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Monday, March 19

  1. page Turnitin edited Turnitin Our new support page for Turnitin is on our new Staff Essentials page.
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Sunday, March 18

  1. page Turnitin edited Case study 1 Joseph is a 19-year-old first year university student currently living in halls. He …
    Case study 1
    Joseph is a 19-year-old first year university student currently living in halls. He smokes cannabis on a regular basis and has done so for a few years. Referral to the Early Intervention Services (EIS) resulted from a GP-visit, which Joseph had been encouraged to attend by a family friend, consequent to his changing behaviour: including hearing voices and increasing social isolation. Joseph’s behaviour became so severe that daily social routines had been affected, including interactions with his friends, and at university. His anxiety towards upcoming exams have also contributed to his stress, triggering delusional thoughts.
    DIAGNOSIS
    The onset of Joseph’s symptoms began over a month ago (ICD-10, Criteria F20). The report indicates he demonstrated ‘negative symptoms’ of social withdrawal - no longer attending parties, instead choosing isolation in his room (Criteria I). The family friend that accompanied his GP visit also highlighted recent changes in Joseph’s personal behaviour. Past hobbies (guitar playing, composing) have since stopped due to a lack of motivation (Criteria H). ‘Negative symptoms’ have caused significant self-neglect, leading to difficulty in education (low-attendance) and thus mounting exam-related stress.
    Joseph’s symptoms have accumulated over the past few weeks. Joseph insights his ‘weird experiences’: consisting of ‘positive symptoms’, present in the form of auditory hallucinations and paranoid delusions. Initially, his thoughts were likeable and easy to ignore, but have since escalated, becoming intrusive and preoccupying him. Additionally, Joseph has emphasised recent fear of people wanting to get or harm him, and thus feels unsafe outside his room.
    The hallucinations have persisted for over a month, but the delusions were recent. The combination of marked apathy and 1-month of hallucinations meets ICD-10 Criteria H and E for schizophrenia (WHO, 1993). Additionally, through social withdrawal and significant decrease in his interpersonal relations, he meets symptoms of Criterion I. Psychoactive substance-induced psychotic disorderwas ruled out as Joseph had history using cannabis for a few years; his symptoms had ‘gotten worse over the last couple of weeks’ which illustrates that he has had the symptoms for a while and is unlikely to be suddenly caused by his cannabis use. Nevertheless, his substance history should be made aware and Joseph should be monitored regularly to ensure correct diagnosis.
    AETIOLOGY
    Schizophrenia is a chronic mental health disorder, often characterised by abnormal social behaviours, impaired thinking and the inability to separate delusions from reality. 1 in 100 people will suffer an episode of psychosis in their life; schizophrenia affects more than 21 million individuals in the world (WHO, 2017). There is no definite cause linked to schizophrenia, though overlapping biological, psychological and social factors that constitute the Biopsychosocial Model, can contribute.
    The general public’s lifetime risk of acquiring schizophrenia is just 1%. However, there is a genetic predisposition in families of an affected individual. In twin studies, the risk of developing schizophrenia for a non-affected identical twin increases by 50% should the other twin be affected (Sullivan, Kendler & Neale, 2003). Although genetic influences are significant in causation of schizophrenia, the lack of total (100%) concordance between identical twins illustrates that other environmental influences are expected.
    Exposure to psychological factors such as life events (e.g. bereavement) or familial stress is more common in schizophrenic patients than control subjects. Despite indirectly, the contribution of psychological stress can precede the risk of relapse (Zipursky, Reilly & Murray, 2012).
    Substance misuse is a social factor highly predominant among people with schizophrenia in relation to the general population (Volkow, 2009). Considering the role of cannabinoids, evidence now demonstrates cannabis to be a casual-risk factor to acquiring schizophrenia (Vaucher et al., 2017). Furthermore, the risk of developing schizophrenia is higher in patients with early-cannabis use (Arseneault et al., 2002). Understanding the impact of cannabis, in interfering with the growing process of the brain during adolescent years, is particularly relevant for the case of Joseph, who admitted smoking cannabis since his teenage years.
    TREATMENT & RECOVERY PROCESS
    EIS are multidisciplinary services working with individuals under age-35 who are experiencing their first psychotic episode, like Joseph. They consist of a range of staff, including: occupational therapists, psychiatrists, and social workers. Multi-disciplinary meetings are regularly held reviewing the process of the service user, and the integration between various staff enables the best approach of effective care and management. Joseph will have an initial assessment enabling staff to prepare an individualised support plan; with treatment commencing two weeks later.
    At present, Joseph does not appear to be a danger to himself or others, showing no signs of inappropriate behaviour; hospitalisation does not need to be considered. It is suggested that Joseph follows a treatment plan of music therapy, cognitive behavioural therapy for psychosis (CBTp; both individual and group-therapy) and antipsychotic drug treatment. Beforehand, he should be referred to a local drug service to treat his cannabis addiction, considering its interference with schizophrenic recovery. A physical assessment should also be carried out before his drug treatment, ensuring suitability to the drug and confirming his symptoms are not due to underlying neurological or seizure disorders.
    Pharmacotherapy is a first-line treatment for schizophrenia and should be consistent throughout therapy sessions. Any choice of medication should be made together with Joseph to ensure his involvement. A recommended antipsychotic drug is clozapine, a second-generation (atypical) drug suited to lessen the positive and negative schizophrenic symptoms exhibited by Joseph. It is found to be more efficacious than first-generation antipsychotics in the overall change in symptoms and tolerating extrapyramidal side-effects (Leucht, Kissling & Davis, 2009). Clozapine operates on the serotonin system instead of the dopaminergic system; this is advantageous over antipsychotic drugs that work as dopamine antagonists as those are less effective in reducing schizophrenic symptoms and have dangerous side-effects (e.g., tardive dyskinesia) (Miyake, Miyamoto & Jarskog, 2012). Furthermore, it significantly lowers suicidal behaviour in schizophrenic patients (Meltzer & Fatemi, 1995), which is beneficial for Joseph considering his suicidal ideation in the past. However, Joseph must be warned of possible side-effects, including: extrapyramidal (slurred speech, tremor) and weight-gain. In view of Joseph’s age, weight-gain may impact his confidence and further his self-stigma.
    A small dose of oral clozapine medication should initially be prescribed in case Joseph is intolerant, and this will be increased to an optimum dosage for 4-6 weeks as a trial (NICE, 2014). If clozapine has no effect, alternative medicines will be required. Physical health side-effects and benefits will be routinely monitored and reviewed in the annual team report; suicide risk assessments must also be regularly carried out.
    Joseph should start with weekly one-to-one CBTp sessions over minimum 16-planned sessions. CBTp is recommended by NICE (2014) as an evidence-based psychotherapy for reducing psychotic symptoms (hallucinations, delusions) and is widely used as an individual-therapy approach. Aiming for patients to recognise their thoughts, emotions and actions, CBTp thus allows them to alter the way they think as a coping mechanism. For Joseph, the onset and development of the voices should be explored to help normalise his experience; addressing what the auditory hallucinations mean may lessen his self-stigmatising perception. Focus must also aim to reduce distress linked with his paranoia delusions, rather than convincing him whether the delusions are real or not. Recent delusions suggest recent causation, scrutiny of recent events may be useful in determining how and why they came about; sleep disruption can often trigger positive symptoms (Pritchett et al., 2012).
    Encouragement to attend weekly group-therapy sessions supervised by a psychologist will also benefit Joseph. This provides a confidential space to share with relatable-others (peer support), discuss coping strategies and build his confidence to interact with people, to develop his social skills. A study by Barrowclough et al. (2006) illustrated group-CBT not only lessened positive schizophrenic symptoms but also reduced self-stigma. If he is uncomfortable with group therapy, individualised occupational therapy is possible so that he can learn daily tasks which facilitates his optimal functioning in adapting to his university environment.
    In an empirical review by Rector & Beck (2001), the effects of CBT and routine care (pharmacotherapy) were examined showing that patients receiving both treatments produced substantial clinical effects on measures of schizophrenic symptoms (both positive and negative) compared to those receiving routine care alone. Therefore, CBT should be used in conjunction with medication for maximum benefit for Joseph.
    Music therapy is an appropriate add-on intervention for Joseph considering his previous interests in playing the guitar and composing. Similarly to CBT, this art-based therapy uses musical experience to improve interpersonal contact, global state and reduce psychotic symptoms in schizophrenic individuals (Gold et al., 2009). However, the effects across studies on the negative symptoms and social functioning are inconsistent (Gold et al., 2005) and the long-term effects are not known. Nevertheless, it appears to help support schizophrenic patients, and for Joseph it could reignite his love of music and encourage his motivation.
    EIS is available for 3 years, though can and should be extended if Joseph has not made a stable recovery (NICE, 2014). If he responds well to treatment and remains stable, he will be offered a return to primary care with his GP for further management. It is recommended that patients take their medication for one-two years following their first psychotic episode, or longer if they relapse (NHS, 2016). Once his symptoms start to subside after the required duration of medication, his treatment will be reviewed by the multi-disciplinary team. Reviewing his therapy sessions and management of his symptoms, a smaller dosage can be considered.
    STIGMA
    At some point in their lives, individuals with schizophrenia will suffer from discrimination. Schizophrenia is a very misunderstood mental disorder, stereotypically-depicted in the media as dangerous, unstable or crime-associated. Although schizophrenic individuals have a higher chance to be violent compared to the general public, the actual proportion of societal violence is very small (<10%) (Walsh, Buchanan and Fahy, 2018). Moreover, schizophrenic males have been perceived more aggressive than females (Penn & Link, 2002). Research suggests that the resulting social stigma experienced in schizophrenic individuals is often associated with depressive symptoms, avoidance behaviour and social anxiety (Gerlinger et al., 2013).
    From the report, Joseph mentioned avoiding friends because he is concerned with their understanding of his illness and how they would view him. This may be due to the negative misconceptions of schizophrenia portrayed in society; Joseph may also be anticipating rejection due to self-stigma, where he internalises discriminating/stereotypical perceptions of society. This experience, in conjunction to a decrease in self-esteem and self-confidence, may have induced a barrier to Joseph’s social participation with friends and at university, thus directly affecting his quality of life.
    The report conveys a sense of denial, depicting Joseph’s social withdrawal as consequence of ‘growing up’. Considering the underlying stigma, he may find it difficult to engage or share his concerns with healthcare professionals when seeking treatment. Staff should avoid ‘labelling’ Joseph’s mental illness when possible, understanding the influence public attitudes have on schizophrenic individuals (Angermeyer & Matschinger, 2003). As mentioned above, group-CBT can teach him how to challenge these misconceptions; interactions with peers within the same setting will increase social participation, provide educational awareness and thus reduce self-stigma.
    LEGAL FRAMEWORK
    Despite not currently posing a risk to himself or others, should Joseph’s symptoms deteriorate or there is a safety concern, he can be detained against his will under the Mental Health Act (1983). For example, in the case where Joseph’s symptoms become severe, but he refuses medication and disregards recommendations by healthcare professionals. Regardless of his consent, he can be admitted to hospital for treatment under Section 3 through the advice of healthcare professionals to alleviate his symptoms. This is done in his best interest and to minimise any risks. The downside being Joseph could perceive this situation as gross intrusion, disrupting his therapeutic relationship with the person responsible. Moreover, should Joseph’s delusional thoughts deteriorate significantly and impact on his ability to make decisions, his capacity will be assessed under the Mental Capacity Act (2005).
    CONCLUSION
    This essay assessed Joseph’s symptoms and diagnosis of schizophrenia using ICD-10 as a guideline. Implementation of EIS provides Joseph with treatment suited to him and is evident in facilitating affected individuals with their recovery, preventing relapse and suicide risks (Craig et al., 2004). The combination of pharmacotherapy and psychosocial interventions are recommended for Joseph; preceding this, he should be treated and educated regarding his substance use for his full recovery process. Thereafter, further monitoring/assessment is required to clarify his diagnosis to ensure it is not due to substance misuse. His key goals would be his relationships with his friends/family and getting him back to university. Should Joseph relapse after his 3-year period with EIS, he will be re-referred to secondary care.
    Further areas such as Joseph’s family should be explored. Joseph was brought to his GP by a ‘family friend’ and the report did not mention his family. Family roles are especially important in the treatment and recovery of an individual with mental health; research has shown that having their involvement and support through this process can achieve a better treatment outcome (Pharoah et al., 2010).
    Reference:
    Angermeyer, M.C. & Matschinger, H. (2003) The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatrica Scandinavica, 108, 304-309.
    Arseneault, L., Cannon, M., Poulton, R., Murray, R., Caspi, A., & Moffitt, T. E. (2002). Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. BMJ: British Medical Journal, 325(7374), 1212–1213.
    Barrowclough, C., Haddock, G., Lobban, F., Jones, S., Siddle, R., Roberts, C., & Gregg, L. (2006) Group cognitive-behavioural therapy for schizophrenia: Randomised controlled trial. British Journal of Psychiatry, 189(6), 527-532. doi:10.1192/bjp.bp.106.021386
    Craig, T.K., Garety, P., Power, P., Rahaman, N., Colbert, S., Fornells-Ambrojo, M., Dunn, G. (2004) The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ: British Medical Journal, 329(7474), 1067.
    Department of Health. (1983) Mental Health Act. London: HMSO.
    Department of Health. (2005). Mental Capacity Act. London: HMSO.
    Dickerson, F.B., Sommerville, J., Origoni, A.E., Ringel, N.B., Parente, F. (2002) Experiences of stigma among outpatients with schizophrenia, Schizophrenia Bulletin, 28(1), 143-55.
    Gerlinger, G., Hauser, M., De Hert, M., Lacluyse, K., Wampers, M., & Correll, C. U. (2013). Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry, 12(2), 155–164. http://doi.org/10.1002/wps.20040 [Accessed: 11 March 2018]
    Gold C, Heldal TO, Dahle T, Wigram T. (2005) Music therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews, (2):Art. No.: CD004025. DOI: 10.1002/14651858.CD004025.pub2.
    Gold C., Solli H. P., Kruger V., Lie S. A. (2009). Dose-response relationship in music therapy for people with serious mental disorders: systematic review and meta-analysis. Clinical Psychology Review, 29, 193–207.
    Leucht, S., Kissling, W., Davis, J.M. (2009) Second- generation antipsychotics for schizophrenia: can we resolve the conflict? Psychological Medicine, 39(10), 1595-602. doi: 10.1017/S0033291709005455.
    Meltzer, H.Y. & Fatemi, H. (1995) Suicide in Schizophrenia: The Effect of Clozapine. Clinical Neuropharmacology, 18, S18-24
    Miyake, N., Miyamoto, S., & Jarskog, L.F. (2012) New serotonin/dopamine antagonists for the treatment of schizophrenia: are we making real progress? Clinical Schizophrenia & Related Psychoses, 6(3), 122-33.
    National Institute for Health and Care Excellence. (2014) Schizophrenia. Available from: https://www.nice.org.uk/guidance/CG178 [Accessed: 5 March 2018].
    NHS Choices. (2016) Schizophrenia. Available from: https://www.nhs.uk/conditions/schizophrenia/ [Accessed: 10 March 2018]
    Penn, D.L. & Link, B. (2002) Dispelling the Stigma of Schizophrenia, III: The Role of Target Gender, Laboratory-Induced Contact, and Factual Information. Psychiatric Rehabilitation Skills, 6, 255–270. https://doi.org/10.1080/10973430208408435 [Accessed: 9 March 2018]
    Pharoah, F., Mari, J., Rathbone, J., & Wong, W. (2010). Family intervention for schizophrenia. The Cochrane Database of Systematic Reviews, (12), CD000088. Advance online publication. http://doi.org/10.1002/14651858.CD000088.pub2 [Accessed: 14 March 2018]
    Pritchett, D., Wulff, K., Oliver, P.L., Bannerman, D.M., Davies, K.E., Harrison, P.J., Peirson, S.N., Foster, R.G. (2012) Journal of Neural Transmission, 119(10), 1061-175. https://doi.org/10.1007/s00702-012-0817-8 [Accessed: 10 March 2018
    Rector, N. A., & Beck, A. T. (2001). Cognitive-behavioral therapy for schizophrenia: An empirical review. Journal of Nervous and Mental Disease, 189, 278–287.
    Stahl, S. M. (1999). Selecting atypical antipsychotics by combining clinical experience with guidelines from clinical trials. Journal of Clinical Psychiatry, 60, 31–41
    Sullivan, P.F., Kendler, K.S., Neale, M.C. (2003) Schizophrenia as a complex trait: evidence from a meta-analysis of twin studies. Archives of General Psychiatry, 60(12), 1187-92.
    Vaucher, J., Keating, B.J., Lasserre, A.M., Gan, W., Lyall, D.M., Ward, J., Smith, D.J., Pell, J.P., Sattar, N., Pare, G., Holmes, M.V. (2017) Cannabis use and risk of schizophrenia: a Mendelian randomization study. Nature: Molecular Psychiatry, 00, 1-6.
    Volkow, N.D. (2009) Substance use disorders in schizophrenia — clinical implications of comorbidity. Schizophrenia Bulletin, 35(3), 469-472. https://doi.org/10.1093/schbul/sbp016 [Accessed: 5 March 2018]
    Walsh, E., Buchanan, A., Fahy, T. (2018) Violence and schizophrenia: Examining the evidence, The British Journal of Psychiatry, 180(6), 490-495.
    World Health Organization. (1993) The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization.
    World Health Organisation. (2017) Schizophrenia. Available from: http://www.who.int/mental_health/management/schizophrenia/en/ [Accessed: 5 March 2018]
    Zipursky, R.B., Reilly, T.J., Murray, R.M. (2013) The Myth of Schizophrenia as a Progressive Brain Disease, Schizophrenia Bulletin, 39(6), 1363–1372. https://doi.org/10.1093/schbul/sbs135 [Accessed: 8 March 2018]
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  2. page Turnitin edited Turnitin Case study 1 Joseph is a 19-year-old first year university student currently living in …
    TurnitinCase study 1
    Joseph is a 19-year-old first year university student currently living in halls. He smokes cannabis on a regular basis and has done so for a few years. Referral to the Early Intervention Services (EIS) resulted from a GP-visit, which Joseph had been encouraged to attend by a family friend, consequent to his changing behaviour: including hearing voices and increasing social isolation. Joseph’s behaviour became so severe that daily social routines had been affected, including interactions with his friends, and at university. His anxiety towards upcoming exams have also contributed to his stress, triggering delusional thoughts.
    DIAGNOSIS
    The onset of Joseph’s symptoms began over a month ago (ICD-10, Criteria F20). The report indicates he demonstrated ‘negative symptoms’ of social withdrawal - no longer attending parties, instead choosing isolation in his room (Criteria I). The family friend that accompanied his GP visit also highlighted recent changes in Joseph’s personal behaviour. Past hobbies (guitar playing, composing) have since stopped due to a lack of motivation (Criteria H). ‘Negative symptoms’ have caused significant self-neglect, leading to difficulty in education (low-attendance) and thus mounting exam-related stress.
    Joseph’s symptoms have accumulated over the past few weeks. Joseph insights his ‘weird experiences’: consisting of ‘positive symptoms’, present in the form of auditory hallucinations and paranoid delusions. Initially, his thoughts were likeable and easy to ignore, but have since escalated, becoming intrusive and preoccupying him. Additionally, Joseph has emphasised recent fear of people wanting to get or harm him, and thus feels unsafe outside his room.
    The hallucinations have persisted for over a month, but the delusions were recent. The combination of marked apathy and 1-month of hallucinations meets ICD-10 Criteria H and E for schizophrenia (WHO, 1993). Additionally, through social withdrawal and significant decrease in his interpersonal relations, he meets symptoms of Criterion I. Psychoactive substance-induced psychotic disorderwas ruled out as Joseph had history using cannabis for a few years; his symptoms had ‘gotten worse over the last couple of weeks’ which illustrates that he has had the symptoms for a while and is unlikely to be suddenly caused by his cannabis use. Nevertheless, his substance history should be made aware and Joseph should be monitored regularly to ensure correct diagnosis.
    AETIOLOGY
    Schizophrenia is a chronic mental health disorder, often characterised by abnormal social behaviours, impaired thinking and the inability to separate delusions from reality. 1 in 100 people will suffer an episode of psychosis in their life; schizophrenia affects more than 21 million individuals in the world (WHO, 2017). There is no definite cause linked to schizophrenia, though overlapping biological, psychological and social factors that constitute the Biopsychosocial Model, can contribute.
    The general public’s lifetime risk of acquiring schizophrenia is just 1%. However, there is a genetic predisposition in families of an affected individual. In twin studies, the risk of developing schizophrenia for a non-affected identical twin increases by 50% should the other twin be affected (Sullivan, Kendler & Neale, 2003). Although genetic influences are significant in causation of schizophrenia, the lack of total (100%) concordance between identical twins illustrates that other environmental influences are expected.
    Exposure to psychological factors such as life events (e.g. bereavement) or familial stress is more common in schizophrenic patients than control subjects. Despite indirectly, the contribution of psychological stress can precede the risk of relapse (Zipursky, Reilly & Murray, 2012).
    Substance misuse is a social factor highly predominant among people with schizophrenia in relation to the general population (Volkow, 2009). Considering the role of cannabinoids, evidence now demonstrates cannabis to be a casual-risk factor to acquiring schizophrenia (Vaucher et al., 2017). Furthermore, the risk of developing schizophrenia is higher in patients with early-cannabis use (Arseneault et al., 2002). Understanding the impact of cannabis, in interfering with the growing process of the brain during adolescent years, is particularly relevant for the case of Joseph, who admitted smoking cannabis since his teenage years.
    TREATMENT & RECOVERY PROCESS
    EIS are multidisciplinary services working with individuals under age-35 who are experiencing their first psychotic episode, like Joseph. They consist of a range of staff, including: occupational therapists, psychiatrists, and social workers. Multi-disciplinary meetings are regularly held reviewing the process of the service user, and the integration between various staff enables the best approach of effective care and management. Joseph will have an initial assessment enabling staff to prepare an individualised support plan; with treatment commencing two weeks later.
    At present, Joseph does not appear to be a danger to himself or others, showing no signs of inappropriate behaviour; hospitalisation does not need to be considered. It is suggested that Joseph follows a treatment plan of music therapy, cognitive behavioural therapy for psychosis (CBTp; both individual and group-therapy) and antipsychotic drug treatment. Beforehand, he should be referred to a local drug service to treat his cannabis addiction, considering its interference with schizophrenic recovery. A physical assessment should also be carried out before his drug treatment, ensuring suitability to the drug and confirming his symptoms are not due to underlying neurological or seizure disorders.
    Pharmacotherapy is a first-line treatment for schizophrenia and should be consistent throughout therapy sessions. Any choice of medication should be made together with Joseph to ensure his involvement. A recommended antipsychotic drug is clozapine, a second-generation (atypical) drug suited to lessen the positive and negative schizophrenic symptoms exhibited by Joseph. It is found to be more efficacious than first-generation antipsychotics in the overall change in symptoms and tolerating extrapyramidal side-effects (Leucht, Kissling & Davis, 2009). Clozapine operates on the serotonin system instead of the dopaminergic system; this is advantageous over antipsychotic drugs that work as dopamine antagonists as those are less effective in reducing schizophrenic symptoms and have dangerous side-effects (e.g., tardive dyskinesia) (Miyake, Miyamoto & Jarskog, 2012). Furthermore, it significantly lowers suicidal behaviour in schizophrenic patients (Meltzer & Fatemi, 1995), which is beneficial for Joseph considering his suicidal ideation in the past. However, Joseph must be warned of possible side-effects, including: extrapyramidal (slurred speech, tremor) and weight-gain. In view of Joseph’s age, weight-gain may impact his confidence and further his self-stigma.
    A small dose of oral clozapine medication should initially be prescribed in case Joseph is intolerant, and this will be increased to an optimum dosage for 4-6 weeks as a trial (NICE, 2014). If clozapine has no effect, alternative medicines will be required. Physical health side-effects and benefits will be routinely monitored and reviewed in the annual team report; suicide risk assessments must also be regularly carried out.
    Joseph should start with weekly one-to-one CBTp sessions over minimum 16-planned sessions. CBTp is recommended by NICE (2014) as an evidence-based psychotherapy for reducing psychotic symptoms (hallucinations, delusions) and is widely used as an individual-therapy approach. Aiming for patients to recognise their thoughts, emotions and actions, CBTp thus allows them to alter the way they think as a coping mechanism. For Joseph, the onset and development of the voices should be explored to help normalise his experience; addressing what the auditory hallucinations mean may lessen his self-stigmatising perception. Focus must also aim to reduce distress linked with his paranoia delusions, rather than convincing him whether the delusions are real or not. Recent delusions suggest recent causation, scrutiny of recent events may be useful in determining how and why they came about; sleep disruption can often trigger positive symptoms (Pritchett et al., 2012).
    Encouragement to attend weekly group-therapy sessions supervised by a psychologist will also benefit Joseph. This provides a confidential space to share with relatable-others (peer support), discuss coping strategies and build his confidence to interact with people, to develop his social skills. A study by Barrowclough et al. (2006) illustrated group-CBT not only lessened positive schizophrenic symptoms but also reduced self-stigma. If he is uncomfortable with group therapy, individualised occupational therapy is possible so that he can learn daily tasks which facilitates his optimal functioning in adapting to his university environment.
    In an empirical review by Rector & Beck (2001), the effects of CBT and routine care (pharmacotherapy) were examined showing that patients receiving both treatments produced substantial clinical effects on measures of schizophrenic symptoms (both positive and negative) compared to those receiving routine care alone. Therefore, CBT should be used in conjunction with medication for maximum benefit for Joseph.
    Music therapy is an appropriate add-on intervention for Joseph considering his previous interests in playing the guitar and composing. Similarly to CBT, this art-based therapy uses musical experience to improve interpersonal contact, global state and reduce psychotic symptoms in schizophrenic individuals (Gold et al., 2009). However, the effects across studies on the negative symptoms and social functioning are inconsistent (Gold et al., 2005) and the long-term effects are not known. Nevertheless, it appears to help support schizophrenic patients, and for Joseph it could reignite his love of music and encourage his motivation.
    EIS is available for 3 years, though can and should be extended if Joseph has not made a stable recovery (NICE, 2014). If he responds well to treatment and remains stable, he will be offered a return to primary care with his GP for further management. It is recommended that patients take their medication for one-two years following their first psychotic episode, or longer if they relapse (NHS, 2016). Once his symptoms start to subside after the required duration of medication, his treatment will be reviewed by the multi-disciplinary team. Reviewing his therapy sessions and management of his symptoms, a smaller dosage can be considered.
    STIGMA
    At some point in their lives, individuals with schizophrenia will suffer from discrimination. Schizophrenia is a very misunderstood mental disorder, stereotypically-depicted in the media as dangerous, unstable or crime-associated. Although schizophrenic individuals have a higher chance to be violent compared to the general public, the actual proportion of societal violence is very small (<10%) (Walsh, Buchanan and Fahy, 2018). Moreover, schizophrenic males have been perceived more aggressive than females (Penn & Link, 2002). Research suggests that the resulting social stigma experienced in schizophrenic individuals is often associated with depressive symptoms, avoidance behaviour and social anxiety (Gerlinger et al., 2013).
    From the report, Joseph mentioned avoiding friends because he is concerned with their understanding of his illness and how they would view him. This may be due to the negative misconceptions of schizophrenia portrayed in society; Joseph may also be anticipating rejection due to self-stigma, where he internalises discriminating/stereotypical perceptions of society. This experience, in conjunction to a decrease in self-esteem and self-confidence, may have induced a barrier to Joseph’s social participation with friends and at university, thus directly affecting his quality of life.
    The report conveys a sense of denial, depicting Joseph’s social withdrawal as consequence of ‘growing up’. Considering the underlying stigma, he may find it difficult to engage or share his concerns with healthcare professionals when seeking treatment. Staff should avoid ‘labelling’ Joseph’s mental illness when possible, understanding the influence public attitudes have on schizophrenic individuals (Angermeyer & Matschinger, 2003). As mentioned above, group-CBT can teach him how to challenge these misconceptions; interactions with peers within the same setting will increase social participation, provide educational awareness and thus reduce self-stigma.
    LEGAL FRAMEWORK
    Despite not currently posing a risk to himself or others, should Joseph’s symptoms deteriorate or there is a safety concern, he can be detained against his will under the Mental Health Act (1983). For example, in the case where Joseph’s symptoms become severe, but he refuses medication and disregards recommendations by healthcare professionals. Regardless of his consent, he can be admitted to hospital for treatment under Section 3 through the advice of healthcare professionals to alleviate his symptoms. This is done in his best interest and to minimise any risks. The downside being Joseph could perceive this situation as gross intrusion, disrupting his therapeutic relationship with the person responsible. Moreover, should Joseph’s delusional thoughts deteriorate significantly and impact on his ability to make decisions, his capacity will be assessed under the Mental Capacity Act (2005).
    CONCLUSION
    This essay assessed Joseph’s symptoms and diagnosis of schizophrenia using ICD-10 as a guideline. Implementation of EIS provides Joseph with treatment suited to him and is evident in facilitating affected individuals with their recovery, preventing relapse and suicide risks (Craig et al., 2004). The combination of pharmacotherapy and psychosocial interventions are recommended for Joseph; preceding this, he should be treated and educated regarding his substance use for his full recovery process. Thereafter, further monitoring/assessment is required to clarify his diagnosis to ensure it is not due to substance misuse. His key goals would be his relationships with his friends/family and getting him back to university. Should Joseph relapse after his 3-year period with EIS, he will be re-referred to secondary care.
    Further areas such as Joseph’s family should be explored. Joseph was brought to his GP by a ‘family friend’ and the report did not mention his family. Family roles are especially important in the treatment and recovery of an individual with mental health; research has shown that having their involvement and support through this process can achieve a better treatment outcome (Pharoah et al., 2010).
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