Filamer Chistian University

College of Nursing
Roxas City

Masquerade of
Loneliness;
A behavioral Analysis

Submitted By:
Adoyogan, Jason A.
BSN III- Barcelo

Submitted to:
Mrs. Elaine Camacho, RN
Clinical Instructor
 Introduction:

Schizophrenia is fairly common, found in approximately 1% of the general

population. Schizophrenia is not “split personality”. Although the word schizophrenia
means “splitting of the mind”, it refers to the disconnection between thought and
language that occurs in this disease. Schizophrenia accounts for 30% of all hospital
admissions, and is estimated that 30% of the homeless have schizophrenia. The onset of
the disorder typically occurs between 20 and 35 years of age, although late onset
schizophrenia occurring between the ages 66 and 77 years is not uncommon.

Reference: Porth, C. M., Pathophysiology – Concepts of Altered Health States, 6th

edition, ©2002 by Lippincott Williams and Wilkins, page 1226

General Objective

After the behavioral analysis, the students will be able to gain knowledge, skills
and appropriate attitude regarding Schizophrenia.

Specific Objectives

After this behavioral analysis, the students will be able to:

1. identify signs, symptoms and causative factors of Schizophrenia;
2. analyze the data gathered regarding the patient’s case;
3. enumerate the theories that could be applied in the patient’s case;
4. discuss the psychopathology of the case presented; and
5. formulate appropriate plan of care for the patient.
I. Psychiatric History
A. General Data

Name: J.B.
Age: 28 years old
Sex: Male
Birth Date: July 19, 1982
Address: Agcuyugan Pulo, Barotac Nuevo, Iloilo
Civil Status: Single
Education Level: College Graduate (Marines)
Patient’s Occupation: Seaman (Presently Jobless)
Father’s Name: Mr. F.B.
Occupation: Laborer in a junkshop
Mother’s Name: Mrs. J.B.
Occupation: Housewife/Quack Doctor (albularyo)
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: October 21, 2010
Attending Physician: Dr. C.S.
Informants: Patient, and Watcher

B. Chief Complaint
 Refused to take food and medicine

C. History of Present Psychiatric Illness

Two weeks prior to admission, the patient was noted to be talking and
mumbling with himself. He was observed to be withdrawing himself from others.
He would not eat and refused to take his maintenance medications. He is also
noted to have poor hygiene and he would not sleep. Due to these reasons, her
eldest sister decided to seek admission at PMHU and was given the following
medications: Olanzapine 10mg ½ tab HS, CPZ 100mg HS, Fluph dec., ½ cc (IM),
and Biperidine 2mg PRN for adverse drug reaction

D. History of Past Psychiatric History

 The first behavioral change that the patient manifested happened in 2006
when the patient ran away with no apparent reason. The patient was said to be
confused. This happened after the patient worked as a seaman. After this, the patient
stopped working because he experienced auditory hallucinations. The patient heard a
voice telling him that he was following a star. The patient would not sleep at
midnight, would open his closet and disarrange things. He then neglects about caring
for himself which resulted to his poor hygiene. The patient was then admitted at
PMHU and received the following medications: Olanzapine 10mg ½ tab HS and
CPZ 100mg HS

E. Medical/Surgical History

 There is no current medical condition noted that is significant to the patient’s

case.
 The patient’s watcher (His cousin) claimed that the patient was fully
immunized when he was a child because her mother would always bring the
patient to the nearby clinic for check-ups. The information however, can’t be
verified because there are no other sources that can prove his claim.
 The patient had no previous hospitalizations, surgeries, accidents and serious
medical problems.
 Whenever the patient experiences medical problems, his mother would use
herbal remedies to cure them.

F. Family History (Separate Sheet)

G. Personal History
Developmental Stages
Prenatal History
• There were no problem/complications during pregnancy.
 • Whenever the patient’s mother experiences any illness/medical problems,
she uses herbal plants to cure them. This is because her mother was a
quack doctor (albularyo). There are no sufficient sources to tell what those
herbs her mother used during pregnancy were.

Birth and Infancy (0-18 months)-Trust vs. Mistrust, Oral Stage

• There are no problems with labor and delivery. The patient was born
vaginally.
• Breastfed until 1 year of age. Bottle fed thereafter.
• Given complementary foods at 6 months.

Toddler (18 months-3 y/o)-Autonomy vs. Shame and Doubt, Anal Stage
• Started toilet training at 2 years of age. The informant couldn’t tell
whether the patient’s toilet training was rigid or not.
• The patient started to walk at the age of 1 ½ years old.

Preschool (3-6y/o)-Initiative vs. Guilt, Phallic Stage

• The patient is closer to his mother than his father (oedipal complex). This
complex is unresolved until the present time. A specific theory suggests
that people who have unresolved oedipal/Elektra complex will have
difficulty establishing relationships with the opposite sex. This is evident
in the patient at the present.

School Age (6-12y/o)-Industry vs. Inferiority, Latency Stage

• Plays with his cousin.
• The patient is said to be joining in school affairs but not much.
• The patient is intelligent according to his cousin.
• He is an introvert type of person. Though he speaks less he had friends in
school.

Adolescence (12-18y/o)-Identity vs. Role Confusion, Genital Stage

 • The patient was an average student in school.
• According to his cousin, he was a good child. He never makes any
problems for his family.
• He doesn’t engage in smoking.
• The patient wasn’t able to establish any relationship with the opposite sex
at this time.
• The patient was not supported by his father during his high school
education. He was the one who provided for this matter. His cousins
helped him.

Early Adulthood (18y/o-present)

• The patient still wasn’t able to develop or establish any satisfying
relationship with the opposite sex. He was productive though before his
illness manifested.
• The patient was the one who provides for his college education because he
was not supported by his father.

H. Premorbid Personality
The patient was a good son and a brother for his family. Though he is a quiet
type of person, he is friendly. He is helpful to his family. He neither smokes nor
drinks alcohol excessively. He is a responsible type of person according to his cousin.

II. Mental Status Examination

A. Appearance
 Patient is awake and calm, clad in clean clothes and properly groomed.
 Frequent mumbling and blinking of eyes was noted.
 The patient has a good posture.
 The patient has direct eye contact with the person his is talking with.
B. Speech
 The patient has a soft but audible voice of the normal low-male pitch.
Sometimes, his voice could hardly be heard.
 No pressure noted while speaking.
 Patient speaks in a normal pace.
 The patient answers whenever he is asked.
C. Affect
 The patient has appropriate affect.

D. Thinking and Perception

a) Thought Form
The patient has appropriate thought form.
b) Thought Perception
The patient perceives thoughts normally and logically as evident in the
4 NPIs.
c) Thought Content
The patient’s thoughts are coherent, and logical. Answers in a direct
manner and does not include other things that are not relevant to the topic.
These are evident in the 4 NPI’s.

E. Sensorium
a) Alertness
The patient is alert as evidenced in NPI #3 when the patient heard the
bell and he asked the student nurses if they could take a lunch.
From NPI #3:
(The bell rings)
Patient: “Manyaga ta……”

b) Orientation
The patient is oriented to time and place as evidenced by NPI #2:
Nurse: “Pwede mo mahambal kung ano ta nga adlaw kag tuig subong?”
Patient: “December 3, 2010”

c) Concentration
The patient has focus and concentration as evidenced by NPI #3 when
he was asked to spell backwards a specific word:
Nurse: “Pwede mo nong ma-spell pabaliktad ang word nga star?
Patient: “R-A-T-S. Daw rats…”

d) Memory
a. Immediate Memory
The patient has a good immediate memory as evidenced by
NPI #2:
Nurse: “Nong, mahatag ko sang tatlo ka words, tapos, liwaton
nomi sang hambal….Ball-Blue-Bag…”
Patient: “Ball-Blue-Bag”

b. Recent Memory
The patient has a good recent memory as evidenced by NPI #2:
Nurse: “Nong, ano ang sud-an mo kagina sang aga?”
Patient: “Karne”

c. Remote Memory
The patient has a good remote memory as evidenced by NPI
#2:
Nurse: “Natandaan mo pa Kung sin-o ang kapitan sang
ginsakyan mo nga barko sang 2004?”
Patient: “Si kapitan Robles”

e) Calculation
The patient has a fair calculating ability as shown by NPI #3:
 Nurse: “100-8”
Patient: “93”
Nurse: “Tama”
“93-8”
Patient: (paused for a while) “…ok ko guro kung isulat ko…pero kung
indi, madugay ko mag-solve..”
Nurse: “Ok lang nong. Mahulat lang kami…
Patient: (After almost half a minute) 85
Nurse: “Tama”

f) Abstract Reasoning
The patient has a poor abstract reasoning as evidenced by NPI # 3:
Nurse: “Nong, ano imo pagkaintindi sa muni nga hambalanon:
Aamhin pa ang damo kung patay na ang kabayo?”
Patient: “Ano to?”
Nurse: “Liwaton ko nong…. ano imo pagkaintindi sa muni nga
hambalanon:
Aamhin pa ang damo kung patay na ang kabayo?”
Patient: “Wala ko kamaan”
Nurse: “Ok lang nong. Kung ano man lang ang imo pagkaintindi..
Patient: (After a while) “indi ka mabuhi kung wala ka pangabuy-anan.

g) Insight
From NPI #2:
Nurse: “Bal-an mo bala kung ngaman ari ka diri?”
Patient: “Gindala ko di sakon mga utod guro…”
Nurse: “Ngaman gindala ka di nila?”
Patient: “Wala ko kabalo”
(The patient then looked away)
The patient’s insight is intact. It is unclear however if the patient is indeed telling
the truth when he answered that he doesn’t know why his siblings had brought him in the
mental unit. It could be that the patient doesn’t really know or that he is in-denial of his
present illness.

h) Judgment
The patient has a good judgment on how to react if a certain
unexpected circumstance occurs. This is evidenced in NPI #3”

Nurse: “Nong, hatagan ka namon sang situation, dason, ihambal nimo

Samon kung ano ang imo nga himuon…
Kung ara ka sa inyo nga balay dasun nagkasunog, ano imo
himuon?”
Patient: “Patyon ang kalayo eh…”
Nurse: “hay kung dako na gid ang kalayo?”
Patient: “Madalagan kag mangayo bulig”

III. Psychopathology
(On a separate sheet)

IV. Psychodynamics

 Dorothea Orem’s Self-care Deficit Theory

o The patient is treated as a whole human being. Patient must be
assisted in performing activities contributing to health or to its recovery that
he can perform unaided if he have the necessary will, knowledge and skills
and to do it in such a way as to help the patient regain independence as soon
as possible.
o In this case, the patient is unable to perform self-care unaided.

 Sister Callista Roy’s Adaptation Theory

o This theory suggests that human beings are open systems who
are in constant interaction with their environment. As being open systems,
there is an exchange of both matter and energy.
o Stress could be classified into two: Situational and
developmental. These two types of stress can result either in the stimulation of
the individual to perform better and improve (to adapt), or to regress
(acquiring health problems).
o As an application to the present case, the patient was unable to
handle stress. There is a poor coping mechanism which resulted in the failure
of adaptation.

 Sigmund Freud’s Psychosexual and Psychoanalytical Theory

o The patient had an unresolved oedipal complex in his phallic
stage of development which is evidenced by his being distant to his father and
being close with his mother.
o It is also said that people having unresolved complexes in the
phallic stage will have difficulty establishing relationships with the opposite
sex. This is also evident until the present time.
o According to Freud, schizophrenia is a form of regression –
back to the oral stage of development. The oral stage is the first stage of
psychosexual development. A baby is born a bundle of id – is self-indulgent
and concerned only with a satisfaction of his/her needs. There is a need to
gratify these impulses but their experiences in the real world result in conflict.
People with schizophrenia are overwhelmed by anxiety because their egos are
not strong enough to cope with id impulses.
o As the patient is still living in the real world, this may result in
further DELUSIONS such as hearing voices which may have an ultimate
authority such as God.
o This explanation suggests that schizophrenia has a
psychosomatic cause – the origin is solely in the mind. At best it could only
be a partial explanation of some symptoms, e.g. delusions. In reality, Freud is
denying the very experience of patients with schizophrenia. It is unscientific
and extremely difficult to test. Concepts such as ‘repression’ are difficult to
observe and measure, although this difficulty does not invalidate the theory.
The theory is based on unrepresentative samples, case studies, from which it is
difficult to generalize. And it involves poor methodology. The theory fails to
account for gender differences - the onset for males is around 20 years, and
for females 30 years. Nor does the theory explain why, prior to diagnosis,
their behaviour has appeared ‘normal’. Furthermore, it excludes a
consideration of the environment.

 Social and Family System Model-Dysfunctional Families

o This explanation suggests that schizophrenia is the result of
dysfunctional families. In contrast to the biological or medical approach
which may be regarded as more humane, attaching no blame to the individual,
this model by implication is attaching blame to the family. BATESON (1956)
claimed that parents predispose their children to schizophrenia by
communicating in double binds. Double binds are a no-win situation for the
child, e.g. a parent might complain about a child’s lack of affection, but when
the child does give affection, s/he is told that s/he is too old for that.
BATESON used the term ‘double bind’ to explain these ideas of contradictory
messages.

 Social and Family System Model – Emotions and Environment

o Support for this view comes from the work of BROWN (1966)
who examined the progress of patients with schizophrenia discharged from
hospital. BROWN found that those patients who came from families
characterized by high expressed emotion (high conflict, constant interference)
were more likely to return to hospital in a shorter period of time. 58% of
patients returned to high EE families experienced a relapse compared with
10% returning to low EE families. The implications of this research are that
the environment has a significant role to play in the course of the development
 of schizophrenia. However, the direction of causation is unclear – it may be
that living with a person with schizophrenia is causing hostility and high
expressed emotion within the family. Alternatively, it may be the family that
is causing the relapse. The effects of stress on the immune system and on the
incidence of disease and illness are well-known (Brady, Selye, Kiecolt-Glaser,
Jacobs & Charles, Friedman and Rosenman). If stress has a role in physical
illness, it may well have a role in mental illness.

 Social and Family System Model – Cognitive Deficits

o Also, it may be noted that schizophrenia is characterized by

cognitive deficits – disorganized speech, hallucinations, delusions – and a
cognitive model focuses more tightly on these deficits. Deficits in
information processing may leave people vulnerable to the behaviours
typically seen as symptoms of schizophrenia. The cognitive approach tends to
be descriptive rather than explanatory and tend to use the biological model to
explain the origin of schizophrenia. Research does suggest that people with
cognitive deficits are highly susceptible to the influences of stress.

 Social and Family System Model – Diathesis Stress Model

o The diathesis-stress model combines biological and genetic
factors with levels of stress. Diathesis refers to a predisposition (innate) and
the stress is environmental (nurture). This model suggests that mental
disorders are the result of an interaction between nature and nurture. Tienari’s
Finnish study revealed that none of the adopted children raised in ‘healthy’
families developed schizophrenia, but 11% in severely disturbed families went
on to do so. The bio-psycho-social approach is a more eclectic approach to
studying and understanding schizophrenia.

V. Nursing Care Plans

(on a separate Sheet)