Running head: DANCING WITH PSYCHOSIS 1

Dancing with Psychosis

Samuel Kooyman

Nursing: 4842L: Mental Health Nursing

Professor: Michael Criscione

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Abstract

The basis for all interventions in mental health starts with understanding how the

mind operates and being able to address various scenarios. In looking at different patient

conditions, it is evident that disorders of the mind tend to be more arduous to treat effectively

than others. However, psychosis in particular carries implications outside the realm of reality in

which a client struggles to differentiate thoughts from the real world. In fact, finding an underline

cause for the condition relates back to other mental issues such as schizophrenia, depression and

bipolar one disorder. By identifying a cohort cause for the disruption of mental processing, it

becomes all the easier to provide adequate treatment to the patient experiencing psychosis.

Therefore, this study investigates the borderline and abstract conditions revolving around the

mental diagnosis of psychosis in a client with multiple other disorders. A breakdown of

psychosis and the stressors related to the disease such as family issues are portrayed to be

addressed. Evidence summarizing the key aspects of treatments, evaluations and continued care

are discussed throughout the study. The collection of work gives an in-depth overview of how

psychosis can be diagnosed and treated to provide a better outcome for patients struggling with

conditions of maladaptive mental health.

Keywords: Psychosis, schizophrenia, bipolar one disorder, hemoglobin, hematocrit,

prothrombin time, cannabis, milieu, and major depression.

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Dancing with Psychosis

The proper treatment for patients with mental health disorders ranges greatly based upon

all aspect of wellness, not just the mind. Although most health conditions can be treated to full

extent, psychiatric issues tend to be quarrelsome. A diagnosis of psychosis acts in accordance

with other disorders of the mind which in return distort reality. Yet, a “Earlier diagnosis of

psychosis improves long-term outcomes” (MacGill 2017 p.1) in patients who actively seek

treatment. Hence, there is a constant need for intervention and treatment plans to aid those

patients and get them back to a state of balance.

Objective Data:

To start, this study involved observing and interacting with a patient admitted on

September 20, 2019 to Saint Elizabeth’s Youngstown campus hospital. The client termed J.H.

was assigned on September 24, 2019 and appeared very enthusiastic at meeting with student

nurses. However, before any interaction took place out in the common room of the unit floor

chart reviews were conducted. A breakdown of the entire patient’s record was looked over and

studied to get a more in depth understanding of what the problems were that brought him to the

metal health unit. In the charting for the patient it was indicated that J.H. was diagnosed with

psychosis in relation to a variety of previous mental health disorders. Therefore, there was a need

to seek background history on past admissions and recover a few other characteristics revolving

around the most recent hospital visit. Listed in past medical history was a comprehensive panel

of previous diagnoses and admission reasons. The patient presented to have multiple mental

health diseases which included schizophrenia, major depression and bipolar one disorder. These

in conjunction with the current disorder of psychosis led to a relapse in condition and a return to

the psychiatric floor.

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In further investigation before and after meeting with the patient it was discovered that

his disease is not prevalent without a “partner in crime” per say. A specific understanding to what

complexities psychosis emerges from is not known and “There is no biological test for psychosis

itself, and if laboratory tests are done, it is to rule out other medical problems that might provide

an alternative explanation” (MacGill, 2017 p. 5). As a result, it has been deemed that for J.H. that

schizophrenia specifically led to a decline in functioning.

The prevalence of multiple functional delays called for lab tests to be conducted along

with other treatment plans. Based on the patient’s lab results from his current admission it

showed evidence of decreased hematocrit, hemoglobin, and prothrombin time levels. A decrease

in the levels of these imperative blood components brings about the question as to why. A few

possibilities relate to side effects of medication, drinking and admittance of the patient cutting

himself. In addition, the patient tested positive for cannabis and admitted being an avid

marijuana smoker. The combination of these tests plays a critical role in identifying some

underlying causes to the patient’s behaviors.

In meeting with J.H. after the initial breakdown of his chart assessments it was interesting

to see a man who was very composed and intellectual. The presence of flight of ideas and

hallucinations became apparent as questions were asked to convey his recent admittance to the

unit. To add, he was very irrational and had disrupted interpretations of reality based on his

stories and future outlook. Therefore, treatment and security measures associated with him

focused on smoking cessation, compliance and educating. He was also prescribed a few

medications such as amlodipine, carbamazepine and paliperidone to help treat his bipolar and

schizophrenic symptoms. By having established ground through interaction, it became easier to

get a full understanding of his psychosis and identify factors associated with it.
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Summarize the psychiatric diagnoses:

The patient presented to the psychiatric floor with psychosis and had previous diagnoses

of schizophrenia, major depression and bipolar one disorder. Although the diagnosis of psychosis

carries with it a variety of other mental health issues, it becomes complex to explain on its own.

However, the Diagnostic and Statistical Manual of Mental Disorders defines psychosis as “Gross

impairment in reality testing or “loss of ego boundaries” that interferes with the capacity to meet

the ordinary demands of life” (Arciniegas, 2015 p. 2). In return it can be expected that a patient

with this diagnosis would experience flight of ideas, hallucinations and loss of reality. More

specifically, J.H. experienced episodes of agitation, delusions and talking to himself.

Another prudent diagnosis the patient had was schizophrenia which is summarized as a

breakdown in the relation between thought and reality. This disease correlates most with

psychosis due to the behavioral outcomes associated with it. An example related to J.H. would be

him claiming “I saw Jesus at lake Girard, and he stood there with his head down disappointed in

me,” leading him to become a man of faith. In addition, he also had diagnoses of major

depression and bipolar one disorder. These findings play a part in the mood aspect of a person

from day to day. With depression a patient can become very isolated and have suicidal ideations

along with hopelessness in life. J.H. had major depression after finding out about a murder in his

family where he became enraged which led to him cutting himself daily. As for bipolar one

disorder, it tends to correlate with episodes of mania and depression. Patients with this diagnosis

have periods of extreme energy and then may have severe regression. Therefore, it is important

to face each diagnosis at its core and establish ways to treat the problem.

Identify the Stressors and Behaviors:

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J.H. has a long history with admittance to the psychiatric floor for a wide range of

reasons. In the most recent case, he was brought in by the Girard police department due to a

public disturbance. According to the notes he was dancing in the street with a hammer and a

foam pumpkin. At one-point neighbors said he threw real pumpkins at cars as they drove down

the street. Once the police arrived, he was yelling about the four horsemen and praying to Jesus

for guidance. After being brought to the hospital he called the cops “pigs” and attempted to put

hands on them so that he could pray away their sins.

This behavior when asked was precipitated by just wanting to have a good time and

listening to some rock music. J.H. then mentioned about the murder in his family and the falling

out of those close to him. A series of depression and other psychological weights brought about

the defiance and acting out. In talking about stressors that trigger these behaviors he claimed that

without marijuana he feels lost and has visions of Jesus telling him what to do. It is clear that

family tragedy and lack of support is the defining characteristic in J.H.

Discuss the patient and family history of mental illness:

In talking with J.H. about his medical history and past experiences, it is obvious to

anyone from the outside looking in that tragedy played a crucial part in his mental illness. As

mentioned previously, he had a family member very close with him get stabbed to death by

another family member. It can be assumed that some of the family has a genetic predisposition to

mental illness due to the circumstances at large. There is no record of anyone older in his family

lineage having a psychiatric problem or acting out inappropriately, so J.H. is the first to express

this foreign behavior. Yet, a research study highlights that “Genetic epidemiological data [is]

beginning to favor the view that schizophrenia, bipolar disorder, and schizoaffective disorders
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share at least some genetic liability” (Owen, 2007 p. 6). No matter the case, it is critical that

those with mental illness be treated properly whether they have a family history or not.

Describe the psychiatric evidence based nursing care provided:

The principle of milieu therapy in relation to nursing care for those with psychiatric

illness revolves around promoting a healing environment for all. There is a variety of different

approaches to establishing evidence-based nursing care in this field to help tackle prominent

diagnoses. For example, the nurse’s practice with the patient’s communication skills, promoting

client autonomy, and holding one’s self accountable along with many more techniques. One of

the most noticeable principles of milieu therapy is the fact that “Every interaction is an

opportunity for therapeutic intervention” (Psychiatric, 2019 p.2). A primary goal for the nurse’s

is to teach about controlling one’s temper when faced with a conundrum that may present itself

as a stressor. Distinct aspects of nursing care have developed over the years and research-based

practice has set guidelines on effective treatment plans. Having set goals, direction and a

structured environment helps cultivate a holistic atmosphere for mental health resolution.

Analyze ethnic, spiritual and cultural influences:

Communicating with the patient brought to light just how religious his mental illness has

made him. There were multiple points in conversation where J.H. would take time to pray and

address Jesus as his savior. With tragedy being indisputable in his life, there is no real question as

to why his faith is at a pinnacle level. However, the way he displays his spiritual practices are

outside the accepted norm in society which in return landed him in police custody. According to

the report, J.H. was dancing in the street with a hammer and chanting about the four horsemen of

the apocalypse. His behaviors gradually progressed to the point of endangering others and

himself. Once the cops made it to the scene, they were confronted by him saying “Crucify me”
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and receiving other taunts. A side note from the arrest is the fact that the patient mentioned

seeing Jesus and God before at various points in his life. Obvious signs of hallucinations from

schizophrenia are present which have caused him to believe in communicating with a higher

power. In addition, cultural and ethical factors have played a role in his cognitive development

through means of expression.

The patient has a European background and was raised up as a Catholic, but for a period

of time admitted being an atheist. A series of unforeseen events led to J.H. having severe

depression and turning to maladaptive coping mechanisms. He claims that his parents and

grandparents smoked marijuana on occasion, so he picked up on the habit. To add, the client

factored in alcohol and turned to cutting himself when the stress escalated. All factors considered

he veered to faith and now accepts Jesus as his savior. Therefore, past experiences and cultural

practices greatly influenced J.H. throughout his life.

Evaluate the patient outcomes:

With any treatment plan comes the need to evaluate patient outcomes both during and

after the hospital stay. In this case, a regimen of medication and tobacco cessation are the

primary focuses in the care plan. J.H. claims that the medications have been helping with his

mood, but he would rather just smoke to stay mellow. The patient stated to smoking around an

ounce of weed a week and being able to function just fine. It was brought to his attention that

reducing or quitting cannabis would aid in the recovery process and promote the medication to

work more effectively. The medications prescribed like carbamazepine and paliperidone are used

to treat the client’s conditions and bring him back to a relatively normal state of functioning. By

providing a stable environment and encouraging group therapy sessions, J.H. can hopefully
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receive the balance he needs in life to be a prosperous citizen. Overall, the goal is to provide

achievable outcomes that the patient can obtain through the treatment plans assigned to him.

Summarize the plans for discharge:

Discharge planning revolves around assuring a stable mind set and preventing

readmission to the mental health unit. The goal for all psychiatric patients is to promote wellness

above dysfunction. J.H. has an indubitably unstructured path ahead due to very little support

from outside resources. This alone makes the discharge planning more difficult because having

structure is a key aspect to successful home life. Group therapy sessions and counseling greatly

aided J.H. in his expression of thoughts and concerns. The need to follow up with counseling

may prove pivotal in keeping him from readmission.

Another discharge plan focuses on smoking cessation because hallucinations and

“magical thinking” are exponentialized when he smokes marijuana. A habit can be arduous to

break and J.H. giving up smoking seems unlikely. Having smoked for over 20 years has made

weed second nature to his daily living routine. The hospital staff has formulated that with

teaching and a will to change, that one day quitting marijuana may be possible. With all things

considered, the discharge planning factors in the patient’s primary outside precipitators to his

illness. By incorporating those goals with the prescribed medications, it is hopeful that J.H.

improves his conditions.

Prioritized list of all actual diagnoses:

A combination of diagnoses have been assigned to J.H. from clinical observation and

other tests. The primary being psychosis because of a pyramid of other symptoms causing a

fluctuation with reality. This condition must be broken down into individualized components

before any treatment can be personalized. Once subcategories are identified a concise list of
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diagnoses can be attributed to the problem. J.H.’s schizophrenia is the most dominant mental

problem due to hallucinations and altered reality.

Schizophrenia is a mental disorder that deals with an imbalance in dopamine levels. As a

result, mood along with perceptions of reality may be altered. Another major problem that falls

just below the other two is major depression. Depression causes isolation and instable moods

which are expressed through multiple outlets in daily living. Although this can be treated in most

cases, it is prudent that these clients are observed closely because of an increase in energy when

on a medication regimen. The boost of moral may lead to one caring out a suicidal ideation and

therefore it is important to educate patients about the risks.

The last diagnosis that J.H. had that should be prioritized for care is bipolar one disorder.

This condition is best broken down by episodes of mania and depression. Having to adjust

treatments based on what symptoms are currently being displayed is a key point in stabilizing a

client. Once goals are made to correct underlying issues, progress towards bringing patients just

like J.H back to adequate functioning can be achieved.

List of potential nursing diagnoses:

Potential nursing diagnoses that relate back to the conditions the patient is displaying can

be formulated by looking at overall functioning. Therefore, factors such as disturbed social

interaction related to impaired thought process as evidence by exaggerated faith practices and

chanting may be coherent with the patient’s schizophrenia. Another label could be disturbed

sensory perception related to psychological stress as evidence by hallucinating Jesus. These odd

behaviors are not social norms and therefore tend to be scrutinized by those from the outside

looking in. Psychosis is a compound mental health disorder that incorporates multiple other

conditions into the overall diagnosis.

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In the case of J.H., major depression and bipolar one disorder are the two main

contributors to his behavior. A few nursing diagnoses that go along with these revolve around

hallucination, injury and social isolation. The risk for injury related to rage reaction as evidenced

by cutting his arms is a priority because of self-mutilation concerns. Any patient with major

depression is at an increased risk for suicide and social isolation because of impaired cognitive

thought processes. To add, he has a risk for interrupted family processes related to erratic

behavior as evidenced by dancing in the street with a hammer. All things considered, the

possibilities for nursing diagnoses seem endless based on his observed condition.

Conclusion:

In reflection of the clinical experience and this case study, a plethora of knowledge was

gained focusing on mental health issues as a whole. J.H. had multiple diagnoses which all

showed in some degree during the interview process. Listening to the stories and reason for

admittance to the unit was the first sign implicating psychosis. Having observed the basic

psychiatric issues in a person is vastly different than seeing them in movies or books. Directly

talking to patients with mania and schizophrenia as an example really show how the use of

therapeutic communication allows for learning to take place. The engaged clients benefit the

most from social contact that associates norms with daily living. In return, the nurse along with

the patient are able to benefit in each their own way towards achieving a goal. Identifying the

prevalent disorders and learning about how they interfere with an individual also allowed for

empathy and a cause to understand one’s train of thought.

In doing some metacognition about the case study, both knowledge and professionalism

were gained through the experience. Mental health as whole is a fascinating field which offers a

different take on nursing care. Having the chance to further investigate for a causation is always
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rewarding in the sense of improving on one’s skills. The opportunity to further investigate into

J.H.’s case would undoubtably bring about more situations where he was garrulous with others

and acted out of the ordinary. In return making this study all the more informative and the

experience even more rewarding for future development. With any beginning there is an end, and

hopefully one day the mental health crisis will be a thing of the past. In sum, sometimes the

worst place a person can be is in their own head, so having an outlet for support is crucial in

ensuring stability no matter the situation.

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References

Arciniegas, D. B. (2015, June 21). Psychosis. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455840/.

MacGill, M. (2017, December 14). Psychosis: Causes, symptoms, and treatments.

Retrieved from https://www.medicalnewstoday.com/articles/248159.php.

Owen, M. J., Craddock, N., & Jablensky, A. (2007, June 5). The genetic deconstruction of

psychosis. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2632314/.

Psychiatric Nursing. (2019, May 21). Retrieved from

http://currentnursing.com/pn/milieu_therapy.html.
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