Running head: PSYCHIATRIC COMPREHENSIVE CASE STUDY

Psychiatric Comprehensive Case Study

Kenneth Jones

Youngstown State University

3/13/2018
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Psychiatric Comprehensive Case Study

C.S. is a 31-year-old Caucasian male who presented to the emergency department after attempting

suicide by taking 6 aspirin and 4 niacin tablets, then becoming scared, called an ambulance. Upon

arriving at the emergency department, laboratory tests were collected which showed a blood

alcohol level of 0.07. All other tests including a urine drug screen came back negative. The patient

was then transferred to the adult psychiatric care unit. The diagnosis given to the patient as

indicated by the DSM IV-TR, Axis I is schizophrenia. This patient is experiencing high levels of

anxiety and depression, is an alcoholic and drug user per his own admission. During admission,

it was noted that the patient was having visual hallucinations of a cat. Because of him being

brought in for attempted suicide, he is under suicide watch and checked on every 15 minutes. C.S.

was willing to speak to a student today (Tuesday February 27th), he ate his breakfast before sitting

down to talk. His appearance was disheveled and looked to be malnourished. The patient had a

very flat affect. Although he spoke a lot, there was no emotion in any of his speech. He sat

comfortably slouched in a chair and fidgeted with his hands. C.S. stated that both his anxiety and

depression were a 10 out of 10. When he spoke, he answered all questions but seemed to skip

around in the time line making it hard to understand the timing of the story he was telling. C.S.

before admission was not on any medications and was not currently under a doctor’s care. After

admission, he was put on several medications having no known allergies to help with his anxiety,

depression, schizophrenia and alcoholism. the medications were Depakote (valproic acid) 250mg

bid for treatment of schizophrenia, Librium (chlordiazepoxide) 10mg tid for possible alcohol

withdrawal, Haldol (haloperidol) 5mg q6 hours prn, for agitation, Vistaril (hydroxyzine) 50mg q6

hours prn for agitation, Desyrel (trazodone) 50mg prn at bedtime for sleep, and lastly, Folic acid

1mg and thiamine (vitamin B4) as a supplement for malnourishment due to alcoholism.
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The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen Bleuler. The

word was derived from the Greek skhizo (split) and phren (mind). Various definitions of the

disorder have evolved, and numerous treatment strategies have been proposed, but none have

proven to be uniformly effective or sufficient (Townsend, 2015, p. 420). There are actually 4

different phases of schizophrenia; The first phase or Premorbid Phase is actually seen in many

individuals which includes shyness, poor school work, poor behaviors, poor relationships. The

second phase or Prodromal Phase is when “the person experiences substantial functional

impairment and nonspecific symptoms such as a sleep disturbance, anxiety, irritability, depressed

mood, poor concentration, fatigue, and behavioral deficits such as deterioration in role functioning

and social withdrawal. Positive symptoms such as perceptual abnormalities, ideas of reference,

and suspiciousness develop late in the prodromal phase and herald the imminent onset of psychosis

(Townsend, 2015, p. 421). The third phase is Schizophrenia, this is the active phase of the disorder

when psychotic symptoms manifest. There is a specific diagnostic criterion for schizophrenia from

the DSM-5 as Townsend (2015) provides:

 A. Two (or more) of the following, each present for a significant portion

of time during a 1-month period (or less if successfully treated). At least

one of these must be (1), (2), or (3):

1. Delusions

2. Hallucinations

3. Disorganized speech (e.g., frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

5. Negative symptoms (i.e., diminished emotional expression or avolition)

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Lastly is the Residual Phase which is when there are periods of remission. Remission can

be attained through drug therapy as long as the patient remains on medications, there are also

several other treatments that have been tried and researched. Two major neurochemicals in our

brain that elicit behaviors are dopamine and serotonin. There are studies that show a change in

these levels can help in the treatment of schizophrenia. One study shows how dopamine

dysfunction might underlie psychotic symptoms. “Several lines of evidence indicate that

schizophrenia is a disorder of abnormal dopamine signaling. One of the leading studies is aberrant

salience hypothesis of schizophrenia where individuals have increased dopamine released from

things other than rewards. “Research converges in support of a model of aberrant salience in

schizophrenia, wherein excessive striatal dopamine release in response to meaningless or

irrelevant stimuli may drive positive symptoms of psychosis, whereas an absence of dopamine

firing critical for motivation may underpin negative symptoms of the disorder” (Whitton,

Treadway, & Pizzagalli, 2015, p. 7). Medications and psychotherapy are most generally use for

dopamine receptors. Serotonin is also a major contributing factor with schizophrenia and one of

the studies shows that Vitamin D may play a part in this. “There may be a very important

interaction between genetics and vitamin D hormone that could play a role in modulating the

severity of mental illness. Individuals with polymorphisms in serotonin-related genes are already

predisposed to dysregulation in the synthesis or metabolism of serotonin; thus, any additional

decrease in serotonin synthesis as a consequence of inadequate levels of vitamin D may

exacerbates defects in executive function, sensory gating, and impulsive behavior” (Patrick &

Ames, 2015, p. 4). Traditional drugs such as Depakote and Lithium are still considered the gold

standard treatment. C.s. was experiencing hallucinations of seeing a cat and has a flat affect upon

admission but there was no time frame that could be established and the patient is now on
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Depakote. The patient has spent time in a mental health unit in Pennsylvania. C.S. claims that the

reason that he is in this facility is because he attempted suicide due to being out of control and a

dependence on alcohol. “Suicide is one of the leading causes of death worldwide, among the top

ten causes of death in every country, and on of the three leading causes of death for people between

the ages of 15-34. Individuals meeting criteria for schizophrenia are at particularly high risk of

dying by suicide with a lifetime level of 4.9% and, further, suicide is the leading cause of premature

death in this population” (McGirr & Turecki, 2007, p. 217).

During our conversation, C.S. was more than cooperative with answering questions but

seemed to skip around making his precipitating events hard to coordinate even though there were

plenty discussed. In hindsight, I wish I would have redirected questions to establish a better

timeline and ask more in-depth questions about his parents who are still married. When asked why

he was here, C.S. stated that “I was out of control, I took 6 aspirin and 4 niacin pills. I got nervous

and called for help”. C.S. went on to say that he was a saw operator but lost the job because his

brother went to Florida and he doesn’t drive, then got a job at Burger King but lost it for attendance

because of calling off and a no show. C.S. at that time said he had a binge drinking problem. C.S.

grew up in Mercer, Pennsylvania, he has gone to jail 3 times, for 30, 60, and 90 days. He still owes

money there and had lived in Transfer, Pennsylvania before moving to North Jackson. He liked it

in Transfer because he worked on a horse farm and had his own trailer he lived in after his parents

had kicked him out. He stated that he was once married but was divorced in either 2008 or 2009

and has two children around ages 5 and 12 but haven’t seen them because his ex-wife won’t allow

it. He stated that his brother and girlfriend live in Lordstown, Ohio and he lives in North Jackson,

Ohio in a trailer park. His brother owns and pays for his phone and at times turns it off to make

him mad. C.S. stated he fights with him a lot because he tries to control him through his phone.
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C.S. stated that he has burnt many of the bridges with his family because of alcohol and his family

will not help him with anything. He has been riding a bike for transportation for the last 8 or 9

years due to prior DUI’s. C.S said that he has been drinking since he was young and that drinking

helps him with social anxiety. He can only be around people after he has had a few drinks. C.S

claims that he takes all of his money from paychecks to buy alcohol and that when not working,

relies on his brother or friends to supply alcohol. He wants to get help with housing so he can get

his cat named Kelly-Calico and have a place to live.

As far as a history of mental illness in his family and self, C.S. stated that his father was a

heavy drinker but did not talk about his mother. He also did not state any abuse either mentally or

physically from his family. He did say that he was bullied all through school but did not say

whether this was a cause for his drinking. C.S. also stated that his brother Jimmy was a drug user

even though he had said he was a positive influence on his life and did many things for him. So

even if no abuse or history of mental illness, there is a history of drug abuse and alcoholism.

Although no records with information, it was noted that he was in another mental health facility

for prior treatment.

As for evidence based nursing care, C.S. is receiving standard care for someone that was

admitted involuntarily for attempted suicide. He is monitored not only for suicide prevention but

also seizure precautions because of his alcoholism. The reason for this is “since the rate of

suicide attempts in schizophrenia, reported to lie between 20-40%, is considerably higher than

that of death by suicide, the predictors of suicide attempts are dubious predictors of suicide

completion in this population” (McGirr & Turecki, 2007, p. 218). This requires a visual check

every 15 minutes. Milieu is considered the patients surroundings. C.S. has a shared room and is

monitored, there is a large open common area with lots of windows to allow natural light, paint
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colors that are neutral and plants on the window sills. There are plenty of tables and chairs so

that the patient can eat alone or with a group and has ample space to move around. There are

also two telephones that can be used to make outside calls. Off of the common area, there is a

small “kitchen” where water can be attained. Attached to the common area across from the

nurse’s desk is another room where groups can be attended in a more private setting. Most

importantly there is a schedule posted outside the room that gives the day’s schedule so the

patient knows what time meals are, what time groups are, and what time visiting hours are being

held. This gives the patient a sense of schedule and offers continuity day to day. All of the

patients are encouraged to provide their own personal care, eat all meals, participate in group

therapy, and engage with their therapist. There are also specific times that telephone calls can be

made and that family or friends may visit. At this current time, C.S. does not have visitors and

his brother will not accept any of his phone calls.

I don’t believe that C.S. really has any ethnic, spiritual or cultural influences. When asked

if he had ever tried other ways to cope or tried programs to help you cope with life instead of

alcohol, his reply was “I have gone to church and to AA. AA helps but did not make it to meetings

because of my ride”.

This patient will most likely have a poor outcome at this time. He really has no other coping

skill except for drinking. He will need meds once he leaves the facility and doesn’t have

transportation or insurance at the time to make it to appointments to get medications filled. He

doesn’t seem to have an interest in not drinking. He claims that he does, but just saying it one time

does not show a true want to change behavior. C.S. stated that his expected outcome is ‘to have

the social worker help me find a place stay. If I don’t, I will have to stay in the homeless shelter.

I don’t want to do that because the food is bad and they are sometimes full. I just want help finding
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a place, maybe a drug or treatment place that I can stay at and get better. This place helps find

resources. I really want to find an inpatient program”.

Currently there is no plan for discharge for C.S. He needs to have Depakote levels drawn

on March 1. Until his levels are stable, he will have to remain an inpatient. He has quite a bit of

work to do on his social skills and coping skills before he will have a positive discharge plan.

Actual nursing diagnoses listed in order of priority include:

1. Disturbed thought process related to schizophrenia and alcohol AEB hallucinations

and inability to problem solve.

2. Imbalanced nutrition less than body requirements r/t economic factors and alcohol

abuse AEB lack of food, reported food intake less than recommended daily

allowance.

3. Social isolation r/t alteration in mental status, unaccepted social behavior AEB

absence of supportive significant other, no eye contact, and flat affect.

4. Anxiety r/t situational crisis, change in economic status, AEB restlessness,

tendency to blame others, and financial factors.

5. Impaired verbal communication r/t absence of significant others, chronic low self-

esteem AEB absence of eye contact and difficulty in use of body expressions.

6. Impaired home maintenance r/t inadequate support systems insufficient finances

AEB reported financial crisis and reported outstanding debts.

7. Interrupted Family Process r/t situational crisis or transition AEB knowledge deficit

regarding community and health care support.

8. Impaired Social Interaction r/t difficulty with communication, feeling threatened in

social situations, inadequate emotional responses and self-concept disturbance

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(verbalization of negative feelings about self) AEB observed use of unsuccessful

social interactions behaviors, spends tines alone by self.

Some potential nursing diagnoses may include:

1. Risk for injury r/t cessation of alcohol intake with varied autonomic nervous

system responses, involuntary clonic/tonic muscle activity (seizures), and

equilibrium balancing difficulties, reduced muscle and hand/eye coordination

with desired outcomes of experience no physical injury and demonstrate

absence of untoward effects of withdrawal while on the unit.

2. Anxiety/Fear r/t cessation of alcohol intake/physiological withdrawal,

situational crisis (hospitalization) AEB increased tension, apprehension, fear of

unspecified consequences, feelings of inadequacy, shame, self-disgust, and

remorse with desired outcomes of demonstrating problem solving skills and use

resources effectively and expressing sense of regaining some control of

situation/life before discharge.

Lastly in conclusion, schizophrenia is such an unpredictable disease that has the

ability to steal one’s life away. Although other treatments are tried with some success, the

ultimate goal is for the patient to take medication for the rest of their life. Unfortunately,

there are side effects and individuals who believe they no longer need medication that

relapse on a regular basis. There needs to be work on longer term treatments that won’t

require a daily dose of medication and will keep patients in a therapeutic level of treatment.

As for my patient, I do not know if C.S. has schizophrenia or just overwhelming depression

that has left him with a feeling of hopelessness. I believe alcohol had taken over his life at

a very young age and continued to drink as he aged. Bridges with family and friends were
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all burned and without a job could no longer support himself or his disease and left him

desperate and hopeless. He seems to understand the system somewhat and really thinks

that a social worker will help him to solve his problems of homelessness and income.

Although he says he would like treatment, I truly believe he is just trying to survive to have

a place to live and a form of income so that he may have another drink.
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References

McGirr, A., & Turecki, G. (2007, September 9). What is specific to suicide in schizophrenia

disorder? Demographic, clinical and behavioral dimensions. ScienceDirect, 98, 217-224.

http://dx.doi.org/10.1016/j.schres.2007.09.009

Patrick, R. P., & Ames, B. N. (2015, February 24). Vitamin D and the omega-3 fatty acids

control serotonin synthesis and action, part 2 relevance for ADHD, bipolar disorder,

schizophrenia, and impulsive behavior. The FASEB Journal, 1-8.

http://dx.doi.org/10.1096/fj.14-268342

Townsend, M. C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based

practice (8th ed.). United States: F.A. Davis Company.

Whitton, A. E., Treadway, M. T., & Pizzagalli, D. A. (2015, January 28). Reward processing

dysfunction in major depression, bipolar disorder and schizophrenia. Curr Opin

Psychiatry, 1, 7-12. http://dx.doi.org/10.1097/YCO.0000000000000122