SCHIZOAFFECTIVE BIPOLAR CASE STUDY 1

Schizoaffective Bipolar Case Study

Katelyn Dustman

Youngstown State University

SCHIZOAFFECTIVE BIPOLAR CASE STUDY 2

Abstract

This case study is based on a patient with Schizoaffective Bipolar disorder. The patient, P.H. , a

fifty-two year old male was pink-slipped due to delusions and manic symptoms. This case study

will discuss objective data, a summary of the psychiatric diagnosis, stressors and behaviors that

lead to hospitalization, patient and family history of mental illness, evidence based nursing care

provided, ethnic and spiritual influences impacting the patient, patient outcomes, plans for

discharge, list of actual and potential nursing diagnoses, and a conclusion.

Keywords: Schizoaffective Bipolar Disorder, psychiatric nursing, evidence based care,

mental illness
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Schizoaffective Bipolar Case Study

Objective Data

P. H. a fifty-two year old male was admitted to the psychiatric inpatient unit at St.

Elizabeth’s Youngstown on March 1st, 2021. The patient came to the hospital via ambulance for a

Chronic Obstructive Pulmonary Disorder (COPD) exacerbation. They were then pink-slipped in

the emergency department because of delusions, manic symptoms, and report of being off

psychiatric medication for one year. The patient’s psychiatric diagnosis was Schizoaffective

Bipolar Disorder and they were currently in a manic phase. Lab results showed the patient was

positive for cannabinoid use. P. H. admitted to the use of marijuana on a daily basis. There were

no TSH or T4 labs drawn and patient’s psychiatric medications did not warrant a lithium level so

it was not drawn. Medications the patient was prescribed included divalproex (Depakote) –

manic symptoms, haloperidol (Haldol) – agitation, hydroxyzine (Vistaril) – anxiety, paliperidone

(Invega) – schizoaffective symptoms, and trazadone (Desyrel) – insomnia. On the date of care

(March 5th , 2021) the patient was animated, neatly dressed and groomed, and very restless

(akathisia). He displayed circumstantial thinking with delusions of grandeur and religion. He

denied any hallucinations. When conversing with the patient he explained that he was God and

that his adopted daughter’s sons were the son of God and the holy-spirit but they were too young

to understand it yet. When trying to reorient the patient he stated that everyone tries to tell him

that he’s not God but they are wrong. Then when I tried to distract the patient using

games/activities or a change in conversation topic the patient would always revert back to talking

about his delusion. I was able to get the patient to discuss some of his childhood with me. He

reported that when he was a young boy he always played with girl toys and that his mom was

fine with it. One day he said he wanted to wear a very girly outfit to school and his mom told
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him no he needed to wear boy clothes and made him change. When he got home from school that

day all his girl toys were gone and replaced with boy toys. The patient also reported being

sexually abused by a male close family friend. The patient then went back to discussing how he

was God.

Summarize the Psychiatric Diagnoses

Schizoaffective Bipolar Disorder is a mixture of schizophrenia and bipolar symptoms.

People with the disorder can experience both mania and depression usually accompanied by

psychotic symptoms associated with schizophrenia.

The mayo clinic describes schizophrenia:

Schizophrenia is a serious mental disorder in which people interpret reality abnormally.

Schizophrenia may result in some combination of hallucinations, delusions, and

extremely disordered thinking and behavior that impairs daily functioning, and can be

disabling. People with schizophrenia require lifelong treatment. Early treatment may help

get symptoms under control before serious complications develop and may help improve

the long-term outlook. (2020)

Some signs and symptoms they identify for schizophrenia are delusions, hallucinations,

disorganized thoughts, and negative symptoms (Mayo Clinic, 2020).

Bipolar disorder is characterized by periods on mania and periods of depression. During

periods of mania a person experiences hyperactivity, disorganized thinking, insomnia, euphoria,

and are easily distracted. Depression on the other hand causes a person to have a severe lack of

energy, anhedonia (inability to feel pleasure), loss of interest, frequent napping or sleeping for

long periods of time, feeling hopeless, suicidal ideations, and feelings of sadness and/or anxiety.
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Identify Stressors and Behaviors

P. H. reported that he was unable to refill his medications for a year because of the

pandemic. He stated that he was unable to get an appointment with a doctor to get the refill. The

patient initially came to the hospital for a COPD exacerbation but was pink-slipped due to

psychotic symptoms. However the patient reported that he was in the psychiatric unit voluntarily

and stated he came in because he was feeling overwhelmed and needed a “sabbatical” before he

opens his new church.

Discuss Patient and Family History of Mental Illness

The Patient and family history of mental illness is not very clear for this patient. He

reports being seen at other psychiatric facilities but there were not any listed in his electronic

medical record (EMR). The patient reports no family history of mental illness and nothing was

noted in his EMR.

Describe Psychiatric Evidence Based Nursing Care Provided

There was a variety of psychiatric evidence based care provided to the patient. One

example I mentioned previously is the way to care for a patient experiencing delusions. It is

important to first try and reorient the patient and tell them the delusion is not real. This is

important because to the patients these delusions are very real and they can have a hard time

separating delusion from reality. If reorientation does not work we then move on to distraction. It

is important to only reorient the patient once because they might get frustrated if they are

constantly being confronted about their delusion. Some different distraction techniques include

changing the topic of conversation, playing a game, drawing, watching television, etc. In the case

of this patient he was unable to be reoriented and he did not want to be distracted. I suggested

playing a game, drawing, and changing the subject of conversation but the patient always circled
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back to talking about his delusion. Another example of evidence based care was having the

patient in the milieu. This can help because sometimes the other patients will point out the fact

that the patient’s delusion is not real. This can be better than the nurse doing this because it is

less threatening and confrontational to the patient. Another example of evidence based care was

providing the patient with areas that are less stimulating like their room for example. This was

helpful because the patient was in a manic phase so having an abundance of stimuli can

exacerbate their manic symptoms. Similar to decreasing external stimuli, empowerment was

used for this patient. Beyhan Bag decribed that, “The empowerment approach consists mainly of

counseling and social support for individual. The main goal is to keep the mentally impaired

person away from stressful life situations” (2021, p. 371). Stefan Scheydt, Maria Müller Staub,

Fritz Frauenfelder, Gunnar H. Nielsen, Johann Behrens, and Ian Needham discussed how

patients with mental illness can have difficulty filtering stimuli/stress and coping with it. They

stated, “For people with low filtration capacity or lack of coping resources, stress reactions can

be the result of sensory overload. These reactions can manifest themselves in ineffective

behaviors such as social isolation or aggressive behavior” (2017, p. 111). Therefore, it is

important to try to keep the patient away from stressful situations and an abundance of stimuli

until they are stabilized. In the case of this patient it was very important because when he began

to feel overwhelmed he would become aggressive. A final example of evidence based care is the

prescription of hydroxyzine (Vistaril) and paliperidone (Invega). These two medications are

antipsychotic medications used to treat schizoaffective disorder.

Analyze Ethnic, Spiritual and Cultural Influences

Eva Ouwehand, Arjan W. Braam, Joannes W. Renes, Hanneke J. K. Muthert, and Hetty T.

Zock discussed the role religion plays in psychiatric patients. They concluded:
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The role religion plays in relation to mental health can be ambiguous. Increased

religiosity can be a sign of religious coping with the symptoms of the illness but might be

an indication of the severity of psychosis as well. (2020, p. 30)

This patients association with religion was most definitely an indication as to the severity of his

psychosis. The patient’s entire delusion was centered on religion. He discussed that he believes

he is God and his grandsons are the Holy Spirit and son of God. He also spoke about starting a

new international church that was going to be completely online. He was very focused on

religion.

Evaluate Patient Outcomes

The patient certainly appeared to be progressing toward stability throughout the day.

When the patient was brought into the emergency department he was apparently being very

aggressive and delusional. Throughout the day I was with the patient he did not have any

outbursts of aggression. In fact he appeared very calm and relaxed. While the he was still

experiencing the delusion, he was able to recognize that people did not believe him and he was

able to give a very clear outline of the delusion he was having.

Summarize Plans for Discharge

The only plans for discharge that were discussed was that the patient would be returning

home to his daughter, son-in law, and grandchildren. There was a note in the EMR stating that

the patient’s daughter has been dealing with the delusion the patient has and was still willing to

accept him back into the home. She did not believe he was a danger to himself or to others. I

believe that the patient would benefit from an outpatient treatment program.
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Prioritized List of Actual Diagnoses

-Ineffective airway clearance related to bronchospasms and increased secretions as evidenced by

statement of difficulty breathing

-Impaired gas exchange related to altered oxygen supply (air-trapping) as evidenced by reduced

tolerance for activity

-Defensive Coping related to suspicions of the motives of others as evidenced by difficulty in

reality testing of perceptions, grandiosity, hostility and aggression.

-Disturbed thought process related to chemical alterations and repressed fears as evidenced by

delusions, inappropriate non-reality based thinking.

-Impaired social interaction related to impaired thought process involving delusions as evidenced

by inability to make eye contact, inability to respond to social conversation, and inappropriate

emotional response

-Interrupted family process related to erratic, out of control behavior as evidenced by inability to

deal with crisis situations constructively

List of Potential Diagnoses

-Risk for injury related to extreme hyperactivity and physical agitation

-Risk for infection related to chronic disease process

-Imbalanced nutrition related to dyspnea and anorexia

-Risk for violence related to manic excitement and impulsivity

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Conclusion

Schizoaffective Bipolar disorder is a combination of schizophrenia and bipolar disorder.

Signs and symptoms including mania, depression, delusions, hallucinations, disorganized

thinking, etc. Patients with schizoaffective bipolar disorder benefit from a variety of evidence

based care including reorientation and distraction, decreasing external stimuli/ stress,

empowerment, and medications. This patient was a very good example of schizoaffective bipolar

disorder. He displayed delusional thinking, disorganized thinking and manic symptoms.

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References

Bag, B. (2020). Empowerment: A Contemporary Approach to Community Mental Health

Nursing Practice. Current Approaches in Psychiatry / Psikiyatride Guncel

Yaklasimlar, 12(3), 368–381.

Mayo Clinic. (2020). Schizophrenia. Retrieved from https://www.mayoclinic.org/diseases-

conditions/schizophrenia/symptoms-causes/syc-20354443

Ouwehand, E., Braam, A. W., Renes, J. W., Muthert, H. J. K., & Zock, H. T. (2020). Holy

Apparition or Hyper-Religiosity: Prevalence of Explanatory Models for Religious and

Spiritual Experiences in Patients with Bipolar Disorder and Their Associations with

Religiousness. Pastoral Psychology, 69(1), 29–45.

Scheydt, S., Müller Staub, M., Frauenfelder, F., Nielsen, G. H., Behrens, J., & Needham,

I. (2017). Sensory overload: A concept analysis. International Journal of Mental Health

Nursing, 26(2), 110–120.

Videbeck, S. L. (2020). Psychiatric-Mental Health Nursing. Philadelphia: Wolters Kluwer

Health