Running Head: Schizoaffective Disorder Case Study 1

Schizoaffective Disorder Case Study

Emily M. Vela

Youngstown State University

Running Head: Schizoaffective Disorder Case Study 2

Abstract

Patient PB was observed on October 4th, 2016 in the Psychiatric Intensive Care Unit at

Trumbull Memorial Hospital. The patient was admitted for increased delusions and

hallucinations, as well as homicidal ideation against her husband. The patient was not

medication complaint and was started on new medications in the emergency room. The

patient wandered the hallways and her room, only speaking when spoken too. Her

thought processes are disorganized with flight of ideas and is delusional and paranoid.

The articles reviewed discussed the use of lithium or carbamazepine in schizoaffective

disorder and its effect on hospitalizations after long-term use and a review of

schizoaffective disorder, including pharmacological management, co-morbidities and

schizoaffective verses schizoaffective disorder.

Keywords: schizoaffective disorder

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Observations and Objective Data

PB is a 44-year-old African American female with a long history of

schizoaffective disorder. She was brought into the emergency department on September

30th, 2016 by emergency medical service after they received a phone call that she was

having homicidal ideation towards her husband. The patient was having delusions that

her husband was cheating on her causing her to have homicidal ideations. Per her

admission paperwork, she stated to the emergency department, I am going to kill this

MF, better sleep with one eye open.

The patient was pink slipped onto the floor due to increased psychosis and

homicidal ideation. The DSM IV-TR Axis I diagnoses the patient with schizoaffective

disorder. Her attending physician did not fill out Axes II-IV. Upon her admission, the

patient was noted to be irritable and angry. She was alert and oriented to the date, month

and year. She spoke with a normal volume and tone, however her affect was labile and

angry. The patients thought process was disorganized with flight of ideas and looseness

of association. The patient denied auditory and visual hallucinations, but was responding

to stimuli. The patient was recorded in her History and Physical as being delusional and

paranoid. The patient denied suicidal ideation and homicidal ideation, regardless of the

fact that she was brought in by emergency services for threatening homicidal ideation on

her husband.

On October 4th, 2016, the day of patient observation, she was seen wandering the

hallway. She spoke to the nurses in a friendly tone and asked them when the doctor

would arrive. While she was being friendly with the staff today, her nurse said that she

had been hostile and aggressive with the respiratory therapist. The patient was fixated on
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finding her identification card because she needed to pick up her social security check.

She asked multiple nurses if she could go and find her identification before the doctor

came, as she needed to cash her social security check so that she could pay him.

Afterwards, the patient returned to her room, stating it was too freaking cold in

the hallway. She asked the nurses to wake her up when the doctor came to the floor.

While she was in her room, further discussion with her nurse revealed that the patient was

frequently placed on the floor, and that her husband was also a patient on the psych floor.

The nurse said that she had gotten reports that the husband often encourages the patient to

skip doses of her medications, leading to an increase of her symptoms and causing her to

have to be hospitalized. The nurse also disclosed that the patient encouraged her husband

to skip his medication as well, which has lead to him being hospitalized multiple times

too.

When the breakfast trays arrived, the patient wouldnt come out of her room,

stating that it was too cold. The nurse tried to convince her to come out and eat, but

took the tray to the patients room upon her refusal. Once again, the patient asked the

nurse if the doctor was up yet, stating that she needed to find her identification card

before she saw him. The nurse redirected her and got her to eat some of her breakfast.

The patient walked around the floor with a tense posture and a depressed facial

expression. While her tone was friendly, her facial expressions did not match her pitch or

tone. She was wearing a pair of pajamas that she had brought from home, which were

soiled and dirty. She had unkempt hair and poor hygiene. She was restless, often pacing

the hallways or in her room. After breakfast, she finally decided to lie down and sleep

until the doctor arrived. She had no reports of akathisia, dyskinesia or akinesia. When the
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nurse asked how her mood was, she simply said okay and then continued to wander the

hallway. She was oriented to the date and time, however her judgment was impaired as

evidenced by her obliviousness as to why she was hospitalized. According to her nurse,

she does not grasp the concept of her diagnosis of schizoaffective disorder and does not

understand how it affects her.

The patients medical history includes diabetes mellitus and hypertension, along

with a long history of schizoaffective disorder. She was being housed in the Psychiatric

Intensive Care Unit and was on suicide and self harm precautions.

P.B. presents with multiple limitations, including difficulty communicating

thoughts and feelings, anger, no insight to her mental illness and refusal of treatment due

to her belief that there is nothing wrong with her. The patient lacks social skills and

possesses a negative attitude about her life. She has poor concentration and poor

judgment and is unable to sequence information. The patient also struggles with martial

conflicts with her husband of five months. Her assets include a loving, supportive family.

Upon being seen in the emergency department, the patient was started on

Wellbutrin 150 mg for depression, Klonopin 0.5 mg for anxiety, Risperdal 3 mg for

schizophrenia and Depakote 500 mg as a mood stabilizer. These medications were added

on to her already extensive list of daily medications. Currently, the patient takes Novolog

on a sliding scale for her diabetes, along with Levemir, 50 units subcutaneously every

night for her diabetes. Metformin 500 mg is also taken twice a day to help with her

glucose levels. The patient takes lisinopril 20 mg everyday and metoprolol 100 mg twice

a day for control of her hypertension. 10 mEq of Potassium Chloride are also taken daily

as a vitamin supplement. The following medications are taken on an as needed basis: 600
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mg of acetaminophen for pain or fever, 180 mcg of albuterol for shortness of breath, 10

mg of bisacodyl for constipation resulting from antipsychotic medications, 25 mg of

diphenhydramine for allergies, which is also given in conjunction with 2-5 mg injection

of haloperidol for agitation. A 1 mg injection of Glucagon is given to increase blood

glucose, as well as glucose 12.5 gm IV push if needed for low blood sugar. Lorazepam

0.5 mg is taken as needed for anxiety and agitation. 100 mg of trazodone is given at night

for insomnia.

Discharge criteria for this patient includes being free of paranoid thoughts and

consistent stabilization of mood. The patient is to be discharged home with her husband

once she is deemed stable and free of homicidal ideations.

Psychiatric Diagnosis and Expected/Common Behaviors

Schizoaffective disorder is defined by the co-occurrence of a manic or major

depressive syndrome and at least one of some symptoms suggesting schizophrenia

(including several Schneiders first-rank symptoms, but also hallucinations of any type

throughout the day for several days or intermittently throughout a 1 week period []

(Maj, Pirozzi, Formicola, Bartoli, and Bucci, 2000, p. 95-96). Schizoaffective disorder

has three measures that separate it from schizophrenia. According to the DSM-IV, this

disorder is defined by: a) the co-occurrence at some time during a period of illness, of a

manic, major depressive or mixed syndrome and of symptoms meeting the criterion A for

schizophrenia; b) the presence, during the same period of illness, of delusions or

hallucinations for at least two weeks in the absence of prominent mood symptoms; c) the

presence of symptoms meeting criteria for a mood episode for a substantial portion of the

total duration of the active and residual periods of illness (Maj et al., 2000, p. 96).
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Schizoaffective disorder is further broken down into three criteria. According to

the DSM-IV, Criterion A states that patients must have a major mood episode that is

coexisting with symptoms that meet criterion A for schizophrenia, such as delusions and

hallucinations. Criterion B states that the delusions or hallucinations must persist for at

least two weeks with an absence of prominent mood symptoms. Finally, Criterion C

states the mood symptoms must be present for a substantial portion of the illness

(Kantrowitz & Citrome, 2011, p. 319).

Furthermore, Kantrowitz and Citrome (2011) state that schizoaffective disorder

can be divided into two subtypes. These two subtypes are bipolar type and a depressive

type. Bipolar type has the psychotic symptoms as well the presence of a manic or mixed

episode. Schizoaffective disorder can be classified as depressive if major depressive

episodes have taken place. The patient presents with bipolar type schizoaffective disorder,

as evidenced by her manic and mixed episodes.

Kantrowitz and Citrome (2011) compared patients with schizophrenia to patients

with schizoaffective disorder in numerous studies and found that patients with

schizoaffective disorder performed better than patients with schizophrenia. They found

that patients with schizoaffective disorder may be particularly superior in temporal lobe

dependent cognitive functions, such as delayed recall (Kantrowitz & Citrome, 2011, p.

323). Additional studies performed used visuomotor tasks (such as paired associated

learning and motor screening) to rank patients in neurocognitive performance. These

studies have found that patients with schizoaffective disorder were superior over

schizophrenic patients (Kantrowitz & Citrome, 2011). This study would suggest that the

patient diagnosed with schizoaffective disorder would be better able to maintain a higher
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functioning than a patient who is diagnosed with schizophrenia. This patient, however

would have been an outlier in this study as her cognition was severely impaired due to the

anger, anxiety and depression that was caused by the delusions and hallucinations.

Kantrowitz and Citrome (2011) also compared the medical diagnoses of patients

with schizoaffective disorder and schizophrenia. They found that patients with

schizoaffective disorder were more likely to suffer from metabolic disorders than

schizophrenic patients. Patients with schizoaffective disorder were 19% more likely to

have diabetes, 44% more likely to have coronary artery disease and 18% more likely to

have dyslipidemia (Kantrowitz & Citrome, 2011, p. 325). While the exact reasoning as

to why they are at higher risk is unknown, it is believed that it is due to multifactorial

risks that most schizoaffective patients have, including genetics disposition, unhealthy

lifestyle, and a potential impact of the antipsychotic drug therapy (Kantrowitz & Citrome,

2011). Relating to the patient, this helps to explain possible reasons for her diabetes

mellitus, as she suffers from schizoaffective disorder and has been on long-term

antipsychotic drug therapy while living an unhealthy lifestyle.

Baethge, Gruschka, Berghofer, Bauer, Muller-Oerkinghausen, Bschor, and

Smolka (2004) discussed the effect of long-term lithium/carbamazepine therapy on

patients with schizoaffective disorder. They found that the course of the illness was

significantly improved during prophylaxis as shown by the sharp decline in

hospitalization rate (Baethge, Gruschka, Berghofer, Bauer, Muller-Oerkinghausen,

Bschor, & Smolka, 2004, p. 47). The importance of this study is that it shows that

schizoaffective patients who receive drug therapy from lithium/carbamazepine

experience significant and lasting improvements in their condition (Baethge et al.,

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2011, p. 49). The patient, who is currently not taking lithium or carbamazepine, has

frequent hospitalizations due to her schizoaffective disorder. However, it cannot be

determined if the lithium/carbamazepine therapy would help to decline this patients rate

of hospitalizations as she is not medication compliant.

Precipitated Stressors and Behaviors

This patient has had to multiple psychiatric hospitalizations in her lifetime due to

her schizoaffective disorder. The stressor that triggered her hospitalization on September

30th, 2016 was the patients husband. The patient and her husband had gotten married five

months ago. Since the wedding, the husband has frequently encouraged the patient to

stop taking her medications. Because of this, she began to have delusions that her

husband was cheating on her. These delusions caused her to have homicidal ideations

towards her husband and she attempted to murder him. The police were called and the

Niles Police Department brought her into the emergency room, where she was admitted

onto the psychiatric floor.

Patient History

The patients chart did not have much information on her history. She has had

multiple admissions onto the psychiatric floor due to schizoaffective disorder. She has no

history of suicide attempts and no family history of suicides. The patient denies drug and

alcohol use. She also denied sexual and physical abuse.

Psychiatric Nursing Care and Milieu Activities

The psychiatric nursing care provided to this patient followed the concept of

milieu therapy, where each interaction with the patient is an opportunity for therapeutic

intervention. The nurses established trust and rapport with the patient, making it easier for
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her to come to them with issues and problems. The patients ability to carry out activities

of daily living were assessed and the nurses were working on maximizing the patients

level of functioning in order to help her return to her normal level of functioning. They

assessed the patient frequently for signs and symptoms of schizoaffective disorder that

would indicate an increase of delusions or an episode of mania. The nurses maintained a

safe environment for the patient, allowing her to pace and wander without harming

herself and they redirected her when she began to obsess over certain things, such as

finding her identification card. The nurses also presented her with offering of self by

making sure she knew she could come to them at any time to talk. They spoke to her in a

calm and level tone and she would lower her voice to match their pitch and tone, helping

to calm her when she began to get agitated. The patient did not attend any milieu

activities.

Social

The patient is an African American female who was born and raised in Cleveland,

Ohio. She got married five months ago and currently lives with her husband. Her chart

states that she had a son, but does not elaborate as to what happened to him. She is

unemployed and collects social security. Her chart states that she is a Christian, but her

religion does not seem to impact her day-to-day life. Her ethnicity has made her more

susceptible to hypertension and her culture does not seem to influence her life.

Patient Outcomes

The patient outcomes are as follows: the patient will state to a staff member that

depressive symptoms are under control. She will not have depressive symptoms interfere

with the completion of ADLs for three days. She also will not have depressive symptoms
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interfere with the completion of social and leisure activities. The patient will have no

episodes of self-harm for three days and will be able to verbalize three alternatives to

violent behaviors towards self or others. The patient will also identify three community

resources that will be used to reduce depressive symptoms. She will also identify to staff

two strategies to decrease personal anxiety and will state at least two personal risk factors

and defining characteristics of anxiety.

Plans for Discharge

The patient is to be discharged home with her husband. In order to be discharged,

the patient must consume adequate nutrition to maintain bodily needs by the time of

discharge. She must be able to demonstrate the ability to recognize, accept and cope with

symptoms of depression by the time of discharge. The patient must be free of paranoid

thoughts and delusions and must be free of suicidal and homicidal ideation.

Actual Nursing Diagnoses

One nursing diagnosis for this patient was Sensory and Perceptual Alterations

related to history of depression, history of psychiatric illness, conflict and insecurity and

ineffective coping skills as evidenced by irritability, delusions and blaming. Another

diagnosis is impaired verbal communication related to psychiatric history and insecurity

as evidenced by poor concentration, and a depressed, flat affect. She also had a diagnosis

of Imbalanced Nutrition: Less than bodily requirements related to poor nutrition and

paranoia as evidenced by patient not eating meals.

Potential Nursing Diagnoses

A list of potential nursing diagnoses are as follows:

Risk for injury related to delusions and hallucinations

Risk for violence related to delusions and paranoia
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Self care deficit related to depression and anxiety

Social isolation related to depression
Ineffective coping related to delusions and anxiety
Impaired social interaction related to depression, anxiety and delusions.
Ineffective role performance related to psychiatric hospitalization as

evidenced by homicidal ideations towards husband.

Citations

Baethge, Christopher, Gruschka, Philipp, Berghfer, Anne, Bauer, Michael, Mller-

Oerlinghausen, Bruno, Bschor, Tom, Smolka, Michael N. (2004). Prophylaxis of

schizoaffective disorder with lithium or carbamazepine: outcome after long-term follow-

up. Journal of Affective Disorders, 79(1-3), 43-50

Kantrowitz, Joshua, & Citrome, Leslie (2011). Schizoaffective Disorder: A Review of

Current Research Themes and Pharmacological Management. CNS Drugs, 25(4), 317-

331

Maj, Mario, Pirozzi, Raffaele, Formicola, Anna Maria, Bartoli, Luca, & Bucci, Paola

(2000). Reliability and validity of the DSM-IV diagnostic category of schizoaffective

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disorder: Preliminary data. Journal of Affective Disorders, 57(1-3), 95-98