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PSYCHIATRIC CASE STUDY

Psychiatric Case Study

Youngstown State University

NURS 4842L

Lucas Call

November 21, 2021

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PSYCHIATRIC CASE STUDY

Abstract

This paper will analyze the background information, current treatment plan, and plans

after discharge for a patient that is diagnosed with schizoaffective disorder, antisocial personality

disorder, and polysubstance abuse. This patient presented to the emergency room after being sent

in by the rehabilitation facility he was attempting to be admitted to. He is a single, white, 28-

year-old male with a long history of mental illness and previous hospitalizations. Throughout this

paper, this patient’s psychiatric diagnoses, behaviors, medication regimen, and plans after

discharge will all be discussed. In addition, the crucial nursing interventions along with some of

the specific nursing diagnoses that are commonly associated with psychiatric nursing and how

they positively affect the care provided to those patients are described. Information from a brief

conversation between this patient and myself will be incorporated when discussing this patient’s

background, past and present behaviors, and discharge plans.

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Objective Data:

This patient is a 28-year-old male that was admitted to the hospital on October 27, 2021

after coming into the emergency room on his own accord seeking a psychiatric evaluation that

was required for admission to a rehabilitation facility. He previously attempted to admit himself

into the rehabilitation facility but was denied due to his current delusions and hallucinations and

was redirected to the emergency room. During his time in the emergency room, the patient

became agitated and had to be medicated with Ativan and Haldol. Since this patient has a history

of violent behavior and was agitated prior to coming to the unit, he was place in assault

precautions upon his arrival. His psychiatric diagnoses include schizoaffective disorder (bipolar

type), antisocial personality disorder, and polysubstance abuse. Additional medical conditions

this patient has been diagnosed with include Hepatitis C and tobacco abuse. Upon assessment of

the patient’s chart, all laboratory values appeared normal. This patient has a long history of

hospitalizations due to mental illness, with his last hospitalization being in May of this year. This

patient has a history of substance abuse, and his drug screen upon admission was positive for

both marijuana and amphetamines. He also stated that he smokes cigarettes daily. He is currently

unemployed, homeless, and has no family that he’s close with so he has been staying with

friends while searching for a permanent residence.

This patient’s prescribed medications include Aripiprazole (Abilify), Aripiprazole

Lauroxil (Aristada), Oxcarbazepine (Trileptal), and Benztropine Mesylate (Cogentin). Both

Abilify and Aristada are antipsychotics, whereas Aristada is the long-acting injection form of

Abilify. This patient is prescribed 20 milligrams of Abilify daily and receives his 662 milligram

injection of Aristada every 30 days. Antipsychotics are used to treat this patient’s psychosis and

stabilize his mood. “Current U.S. treatment guidelines recommend LAI antipsychotics for
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patients with recurrent relapses related to nonadherence to oral preparations and for those who

prefer that mode of administration” (Clark et al., 2018. pg. 92). Due to this patient’s lack of

compliance with his medication regimen, he is a great candidate for Aristada. Another

medication he is prescribed is Trileptal. This patient is prescribed 450 milligrams of Trileptal

twice a day. Trileptal is an anticonvulsant that is used to stabilize his mood. The final medication

he is prescribed in Cogentin, which is an anticholinergic that is administered to provide relief

from side effects of some antipsychotics This patient receives one milligram of Cogentin twice a

day.

On the date of care, November 2, 2021, I observed the patient in the unit’s group session

as the nurse discussed the most commonly diagnosed psychiatric conditions and some signs and

symptoms of each. He appeared interested in the topic but did not engage in any of the group

discussions. As the patient sat down for our interview after dinner, he appeared to have good

hygiene, he was well-groomed, and had scars and tattoos on both forearms with a small star

tattoo under his left eye. Throughout our conversation, the patient appeared restless and agitated,

spoke rapidly, and never made eye-contact. He explained that he was currently feeling anxious

and agitated because he wanted to be discharged that day. The patient’s affect was congruent

with his mood as it was evident, he was very anxious. His ability to concentrate was fairly poor

along with his attention span as our conversation only lasted for a few minutes. This patient is

extremely impulsive as he stated he has been in and out of jail multiple times and has recently

been hooking up with many different women. The patient explained he was currently having

both auditory and visual hallucinations. He stated that he sees people walking all around him

especially in the dark and these people are talking about him in “demonic voices”. Later in the

conversation, the patient expressed grandiose delusions when he referred to himself as having a
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“sixth sense” where he could see into everyone’s souls and determine if they were “dead inside”.

As we wrapped up our conversation, the patient explained that he has attempted suicide in the

past, but currently denies any suicidal ideations.

Summarize Psychiatric Diagnoses

The primary psychiatric diagnosis for this patient is schizoaffective disorder (bipolar

type). According to Videbeck (2020), “Schizoaffective disorder is diagnosed when the client is

severely ill and has a mixture or psychotic and mood symptoms” (pg. 256). Common

characteristics displayed by those with this condition include hallucinations, delusions, depressed

mood, mania, and disorganized thinking. According to the American Psychiatric Association in

the DSM-V, the listed criteria for a diagnosis of schizoaffective disorder include a period of

illness where the patient experiences a major mood episode, more than 2 weeks of delusions and

hallucinations, symptoms associated with the criteria of a major mood disorder, and proof that

their behavioral disturbances are not due to the effects of a substance (pg.143). This patient

meets all of the qualifications for a diagnosis of schizoaffective disorder and since he has both

episodes of depression and mania he would fall into the bipolar subtype.

Additionally, this patient has been diagnosed with antisocial personality disorder.

Videbeck (2020) states that, “Antisocial personality disorder is characterized by a pervasive

pattern of disregard for and violation of the rights of others, and by the central characteristics of

deceit and manipulation” (pg. 335). Patients diagnosed with antisocial personality disorder

usually appear normal and engaging, but they are always manipulating those around them and

doing everything for their own personal gain without regard to others. Per the DSM-V, the

diagnostic criteria for antisocial personality disorder include:

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A. A pervasive pattern of disregard for and violation of the rights of others, occurring

since age 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behaviors, as indicated by

repeatedly performing acts that are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for

personal profit or pleasure.

3. Impulsivity or failure to plan ahead.

4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent

work behavior or honor financial obligations.

7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,

mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of

schizophrenia or bipolar disorder. (pg. 659).

Since it is uncommon to diagnose a personality disorder in younger individuals due to

incomplete brain development, this is a fairly new diagnosis for this patient as he is only 28 years

of age.

This patient’s final psychiatric diagnosis is polysubstance abuse. Substance abuse

disorders are very commonly associated with the diagnosis of schizoaffective disorder.

According to the American Psychiatric Association, “The essential feature of a substance abuse
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disorder is the cluster of cognitive, behavioral, and physiological symptoms indicating that the

individual continues using the substance despite significant substance-related problems” (pg.

483). This specific patient abuses a multitude of substances including tobacco, cannabis, and

amphetamines. He stated he has been using marijuana since age 16 and methamphetamines and

heroin since age 21. Patients suffering from substance abuse disorders are solely focused on

attempting to obtain and use their substance of choice and often find themselves in poor

situations because of it.

Stressors and Behaviors

Leading up to this current admission, the patient explained that he had been using more

than normal and was experiencing excessive hallucination when under the influence of those

substances. The patient stated he has not been sleeping or eating and only using drugs as of late.

Some of his stressors include homelessness, unemployment, and lack of any social connection.

He has no contact with his younger sister and his father passed away two years ago. Since the

patient is unemployed and not involved within the community, his opportunities to build

relationships with those positive influences is limited. Another recent stressor was the ending of

his engagement to his fiancé. Since then, the patient has been very impulsive with his sexual

behavior.

Patient/Family History of Mental Illness

Throughout our conversation, the patient explained that he has had hallucinations, both

visual and auditory, since he was a little boy. He stated that these hallucinations have made him

afraid of the dark throughout his adult years. This patient has a history of suicidal ideations and

attempts in the past. The patient also stated that he grew up in an He has a lengthy history of

hospitalizations due to his mental illness. In total, he has five admissions to Trumbull Memorial
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Hospital and his most recent was in May of 2021. When discussing his family, the patient denied

any history of mental illness. He stated he doesn’t know his father’s side of the family, but his

mother was very abusive and suffered from alcoholism.

Psychiatric Evidence-Based Nursing Care

Throughout the patient’s time spent on the unit, he has been regularly attending group

therapy sessions. During our conversation he explained that he felt like they were beneficial and

helping him develop alternative coping strategies other than drug use. Another important aspect

of care the patient was receiving was education pertaining to the new psych medications he was

being prescribed. When he was last admitted to the unit, he was discharged on Depakote and

Risperdal, but his medications have been altered during this admission. Educating the patients on

why they are being prescribed certain medications and some of the side effects they may

experience is a vital role of the nurses on the unit. “The results of this current study indicated that

participants with schizophrenia or schizoaffective disorder were likely to understand their

symptoms and illnesses and the necessity of taking antipsychotic medication after being exposed

to the intervention” (Choe et al., 2016). This study supports the importance of medication

education with patient compliance after discharge and improving their ability to recognize

certain side effects that coincide with the medications they are taking. Our conversation is

another example of a nursing intervention that the patient participated in which allowed him to

discuss his medications and ways to improve on his coping strategies. Throughout the

conversation the patient explained the positive coping strategies he uses are counting backwards

and taking deep breaths to relax.

Ethnic, Spiritual, and Cultural Influences

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This patient’s cultural background includes growing up in an abusive household with an

alcoholic mother which already predisposes him to the development of mental illness throughout

his life. This patient’s difficult childhood played a substantial role in the way he would go about

life as an adult. Spiritually, this patient explained that he was not religious and that all he needed

to guide him was himself and the devil.

Patient Outcomes Related to Care

Throughout this patient’s admission he has been attended group sessions, taking a new

medication regimen, and talking with staff regarding plans after discharge. During our

conversation he explained that he felt like his new medications were working and he was not

having as many hallucinations. He also explained that he was going to enjoy getting an injection

every 30 days rather than taking pills every day. He also explained that he had been regularly

attending group sessions and that he felt they were beneficial in improving his self-esteem and

coping strategies. Since he came to the hospital seeking a psychiatric evaluation for admission to

a rehabilitation facility, he explained that he wants to return to seek treatment after he is

discharged from the hospital.

Discharge Plans

Following discharge from the unit, the patient plans to return home while awaiting

placement into a rehabilitation facility. It will be beneficial that he was switched to Aristada,

upon this admission because it will hopefully increase his compliance with medications. Due to

his poor track record with compliance to his medication regimen he was a great candidate for the

long acting injection rather than daily oral medications. Once he gets admitted to a rehabilitation

facility and is receiving proper treatment for substance abuse, his chances of remaining clean

from drugs and alcohol with greatly increase and provide himself with the ability to turn his life
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around. Throughout our conversation we discussed employment opportunities. This patient

explained that he worked intermittently doing construction in the past and would like to get back

in the workforce after leaving rehab. We had a great discussion about all of them positive

benefits of returning to the workforce such as giving the patient a purpose in life and a reason to

abstain from the substances he has used in the past. This patient also stated that he felt as if he

had no positive influences in his life. We discussed the benefits of becoming more involved

within the community whether it be through joining substance abuse therapy groups or the

workforce and the opportunities community involvement will provide him in making those

friends that will serve as positive influences in his life.

Prioritized Nursing Diagnoses

1. Self-neglect related to psychotic disorder as evidenced by chronic substance abuse,

poor medication compliance, and impulsive behaviors.

2. Risk for other-directed violence related to poor impulse control as evidenced by

multiple stents in jail, chronic substance abuse, and antisocial personality disorder.

3. Readiness for change related to substance abuse as evidenced by reasons for coming

to the hospital and desire to enter a rehabilitation facility upon discharge.

4. Risk for suicide related to psychiatric diagnoses as evidenced by previous suicide

attempts, substance abuse, and hallucinations

Listed Nursing Diagnoses

Hopelessness related to overwhelming stress

Insomnia related to chronic substance abuse

Risk for noncompliance related to insufficient knowledge of medications

Risk for ineffective relationships related to psychiatric diagnoses

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Knowledge deficit related to insufficient interest in learning

Ineffective coping related to history of abuse as a child

Conclusion

Overall, this patient presented to the emergency room having active hallucinations after

being sent in by the rehabilitation facility he was attempting to be admitted to. He has a long

history of mental illness and previous stays in both the hospital and jail due to his illnesses.

Throughout this specific admission the physicians altered his medication regimen to make it

easier for him to comply with and are encouraging him to seek out care at a rehabilitation facility

upon discharge. Throughout our conversation, this patient’s restlessness and agitation were

evident through his body language, but he verbalized his desire to admit himself into a

rehabilitation center and stick with his medication regimen after discharge. He explained that he

has a plan for what he wants to do to change his life around and live a meaningful life as he

knows he can. He plans to rejoin the workforce and eventually get himself his own place to live.

Although this patient has made some poor choices throughout his life, much of the reasoning

behind the development of his mental illnesses and lifestyle could be attributed to his upbringing

as a child and the lack of positive influence in his life. Hopefully, once he is discharged from the

unit, he actually able to get himself into a rehabilitation facility, abstain from the substances he’s

abused in the past, and change his life around the way he wants to.
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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Choe, K., Kang, Y., Sung, B. J., & Yoo, S. Y. (2016) Impact of Psychoeducation on Knowledge

of and Attitude Toward Medications in Clients with Schizophrenia and Schizoaffective

Disorders. Perspectives of Psychiatric Care, 113-119. https://doi.org/10.1111/ppc.12106

Clark, C., Davis, E., Ehret, M. J., & Luttrell, S. J. (2018). Aripiprazole Lauroxil NanoCrystal®

Dispersion Technology (Aristada Initio®). Clinical Schizophrenia and Related

Psychoses, 92-96.

https://web-p-ebscohost-com.eps.cc.ysu.edu/ehost/pdfviewer/pdfviewer?

vid=2&sid=96cbccf5-a050-42d5-b46b-be122884da11%40redis

Videbeck, S., L. (2020). Psychiatric-Mental Health Nursing (8th ed.). Wolters Klumer