Psych Case Study

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Psychiatric Mental Health Case Study Joe Wrask Youngstown State University

Abstract

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In this case study, it will focus on a patient that was diagnosed with depression, bipolar disorder, and anxiety. It will discuss various things like patient history, summary of diagnoses, precipitating factors, and more. In this case study, the patient is a female and will be referred to her initials as M.S. As this study continues, it will explain how all of these factors come together to cause her mental illness and mental state at present time. With all information given to the staff, objectively and subjectively, it can help the patient and staff move forward to the end goal of leaving the unit and continuing the path of becoming more mentally stable. Mental illness is mostly caused by neurotransmitters in the brain that are not working correctly and traumatic events that happen in a person’s life. In this patient’s case, she experienced both of these causes in her situation. As the study moves forward, it will keep the patients information confidential and will respect her situation regarding the material covered.

Objective Data:

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M.S. was involuntarily admitted on September 11, 2018 and the date of care was on September 13, 2018. According to the DSM-5 she is diagnosed with depression, bipolar disorder, and anxiety. During the date of care, I sat down with her and we talked mainly about why she was brought to the unit, but also her history. During the conversation, she was withdrawn and very down emotion wise, but she made a couple friends that seemed to brighten her mood. As time went on, M.S. opened up more and more and felt comfortable telling me her past history which will be discussed later on on this case study. At one point during the conversation, she was called to the side and was told she needed to stay one more night because of a new medicine that was started. This, in turn, led her to become very sad and emotional and she withdrew herself from the conversation. As far as medical conditions, she was diagnosed with cervical cancer, but she beat it and is now cancer free. I used that information to try to uplift her emotions and give her a sense of accomplishment. Prescribed Psychiatric Medications: M.S. was prescribed a numerous amount of medications. One medication was aripiprazole (Abilify) and it is an antipsychotic that is used to treat bipolar disorder. She took 10 mg by mouth, two times per day. Another medication that she was taking is extended release aripiprazole (Aristida), which is given intramuscularly at 675/ 882 mg once monthly. This is just like Abilify, but in an extended release, injected form. To help her with depression, she takes citalopram hydrobromide (Celexa). This medication is taken by mouth at 40 mg once per day. M.S. also takes hydroxyzine hydrochloride (Vistaril). She takes this PRN (as needed) for her anxiety issues. Another PRN medication she takes is haloperidol (Haldol) and is used for times when there is a psychosis event. Cogentin is also prescribed to combat any form of EPS adverse reactions from the Haldol. Lastly, a Nicoderm Patch is applied everyday for nicotine addiction,

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but needs to be rotated to each arm, each day. These medications are to help the psychiatric diagnoses that are discussed next. Psychiatric Diagnoses: Patient M.S. was diagnosed with depression, anxiety, and bipolar disorder. Many of psychiatric diagnoses coincide with one another and are prevalent amongst each other. Depression is characterized by a daily feeling of sadness and loss of interest in daily activities that were once pleasurable. According to a study done by Shengnan Wei1, Haiyan Li, Jinglin Hou, Wei Chen, Xu Chen and Xiaoxia Qin, they compared suicide attempts done from people with major depressive disorder (MDD) and those who don’t. In the findings, it suggested that people who have MDD are at a higher risk to attempt suicide rather than someone without a psychiatric diagnosis. This was conducted with a sample of 127 participants. Along with depression, external stressors like employment status, culture, marital status, past history, gender, etc. accompanied the risk of suicide attempts. As for M.S., she has a psychiatric diagnosis, is a female, was raped as a child, takes various psychiatric medications, and is single. She already has a risk factor by having psychiatric diagnoses, but when there are accompanying factors, it poses a higher risk. She also is diagnosed with anxiety and bipolar disorder. Anxiety can cause nervousness and constant worrying. As this continues everyday, it can start to cause physical signs and symptoms. Bipolar disorder occurs when there are extreme swings in mood as characterized by very low depressed stages to mania. A study was done by Norm O’Rourke, Marnin J. Heisel, Sarah L. Canham, Andrew Sixsmith, BADAS Study Team and they researched the predictors of suicide ideation among adults with bipolar disorder. They found that depression, substance misuse and other cognitive impairments accompany bipolar disorder. One interesting finding was that at a younger age, bipolar disorder is a suicide risk factor. O’Rourke

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et al stated, “This may suggest that older adults with BD have acclimated to their diagnosis and symptomatology, and have devised (effective) coping strategies over time.” With all three of these diagnoses together, it is important for anyone to follow a strict medication schedule and eliminate any external stressors that can spike these. Precipitating Factors: For anyone, something always tends to lead us to make decisions or causes us to think differently. While talking to M.S., she explained events that led up to her involuntary admission to the psychiatric unit. She started off by stating that she turned 40 years old on September 10, 2018 and she was looking forward to seeing her friends. Her friends did not show up to the party, so that made her act out based on how she was feeling at the time. She also included that she was nervous and did not know what to expect turning 40 years old. With these two situations and her diagnoses, she took a numerous amount of Tegretol which caused her to overdose. This then landed her into the unit because she had the intent to harm herself. While continuing to talk to M.S., she mentioned to me that she was diagnosed with cervical cancer, but she is now cancer free. She also said that many of friends and family have died, but she didn't state specifically who they were (best friend, siblings, grandparents). As I spoke to M.S., she brought up her childhood memories and it seemed that she only had unpleasant things to share. As a child she had a baby-sitter who raped her. This obviously caused an unimaginable emotional stress and she went to her parents for safety. When she did this, her mother did not care to do anything about it, but her father was always there for her. Even till this day, she does not speak to her mom and only to her dad. When things like this happen in someone’s life, it can cause so many issues related to emotions, social belonging, physical health, and much more. For M.S., she had to deal with

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many things that she didn't have control over and it led her down a path that makes her feel that she shouldn’t be here anymore. Patient and Family History of Mental Illness M.S. has been depressed for most of her life and then developed bipolar disorder and anxiety. She tried to manage her illnesses with medication through out her life and they did work, but medication management was an issue for her. Like stated before, she was raped as a child. To have that horrific stressor on top of a mental illness, it can be lead to severe cases. She also had a previous suicide attempt. As far as any familial mental illnesses, she did not mention anything and wasn't anything in her chart that had any evidence of mental health disorders in her family. Psychiatric Evidence Based Nursing On the psychiatric unit at St. Elizabeth’s main campus, it does a good job at providing an environment that allows a patient to have little to no extra stimulation. This allows the patient to relax and get their mind off of what brought them in or reflect on what happened. Every morning after breakfast, each patient verbalizes a simple goal that they can complete for the day whether it is not crying for that day or saying hello to everyone on the unit. The environment also consisted of “very basic” stimuli. This means things like beige walls, one television in the common, one bed, and no decorations. Even though this seems like a place that nobody would want to be in, it allowed patients to be in a place where they didn't have to overload their brain with extra stimuli that they didn't need. In a study done by Richard E. Boettcher and Roger Vander Schie, they introduced Milieu therapy to a specific ward in a hospital. Their end goal was to participate in the program and send them back to the community. They found that of the 58 patients who had left the floor, 3 returned. This study was conducted in 1971 and it goes to show

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that Milieu therapy is an important thing to conduct while in the unit. Nurses and researchers also learn from evidence based practice, which this study consisted of. Ethnic, Spiritual, and Cultural Influences M.S. did not comment on religious except when she said that she grew up in a catholic family and went to church when she was a child. In the chart on the EHR, it was stated that she was spiritual. It is unable to determine if spiritualism is a big part in her life, but people who tend to have no religious views, usually attempt suicide more often and have other issues. Patient Outcomes During her time at the unit, she attended groups everyday and made a couple of friends amongst the patients. Spending time in the unit and talking with others made her think back on her overdose and was disappointed in herself. Talking with others and knowing that something similar has happened to someone else gives a person hope that they can get better. Plans for Discharge She was supposed to leave on the day of clinical, but spoke to the psychiatrist who told her that she needed to stay one more night. This news turned her mood around and she exhibited by anger, frustration, social isolation, and crying. When she does leave, she plans to go back home to see her daughter. Nursing Diagnoses •

Risk for self injury r/t feelings of hopelessness AEB overdose on Tegretol, previous suicide attempt.

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Ineffective coping skills r/t impulsive use of extreme solutions AEB overdose on Tegretol, smokes marijuana, smokes cigarettes.

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Disturbed thought processes r/t overwhelming life circumstances AEB raped as child, history of cervical cancer, many loved ones who have died.

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Self-care deficit r/t substance use AEB smokes marijuana, smokes cigarettes, overdose on Tegretol.

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Chronic low self-esteem r/t feeling of shame and guilt AEB extreme sadness when friends did not show up for her birthday, depression.

Conclusion M.S. was a very kind person and was open to talk about many things that must have been difficult for her to deal with on a day to day basis. Unfortunately for M.S., she had a very hard life and with all the stressors that occurred, she developed a mental illness and ineffective coping techniques that can kill her if she doesn’t continue treatment. M.S. knows that she shouldn't have done what she did, but when someone has mental illnesses like these and traumatic events that occur in their lives, it is hard to “beat” those stressors.

Reference Page Boettcher, Richard E., and Roger Vander Schie. “Milieu Therapy with Chronic Mental Patients.” Social Work, vol. 20, no. 2, 1975, pp. 130–134., doi:10.1093/sw/20.2.130.

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O’Rourke, Norm, et al. “Predictors of Suicide Ideation among Older Adults with Bipolar Disorder.” Plos One, vol. 12, no. 11, 2017, doi:10.1371/journal.pone.0187632.

Wei, Shengnan, et al. “Comparison of the Characteristics of Suicide Attempters with Major Depressive Disorder and Those with No Psychiatric Diagnosis in Emergency Departments of General Hospitals in China.” Annals of General Psychiatry, vol. 16, no.

1, 2017, doi:10.1186/s12991-017-0167-x.