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1. Apply understanding of the stress-vulnerability model to case scenarios of vulnerable people experiencing schizophrenia and bipolar affective disorder

2 Distinguish between therapeutic and non-therapeutic communication skills in providing care to someone experiencing schizophrenia or bipolar affective disorder

3 Apply the concept of recovery in mental health in relation to the scope of nursing practice

4 Identify indicators of altered mood, perception, and thinking with someone experiencing schizophrenia or bipolar affective disorder

5 Construct a care plan based on individualised needs of people experiencing schizophrenia or bipolar affective disorder

6 Compare and contrast a range of evidence-based biological (including psychopharmacological) and psychosocial interventions for working with people who experience altered mood, perception, and thinking

7 Apply ethico-legal concepts in provision of care for people experiencing schizophrenia or bipolar affective disorder

Description of the Case

Dimitrie is a young adult man with Asian descent, have olive skins, dark black hair and was wearing a pair glasses. He was dressed casually in casual chino pant and long sleeve shirt. He was clean-shaven; his hair was long and unkempt and did not show any evidence of self-harm. He maintained an intermittent eye contact while fidgeting with hands frequently.

A good rapport was established; he was friendly and cooperated fully with the nurse. He was visibly anxious at times about his problem and sometimes distracted by the voices. He generally remained calm, no sign of agitation, and maintained eye contact during the sessions. He was seated during the assessment occasionally turning his head to either side due to the voices.

His effect was not labile and was appropriate to given context and congruent with his stated mood. He is reactive to what is being discussed; he stated sometimes being distressed and upset from the voices. His facial expression was worried and notably blunted. Further, he displayed dramatic facial expressions in reaction to the questions from the nurse.

Dimitrie stated his mood was unhappy and pretty depressed. He was not comfortable and was scared from the voices. He has hope for the future but stated reduced his concentration level and could not write any longer. He has no thought of deliberate of suicide or self-harm. His sleep pattern is disrupted because voices often wake him up.

He was speaking fluently, in a clear and normal tone. He paused between answers and questions due to lack of concentration because of the voices heard. He restricted the amount of speech and replies to monosyllables. Also, Dimitrie was hesitant and responded only to questions asked.

Dimitrie was easily distracted by the voices and speech to answer to questions only. His speech was often associated with frequent stops and interruptions of thought without any associated explanations in the middle of the sentences. Overall he was answering the questions spontaneously.

Dimitrie thought processes were coherent and logical; he did not hint on any current suicidal ideation, intent and plan, stating that he did not want to harm himself or others. However, there is evidence of paranoid delusion. He reported auditory hallucinations, he was hearing voices, always criticising him for not being good enough. The voices could talk to him and never leave him alone including while he slept, leading to several sleep disruptions.

Assessment of Dimitrie

Dimitrie reported auditory hallucinations and aware nobody could hear the voice but himself. He reveals the voices made him uncomfortable and scared, sometime he speak with the voices and said the voice always criticising him.

He was alert and orientated to time and place, was taking time to answer the questions. In regard to his cognitive functioning, he was able to count back by seven and stated he was not good in mathematics before. He appeared to maintain attention and concentration to the nurse tasks.  He was able to follow the assessment procedure but needs formally tested and assessed with Mini-Mental Stated Examination (MMSE).

Dimitrie insights were significantly impaired, he is aware that he had stopped his medications which lead to relapse of psychosis and stated “I am not well but I am not crazy”. He is being in denial of symptoms of mental illness. Dimitrie was unreliable and exhibited poor judgements and nevertheless, consent for admission to the mental clinic and he is willing to take his medications again.

Self affects many young adults. The associated emotional aspects include anxiety, sadness, lose of interest and anger. These patients may experience strong tendencies for self-harm due to their string feelings (Beckman et al., 2016). According to the case study, the client did not mentioning intention to harm themselves but indicated that voices criticised him a lot of not being good enough. As such, the voices could result to suicidal ideation to end the resultant emotional pain. The loneliness and sense of despair can affect them greatly.

Schizophrenic patients experience social isolation to larger extents than other people. They have problems getting into relationships and maintaining the social ties. This could be because of the distress and lack of competency in applying coping skills to manage the associated symptoms.  Further, stigmatization and lack of adequate awareness about mental illnesses affects the patients as people do not understand their conditions and demands. Schizophrenic patients require social relationships to help them manage their symptoms effectively and improve their quality of health. They also need rehabilitation support programs that are a component of the social environment (Tapor, Ljungqvist & Strandberg, 2016).

When decision making abilities are impaired, the likelihood of favourable health outcomes decreases significantly. This can be manifested by the schizophrenic patients failing to provide their consent to medical procedures. The patients suffering from impaired decision making may fail to think coherently, logically and evaluate the consequences of their decisions in light of their health challenges. It is important to evaluate the decision making ability of the patient to employ the right interventions as a way of improve the quality of their health. 

Symptoms of Schizophrenia in Dimitrie

When sleep pattern are disrupted, the normal lives of the affected individuals are negatively impacted significantly. It should be noted that prolonged sleep disruptions among the schizophrenic patients causes perceptual distortions manifested through disrupted thought processes as well as increased hallucination occurrences (Waters et al., 2018). The occurrences of sleep deprivation and pattern disruption are more manifested in cases where medications have been terminated. The result would be poor quality of life and disruptions of normal life activities (Kaskie, Graziano & Ferrarelli, 2017). 

Suicide is a leading cause of death among schizophrenic patients. In most case, the emotional burden faced by the schizophrenic patients coupled by the loneliness may prompt them to engage in suicidal ideation related activities. This can also be attributed to the fact that the patients are often lonely and isolated from other people in the society (DeSon et al., 2018). The loneliness as manifested by Dimitrie in the case study can easily stimulate self-harm instincts. It is clear that Dimitrie engages into conversations with voices in his mind. Further, the voices often blame him for not being good enough. The magnitude of the blame can prompt self-hatred and eventually probability of self-harm which may be suicidal (Depp et al., 2016). As he admits that he is not feeling well denying the fact that he is suffering from symptoms of schizophrenia. It indicates his unreliability and ability to make poor decisions. These reasons are indicative of the fact that Dimitrie has poor decision making abilities that when associated with loneliness can lead to self harm.

According to Haley (2013), disrupted thought processes can significantly affect the lives of the victims and the people around them. These processes affect decision making the schizophrenic individuals to be vulnerable to self-harm when they are not adequately monitored and taught self-coping skills. The logic, motivation and coherence of one’s thinking processes directly affect the quality of lives of the schizophrenic patients and consequently their health outcomes (Nelson et al., 2014). As such, Suicidal ideation prevention should be a major priority for any focused nursing intervention to help Dimitrie.


  1. The patient will be free from the frequent delusion occurrences and manifest the ability to function normally without reacting to delusional thoughts.
  2. The patient to be able to satisfactory demonstrates at least two coping skills for dealing with the delusional thoughts and possibility of suicidal ideation. 


1. Promote and encourage healthy habits as a way of optimizing functionalities.

2. Seek to engage the client based on their environment.

3. Teaching Dimitrie about coping skills that can help them reduce the worrying thought processes.


1. The healthy habits that should be encouraged include self-care, strict adherence to the medication therapy, and harbouring the freedom to often consult and share symptomatic views with the professional nurses (Shah et al., 2011).

These interventions will enable the client to appreciate and embrace importance of nursing care to their lives and hence reduce instances of disrupted sleep patterns among others. This intervention will enable the patients to understand and apply the coping skills to deal with their delusional thought processes.

2. According to Shah et al., (2011), clients can be distracted by engaging in conversations about the realities in their environment to disrupt their delusions. The patient can also be engaged in reality-based games to derail them from the regular delusions. These games include card games, art and craft among others.

 These activities ensure that the patient focuses their attention to external environmental cues and challenges and hence learn to forget about their internal tensions and fears. In this manner, they shall have learned of a major coping skill as well as learn to avoid frequent delusional thinking occurrences.

3. It should be noted that the basis of the disruptive thinking processes is a result of the delusions and hallucinations. Notably, Dimitrie should be coached on the specific coping skills that they can engage in themselves and in the company of others. This intervention is important because schizophrenia is a mental illness that may be difficult to manage, hence the client should be well equipped with the right tools to manage the symptoms and hence maintain coherent and logical thought processes (Comparelli et al., 2018).

 According to Kate et al., (2014), some of the coping skills that the patients can be taught and tested on include going to the gym, listening to favourite music, watching movies, thought-stopping methods and calling specific help lines. Cumulatively, these techniques will help Dimitrie to understand and apply coping skills effectively to manage the disrupted thought processes.

The first positive interaction the nurse employed was according the client a favourable environment to express themselves. The nurse was patient with Dimitrie and allowed them to express themselves despite the numerous thought process disruptions. This environment allowed for accurate diagnosis of Dimitrie and hence leads to better nursing interventions.

The second positive interaction from the interviewer was compassion. It is important to avoid engaging in arguments with the schizophrenic patients because one cannot change them. They already have enough burdens in their minds and arguments are the least they can accommodate. One should limit noise around them and show that they understand the impact of schizophrenia to the patient during the interview.

Goals and Interventions for Treatment

The third Positive interaction was offer to provide support. During the interview, the nurse identified some of the challenges affecting Dimitrie and offered to help him with the management of some of the issues to improve his quality of life and health outcomes. This reassurance of hope to a better and healthier future is important while communicating to the schizophrenic patients.

The fourth positive aspect was maintenance of proper non-verbal cues. It is important for the verbal aspect of the interview to match non-verbal cues such as facial expressions as well as more use of gestures than unnecessary talking and turn takings. These cues enabled Dimitrie to develop trust in the nurse and disclose important information.

The first negative interaction was not appreciating the efforts made by the schizophrenic patient. The interviewer would have applauded Dimitrie’s efforts to boost his self-confidence and hence improve his social interaction abilities. This is because, Dimitrie suffers from loneliness and disruptions from voices that he should be motivated to talk by alluding to his better speaking skills relative to other patients that had consulted such services previously.

The second negative interaction according to the case study relates to low sensitivity to the feelings and emotions of the patient. During the interview, at times the patient could manifest dramatic facial expressions. It could be better for the nurse to stop talking during such instances and inquire what exactly the client felt about the specified messages. In this manner, they could be able to collect more information and gain more insight on the condition of the patient.


Beckman, K., Mittendorfer-Rutz, E., Lichtenstein, P., Larsson, H., Almqvist, C., Runeson, B., &Dahlin, M. (2016). Mental illness and suicide after self-harm among young adults: long-term follow-up of self-harm patients, admitted to hospital care, in a national cohort. Psychological Medicine, 46(16), 3397-3405.

Comparelli, A., Corigliano, V., Lamis, D. A., De Carolis, A., Stampatore, L., De Pisa, E., ... & Pompili, M. (2018). Positive symptoms and social cognition impairment affect severity of suicidal ideation in schizophrenia. Schizophrenia research, 193, 470.

Depp, C. A., Moore, R. C., Perivoliotis, D., Holden, J. L., Swendsen, J., & Granholm, E. L. (2016). Social behavior, interaction appraisals, and suicidal ideation in schizophrenia: The dangers of being alone. Schizophrenia research, 172(1-3), 195-200.

DeSon, J., Fortgang, R., Owrutsky, Z., Berman, K., & Dickinson, D. (2018). F248. Suicidal Behaviors and Non-Suicidal Self-Harm in a Schizophrenia Sample. Biological Psychiatry, 83(9), S335.

Haley, J. (2013). Leaving home: The therapy of disturbed young people. Routledge.

Kaskie, R. E., Graziano, B., & Ferrarelli, F. (2017). Schizophrenia and sleep disorders: links, risks, and management challenges. Nature and science of sleep, 9, 227.

Kate, N., Grover, S., Kulhara, P., & Nehra, R. (2014). Relationship of quality of life with coping and burden in primary caregivers of patients with schizophrenia. International Journal of Social Psychiatry, 60(2), 107-116.

Nelson, B., Whitford, T. J., Lavoie, S., & Sass, L. A. (2014). What are the neurocognitive correlates of basic self-disturbance in schizophrenia?: Integrating phenomenology and neurocognition. Part 1 (Source monitoring deficits). Schizophrenia research, 152(1), 12-19.

Shah, R., Kulhara, P., Grover, S., Kumar, S., Malhotra, R., & Tyagi, S. (2011). Relationship between spirituality/religiousness and coping in patients with residual schizophrenia. Quality of Life Research, 20(7), 1053-1060.

Topor, A., Ljungqvist, I., &Strandberg, E. L. (2016). The costs of friendship: severe mental illness, poverty and social isolation. Psychosis, 8(4), 336-345.

Waters, F., Chiu, V., Atkinson, A., & Blom, J. D. (2018). Severe Sleep Deprivation Causes Hallucinations and a Gradual Progression Toward Psychosis With Increasing Time Awake. Frontiers in psychiatry, 9.

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