Running head: COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Josh DeSalvo

Youngstown State University

COMPREHENSIVE CASE STUDY 2

Abstract

A case study was performed on a 22 y.o. male who presented to the BAC with severe

anxiety as well as behaviors of crying loudly for his girlfriend, evidence of flight of ideas,

pressured speech, exaggerated facial and verbal expressions, inappropriate behavior through

wearing girlfriend’s jeans and refusing to remove them because he stated, “I feel closer to her,”

curled up in bed while punching the pillow, displayed word salad and rambling speech, and at

times was religiously preoccupied. This case study looks to identify precipitating events to

hospital admission, behaviors observed throughout care, treatments being provided and their

effectiveness, psychological diagnoses and the symptoms related, family history of mental

illness, psychiatric evidence based nursing care the patient participates in, any evidence of

ethnic, cultural, or spiritual influences impacting patient, priority nursing diagnoses to address

based on psychological diagnoses and patient situation, potential diagnoses, how patient is

progressing or regressing in treatment by identifying outcomes in care, and determining plans for

discharge.
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Objective Data:

The patient, D.N., presented to the E.D. for a Psychiatric evaluator on 11/6/17. Per report,

D.N. was found outside his apartment with evidence of extreme anxiety due to relationship

issues between himself and his girlfriend. D.N. was received to the BAC and reported feeling

anxious with a complaint that has been persistent, moderate in severity, and worsened by

emotional upset. While in BAC, D.N. was observed as crying loudly for his girlfriend, evidence

of flight of ideas, pressured speech, exaggerated facial and verbal expressions, inappropriate

behavior through wearing girlfriend’s jeans and refusing to remove them because he stated, “I

feel closer to her,” curled up in bed while punching the pillow, displayed word salad and

rambling speech, and at times was religiously preoccupied and required medication to be

appropriately maintained in the BAC. D.N. required an involuntary admission to the unit on

11/7/17. After admission and orientation to unit, D.N. was observed as loudly crying to self.

D.N., however, was medication compliant and received PRN Ativan and Haldol given P.O.

Initial assessment findings related to D.N.’s psychological state included avoidance gaze,

exaggerated expressions, unstable affect, alert, excessive motor activity (restless), evasive

interview behavior, distractible, inability to concentrate, flight of ideas, paranoid preoccupations,

no evidence of hallucinations, delusions of grandeur and persecution, confabulation of memories,

poor judgment and insight, and no SI or HI. According to the psychiatrist progress note, D.N.

would not respond to questions, just stared. D.N. was agitated when leaving room, PRN meds.

administered, refusal to sign involuntary permit, yelling and crying, and D.N. stated he hopes the

medication will help him out. On 11/7/17, D.N. attended community meeting and stated his goal

was, “To get better for my girl,” as well as, attempting to participate in 4:00 wellness group,

however, D.N. became quickly agitated and began yelling, requiring removal from the group. As
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clinical picture progressed, at 6:44 a.m. of 11/8/17, D.N. was observed out of his room acting

bizarre, smelling the air and growling at staff, blurting out random words, and was easily

agitated. D.N. was administered Ativan 1 mg P.O. for anxiety and agitation. According to

reassessment data relating to D.N.’s psychological status, attentive concentration was observed,

recent and remote memory intact, speech remained fast and pressured, unkempt appearance,

cooperative with positive attitude, intermittent eye contact, euthymic mood, bizarre affect,

thought process and association is logical and tangential, paranoid delusions present, and

progress note concluding with D.N. not improving as expected. On 11/8/17 at 10:16 a.m., D.N.

attended group therapy. D.N. was in and out of room but was willing to sit and listen

appropriately, minimal participation but appropriate and normal speech, logical thought process,

flat affect, and euthymic mood. On 11/9/17, student nurse and patient interaction phase occurred.

D.N. was pleasant and cooperative however inappropriate social interaction behavior through

lack of respect for personal space, lack of social etiquette through passing gas and asking

interviewer about it, and lifting up shirt to show tattoos. D.N. displayed intermittent eye contact,

restlessness related to anxiety through shifting weight and constantly crossing and uncrossing

arms, flight of ideas, and rambling speech. D.N. identified stressor relating to breakup with

girlfriend but did not identify possible implementation of maladaptive coping mechanisms

resulting in hospitalization. D.N. exhibits high interest in cannabis substance and desired use for

medicinal purposes in his care. D.N. identified shadow boxing as a possible coping mechanism

but did not identify how it could be used appropriately in the event of a stressor. D.N. did not

identify strong family support system and denied religious affiliation. Care concluded with D.N.

on 11/9/17 at 8:30 p.m. in which D.N. refused his scheduled Zyprexa 10 mg P.O., and also
COMPREHENSIVE CASE STUDY 3

refused his scheduled Lamictal 50 mg P.O. D.N. informed the nurse that, “I only want my

Ativan, and I refuse these other ones.” D.N. was respectful, yet firm on his decision.

Based on the presenting data, clinicians have used the DSM IV-TR, Axes I-V in order to

diagnose D.N. with Schizoaffective disorder, bipolar type. Criteria necessary to meet this

diagnosis include, “This mental disorder is diagnosed when the symptom criteria for

Schizophrenia are met and during the same continuous period there is a Major Depressive,

Manic or Mixed Episode. During that same period hallucinations or delusions must be present

for at least 2 weeks while there are no mood symptoms” (“BehaveNet,” 2017). Due to this

diagnosis, D.N. has been prescribed Zyprexa, an atypical antipsychotic, in which the drug

antagonizes dopamine, serotonin 5-HT2, and other receptors in order to re-establish

neurotransmitter levels and treat both positive and negative symptoms of schizophrenia

(“Epocrates,” 2016). D.N. is also ordered maintenance doses of Lamictal, bipolar disorder/mood

stabilizer, in which the drug inhibits voltage-dependent sodium channels, decreasing presynaptic

glutamate and aspartate release. D.N. presented with subjective anxiety that has been persistent,

moderate in severity, and worsened by emotional upset. D.N. has Ativan, anti-anxiety and

benzodiazepine, ordered prn in which the drug binds to benzodiazepine receptors and enhancing

GABA effects forcing the body to slow down physiologically (“Epocrates,” 2016). D.N. also has

a severe dependence with cannabis, and anxiety related to lack of use or possible withdrawal

may also be treated by Ativan. D.N. is also participating in group therapy and individual therapy

sessions daily in order to foster coping techniques that promote adequate adaptation to stressors

particularly in managing thoughts, preventing self-isolation, improving problem solving skills,

accepting personal responsibility and personal control of situations, developing effective impulse

control, understanding effective social interaction, and identifying personal sense of drive
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through developing goal related thinking. D.N. is seen daily by psychiatrist who observes

patient’s behaviors, responses to medication and treatment, and general psychological state. D.N.

is maintained in a locked environment in which negative environmental stimuli are removed

from the patient and a structured schedule is provided in order to minimize anxiety and develop

patient to healthcare team trust. PRN medications are ordered in the event of illness exacerbation

and administered to prevent self-harm of patients and other directed violence. Individual group

therapy sessions are conducted to provide patients the opportunity to reflect on illness, past

behaviors, and past experiences in order to effectively develop coping strategies to deal with

future stressors, heal past emotional and psychological trauma, and promote healthy interaction

as a member of society.

Summarize:

D.N. presents with psychiatric diagnoses of schizoaffective disorder, bipolar 1 disorder,

and subjective complaints of anxiety. Each diagnoses has its own set of expected symptoms but

origin may be related to anxiety along with neurotransmitter imbalances.

According to Townsend (2017, p. 429), schizoaffective disorder, “…is manifested by

schizophrenic behaviors, with a strong element of symptomatology associated with mood

disorders (depression or mania). The client may appear depressed, with psychomotor retardations

and suicidal ideations. Or symptoms may include euphoria, grandiosity, and hyperactivity. The

decisive factor in the diagnosis of shizoaffactive disorder is the presence of hallucinations and/or

delusions that occur for at least 2 weeks in the absence of a major mood episode.” Specific

behaviors related to a schizoaffective disorder include, “…delusions, severity of hallucinations,

impaired understandability, derailment, illogical thinking, bizarre behavior, inappropriate affect,

COMPREHENSIVE CASE STUDY 3

affective flattening, alogia, avolition-apathy, and anhedonia” (Robinson et al., 1999). Due to

prior hospitalization and current behaviors, D.N. also required a diagnosis of bipolar 1 disorder.

Townsend also states, “Bipolar 1 disorder is the diagnosis given to an individual who is

experiencing a manic episode or who has a history of one or more manic episodes. The client

may also experience episodes of depression” (book ch. 26). As far as common behaviors

associated with bipolar disorder type 1, Skjelstad, Malt, and Holte (2010, pp. 1-13) identified,

“…irritability and aggressiveness, sleep disturbances, depression and mania symptoms/signs,

hyperactivity, anxiety, and mood swings,” to be clinically significant in diagnostic criteria. Upon

admission to hospital, per EMS and Pt. report, D.N. was experiencing severe anxiety. Townsend

(2017, p. 531) determines abnormal anxiety as, “…out of proportion to the situation that is

creating it and a level of anxiety that interferes with social, occupational, or other important areas

of functioning.” Anxiety can often be difficult to identify due to its subjective nature, however,

common feelings are experienced across this patient population as well as some identifiable

physical signs such as, “excessive worry, motor tension, hyperarousal, insomnia, chest pain,

abdominal pain, headache, and fatigue” (“Effective recognition,” 2004).

Identify:

Stressors often determine our ability to effectively function in society. Due to mental

illness, it is difficult to develop effective coping mechanisms to promote adequate cognitive view

points and establish optimal behavior responses to situations. Often times, medication regimens

are required to alter our brain chemistry in order to maintain normal neurotransmitter levels and

promote biological homeostasis. In D.N.’s circumstance, lack of medication compliance may

have contributed to a schizoaffective, bipolar type 1 disorder, and anxiety exacerbation. D.N.’s

prior hospital admission was 10/27/17-11/3/17, where he was admitted for mania and psychosis.
COMPREHENSIVE CASE STUDY 8

Pt. was treated in the inpatient psychiatric setting with Zyprexa and PRN medications. Pt.

responded well to treatment and was discharged to home. However, in the opinion of his

psychiatrist, pt. continued to present as hypomanic and disorganized, but court didn’t support

continued stay. Pt. verbalized that he was not compliant with medication since discharge and

used cannabis. So, lack of medication compliance and substance use may have contributed to

brain chemistry imbalance and exacerbation of disease state. Pt. also identified social interaction

issues due to recent break-up with girlfriend that contributed to anxiety state in which pt. was

crying loudly for his girlfriend with evidence of flight of ideas, pressured speech, inappropriate

social behavior in which D.N. was wearing his girlfriend’s jeans and refused to take them off,

exaggerated facial and verbal expressions, insomnia, word salad, religiously preoccupied, and in

active acute psychosis. Pt. also identified other precipitating stressors including financial stress

due to lack of gainful employment.

Discuss:

As identified in the previous section, D.N. has a history of illness exacerbation pertaining

to mania and psychosis. Patient’s chart also identified previous history of psych. med. use, as

well as, a previous history of suicide attempt. No information was provided on suicide attempt

specifics such as method, support provided, or reason for attempt. Chart also identified a family

history of mental illness, however, no information was provided to paternal or maternal

transmission, diagnosis, symptoms observed, age of onset, or treatment provided. According to

Cardno and Owen (2014), “Schizoaffective disorder has been less investigated but shows

substantial familial overlap with both schizophrenia and bipolar disorder. A twin analysis is

consistent with genetic influences on schizoaffective episodes being entirely shared with genetic

influences on schizophrenic and manic episodes, while association studies suggest the possibility
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of some relatively specific genetic influences on broadly defined schizoaffective disorder,

bipolar subtype.”

Describe:

When dealing with psychiatric illnesses, a multi-dimensional approach is crucial in order

to develop patient trust, improve cognitive distortions, promote social interaction, improve

behavior modification, maintain a healing, structured environment, and reestablish chemical

equilibrium within the body. Certain psychiatric evidence based nursing care is necessary in

order to foster the most beneficial outcomes for the patient. As far as individual psychotherapy

goes from a nursing stand-point, nurses, identified by Townsend (2017, p. 439), need to focus

on, “Reality-oriented individual therapy is (as) the most suitable approach to individual

psychotherapy,” and later states, “The primary focus in all cases must reflect efforts to decrease

anxiety and increase trust.” Particular steps taken to reach this goal are done by being honest,

direct, and providing respect for the patient’s dignity. Education should be provided to help the

client identify evidence of stressors and their emotional feelings to those stressors as well as

ways to react appropriately interpersonally, emotionally, and behaviorally to frustration.

(Townsend, 2017, p.440). D.N. is scheduled to meet with his psychiatrist daily to determine

psychological status and progression in treatment. Patient is also scheduled to attend daily group

therapy and be an active participant in the activities provided. However, according to psychiatric

evidence based nursing care, “Group therapy in inpatient settings is less productive. Inpatient

treatment usually occurs when symptomatology and social disorganization are at their most

intense. At this time, the least amount of stimuli possible is most beneficial for the client”

(Townsend, 2017, p. 440). With D.N., pt. attempted to attend the 4:00 p.m. wellness group on

11/7/17, however, he became quickly agitated, started yelling, and left the room. Pt. on 11/8/17
COMPREHENSIVE CASE STUDY 10

attempted to attend group therapy at 10:16 a.m. however, he was in and out of room with

minimal participation but improvement was noted in concentration, speech, logical processing,

and treatment of others. According to Townsend (2017, p. 441), the benefits of group therapy

can be particularly beneficial in long term treatment of schizoaffective disorder patients by

promoting, “social interaction, a sense of cohesiveness, personal identification, and reality

testing.” Behavioral outbursts often identify disease exacerbation. Behavior therapy is a

fundamental aspect of care for schizoaffective patients. Townsend identifies that, “In the

treatment setting, the healthcare provider can use praise and other positive reinforcements to help

the client reduce the frequency of maladaptive or deviant behavior.” D.N. is provided behavior

therapy with each healthcare interaction and care provided in order to promote behavior change.

In the realm of behavior involves social skills training. According to Townsend (2017, p. 441),

“Social dysfunction is a hallmark of the disorder,” and later states, “The educational procedure in

social skills training focuses on role-play. A series of brief scenarios are selected. These should

be typical situations clients experience in their daily lives and be graduated in terms of level of

difficulty. The health care provider may serve as a role model for some behaviors.” Social skills

training, like behavior therapy, is an opportunity for the health care provider to role model

appropriate behavior in every social interaction and help the patient identify areas of weakness in

order to facilitate optimal social interactions in the future. Although therapy can be intentional

and direct in patient care, subtle therapy can be provided to the patient through the environment

they occupy. Milieu therapy helps to establish a structured environment through hospital rules

and policy in the hope that through, “ group and social interaction; rules and expectations are

mediated by peer pressure for normalization of adaptation. When patients are viewed as

responsible human beings, the patient role becomes blurred. Milieu therapy stresses a patient’s
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rights to goals and to have freedom of movement and informal relationships with staff”

(Townsend, 2017, p. 441). D.N. identified the benefits of connecting with other patients during

the interview process, and stated how it helps to reduce anxiety and promote a feeling of

connection. D.N. is also encouraged to establish a daily goal in order to promote pt. autonomy

and self-confidence that can be transitioned to the non-hospital setting. Mental illness often

results from biological and biochemical imbalances effecting the presentation of disease states.

For schizoaffective disorder, medication is required for effective health maintenance and optimal

quality of life. Anitpsychotic medications, “…are effective in the treatment of acute and chronic

manifestations of schizoaffective disorder and in maintenance therapy to prevent exacerbations

of symptoms. Without drug treatment, an estimated 72 percent of individuals who have

experienced a psychotic episode relapse within a year. This relapse rate can be reduced to about

23 percent with continuous medication administration” (Townsend, 2017, p. 443). D.N. is on a

medication regimen of olanzapine, 2nd generation antipsychotic, 10 mg/2 times a day for

schizoaffective disorder and evidence of psychosis. Pt. also receives Ativan 1 mg for acute

anxiety and agitation exacerbations. However, D.N. has a history of medication incompliance

and on 11/9/17 D.N. refused his scheduled Zyprexa 10 mg by mouth and also refused his

scheduled Lamictal 50 mg by mouth. As long as the patient is not a harm to himself or others, he

has the right to refuse this level of treatment. Patient education is crucial in order to develop

rapport as well as to help the patient gain a better understanding of their disease state in order to

promote necessary personal action to constantly improve their condition.

Analyze:

In continuation, ethnic, spiritual, and cultural influences can play a major role in

influencing patient’s behaviors and cognitive outlooks on life. D.N. is a caucasian male who was
COMPREHENSIVE CASE STUDY 12

raised in the United States the entirety of his life. He lived in a suburban to urban environment

and was considered middle to low socioeconomic status when he lived with his parents. D.N. is

now unemployed and would be considered under the federal established poverty line. D.N.

stated on admission that part of the contributing factors or precipitating events leading to his

illness exacerbation included financial stress. D.N. stated he has read the Bible, Koran, and

Torah. D.N. stated that he believes in God but enjoys doing what he wants to do. He stated his

mantra is peace, love, and happiness and everything else will fall into place. Part of D.N.’s

psychiatric disorders includes a history of severe cannabis use disorder or dependence. Use of

particular substances may relate to the type of culture D.N. surrounds himself with and

contribute to financial stress and ineffective coping skills.

Prioritized:

Nursing diagnoses help to identify a problem and the contributing factors, in order, to

help establish goals and implement interventions to help the patient reach the desired, realistic

goals in their care. For D.N., several nursing diagnoses are appropriate for his present

circumstances such as the following: Ineffective Health Maintenance related to cognitive

impairment and ineffective individual coping as evidence by lack of medication regimen

compliance, exacerbation of psychosis, and attempts to self-medicate through substance abuse of

cannabis; Ineffective coping related to inadequate support systems, unrealistic perceptions,

inadequate coping skills, disturbed thought processes, and impaired communication as evidence

by recent breakup with girlfriend and no known familial support, lack of understanding of

disease process and necessity for medication management, history of severe cannabis

dependence, delusions of grandeur and persecution present on admission, and ineffective

communication evident through flight of ideas and poor concentration; Social isolation related to
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lack of trust and delusional thinking as evidence by poor group meeting attendance and focus,

and delusions of persecution present; Impaired social interaction related to impaired

communication patterns and disturbed thought processes as evidence by poor social boundaries,

thought pattern consisting of flight of ideas, poor concentration in interactions, and delusions of

grandeur and persecution present. Interventions need to target the source of the problem and

effectively implemented with understood outcomes relating to a measureable result in a time

frame in order to deliver the most optimal care for this patient as possible. Although, these are

prioritized nursing diagnoses for this particular patient, there is a potential for many other

nursing diagnoses as well.

List:

Based on the patient’s medical diagnoses, the patient may present with anyone of the

following potential diagnoses if their symptoms so shall indicate, such as: Ineffective activity

planning related to compromised ability to process information; Anxiety related to unconscious

conflict with reality; Impaired verbal communication related to psychosis, disorientation,

inaccurate perception, hallucinations, delusions; Deficient diversional activity related to social

isolation, possible regression; Interrupted family processes related to inability to express

feelings, impaired communication; Fear related to altered contact with reality; Hopelessness

related to long-term stress from chronic mental illness; Insomnia related to sensory alterations

contributing to fear and anxiety; Risk for compromised human dignity: risk factor: stigmatizing

label; Risk for loneliness: risk factor: inability to interact socially; Risk for self- and other-

directed Violence: risk factors: lack of trust, panic, hallucinations, delusional thinking; and

readiness for enhanced hope: express desire to enhance interconnectedness with others and
COMPREHENSIVE CASE STUDY 14

problem-solve to meet goals. Although the patient is not diagnosed with these nursing diagnoses,

a flexible approach must be taken in order to deal with the priority problem at any given time.

Evaluate:

In order to determine that nursing interventions are effective, goals must be evaluated to

determine if the establish goal was met or not met and what revisions need to made. For D.N.,

based on the nursing care plan, his goals maintain a sense of continuity in the sense that even

though the goal was met this shift; we also want to see the patient continue to meet the goal

throughout the entire stay. These types of goals, based on the chart, are often written as short

term goals and relate to self-harm behaviors. For example, the goal for 11/7/17 included the

client’s ability to verbalize suicidal ideations and 11/8/17 included the exact same goal as well as

absence from self-harm and maintaining adequate nutrition. D.N.’s long term goals relate more

so to behavior and cognitive changes pertaining to his chronic illness rather than the short-term

goals relating to illness exacerbation. Examples of long-term goals may include appropriate

social interaction. For the goal, appropriate social interaction on 11/7/17, patient did not meet the

goal due to being withdrawn to room much of shift, disheveled appearance, poor concentration,

and would walk away during any interaction. As D.N.’s stay continued, goals such as patient’s

ability to verbalize a decrease in frequency and intensity of racing thoughts were considered to

be continually evaluated or looked at on an ongoing basis. D.N.’s behavior and cognition on days

of 11/8/17 and 11/9/17 included descriptions as pt. presently denies SI, HI, and hallucinations

,however, pt. was seclusive to self even while up and out on unit. Pt. did attend evening group

and was compliant with medications. Observations of 11/9/17 stated pt. was up and about on the

milieu and attended probate this morning. Pt. is cooperative, thoughts have slowed, and no unit

or behavioral cautions are implemented at this time. D.N. is recommended to see his psychiatrist
COMPREHENSIVE CASE STUDY 3

daily in order for a psychological assessment to take place and determine the effectiveness of

treatment and if goals are effectively being met. On 11/8/17, according to the psychiatrist

progress note, D.N. was not improving as expected. Thus, goals need to be modified and original

discharge plans relating to outpatient care revised.

Summarize:

Plans for discharge begin with admission. Care is tailored to promote patient autonomy in

which the patient plays an active member in his/her care in order to promote better and more

sustainable outcomes. However, goals cannot always be effectively reached due to complications

relating to illness, financial barriers, lack of access to resources, patient motivation level, or any

number of unforeseen events. In order to promote patient safety and improve health outcomes,

discharge plans may need to be revised for the individual’s situation. Due to D.N.’s improvement

trajectory, his discharge and outpatient care required to be bumped back in order put D.N. in the

most optimal position to be as healthy as possible upon discharge. Upon admission, D.N. had an

appointment in Struthers with Psycare on 11/13/17 at 11:45 a.m. and he was also scheduled to

see Dr. Norvak on 11/10/17 at 1:00 p.m. However, based on psychiatric assessment relating to

patient’s social interactions, intensity and severity of racing thoughts, presence of bizarre

behavior, and lack of medication compliance, required the outpatient appointments to be moved

to 11/17/17 in which D.N. will attend appointments at Struthers Psycare at 10:45 a.m. and see

Dr. Norvak for med. management at 2:00 p.m. on 11/17/17.

COMPREHENSIVE CASE STUDY 16

References

Robinson, D. G., Woerner, M. G., Alvir, J. M., Geisler, S., Koreen, A., Sheitman, B., Chakos,

M., Mayerhoff, D., Bilder, R., Goldman, R., & Lieberman, J.A. (1999). Predictors of

treatment response from a first episode of schizophrenia or schizoaffective disorder. The

American Journal of Psychiatry, 156 (4), 544-549.

https://ajp.psychiatryonline.org/doi/full/10.1176/ajp.156.4.544

BehaveNet (2017). Schizoaffective disorder. Bellevue, WA: BehaveNet®

Drugs. (2016). In Epocrates an Athenahealth Service for Android hTc (Version 5.1) [Mobile

application software] Retrieved from

http://www.epocrates.com/mobile/Android/athenahealth

Townsend, M.C. (2017). Psychiatric mental health nursing: Concepts of care in evidence-based

practice. Philadelphia, PA: F.A. Davis Company

Skjelstad, D.V., Malt, U. F., & Holte, A. (2010). Symptoms and signs of the initial prodrome of

bipolar disorder: A systematic review. Journal of Affective Disorders, 126 (1-2), 1-13.

Effective recognition and treatment of generalized anxiety disorder in primary care. (2004). The

Primary Care Companion to the Journal of Clinical Psychiatry: Official Journal of the

Association of Medicine and Psychiatry, 6(1), 35-41.

Cardno, A. G. & Owen, M. J. (2014). Genetic relationships between schizophrenia, bipolar

disorder, and schizoaffective disorder. Schizophrenia Bulletin, 40(3), 504-515. doi:

10.1093/schbul/sbu016