HPI: The patient is a male seen within the context of his post-hospitalization visit. He was previously admitted to the hospital-based on aggression and agitation. At the time of his hospitalization, the patient was diagnosed with Chronic Paranoid Schizophrenia. In 2010, the patient was a resident of Bellvue Personal Care Home; he has been residing there after his recent discharge. However, the patient claims to live with his mother and sister, who cause him much stress. In addition, the patient states that he might be using his medications incorrectly; he claims to have seized smoking (he has been abstinent from cigarettes for six days). The apparent mood components were identified, thus informing the patient’s new diagnosis of Schizoaffective Disorder.
Objective MSE: The patient is casually dressed and groomed. He looks very good today. He has a good skin color. He is alert. He appears to be in good spirits. He makes good eye contact. He is calm and cooperative. Speech is regular in rate and tone, relevant, with some response latency. Thoughts appear to be goal-directed. He describes his mood as “good.” Affect is restricted. He denies any mood lability or instability, nor is there any noted. There is no evidence of any delusional thinking. There is no evidence of any perceptual disturbances. There is no evidence of any suicidal or homicidal ideation, and he denies them as well.
Assessment: The patient is John, who has a constellation of diseases in the form: Schizoaffective Disorder, Nicotine Use Disorder, Panic Disorder with Agoraphobia, Mild Intellectual Disability, Peptic Ulcer Disease; Gastritis; Hyperlipidemia; Obesity; Type II Diabetes; Early Diabetic Retinopathy; Disc Disease; Abnormal Tongue Movements; History of Thyroid Disease; Recent hospitalization and Housing issues.
Neurobiology of the Disorder
Schizophrenia is characterized by the development of psychosis, hallucinations, delusions, disorganized speech and behavior, affective dullness, cognitive deficits, disability, and social activity. The cause is unknown, but a large role is assigned to the genetic and environmental factors. Symptoms most often develop during adolescence and adolescence, one or more symptomatic episodes must last more than 6 months before a diagnosis can be made (Borelli & Solari, 2019). Treatment is drug therapy, cognitive therapy and psychosocial rehabilitation. Early detection and treatment have a positive effect on long life.
The disease is characteristic and acute for all people. The incidence of schizophrenia in the world is about 1% (Borelli & Solari, 2019, p. 1332). Men and women are affected about equally and relatively consistently across all cultures. City life, poverty, childhood trauma, lack of parental attention, and prenatal infections are risk factors and genetic predispositions. The disease begins in late adolescence and lasts throughout life, usually accompanied by impaired psychosocial function. The average age of onset of the disease is the mid-20s in women and somewhat earlier in men; about 40% of men have their first episode before the age of 20 (Borelli & Solari, 2019, p. 1332). Rarely debuts in childhood, may occur in early adolescence or the elderly, although the specific cause is unknown, schizophrenia has a biological basis, as evidenced by:
- Changes in the structure of the brain, such as enlargement of the ventricles of the brain, thinning of the cerebral cortex, reduction in the size of the anterior hippocampus and other parts of the brain;
- Neurochemical changes, especially changes in markers indicating impaired transmission of dopamine and glutamate (Borelli & Solari, 2019);
- Recently identified genetic risk factors.
Although schizophrenia rarely presents in early childhood, childhood factors influence the onset of the disease in adulthood. These factors include:
- Genetic predisposition;
- Intrauterine, birth or postpartum complications;
- Viral infections of the central nervous system;
- Childhood trauma and neglect of the child’s needs;
Although most people with schizophrenia do not have a hereditary history for the disorder, genetic factors play a strong role in the development of the disease. In the presence of first-degree relatives with schizophrenia, the risk of developing the disease increases by 10-12%, compared with the risk of 1% in the general population, concordance in monozygotic twins is about 45% (Borelli & Solari, 2019, p. 1332). Neurobiological and neuropsychological tests suggest that patients with schizophrenia are more likely than in the general population to experience nystagmus, impaired cognitive functions, concentration, and sensory deficits. The generality of these findings regarding psychotic disorders suggests that our traditional diagnostic categories do not reflect the underlying biological differences between psychoses. Environmental stressors can cause psychotic symptoms to appear or recur in susceptible individuals (Borelli & Solari, 2019). Stress can be pharmacological or social; evidence is emerging that environmental events can initiate epigenetic changes that may influence gene transcription and disease onset.
Schizophrenia is a chronic disease that can progress in several stages, although their duration and nature may vary significantly in different patients. Patients with schizophrenia usually seek medical help after the onset of psychotic symptoms for about 12–24 months, but currently, the disease is recognized earlier in this vein (Stępnicki et al., 2018). The symptoms of schizophrenia usually impair a person’s ability to perform complex and complex cognitive and motor functions. Thus, symptoms often affect work, social relationships, and self-care. As a result, the patient loses his job, is isolated from society, his relationships worsen and his quality of life decreases.
Schizoaffective Disorder
Schizoaffective disorder is characterized by psychosis, other manifestations of schizophrenia, and significant mood symptoms. The difference between schizophrenia is the manifestation of ≥ 1 episode of depression or mania throughout life (Tiihonen et al., 2017, p. 691). Schizoaffective disorder is actual when there are both psychoses and symptoms of a mood disorder at the same time. Diagnosis requires that significant affective symptoms be present for > 50% of the total duration of illness, concomitant with ≥ 2 symptoms of schizophrenia (Tiihonen et al., 2017, p. 691). Thus, this disorder is a particular type of schizophrenia.
Treatment for Schizoaffective Disorder
The most effective approach is a combination of medication, psychotherapy and community support. Because schizoaffective disorder often results in long-term dysfunction, combination treatment is required (Tiihonen et al., 2017). For the treatment of the manic type, 2nd generation antipsychotics may be sufficient. Treatment of the depressive type begins with the appointment of 2nd generation antipsychotics (Tiihonen et al., 2017). Then, once the positive psychotic symptoms have stabilized, antidepressants should be administered if the depression requires treatment. Selective serotonin reuptake inhibitors are preferred, given their safety profile.
Current medications:
- Geodon 80 mg, po bid
- Clonazepam 1 mg po qid
- Fluoxetine 40 mg one po q day
- Lithium Carbonate 300 mg, three tablets po q h.s.
Plan/Rationale: Firstly, John has to continue his medic plan because of its effectiveness. Next, it is necessary to analyze the proposed treatments and drugs in John’s case to understand their effectiveness. First of all, the patient takes Geodon, which are capsules intended for oral administration. John takes the lowest dosage, which can be explained by the concomitance of other medications and by the absence of a severe stage of the disease. The remedy is recommended for use during acute manic or mixed episodes during schizophrenia (Tiihonen et al., 2017). The drug’s effectiveness has been proven by several controlled studies in adults with schizophrenia. In John’s case, the use of this drug is explained by the fact that he has a set of diseases that can affect the sensitivity to treatment (Tiihonen et al., 2017). Geodon, on the other hand, is characterized by versatility and an almost complete absence of side effects for John. The drug is not suitable for people with type 1 diabetes, but John has type 2.
The next drug included in the treatment plan is clonazepam. The clinical action is manifested by a strong and prolonged anticonvulsant effect. It also has antiphobic, sedative, muscle relaxant and mild hypnotic effects. For John, the relevance of this drug is due to the need to reduce the impact of stressors and control the outbursts of aggression that occur in him after the disorder. In addition, clonazepam controls the possible negative effects of long-term geodon use. After oral administration, it is rapidly and completely absorbed from the gastrointestinal tract, the absolute bioavailability is about 90% (Tiihonen et al., 2017, p. 689). After a single oral intake, it is usually achieved within 1–2 hours, but in some patients it can be achieved within 4–8 hours (Tiihonen et al., 2017, p. 689). Side effects that are relevant for John have increased drowsiness and behavioral disturbances. However, they are not observed in the patient based on information about his mood and self-confidence.
John’s third drug is fluoxetine. It is an antidepressant of the group of selective serotonin reuptake inhibitors. The patient must control and prevent depressive phases since they are characteristic of John’s disorder (Tiihonen et al., 2017). He takes the optimal amount of the drug daily, but an increased dose. It means that the depressive phase is still relevant for well-being, which explains the need for the drug (Tiihonen et al., 2017). It is important to note that John does not have suicidal thoughts since fluoxetine is contraindicated in this case. The most likely side effect may be insomnia in its various manifestations (Tiihonen et al., 2017). However, the combined use of the drug with clonazepam can partially or completely avoid this.
Finally, the fourth remedy is lithium carbonate, which is necessary for fixing the mental state. It also has antidepressant, sedative and antimanic effects. The effect is due to lithium ions, which, antagonists of sodium ions, displace them from cells and thereby reduce the bioelectrical activity of brain neurons. The beneficial effect of lithium in migraine may be due to changes in the concentrations of serotonin and histamine in platelets (Tiihonen et al., 2017). The antidepressant effect may be associated with an increase in serotonergic activity and a decrease in the regulation of the function of β-adrenergic receptors (Tiihonen et al., 2017). This drug is not contraindicated for John, and side effects are not relevant. Based on this, combining all of the above drugs is a highly effective treatment for schizoaffective disorder.
Separately, it is worth mentioning outpatient examination and therapy, which are relevant with a certain frequency for John. It is the most important part of the treatment plan because it allows specialists to monitor and notice changes in the patient’s behavior and condition promptly. Changes in dosages of drugs, the introduction of new ones or the end of taking old ones depend on this. Finally, through John’s analysis, it is possible to conclude the side effects or dysfunctions that may begin to appear.
References
Borelli, C. M., & Solari, H. (2019). Schizophrenia.JAMA, 322(13), 1322. Web.
Stępnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current Concepts and Treatments of Schizophrenia.Molecules (Basel, Switzerland), 23(8), 2087. Web.
Tiihonen, J., Mittendorfer-Rutz, E., Majak, M., Mehtälä, J., Hoti, F., Jedenius, E., Enkusson, D., Leval, A., Sermon, J., Tanskanen, A., & Taipale, H. (2017). Real-World Effectiveness of Antipsychotic Treatments in a Nationwide Cohort of 29 823 Patients With Schizophrenia.JAMA psychiatry, 74(7), 686–693. Web.