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Affective and Organic Disorders: Developing Mental Health Nursing Practice
Schizoaffective Disorder is a mental health condition in which individuals suffer from symptoms synonymous with schizophrenia and a mood disorder or bipolar disorder. More specifically, when mood disorders are prominent, such that an individual has episodes of mania and severe depression and also struggles with the onset of psychotic symptoms, such as hallucinations and delusions, that person is likely to suffer from the disorder schizoaffective. According to Yasuhiko et al, (2018) schizoaffective disorder is thought to be between the diagnosis of schizophrenia and the diagnosis of bipolar disorder, as the symptoms of both diseases are often manifested. Despite the problem with the term Schizophrenia, we cannot deny that many are very distressed and unhappy because of the experience of hearing voices and delusionary belief (DOH, 1992). However, the presence of schizoaffective disorder may ultimately warrant an alternative diagnosis of bipolar disorder. When an individual suffers from schizoaffective disorder, this is likely to affect their academic or occupational functioning, as well as their ability to interact socially. In addition, people who suffer from this mental illness often have difficulty caring for themselves and experience problems of perception. The life expectancy of a person diagnosed with schizophrenia is reduced by 10 years compare with someone without mental health problem (Brown et al 2000, Mental Health and Disorder 2000).
Schizoaffective disorder is a serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations, delusions (false beliefs), abnormal thinking and alteration of labour and social functioning. It is a major public health problem worldwide. Its worldwide prevalence appears to be discretely less than 1%, although pockets of greater or lesser incidence have been identified (Andrew, 2015). Schizoaffective Disorder begins most frequently between the ages of 18 and 25 in men and between the ages of 26 and 45 in women. However, it is not uncommon for it to start in childhood or early in adolescence. The installation can be sudden, in the space of days or weeks, or slow and insidious, over the years. There are several disorders that share their characteristics with Schizoaffective Disorder. A schizoaffective disorder that resembles schizophrenia, but in which symptoms were present less than 6 months, are called schizophreniform disorders. Disorders in which psychotic symptoms last for at least one day but less than a month are called brief psychotic disorders. A disorder characterized by the presence of mood symptoms, such as depression or mania, along with other symptoms typical of schizophrenia, is called schizoaffective disorder. A personality disorder that may share symptomatology of schizophrenia, but in which the symptoms are not severe enough to meet the criteria of psychosis, is called a schizotypal personality disorder (Patrick, 2018).
John, male, 23 years old, single, born in London. He was referred to the medical service of the Memory clinicon 06/01/2018, from his residence, to follow up his treatment for being presenting crisis of clinical exacerbation, with symptoms of aggression and agitation. Rio records that John was seen by liaison psychiatry in 2012 after an overdose and was referred to Alan Davis for learning Disability psychology team. He has been hospitalized on other occasions due to psychiatric problems. He lives with his mother, sister and brother in his own house. He does not have an active social life, presents difficulties in family relationships, quiet disposition and isolates himself socially. At home, John has been using medication for about 5 years. He reports that he has no personal morbid antecedents. He is totally independent in meeting the following basic needs: eating and drinking, using the toilet, moving about, dressing and undressing. It does not know exactly its weight and its height presents/displays a good state of hydration and nutrition (Fuller, 2019). He does three meals daily, without restriction of any food according to the possibilities and also does not make use of psychoactive substances (alcohol, tobacco or other drugs). In his family history, there are psychiatric antecedents (sister with mental disorders). He was calm and silent throughout the nursing interview and he has a good standard of hygiene, bathing daily. His previous pathological history is Schizophrenia.
Mental State Examination
The mental state assessment was performed at the time of the interview. These includes the following items: general description (appearance, psychomotor activity and behaviour, HADS, attitude towards the examiner and verbal activity), mood feeling and affection, perception, thought process (the form and content of thought), sensory and cognition (awareness, orientation, concentration, cognition, BADL, memory, information and intelligence), judgment and credibility (Larry, and Leslie, 2015).
Appearance: John presents good hygiene, well kempt with no concerns regarding personal care. He is apparently calm and collaborative, with a low stare, hardly looking at the interviewer.
Psychomotor activity and behaviour manifest calm behaviour.
Attitude towards the examiner: presents itself as collaborative, attentive, but with sometimes reserved attitudes.
Verbal activity: demonstrates a sometimes incoherent discourse with disorganised, spontaneous thinking on certain subjects and disorganisation of language (jumps from one subject to another and sometimes does not understand what is spoken) (Rosenberg, 2014).
Mood, Feeling and Affection: John has a sad mood. His affection is appropriate to the situation.
Perception: John did not present disturbances of the perception manifested by hallucinations (visual and auditory) and delusions. He displays disorganised thoughts and ideas, so in certain subjects, he/she does not have the capacity to respond.
It has a stabilizing action on the central and peripheral nervous system and a selective depressant action, thus allowing the control of the most varied types of excitation. It is therefore of great value in the treatment of mental and emotional disorders (Lakeman, 2006).
Inform John of the adverse reactions most frequently related to the use of medication and that, in the event of side effects of any of them, especially drowsiness, torticollis, pressure drop, sedation, the doctor should be informed immediately to guide him avoid alcoholic beverages during treatment (Rosenberg, 2014).
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NMC (2007) Clearly specifies standards that registered nurses must meet when administering prescribed medicines to patients. Patients should be adequately informed, using the language they understand, the nature of their illness, medical benefit, action, duration of treatments, and the importance of medications they are taking, with potential side- effects of the medicines. (NICE 2007a).
The causes of Schizoaffective Disorder and Borderline Learning Difficulties are still unknown. However, there is a consensus in attributing the disorganisation of the personality, verified in Schizoaffective Disorder and Borderline Learning Difficulties patients, to the interaction of cultural, psychological and biological variables, among which the genetic ones stand out (Steven Matthysse, and Seymour, 2014). There is no single cause to explain all cases of Schizoaffective Disorder and Borderline Learning Difficulties. Contrary to popular belief, John with Schizoaffective Disorder and Borderline Learning Difficulties is not a victim of poor background or environmental factors. He is victims of genetically engineered developmental errors. More recent research has found abnormalities in the developing foetus rather than after birth. It can be said that no specific factor causing Schizoaffective Disorder and Borderline Learning Difficulties has yet been known. There is, however, evidence that it would be due to a combination of biological, genetic and environmental factors that contributed to varying degrees for the onset and development of the disease (Daily, Ardinger, and Holmes, 2000). Another factor is almost every country where surveys have been conducted, the public believes the causes of Psychosis are more likely to be adverse Psychosocial events and circumstances (such as poverty, trauma and abuse) then biogenetic factors (Morrison et al 2005).
The severity and type of symptomatology can vary significantly between different people with Schizoaffective Disorder and Borderline Learning Difficulties. Together, symptoms are grouped into three major groups: delusions and hallucinations, abnormal thinking and behaviour, and negative symptoms (Frederic, 2014). An individual may have symptoms of one, two, or three groups. The symptoms are serious enough to interfere with the ability to work, have relationship with people and care.
Delusions: Delusions are false beliefs which generally imply a misinterpretation of perceptions or experiences. For example, John exhibits delusions of theft or imposition of thought, believing that others can read his minds, that their thoughts and impulses are imposed upon him by external forces (Frangou, and Byrne, 2000).
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Hallucinations: Hallucinations of sounds, visions, smells, tastes, or touch may occur, although hallucinations of sounds (called auditory hallucinations) are the most frequent. John can “hear” voices that comment on his behaviour, talk to each other, or make critical and abusive comments.
Change of Thought: It consists of unorganised thinking, which becomes patent when the expression is incoherent, changes from one theme to another and has no purpose. The expression may be slightly disorganised or be completely incoherent and incomprehensible (Frances, 2000).
Inappropriate Behaviour: This type of behaviour can take the form of simplicity of childish character, agitation or appearance, hygiene or inappropriate behaviour. Catatonic motor behaviour is an extreme form of inappropriate behaviour in which a person can maintain a rigid posture and resist efforts to move or, on the contrary, show movement activity without prior and meaningless stimulation.
Negative Symptoms: Negative or deficit symptoms of schizophrenia include coldness of emotions, poor expression, anecdotal, and associability. The face of John appears immobile; has little eye contact and does not express emotions. There is no response to situations that would normally make him laugh or cry (Tony Thompson and Mathias, 2000).
Risk Factors of Schizoaffective Disorder and Borderline Learning Difficulties
Although no particular cause has been identified that is directly responsible for the development of the schizoaffective disorder, professional practitioners in this field consider that there is a combination of factors that combine to bring about their onset (Voelker, 2002). These factors are described below:
Genetic factors: Schizoaffective disorder is similar to other health conditions in the sense that its occurrence is related to a genetic component. Individuals who have a first-degree relative with schizophrenia, bipolar disorder, or schizoaffective disorder face an increased risk of developing symptoms of the disease at some point in their lifes, unlike those who do not have a similar family history (Lakeman, 2006).
Physical Factors: Neuroimaging studies have shown that the brain volume of people with the schizoaffective disorder is lower than that of individuals who do not suffer from this condition. In addition, it is thought that there are real structural differences in the brains of those people suffering from schizoaffective disorder.
Environmental factors: As with the development of Schizoaffective Disorder and Borderline Learning Difficulties, researchers have discovered that exposure to toxins or viruses within the uterus can potentially lead to the onset of schizoaffective disorder later in life (Frederic, 2014). In addition, evidence has shown that when complications occur during labour, the potential damage to the brain due to such complications may lead to the eventual onset of the schizoaffective disorder.
There is no definitive diagnostic test for Schizoaffective Disorder and Borderline Learning Difficulties. The psychiatrist establishes the diagnosis based on an overall assessment of the patient’s history and symptoms. For the diagnosis of schizophrenia to be established, the symptoms should persist for a minimum of six months and must be associated with a significant deterioration of the employment, school or social activity (Steven Matthysse, and Seymour, 2014). The information provided by the family, friends or teachers is very important to establish when the disease started. People with a schizophrenia diagnosis are 10- 15% likely of dying from suicide (DOH, 1992) and early years of the illness may present a particular risk. (McGarry and Jackson, 1999). The physician should rule out the possibility that the patient’s psychotic symptoms are due to a mood disorder. It is common to perform laboratory tests to rule out the possibility of drug abuse or an underlying clinical, neurological or endocrine disorder that may present with psychosis characteristics, such as certain brain tumours, temporal lobe epilepsy, autoimmune diseases, immune disorders, liver diseases and adverse drug reactions. Individuals with schizophrenia have brain abnormalities that can be seen on a CT scan or MRI (Daily, Ardinger, and Holmes, 2000). However, the defects are insufficiently specific to be useful in diagnosis.
Nursing Assessment and Evaluation of Person Centred Recovery
Over the last decade, mental health care has become supported by service users, with recovery as an important aspect of treatment. The recovery-orientated practice has a global concentration and is incorporated into different mental health policies. Recovery concentrates on hope and on reintegrating service users back into society and their life before diagnosis (Larry, and Leslie, 2015). The general objectives of treatment are to reduce the severity of psychotic symptoms, to prevent recurrences of symptomatic episodes and to impair the functioning of the individual and to provide support so that the individual can perform as well as possible. Antipsychotic medications, rehabilitation and community support activities and psychotherapy represent the three main components of treatment. Antipsychotic medications are often effective in reducing or eliminating symptoms such as delusions, hallucinations, and disorganised thinking. After the disappearance of acute symptoms, the continued use of antipsychotic medications substantially reduce the likelihood of future episodes. Unfortunately, antipsychotic drugs produce significant adverse effects, including sedation, muscle stiffness, tremors, and weight gain (Andrew, 2015). A small number of individuals with Schizoaffective Disorder and Borderline Learning Difficulties are unable to live independently, either because they present severe symptoms and are not responsive to therapy or because they lack the skills necessary to live in the community. In such cases, continuous treatment is necessary for a safe and supportive environment. Psychotherapy is another important aspect of treatment. In general, the goal of psychotherapy is to establish a collaborative relationship between the patient, his family, and the physician. Person-centred care support practitioners to consider service users’ personal needs and to allow them to establish informed judgments about their own care and cure with support from health professionals (Yasuhiko et al, 2018).
Role of the Mental Health Nurse
Although Larry and Leslie, (2015)point out that nurses face difficulties to work with aspects related to mental health in basic care, the need for care of the individual with a mental disorder and his family is a reality. This creates new perspectives for the work of the nurse in the field of mental health, characterized by the transition from Memory clinic practice to treatment of the “mentally ill” to another that incorporates new principles and knowledge, based on interdisciplinarity and recognition of the other as a human being, inserted in a family and community context. People must not worry about how the nurse has acted in this process, since most of the time he/she is the care coordinator of the Memory clinic team, and one of the great challenges to mental health is to establish competence.
Nurses play an important role in assisting people with mental disorders, such as raising the awareness to the population about the importance of their insertion in the community, including collaborating and taking responsibility for the construction of new spaces for psychosocial rehabilitation, if valued; after all, the citizenship of these patients and their families are assured in the policy of deinstitutionalisation. Nurses, therefore, need to be ready to work with John with limitations and his family. The activities that the professional performs in the Memory clinic and attitudes that aim to support him and treat him in order to value not only the illness but, mainly to the person of integral form, favours the reintegration of the patient to the social life with qualified measures (Fuller, 2019).
While the aetiology is unknown, all the therapeutic methods attempted in schizophrenia have the stamp of empiricism and groping. As a general rule, it is said that in the acute or initial periods the medications are justified (the remission or social cure of Schizoaffective Disorder and Borderline Learning Difficulties, compatible with a certain professional activity and the extra-senatorial life, is obtained in about 60% of the cases) and physical-chemical, whether to stimulate or correct the organic functions, or to imprint new rhythm to the body (shock therapy), and that in the phases of remission and chronicity fit psychotherapy and other methods such as praix-therapy are used (Yasuhiko et al, 2018). In response to major harm occurrences that have demonstrated a need for multidisciplinary teams and agencies, co- ordinated by a consistent key worker to actively involve the patient, family and carers, the Care Programs Approach (CPA) (DOH, 1990; reviews 2000a) was developed. The main purpose of nursing care is to awaken the schizophrenic’s interest in John’s life, a dignified life and participation in his family and social environment, despite the illness. It is important to value and encourage John to participate in his clinic treatment, so that the chances of adherence to treatment may be greater. Nursing care should aim to improve symptoms, prevent relapse and avoid institutionalisation.
The patient (John) is a carrier of Schizoaffective Disorder and Borderline Learning Difficulties based on such findings: persecutory delusions, hearing unpaid voices, unreasonable ambitions, and loss of contact with reality, simulation of difficulty in walking, psychotic episodes associated with aggression, agitation the exaggerated libido and carelessness with personal hygiene (Larry, and Leslie, 2015). The great question about the patient is the continuity of treatment and their awareness of the importance of adherence to treatment. Drug therapy associated with psychosocial model is essential because it is also a reflection of the entire history of each patient. The pharmacological evolution of antipsychotics has provided a high drug potency with satisfactory results in the course of treatment. Thus, maintenance of drug treatment will lead the individual during the evolution of the disease to an improvement in symptoms. But there are undesirable side effects, such as extrapyramidal manifestations (akathisia, acute dystonia, and parkinsonian symptoms) in addition to silk, weight gain and impotence. All these effects compromise the acceptance of the drug, but with the progress of its use, the maintenance phase has a control and a decrease in these symptoms (Lakeman, 2006).
Discontinuation of treatment may lead to further seizures, the need for higher doses of the drug, and often the need for internal doses. It is of great importance to offer patient individual therapy, support groups, occupational therapy and guidance for the family. A multidisciplinary team is essential for adherence to treatment (Patrick, 2018). However, medical staffs are confronted with patients who perform all these activities and do not evolve to improvement due to lack of psychosocial and family support, as is the case of this patient. If they ask the reason for his carelessness with treatment outside the Institution, they find that being a homeless street patient, without psychological, economic and effective support, he would end up needing internal translations, mostly for the same reason, or the medicines.
Through this case study, it was possible to know a little more about the Schizoaffective Disorder and Borderline Learning Difficulties. Above all, this work made it possible to obtain a holistic view of nursing action and not just a technical-pharmaceutical approach. It was concluded that the systematisation of nursing care is favourable for a good prognosis. In practice, the best care is the individualized and humanized, assisting the patient as a unique being, respecting their biopsychosocial needs. It can be seen that the promotion of care is not necessarily done through technical procedures, in a hospital bed or in an outpatient clinic. Listening attentively, respect, willingness to interact, trust and bonding are elements that need to be used to provide qualified care, especially in psychic patients. Through the study carried out, we were able to value these concepts even more and realize their importance in the act of caring and, thus, lead them to apply in future practice.
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