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Mental Health Case Study

Caliope Gialousis

YSU Mental Health Nursing Clinical

Abstract

This case study explores the situation of an 18 year old woman admitted to Trumbull Memorial

Hospital with major depressive disorder, cluster B personality disorder, and severe anxiety.

Information was collected using observation, interview, and clinical data. The purpose of this

study is to understand the individual’s case in order to provide proper care. In this study, the

focus is on the individual’s psychiatric diagnosis, mental health history, current stressors and

behaviors, influences on the patient, and potential nursing diagnoses. Ethical, cultural, and

spiritual concerns will also be discussed.

Objective

S.A. is an 18 year old female who presented to Trumbull Memorial hospital on January

26, 2019 due to self-harm relapse after being released from Generation Psychiatric Hospital on

January 24. She presented to the ED by herself with open wounds to her arms stating she had to

do this because “cutting is the only way the pain and voices will stop.” She stated she feels

worthless and cutting is her only effective coping mechanism. Her behavior was noted as

eccentric and provocative when in the presence of males. Her toxicology report came back

positive for marijuana, but all other labs came back negative or within defined limits. She was

pink slipped and transferred to the psychiatric unit. Her psychiatric diagnosis, according to the

physician using the multi-axial system of the Diagnostic and Statistical Manual or Mental

Disorders IV: Text Revised (DSM-IV-TR) was: Axis I - severe major depressive disorder with

anxiety, Axis II - cluster B personality disorder, Axis III – seizures, pseudotumor, and asthma,

Axis IV - homelessness, unemployment, and lack of education, and Axis V - GAF score 51-60,

presenting moderate symptoms. Though not diagnosed, the patient also believes she has multiple

personalities that she can bring forth on command.

On January 29, 2019, the date of care, my first interaction with the patient was in a group

setting. The patient was very eccentric and immature. She was loud and seemed to be seeking

attention from all the members of the group. After the group, I was able to interact with the

patient one on one. During the more personal encounter, her communication was clear and

effective, and she was able to hold a conversation while properly answering all questions. She

was much more calm and mature than our first encounter and she was very friendly. Her facial

expression was animated and her gestures and posture was relaxed with a pleasurable affect. The
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patient was neatly dressed, but her hair was unkempt.

On that day, she was being treated for her psychiatric conditions and her medical

conditions. As listed above, her medical conditions are seizures, asthma, and a pseudotumor.

Her seizures were being treated with 150 mg of Trileptal twice a day and seizure precautions.

The asthma was under control and only treated as needed with albuterol. The patient had open

wounds from cutting herself that were being treated with Neosporin daily and 650 mg of Tylenol

as needed for pain. Her psychiatric conditions were being treated with a variety of medications.

Trazadone 100 mg was prescribed QHS daily. This is an SARI antidepressant being used as a

sleep aid. Celexa, an SSRI antidepressant, was used for the treatment of the patient’s major

depressive disorder. She was prescribed 20 mg daily. PRN medications were also prescribed. 5

mg of Halodol (antipsychotic) was available for the treatment of agitation and 50 mg of Atarax

(antihistamine) was available for anxiety. Since the patient was admitted with self-harm, certain

measures were put in place. The patient was placed on unit restrictions as well as self-harm

precautions. Safety was maintained by reducing the risk of self-harm by removing all potentially

hazardous items, doing a visual check on the patient every 15 minutes if the patient was not in an

open area, and locking all doors. There are also measures and standards in place in the case of an

emergency.

Summarize

The patient had two main psychiatric diagnoses, major depressive disorder and cluster B

personality disorder. According to Townsend (2017), depression is an alteration in mood that is

expressed by feelings of sadness, despair, and pessimism. There is a loss of interest in usual

activities and somatic symptoms may be evident. Changes in appetite and sleep changes are
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common. Major Depressive Disorder (MDD) is one of the leading causes of disability in the

United States. Townsend states, “MDD is characterized by depressed mood or loss of interest or

pleasure in usual activities. Evidence will show impaired social and occupational functioning

that has existed for at least 2 weeks, no history of manic behavior, and symptoms that cannot be

attributed to the use of substances or a general medical condition.” Cluster B personality disorder

is a grouping of disorders. According to the Diagnostic and Statistical Manual of Mental

Disorders, fourth edition, Text Revision (DSM- IV-TR) (American Psychiatric Association

2000), cluster B-PD includes the borderline, antisocial, histrionic, and narcissistic types. Persons

with cluster B-PD often appear dramatic, emotional, and erratic (Mergui, 2015). Townsend

(2017) characterizes all four disorders. Borderline as a pattern of intense and chaotic

relationships, with affective instability and fluctuating attitude toward other people. Histrionic is

characterize by colorful, dramatic, and extroverted behavior in excitable, emotional people.

Narcissistic persons have an exaggerated sense of self-worth. They lack empathy and are

hypersensitive to the evaluation of others. Antisocial is characterized by a pattern of socially

irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of

others.

Identify

This patient has a long list of precipitating factors since childhood that may have led to

her current admission and diagnoses. The patient was taken from her mother at a young age due

to lack of care related to drug use. After being taken, she was placed in foster care with her aunt

and uncle in North Carolina. While in their home she suffered emotional, physical, verbal, and

sexual abuse. According to the patient, her depression began in this home. She was unable to
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finish high school because of her situation. After being with them for 9 years, she ran away. She

came to Ohio in hopes of reconnecting with her mother, only for her mother to turn her away. In

a study conducted by the Department of Psychology at the University of Saragodha, Ashiq et. al

(2018) found that childhood traumatic experiences have a significant impact on cluster B

personality disorder. The study supports findings that indicate that childhood traumatic

experiences are risk factors for a wide range of personality disorders. She is now homeless,

uneducated, and unemployed. Due to her lack of resources she has trouble with medication

management and does not have many coping skills. Her only coping skill is self-harm. The

patient feels that by cutting herself, she is releasing her emotions and the voices she hears. The

patient is aware that she is not coping properly and does not have the means to fix her mental

state by herself so she came to the hospital to seek help.

Discuss

The patient’s history of mental illness goes back to her early childhood. She stated she

has been depressed since being taken from her mother and placed in foster care. She had a single

past suicide attempt while she was still in North Carolina and was placed in Holly Hill Hospital.

She received treatment and was released. After coming to Ohio, she sought care at Generations

Hospital for her depression and self-harm. She was placed on IOP at St. Elizabeth’s Hospital

prior to her admission to Trumbull Memorial Hospital.

She states her family have a lengthy history of mental illness, a lot of which has went

undiagnosed and untreated. The patient does not know her father’s history due to lack of

relationship but believes he is an alcoholic. Her mother has a long history of addiction that she is

still battling. Her mother was also diagnosed with bipolar depression and anxiety. Her
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grandfather on her mother’s side was also an addict. While undiagnosed, she believes her uncle

suffers from anger problems and other personality disorders. Her sister suffers from severe

anxiety and panic disorders. She did not specify, but she stated there are numerous other people

in her family who suffer from depression, bipolar, anxiety, and addiction. The patient states she

was not the only person in her family who suffered from abuse. She said there is a long running

cycle of people being abused and then becoming abusers themselves. The patient hopes that by

seeking help she can break these cycles.

Describe

Implementing evidence-based practices in routine mental health care settings is a

complex process involving coordination of local, state, and national stakeholder groups (Peterson

et. al, 2013). There are constant examples of evidence based care on the psychiatric unit. On this

shift, crisis intervention techniques were implemented, psychodynamic therapies and stress

management were offered, and safety protocols were used. The nurses provide counseling,

administer medication, evaluate treatments, and facilitate group therapy sessions. While my

nursing care as a student on the floor is limited, I was able to provide therapeutic conversation

and encourage the patient to go to group and participate in activities.

The patient was very involved in group activities. She attended both group sessions that

occurred while we were on the floor. It was also noted in morning report that she had been

participating in all previous group sessions as well. While in group, the patient answered every

question and had a response to everything that the group leader said. Even though participation is

encouraged, the patient’s over the top responses and attention seeking behaviors can be attributed

to her diagnosis of cluster B personality disorder. She was very friendly with all the nurses and
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her peers, but developed overly friendly and flirtatious relationships with males on the unit,

which is also a characteristic of her cluster b diagnosis.

Analyze

This patient is an 18 year old Caucasian female. She is unsure of her ethnicity but

believes her mother is German. She does not know her father, so she is not sure of his ethnicity.

She only knows that he is Caucasian as well. According to her, she did not grow up with many

spiritual or cultural influences. She believes in a higher power, but she is not sure of what that

being may be. She was never taught about religion and has only went to church a handful of

times in her life. According to her, most of her life she felt alone so never had any sort of culture

or behavioral patterns transmitted to her from those around her. However as mentioned earlier,

she does feel that she grew up around a culture of abuse. This is the only thing she can think of

that has been passed on amongst her family.

Evaluate

On the day of care, the patient stated she is feeling better than when she came to the the

emergency department on the day of admission. There are numerous outcomes that the patient

needs to meet in order to be restored to mental well-being. Unfortunately, the patient is only on

this unit for a short period of times so there are only so many outcomes that can be met during

this time.

Some outcomes that were met include:

 Patient will seek help when experiencing self-destructive impulses

 Patient will participate in one activity by the end of the day

 Patient will give an accurate and nonjudgmental account of four positive qualities as well

as identify two areas he or she wishes to improve

 Patient will demonstrate compliance with any medication or treatment plan within the

next two weeks

Some outcomes that were not met include:

 Patient will identify at least two-three people he/she can seek out for support and

emotional guidance when he/she is feeling self-destructive before discharge

 Patient will demonstrate alternative ways of dealing with negative feelings and

emotional stress

 Patient will learn impulse control

Summarize

Upon discharge the patient is planning on going to stay with a friend until she is able to

get back on her feet. Immediately after discharge, she will begin IOP through St. Elizabeth’s and

will be seeing a counselor. She plans on taking advantage of resources offered to help here with

medication adherence. Her long-term goals after discharge include getting her GED and starting

a job. She hopes to get her mental health restored so that her day to day life becomes easier. She

does not want to have to rely on others in the future to help her live the kind of life she wants to

live. She is motivated to better herself and hopes that outpatient therapy will continue to help her

learn new coping mechanisms so that she no longer wants to cut herself to relieve her symptoms.

She understands that she is diagnosed with a personality disorder that cannot be treated with

medication, so she knows that she will have to go through cognitive therapy on an outpatient

basis to help with the way she thinks.

Prioritize

1. Risk for suicide r/t impulsiveness and attention seeking behavior

2. Risk for self-directed violence r/t feelings of sadness

3. Ineffective coping r/t inadequate social support

4. Chronic low self-esteem r/t impaired cognitive self-appraisal

5. Self-care deficit r/t depression

List

 Anxiety

 Disturbed sleep pattern

 Fear

 Hopelessness

 Imbalanced Nutrition: Less than body requirements

 Ineffective role performance

 Powerlessness

 Risk for injury

 Social Isolation
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Conclusion

S.A, a patient diagnosed with major depressive disorder and cluster B personality

disorder, has been suffering from mental illness for many years. She has faced hardships

throughout her life that may have played a role in the development of her conditions. She is

working on finding the means to cope with these problems and progress to a better self. Her

goals include learning effective coping mechanisms, finding helpful resources, and medication

adherence. It will be a long road ahead for this patient, but I hope she is able to get better and

live the life she is so badly longing for.

References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An evidence-based guide

to planning care (10th ed.). Maryland Heights, MO: Elsevier.

Ashiq, A. & Riaz, M. (2018). Direct and indirect effects of childhood traumatic experiences on

cluster B personality disorders in adults. Pakistan Journal of Medical Research, 57(4),

160-164.

Mergui, J., Raveh, D., Gropp, C., Golmard, J., & Jaworowski, S. (2015). Prevalance and

characteristics of cluster B personality disorder in a consultation-liaison psychiatry

practice. International Journal of Psychiatry in Clinical Practice, 19: 65-70.

Peterson, A., Bond, G., Drake, R., McHugo, G., Jones, A., & Williams, J. (2013). Predicting the

long-term sustainability of evidence-based practices in mental health care: an 8-year

longitudinal analysis. Journal of Behavioral Health Services & Research, 41(3), 337-346

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

practice (7th ed.). Philadelphia: F.A. Davis.