ECLECTIC THERAPEUTIC INTERVENTION OF A CASE STUDY

The undermentioned analysis is concerned with a instance survey ( appendix I ) of a 32 year-old Irish male named Sean Murphy. He has been referred for clinical appraisal by his canvasser, in order to have intervention and in assistance of an approaching tribunal instance for incendiarism and burglary. The purpose of this instance survey is to place the key jobs with Sean ‘s behavior and how these jobs affect his life, to bring forth a probationary diagnosing and to propose relevant intervention programmes to better Sean ‘s behavior. To keep confidentiality, Sean will be referred to as ‘the client ‘ throughout the undermentioned instance survey.

Section A: Diagnosis

The client is clearly enduring with psychotic episodes in which he believes a concealed force called ‘the administration ‘ is commanding his ideas and sexual feelings. He demonstrates cognitive disfunctions as he holds implausible beliefs about himself and the universe around him ( i.e. , that his head is being controlled ) and is highly leery of others. He believes that external forces ( chiefly ‘the administration ‘ ) “ manipulated ” him to perpetrate old offenses, which shows he lacks a existent appreciation of world and is incognizant of his ain actions. The client is besides socially withdrawn ; he lives entirely, seldom contacts his female parent and it appears that he does non hold any close friendly relationships. In add-on to this, the instance survey presents the client as an person at the underside of the societal ladder ; he spent his adolescence homeless, has been imprisoned on more than one juncture, and is unable to keep close relationships. All of the above features displayed by the client are presented by Davey ( 2008 ) and NHS Choices ( 2010a ) as typical of Schizophrenia.

His maladaptive behavior appears to run into the demands of standards A, B and C of the DSM-IV ‘s diagnostic of ‘Schizophrenia ‘ ( American Psychiatric Association 1994 ) ( see appendix ii ) as he suffers eccentric psychotic beliefs, lives entirely, lacks the ability to keep relationships, is unemployed and believes he has been the topic of psychological use for over six months. However, the instance survey lacks item sing standards D, E and F ( appendix two ) . To set up whether the client to the full meets the ‘Schizophrenia ‘ demands, farther inquiring is required approximately ; other mental unwellnesss, medication/ substance maltreatment history, and household background of mental unwellness. Further to this, the client ‘s behavior mostly displays features of ‘Paranoid Schizophrenia ‘ ( appendix three ) as he experiences psychotic beliefs of persecution in which he lives in “ continual fright ” and is “ highly leery of others and their motivations ” . Conversely, he does non demo any features of the ‘Catatonic ‘ ( appendix four ) , ‘Disorganised ‘ ( appendix V ) ‘Undifferentiated ‘ ( appendix six ) or ‘Residual ‘ ( appendix seven ) subtypes. With this in head, the client can be tentatively diagnosed as ‘Paranoid Schizophrenic ‘ . It is interesting to observe that when the DSM-V is released in May 2013 as an ascent of the DSM-IV, the standards of Schizophrenia diagnosing will be revised ( American Psychiatric Association 2010 ) . The subtypes of Schizophrenia are proposed for remotion, and will be replaced by one revised continuum of ‘Schizophrenia ‘ ( appendix two ) . The dimensions of the upset ( i.e hallucinations, psychotic beliefs, avolition and impaired knowledge ) will be assessed on a 0-4 graduated table based on the badness of the symptoms ( appendix eight ) ; whereby persons will be diagnosed as mild or terrible schizophrenic. Besides, due to the fact that many Schizophrenics suffer from temper pathology ( Bowle et al 2006 ; Crumlish et Al 2005 ) , for illustration, the client reports a ‘depressed province of head ‘ , the DSM-V proposes to include standards for Depression and Mania in the procedure of diagnosing, in order to cut down the prevalence of depression with antidepressant-based intervention ( Addington, Addington and Patten 1998 ; Peralta and Cuesta 2009 ) . It is of import to observe that these alterations are likely to impact the client ‘s diagnosing and will present jobs with his proposed intervention programme in the long-run.

Street drugs such as LSD, pep pills and hemps have been significantly linked with a likeliness of developing psychosis ( Arendt et al 2005 ; Henquet et Al 2005 ; Maki et Al 2005 ) . The NHS studies that cannabis “ can do anxiousness, paranoia and loss of motive ” ( NHS Choices 2010b ) which appears to reflect the presenting client ‘s paranoid province. Prolonged usage of these drugs prevents re-uptake of the neurotransmitter Dopastat ; ensuing in extra degrees of Dopastat in the encephalon ( Mathias 2008 ) . These extra degrees have been found more frequently in Schizophrenic persons compared to non-Schizophrenics, as seen in station mortems ( Seeman and Kapur 2001 ) . This phenomenon is known as the ‘dopamine-hypothesis ‘ ( Davey 2008 ) and indicates that Dopastat plays an of import function in the development of Schizophrenia. For this ground, it is imperative that the client ‘s history of drug wonts is sought to set up if drug maltreatment is a possible cause of his behavior. Although the dopamine-hypothesis is plausible, antipsychotic drug tests do non expose betterments in behavior until several hebdomads after ingestion of medicine ( Sanislow and Carson 2001 ) despite the fact that they cut down Dopastat degrees within proceedingss. If Dopastat was a cardinal trigger of psychosis, so the psychotic episodes should besides cut down within proceedingss.

It is reported in the literature that the “ highest rates of schizophrenic disorder diagnosing are found in hapless inner-city countries and those of low socioeconomic position ” ( Davey 2008: 231 ) . This could be due to the fact that these countries present more life emphasiss to their dwellers ; therefore act as ‘psychosis hazard factors ‘ ( Byrne et al 2004 ) , known as the ‘sociogenic hypothesis ‘ ( Davey 2008 ) . The client is presented as person from a low societal position ; as he left school with no makings, is unemployed, and is frequently involved in offenses of arson/burglary, hence this societal theory could assist to explicate his instance. However, the ‘sociogenic hypothesis ‘ may be merely a political prejudice. Lower category persons may be diagnosed more as Schizophrenic because they “ fit ” the stereotype that Schizophrenics are hapless and stupid ( Angermeyer and Matschinger 2004 ) . In add-on, the theory ‘s outstanding statement is that persons from lower societal categories are more frequently diagnosed as Schizophrenic, nevertheless it fails to admit that one of the chief symptoms of Schizophrenia is in fact ‘social disfunction ‘ ( American Psychiatric Association 1994 ) ( see standard B in appendix two ) , hence the lower category position is most likely a merchandise of the unwellness itself, instead than a cause. The instance analyze provinces that the client was categorised as “ educationally subnormal ” at a immature age despite the fact that he reads and writes good. The effects of this label being placed at a immature age may hold developed a ego carry throughing prognostication in which he believed and acted in understanding with his “ subnormal ” label ; therefore turning to alcohol, offense and homelessness, and finally retreating from world.

With both the Dopastat and sociogenic hypotheses in head, the overarching attack of Schizophrenia seems to take a diathesis-stress position. This argues that some persons possess a sensitivity to developing the upset which is so triggered following a series of nerve-racking life events ( Nuechterlein et al 1994 and Fowles 1992 ) . The Holmes and Rahe Stress Scale ( Holmes and Rahe 1967 ) ( see appendix nine ) lists 43 nerve-racking life events which can hold an influence on the development of unwellnesss. The scale nowadayss five emphasiss experienced by the client ; jail term, decease of a household member ( male parent ) ; personal hurt or unwellness ( as he spent clip in a psychiatric ward ) , alteration in abode ( has lived at place, in attention, homeless, in prison ) and alteration in fiscal province ( because he is now unemployed ) . Although this graduated table includes a big list of life stressors, it does non take into history the deficiency of parental bond, the maltreatment he experienced as a kid and the sheer emphasis that the client ‘s psychotic beliefs are doing, i.e. he lives in “ continual fright ” . Although the diathesis-stress position seems plausible in depicting the current client ‘s instance, this theory suggests that Schizophrenia can merely be developed after relevant life emphasiss. Contrary to this, Despert ( 1937 ) reported nine Schizophrenic kids under the age of 7 old ages who did non see relevant degrees of emphasis ; and farther to this, the University of North Carolina ( 1999 ) claims that Childhood Schizophrenia is chiefly due to complications with early encephalon development, instead than nerve-racking life events. The presenting client has displayed marks of societal backdown since school age, proposing that his schizophrenic inclinations may hold been developing from a younger age ; therefore perchance the merchandise of dysfunctional encephalon development. With this in head, it is still clear that he experienced many nerve-racking events in his childhood and the diathesis-stress theoretical account appears the most plausible theory in depicting his instance.

The instance survey studies that the client spent six months in a psychiatric establishment at the age of 20. However, information is unknown sing why he was admitted, his diagnosing, the intervention he received ( drugs or therapy ) and why he was released. Therefore, this information must be sought in order to roll up a full medical history of the client. The clinician besides needs information sing possible substance maltreatment throughout the client ‘s life, every bit good as a full study of any history of mental unwellness in his household.

In decision, it appears that the presenting client has developed symptoms of Schizophrenia due to a figure of nerve-racking life events during his childhood, adolescence and early maturity which can be best explained in footings of the Diathesis-Stress theoretical account. After analyzing his behavior he can be tentatively diagnosed as ‘Paranoid Schizophrenic ‘ , codification 295.30, supplying that the above factors are investigated further.

Section B: Treatment

It is now imperative that a attention program is devised for the client diagnosed as ‘Paranoid Schizophrenic ‘ ( code 295.30 ) due to the fact that there is a high prevalence of suicide amongst Schizophrenics due to the psychotic symptoms and depression ( Royal College of Psychiatrists 2010 ; Bowle et Al 2006 ) . Forms of schizophrenic disorder have other wider deductions on a scope of other life factors, such as ; societal support webs and employability ( Manning and White 1995 ; Rinaldi and Hill 2000 ) , therefore it is of import that the presenting client receives a good intervention program every bit shortly as possible.

Antipsychotic drugs are regarded as the best signifier of intervention for persons enduring with psychotic episodes ( psychotic beliefs or hallucinations ) ( National Institute for Health and Clinical Excellence 2011 ) . In add-on to this, ‘Clozapine ‘ has been found to be the most effectual antipsychotic drug on the market ( McEvoy et al 2006 ) . As an illustration, a three-month appraisal found a larger lessening in positive and negative Schizophrenic symptoms amongst patients treated with Clozapine, compared to patients treated with Quetiapine or Risperidone ( McEvoy et al 2006 ) . This suggests that Clozapine may be good for the intervention of the presenting client, as it significantly reduces symptoms ; of which the client suffers upseting, eccentric psychotic beliefs of persecution. However, Clozapine has been reported as unbearable in some instances, as it produces a scope of physical side effects. Arsenjo et Al ( 2010 ) study that Clozapine patients may develop agranulosis – a decrease of white blood cell production – as a consequence of taking the drug. For this ground, patients having the drug are required to hold blood trials every 1-2 hebdomads as a safeguard. Despite the fact that this signifier of intervention can do serious physical jobs ( Arsenjo et al 2010 ) ; the current Zeitgeist in Western society remains to see mental unwellness in footings of medical scientific discipline. The usage of antipsychotic drug interventions is a convenient intervention accepted as the ‘norm ‘ by many practicians, because it is inexpensive, easy to bring forth, administer, and step ( Gallagher 2007 ) .

In footings of the client presented in the current instance survey, supplying antipsychotic medicine could turn out debatable, due to his paranoid nature. He is highly leery of “ professionals who attempt to care for him ” ; therefore he could non be trusted to take the recommended dose every twenty-four hours. As an option, ‘depot ‘ major tranquilizers, in peculiar Resperidone, seem to be a relevant intervention for the client. This consists of the client undergoing injections of the antipsychotic drug into the musculus every two weeks ( NHS Tower Hamlets 2008 ) . Resperidone is recommended as it is the lone untypical antipsychotic available as a ‘depot ‘ , cut downing the opportunity of musculus stiffness which is frequently found amongst typical terminals ( NHS Tower Hamlets 2008 ) .

In reappraisal of the above mentioned antipsychotic intervention methods, the current client should be given a attention program dwelling of ‘depot ‘ Resperidone major tranquilizers, because in this manner, the professional wellness squad can supervise that he is having the right dose, instead than it being the client ‘s duty ; who is extremely paranoid and can non be trusted to take the medicine on his ain agreement. This signifier of intervention purposes to brace the Dopastat degrees in the encephalon, in line with the dopamine-hypothesis of Schizophrenia ( Davey 2008 ) and should cut down the badness of his psychotic beliefs. If the client fails to run into an assignment for his medicine, his GP or Practise Nurse will be responsible to reach the client ‘s Community Psychiatric Nurse, who could set up a place visit, to administrate the drug in his ain place.

In add-on to antipsychotic drugs, psychotherapeutics has been found effectual at handling the societal side of Schizophrenia ; “ most people who went to a self-help group were really satisfied with the experience and said they got better ” ( Seligman 1995 ) . Psychotherapy can include guidance, group therapy, or Cognitive Behavioural Therapy ( CBT ) and purpose to increase the interpersonal, societal, employability and grudge issues of patients. CBT consists of one-to-one therapy meetings with a professional, and it is advised that at least 16 Sessionss are required for a important betterment ( National Institution for Health and Clinical Excellence 2011 ) . Bradshaw ( 1998 ) reported that a three-year class of CBT of a Schizophrenic adult female found major betterments in psychosocial operation, attainment of intervention ends and decreases in symptomology and hospitalization. Further to this, Seligman ( 1995 ) further reported that “ psychotherapy entirely worked every bit good as psychotherapeutics combined with medicine ” ; connoting that psychotherapeutics may be even more effectual than drugs ; although this has non been agreed by other literature ( Dickerson 2000 ) . Cases like the above ( Bradshaw 1998 ) indicate that psychotherapeutics can hold a positive consequence on Schizophrenic persons. It would be good for the client to take portion in a long-run class of CBT alongside his medicine of Resperidone ‘depot ‘ because it will increase his interpersonal societal accomplishments and aid him with covering with mundane issues. The factors that the client should turn to during his therapy clip are ; societal accomplishments, relationships/friendships, education/employment, and heartache. It would besides be good for the client to speak about the nerve-racking events that occurred in his childhood, which may supply an apprehension of why his psychosis developed, in line with the diathesis-stress position ( Nuechterlein et al 1994 ) ; although an initial meeting will give the client to pick of what he wishes to discourse.

The client has been unemployed for the bulk of his life, and likewise, 96 % of persons diagnosed with Schizophrenia in the UK were unemployed in 1999 ( Perkins and Rinaldi 2002 ) . However, Rowland and Perkins ( 1980 ) have stressed the importance of work for Schizophrenic persons. They argue that work ensures a good quality of life as it ; increases societal contacts, offers societal support, provides position and individuality, and offers construction of clip along with a sense of accomplishment, to which Shepherd ( 1984 ) agrees. The chief barrier tends to be with employers reluctance to engage individuals with a psychiatric record ( Manning and White 1995 ; Rinaldi and Hill 2000 ) , nevertheless the ‘Supported Employment Programme ‘ purposes to contend against this stigma. This programme offers work experience to persons having attention from mental wellness services, in order to fit them with necessary work accomplishments to derive future employment ( NHS Foundation Trust 2011 ) . It is extremely recommended that the client joins this programme, but he must first take portion in therapy sing societal accomplishments, etc.

Furthermore, cyberspace forums have been found a utile attack with covering with the disaffection and isolation experienced by Schizophrenics ( Haker, Lauber and Rossler 2005 ) . This is interesting because another Zeitgeist of modern Western civilization is the cyberspace. This signifier of self-help will be good to the client, because it will enable him to speak to people in similar state of affairss to him without necessitating face-to-face contact. This will assist because the instance survey claims he is leery of “ professional ” aid, hence advice provided by persons similar to him may be more recognized. As he is unemployed, he may non hold internet entree in his place, nevertheless Coventry Library offers free cyberspace entree to its members ( Coventry City Council 2011 ) . Therefore, it is recommended that the client joins rank of Coventry Library, where he can pass up to 1 hr a twenty-four hours on the internet free of charge, during which clip he should see some online Schizophrenia Support Forums. This may increase his self-esteem due to the feeling of ‘belonging ‘ to the forum, and will besides supply construction for his yearss.

In decision, the best intervention programme for the current client will be to ; supply injections of Resperidone ‘depot ‘ one time a two weeks at the client ‘s GP surgery, supply 1-hour Cognitive Behavioural Therapy Sessionss with a healer once a two weeks, and the client would be extremely advised to pass at least 1 hr a hebdomad on the Schizophrenia support web sites. A attention program will be devised, and the intervention can get down directly off. The attention program will be reviewed in 3 months ‘ clip, at which point, any necessary alterations can be made.

Decision

After reexamining the instance survey of Sean Murphy, it appears that he can have a diagnosing of ‘Paranoid Schizophrenia ‘ supplying assorted factors are investigated farther ; possible drug/substance maltreatment, inside informations of old psychiatric admittance, history of medicine and household mental wellness background. The most good intervention program for Sean would unite ‘depot ‘ Resperidone medicine to cut down the badness of his psychotic beliefs, aboard Cognitive Behavioural Therapy to turn to his societal accomplishments.