When speaking with Nina about her psychosis, she is often tangential and loosely associated with time. For example, Nina will begin talking about her appointment with the psychiatrist last week, and a sentence later say that she was talking to him about being pushed into the street by the spirits. When asked when the event occurred, she reported that it occurred in 2004, but the meeting with the psychiatrist occurred in 2012. Nina will also perseverate on certain topics such as “fornicating with the spirit man”, having an alien baby at age 5, and how “Jesus breathed life back into [her] when [she] died of lung cancer”. Nina does not however, display disorganized behavior and she always appears with good hygiene and groom. She also does not currently appear to have any negative symptoms. Nina presents with a good mood and appropriate affect.

Multi-Axial Assessment for Nina

I. Schizophrenia
II. deferred
III. Arthritis in both knees; Type II Diabetes
IV. Unable to work; Problems with Social Network
V. 45

Treatment

Nina is currently an Assertive Community Treatment (ACT) client, and this treatment modality is the best fit for Nina and for clients like Nina who have experienced multiple hospitalizations for psychosis. Assertive Community Treatment is an evidence-based practice which provides a much different and progressive type of service than an inpatient facility; it offers community-based, at home care for clients with severe and persistent mental illness (ACTA 2012). Through ACT, a multidisciplinary team of social workers, a nurse, psychiatrist, peer-support, and mental health practitioner provide mental health care to clients both in the office and in the community. In the morning, ACT teams travel to the homes of 7-12 clients each day to provide at home care. During this visit, social worker observes clients take AM medications and observes the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance; the whole visit lasts approximately 10-15 minutes. In the afternoon, staff involves clients in different support groups such as co-occurring groups, shopping, art, nutrition, and walking groups. Staff also use afternoons to see clients in the office and assist clients with miscellaneous appointments and needs.

Programs like ACT are beneficial to clients who have many needs, who have difficulty with medication adherence, or who have chronic symptoms and who wish to continue to live independently (ACTA 2012). A program like ACT can benefit Nina because she has chronic symptoms; every day she feels the snakes inside of her stomach or talks about the spirits weighing her down. While Nina does report that she has a mental illness called schizophrenia, her definition of her illness is far different than most. Nina believes she was cursed and that is her illness. She does not think that she hallucinates or has delusions but that the spirits are real. Nina’s little insight into her illness would make it difficult for her to live independently without ongoing mental status assessments and medication management. Nina has stated that she would probably take more medication if she did not have ACT because “the spirits eat the pills” so she would take more to compensate. Nina states that she appreciates ACT “observing” her and assessing her mental health.

Research also supports the benefits of ACT programs in regard to decreased rates of hospitalization, higher rates of medication adherence, and improved quality of life. Zygmunt et al. reviewed literature about the necessity of medication adherence for clients with schizophrenia, stating that 50% of those diagnosed with schizophrenia will stop taking medications within a year after first discharge (2002). Once clients have stopped taking medications, they will experience increased risk of relapse (3.7% greater than compliant clients), and symptoms can negatively impact quality of life. Researchers then studied psychosocial techniques and therapies for improving medication compliance. Zygmunt el al. did find that programs such as ACT were more effective, as was motivational interviewing, because each focused on behavioral training. Findings suggest that clients will be more compliant when given concrete instructions and problem-solving strategies. Behavioral training was effective because clients were provided direct feedback for compliance.

Other alternative behavioral treatments include Cognitive Behavioral Therapy. First and foremost researchers maintain that medication compliance is critical for ACT clients, but that CBT and training can improve client’s functioning and reduce symptoms because it provides skills training and helps clients improve coping skills for dealing with their mental illness. Pinninti et al. (2010) believes that “the improvement in functioning included interventions, such as helping clients make appropriate life decisions, improving social and leisure skills, and dealing with barriers to employment”. However, behavioral training can be difficult for clients who have little insight into their illness. For Nina, attempting CBT on its own is quite a challenge, and one that I have actually attempted. When I first started doing wellness visits at Nina’s, she was always cooperative, calm, euthymic, and conversational. She had spoken to me about interpersonal problems with a friend, and I asked if she would like to try CBT. Nina was eager to try, but I quickly learned that she was not as stable nor had as much insight as I had thought. During the first session she perseverated about the spirits and snakes the entire session. Following sessions were similar. Thus CBT may not be the best option for all clients, but if clients are stable on the medications, it can be more helpful, and it can also complement ACT programs.
Cultural Considerations

As an African American female raised in Highland Park (Detroit), Nina has a specific set of cultural values which affects the way she views her illness and recovery (Castillo 1997). In Nina’s specific culture, witchcraft is a real and accepted norm, and she believes that at the age of 18, a neighbor cast a spell on her. Nina believes this was the moment when she first experienced a spirit of a dead woman entering her body. Ever since then, she believes that spirits have entered her and stayed with her because she was cursed to be a vessel for the spirits. When discussing Nina’s illness with clinical jargon, such as calling the spirits “hallucinations”, Nina becomes angry and says she is misunderstood and that no one believes her.

Thus, in discussing Nina’s illness, it is much more helpful to her and client-centered to refer to her manifestations in her own terminology, “spirits”, and to explore the implications of these manifestations along with ways to cope with them. At first, this was difficult for me to approach due to my diagnostic ethnocentrism revolving around traditional western cultural schemas. However, after reminding myself to take a client-centered approach and use Nina’s own language and reflective listening, I became better able to build rapport and connect with Nina. For example, instead of discussing what the spirits are, Nina and I discuss how the spirits effect her life. Nina feels much guilt because she believes she has many children who she cannot spend time with, so instead of continuously conducting and failing with reality testing, we discuss how this guilt affects Nina, how she can cope, and how she can move forward.


References

ACTA (2012). ACT model. Assertive Community Treatment Association. http://www.actassociation.org/. Retrieved March 1, 2012.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.
Castillo, R. J. (1997). Cultural assessment. Culture & Mental Illness, 55-75.

Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health., 46, 4, 337-41.

Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock's Synopsis of Psychiatry (10th ed.). Philadelphia: Wolters Kluwer.

Zygmunt, A., Olfon, M., Boyer C., & Mechanic, D.(2002) Interventions to improve medication adherence in schizophrenia. Am J Psychiatry, 159, 10. 1653-64.

Posted by desolada at September 10, 2012 08:14 PM

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