Mental Health Case Study 1

Katie Dougher

Mental Health Case Study

Youngstown State University

November 30, 2017

Mental Health Case Study 2

Abstract

This paper will explore an individual who was a patient on the psychiatric unit at Trumbull

Memorial Hospital. This will go in detail about the background of a 25 year old female with a

psychiatric diagnosis of depression with psychosis, paranoia, and a past medical history of

seizures. The information throughout this case study will be provided by the patient and the

medical chart provided by the hospital. The information discovered from these two sources will

explain the patients’ diagnosis and pertinent events leading to the admission to the hospital. I will

also discuss the family history, stressors impacting the individual, patient behavior, and any past

history of the patients’ mental illness.

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Objective Data

D.E. is a 25 year old patient admitted on September 15, 2017. The date of care provided

was on September 19, 2017 two days after the admission to the psychiatric unit. The

individual’s diagnosis according to the DSM IV-TR Axes I through V is the following:

Axis I diagnosis is major depression disorder with psychosis. According to The American

Journal of Psychiatry the psychosis is being classified as the decimal point under the

severity code. Also according to the Schizophrenia Bulleting article people who suffer

from a combination of major depressive disorder and psychosis is a serious condition.

The psychosis can manifest itself as “nihilistic” types of delusions for example they may

believe bad things are going to happen. This is the main reason why the patient was

admitted. The patient expressed during our interview that she has been feeling sad and

when she feels this way has thoughts of suicide. Along with the depression she has been

hearing voices that tell her to kill herself and seeing an angel she calls “Azazel”. Axis II

includes personality disorders this patients also had a diagnosis of paranoia. She felt that

“Azazel” was always trying to get her and make her do things she didn’t want to do.

Psychosis does not fit into this axis as evidenced by the hallucinations and delusions the

patient is experiencing. The DSM-II established that psychosis meant severe and had

nothing to do with being out of touch with reality. Even though patients with psychosis

will seek help because of the disturbing experiences like the altered perceptions, odd

beliefs, and distressed emotions. The patient also had mental delays; this is portrayed as

the patient acting a younger age than she is near that of a school aged child. Axis III is for

medical or neurological conditions that may exacerbate the individual's current or past

psychiatric problems. Though the patient did have a past medical history of seizures it is
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not related to the exacerbation of her depression with psychosis. Axis IV includes the

psychosocial stressors the patient has experienced. The patient appeared happy and social

when I initially approached her. As we began our conversation, the topic about her home

came up and she started to get upset. As we continued on she explained that her

grandfather had passed away from diabetes mellitus and this is when her depression

started. Axis V is the level of function the individual attains. The scale ranges from 0-

100, 100 being that the person has no problems or has a superior functioning in several

areas. During my interaction with the patient she her appearance and behaviors were sad

facial expressions with a relaxed posture. Her appearance neat she was dressed

appropriately but lacked hygiene, her hair was unkempt and bodily odor was significant,

she also had excessive drooling which may be related to her medications. She described

the reason for her being admitted to the hospital. She explained that she wanted to kill

herself and that her grandpa passing had a lot to do with it. She also said that she and

some friends were playing with an Ouija board and since then she can see angels and

demons. She said that she can see them all the time and the main one she sees is

“Azazel”. The patient states that this angel tells her to hurt herself and if she doesn’t

listen he will hurt her instead. Since the patient had suicidal tendencies certain safety

precautions were taken. She was on unit restrictions and patient self harm precautions.

The patient was prescribed several medications while on the psychiatric unit. She was

prescribed Paliperidone an antipsychotic that is for the psychosis, hallucinations and

delusions, Haldol as needed which is also an antipsychotic Zoloft for depression,

Lamictal and Keppra for seizures. Due to certain medications and diagnosis of the patient

multiple labs had to be monitored or considered. Since the patient has major depressive
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disorder the lab values of TSH and T4 were drawn. This is done because depression can

have similar effects on the body as hypothyroidism. To be able to diagnose the patient

with depression hypothyroidism has to be ruled out. Continuing with the labs the patient

was taking the medication Invega also known as Paliperidone, it is important to monitor

the white blood cell count when taking this medication. This is because Invega will

decrease the amount of white blood cells in the individual which may lead to infections

or other illnesses. The patient was taking a combination of antipsychotics and

antidepressants. The antipsychotics were for the psychosis and the antidepressants were

for the major depressive disorder. According to the Schizophrenia Bulletin article, this

combination is more effective than using just an antidepressant monotherapy or an

antipsychotic monotherapy individually. The patient was also on

antiepileptic/anticonvulsant medications that included Keppra and Lamictal for her

history of seizures.

Summarize: Psychiatric Diagnoses and Expected Behaviors

Depression with psychosis, this condition causes the individual to experience sadness,

hopelessness these feelings being associated with the depression part of the diagnosis. Although

with the psychosis the individual may see, hear, smell or believe things that are not real. This can

become very dangerous for an individual because hallucinations, magical thinking, somatic

delusions and specifically in this case delusions of grandeur can cause the person can cause self

harm or harm to others, these being common behaviors of individuals with depression with

psychosis. Also according to the Challenges in the Treatment of Major Depressive Disorder with

Psychotic Features article an individual suffering from the combination of depression and

psychosis manifest nihilistic delusions and belief that bad things are going to happen.
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Identify: Stressors and Behaviors

There were multiple stressors that lead to the exacerbation of the patient’s diagnosis. One

of the stressors related to the death of her grandfather due to diabetes. According to the British

Journal of Psychiatry in psychotic depression the individual experiences greater loss, a traumatic

event, humiliation and entrapment by any other existing illness. This being an explanation of

why the death of her grandfather was a stressor and may have triggered her depression. A second

stressor is living with her mother and grandmother. The patient had explained that her mother

and grandmother constantly yell at her for no reason causing her to become sad and distant. A

third stressor is the use of Facebook the patient had explained that she talks to people overseas

and tries to develop relationships but they are so far away. She develops feeling for these

individuals and gets depressed due to the fact she cannot go see them. Another stressor as

mentioned previously is the Ouija board and feeling as if she resurrected angles and demons

exacerbating the hallucinations and delusion. The appearance of “Azazel” may be due to the

show “Supernatural”. A different stressor mentioned is she was fired from her previous job. She

worked at a place called Sifron, the patient stated she was fired because her boss thought she was

a terrorist from ISIS. This may be identified as another delusion the patient is experiencing.

When asked what coping skills were used during these times of stress she explained she listens to

music and talks to her current boyfriend. The patient did say these techniques did work and help

her calm down when she was feeling overwhelmed. She also explained that she is learning to

new coping skills as she attends group and will apply them when she is feeling sad or hearing

voices telling her to hurt herself.

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Discuss: Patient and Family History

There is no pertinent family history of mental illness related to the patient’s current

psychiatric condition. The grandfather passed from diabetes as previously mentioned. The

mother and grandmother had no mental illness listed in the medical chart.

Describe: Nursing Care and Milieu Activities

The nursing care provided on the psychiatric unit for this patient mainly was patient self

harm precautions. These precautions were placed because the patient had suicidal tendencies due

to depression with psychosis. The patient had hallucinations that included hearing voices and

seeing a figure that would tell her to kill herself. The nurses had to keep a close watch on the

patient to ensure her safety. Individuals who are left alone tend to try to commit suicide when no

one is paying attention. Paying close attention and setting these precautions decrease the risk of

the patient being able to commit suicide.

There are several components of the milieu that are set up in the hospital to ensure a

healing environment for the patients. A milieu provides therapeutic and comforting environment

allowing the patients to feel safe in their surroundings. Also included in the milieu is therapeutic

inter-personal relationships and co-operative attentiveness to patients. On the floor there is a

room where multiple group therapies are held for the patients they learn how to deal with stress,

coping techniques, relaxation techniques and how to deal with their problems in a positive

manner are a few that are held on the floor. There is also a spirituality group conducted by a

pastor that allows the patient to be in touch with religion while they stay at the hospital. During

group therapy there are different activities held, for example they may get a handout to fill out
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about coping skills and then go around the room and share something they wrote down. This

promotes social interaction among the other patients as well as the nurses in charge of group.

Also there is a patio where patients can go outside and get fresh air, enjoy nature, get some sun

or to just enjoy the outdoors. Groups are also help on the patio to give a different atmosphere.

There are plants inside on the unit throughout the floor as well, this is because some patients find

nature relaxing and like to have the feeling of nurturing something. On the day of care for D.E.

she did attend the morning group. The activity was to share a dream they had the night before.

When it was her turn to share she did not pertain to the question asked she went on about her

hallucinations and how they make her want to kill herself and how the figure “Azazel” had

scratched her recently that day. D.E. tried to show the group her scratch but there was no

apparent injury present. As group continued she did not participate much after that, she remained

quiet for the rest of the session.

Analyze: Ethnic, Spiritual, and Cultural Influences

D.E did not state that she had a specific religion when she was asked; she did say that she

has attended a Catholic church in the past but she has not gone in a long time. D.E. did say she

believed in God and that she sometimes prays when she is feeling scared about seeing the figure

“Azazel”. This could be important to know because this may be related to her hallucinations of

seeing angles and demons. This could also be significant because it can affect how she portrays

her suicidal tendencies.

Evaluate: Patient Outcomes Related to Care

D.E. stated that she was feeling a lot better compared to her first day on the unit. She did

explain how she still had thoughts of hurting herself and she could still hear “Azazel” and other
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spirits. D.E. said the only reason she was still thinking about hurting herself was because

“Azazel” was telling her to. She expressed that she didn’t want to die or hurt or herself but if she

doesn’t listen to the voices the angel will hurt her anyway. During her care on the unit she still

seemed to be having auditory and visual hallucinations. For example, during the morning group

therapy she was trying to show the scratches the angel had left on her arm but there was no

apparent injury seen. The patient stated that once she got out of the hospital she was going to buy

an EVP recorder and have an exorcism done. I suggested that she speak with the pastor because

of her interest in religion before continuing or acting on those actions. For major depressive

disorder with psychosis optimal continuation of maintenance therapy and monitoring need to be

continued. This is due to the fact that psychotic depression is at a high risk of relapse proven in a

follow up study of this mental illness. A reason for relapse may be due to the patient being non-

compliant with their medications. The main reason for noncompliance is the extra pyramidal

symptoms or side effects. Even though antipsychotics help with the psychosis, this type of

medication only provides symptomatic control. Resulting in a large amount of symptoms

returning in many instances.

Discharge Plans

Upon discharge the patient plans to return home to her mother and grandmother. Also she

states she is going to continue working at Sifron. The patient is going to have frequent check-ups

with a doctor and hopefully continue her medication regimen when returning home.

Nursing Diagnoses

Nursing diagnoses related to the patient’s condition include: Impaired social interaction

related to lack of proper communication skills as evidenced by preoccupation of thoughts or

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repetitiveness, Sleep pattern disturbance related to auditory hallucination as evidenced by

hearing voices tell her to kill herself, Disturbed thought process related to hallucinations as

evidenced by seeing figures that are not there, Self-care deficit related to mental delays or lack of

skills as evidenced by excessive body odor and unkempt hair. Chronic low self-esteem related to

emotional abuse as evidenced by mother and grandmother putting her down about her condition,

Disturbed sensory perception related to visual and auditory hallucinations as evidenced by

hearing voices and seeing figures, Interrupted family process related to developmental crisis as

evidenced by change in mutual support.

Potential Diagnoses

Risk for self-directed violence related to auditory hallucinations, Risk for self neglect

related to delays in learning, Risk for infection related to medication that decreases white blood

cells, Risk for fatigue related to lack of sleep.

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Works Cited

Iqbal, Z., Birchwood, M., Chadwick, P., & Trower, P. (2000). Cognitive approach to depression

and suicidal thinking in psychosis. 2. Testing the validity of a social ranking model. Retreived

November 30, 2017, The British Journal of Psychiatry, 177, 522-528.

Psychosis as a State of Aberrant Salience: A Framework Linking Biology, Phenomenology, and

Pharmacology in Schizophrenia. (2003, January 01). Retrieved November 25, 2017, from

https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.160.1.13

Rothschild, A. J. (2013, July). Challenges in the Treatment of Major Depressive Disorder With

Psychotic Features. Retrieved November 27, 2017, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686458/