MENTAL HEALTH CASE STUDY 1

Mental Health Case Study: Bipolar Affective Disorder

Luray Hixson

Youngstown State University

MENTAL HEALTH CASE STUDY 2

Abstract

This study focuses on a Caucasian female patient who suffers from bipolar

affective disorder. In the case of this female, she is suffering from a current manic

episode, which there are also psychotic symptoms that are also present. She came to the

emergency room at Saint Elizabeth Hospital in Youngstown, OH on October 3rd, 2016 via

self from Turning Point Residential where she currently resides. Reasoning for being sent

to the hospital included symptoms of paranoia, anxiety, noncompliance of medication

regimen, increased mania, and fear. The fear stems from the patient thinking that her

husband is going to find her where she has been staying (Turning Point) and is afraid for

her safety. Date of care was three days after admission, October 6th, 2016. Information

that will be discussed in this paper will include objective data retrieved and collected by

student nurse, medical and social history, evaluation of patient and her outcomes, and

possible nursing diagnoses that could be cared for by staff.

MENTAL HEALTH CASE STUDY 3

Objective Data

In regards to following HIPAA requirements, the patient this study was done on

will be referred to as Jane Doe to continue and respect patient privacy. Jane is a fifty

four year old Caucasian female who was admitted to Saint Elizabeth Psychiatric Unit on

October third of the current year. She is a smoker, occasional drinker, and does not

currently have a job and has not for some time now. Date of care and the basis of this

case study were performed on October sixth also of the same year, three days following

admission. Patient claimed to have had walked to emergency room from unspecified

previous location (believed to be Turning Point), as she was scared that her husband was

going to find her. She presented with various symptoms associated with her bipolar

affective disorder, such as being in a manic state, paranoia, anxiety, and fearsome of

personal safety. Voluntary admission was continued throughout stay, and patient did not

seem rushed or too eager to get discharged.

When first approaching Jane on the floor, she was very disoriented and almost

seemed to be talking to herself in a hushed manner. On the day of care, the patient was

very eager to speak with the student nurse because she claimed, nobody understands or

will listen to me, when asked to clarify, she disregarded the question and agreed to sit

with the student nurse at a secluded table. Her thought process was very disorganized and

all over the place as far as trying to answer questions and explaining why she was so

upset. Each individual topic that was attempted to speak about, included various flight of

ideas that could go back as far as when she was two years old and never seemed to

answer the initial question.

MENTAL HEALTH CASE STUDY 4

Janes affect was very depressed and noticeably saddened. It was observed

throughout entire interaction that she was continuously very tearful and crying, spoke

softly, and did not try to socialize with other patients that were on the unit. When asking

her about why she is having such a hard time, she began to ramble on with minute details

as a way of explaining everything. It began with when she was two years old, and

suffered a head injury from falling out of a moving car. Although she forgives her mother

for letting it happen, she believes that is what caused her to be the way that she is. Not

only is she bipolar but she also suffers from depression, migraines, chronic obstructive

pulmonary disorder, and emphysema. She did however claim that she is MRDD and that

is why she is unable to keep a job as well as why she needs help. The student nurse

began to try and clarify as to what she would refer to as getting help as well as what

she is looking for, but again, the question was disregarded and she began talking about

something different.

Although the patient was clearly very upset and sad with different stressors in her

life, she seemed almost euphoric. Her son was the main topic of conversation, and when

speaking about him her mood would completely change. She praised him, and spoke

about his childhood as well as every vacation that she took him on, but when her husband

was brought up she would flip back to being saddened. She claimed that my husband

wants to kill me, and said it was due to wanting to claim my insurance money. Her

take on the situation is that she is very depressed and is regretting all of her decision that

she has made in her life. One of these decisions included leaving her family behind to

live with her husband at such a young age, leading to missing spending time with her

father who passed in several years ago. Her stressors that she deals with is mainly having
MENTAL HEALTH CASE STUDY 5

to deal with so many deaths that have occurred in such a short period of time including

her father, mother, aunt, close friend, and other various family members. Of all of the

deaths she has had to deal with, she claims that she is still unable to get over her fathers

passing and that she does not think she will ever be able to accept it. Not only are the

death of her family members causing her stress, but also the stillborn that she had had

before she had her only son. Jane claims that her husband was never there for her, and

that all he cares about is drinking and making my life a living hell.

Jane Doe includes many stressors in her life, that she feels are unobtainable as far

as trying to overcome them. It has been tried in the past to put her on a medication

regimen in order to help treat her depression and bipolar disorder, however she refuses to

follow it. She has run into several problems as far as trying to pay for the medications,

forgetting to take them, fear that her husband would kill her with the pills, as well as not

understanding why she was on them to begin with. Her current medication regimen while

admitted on the psychiatric floor includes psychiatric medications, antihistamines,

anticonvulsant, folic acid, and a diuretic. She is prescribed Abilify (10mg daily and 5mg

nightly) for treatment of her bipolar disorder and to help with the depression. She is

prescribed Flexeril (5mg nightly) to help with pain and stiffness due to some muscle

spasms, as well as Benadryl (50mg three times daily). It is believed and assumed that the

Benadryl as well as the Flexeril are prescribed in relation to possible side effects that may

be caused by the antipsychotic. This assumption was made by the student nurse due to the

observation of continuous tongue movement and lip smacking (possible tardive

dyskinesia), as well as continuous movement by the patient.

MENTAL HEALTH CASE STUDY 6

Summarize

A person having lows and highs characterizes bipolar affective disorder, also

called manic-depressive illness. This states that a person may be feeling very down,

depressed, and sad but then can go to the other extreme of the spectrum and be described

as being manic which means being overly energized, euphoric and compulsive. These

episodes can last as little as a few days to weeks to months to even lasting years in an

extreme high or extreme low. In some cases, which apply to the one in this case study,

psychotic symptoms may also be present. These psychotic symptoms include having

hallucinates or delusions, and Janes fear of her husband killing her confirm that she is

having delusions.

According to Historical Underpinnings of Bipolar Disorder Diagnostic Criteria,

manic-depression as a psychotic disorder is characterized by a varying degree of

personality integration and a failure to test and evaluate correctly external reality in

various spheres (Mason 2016). The article goes it to vast detail of how bipolar disorder

is diagnosed rather than just diagnosing someone with schizophrenia. Sometimes with

bipolar affective disorder, illusions, delusions, and hallucinations may be present which

may lead one to believe that their diagnosis is schizophrenia. However, in Janes case not

only does she present with these illusions, she also shows signs of both a depressive AND

manic episode. This type of episode is called a circular type and occurs when both the

manic and depressive episodes appear simultaneously (Mason 2016). With the

interaction with this patient, it is noticed how she goes from almost a euphoric mood and

then flips suddenly to a more depressed mood which shows how she can possess both

episodes during the larger episode. Although, it is said that mania does not necessarily
MENTAL HEALTH CASE STUDY 7

have to be completely euphoric, it can also be accompanied by Mixed mania: such as

depressive and irritable, rather than the pure (elated) mania (Gershon 2000). Symptoms

such as flight of ideas, physical restlessness, attention easily drawn to irrelevant stimuli

and using family history is suggested to look for when diagnosing someone with an

Affective Disorder (Mason 2016).

Furthermore, this patient has a history and current diagnosis of depression.

Throughout her life she has gone through various situations in which could have

contributed to her depressive demeanor. Sheri Johnsons take on depression in Stress,

Coping and Depression describes that cognitions about the self, world, and the future

as vulnerability factors for depression (Johnson 2000). Such factors could include her

decreased self-esteem and feelings of hopelessness and being unimportant in her son and

husbands lives. Not only does this article hit the nail on the head with Janes depression

but it also states how someone can distort the meaning of events and the

helpless/hopelessness is what leads to serious depressive states (Johnson 2000). Not only

does she feel hopeless, but she sees her life as sad, events such as her fathers death and

her inability to have a good relationship with her mother, as well as her unstable

relationship with her husband have led her into this state of depression. In order to sum of

the disease of depression, it is stated, negative life events and attaching great importance

to personal relationships with others was especially predictive of depressive reactions

(Johnson 2000). Unfortunately, this patient was unable to get over these depressive states,

and it has continued throughout her every day life.

MENTAL HEALTH CASE STUDY 8

Identify

As stated earlier, Jane has various stressors in her life that may have lead to her

recent and possible previous hospitalizations. She claims that she has never really gotten

over her detached relationships between her immediate family such as her mother and

father. Her and her mother were not on good terms due to Jane moving out of her home at

the early age of 18, and that was because her mother did not approve and ended up

severing contact. This had taken a terrible toll on the patients emotional status, because

she said she felt alone and unwanted. She had lost other members of her family as well

as close friends throughout her life in which she stated there were too many to count, but

her father is the death that she took the hardest. There was not enough time for her to

spend with her father, and it was assumed that she was not allowed to see him as often as

she would have likes. This is what she relates to her being so depressed as well her

stillborn child that she lost with her current husband.

A lot of her stressors relate back to her current husband; every story that she had

disclosed seem to go back to the husband as the one to blame for reasonings to be upset.

Her husband has absolute control over her, which led her to behave in the way she did.

She would admit herself to hospitals as a way to get away from him. The behaviors that

she did present with were all in relation to him, and were mostly the behavior of fear and

paranoia. It is without question that she relates a lot of her problems as well as mental

illness to him.
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Discuss

The patient states that her father had a history of alcoholism, but does not recall

any family history of mental illness. She states that she has dealt with her mental illness

for most of her life, and feels that her brain injury at the age of two is the cause. There are

past hospitalizations that she has had in relation to the same problem in which got her

admitted for the current hospitalization at Mercy, although she is unable to state when

and how many times. The patient denies any suicidal attempts but does admit that she has

thought about it but does not have any plan.

Describe

The psychiatric unit at Mercy Health provides the patients with a set schedule that

they must follow while admitted to the floor, in which gives them a sense of structure that

they may not normally have in their lives. Within this schedule includes group therapies,

in which provide the patients a place to discuss their illnesses and any maladaptive

coping mechanisms that they might need to alter. These groups also provide patients with

ways to deal with stress, anger, addiction, problem solving skills, and insight on their

illnesses. In addition to these group therapies, they meet with their psychiatrists, social

work, as well as their nurses to speak about any issues as well as providing them with

addition education on their illnesses, and bring them back to reality.

Analyze

The patient denies any social or ethnic restrictions on her life. She states that she

is Christian and fully believes in her faith, but does not attend church regularly and has

not been there for many years. With her fathers history of alcoholism, it is possible that

she may also submit to the same addiction. She admits that she does drink quite
MENTAL HEALTH CASE STUDY 10

occasionally with friends but states that she does not feel like she wouldnt be able to not

go without a drink for a day. Her husband is also a very heavy drinker, so it can be

assumed that she is surrounded by a lot of people who drink that are close to her.

Evaluate

Patient will verbalize stressors in her life. Pt will verbalize understanding of

illness. Pt will remain free of injury during hospital stay. Pt will verbalize any suicidal

ideation. Pt will interact adequately with others. Pt will demonstrate a normal sleep patter.

Pt will voluntarily submit to prescribed medication. Pt will define and explain acceptable

behaviors. Pt will admit to maladaptive coping mechanism and in return state more

efficient coping techniques. Pt will select activities and hobbies that she may feel will

help with self-esteem. Pt will engage in goal-directed activity. Pt will verbalize short-term

and long-term goals. Pt will identify and verbalize two people she feels can help during

an emotional period.

Summarize

The patient will participate in group therapy throughout admittance until

discharged from the hospital, as well as perform coping techniques that she has learned

from the therapy. The groups will also help with an acceptable atmosphere to discuss her

illness and to gain insight from other patients who may be going through the same thing.

The patient will also submit to education on her medications as well as keeping a

therapeutic medication regimen and provide any concerns as to why she would be unable

to do so. Her medication regimen for her psychiatric disorder would include Abilify,

Flexeril, Desyrel and Depakote (clarification of all these anti-depressants prescriptions

are pending). Plans of placement for discharge include going to a disabled family home
MENTAL HEALTH CASE STUDY 11

(per patient request) or that be discharged to a womans shelter. Acceptances to these

facilities are still pending and unable to be a definite place of stay.

Prioritize

Risk for suicide r/t impaired cognition AMB verbal suicide ideation without plan.

Ineffective coping r/t inadequate social support AMB abusive husband and no living

relatives. Ineffective health maintenance r/t lack of ability to make good judgment AMB

unkempt appearance, not following medication regimen. Powerlessness r/t dependence

on others AMB depending on husband to have sufficient living and submitting to group

homes. Disturbed sleep pattern r/t manic episode AMB decreased hours of sleep.

Impaired social interaction r/t disturbed thought process AMB discomfort in social

situations and dysfunctional interaction with others. Social isolation r/t alterations in

mental status AMF delusions, insecurity, and sad affect.

List

Ineffective activity planning r/t unrealistic perception of events. Risk-prone health

behavior r/t low state of optimism. Disturbed energy field r/t disharmony of mind, body,

spirit. Ineffective health maintenance r/t lack of ability to make good judgments regarding

ways to obtain help. Self-care deficit r/t depression, and cognitive impairment. Chronic

low self-esteem r/t repeated unmet expectations. Social isolation r/t ineffective coping.

Risk for complicated grieving r/t lack of previous resolution of former grieving response.

Risk for loneliness r/t stress, conflict. Risk for suicide r/t psychiatric disorder and poor

support system. (Ackley et. al 2014)

MENTAL HEALTH CASE STUDY 12

References

Johnson, S. L. (2000). Stress, coping, and depression. Mahwah, NJ: L. Erlbaum

Associates.

Soares, J. C., & Gershon, S. (2000). Bipolar disorders: Basic mechanisms and

therapeutic implications. New York: Marcel Dekker.