Liz Ammons, RT Student



Case StudyAbstractThis patient is an 18 year old male admitted involuntarily in mid-January after becoming assaultive towards his mother after Christmas. Prior to admission, the patient was in the emergency room at Rowan Regional Medical Center. Throughout this case study, the patient with be known as “Corey” to protect his privacy and uphold his confidentiality. Key WordsSchizophrenia, major depressive disorder, mood disorder NOS (not otherwise specified), psychosis NOS, schizoaffective, ADHD (attention deficit/hyperactivity disorder), schizoid personality, selective mutism, divalproex, duloxetine, lorazepam, geodon, busparPurpose StatementThe purpose of the comprehensive case study is to further the understanding of mental illnesses treated at Broughton Hospital, specifically “Corey” and his treatment during hospitalization. Diagnosis and Literature Review: According to Merck Manual Medical Library, Diagnostic and Statistical Manual of Mental Disorders IV-TR, and National Library of Medicine.Schizophrenia - Schizophrenia is a chronic illness characterized by loss of contact with reality, hallucinations, delusions, disorganized speech and behavior, flattened affect, cognitive deficits, and occupational and social dysfunction. Although there is no known cause, there is a strong biologic basis. An average of 10% of individuals with schizophrenia commit suicide and are at a greater risk of displaying aggressive behavior. Treating this disorder includes drug therapy (antipsychotic medications), psychotherapy, and rehabilitation. Major Depressive Disorder – Major depressive disorder is a mood disorder classified by having one or more major depressive episodes (at least two weeks of depressed mood or loss of interest or pleasure in nearly all activities). The patient cannot have a history of mania, mixed, or hypomanic episodes. Insomnia is a common sleep disturbance for people with major depressive disorder. Mood Disorder NOS – A mood disorder is a condition in which a disturbance in one’s mood is the predominant feature. Mood disorder NOS is defined by having mood symptoms that do not meet the criteria for a specific mood disorder. It is difficult to choose between depressive disorder NOS and bipolar disorder NOS due to acute agitation. Psychosis NOS – Psychosis is defined as the loss of contact with reality, usually including delusions or hallucinations. Substances and medical conditions can cause psychosis including alcohol, brain tumors, dementia, and HIV. Psychosis is a part of a number of mental illnesses including bipolar disorder, personality disorders, and schizophrenia. Psychotic symptoms can include disorganized thought and speech, delusions, and hallucinations. A diagnosis of psychosis NOS is made when it is difficult there is not enough information to choose between schizophrenia and other psychotic disorders. Schizoaffective – Schizoaffective disorder is characterized by both a loss of contact with reality and mood problems. Changes in appetite and energy, disorganized speech, problems sleeping, and social isolation are all symptoms of schizoaffective disorder. Antipsychotic medications are used to treat psychotic symptoms while antidepressants are used to improve mood.ADHD – Attention deficit/hyperactivity disorder is a syndrome of inattention, hyperactivity, and impulsivity. According to the DSM-IV-TR, there are three types: predominantly inattentive, predominantly hyperactive-impulsive, and a combination of the two. There is no single cause of developing this disorder, though potential causes include genetic, biomechanical, sensorimotor, physiologic, and behavioral factors. Diagnosis and clinical and based on a comprehensive evaluation. Treating ADHD include behavioral therapy and drug therapy, typically with stimulants. Schizoid personality – Schizoid personality is classified as a Cluster A personality disorder. Personality disorders are pervasive, inflexible, and stable patterns of behavior that can cause significant distress or functional impairment. Patients with a classification of Cluster A personality tent to be detached and distrustful. Schizoid personality is characterized by introversion, social withdrawal, isolation, and emotional coldness and distancing. People with this specific personality disorder are typically absorbed in their own thoughts and fear closeness and intimacy with others. All personality disorders are thought to be caused by both genetic and environmental factors and can be treated with psychotherapy and sometimes drug therapy. Selective mutism – Selective mutism is a condition in which a child, typically, who can speak well stops speaking, usually in a social situation. There is no known cause, though some researchers believe that the child inherit a tendency to be anxious or inhibited. The pattern of mutism must be observed for a month or more before diagnosis is given. Divalproex – Divalproex is another name for Depakote. This medication is used to treat certain types of seizures, mania in people with bipolar disorder, and can be also prescribed for people suffering with migraines. Divalproex can be given as a capsule, extended-release tablet, delayed release tablet, a sprinkle capsule, or syrup. This medication should be taken either once or twice a day, depending on the form the medication comes in. Duloxetine – Duloxetine is also another name for Cymbalta. This medication is classified as an antidepressant. It is used to treat depression and generalized anxiety disorder. It an also be prescribed to patients who have pain and tingling associated with diabetic neuropathy and patients with fibromyalgia. Duloxetine comes as a delayed release capsule to be taken by mouth once or twice a day as prescribed. Lorazepam – Lorazepam is another name for Ativan. This medication is used to relieve anxiety by slowing activity in the brain to allow relaxation and is classified as a benzodiazepine. It is either prescribed as a tablet or liquid to be taken by mouth usually two to three times a day. Lorazepam can also be administered to patients experiencing side effects of cancer treatment and patients going through withdrawal to alleviate agitation. Geodon – Geodon is used to treat symptoms of schizophrenia and mania or mixed episodes in people with bipolar disorder. This medication is classified as an atypical antipsychotic that works by altering the activity of certain natural substances in the brain. Geodon comes as a capsule to be taken by mouth usually twice a day with food at the same times everyday. BuSpar – BuSpar is used to treat anxiety disorders or short-term symptoms of anxiety. It is also sometimes used to treat symptoms of premenstrual syndrome. BuSpar comes as a tablet to be taken by mouth two or three times a day. Admission HistoryTime of admission: mid-JanuaryAge: 18 years oldEstimated length of stay: 90 daysReason for admission: “Corey” has had multiple involuntary commitments in the past. He was brought from the emergency department at Rowan Regional Medical Center to Broughton Hospital. He was assaultive towards his mother in mid-December. Initially he was cooperative in the emergency department but after a few days, his behavior deteriorated. He assaulted an emergency room nurse and began picking his skin and urinating in his bed. Upon admission at Broughton Hospital, “Corey” refused to talk to any of the admitting staff. It was noted that he had hypersomnia and weight loss.History of present illness: Though this is the first admission for “Corey” at Broughton Hospital, he has a history of increased irritability and depression within the last six months prior to admission, displaying lack of motivation and anhedonia (inability to experience pleasure). While in school, “Corey” was diagnosed with ADHD, inattentive type, and was placed in special education classes. Mother has stated that he refused to take his medications and “Corey” has been involuntarily committed multiple times. Diagnosis: Upon admission: Axis I – schizophrenia; major depressive disorder, Axis II – deferred, Axis III – none known, Axis IV – support; housing; social; economic; educational; legal; and occupational, and Axis V – GAF (Global Assessment of Functioning) 20. Updated on 3/26/2012: Axis I – mood disorder NOS; psychosis NOS; rule out schizoaffective; ADHD by history, Axis II – personality disorder NOS with features of schizoid personality, Axis III – none known, Axis IV – economic; educational; housing; legal; occupational; social; and, Axis V – GAF 35.History and PhysicalFamily medical/psychiatric history: Father is being treated for depression and bipolar disorder and is recovering from alcoholism, according to patients’ mother.Functional history: “Corey” completed the 9th grade of high school and attended Rowan-Cabarrus Community College to obtain his GED, however he was unsuccessful. He was diagnosed with ADHD and was enrolled in special education classes in elementary school. In addition to attending public school, “Corey” was home-schooled and attended a private school as well. “Corey” has no past employment history, though is applying for Social Security benefits. Past medical history: None knownSocial History: Prior to admission, “Corey” lived at home with his mother, step-father, and younger siblings. He has an older sister, though she does not live at home. His parents are divorced and according to “Corey’s” mother, his father is living in an assisted living home. “Corey” has little to no contact with his biological father. He has attended church in the past, however due to circumstances he is currently inactive in the church. Review of Systems: “Corey” has a history of digging in the skin on his face with his fingers to make it bleed. Upon admission, there was no report of bleeding. Since admission, “Corey” has been observed displaying this behavior and has been encouraged and redirected not to do so, however this is has only been somewhat successful. According to the records that were sent with “Corey” upon admission, he has lost twenty pounds within the last three months. All other systems report no problems.Physical examination: Upon admission, “Corey” was adequately nourished, appeared calm with a steady gait while walking to the unit. He was alert but was mute. “Corey” only allowed a brief examination at his bedside. Nothing was abnormal during the physical examination. Vital Signs upon admission are as follows: Temperature: 97.9; Pulse: 84; Respirations: 18; Blood Pressure: 112/75; Height: 5 ft 11 in; Weight: 130 lbs. Medications: Divalproex (at bedtime), Duloxetine (for depression),Lorazepam (akthesia/anxiety),Geodon (psychosis, mood), andBuSpar (for anxiety).Allergies: None knownSchizophreniaDefining Schizophrenia“Schizophrenia is a disabling brain disorder that has severely affected people throughout history” (National Institute of Mental Health [NIMH], 2009, p. 3). Schizophrenia is a chronic condition with a wide array of symptoms and problems arising from both the condition and treatment of symptoms. Schizophrenia symptoms fall into three main categories; positive, negative, and cognitive symptoms (NIMH, 2009).Positive symptoms of schizophrenia are added things that are not seen in healthy people. These symptoms can come and go and vary in severity depending on whether an individual is receiving treatment or not. The most common positive symptoms are hallucinations, delusions, thought disorders, and movement disorders (NIMH, 2009). Negative symptoms of schizophrenia are things that have been subtracted from a healthy person’s emotions or behaviors. These kinds of symptoms are harder to recognize as part of the disorder as they can be mistaken for depression or other conditions. These symptoms include flat affect, lack of pleasure in life, lack of ability to plan and sustain activities, and lack of interaction even when forced (NIMH, 2009). Cognitive symptoms are subtle and, like negative symptoms, can be difficult to recognize as part of a schizophrenic diagnosis (NIMH, 2009). These symptoms can be seen as poor executive functioning, trouble focusing or paying attention, and working memory issues (NIMH, 2009). Demographic InformationSchizophrenia occurs in 1% of the population, and affects men slightly more often than women (San et. al. 2013). The majority of diagnosed cases of schizophrenia (63.8%) occur between the ages of 30-45 years (San et. al. 2013). Schizophrenia can be harder to diagnose in adolescents because the first signs can include a change in social circles, drop in grades, sleep issues and irritability, which are all common behaviors among teens anyway (NIMH, 2009). Primary education is the most frequent level of education achieved by those diagnosed with schizophrenia and family support was considered “high” or “very high” in only 34.4% of patients (San et al, 2013).Client StrengthsMy client, Corey has many strengths, including connections to church, which could be used as an effective outlet to reintegrate client into social settings. Corey has at least some support in family, and comes from a healthy home with mother, step-father, and younger siblings. Corey has been well-educated, and he has attended public, private and homeschooling. He aspires to obtain his GED showing he has goals for the future. Upon admittance to the facility he has shown that he is alert and understands instructions.Client NeedsCorey is prone to physical assault and inflicting self-harm when agitated. Although many people with schizophrenia show no signs of violence, sometimes symptoms such as delusions can lead to violent actions in patients with schizophrenia (Roberts, & Bailey, 2011). The medications that are prescribed can also cause more violent tendencies due to side-effects of the medications.Corey is selectively mute, and refuses to talk or talks minimally when prompted. This is a classic negative symptom of schizophrenia (NIMH, 2009) and this symptom is so subtle that it can be mistaken for just being rude or unwilling when in reality it is a serious sign of illness that many people with schizophrenia present with.Corey displays a lack of motivation and lack of pleasure in his life. This is yet another common negative symptom that is experienced by many individuals with schizophrenia (Boutros, Mucci, Diwadkar, & Tandon, 2014).Corey refuses to take his medication, resulting in multiple instances of being involuntarily committed. Many people who have schizophrenia relapse or regain symptoms because they stop taking their medication due to feeling like they do not need it anymore (H?fner, Maurer, & an der Heiden, 2013). While initially behaving cooperatively, Corey’s behavior deteriorates and he becomes more irritable over time. Irritability can be a negative symptom derived from cognitive issues associated with schizophrenia. Many individuals with schizophrenia experience irritability when on the wrong medication or intermittently off their medication which is a sound reason for Corey’s change in behavior (Boutros et al, 2014).Environmental BarriersA major stigma surrounds the diagnosis of schizophrenia, making it one of the most important factors in early detection of the disorder (Yiwei, Mayumi, Hatsumi,& Kouhei, 2014). If the disorder goes undiagnosed because of the stigma surrounding it, it can lead to worsening symptoms and degeneration of behaviors of those affected. Corey comes from a semi-rural area of NC, meaning he could have had his diagnoses put off for fear of how others would treat him with the label of “schizophrenic” hanging over him.Family finances can affect how the disorder is treated. Those in wealthier families are exposed to more treatment options and better opportunities to integrate in the community (Yiwei et al., 2014). Corey’s family is in a well enough position to offer him home-schooling and in an affluent enough area that he has access to special education classes at his public school.Education level of those affected can determine how well a patient can adapt to changes and how well they can reintegrate in community once diagnosed (NIMH, 2009). Corey has had access to both public and home-schooling, and is interested in furthering his education, shown by his attempt to take the GED.Cultural InformationAttends church when available.Corey is an 18 year old male. Only 1.8% of schizophrenia cases are diagnosed and documented before the age of twenty (San et al., 2013).Co-morbid Major Depressive DisorderCo-morbid ADHDBiological father has been diagnosed with depression and bipolar disorder. There is a definite connection between genetics and schizophrenia but the link has not been concluded with research yet (NIMH, 2009).Lives in piedmont area of North CarolinaEfficacy ResearchVirués-Ortega, J., Pastor-Barriuso, R., Castellote, J. M., Población, A., & de Pedro-Cuesta, J. (2012). Effect of animal-assisted therapy on the psychological and functional status of elderly populations and patients with psychiatric disorders: A meta-analysis. Health Psychology Review, 6(2), 197-221. doi:10.1080/17437199.2010.534965SummaryThe authors of this study are interested in whether animal-assisted therapy (AAT) could affect well-being by nurturing the idea of increased social support and interaction with the client. Animals have always played an important part in human civilization, from pets, to hunting tools, to livestock. Companion animals were always thought to be used for a practical purpose but the fact that certain traits have been bred into different breeds shows that companion animals share a strong bond with their humans. Despite this long tradition of connection between species, the thought that such a bond could positively affect human behavior is a recent one. Early use of animals in health promotion can be tracked to the 1700’s, where animals were used as a source of “amusement, and to awaken the social and benevolent feelings” (p.198) however; clinical application wasn’t documented until the 1970s. A meta-analysis was conducted on different groups who have poor social functioning, including “elderly participants, those with depression and schizophrenia” (p.197). Intervention studies conducted on the direct effects of pet interaction on improved social functioning show a reduction in disturbances in behavior for patients with dementia and schizophrenia, reduced depression in patients with depression, and an increase in socialization for elderly people who are institutionalized.2. Subjects and MethodsThe search for information to add to this meta-analysis was done using Medline, PsychINFO and the Cochrane Central Register of Controlled Trials to review the “health-related effects of AAT in the elderly and patients with a medical or psychological condition” (p.202). The search period included trials and studies from January 1975 through January 2009, held no language restrictions, and reviewed references of select articles and some previous reviews related to the subject. Exclusions to the search include:“Non-AAT studies, non-original or unpublished research (reviews, editorials, non-research letters, book chapters, doctoral dissertations), observational epidemiologic studies, involved healthy non-elderly populations, less than five participants, comprised of a single day or shorter intervention, used anecdotal or qualitative outcome recording (clinical observations, unstructured interviews), used no pretest measurement, and studies that had insufficient data reporting (no outcome means or standard deviations)” (p.202).The authors screened titles and abstracts to further weed out unrelated results. For each selected study, participant’s demographics, study details and design, intervention features, outcome variables and measurements, as well as reported effects were collected. The type of interaction with the therapy animal was classified as either “spontaneous, prompted, or guided” depending on how much guidance was needed by the therapist/participant. Delivery was categorized into either individual or group, intensity was defined by whether the interaction was permanent (adoption) or periodical, and the frequency of the interaction was charted by hours per week. The overall study was assessed on a scale of 100 points from an “adapted assessment by Downs and Black for randomized/non-randomized studies” of health interventions (p. 202). Approximately 21 studies fit the criteria needed to be included in the analysis after excluding those that did not focus on the targeted populations. All the studies were published between 1985-2008, and many were done in the U.S. Ten included elderly patients, five dementia studies, and six psychiatric studies and all but two involved mixed sexes. Sample size of the studies ranged from 7-144 participants and the majority of the studies were based around natural or spontaneous human-animal interactions. Most studies conducted AAT in groups and mainly used dogs as therapy animals. Minus four studies, all accepted used periodic AAT sessions with an average intensity of 2 hours a week, with the former involving permanent adoptions. Length of therapy ranged from 1-69 weeks with the average length being seven weeks. 3. Findings and ImplicationsIn regards to depression, anxiety, and behavioral disturbances, AAT produced significant responses in 95% of participants with slightly more effect on those involving psychiatric patients than unimpaired older adults. There was a marginally bigger effect in individual interventions over group interventions. The effects of AAT were shown to be more productive in regard to ”behavioral disturbances for elderly patients with dementia than cognitively unimpaired elderly or psychiatric patients” (p.211). AAT in this study has shown little to no effect on loneliness or daily living skills but this could be attributed to the length of treatment not being long enough (could be treated better by adoption than periodic sessions). AAT did show large beneficial effects for psychiatric patients with social functioning problems, more so than for any elderly populations. Prompted or guided AAT sessions also showed larger effects when dealing with social functioning issues.4. Applications for this CaseI believe this would be an appropriate modality for my client, Corey. Corey shows many negative symptoms of schizophrenia, and is prone to self-destructive behaviors when agitated. Although he is initially calm in situations regarding others, his behavior deteriorates over the length of the interaction. He is also selectively mute which further limits his social interactions. I believe that interaction with an animal in an AAT would be extremely beneficial for Corey. Having a positive connection with another being without having to be vocal could show Corey that there are bonds he can build without his words. Seeing the healthy relationship between the therapist and therapy animal can also be a model for a healthy relationship and could give Corey a sense of safety when in a session. Having a positive correlation between social connections could lead Corey to become more trusting of those close to him, such as his mother, and leave room for a less violent relationship and better adherence to medications as well. The presence of an AAT trained animal can be naturally soothing and help build a trusting bond between Corey and the therapist quicker and weaken his urge to become uncooperative as time passes. The immediate reaction an AAT animal has could help Corey see how his behavior affects those around him, and practice appropriate behaviors in a simpler way than with another human.The research shows that the lengthier the time spent with the animal in therapy, the more positive effects were seen. I would suggest to Corey that he could adopt a therapy animal as part of continuing his self-improvement post-discharge.Treatment Planning and Implementation Strengths:Fair family and community support systems (large family, close to church)Well educated and attentive (seeking GED)Independent and motivated (seeking social security benefits)Needs:Decrease self-harm stemming from negative symptoms associated c schizophreniaIncrease social skillsIncrease pleasure c aspects of lifeIncrease medication adherencePrioritized Goals:Decrease negative symptoms associated c schizophreniaIncrease knowledge of community resources availableImprove Pt.’s knowledge of medications and educate the importance of adherence to medications e.m.p.FacilityCorey was involuntarily admitted to Broughton Hospital for a stay of 90 days. Broughton Hospital serves an estimated 35% of the state’s population for care and treatment of persons c mental illness (Broughton). Broughton serves many populations including adolescent through geriatric, as well as long term care. Besides direct care services, the hospital serves as an educational facility for the community, providing various training and internship programs. InterventionAnimal Assisted Therapy (AAT), as concluded in the efficacy research above, has been proven to show significant responses in 95% of participants, c more effect involving psychiatric patients than older adults. This type of intervention is extremely beneficial for the client due to his need for lessened negative symptoms and increase in social stability. AAT could potentially help c many of the Pt.’s needs, as previously stated in efficacy research. As determined by meta-analysis, individual guided sessions lasting longer than 2 hours per week for the duration of Pt.’s stay would be the most beneficial. The average length of treatment c AAT in the meta-analysis is seven weeks, while the Pt.’s length of stay is twelve weeks. Since length of Tx. positively affects the response, I would increase the Pt.’s time in AAT from 2 hours per week to 30 minute b.i.d. sessions c the therapist for the length of the Pt.’s twelve week stay at Broughton. The Tx. will take place in an open, indoor space c room for movement from both the Pt. and the therapy dog.Behavioral Objectives:Skill Acquisition and Practice - During b.i.d. 30 minute sessions of animal assisted therapy, Corey will interact and practice at least 3 positive interactions c the therapy dog per session, or ad. lib., to decrease the negative effects associated c schizophrenia.Functional Use - Between sessions c AAT, Pt. will perform 3 positive social interactions q.i.d., c at least one staff member of Broughton, and one fellow resident to increase social confidence and decrease negative effects associated c schizophrenia.SOAP NoteSubjective:For the first three days, Corey did not speak at all, but engaged c the therapy dog by petting her and making some eye contact. After a few interactions Corey began to speak about the therapy animal; “Do you think she likes me?” “I want her to be happy.” “She’s much nicer than the nurses, do you think they’ll like me too?” Corey begins talking, but only about the animal. After three weeks, Corey notes to the therapist, “I like having a friend here, I wish I had more.” Halfway through Tx., Corey says, “I’ve never talked to people like this before, I love having her [the therapy animal] around.” “She’s so silly, I love watching her run around making everyone happy. I wish I could be more like her” Corey shows obvious enjoyment of the therapy dog’s company.Objective:For the first five days of Tx. Corey refuses to talk at all, only making eye contact c the therapy animal and occasionally petting her. Over the next week, the Pt. becomes visibly more relaxed and interactive c the animal and therapist, even beginning to talk about the therapy dog to the therapist. Corey shows interest in his surroundings by branching out, c the therapy dog at his side, to others around him about the therapy dog. The Pt. slowly begins to talk openly to staff members, but still steers clear of other residents. When mention of the therapy dog is heard, Corey visibly brightens, and shows an improvement in mood by smiling and laughing c staff members and therapist.Analysis:The security of an animal that cannot judge him seems to have given the Pt. confidence to speak when others can hear him. Over time he becomes more receptive to human interaction, at least c the staff. The more time that is spent c the therapy dog, the more talkative and less withdrawn Corey becomes and the less frequent he self-harms. The more the Pt. participates in AAT, the more willing he is to interact appropriately c other people, in his attempt to emulate the therapy dog’s demeanor c others.Plan:The Tx.. plan seems to be improving Corey’s behavioral issues. While he has not progressed to the point of talking c peers, the Pt. shows improvement in conversing c staff members of Broughton. With enough time, the Tx. team believes that Corey will progress far enough to socialize c peers and the help of a therapy animal. The Pt. shows visible improvement in mood and disposition when interacting c therapist and staff members, but persists in shutting out fellow residents and possible peers which would be an aspect to continue working towards in the future.Discharge Plan“Corey” is an 18 yo M c primary Dx of schizophrenia and major depressive disorder and a Hx of ADHD. The Pt. has a Hx of self-harm, anhedonia, and becomes selectively mute when irritated or exhausted. Pt. goal is to decrease negative symptoms associated c schizophrenia.Tx. included guided AAT c therapist for 30 minute sessions b.i.d. and lasted the Pt.’s full 90 day stay at Broughton Hospital.Pt. was unresponsive to treatment for first week before showing any signs of improvement. After initial unresponsiveness, Pt. showed steady gains in social confidence and increased mood. After finding confidence in the therapy animal, Pt. continued to show growth by positively interacting c staff members.Pt.’s negative symptoms of schizophrenia have decreased dramatically over 90 days. Comparison of social behaviors before and after Tx., show significant progress c staff members but little progress c peers. While no longer assaultive towards staff, Pt. tends to ignore peers and disregard social interactions c them.Pt. is to continue working on socialization skills c peers after discharge from Broughton on March 26th. The Pt. is to engage in the UNC-STEP outreach program at the closest available clinic to work c a peer specialist on tackling his remaining needs. The CTRS and Pt. are to discuss an appropriate schedule of check-ins and continue working c AAT at UNC-STEP 3x per week; or alternatively, the Pt. is to take initiative in the process of adopting a therapy animal to work c on his own ad. lib. in addition to seeking out group sessions at UNC-STEP 2x per week. The Pt.’s mother has agreed to let Corey return home, and has agreed to help in the adoption process so he can follow the latter plan. Both the Pt. and his mother have given written consent for the plan.Referrals NeededResident Name: CoreyDate of Referral: 3/26/2012Reason for Referral: Socialization skill improvement through outpatient settingPossible areas for Referral:Increased ability to interact c peersImproved social confidence when in unfamiliar situationsImproved management of negative symptoms (controlling mutism, controlling aggression)Improved self-reliance (medication adherence, adopting therapy animal)Improved emotional functioning lessened depressive moods, increase enjoyment of life)Referral made by: Liz AmmonsPt. has given written consent to continue Tx. through AAT c outpatient group therapy under the supervision of a peer specialist at UNC-STEP Program.Signature: Liz Ammons RT StudentDate: 3/26/2012ReferencesBoutros, N. N., Mucci, A., Diwadkar, V., & Tandon, R. (2014). Negative symptoms in Schizophrenia. Clinical Schizophrenia & Related Psychoses, 8(1), 28-35B. doi:10.3371/CSRP.BOMU.012513Broughton Hospital (n.d.) About Broughton Hospital. Retrieved from: , H. H., Maurer, K. K., & an der Heiden, W. W. (2013). ABC Schizophrenia study: An overview of results since 1996. Social Psychiatry & Psychiatric Epidemiology, 48(7), 1021-1031. doi:10.1007/s00127-013-0700-4National Institute of Mental Health (NIMH). (2009). What is Schizophrenia? Schizophrenia. Retrieved:9/16/14 from: Roberts, S., & Bailey, J. (2011). Incentives and barriers to lifestyle interventions for people with severe mental illness: a narrative synthesis of quantitative, qualitative and mixed methods studies. Journal of Advanced Nursing, 67(4), 690-708. doi:10.1111/j.1365-2648.2010.05546.xSan, L., Bernardo, M., Gómez, A., Martínez, P., González, B., & Pe?a, M. (2013). Socio-demographic, clinical and treatment characteristics of relapsing schizophrenic patients. Nordic Journal of Psychiatry, 67(1), 22-29. doi:10.3109/08039488.2012.667150Virués-Ortega, J., Pastor-Barriuso, R., Castellote, J. M., Población, A., & de Pedro-Cuesta, J. (2012). Effect of animal-assisted therapy on the psychological and functional status of elderly populations and patients with psychiatric disorders: A meta-analysis. Health Psychology Review, 6(2), 197-221. doi:10.1080/17437199.2010.534965Yiwei, L., Mayumi, W., Hatsumi, Y., & Kouhei, A. (2014). Characteristics linked to the reduction of stigma towards schizophrenia: A pre-and-post study of parents of adolescents attending an educational program. BMC Public Health, 14(1), 1-18. doi:10.1186/1471-2458-14-258 ................
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