PSYCHIATRIC COMPREHENSIVE CASE STUDY 1

Psychiatric Comprehensive Case Study

Adam Sniezek

Youngstown State University

PSYCHIATRIC COMPREHENSIVE CASE STUDY 2

Abstract

This case study examines the case of a forty-six year old male who presents with a primary

diagnosis of severe major depression without psychotic features. The purpose of this case

study is to discuss on the nature of the patient’s psychiatric diagnosis, the presence and

impact of concurrent diagnoses, and the nursing care surrounding the diagnoses. Also

discussed will be the precipitating factors, as well as cultural, spiritual, social, and ethnic

factors that impact the patient’s overall mental health. Evaluation of patient outcomes in

the future will also be considered in relation to nursing diagnoses set forth by NANDA.

Key Words: depression, mental health

PSYCHIATRIC COMPREHENSIVE CASE STUDY 3

Objective Data

The patient, LLT, is a forty-six year old male that was involuntarily admitted to the

Behavioral Health unit on February 22nd, 2019. Before approaching the patient on the day

of care, he remained alone at a table. He was hunched over and staring at the floor. He did

not remove his gaze until I sat down with him. Upon sitting down, the patient did not say

anything, and maintained a flat affect. He seemed to be slightly suspicious when I sat down

and introduced myself. After asking a few questions, the patient started to open up more.

He later told me that he was judging my character and deciding on whether he wanted to

talk to me or get up and go to his room during our initial encounter. Upon asking him more

questions, his responses became more sincere and more in depth. He did not maintain

steady eye contact, and his affect was relatively flat for the entirety of the conversation.

There were a couple times where his mood would change and he would laugh. The patient,

sans the first couple of minutes, remained relaxed and friendly. His speech was very clear

and his sentences and thought processes were complete. He did not exhibit any excessive

or sudden movements, but did seem to be slightly restless. He got up to get coffee a couple

of times during the encounter and moved around a little bit while conversing, but as stated

before, it was not excessive. His dress was neat and he was neatly groomed. He scored

thirty points on the Mini-Mental State Examination.

The admitting diagnosis for the patient was severe major depression without

psychotic features, which is classified as an Axis I disorder under the Diagnostic and

Statistical Manual of Mental Disorders (DSM) IV. Concurrently, the patient has a history of

severe manic bipolar I disorder with psychotic behavior, as well as a history of

schizoaffective disorder. Both of these diagnoses also fall under the Axis I categorization.
PSYCHIATRIC COMPREHENSIVE CASE STUDY 4

Both severe major depression and severe manic bipolar I disorder can additionally be

categorized as mood disorders. The patient also presented with a variety of other medical

diagnoses. These included chronic hypertension, pure hypercholesterolemia, osteoarthritis

of the cervical spine, myalgia, asthma, and COPD. The patient was taking atorvastatin

(Lipitor) to decrease blood cholesterol levels and to lower blood pressure. Alcohol

cessation was also practiced to help lower blood pressure. To help with alcohol

withdrawal, the patient was given lorazepam (Ativan) and chlordiazepoxide (Librium).

Additionally, the patient used hot and cool compresses to manage osteoarthritis pain, and

practiced meditation to relieve tension related to myalgia. The patient was also on a

regimen at the hospital to decrease his smoking habit that is related to his COPD. In

addition, there were psychiatric medications that were also ordered. Benzotropine

mesylate (Cogentin), and anti-tremor medication, was used for acute dystonia, which could

be a side effect of other psychiatric medications. Desvenlafaxine succinate (Pristiq) was

given to act an anti-depressant. Divalproex (Depakote) was given to treat bipolar disorder.

Hydroxyzine (Vistaril), an antihistamine, was given to reduce anxiety symptoms. And

finally, haloperidol lactate (Haldol), an antipsychotic, was given to reduce agitation. It is

worth noting that lorazepam, benzotropine mesylate, hydroxyzine, and haloperidol lactate

were only given on an as needed basis.

Many security measures were maintained on the Behavioral Health unit. Every

fifteen minutes, a nurse would perform a visual check to make sure that each patient was

safe and accounted for. Other safety measures were built into the facility itself. These

included unbreakable polished steel mirrors, breakaway handles, continuous mortise

mount door hinges, and plexiglass windows. Additionally, nurses are taught to always have
PSYCHIATRIC COMPREHENSIVE CASE STUDY 5

an exit plan in place, never allowing there to be a patient between them and a door. The

unit is also considered a locked unit, so individuals are only allowed to enter or exit if they

have clearance or if they are verified by means of the nurses’ station. All of these measures

are put into place to ensure patient safety and wellbeing.

Summary of Psychiatric Diagnoses

The patient’s main psychiatric diagnosis was severe major depression without psychotic

features. According to Belmaker and Agam (2008), “the diagnosis of major depressive disorder

requires a distinct change of mood, characterized by sadness or irritability and accompanied by

at least several psychophysiological changes” (p. 55). These changes can affect a wide variety

body functions, and can include constipation, sleep disturbances, suicidal thoughts, slowing of

speech or movements, crying, loss of sexual desire, loss of appetite, and loss of ability to

experience pleasure in daily life, such as at work or with friends. Additionally, the changes must

last for at least two weeks and interfere substantially with daily functioning for the diagnosis to

be met (Belmaker & Agam, 2008, p. 55). The patient also has a history of severe manic bipolar I

disorder with psychotic behaviors. According to Townsend and Morgan (2017), diagnosis of

bipolar I disorder “is given to an individual who is experiencing a manic episode or has a history

of one or more manic episodes” (p. 501). It is noted that clients who experience bipolar I

disorder may also have experienced episodes of depression (Townsend & Morgan, 2017, p. 501).

The patient also has a history of schizoaffective disorder. This disorder is characterized with

schizophrenic behaviors with substantial symptomatology associated with mood disorders

(Townsend & Morgan, 2017, p. 429). Mood disorders, as mentioned previously, include his

diagnoses of severe major depression and severe manic bipolar I disorder. According to

Townsend and Morgan (2017), “the decisive factor in the diagnosis of schizoaffective disorder is
PSYCHIATRIC COMPREHENSIVE CASE STUDY 6

the presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a

major mood episode” (p. 429). The patient had been experiencing hallucinations during his stay

of care, which involved visions of demons, which will be expanded upon later.

Identification of Stressors

There were multiple events that could have led to the patient’s admission to the unit.

When the patient was thirteen, he came home from school to find his mom deceased on the

sidewalk. “Her boyfriend at the time was jealous,” stated LLT. Due to this, the boyfriend

threw the patient’s mom from their third-story apartment window. To cope with that

incident, the patient began to do drugs, specifically cocaine. To this day, he has still not

found a healthy way to cope with this incident, saying, “it is not something that you can

simply get over.” It wasn’t until nine years ago that the patient stopped doing drugs. He

stated that he had a girlfriend nine years ago that helped him “find God.” Since then he has

been clean, up until one month ago when he relapsed. As a side note, cocaine and

amphetamines are known to cause the release of monoamines as well as decrease their

reuptake. Although the mood elevating effects are almost instantaneous, they have been

known to cause agitation in patients with severe depression (Belmaker & Agam, 2008, p.

58). According Belmaker and Agam (2008), these stimulants can “deplete the presynapse

of monoamines and thus cause a “crash” into depression” (p. 58). To further this, Araos et

al. (2017) state, “the chronic use of cocaine is accompanied by the appearance of

cardiovascular and nervous comorbid conditions, especially cerebrovascular accidents and

psychiatric disorders (p. 307). Around the time he started doing cocaine again he had also

stopped taking his prescribed medications. I found out later, when looking through the

patient’s chart, that his son had also passed away just recently, which could explain both
PSYCHIATRIC COMPREHENSIVE CASE STUDY 7

the relapse and the noncompliance that had occurred. Since then, the patient has been

experiencing increased depression, anxiety, suicidal ideations, paranoia, and

auditory/visual hallucinations, all worsened by substance abuse and medication

noncompliance. The patient’s presentation worsened the day directly preceding

admission. He had attempted suicide, which consisted of drinking 72 beers over the course

of the day, taking a handful of Benadryl, and doing a half-gram of cocaine. Upon entry to

the ED, he reported being suicidal, expressing that he “wanted it all to end.”

Discussion of Patient and Family History

The patient has a history of depression with suicidal ideation, severe manic bipolar I

disorder with psychotic behavior, and a history of schizoaffective disorder. The patient

was being treated for his depression at Coleman Professional Services on Belmont Avenue.

Due to the patient living in a single household for much of his early life, there is no paternal

history of mental illness on file. There is also no maternal history of mental illness on file.

To date, the only family history of mental illness that is known by the patient is anxiety

disorder experienced by his sister.

Description of Nursing Care

When talking to the patient, he had mentioned that during his stay he had not been

taking part of any group activities. He said that he “does not do well around other people.”

He would much rather spend time alone, because it is “less overwhelming.” However, on

the night of care, the patient did participate in group therapy. He did not contribute to the

discussion, but was present for the entire meeting. When asked what his goals were for the

day by the group leader, he remained silent. He remained calm and courteous through the

whole session. Group therapy has many benefits for the mental health population in the
PSYCHIATRIC COMPREHENSIVE CASE STUDY 8

hospital. According to Ardashir, Bayat, Nazafarin, and Haghgoo (2018), “group therapy

strengthens the communication network by strengthening factors such as group

interconnectedness; therefore, the patients experience hope, altruism and tranquility in

their interaction” (p. 233). During the night of care, the main topic of the group therapy

was empathy. This was taught in order for the patients to be able to put themselves in

others’ shoes and remember that everyone has different perspectives and outlooks in

regards to different situations.

Analysis of Influences

The patient was born and raised in the Austintown area. The patient is of African

American descent. He states his nationality is “southern.” The patient is not religious but

believes in God. He believes that all religions worship the same God, so he does not

associate with any particular religion as a result. Upon talking about his admission, the

patient stated, “the demons finally got to me.” In the chart it mentioned that the patient

was seeing hallucinations of demons that would tell him to harm himself. The patient also

practices meditation, which he states has helped him grow as a person throughout parts of

his life. The patient states that he is not particularly influenced by culture. The patient is

on disability through social security, has Medicaid, and uses food stamps. Growing up he

states that he “never had a father figure.” He and his two siblings lived with their mother

up until her death. He then moved in with his aunt, who treated him poorly. Due to this, he

moved in with his uncle, which was a more positive experience. He is currently single and

lives with his cousin. He believes that the healthcare system could be a lot better. He

believes insurance should cover hospitalization, dental services, and medication costs. He

also believes that individuals should not have to pay copayments. He states, “this is what
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insurance is for.” He also believes that hospitals should only keep patients for as long as

they need to be there, not any more or any less time.

Evaluation of Outcomes

Some short-term goals that could be included in the plan of care for the patient

include “absence of self harm during the day of care” and “ability to verbalize stressors

during the day of care.” These goals are goals that can be accomplished during a shift and

both focus on the safety of the patient and help the patient determine any predisposing

events or stressors that could have led to the hospitalization. With these goals established,

we can start to look more into the long-term goals for the patient. These are goals that will

take more time to realize, and will require a more in depth process to achieve. Long-term

goals could be simply related to the diagnosis, such as “patient will present with a decrease

in depressive symptoms and schizoaffective symptoms.” They could also revolve around

healing when dealing with particular stressors, such as “patient will be able to verbalize

acceptance of situations over which he has no control.” On the night of care, the patient

verbalized that his main goal was to get back to the place he was before he relapsed. His

hope was that he could finally come to terms with his mother’s death and that he could

travel to different schools in the area to tell his story, with the aspiration “to help just one

person.”

Summary of Discharge Plans

The patient expressed the desire to receive treatment outside of the hospital upon

discharge. He stated that he would like to be discharged to a crisis unit and possibly

receive treatment and support at Trinity United Church of Christ in Wooster or New
PSYCHIATRIC COMPREHENSIVE CASE STUDY 10

Beginnings Residential Treatment Center in Youngstown. He also plans to continue his

already established treatments at Coleman Professional Services.

Prioritized List of NANDA Diagnoses

1. Self-Neglect r/t depression and cognitive impairment a.e.b. relapsing into drug use

and attempting suicide

2. Risk for Complicated Grieving: risk factor: lack of previous resolution of former

grieving process a.e.b. not fully coming to terms with mother’s death and having to

deal also with son’s recent death

3. Social Isolation r/t ineffective coping a.e.b. not attending group therapy and

spending most free time in own room

4. Hopelessness r/t feeling of abandonment and long-term stress a.e.b. not having

father present in life and mother dying at a young age

5. Chronic Sorrow r/t unresolved grief a.e.b. still grieving loss of mother

List of Potential Nursing Diagnoses

1. Grieving r/t death of a significant other a.e.b. recent death of son and unresolved

grieving from death of mother

2. Ineffective Coping r/t inadequate opportunity to prepare for stressor a.e.b. sudden

death of both mother and son

3. Anxiety r/t situation crises a.e.b. relapsing and being hospitalized

4. Ineffective Activity Planning r/t defensive flight behavior when faced with proposed

solution a.e.b. refusing to set goals for the day of care

5. Decisional Conflict r/t interference with decision-making a.e.b. being unable to think

clearly due to the current situation

PSYCHIATRIC COMPREHENSIVE CASE STUDY 11

6. Deficient Diversional Activity r/t environment lack of diversional activity a.e.b.

statements made regarding boredom

7. Risk-Prone Health Behavior r/t multiple stressors a.e.b. consuming drugs and

alcohol in response to life stressors

8. Risk for Loneliness r/t physical and social isolation a.e.b. unwillingness to put self in

social situations and isolating self

9. Chronic pain r/t actual or potential tissue damage a.e.b myalgia and osteoarthritis of

cervical spine

10. Readiness for Enhanced Resilience r/t patient demonstrating positive outlook, and

expressed desire to enhance resilience and make progress towards goals/make use

of available resources

11. Spiritual Distress r/t death and life change a.e.b. death of son and current

hospitalization

12. Risk for Suicide r/t grieving a.e.b. stating that he “wanted it all to end”

Conclusion

The patient will conclude with treatment on the Behavioral Health unit at St.

Elizabeth’s Hospital and plans to utilize other community resources to achieve his goals.

He states that he plans to use this a jumping off point from which he can turn his life

around, so that he can inspire a younger generation who may be going through similar

situations he went through at that age.

PSYCHIATRIC COMPREHENSIVE CASE STUDY 12

References

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Sanchiz, P., . . . De Fonseca, F. R. (2017). Differences in the rates of drug

polyconsumption and psychiatric comorbidity among patients with cocaine use

disorders according to the Mental Health Service. Journal of Psychoactive Drugs,

49(4). 307. Retrieved from https://eps.cc.ysu.edu:3248/ehost/pdfviewer/

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4010

Ardashir, A., Bayat, A., Nazafarin, H., & Haghgoo, A. (2018). The effects of group cognitive

behavior therapy (GCBT) on suicidal thoughts in patients with major depression.

Middle East Journal of Family Medicine, 16(2), 233. Retrieved from https://eps.cc.ysu

.edu:3248/ehost/pdfviewer/pdfviewer?vid=2&sid=ef31af35-4b66-49e6-8661-

931720122601%40sessionmgr4006

Belmaker, R. H., & Agam, G. (2008). Major depressive disorder. The New England Journal of

Medicine, 358(1), 55-58. Retrieved from https://www.nejm.org/doi/full/10.1056/nej

mra073096

Townsend, M. & Morgan, K. (2017). Essentials of psychiatric mental health nursing: Concepts

of care in evidence-based practice. Philadelphia, PA: F.A. Davis.