Case study psychosis Essay Example
10CASE STUDY PSYCHOSIS
Case study psychosis
Part A: HISTORY
Reason for referral
Andy presents as fidgety and avoids eye contact; she occasionally looks around with the feeling that she is being watched. She experiences auditory hallucinations. She believes that the roommates are working for the M15 and they are out to get her.
History of presenting problem (HPI)
Andy has been experiencing the same symptoms for the last 2 months. She feels that she is being judged and that others are putting thoughts into her mind. He believes that the M15 has implanted into her brain chip that is tracking his location. He wants the device to be removed because she feels she has done nothing wrong. He has been isolating himself in his room, and he believes that other roommates are poisoning his food and consequently he is not eating appropriately he feels afraid. He admits to being in possession of a knife and a baseball bat in his room but he does not want to hurt anyone .he has thought about that fact, and he is afraid of getting caught. He feels secure in his parents’ house, but he is reluctant to get them involved as he feels guilty.
Past psychiatric /mental health history
He has had suicidal thoughts by taking an overdose of sleeping pills.
He feels fit and well physically
No relevant family history was given.
Smokes weed (10 bags a day) and also speed off at the weekend but he does not drink alcohol but the number of weed he smokes he still hears voices.
Part B: MENTAL STATE EXAMINATION
He appears physically well though shows some little confusion and extremely afraid.
He appears fidgety and avoids eye contact, he is excessively worried and feeling guilty. He exhibits a high degree of isolation. He is equally disturbed and critical about himself.
He is overly isolated and worried
Andy speaks well can describe what he feels without trouble. But the motor speech and the sensory speech are all functional. He articulates the words well and can be heard correctly.
The patient thought the form is incoherent though he puts his word into the right context. He can express his thoughts and emotions well and an in a coherent manner.
The patient is full of hallucinations of a chip in his head; he is obsessed with the need not to hurt the parents to the extent of willing to share his case with the parents. He also has mental preoccupations of voices in his mid that cannot disappear even after taking rolls of bhang.
Part C: CARE PLAN
The main aim of the care plan is to plan for the next steps of patient management after the completion of the assessment process.
Before planning on how to manage the patient, psychosis just like any emergency diseases like asthma needs an alternative plan in case of crisis. The crisis management plan for this patient would include.
i. A deep assessment of the previous cases of which the individuals within reach of the patient user care can effectively handle and contribute.
ii. A history of the chronological risk activities that the patient has undergone including the various instances of the crisis in the past.
iii. A well-detailed risk assessment factors that would increase of decrease the risk as well the interventions that would ensure a good result after taking the interventions.
iv. A well-stratified result that entails many strategies and the action course that would prove a beneficial course of action. The care giver would develop the plan while collaborating with the service user and the close family members while giving every member a task to handle in the whole activity. These would include two members of the family a brother and one of the closest friends at school. The plan, however, will be left open for review periodically as the patient recovers from the disease (Hyman, 2010).
One of the most crisis prevention management strategies that the patient needs first is the prevention of suicide. According to the medical history, the patient admits that in some months back, he attempted suicide. The patient hence is at a very big risk of performing suicide if then risk mitigation strategy is not put in place early enough. Another crisis planning would involve the priority medication review. Occasionally the medication that the patient is using should be reviewed to make it more updated about the patient’s recovery data. However in the condition of the patient so far a lot of psychosocial support should be given to the patient to allow him come up with his studies more with the aim of alleviating the worry and guilt.in case a certain crisis that is mentioned in the patient is contributed by the increased deterioration in the mental status then the patient might consider long term medication management plan a priority. The long term medication in case it had to be initiated the doctor, and the relevant medical specialties must be consulted before the drugs and management strategies are changed (Barry et al., 2011).
The interventions that are put forward in the treatment of psychosis are based on the practices according to the evidence based practices depending on their extent of efficacy with the patient. Most commonly used method is the randomized controls trials. One of the best evidence based therapies for psychotic individuals is the cognitive behavior therapy (CBT) and relevant family interventions. However, the patient care provider may turn to low-intensity methods like mindfulness and coping strategies (Schmidt, Hesse, & Lykke, 2011).
The baseline medication for almost all psychotic patients is Antipsychotic medications. They help the patient to achieve a state of recovery from the distress and experiences like in the case of anxiety and isolation in Abby. The antipsychotic drugs are classified into two namely first generation antipsychotics and second generation antipsychotics. The first generation antipsychotics include Zuclopenthixol, Haloperidol, and Flupentixol amongst others. The second generation antipsychotics include drug like olanzapine, risperidone, Amisulpride and Quetiapine amongst others. However, the choice of the specific medication to be taken by the patient will depend on the collaborative decision making between the patient and his carer. The choice of the drugs could be made underlining four factors; how severe the symptoms are ;the route of administration that is more preferred; the speed of onset of action of the drug, depends on whether it’s used for emergency or normal statuses and lastly the side effect profile of the drug that the patient ought to use (McGlashan, Walsh & Woods, 2010). Some side effects can be more severe on one individual as compared to the other .however in the patient no allergy was identified but was placed on first-generation antipsychotic.
The patient will also need adjunctive agents in the process of treatment which would include the use of drugs like antidepressants and mood stabilizing agents. The severity of the symptoms, the speed or onset of resolution, the number of episodic events and tolerability will demand the recommendation of the drug the patient is given. For instance, in this case, the patient needs a faster recovery so that he embarks on the normal studies to catch up with others and so the drug choice will be one that ensures the effects as fast as possible (Schmidt, Hesse, & Lykke, 2011).
The treatment team chose to use the stepped intensity approach in intervening on the psychological matters. The approach is seen to be more efficient since it improves the access of the patient to primary care and also has a likelihood of benefits for secondary and tertiary care settings. The stepped intensity psychological therapies are divided into 3 phases namely phase one, phase 2 and phase 3 interventions.
The phase one interventions will be done with three activities i.e.
i. Psycho education and guided self-help-.The psycho education and self-management improve the comprehension of mental needs of the patient, the self-managerial skills and treatment options. In the end, it’s designed to reduce the relapse risk, improve functionality and improve medication concordance. Secondly, the phase one interventions will be achieved (Ross, 2014).
ii. Peer support –this would be aimed at providing the support from someone who has gone through the experience of the psychosis disease and would freely share personal advice with the patient about how to live with psychosis and effectively recover. A lot of evidence shows that peer support can adequately assist in improving the patients coping skills, quality of mental health and the general quality of life.
iii. Befriending –this would involve facilitation of a long term friendship at school with the students to help him with both the social and emotional support. Befriending would reduce the rates of hospitalization of the patient and the relapse rates. The intervention is also put forward to reduce the depressive tendencies in the patient and most importantly to challenge the delusional beliefs (Barry et al., 2011).
The phase two intervention were analyzed to be more effective locally and armless intensive strategies form psychosis interventions. The phase’s two interventions would assist in facilitation of the access to care for the patients who are getting the condition for the first time like Andy. The phase 3 interventions would just involve the gold standard interventions and then family intervention to therapies.
Lastly the patient needs a comprehensive cognitive behaviour therapy. The cognitive behaviour therapy will assist the patient in encouraging him to ta take an active role in his treatment. Through the cognitive behaviour therapy, the patient will understand the impact of the disease on the thoughts, physical sensations, behaviour and feelings. This would in turn assist the patient in inducing the distress and the disturbance that is associated with the disease. The person will be able to effectively manage his delusional and hallucinogenic felling effectively when they understand its course well which at last contribute well to the patients recovery(First,2013).
The family has to be included in the psychological intervention; the families should be given the family work or anyone who is in close contact with the patient. The family work should be offered regularly in some cases where the family are experiencing a lot of challenges.in this case Andy’s family is experiencing a very big challenging moment .the parents are extremely worried on the proceeding of the education dynamics of their son and equally if the disease will terminating their sons education. These worries affect their psychological stability this calls for a lot of support to the family to give them awareness that would in turn assist even in managing the patient (Carpenter, & van Os, 2011).
The nursing intervention s on the patient starts with development of a rapport and trust .The nurse must not touch the patient without telling him what he is up to. For example in this clinical case Andy is too frightened and suspicious of his environment such that any strange engagement can come with a stern opposition. The nurse should apply an accepting, consistent approach, short and repeated contacts until the he develops the trust with the patient. The care giver must use a clear and unambiguous language and maintain the words of hope for possible improvement of the patient (Carpenter & van Os,2011).
The nurse should maximize the level of patient functioning .while managing the patient ,there is need for the patient to recover as soon as possible .the care giver hence should let the patient do some simple things by themselves this would help in reducing the level of dependence in the patient. Check positive behaviour in the patient and reward while working hand in hand with him to improve the positive work and behaviour helping the patient to be well acquainted with his personal responsibility in his health improvements.
The nurse should aim at improving the social skills of the patient. The patient has deteriorated social perspective like isolation from people and tendencies of suspecting people .such attributes can compel the patient into attacking innocent people around him if his social skills are nit worked on. The nurse must support home in seeing that he gets to learn the social skills. While doing so safety of the patient should be paramount more so on the suicidal attempts. There should be a safe way of keeping the patients medication (First,2013).
Nutrition is another pillar to the recovery of the patient. The nurse must monitor the nutritional status of the food. Some cases like the in a paranoid patient who thinks the food may be poisoned, it’s important that the carer allow him prepare his own meal. The carer was advised to provide the patients food in closed container so that he can open it for himself. Nutrition is important for strength and proper mental functioning.
The hallucinations should be dealt with by providing the reality of the conditions. First it’s important to explore the hallucinations content don’t argue with him about the hallucinations. The nurse would just rebuff the hallucinogenic allegations but also assure him that the hallucinations are real to patient. Drugs also can be given to reduce the symptoms and the patient should be educated on the importance of adherence while monitoring the drug therapy.
McGlashan, T., Walsh, B., & Woods, S. (2010). The psychosis-risk syndrome: handbook for diagnosis and follow-up. Oxford University Press.
Carpenter, W. T., & van Os, J. (2011). Should attenuated psychosis syndrome be a DSM-5 diagnosis?. American Journal of Psychiatry, 168(5), 460-463.
Ross, C. (2014). Schizophrenia: Innovations in diagnosis and treatment. Routledge.
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure
in the clinical process. Guilford Press.
Hyman, S. E. (2010). The diagnosis of mental disorders: the problem of reification. Annual review of clinical psychology, 6, 155-179.
Barry, H., Hardiman, O., Healy, D. G., Keogan, M., Moroney, J., Molnar, P. P. & Murphy, K. C. (2011). Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis. The British Journal of Psychiatry, 199(6), 508-509.
Schmidt, L. M., Hesse, M., & Lykke, J. (2011). The impact of substance use disorders on the course of schizophrenia—a 15-year follow-up study: dual diagnosis over 15 years. Schizophrenia research, 130(1), 228-233.
First, M. B. (2013). DSM-5 handbook of differential diagnosis. American Psychiatric Pub.
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