Case Study Analysis: Schizophrenia and OCD Patient in Community Care

This case study details the voluntary admission of a 34-year-old male, diagnosed with Schizophrenia and OCD, to a community care unit. The study begins with a comprehensive assessment, including a mental state examination, risk assessment, and physical health evaluation, followed by a diagnosis based on DSM-V criteria and NANDA. The core of the case study focuses on a collaborative, evidence-based recovery plan, addressing the patient's social isolation, demotivation, and ritualistic behaviors. The plan encompasses planning and implementation, including group activities and social skill training, expected outcomes, and outcome measurements based on objective data. The interventions aimed to improve the patient's social interaction and reduce isolation, leading to positive outcomes in daily living activities and overall wellbeing, as evidenced by both subjective and objective data, and highlighting the effectiveness of a recovery-focused approach in community care settings.

Introduction
John (Pseudonym to protect privacy and confidentiality) was admitted voluntarily to a
community care unit/psycho-social rehabilitation following a referral from the GP due to respite
for parents. John was diagnosed with Schizophrenia (schizo-typal traits) and OCD, which was
characterized by demotivation, low self-esteem, social withdrawal, anhedonia, negative view of
self and ritualistic behavior. This case study presents, beginning with initial assessment, both
subjective and objective data that were collected using mental state examination, following
DSM-V and NANDA diagnosis. The preliminary findings were used to formulate a
collaborative, evidence based recovery for future focused plan. The recovery plan is presented in
a logical order: planning and implementation, expected outcomes of care, and finally evaluation
and outcome measurements based on John’s objective data (Carey, 2016).
Assessment
In order to attain a holistic insight of John’s mental state, assessment was performed which
included mental state examination, community risk and assessment plan, alcohol and other drug
assessment, and behavioral and symptom identification scale (BASIS-32) (Dwyer, 2012). John’s
current medication included Risperidone (Risperidol consta) 37.5mg IM injection depot for
every two weeks. Although John was recommended to take ZOLOFT (OCD traits) tablets, he
declined due to side-effects of the drug.
Mental state Exam
Being a Greek, the 34-year-old John was dressed in a color t-shirt and cargo pants with small
stains on color appropriate for weather. John appeared to be thin, having poor personal hygiene,
rigid posture, poor eye contact and greasy hair. John could be described as “I’m doing laundry

and shower once every two days”. He looked anergic and walked very slowly, while the
psychomotor retardation was a times slow to initiate tasks. John’s speech was slow in rate, soft,
audible and answered to all the questions in a polite manner. Throughout the conversation, John
seemed to be inactive in the interview. John’s mood was euthymic, hyper vigilant, non-depressed
and mildly anxious. His affect was blunted since he had a very low facial expression, anhedonia,
reactive and inappropriate gestures and wanting to pinch his cheeks every time and then
throughout the conversation. However, Mr. John did not present any formal thought disorder
although he was obsessed with cleaning vegetables and checking locks frequently. He also had
some persecutory delusions because he occasionally stated that “someone is following when I go
out”. John was also isolated, self-neglected and stayed in his bedroom for many hours, socially
withdrawn without any friends. He usually reported that he used to isolate himself in his room
since he was alert and oriented in terms of person, place, time and the environment. This patient
also experienced difficulties in performing day to day life routines, household responsibilities
and thus he had to be prompted severally, in order to get on board. He was also not impulsive
and hence did not present with any perception disorders. John was dependent on his parents and
he was poor in solving problems and making decisions.
Risk assessment
The community and risk assessment plan was used to assess the general vulnerability, dynamic
risk, statics and falls, and nutritional risk. The general vulnerability of Mr. John included a
history of childhood trauma and a record of being bullied at school. Rumination on events
resulted in significant self-neglect, poor self-care and social withdrawal. John was isolative and
never received any social support including from friends and he reported “I feel fear when I
come out and I feel someone is following”. John had also been charged by the police for

removing license plates from a police vehicle. As a result of the persecutory ideas towards the
police, John stated “The police will be here at any time to take me away”. However, this patient
never had no known history of suicidal injury, deliberate self-harm or past attempts, and current
thoughts of suicide or self-harm. Moreover, John was a non-smoker, non-alcoholic and non-drug
abuser.
Physical health
The head to toe assessment was used to obtain the data, whereby John’s vital signs were found to
be within the limits (100% SpO2, 18 breaths per minute, 70 beat per minute, blood pressure 120/
70 mmHg, and temperature 36.4ºC). Additionally, John never experienced any pain, and the
BMI was 22, and hence considered to be normal based on Reinders et al., (2015). He neither had
any abnormalities in gastrointestinal, respiratory and cardiovascular systems, nor did he present
any pressure injuries or wounds on the skin.
Diagnosis
By use of the Diagnostic and Statistical Manual of Mental Disorders, John’s presentation
[Appendix-I], provided the requirement for diagnosis of schizophrenia disorder (American
Psychiatric Association, 2013). John had this diagnosis for past 10 years, and was dependent on
his parents since he was described as “I hope to become more independent, because my parents
are very protective and do things for me”. He also expressed his desire to regain mental
wellbeing and stated that “I want to be more motivated and possibly take on another study course
in future”. John had some persecutory delusions and negative symptoms of schizophrenia since
he was amotivated, and asocialite. He also had negative views about himself and others including
anhedonia secondary to schizophrenia disorder, which could be related to childhood trauma.

The Northern American Nursing Diagnosis Association taxonomy of nursing diagnoses 2015-
2017 (Herdman & Kamitsuru, 2014) was applied to the nursing process to identify one problem
or issue in this patients. Social isolation was one of his problems and was evidenced by
assessment, subjective and objective data. John had difficulty in reality, establishing relationship,
and false belief about the intension of other people on him.
Planning & Implementation
In order to achieve John’s goals for his problem of social isolation, nursing interventions were
required to make a plan using the SMART (specific, measurable, achievable, realistic and
timely) approach (Revello & Fields, 2015). It was evident that John’s mental state was greatly
affected by childhood trauma and bullying at school. Social isolation is positively correlated with
schizophrenia such as low self-esteem, anhedonia and asociality (ref). Based on John’s
presentation, it was required that nursing interventions were to be collaborative with John, so that
a recovery-focused wellness plan could be developed to keep him safe.
Group activities
The group activity used in this case was gathering, whereby John expressed that he would be
interested in making friends and stated “I want to see myself as a friendly person and show an
interest in other people”. Based on his preferences, group interventions with problem-focused
and goal-oriented activities were suggested, in an effort to alleviate social isolation and
loneliness (Henderson). This intervention was given by nurses in collaboration with occupational
therapist and social workers (ref). The group activities were realistic, and thus John was
encouraged to engage with other clients. He was therefore asked to participate in activities such
as card games, group outings, community meetings, walking in groups and cooking a meal. John

was prompted more to get on to board as he was a slow learner and took long time to initiate a
task. John was thus required to be educated to improve significant social interactions by
participating in group activities. He was also advised on how to establish rapport and show
positive regard towards other people and seek for help whenever he needed support in various
activities (Prokofieva). Gardiner reported that group-based activities make clients to continue
feeling safe and competent during interactions. Furthermore, on long term management, clients
will demonstrate willingness and desire to socialize with staff and co-clients and voluntarily
participate in group activities without prompt Ojengbede.
Social skill training
Social skill training is an education which teaches necessary skills for effective communication
with others (ALLY). John was encouraged to attend social skill training which helped to learn
adaptive social skills. John was to be trained in an environment that was free of any stimuli like
loud noises and high traffic (lauren), to avoid deviation of his training. Initially, John would aim
to learn simple basic behaviours like maintaining good eye contact, keeping appropriate
distances, appropriate behaviour, effective communication and making simple decisions. This
therefore encouraged John to do rehearsal and role-play the skills which involved practicing and
positive reinforcement (ally). Moreover, John would adapt and function at a higher level in the
society to improve the quality of his life. However, John took time to adapt these skills because
of his negative symptoms of schizophrenia. Pfammatter reported that these skills increase self-
confidence, self-esteem and positive responses from others. The outcome was that John
improved social interaction with family, friends and relatives.

Evaluation and expected outcomes
Short term goal for John were to engage in one activity accompanied with trusted nursing staff
and attend at least one therapy by the end of day within one week. He was also to maintain
interaction with other consumer while playing, drawing or cooking a meal. Long term goal for
John were to spend time with other clients voluntarily in various group activities to show interest
in coping skills. He would also be comfortable in talking and avoid spending more hours in his
bedroom. This goal is realistic and may be achieved within a period of six months to one year.
The basis-32 and adult well-being scale would be assessed to find any improvements in
behaviour or daily living activities. However, social skill training and group activities helped to
improve John’s status more independently and lower asociality.
Outcome assessment
The main issue with John was social isolation and the combination of group activities and social
skill training interventions helped him in developing interpersonal and social skills. Outcome
assessment for these interventions were adult well-being scale and behavioural and symptom
identification scale (BASIS-32®), and recovery. The wellness plan and monitoring of mental
change every month was necessary with an occupational therapist, social worker, psychologist
and psychiatrist. John currently had little difficulty in performing day to day life activities,
household responsibilities, relation with family members, and isolation/feeling of loneliness. He
had improved in self-care and independent in performing tasks but needed to be prompted for
once. John had recently enrolled in TAFE program, criminal justice and started working for four
hours in his brother in law’s warehouse. Finally, subjective data of recovery stated that “I feel

more confident doing house chores and cooking” and “I will remain active and try to pass my
exams in future”.
Conclusion
John was referred to a community care unit by treating team with a diagnosis of schizophrenia,
where social isolation was a current issue. The nursing process involved assessments such as
mental state examination, risk assessment and physical health to form a nursing diagnosis. Based
on the John preferences, collaborative recovery-focused interventions such as group activities
and social skill training were framed to achieve goals. To improve social interaction, alleviate
social isolation and keep him safe, these evidence-based interventions were used. His
intervention plan provided reasonable outcomes which had improved his wellbeing in the
community.