Case Study 144 Schizophrenia

1. Explain what a negative symptom of schizophrenia is, and

identify at least three negative symptoms of schizophrenia
that R.B. might be experiencing.

A negative symptom of schizophrenia is the absence of something that

should be present in a person but is not present. Negative symptoms
of R.B include:
• Flat or blunted affect
• Poverty of thought
• Lack of motivation
• Social withdrawal
• Poor grooming
• Anhedonia (inability to experience pleasure)

2. Explain what a positive symptom of schizophrenia is, and

identify at least two positive symptoms of schizophrenia that
R.B. might be experiencing.

A positive symptom of schizophrenia is the presence of something that

is not normally present such as:
• Hallucinations
• Delusions
• Disorganized speech (associative looseness)
• Bizarre behavior
R.B. saying that “they” have contaminated his food and “they” told me
not to cooperate are positive symptoms. As well as having
conversations when no one is there.

3. Give the definition of each of the following types of

delusional thinking:

a. Thought broadcasting - Belief that thoughts can be heard by other

people too
b. Thought insertion - Belief that others people’s thoughts are being
inserted or substituted into one's brain or conversation
c. Grandeur - Belief about grand or exaggerated accomplishments;
belief that one is very important or has great power
d. Ideas of reference - Belief that events are related to one when they
are not; giving great personal significance to a trivial event
e. Persecution - Belief that one person is being singled out by others
for harmful reasons
f. Somatic delusions - Belief that one's body is changing in an unusual
way

4. What symptoms indicate that R.B. has paranoid

schizophrenia?

Symptoms that indicate R.B. has exhibited paranoid schizophrenia are

closing all the blinds and windows so that no one can watch him, along
with believing that people have contaminated his food, and that people
are actually watching him, and frequent auditory hallucinations “they
told me not to cooperate”.

5. Why is it important to know R.B.’s history before he is

diagnosed with schizophrenia?

It is important to know R.B’s history before his diagnosis because it will

be easier to recognize the onset of symptoms. It is also important to
know the history to determine when the symptoms started.

6. What diagnostic screenings are important in evaluating

R.B.?

• Physical exam - This may be done to help rule out other

problems that could be causing symptoms and to check for any
related complications.

• Tests and screenings - These may include tests that help rule
out conditions with similar symptoms, and screening for alcohol
and drugs. The doctor may also request imaging studies, such as
an MRI or CT scan.
 • Psychiatric evaluation - A doctor or mental health professional
checks mental status by observing appearance and demeanor
and asking about thoughts, moods, delusions, hallucinations,
substance use, and potential for violence or suicide. This also
includes a discussion of family and personal history.

• Diagnostic criteria for schizophrenia - A doctor or mental

health professional may use the criteria in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), published by the
American Psychiatric Association.

7. What are the most initial interventions in treating R.B.?

• Protect him from harm to self and others by creating a supportive,

structured environment
• Engage in supportive and directive communication
• Establish a relationship with R.B. in which he feels safe
• Perform acute symptom stabilization; psychopharmacologic
treatment

CASE STUDY PROGRESS

8. Which class of antipsychotic medications is considered first-

line therapy for schizophrenia?

Atypical antipsychotics are now chosen as first-line antipsychotics

because they treat both the negative and positive symptoms of
schizophrenia and because they produce minimal extrapyramidal side
effects, such as tardive dyskinesia. Patients often adhere to treatment
better, and there are fewer side effects than with the traditional
antipsychotics.

9. K.B. will need to be monitored closely. How will this be

done?

• Increasing staff supervision

• Reducing stimulation (such as crowds, noise)
• Providing diversional activities that are constructive and outlets for
physical energy, and addressing his paranoia.
• Cognitive-behavioral approaches will be implemented. The staff will
work to deescalate tension verbally.
• Only if necessary, in cases of severely aggressive behavior of K.B,
will measures such as seclusion, chemical treatment (medication),
or physical restraints be used.

10. What are types of psychosocial treatments may be used to

treat R.B.’s schizophrenia? Name at least five.

• Individual therapy
• Milieu therapy
• Family therapy
• Group therapy
• Social skills training
• Recreational therapy
• Vocational therapy
• Case management

11. What are the common side effects of atypical

antipsychotics such as olanzapine (Zyprexa)?

b.) Drowsiness
c.) Dry mouth
e.) Nausea
f.) Weight gain

12. Is he having a delusion or a hallucination? Explain your

answer

As you go in to give R.B. his medication, he speaks to you in

fragmented sentences. "Is that a bird? The little flowers jump
up and down. What says the moon?" Before you can say
anything, he asks, "Do you see that bird over my bed?" She is
telling me not to leave this room. If I move she will swoop
down and try to peck at my eyes. Be careful!”

K.B. is having a hallucination. Hallucinations involve perceiving a

sensory experience for which there is no external stimulus (he sees a
bird over his bed and hears it talking to him). A delusion is a false
belief that a person thinks is true even with evidence to the contrary.
For example, a person sees a bed and becomes fearful because he
believes it is his coffin.
13. Which responses by the nurse are appropriate? Select all
that apply.

a.) “I don’t see a bird over your head, but I can understand how that
would be upsetting to you.”
c.) “Tell me more about what you’re seeing.”
d.) “The voice you are hearing is part of you illness. It can’t hurt you.”

Keep a calm demeanor and stay with R.B. If you do not understand
what R.B. is saying, you need to let him know. It is important to be
gentle but clear. Tell R.B. that you are not understanding him, and that
you would like to be able to understand him. It is important not to
negate what R.B. is experiencing, yet you need to offer what you
perceive. Tell him, "I do not see a bird over your bed, but I can
understand how that would be upsetting to you." Do not argue with the
patient. Notify the physician if his behavior becomes aggressive.