NU 674 Unit 2 chronic illness trajectory review example

Sixteen Years of Schizophrenia in One Man's Life: A Trajectory Review Marking the Phases, the Pattern Before Each Relapse, and the Phase Now Being Planned For

Student Name

Department of Nursing, Herzing University

NU 674: Psychiatric Mental Healthcare II

Instructor Name

January 29, 2026

Sixteen Years of Schizophrenia in One Man's Life: A Trajectory Review Marking the Phases, the Pattern Before Each Relapse, and the Phase Now Being Planned For

Why a Trajectory Review

Mr. W. is the composite 36-year-old man with schizophrenia in the care of a California full service partnership team, recently discharged after his second hospitalization in 18 months. The team's discussions have focused on the latest relapse. This review steps back to the whole course of the illness, because patterns that span years are invisible in a single admission. It uses the chronic illness trajectory framework, which describes a chronic illness as moving through phases, such as onset, acute, stable, unstable, crisis, and comeback, each calling for different management goals, and which treats the course as something that can be shaped rather than only observed (Corbin & Strauss, 1991).

The Course, Phase by Phase

Before onset, ages 17 to 19. Grades fell in his last year of high school; he withdrew from friends, began using cannabis daily, and became preoccupied with the idea that neighbors were watching him. His mother remembers this as the time "he stopped being himself."

Onset and first acute phase, age 20. He was hospitalized for two weeks after telling a teacher at community college that the instructors were implanting thoughts. He was diagnosed with schizophrenia, started on risperidone, and responded well within six weeks.

First stable phase, ages 20 to 23. He lived with his mother, took classes part-time, worked at a grocery store, and took risperidone consistently, with some weight gain he disliked.

First unstable phase and relapse, ages 23 to 24. Feeling well, he stopped risperidone, citing weight gain. Over five months, he slept less, stopped going to work, and grew suspicious of coworkers. He was hospitalized at 24.

Repeated relapses, ages 24 to 30. Five hospitalizations in six years, each after stopping medication, several involving police contact. He lost his job, left college, and used cannabis heavily. Between admissions, he recovered to near his previous level each time, which suggests an illness responsive to treatment rather than one resistant to it.

Second stable phase, ages 30 to 34. After an admission at 30, he agreed to try aripiprazole, which caused less weight gain, took it consistently, reduced cannabis, and enrolled in the full service partnership at 33. He had no hospitalizations for four years.

Current unstable and crisis phase, ages 34 to 36. After his aripiprazole was changed to risperidone during a hospital admission for pneumonia at 34, because of a formulary substitution, he gained weight again and stopped taking it. Two hospitalizations followed within 18 months, each after stopping medication. He has now lost his housing with his mother.

Phase now in front of the team: comeback, the period after an acute episode when function is being rebuilt, complicated by housing instability.

The Pattern Across Relapses

Three patterns emerge across his relapses. First, every relapse followed stopping antipsychotic medication, and in three of them, weight gain was his stated reason. Stopping antipsychotics after a first episode has been associated with a several-fold increase in the risk of relapse (Robinson et al., 1999), and his history is consistent with that finding. Second, the relapses developed over weeks to months, not days, with a recognizable sequence: shorter sleep, then withdrawal from work or classes, then suspicion of specific people. That sequence, his relapse signature, gives time to intervene if someone is watching for it; monitoring early warning signs with patients and families has been used to predict relapse in schizophrenia (Birchwood et al., 1989). Third, his longest stable period came on a medication he found tolerable, with a team that saw him often; it ended not because he chose to stop treatment but because a hospital changed his medication for administrative reasons.

What the Long View Changes

Seen over sixteen years, Mr. W.'s course does not describe a man who refuses treatment. It describes a man who takes medication he can tolerate and stops medication that causes weight gain, whose relapses follow a predictable sequence over weeks, and who recovers well after each episode. That reading has three consequences for the phase in front of the team.

First, the medication question should include tolerability, not only adherence. Returning to aripiprazole, which he tolerated for four years, is a stronger option than the team's recent discussion of injectable risperidone suggested, and aripiprazole is also available as a long-acting injection if he later wants that.

Second, his relapse signature should be written down with him and shared, with his permission, with his case manager and his mother, so that shorter sleep and withdrawal prompt contact before suspicion develops.

Third, the formulary substitution that ended his stable period is a system failure. His record will carry an alert stating that aripiprazole should not be substituted without contacting the team.

Management Goals for the Comeback Phase

In the trajectory framework, the goal of a comeback phase is to rebuild function and return to stability, and the work is shared among the person, family, and professionals. For Mr. W., the goals for the next six months are secure housing, a medication he tolerates taken consistently, a written relapse signature with an agreed response, and a return to some daily structure, such as work or classes. Each goal draws on something the long view showed to have worked before.

What the Review Cannot Tell Us

The review relies on records and on accounts from Mr. W. and his mother, both of which may be incomplete for the early years. It cannot say whether his current cannabis use, which has increased since losing his housing, will make this comeback harder than the last. And it cannot predict whether he will accept aripiprazole again; that is a decision for him, which the review makes better informed. The review will be shared with him in plain language, since the pattern it describes is his own story, and he may recognize parts of it, or correct them, in ways the records cannot. His own account of why he stopped each medication, and of what helped him stay well between 30 and 34, is the evidence most likely to shape what works now.

References

Birchwood, M., Smith, J., Macmillan, F., Hogg, B., Prasad, R., Harvey, C., & Bering, S. (1989). Predicting relapse in schizophrenia: The development and implementation of an early signs monitoring system using patients and families as observers, a preliminary investigation. Psychological Medicine, 19(3), 649-656. https://doi.org/10.1017/S0033291700024247

Corbin, J. M., & Strauss, A. (1991). A nursing model for chronic illness management based upon the trajectory framework. Scholarly Inquiry for Nursing Practice, 5(3), 155-174. https://doi.org/10.1891/0889-7182.5.3.155

Robinson, D., Woerner, M. G., Alvir, J. M. J., Bilder, R., Goldman, R., Geisler, S., Koreen, A., Sheitman, B., Chakos, M., Mayerhoff, D., & Lieberman, J. A. (1999). Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Archives of General Psychiatry, 56(3), 241-247. https://doi.org/10.1001/archpsyc.56.3.241