Diagnosis criteria and clinical treatment of mental disorders have been changing over the years to eliminate cases of misdiagnosis and inadequate care. Diagnostic Statistical Manual of Mental Disorders (DSM-V) came up with changes in the Diagnosis process of (DSM-V) disorders explaining the anticipated impact of the changes in mental health professionals. The manual helps the clinician to align the disease with the International Classification of Diseases (ICD-9) while considering the social, political, and cultural dynamics influenced by the development of the DSM-5. The manual assesses and conceptualizes cases of individuals suffering from mental disorders, which guiding the clinicians on the best treatment plan. According to Buckley (2014), DSM-V helps the clinician to issue clinical information to the patients and the family effectively and also help the clinician to implement effective intervention useful for improving clinical outcome. The clinician applies the manual when predicting future care management and also in differentiating various mental disorders. DSM-V has proven to be very useful in the diagnosis and treatment of various mental disorders leading to a favorable clinical outcome. The paper will follow the clinical guideline presented in DSM-V in providing care and treatment of a patient who has Schizophrenia. The focus will be on the background information of the patient will be analyzed, DSM-V diagnosis, treatment plan, objectives, and methods of care intervention to achieve the required outcome.
Background History Identifying Information (hypothetical only)
A 25-year old African-American man named Kyle was brought to the emergency room by the police officers of the company from which he had been suspended six months ago. The manager of his department had called the CEO and reported that Kyle had stormed into his office and accused him of taking bribe from him for promotion, which he never received. Kyle was successful in academics, and when he began his job at the audit firm, but his behavior became odd during the past one year. Kyle stopped hanging out with his friends and stayed alone in the workplace and at home. His social life became miserable, and he could no longer hold a conversation in a social gathering or with his close family members. He could spend days without speaking to any family member despite living in the same compound. Kyle had been sacked for missing work and attending work very late in the morning and leaving earlier. Also, his work organization had been affected where he could no longer accomplish his task on time and could not work as teamwork. He stopped caring about his appearance; he could go days without taking a bath and wore the same clothes for days. During the clinical visit, his brother said that he had seen him sometimes mumbling to himself and other times talking loudly to people who were not there. Sometimes he emerges from his room and commands his family to keep quiet even when they were quiet doing their daily chores.
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Reason for Referral Presenting Problems DSM-V Diagnosis
Kyle was referred to the emergency room after showing symptoms of frequent hallucinations and delusions. Kyle began talking of organized crimes in the workplace, where the manager had given him the role of organizing the gangsters targeting to break in the finance office. Also, he revealed increased cases of hallucinations where he would walk in the middle of the night to meet with his invisible colleagues. When asked by his father and sister the reason behind his unusual behavior, he failed to explain; he laughed and walked away. His father revealed that for the past three months, Kyle's communication became poor and could not make eye contact and show facial expression when something unusual happens. Upon examination, Kyle was found to be poorly groomed, inattentive and could not communicate effectively with the family members and the doctors. Kyle's father said he had never known his son to use any drugs or alcohol. The test for substance abuse as negative, meaning Kyle has never engaged in alcohol and drug abuse. While in the hospital. Kyle refused to eat food provided in the hospital, fearing that there were some drugs hidden inside the food. The clinician asked for detailed family history to determine whether there are cases of mental disorders in the family. Kyle’s mother and sister said that his great-grandfather had a severe mental illness, and he stayed at the state hospital for 25 years. Also, his mother, who left the family when Kyle was young, had some mental health problems. Based on the information provided, the doctor requested Kyle to sign himself into the psychiatric unit for further checkup and treatment.
Symptoms of Schizophreni a
Schizophrenia is a severe chronic mental disorder that affects the thinking, feeling, and behavior of a person. People with schizophrenia feel that they have lost touch with reality and begin experiencing delusions, hallucinations, agitated body movements, and thought disorders. Patients with Schizophrenia are easily overwhelmed with the external environment and feel disconnected from society (Hooley, Butcher, Nock & Mineka, 2016). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), the lifetime prevalence of schizophrenia ranges between 0.3% to 0.7% (American Psychiatric Association, 2017). T the psychotic features of disorders emerge in mid-teens and mid-thirties. Mostly, adults with this disease reveal symptoms at the peak during their mid-twenties. Being 25 years, the symptoms reveal cases of schizophrenia. The signs and symptoms of Kyle began showing itself when he started losing functional consequences and touch with reality. In the past few years of job, Kyle was focused as revealed through positive results and awards from his manager until a few months ago when he lost focus and isolated himself from his colleagues and family.
The significant symptoms revealed by an individual with schizophrenia include delusions, hallucinations, disorganized speech, catatonic behavior, and reduced emotional expression ( TheMentallight, 2010) . Impairment is a significant area of functioning for a specific duration, which affects their workplace, education, self-care, and interpersonal relations. Kyle revealed such impairment when he was sacked for poor performance, and his self-care deteriorates as he spent days without taking a shower. For the past ten months, Kyle has been revealing signs and symptoms of schizophrenia. According to DSM 5, various features need to be identified before diagnosing an individual with a particular mental disorder (American Psychiatric Association, 2017). The features that led to the diagnosis of schizophrenia by psychiatrists include laughing in the absence of stimulus, anxiety and phobias, depression, disconnection from self, and derealization. Also, Kyle revealed impairment in communication, poor social relationship, and some hostility among colleagues and family members. Therefore, Kyle requires adequate therapy and treatment to help him improve his condition over time.
DSM-5 Diagnosis
DSM 5 outlines various diagnoses of schizophrenia among patients. Before diagnosing the patient with schizophrenia, the patient must reveal some symptoms for at least one month or longer. Kyle went through four diagnoses, including the physical exam, to rule out other problems and check for any related complications. Tests and screening like CT and MRI were conducted to rule out other similar symptoms of a different condition (Hooley et al., 2016). The other test conducted was a psychiatric evaluation, where a profession in mental health conducts some checkups in Kyle while asking essential questions like behavior. The last test is diagnostic criteria for Schizophrenia per DSM-5. The prognosis of Kyle disorder is unpredictable hence requires adequate treatment to eliminate chronic symptoms, psychotic episodes, and inadequate response to antipsychotics. According to (DSM-5), the diagnosis of Kyle s reached through assessment of the specific signs and symptoms presented (American Psychiatric Association, 2017) . (DSM-5) States that for an individual to be diagnosed with schizophrenia, they must exhibit a reduced level of functioning at work or in academics, poor interpersonal relationships and self-care. The signs must be revealed continuously for at least six months. The clinician had to put Kyle under comprehensive differential diagnosis to distinguish schizophrenia from other disorders like major depressive disorder, schizoaffective disorder, obsessive-compulsive disorder, and post-trauma disorder. Schizophrenia disorder is differentiated from other mental conditions based on the timing of delusions and hallucinations, duration of the illness, and severity of depression (TheMentallight, 2010). Since Kyle was not abusing any substance, and he was not suffering from any other medical condition, the doctor diagnosed him with schizophrenia.
In the treatment and management of schizophrenia, diagnostic concepts play an essential role. According to Dadlani, Overtree & Perry (2012), practitioners diagnosing mental illness have to identify the social, political, and historical context of the patient. The actual causes of schizophrenia are unknown, although a combination of various factors is believed to cause the infection. Schizophrenia contains variable phenotypic expressions that are poorly understood. Combinations of brain chemistry, environments, and genetics are believed to contribute to the disorder. In the case of patient Kyle, family history is one of the significant risk factors that led to his condition. When he was referred to the hospital, the father and brother of Kyle informed the doctor that their family has a history of mental disorders. Schizophrenia is a complex disorder, and the weakness of the diagnostic concept of the disorder is based on assumptions of an underlying but still unknown disease. According to Jablensky (2010), there is underlying functional and structural pathology that links schizophrenia with other disorders like bipolar affective disorder, psychoses, and neurodevelopmental disorders. According to Kraepelin, schizophrenia originates from physiology, neuropathology, and biological chemistry of the brain. There is no known cure for schizophrenia, but better care, together with the intake of a given medication, improves the condition over the years.
Treatment Plan Goals (long term)
Treatment for schizophrenia requires adequate planning to ensure the best treatment and management therapy is provide to Kyle. Treatment for schizophrenia is lifelong, where medication and therapies are issued even after the subdue of symptoms. Since schizophrenia is a chronic illness that affects all aspect of an individual’s life, treatment planning aim to reduce symptoms, maximize the quality of life and adaptive functioning and ensure recovery through assisting the patient to achieve personal life goals. The treatment of Kyle will involve three phases of acute, stabilization, and stable ( Remington et al., 2017) . In the first phase of acute, the treatment will include reducing the symptoms up to the patient's baseline. The stabilizing phase involves a time-limited transition to proceed with treatment while the stable phase deals with prolonged treatment and rehabilitation to control symptoms, improve functioning, and total recovery. The treatment plan will thus involve antipsychotics medication and Psychosocial interventions.
Objectives
The overall objectives of the treatment are to improve the patient's condition and help them go back to their healthy lives and activities. Pharmacological treatment is initiated during the acute phase to reduce risky behaviors like suicidal thoughts and emotional distress associated with the disruption of the patient's life. Administering of psychoactive medications during the acute phase treats comorbid condition coon in schizophrenia patients like aggression, affective symptoms, and sleep disturbance. Treatment during the stabilization phase aims to control symptoms, reduce stress, minimize the possibility of relapse, enhance adaption to life in the society, and promote the overall recovery proves. Adequate education and therapies on the causes of the illness and the best way to manage the condition achieve the most favorable results. During the stable phase, the objective of treatment is to sustain remission of symptoms by minimizing the risks and improving the recovery process. Continuous assessment ad monitoring of the patient is crucial to ensure the treatment given is adequate. The purpose of assessment is to maintain ties with the patient through interaction to identify any resurgence of symptoms. Kyle will undergo therapy for one year while under close supervision. From there, the family will be required to monitor him closely and guide him to go back to normal functioning while taking his medication and frequently visiting the psychiatric for check-ups.
Antipsychotics medication
Kyle will be treated using Second-generation agents antipsychotics and First-generation antipsychotics. The goal of treating Kyle using antipsychotic medication is to effectively manage the signs and symptoms of the condition using the lowest dose. Various drugs will be initiated to achieve the desired results while observing the patient over time. The patient will first be treated using Pharmacological Therapy during the acute psychotic episode. During the first two weeks of administering medication, the goal is to reduce hostility and return the patient to their normal functioning. The medicine will be administered based on the response of Kyle to the drug. While taking medication, Kyle will be taken through maintenance therapy to help increase his socialization and improve self-care. Maintenance therapy help in the prevention of relapse. After the remission of a forth psychotic episode, Kyle will continue with drug therapy for a minimum of one year. Another effective medication that the patient will be given is second-generation medications. Another medicine given to the patient is Antipsychotics (SGAs) (Hooley et al., 2016). SGAs have metabolic side effects like diabetes mellitus and weight gain; hence, the reason for the unwillingness of many patients to take medicine.
The treatment will be given in five stages, which cover the acute, stabilization, and stable phases while observing the level of improvement. During the first stage, the patient will undergo first-line monotherapy with an SGA and proceed with the second stage if the patient shows no response. The second phase involves monotherapy treatment with SGA or first-generation (typical) antipsychotics (FGAs). According to Remington et al. (2017), if Kyle still shows no response, he will proceed to stage three of clozapine monotherapy, which involves monitoring and counting of white blood cells. During this stage, the intake of clozapine should be discontinued if agranulocytes occur. The fourth stage involves a combination of clozapine with an FGA, an SGA, while the last step consists in combining therapy with an SGA, an FGA, ECT, and a mood stabilizer. Before administering any of the above antipsychotic medications, the psychiatric will gather adequate information from the patient and family to determine whether the patient has ever shown unfavorable responses to any treatment.
Methods or Interventions/Psychosocial interventions.
Family therapy
Family therapy is given to provide support and education to family members of patients with schizophrenia to ensure adequate treatment and management of the condition. Schizophrenia causes psych disabling experience and stress to the patient and family members since they are the primary care providers. Caring for patients with a mental disorder is burdensome and has an effect on the physical, emotional, or psychological and socioeconomic health problems of the family members (Hooley et al., 2016) . Family intervention reduces emotions, stress, and family burden associated with treatment and disease management. According to Chien, Leung, Yeung, & Wong (2013), the family intervention takes the form of psychosocial, behavioral management, and education approaches. The intervention focus on reducing the expression of anger and guilt by family members, maintain a positive expectation of patients' performance and attain reasonable changes. The family members are educated on the signs of schizophrenia to enhance competency and avoid treatment delays to achieve early recovery. The family members are educated on the support and care to give to Kyle to ensure a quick recovery and get back to daily activities. Therefore, adoption of family intervention when communicating schizophrenia help in reducing emotional buildup, improving coping strategy, and enhancing care essential for the treatment and management.
Individual therapy and cognitive therapy
While undergoing treatment, Kyle will be taken through individual cognitive therapy to help normalize his thought and enhance coping strategy. Cognitive therapy is standardized to help Schizophrenia patients cope with psychotic symptoms, which medicine cannot control. The intervention deals with examination and revaluation of the patient's thoughts and their perception of experience ( Remington et al. , 2017). The therapist uses e the "misinterpretation" of the patient to assist them in managing the condition and going back to normal daily activities. Cognitive therapy helps individuals with schizophrenia to use reasoning and personal experience to develop rational explanations and interpretations for coping, problem-solving, and self-management of the symptoms (Chien et al., 2013). Kyle will be taught how to deal with stress and how to identify early signs in the future. Cognitive therapy reduces symptoms and help the patients with schizophrenia to recover within nine to twelve months. Countries like the United Kingdom and the United States have recommended the adoption of cognitive therapying enhancing treatment and recovery of schizophrenia.
Social skill training
Social skill training is another intervention given to patients with schizophrenia to help patients acquire instrumental and affiliative skills to achieve interpersonal, self-care, and social skills. According to Remington et al. (2017), the goal of social skill training is to help the individual begin functioning as they used to do before. During this therapy, Kyle will be taught specific behavior that will help his social interactions and boost his communication. During social skill training, Kyle will also be taught ways of managing antipsychotic medication, identifying their side effects and warning signs of relapse, and express his need for the community and attend job interviews. Therefore, social skill training is useful to help schizophrenia patients recover their role functioning.
Outcome Measures (what measures you will use to assess client progress/outcome)
Upon issuance of all the necessary treatment and therapies, the progress of Kyle will be evaluated based on mental recovery and return to roe functioning. The recovery outcome will be defined as both objectively and subjectively. The objective dimension will measure the return of Kyle to his usual full-time work and family participation. The Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS) will be used to measure improvement. Other tools used to measure the outcome of the treatment and therapy given on schizophrenia patients include Positive Symptom Rating Scale and the Brief Negative Symptom Assessment. Patients who are diagnosed with schizophrenia reveal a decreased life expectancy between 10 to 25 years compared to healthy persons. Since treatment of Schizophrenia is a lifelong, subjective outcome is measured in terms of life satisfaction, hope, and knowledge of their mental conditions. Positive outcome and incr4sed mortality will be revealed through Kyle’s lifestyle after the treatment like physical exercise, proper dieting, and socialization.
Self-Critique
Treating patients with schizophrenia requires adequate skills to deal with emotions and effective communication. When treating Kyle, I was at one point, overwhelmed with emotions seeing how Kyle was stigmatized and seemed to have lost hope with life. I had to compose myself and establish a therapeutic relationship and help the patient understand the symptoms and management of the condition. As a clinician, I possessed effective communication skills which help in the treatment of schizophrenia and other mental related disorders. I applied my skills in active listening to hear, process, and comprehend the words of the client. As a clinician, I applied the therapeutic skill of data collection using the open-ended questionnaire to get a better understanding of the symptoms and the client's feelings of the condition. Another skill that helped me in the successful treatment of Kyle is cultural competency. Cultural competency skills enabled me to effectively communicate with Kyle and their family members and guide them through the treatment and management of the condition. According to Tummala, Singer, Li, Esposito & Ash (2012), cultural competency entails an assessment of cultural identity, acculturation, family dynamics, and explanatory models of illness and healing. The cultural competency of the therapists determines how the patients and the family perceive the information issued.
While treating Kyle, I might face the challenge of racial attitude been a white psychiatrist, while Kyle is a Black American. Another challenge faced is a communication barrier where the family of Kyle did not understand English fluently; thus, I had to look for an interpreter. Another problem faced when treating schizophrenia is identifying substance use disorders. According to Desmarais, Sellers, Young & Swartz (2012), there is diagnostic uncertainty when searching from substance abuse among adults with schizophrenia arising from insufficient time to observe behavior, poor memory from the patient, inconsistency self-reporting and interference with antipsychotic medication.
Before diagnosing and treating a patient with mental illness, the clinician needs to adhere to an ethical issue, especially those related to culture and the medical profession. The clinician should be aware of moral issues related to culture, as outlined in DSM-IV. The primary ethical problem encountered during the treatment of mental illness like schizophrenia is making informed consent on treatment ( Noordsy, 2016) . Patients with schizophrenia lack insight and the ability to make an informed decision regarding their health and medications. The clinician has to involve the family in deciding on the treatment. Another ethical dilemma arises between telling the truth to patients with schizophrenia who are paranoid and hiding some information for emotional needs. The doctor struggles with helping in recovery while respecting autonomy.
References
American Psychiatric Association. (2017). Diagnosis and statistical manual of mental disorders (DSM-5) (5th ed.). Washington, DC
Buckley, M. R. (2014). Back to Basics: Using the DSM-5 to Benefit Clients. Professional Counselor , 4 (3).
Chien, W. T., Leung, S. F., Yeung, F. K., & Wong, W. K. (2013). Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care. Neuropsychiatric disease and treatment , 9 , 1463.
Dadlani, B.M., Overtree, C., & Perry-Jenkins, M. (2012). Culture at the center: A reformulation of diagnostic assessment. Professional Psychology: Research and Practice, 43(3), 175-182. DOI: 10.1037/a0028152
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Hooley, J.M. Butcher, J.N., Nock, M.K., & Mineka, S.M. (2016). Abnormal psychology (17th ed.). Pearson.
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Noordsy, D. L. (2016). Ethical Issues in the Care of People With Schizophrenia. Focus , 14 (3), 349-353.
Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., & Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry , 62 (9), 604-616.
TheMentallight. (2010). Schizophrenia ABC 20-20 Documentary Part 1 [Video]. TheMentallight. https://www.youtube.com/watch?v=74vTftboC_A
Tummala-Narra, P. T., Singer, R., Li, Z., Esposito, J., & Ash, S.E. (2012). Individual and systemic factors in clinicians’ self-perceived cultural competence. Professional Psychology: Research and Practice, 43(3), 165-174. DOI: 10.1037/a0025783
