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CHAPTER 15 ■ Schizophrenia Spectrum and Other Psychotic Disorders
CASE STUDY AND SAMPLE CARE PLAN—cont’d PLANNING AND IMPLEMENTATION RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE 1. Keep the stimuli as low as possible in Frank’s environment.
2. If these behaviors are observed, ask Frank, “Are you hear- ing the voices again?” 3. Encourage Frank to share the content of the hallucina- tions. This information is important for early intervention in case the content contains commands to harm himself or others. 4. Say to Frank, “I understand that the voice is real to you, but I do not hear any voices speaking.” It is important for him to learn the difference between what is real and what is not real. 5. Try to help Frank recognize that the voices often appear at times when he becomes anxious about something and his agitation increases. 6. Help him to recognize this increasing anxiety, and teach him methods to keep it from escalating. 7. Use distracting activities to bring him back to reality. Involvement with real people and real situations will help to distract him from the hallucination. 8. Teach him to use voice dismissal . When he hears the CO’s (or others’) voice, he should shout, “Go away!” or “Leave me alone!” These commands may help to diminish the sounds and give him a feeling of control over the situation. EVALUATION The outcome criteria identified for Frank have been met. When feeling especially anxious or becoming agitated, he seeks out staff for comfort and for assistance in maintaining his anxiety at a manageable level. He currently denies suicide ideation and has collaborated to develop a personal safety plan. He is experiencing fewer auditory hallucinations and has learned to use voice dismissal to interrupt the behavior. He is beginning to recognize his position in the grief process and is working toward resolution at his own pace. active psychotic phase (schizophrenia), and (IV) the residual phase. ■■ The cause of schizophrenia remains unclear. Most likely, no single factor can be implicated; rather, the disease probably results from a complex inter- action of genetic, biochemical, psychological, and environmental factors. ■■ A spectrum of schizophrenic and other psychotic disorders has been identified. These include (on a gradient of psychopathology from least to most severe): schizotypal personality disorder, delusional disorder, brief psychotic disorder, sub- stance-induced psychotic disorder, psychotic dis- order associated with another medical condition,
2. Monitor Frank’s behavior frequently but in a manner of carrying out routine activities so as not to create suspi- ciousness on his part. 3. Watch for the following signs (considered the pro- drome to aggressive behavior): increased motor activ- ity, pounding, slamming, tense posture, defiant affect, clenched teeth and fists, arguing, demanding, and chal- lenging or threatening staff. 4. If Frank should become aggressive, maintain a calm attitude. Try talking. Offer medication. Provide physical activities. 5. If these interventions fail, indicate a show of strength with a team of staff members. 6. Utilize restraints only as a last resort and if Frank is clearly at risk of harm to himself or others. 7. Help Frank recognize unresolved grief and fixation in denial or anger stage of grief process. 8. Encourage him to talk about the loss of his mother and of fellow Marines in Afghanistan. 9. Encourage him to talk about guilt feelings associated with survival when others died. 10. Assess for presence of suicide risk and collaborate with the patient to develop a personal safety plan. DISTURBED SENSORY PERCEPTION: AUDITORY 1. Monitor Frank’s behavior for signs that he is hearing voices: listening pose, talking and laughing to self, stop- ping in midsentence. Summary and Key Points ■■ Of all of the mental illnesses, schizophrenia undoubtedly results in the greatest amount of per- sonal, emotional, and social costs. It presents an enormous threat to life and happiness. ■■ For many years, there was little agreement as to a definition of the concept of schizophrenia. The DSM-5-TR (APA, 2022) identifies specific criteria for diagnosis of the disorder. ■■ The initial symptoms of schizophrenia most often occur in early adulthood. Development of the dis- order can be viewed in four phases: (I) the pre- morbid phase, (II) the prodromal phase, (III) the
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