Introduction of the patient
A 44-year-old woman (whom we refer to as Joylne) visited a hospital complaining of a psychotic condition and, severe headache and otalgia. Joylen was of Asian origin, unemployed and living with her sister after divorcing her husband of 12 years. Upon exploration of her history, it was revealed that she had been diagnosed with paranoid schizophrenia two years ago. In the beginning, her symptoms included delusions, auditory hallucinations (of commanding and commenting), irritability and somatic passivity. Joylne had been given olanzapine 20 mg/day tablets, leading to remission. Nonetheless, over time, he had several multiple relapses owing to poor medication compliance. Her condition got worse, leading to her sister bringing her to the hospital.
Further examination of her blood sugar and postprandial blood sugar test revealed that Joylne had hyperglycemia, and based on diabetologist guidance, Joylne was diagnosed with Type 2 diabetes mellitus. More so, Joylne was found to have depression based on the diagnosis made by a psychiatrist. Indeed, she had not been able to eat well for the past few days. Thus, the combination of these diseases severely affected Joylne’s health.
Joylne had been brought to the hospital by her sister primarily because of her worsened psychotic condition. The frequency of hallucinations and delusion of persecution towards her sister had increased significantly, making Joylne dysfunctional. Her blood sugar level was more abnormal, and she continued complaining about her ears. Due to these multiple symptoms, the sister deemed it necessary to take her to the hospital. After the tests and diagnosis were completed, Joylne was admitted to the Psychiatric unit for further observation and treatment.
Context
Joylne’s personal history was explored to establish the cause of the schizophrenia. Joylne had an everyday life and was brought up with both parents. She completed college at 24 and was employed by a local company. Later, she got married at 28 years old to a 39-year-old man whom she had met in the course of her work. They got two children, but their marriage started to have problems when Joylne discovered that her husband was cheating on her. Subsequently, they divorced after ten years of marriage (when she was 38 years old). The following year, at 39 years, Joylne developed insomnia symptoms and feelings of confusion and restlessness. Later, the patient also developed auditory delusions and hallucinations. However, these symptoms were not treated, leading to depression. Further questioning of the patient revealed that her paternal uncle also had been diagnosed with mental health problems many years ago. Indeed, the said uncle attempted suicide but was rescued and taken to a mental facility, where he was hospitalised for several months.
The combination of environmental, genetic and social factors plays a significant role in a person developing schizophrenia (Van Os, 2010). Social factors linked to the development of schizophrenia include marital stressors, social isolation, and economic stressors, among others. Because positive symptoms of schizophrenia happen at an earlier age, they are hard to detect; the lack of knowledge by her sister regarding these symptoms led to Joylne remaining untreated for many years (Howes et al. 2017). Annamalai et al. (2017) mention that patients with untreated schizophrenia are likely to develop obesity and type 2 diabetes. In the current case, Joylne’s type-2 diabetes was also not treated earlier, leading to more complications (Annamalai et al. 2017). Joylne was not on any medication for type 2 diabetes because it had not been diagnosed before.
Diagnosis/Conclusion
After a detailed assessment of Joylne by the psychiatrist, the observation made, and the past medical history, the psychiatrist concluded that Joylne had developed schizophrenia condition (Upthegrove et al. 2017). The assessment entailed checking Joylne’s mental status and observing her demeanour and appearance. In addition, the psychiatrist also asked Joylne about her mood, delusions and hallucinations. The answers given by the patient helped in concluding (Upthegrove et al. 2017). However, the discovery that Joylne was also suffering from depression and type 2 diabetes made it complex to treat and manage her condition. This is because the combination of the different pathologies or conditions required a complex treatment plan to manage Joylne’s conditions effectively.
Nursing perspective
The needs of Joylne can be underlined based on the biopsychosocial model, which suggests that a patient’s medical condition should be considered based on physiological, emotional, and social needs (Lehman et al. 2017). Accordingly, the critical priority of the patient is emotional support (family and friendship). As observed by Kaskie et al. (2017), most patients with schizophrenia require emotional support to help them regain their mental health. In addition, Joylne requires medication to address not only her schizophrenia condition but also to treat her type 2 diabetes condition. The biggest concern is that the patient may fail to adhere to medication because of her history of non-compliance (Sass et al., 2018). Another concern is the comorbidities that affect Joylne. For instance, she has been diagnosed with depression and type 2 diabetes, and this will complete the treatment and management plan. In addition, the use of antipsychotic medication can lead to severe side effects that could adversely affect the patient.
The main body of the assignment
The precise cause of schizophrenia is not clear, though studies have revealed that a combination of environmental, genetic and neurological factors contribute to the development of schizophrenia Fatani et al. 2017). Farah (2018) asserts that the origins of schizophrenia remain complex and not well understood. Farah (2018) further observed that schizophrenia has a strong genetic association, with heritability approximated to be nearly 80%. In the current case of Joylne, it is apparent that genetic and environmental factors combined to cause schizophrenia. For example, her family history shows that her mother had been diagnosed with psychosis, indicating a genetic link. A study by Volkan (2020) established that environmental factors may worsen the impact of genetic risk factors for schizophrenia. Therefore, the divorce that Joylne went through and the loss of employment that she subsequently suffered led to mental breakdown, anxiety and self-blame that could have eventually combined to cause schizophrenia. Rosa (2020) agrees that the combination of environmental and genetic factors plays a critical role in the development of schizophrenia. The environmental factors include social isolation, suffered by Joylne and drug abuse.
Volkan (2020) underlines that schizophrenia is associated with various neurobiological abnormalities that include altered synaptic connectivity, abnormal brain development and changes in neurotransmitters. These changes are manifested in schizophrenia. Joylne reported hearing voices and hallucinations. These are atypical schizophrenia symptoms. She also reported distorted beliefs and behaviour, lack of sleep and paranoia. However, the severity and duration of these symptoms differ based on episodes suffered by Joylne.
The complex comorbidity affecting Joylne includes type 2 diabetes, which is linked to her schizophrenic condition. Rosa (2020) points out that individuals with undiagnosed or untreated schizophrenia are at a higher risk of developing obesity and type 2 diabetes. In the current case, Joylne was left untreated for an extended period, worsening the comorbidities. Chestnykh et al. (2021) mention that treating comorbidities complicates the treatment plan, making it difficult for the care team to achieve the treatment and management goals. For example, besides treating schizophrenia, Joylne also requires treatment and management of her depression and type-2 diabetes. The medications needed to treat these comorbidities may have adverse effects on each other or worsen the side effects experienced by the patient. Comorbidities also increase the possibility of the patient not adhering to medication because of the many medications that are needed to treat the multiple conditions (Etchecopar-Etchart et al. 2021).
The role of medication for this patient (mechanism/purpose/goal)
Joylne was initially admitted, complaining of severe headaches, depression and otagia. However, after undergoing tests and checking patient history (Vermeulen et al. 2017). The patient was diagnosed with schizophrenia and type 2 diabetes. Other related comorbidities included depression. Accordingly, before starting medication, the care team, together with the patient and the patient’s sister, formulated the goals and purpose of the medication. These included preventing harm to the patient, managing disturbed behaviour, and reducing the severity of psychosis and related systems such as negative symptoms and aggression (Vermeulen et al. 2017). Another goal was to effect a quick return to the best degree of functioning. As mentioned by Stępnicki et al. (2018), the purpose of antipsychotic medication used in the treatment of schizophrenia is to manage symptoms and signs. This should be achieved at the lowest possible dose. A psychiatrist may prescribe different medications and doses to achieve the desired goal. Since Joylne has also developed type 2 diabetes, it is necessary to use atypical antipsychotic medication such as olanzapine, aripiprazole and clozapine because they have less impact on weight gain. It is essential to combine medication to achieve better outcomes. Thus, chlorpromazine was included in the prescription for the patient. Joylne was prescribed Olanzapine and Chlorpromazine.The mechanism of how these drugs work, including their pharmacodynamics, pharmacokinetics, and pharmacogenetics, are discussed in the next section.
Chlorpromazine
Choi et al. (2020) state that chlorpromazine, besides managing and treating schizophrenia, is also used in treating acute psychosis and bipolar. Thus, it is suitable for Joylne. Chlorpromazine is a typical antipsychotic drug, also referred to as a first-generation antipsychotic. Choi et al. (2020) established that chlorpromazine is an effective medication in the management and treatment of schizophrenia and reduces aggressive behaviour.
The specific mechanism of action of chlorpromazine is not precise. However, it is thought to yield its antipsychotic effect through the post-synaptic blockade at the D2 receptors in the mesolimbic pathway (Goff, 2021). Nonetheless, blocking D2 receptors within the nigrostriatal pathway is believed to cause extrapyramidal side effects (Morgan et al. 2019). Morgan et al. (2019) add that chlorpromazine causes an antiemetic impact arising from the joint blockade of dopamine 2, histamine H1 and muscarinic M1 receptors in the vomiting area. Metabolic processes of chlorpromazine are mainly carried out by liver (CYP450) enzymes (Goff, 2021). Similarly, chlorpromazine is metabolised in the kidney. Its excretion occurs in faeces, urine and bile (Goff, 2021).
Chlorpromazine comes in tablets of 10mg, 25 mg, 50mg, and even 200 mg to be taken orally. However, it can sometimes be administered as intravenous and intramuscular injection. The dosage differs based on the patient. For Joylne, the initial dosage was 50mg/day taken per day and was expected to be taken for a month. Morgan et al. (2019) recommend that a chlorpromazine dosage of 25-50 mg is effective in managing preoperative apprehension. However, Joylne may suffer some side effects caused by chlorpromazine. This is because chlorpromazine belongs to the low-potency typical antipsychotic drug with many anticholinergic side effects. For instance, Patterson-Lomba et al. (2019) point out that chlorpromazine usually results in non-neurologic side effects. Valdovinos et al. (2020) also noted that chlorpromazine is lipid soluble and gets into the body fast, which can lead to increased weight. Chlorpromazine can also cause dry mouth, blurred vision, dizziness and urine blockage or retention (Patterson-Lomba et al., 2019). In cases where chlorpromazine is administered through intravenous and intramuscular injection, it could lead to headache and hypotension. However, since Joylne was taking the drug orally, she was at low risk of experiencing this side effect. Joylne may suffer from hepatotoxicity arising from inflammation of the liver, thus the need for continuous monitoring of the function (Valdovinos et al. 2020).
Chlorpromazine is usually started for a patient like Joylne with schizophrenia. The psychiatrist is the one who prescribes the medication, but follow-up is done by multiple healthcare professionals who are part of the care team, such as psychologists, nurses, social workers and nurses (Stępnicki et al. 2018). Therefore, this care team must monitor Joyle and provide education to the daughter about her mother’s medication. It is also necessary to inform the prescriber of the drug about any patient’s concerns, side effects, and ineffectiveness in treatment. By communicating this information, the care team will be able to enhance the patient care being received by Joylne.
Olanzapine
Olanzapine, which is an atypical antipsychotic medication, was also prescribed for Joylne to alleviate her condition. It helps individuals with schizophrenia to reduce feelings of hallucination and muddled thoughts (Adel, 2017). Thus, the drug was appropriate for Joylne, who also feeling agitated. Accordingly, Joylne was prescribed a 10mg tablet of olanzapine once a day.
Olanzapine works by targeting dopamine D2 receptors found in the mesolimbic pathways in an antagonistic manner (Adel, 2017). Thus, it blocks dopamine from interacting with synaptic receptors, and instead, it binds loosely on the synaptic receptor, enabling normal dopamine neurotransmission. Faden et al. (2022) explain that the effect olanzapine has on the D2 receptors reduces the positive symptoms in patients, such as delusions, disorganised speech and hallucinations (Zubiaur et al. 2021). In addition, olanzapine interacts with serotonin 5HT2A receptors to reduce negative schizophrenic symptoms like poor attention, avolition and alogia (Zubiaur et al. 2021). Thus, taking olanzapine affects the natural chemical messengers in the brain (neurotransmitters) such as serotonin and dopamine (Monahan et al., 2022). Monahan et al. (2022) explain that the pharmacokinetics of olanzapine show a considerable individual difference, leading to variations in drug exposure between patients. The care team must use this difference to formulate individualised dosing for Joylne to prevent concentration-adverse effects or treatment failure (Faden et al., 2022).
Safe diagnosis principles and pharmacovigilance
Traditionally, antipsychotic medication has been prescribed by general practitioners after the diagnosis of schizophrenia. When general practitioners want to initiate schizophrenia medication, the best practice demands that they only prescribe for the established indication, and they need to reach the treatment plan with a psychiatrist before prescribing (Beninger, 2018). For safe prescription, it is critical to be more careful when prescribing antipsychotics to people like Joylne with type 2 diabetes, which has increased cardiovascular risk. Accordingly, it is necessary to observe the principles of safe prescribing that include:
- The psychiatrist should be transparent about the reasoning behind prescribing. In the present case, prescribing olanzapine and chlorpromazine is meant to reduce schizophrenia symptoms.
- Prescriptions should be made based on the patient’s medication history. Thus, there is a need to get accurate medication the patient is currently or recently taken, past adverse drug effects and any drug allergies.
- Safe prescription also requires considering factors that could change the benefits and risks of the drug (Stewart et al. 2017). For instance, when prescribing Joylne, it is necessary to consider her type 2 condition and depressive symptoms. The antipsychotic medication may worsen her type 2 diabetes condition.
- There is also a need to take into consideration the patient’s concerns, expectations and ideas when prescribing; this will promote patient-centred care. Thus, in the case of Joylne, it is necessary to form a partnership with her and her daughter when prescribing.
- To achieve a safe prescription, it is also essential for the psychiatrist to choose the safest, most effective and cost-effective drugs for Joylne. The benefits of the antipsychotic medication prescribed should outweigh the possible harms that may arise.
Patients like Joylne with schizophrenia can be managed through pharmacotherapy. Due to the chronic and relapsing aspect of schizophrenia, it is recommended that the medication be continued for months or years (Yan et al., 2023). However, this places Joylne at risk of experiencing different advanced drug reactions and side effects (Yan et al., 2023). In some situations, the adverse drug reactions could be life-threatening. Therefore, psychiatrists must understand the processes entailed in establishing and reporting these reactions. This process is what underlines the principles of pharmacovigilance. Beninger (2018) states pharmacovigilance is the process or activities meant to detect, appraise, understand and prevent adverse drug effects. Therefore, pharmacovigilance was carried out by all members of Joylne’s care team to ensure that a safe prescription was observed.
Conclusion
The present case of Joylne has significantly impacted my understanding of pathophysiology by increasing my knowledge of how pathology interacts with physiology and physiology to cause disordered physiological processes causing disease or injury. Specifically, I have a better understanding of the pathophysiology of schizophrenia, which has different aetiology and varying susceptibility genes that interact with the environmental factors to produce multiple phenotypes in the schizophrenia spectrum (Stępnicki et al. 2018). Joylne’s case scenario provides a unique account of understanding schizophrenia disorder and the pathophysiological mechanisms of this disorder.
Patients with schizophrenia have a cognitive impairment, though it can be milder or severe depending on the type of schizophrenia (Stępnicki et al. 2018). From the Joylne case scenario, I can also observe that cognitive and social deficits underline the pathophysiology of schizophrenia. This is a characteristic of the whole spectrum of schizophrenia-associated disorders. Genetics combine with environmental factors to hurt the brain, leading to schizophrenia. However, like many mental health diseases, it is hard to fully understand the pathophysiology of schizophrenia because of the many factors that interact to lead to the condition.
The current case has also helped me better understand co-morbidities, which could affect a person’s mental or physical health (Etchecopar-Etchart et al., 2021). For example, Joylne has schizophrenia. However, she was also diagnosed with depression and type 2 diabetes. These are two comorbidities that also affect Joylne’s health and well-being. Therefore, when seeking treatment, besides treating schizophrenia, it is also necessary to treat depression and type 2 diabetes to achieve holistic care of the patient. Comorbidities are still an issue in the 21st century because they complicate the treatment and management of a disease. When a person is diagnosed with multiple conditions, it implies that the symptoms are triggered by more than one condition. For example, in the case of Joylne, hallucinations could be caused by schizophrenia and depression. Thus, the patient would require different treatment plans to address comorbidities. This could be challenging for the care team even with advanced healthcare today.
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