TABLE OF CONTENTS

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1 Acknowledgement 1

3 Introduction And Definition 3-4

4 Clinical Manifestation and Types 5-7

5 Etiology and Complications 7-8

6 Pathophysiology and Treatments 9-13

7 Real case 14-22

8 References articles 23-26

9 Discussion 27-28

10 Conclusion 29

11 References 30
 INTRODUCTION

Schizophrenia is a serious and persistent mental illness that has instilled fear, curiosity, and
reverence through the ages. This complex condition affects an individual s grasp on reality,
severely limiting the ability to live and work independently. The impact of the schizophrenia
extends beyond the individual to families and communities. Schizophrenia is associated with
increased morbidity and mortality, and significant health care costs and resource utilization. The
term “schizophrenia” likely encompasses a syndrome with various symptoms and signs that
share a common feature of impairment in reality testing. Current research aims to identify
mechanisms to explain the diverse phenotypes observed and to identify and understand possible
subtypes. Alterations in the mesolimbic dopaminergic pathways as well as changes in the
prefrontal cortex are thought to play a role in pathology
 DEFINITION

Schizophrenia is a chronic brain disorder. When schizophrenia is active, symptoms can

include delusions, hallucinations, trouble with thinking and concentration, and lack of
motivation. However, with treatment, most symptoms of schizophrenia will greatly
improve.Schizophrenia can run in families and it is likely that the disease has a genetic
component. if one twin of an identical pair has schizophrenia, there is a 46% chance that the
other twin willalso suffer from a schizophrenic disorder. It is not known how many genes are
involved or howthe genetic predisposition is transmitted. In addition, recent evidence suggests
that schizophreniamay result whenneuronsin the brain form inappropriate connections during
foetaldevelopment. It may be that an intrauterine starvation or infection causes such
inappropriateconnections to form and these may lie dormant until puberty when substantial
neuronreorganization occurs in the brain. Identification of specific genes involved in the
development of schizophrenia will provide important clues as to whatgoes wrong in the brains of
people with thedisease and this will guide thedevelopment of improved treatments.Stress
imposed by life events or family circumstances appears to be an important external
eventassociated with schizophrenia. The onset of illness is often associated with a distressful
period inlife and it may be that stress can trigger the onset of illness in those people with a
genetic predisposition to the disease.An imbalance in the concentrations of dopaminergic
andglutamatergicsystems in the brain isalso thought to play a role in the development of
schizophrenia. Thedopaminehypothesis statesthat the behaviour patterns typical of schizophrenia
 are a result of overactivity of dopamine incertain regions of the brain.Serotoninis also important
in schizophrenia and it may be that theserotonin system interacts with the dopamine system to
modify the way in which it operates. Theserotonin receptors which are important in the treatment
of schizophrenia are 5-HT1, 5-HT2 and5-HT3.

CLINICAL MANIFESTATION

People with schizophrenia may have a number of symptoms involving changes in functioning,
thinking, perception, behavior, and personality, and they may display different kinds of behavior at
different times.It is a long term mental illness which usually shows its first signs in men in their late
teens or early 20s, while in women, it tends to be in their early 20s and 30s.A prodrome is
accompanied by what can be perceived as subtle behavioral changes, especially in teens. This
includes a change in grades, social withdrawal, trouble concentrating, temper flares, or difficulty
sleeping. The most common symptoms of schizophrenia can be grouped into several categories
including positive symptoms, cognitive symptoms, and negative symptoms.

Symptoms and signs of schizophrenia will vary, depending on the individual.

 Positive symptoms - also known as psychotic symptoms. For example, delusions and
hallucinations.

 Negative symptoms - these refer to elements that are taken away from the individual.
For example, absence of facial expressions or lack of motivation.
 Cognitive symptoms - these affect the person's thought processes. They may be positive
or negative symptoms, for example, poor concentration is a negative symptom.

 Emotional symptoms - these are usually negative symptoms, such as blunted emotions.

Below is a list of the major symptoms:

 Delusions - the patient displays false beliefs, which can take many forms, such as
delusions of persecution, or delusions of grandeur. They may feel others are attempting to
control them remotely. Or, they may think they have extraordinary powers and abilities.

 Hallucinations - hearing voices is much more common than seeing, feeling, tasting, or
smelling things which are not there, however, people with schizophrenia may experience a wide
range of hallucinations.

 Thought disorder - the person may jump from one subject to another for no logical
reason. The speaker may be hard to follow or erratic.

Other symptoms may include:

 Lack of motivation (avolition) - the patient loses their drive. Everyday actions, such as
washing and cooking, are neglected.

 Poor expression of emotions - responses to happy or sad occasions may be lacking, or

inappropriate.

 Social withdrawal - when a patient with schizophrenia withdraws socially, it is often

because they believe somebody is going to harm them.

 Unawareness of illness - as the hallucinations and delusions seem so real for patients,
many of them may not believe they are ill. They may refuse to take medication for fear of side
effects, or for fear that the medication may be poison, for example.

 Cognitive difficulties - the patient's ability to concentrate, recall things, plan ahead, and
to organize their life are affected. Communication becomes more difficult.
TYPES OF SCHIZOPHRENIA:
The diagnosis is made according to the client’s predominant symptoms:
1. Schizophrenia, paranoid type:
- is characterized by persecutory (feeling victimized or spied on) or grandiose
delusions,hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile
and aggressive behavior.
2. Schizophrenia, disorganized type:
- is characterized by grossly inappropriate or flat affect,incoherence, loose associations,
and extremely disorganized behavior.
3. Schizophrenia, catatonic type:
- is characterized by marked psychomotor disturbance,either motionless or excessive motor
activity. Motor immobility may be manifested by catalepsy (
waxy flexibility or stupor ).
4. Schizophrenia, undifferentiated type:
- is characterized by mixed schizophrenic symptoms(of other types) along with
disturbances of thought, affect, and behavior.
5. Schizophrenia, residual type:
- is characterized by at least one previous, though not acurrent, episode, social withdrawal,
flat affect and looseness of associations.

ETIOLOGY

The cause of schizophrenia is still unclear. Some theories about the cause of this disease
include: genetics (heredity), biology (abnormalities in the brain’s chemistry or structure); and/or
possible viral infections and immune disorders.Evidence suggests that genetic and environmental
factors act together to bring about schizophrenia. The condition has an inherited element, but
environmental triggers also significantly influence it.Below is a list of the factors that are thought
to contribute towards the onset of schizophrenia:

Genetic inheritance
If there is no history of schizophrenia in a family, the chances of developing it are less than 1
percent. However, that risk rises to 10 percent if a parent was diagnosed.

Chemical imbalance in the brain

Experts believe that an imbalance of dopamine, a neurotransmitter, is involved in the onset of

schizophrenia. Other neurotransmitters, such as serotonin, may also be involved.

Family relationships

There is no evidence to prove or even indicate that family relationships might cause
schizophrenia, however, some patients with the illness believe family tension triggers relapses.

Environmental factors

Although there is no definite proof, many suspect trauma before birth and viral infections may
contribute to the development of the disease.Stressful experiences often precede the emergence
of schizophrenia. Before any acute symptoms are apparent, people with schizophrenia habitually
become bad-tempered, anxious, and unfocused. This can trigger relationship problems, divorce,
and unemployment.These factors are often blamed for the onset of the disease, when really it
was the other way round - the disease caused the crisis. Therefore, it is extremely difficult to
know whether schizophrenia caused certain stresses or occurred as a result of them.

Drug induced schizophrenia

Marijuana and LSD are known to cause schizophrenia relapses. Additionally, for people with a
predisposition to a psychotic illness such as schizophrenia, usage of cannabis may trigger the
first episode.Some researchers believe that certain prescription drugs, such as steroids and
stimulants, can cause psychosis.

Complications
Left untreated, schizophrenia can result in severe problems that affect every area of life.
Complications that schizophrenia may cause or be associated with include:

 Suicide, suicide attempts and thoughts of suicide

 Self-injury
 Anxiety disorders and obsessive-compulsive disorder (OCD)
 Depression
 Abuse of alcohol or other drugs, including tobacco
 Inability to work or attend school

PATHOPHYSIOLOGY

Abnormalities in neurotransmission have provided the basis for theories on the pathophysiology of
schizophrenia. Most of these theories center on either an excess or a deficiency of neurotransmitters,
including dopamine, serotonin, and glutamate. Other theories implicate aspartate, glycine, and
gamma-aminobutyric acid (GABA) as part of the neurochemical imbalance of schizophrenia.

Abnormal activity at dopamine receptor sites (specifically D2) is thought to be associated with
many of the symptoms of schizophrenia. Four dopaminergic pathways have been implicated. The
nigrostriatal pathway originates in the substantia nigra and ends in the caudate nucleus. Low
dopamine levels within this pathway are thought to affect the extrapyramidal system, leading to
motor symptoms. The mesolimbic pathway, extending from the ventral tegmental area (VTA) to
limbic areas, may play a role in the positive symptoms of schizophrenia in the presence of excess
dopamine. The mesocortical pathway extends from the VTA to the cortex. Negative symptoms and
cognitive deficits in schizophrenia are thought to be caused by low mesocortical dopamine levels.
The tuberoinfundibular pathway projects from the hypothalamus to the pituitary gland. A decrease
or blockade of tuberoinfundibular dopamine results in elevated prolactin levels and, as a result,
galactorrhea, ammenorrhea, and reduced libido.

The serotonin hypothesis for the development of schizophrenia emerged as a result of the discovery
that lysergic acid diethylamide (LSD) enhanced the effects of serotonin in the brain. Subsequent
research led to the development of drug compounds that blocked both dopamine and serotonin
receptors, in contrast to older medications, which affected only dopamine receptors. The brain tissue
itself appears to undergo detectable physical changes in patients with schizophrenia. For example, in
addition to an increase in the size of the third and lateral ventricles, individuals at high risk of a
schizophrenic episode have a smaller medial temporal lobe.

TREATMENT

The goal of schizophrenia treatment is to reduce the symptoms and to decrease the chances of a
relapse, or return of symptoms. Treatment for schizophrenia may include:-
Nonpharmacological Therapy

The goals in treating schizophrenia include targeting symptoms, preventing relapse, and
increasing adaptive functioning so that the patient can be integrated back into the community.
Pharmacotherapy is the mainstay of schizophrenia management, but residual symptoms may persist.
For that reason, non-pharmacological treatments, such psychotherapy, are also important.

Psychotherapeutic approaches may be divided into three categories: individual, group, and
cognitive behavioral. Psychotherapy is a constantly evolving therapeutic area. Emerging
psychotherapies include meta-cognitive training, narrative therapies, and mindfulness therapy. Non-
pharmacological treatments should be used as an addition to medications, not as a substitute for
them.

Pharmacology

The primary medications used to treat schizophrenia are called anti-psychotics. These drugs do
not cure schizophrenia but help relieve the most troubling symptoms, including delusions,
hallucinations, and thinking problems.

Before beginning anti-psychotic medications, clinicians should warn patients and their families
of adverse effects, and the slowness of response. The patient may be calmer and less agitated almost
immediately, but alleviation of the psychosis itself often takes several weeks. Some clinicians
routinely perform electrocardiography (ECG) before beginning treatment with anti-psychotic
medications and then as often as seems appropriate, for example if doses are increased or agents
change. Because suicide is not uncommon in patients with psychotic illnesses, clinicians should
write prescriptions for the lowest dosage that is consistent with good clinical care.

The first anti-psychotic medications, chlorpromazine and haloperidol, were dopamine D2

antagonists. These and similar medications are known as first-generation, typical, or conventional
anti-psychotics. Other anti-psychotics, beginning with clozapine, are known as second-generation,
atypical, or novel anti-psychotics.
 The conventional anti-psychotic agents are available in generic forms and are less expensive
than the newer agents. They are available in a variety of vehicles, including liquid and intramuscular
(IM) preparations. Some of these agents (haloperidol and fluphenazine) are also available as depot
preparations, meaning that a person can be given an injection of a medication every 2-4 weeks. Of
the second-generation agents, risperidone is available as a long-acting injection that uses
biodegradable polymers; olanzapine, paliperidone, and aripiprazole are also now available in long-
acting injectable forms.

The first-generation antipsychotic drugs tend to cause extrapyramidal adverse effects and
elevated prolactin levels. The second-generation drugs are more likely to cause weight gain and
abnormalities in glucose and lipid control; in addition, they are often more expensive than the first-
generation drugs.

Coordinated Specialty Care (CSC)

This is a team approach towards treating schizophrenia when the first symptoms appear. It
combines medicine and therapy along with social services and employment and educational
interventions. The family is involved as much as possible. Early treatment of schizophrenia can be
key in helping patients lead a normal life.

Psychosocial therapy

While medication may help relieve symptoms of schizophrenia, various psychosocial treatments
can help with the behavioral, psychological, social, and occupational problems associated with the
illness. Through therapy, patients also can learn to manage their symptoms, identify early warning
signs of relapse, and develop a relapse prevention plan. Psychosocial therapies include:

 Rehabilitation, which focuses on social skills and job training to help people with
schizophrenia function in the community and live as independently as possible
 Individual psychotherapy, which can help the person better understand his or her illness, and
learn coping and problem-solving skills
 Family therapy, which can help families deal more effectively with a loved one who has
schizophrenia, enabling them to better help their loved one
  Group therapy/support groups, which can provide continuing mutual support

Hospitalization

Many people with schizophrenia may be treated as outpatients. However, people with particularly
severe symptoms, or those in danger of hurting themselves or others or who cannot take care of
themselves at home may require hospitalization to stabilize their condition.

Electroconvulsive therapy (ECT)

This is a procedure in which electrodes are attached to the person's scalp and, while asleep under
general anesthesia, a small electric shock is delivered to the brain. A course of ECT treatment
usually involves 2-3 treatments per week for several weeks. Each shock treatment causes a
controlled seizure, and a series of treatments over time leads to improvement in mood and thinking.
Scientists do not fully understand exactly how ECT and the controlled seizures it causes have a
therapeutic effect, although some researcher think that ECT-induced seizures may affect the release
of neurotransmitters in the brain. ECT is less well established for treating schizophrenia
than depression or bipolar disorder, and it is therefore not used very often when mood symptoms
are absent. ECT is sometimes helpful when medications fail or if severe depression or catatonia
makes treating the illness difficult.
 REAL CASE

Regarding to the real case

A) PATIENT HISTORY

PATIENT’S IDENTIFICATION

Registered number:3172

Name:Romziah Binti Malek

Age:49 years old

Gender: Female

Race:Malay

Occupation:-

Date of admitted:13/8/2018

Chief complaint:
  Patient was raved and walking nakedly in the village holding a sharp object “PARANG”
intend to harm and injur villagers.
I. History of presenting complaint
 Being naked and walk around the house
 Acting more childish, jumping around
 Sleep disturbance. Almost not sleeping at night.
 She believed there were a voice that force her to kill a person named “En Salim”.
(Auditory Hallucination).
 Noted that patient talk to herself(incoherently)
 Irratabillity
 Delusion

II. Past medical history

 Last admit to Psychiatric Ward of Hospital Slim River last year for 2/12
 The client has a regular medical check up when she was still at normal state. She’s been
taking antihypertensive drugs due to the rise and fall of her blood pressure.
 The client was first admitted at the National Center for Mental Health at the year 2015
because of hostility, untoward behaviors and social withdrawal. She was then diagnosed
to have Schizophrenia, undifferentiated type. According to the client herself, she always
heard voices and even saw things which were vague for her. Meaning, she was
experiencing visual and auditory hallucinations. That was why her father brought her at
the center. She was been manageable and was in and out at the center for 3 years. At the
year 2019, at 12.00 in the afternoon of september 11, she was readmitted accompanied by
her father for she experienced again symptoms like hallucinations and delusions. The
client then denied the presence of auditory and visual hallucinations and claimed to have
a good sleep. She also added that she was been admitted at the center before and taking
up medications like Haloperidol.
 The client was been at the National Center for Mental Health for about 14 years but
sometimes in and out due to the progressive state of her condition.

III. Past surgical history

 Nil
IV. Others (Family history / Drugs history / Social history etc)

 Family history:
 Her aunt at father side was diagnosed with mental illness(bipolar).
 Patient lives with her grandfather and with her younger brother.
 Patient was asingle mother. She claim last working in 2008 as a factory worker
for 2years in Kuala Lumpur
 Patient’s husband has died in 2003.
 Patient is on antipsychotic drug since 2016..
 Drug history:
 No drug history and no allergic of drug.
 No food allergies.

A) PHYSICAL EXAMINATIONS

I. General physical examination:

 Confused, disorientated and delusional
 Poor appearrences (not well managed) and dirty
 Hydration: good
 Has a poor insight
 Mood was affected due to always hearing voices

II. Vital signs

RESULTS NORMAL RANGE

BLOOD PRESSURE 119/79 mmHg 120/80 mmHg
TEMPERATURE 36.9℃ 36.5 – 37.5℃
RESPIRATION RATE 23/rpm 16 – 20/rpm
PULSE RATE 87/min 60 – 100/min
SPO2 100% (under room air) 95 – 100%
 PAIN SCORE 0 0

III. Cardiovascular sign

 Dual rhythm, no murmurs(DRNM)
 S1, and S2 was heard.

IV. Respiratory system

 Air entry is equal bilaterally
 Clear sound

V. Gastrointestinal system
 Soft and no tenderness
 Bowel sound active
 No scar
 No mass

VI. Others (Musculoskeletal, Central Nervous System, Upper and lower limbs etc)

 No abnormality detected (NAD)



DIFFERENTIAL DIAGNOSIS

Undifferentiated Schizophrenia, Chronic and Unstable

 Bipolar disorder
 Psychosis

B) INVESTIGATIONS (Lab, X-Ray,etc)

i. Mental Status Examination

General Appearance - Naked (wearing nothing)

- Aggresive
- Compulsive
- Confused
Mannerisms, tics - Talk to herself (TTH)

Rapport, eye contact - cooperative

-Good eye contact
Speech - Coherent, relevant
- Speaking in ‘Broken English’
Affect - Euthymic

Mood - Affected
-Moderate depressed
Perceptual Disorder - Present

Thought Disorder - Present

Insight - Poor

Orientation - Not alert on time

- Not alert on time
- Not alert on place
Sleep - Bad

Appetite - Fair
- No suicidal thought
- Not compliance
- Hardly to follow instruction

Full Blood Count

RESULT NORMAL RANGE

White Blood Cells 7.86 x 10³/µL 4.0- 10 x 10³/µL

Total Red Cells 4.24 x 10³/µL 3.8-4.8 x 10³/µL

Haemoglobin 14.5 g/dL 12- 15 g/L

HCT 37.2% 36 - 46%

MCV 81.8 fL 80 - 100 fL

MCH 28.8 pg 27 - 34 pg
 MCHC 32.6 g/dl 32 - 36 g/dl

Platelet count 327 x 10³/ µL 150 – 450 x10³ /µL

Neutrophil% 70% 50 - 70%

Lymphocyte% 39.5% 20 -40%

Monocyte% 10.0% 0 - 10%

Eosinophil% 0.3% 0 - 6%

Basophil% 0.1% 0.0 - 0.1%

i. Liver Function Test

RESULT NORMAL RANGE

Protein 81.3 g/L 60- 80 g/L

Albumin 44.6 g/L 35 - 52 g/L

Globulin 34.9 g/L 18 - 36 g/L

Total Bilirubin Color 9.2 umol/L 3.4 - 17 umol/L

Alkaline Phosphate 133 U/L 34 - 120 U/L

Aspartate Amino 43.6 U/L 9.0 - 48.0 U/L

Transminase

Alanine Amino 37.8 U/L 5.0 - 49.0 U/L

Transferase
 ii. Renal Profile

RESULT NORMAL RANGE

Blood Urea Nitrogen 5.2 mmol/L 1.7 - 8.3 mmol/L

Sodium 102.4 mmol/L 135 - 154 mmol/L

Potassium 3.8mmol/L 3.6 - 5.4 mmol/L

Chloride 80 mmol/L 93 - 108 mmol/L

Creatinine 64 umol/L 48 - 95 umol/L

iii. Blood Urea Serum Electrolyte

RESULT NORMAL RANGE

Creatinine Kinase 81.3U/L 26-174U/L

Calcium 2.34 mmol/L 2.1 - 2.42 mmol/L

Phosphate 1.12 mmol/L 0.87 - 1.45 mmol/L

Magnesium 0.99 mmol/L 0.8 - 1.0 mmol/L

CKMB 13 U/L 7 - 25 U/L

iv. Fasting Blood Sugar

RESULT NORMAL RANGE

Fasting Blood Sugar 9.77 mmol/L 3.9 - 6.4mmol/L

C) DIAGNOSIS
 Schizophrenia
 D) MANAGEMENT AND TREATMENT (routine and specific)

Initial management

 Patient brought in by relative due abnormal behavior and unmanageable to the

Emergency Department.
 Emergency Department’s medical officer done history taking and chief complain from
family members and noted have been admit to Psychiatric Ward in Hopital Slim River
last year about 2 month.
 Doctor decide to refers the patient to psychiatric ward.

Ward management

 Patient admit to psychiatric ward accompanied by her relatives and PPK by wheelchair
and hand was strapped.
 Rest the patient in supine position comfortably.
 Serve daily a healthy diet to patient.
 Staff nurse encourage the patient to done daily activities such as eating, bathing, and self-
management to provide back patient’s esteem and confidence.

Routine Management

 General condition of patients is still confused. Start to monitor vital sign 4 hourly.
 Report the condition of patient 4 hourly to the doctors in charge.
 Record the urine input and output of patient in observation chart.
  Encourage the patient to eat the medication as doctor prescribed and injection I/M of
Haloperidol in the morning

Specific Management

 Psychiatrist have done psychotherapy to patient everyday to overcome the patient’s

problem or mood disorder by consulted or interview them.
 Psycho-education therapy to patient and his family to learn and gain knowledge about
patient’s depression disorder to help them understand the condition of patient and support
her due to schizophrenia.
 Psychiatrist also consult the patient’s family to support and give more attention to patient
to stabilize the depression that have been.
 Done the Mental Status Examination (MSE) to evaluate the mental status of patient.
 Blood taking on patient for further investigation and further diagnose
 Focused on the stabilization of the patient by doing some activities such as drawing,
colouring, singing, that make patient comfortable.
 Rehabilitation process activity on patient to allow them in better mood by doing some
interesting activities.
 Prescribed the medication to patient and monitor the side effect of the medication on
patient such as tremor and gastrointestinal disturbance.
 Encourage the patient to attend Occupational Therapy(OT) to regain the patient
physically active to do work
GENER CLASSIFICA MECHANI CONTRAI SIDE & NURSI EVALUAT
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BRAND ACTION DICATIO SE IMPLI-
NAME N EFFEC CATIO
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Haloperi Antipsychotic A Hypersensit CNS: -
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GENERIC/ CLASSIFICATIO MECHANIS CONTRAIN- SIDE & NURSING EVALUATIO
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Chlorpromazi Antipsychotic A piperidone Hypersensitivi CNS: -Monitor

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REFERENCE ARTICLES
 (Articles A)

According to the article written by Frances R Frankenburg, MD; Chief Editor: Glen L Xiong,
MD .

Schizophrenia is a brain disorder that affects how people think, feel, and perceive. The
hallmark symptom of schizophrenia is psychosis, such as experiencing auditory
hallucinations (voices) and delusions (fixed false beliefs).

Signs and symptoms

The symptoms of schizophrenia may be divided into the following 4 domains:

Positive symptoms - Psychotic symptoms, such as hallucinations, which are usually

auditory; delusions; and disorganized speech and behavior

Negative symptoms - Decrease in emotional range, poverty of speech, and loss of

interests and drive; the person with schizophrenia has tremendous inertia

Cognitive symptoms - Neurocognitive deficits (eg, deficits in working memory and

attention and in executive functions, such as the ability to organize and abstract);
patients also find it difficult to understand nuances and subtleties of interpersonal cues
and relationships

Mood symptoms - Patients often seem cheerful or sad in a way that is difficult to understand;
they often are depressed

Diagnosis

Schizophrenia
Diagnostic criteria

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,

(DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have
experienced at least 2 of the following symptoms 

 Delusions

 Hallucinations

 Disorganized speech

 Disorganized or catatonic behavior

 Negative symptoms

At least 1 of the symptoms must be the presence of delusions, hallucinations, or disorganized

speech.

Continuous signs of the disturbance must persist for at least 6 months, during which the
patient must experience at least 1 month of active symptoms (or less if successfully treated),
with social or occupational deterioration problems occurring over a significant amount of
time. These problems must not be attributable to another condition.

Management

Antipsychotic medications diminish the positive symptoms of schizophrenia and prevent

relapses. Clozapine is the most effective medication but is not recommended as first-line
therapy.Psychosocial treatment is essential. The best-studied psychosocial treatments are
social skills training, cognitive-behavioral therapy, cognitive remediation, and social
cognition training.Psychosocial treatments are currently oriented according to the recovery
model. According to this model, the goals of treatment for a person with schizophrenia are as
follows:

- To have few or stable symptoms

 - Not to be hospitalized

- To manage his or her own funds and medications

(Articles B)

According to the article written by Malaysian Mental Health Association(MMHA).

Schizophrenia is an illness with severe disturbance in the brain’s functioning, resulting in

disturbed thoughts and bizarre behaviours. It usually appears during late adolescence and
early adulthood. The cause is still unknown but is believed to be contributed by
predispositions, abnormalities in brain chemistry and stresses faced by the affected person.
Schizophrenia is treatable. It is important to detect and treat early to minimize functional
impairment caused by the illness.

Recognizing Schizophrenia Symptoms

 Delusions (Believing in things that are not true like people reading their minds,
controlling their thoughts or plotting to harm them)
 Hallucinations (Typically hearing voices that are not there, like people talking bad
about them and condemning them)
 Disorganized Thoughts and Speech (Incoherent speech, swearing and strange
mannerisms)
 Negative symptoms (Lack of emotions and expression, lack of motivation, social
withdrawal and personal neglect on appearance and hygiene)
 

Causes of Schizophrenia

The exact cause for Schizophrenia is still unknown. It is a combination of many factors such
as genetic predisposition, psychological make-up of a person and other environmental factors
working together to raise the risk of developing the illness. Research on the cause is still on-
going.
 Treatment for Schizophrenia

 Medications – The main mode of treatment is medication with anti-psychotic drugs.

This is aimed at correcting chemical dysfunction of the brain. Some patients may not be
able to tolerate certain medications very well and experience side-effects which may make
them more stiff and slow. This must be discussed with the doctor to get the most suitable
medication.
 Electro-Convulsive Therapy (ECT) – It is used only in persons where the acute
phase cannot be controlled with medications. This is a relatively safe procedure
administered under anaesthesia.
 Psychosocial Rehabilitation – This is aimed at empowering persons in recovery
from Schizophrenia to understand their illness, manage their illness to prevent relapse,
strengthen their coping mechanisms, build up their self-esteem and set goals for their
recovery.
 DISCUSSION

Similarities between Case A, Case B and Real Case:

According to the article of case A, case B and real case at Hospital Slim River there is
similarities which sign and symptom, investigation and treatment. Article A has stated that
the sign and symptom of schizophrenia are talking in sentences that do not make sense or
using nonsense words, abnormal behavior, talk to herself and sleep disturbance. Article B also
have stated the same sign and symptom that has been write in article A. In real case, patient,
Romziah Binti Malek, 49 years old, Malay was admitted to Hospital Slim River with same
sign and symptoms which is talking in sentences that do not make sense or using nonsense
words, abnormal behavior, talk to herself and sleep disturbance. This shows that sign and
symptoms is the most common sign and symptom to schizophrenia.

Differences between Case A, Case B and Real Case:

There are not many difference in all of the article. There are slightly difference in
management or in chief complain. Article A has mention that what causes schizophrenia.
Experts believe several factors are generally involved in contributing to the onset of
schizophrenia. Chemical imbalance in the brain, experts believe that an imbalance of
dopamine, a neurotransmitter, is involved in the onset of schizophrenia. Other
neurotransmitters, such as serotonin, may also be involved. Family relationships, there is no
evidence to prove or even indicate that family relationships might cause schizophrenia,
however, some patients with the illness believe family tension triggers relapses.
Environmental factors, although there is no definite proof, many suspect trauma before
birth and viral infections may contribute to the development of the disease. Stressful
experiences often precede the emergence of schizophrenia. Before any acute symptoms are
apparent, people with schizophrenia habitually become bad-tempered, anxious, and
unfocused. This can trigger relationship problems, divorce, and unemployment. These factors
are often blamed for the onset of the disease, when really it was the other way round - the
disease caused the crisis. Therefore, it is extremely difficult to know whether schizophrenia
caused certain stresses or occurred as a result of them. Drug induced schizophrenia,
marijuana and LSD are known to cause schizophrenia relapses. Additionally, for people with
a predisposition to a psychotic illness such as schizophrenia, usage of cannabis may trigger
the first episode. Some researchers believe that certain prescription drugs, such as steroids
and stimulants, can cause psychosis.

In article B, they are more focus on their treatment. Article B stated that other that
medication treatment and hospitalization. Many people with schizophrenia may be treated as
outpatients. However, people with particularly severe symptoms, or those in danger of
hurting themselves or others or who cannot take care of themselves at home may require
hospitalization to stabilize their condition. Electroconvulsive therapy (ECT)is a procedure
in which electrodes are attached to the person's scalp and, while asleep under general
anesthesia, a small electric shock is delivered to the brain. A course of ECT treatment usually
involves 2-3 treatments per week for several weeks. Each shock treatment causes a controlled
seizure, and a series of treatments over time leads to improvement in mood and thinking. The
controlled seizures it causes have a therapeutic effect, although some researcher think that
ECT-induced seizures may affect the release of neurotransmitters in the brain. ECT is less
well established for treating schizophrenia than depression or bipolar disorder, and it is
therefore not used very often when mood symptoms are absent. ECT is sometimes helpful
when medications fail or if severe depression or catatonia makes treating the illness difficult.
 CONCLUSION

During our four weeks posting at psychiatric ward and clinic everyone should take two
cases for two clerking case and two case study, document and present in comprehensive and
systematic way in real situation to patient to commit in case study. By this way I also got the
chance to have two clerking case and two case study in psychiatric ward and clinic. I gained
more knowledge in depth by comparing the management of patient with the information that
I collected from internet, clinical instructor, lecturer, doctors, nurses, laboratory and
radiology test result and compared with the patient in real situation that I mention in real case
result.

During my duty period in psychiatric ward and clinic, I provide a holistic care,
diversional therapy in every aspects such as physical, emotional, economical, social culture
view to the patient. I also gained the knowledge about the nursing theory, care and
application in real situation. So this case, Schizophrenia which I study not only gives the
cognitive domain but also provide us the opportunity to develop psychomotor domain which
is very important in Medical Assistant course, so the patient is the main source of conveying
the knowledge to practice in my posting period.

Lastly, I also got the chance to know more about infection the group of bacteria such as
Streptococcus, causes of the infection of bacteria group, its investigation, and treatment in
different article which help me to gain my knowledge. At the same time, I got the best
opportunity to investigate this case in real situation.