Comprehensive Mental Health Case Study

Abigail Schuster

Centofanti School of Nursing, Youngstown State University

NURS.4842L: Mental Health Nursing Lab

Teresa Peck

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 Abstract

This case study goes in depth of a patient diagnosed with Type 1 bipolar disorder. The patient

involved in this study is G.S. he is a 48-year-old Caucasian male. He presented to the mental and

behavioral health unit in the manic phase of his bipolar disorder while simultaneously

withdrawing from alcohol. This caused him to be restless, with pressured speech and limited eye

contact. He was voluntarily admitted to the unit by his aunt who holds the position of his

guardian. She is his primary support system, but they have recently not been getting along. Upon

arrival he was not taking any prescribed medication, he was self-medicating with alcohol and

marijuana. On admission, a detailed assessment was preformed including a comprehensive list of

lab values. The assessment showed many indications of mania including but not limited to

hallucinations, disorganized thinking and tangentiality. After reviewing symptoms as well as lab

values G.S. was prescribed the following: Lithium for the treatment of Bipolar, Risperidone for

delusions, Ativan, and Librium for alcohol withdrawal. This patient has many further concerns as

will be discussed in this case study.

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Patient Demographics and Admitting Diagnosis

G.S. is a 48-year-old Caucasian male who was admitted to the mental and behavioral

health unit on October 19th, 2021. The patient was admitted to the psychiatric unit by his aunt

who is the current guardian of his care. He is divorced with one son in which he states that he no

longer has contact with. G.S. recently lost his job and is currently unemployed. The patient

currently lives with his aunt and as of now she is his only support system. The patient’s primary

language is English, and the patient identified no specific religion. He stated that he believes in

mother earth because he feels connected with the rocks and the universe. He has no known

allergies and is on a regular diet. The patient’s primary problems upon admission were bipolar 1

(manic), psychosis evidenced by delusions, hallucinations, disorganized thought process, alcohol

withdrawal, and discontinuation of prescribed medication.

Summary of Bipolar Disorder

Bipolar disorder is characterized by periods mania and depression. A person experiences

mood shifts that are so severe they effect energy, activity level, concentration, and ability to

carry out daily tasks. When a person is in the manic period they may be elated, irritable, have

decreased amounts of sleep and loss of appetite. These people can experience changes in speech

such as talking quickly, jumping between topics, and experiencing racing thoughts. They may

also become very impulsive, take risks, and feel like they are unusually important or talented.

This is the phase G.S. is currently in of his bipolar disorder and is experiencing many of the

associated symptoms. The other phase of bipolar is depression, when a person is in the depressed

period, they may be very sad, down, worried, or hopeless. They may also feel slowed down or

restless, they may have trouble falling asleep and staying asleep or may even sleep way too

often. Bipolar can cause an increased appetite leading to weight gain. It can also cause slow

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speech or the feeling that there is nothing to say. People in the depressive phase have trouble

concentrating and making decisions, they may feel unable to do even the simplest of tasks, and

or have little interest in almost all activities. Bipolar disorder can be split into three subtypes

these include Bipolar 1 Disorder, Bipolar 2 Disorder, and Cyclothymic Disorder. Bipolar 1

Disorder is where a person experiences extreme mania and hypo depression, this is what G.S.

was diagnosed with. Bipolar 2 Disorder is where a person experiences extreme depression and

hypo mania. Cyclothymic Disorder is when a person experiences both manic and depressive

episodes in cycles but only experiences a moderate rate of both, never severe.

Erickson’s Stage’s of Development

G.S. should be in Generativity vs Stagnation according to Erickson’s developmental

stage’s but has not met this stage. In this stage a person is supposed to be able to develop or

nurture things that will live beyond them such as having children or making positive changes that

can benefit others. This helps create a sense of accomplishment and success. This allows a

person to feel that they are contributing to the world because they are being active members in

their homes or society. When a person cannot meet this phase, it can leave the person feeling

unproductive and uninvolved. In the case of this patient, he most likely got stuck in an earlier

stage of development and was never fully able to move forward from that phase. G.S. show’s

evidence of not meeting this phase since he no longer has contact with his son and must rely on a

guardian for majority of his care and decision making. There may be many contributing factors

as to why he was unable to meet this stage but most likely his mental illness and substance abuse

problems were a large contributing factor.

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Psychopathology leading to Current Admission

G.S. had many contributing factors leading to his current admission onto the unit. These

were some of the things noted in the interview that could have been contributing factors in the

patient’s current condition. The patient stated that his dad was a mean alcoholic. His dad would

hit him, and his mom would not do anything to stop it, she would just watch. He also stated that

his mother died when he was 15 of breast cancer. Prior to his mother’s death she would go

through many periods of extreme moodiness. She was often depressed but her periods of

depression were always followed by periods of her being fun and loving where she would take

him on shopping trips. This is common in bipolar disorder. Prior to the patient’s admission he

stopped taking his prescribed Lithium and Risperidone, he recently lost his job, him and his best

friend got into an argument and are no longer speaking, as well as stating that he has been

fighting with his aunt even more than normal. The patient stated that he smokes cigarettes,

marijuana, and drinks alcohol frequently to help deal with some of these stressors. The patient

also stated only sleeping three hours a night and repeatedly making statements about there not

being enough time to sleep because he has too much to do, which is a frequent symptom in

manic patients. While observing G.S it was also evident that he is easily agitated and paces

frequently. Prior to admission he was on a binge drinking cycle, experiencing hallucinations and

delusions. G.S. also had repressed most of his relationship with his parents, this is most likely

due to the physical and emotional abuse he experienced as a child.

General Description of Patient

G.S. appeared to be dressed and groomed very well with good hygiene, he moved

frequently during the interview like he could not keep still. The patient appeared to be a normal

weight for his height. He had brown curly hair and appeared his age. He showed no evidence of

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tremors but did show some tics and movements. This was evident by the patient frequently

talking with his hands and appearing very restless, which is very common in mania. The patient

has a very rapid speech that seemed pressured to get his point across. The patient was also very

loud but did not appear to have any speech impediment or aphasia. He also had very minimal eye

contact and rapid eye movement as he constantly looked all over like he had somewhere else to

be. The patient had no evidence of rigidity, echopraxia, psychomotor retardation and maintained

a normal gait with normal range of motion. The patient was cooperative and friendly with no

signs of guardedness. He seemed interested in talking but wanted to focus more on whatever it

was he felt he wanted to talk about with little interest in what was being asked.

Patient’s Emotions and Affect

While observing emotions and affect, the patient appeared very emotionally labile. Most

of the interview he appeared to be extremely happy or elated almost as if he was trying to

convince everyone he was happy. He would even sing some of his reply’s during the interview.

He struggled to stay on just one emotion throughout the interview because he would become

irritable with certain topics. These included his aunt, people he knows, and sex. His affect was

congruent with his mood, he had no evidence of being constricted, blunted or flat. G.S. did not

appear to be experiencing euphoria but was experiencing a great deal of mania.

Patient’s Thought Process

When examining thought process a lot of abnormalities were apparent. G.S. was

experiencing flight of ideas where he would jump from topic to topic with no connection. He

was also experiencing some associative looseness because occasionally connections could be

made between thoughts. G.S. appeared to be experiencing both circumstantiality and

tangentiality. Circumstantiality became apparent when the patient would provide many stories

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instead of answering the question asked. Tangentiality was noted on the few occasions where he

would get to the answer. He also enjoyed using expressions when speaking. G.S. appeared to be

experiencing some preservation when he would say the same statements repeatedly such as

“there’s not enough time”. He was only able to concentrate for extremely small amount of time.

However, the patient had no evidence of neologisms, concrete thinking, word salad, clang

associations, echolalia, mutism, or poverty of speech.

Patient’s Thought Content

During the interview G.S. appeared to be experiencing grandiose and somatic delusions.

His grandiose delusions were evidenced by the patient stating that he performs violin concerts all

over the United States and that his art is so good it is going to be put in a gallery. His somatic

delusions were seen when the patient stated that he feels vibrations from rocks. The patient also

was experiencing auditory, visual, and tactile hallucinations. G.S. demonstrated auditory

hallucinations by saying that his money talks to him and that he hears voices in his head. He

demonstrated visual hallucinations when he stated that he saw a tree branch coming out of his

friend’s mouth but this one may have been drug and alcohol induced because he admits to using

drugs and alcohol on that occasion. Lastly, he experienced tactile hallucinations when he stated

he feels the rocks vibrating. The patient denied any suicidal or homicidal thought’s, showed no

signs of obsessions or compulsion’s, patient also did not appear to have a phobia. However, the

patient did appear paranoid about other people judging him with repeated statement’s going on

about what other’s think of him. He also seemed to have some magical thinking and maybe

religiosity. Magical thinking was exhibited with statements about conquering the universe

through nature. Religiosity was shown with statements about connecting with the rocks will help

him conquer the universe. G.S. also made repeated statements that others should listen to his

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constructive criticism but appeared to not accept criticism well in return evidenced by his fear of

people judging him.

Patient’s Sensory and Cognitive Ability

G.S. appeared to be alert and oriented to time, place, person, and circumstances although

he stated several times throughout the interview that he felt he did not know why he was brought

to the unit. He stated feeling wonderful and that his life was great. He believed his auditory

hallucinations causing him to hear voices in his head were a gift and that he was completely

healthy. He also did not find his drinking or marijuana use to be a problem in his life and felt that

they only help his creativity. G.S. believed he needed the creativity to keep creating art for the

gallery in his delusions. He also felt that three hours of sleep a night was an adequate amount and

made several statement’s about not knowing why anyone would need anymore than that. All

these statements are big indicators that G.S. uses denial as an ego defense mechanism.

Judgement and Insight:

G.S. has very limited ability for judgment and insight. An example of his limited

judgment and insight is him stating that he lost his job and his friends due to drinking. However,

he stated that he does not find anything wrong with his drinking or substance abuse. He felt that

it should not be such problem for everyone else. He has some ability to make decisions because

although he sees no problem with drinking, he still will not drink and drive. He knows drinking

impairs his judgement but does not believe that it is a problem and falsely believes that he would

have more problems if he did not drink. He also states that he has been in rehab before but that it

was a mistake. This all stems from him using denial as a defense mechanism. G.S. also stated

that he does not connect well with people and that he is more connected with the universe

indicating he also is very isolated from the outside world.

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Adaptive and Maladaptive Coping Strategies with Ego Defense Mechanisms

G.S. stated no adaptive coping strategies to his current stressors and appears to use all

maladaptive coping strategies along with ego defense mechanisms to help him cope with his

problems. His maladaptive coping strategies included smoking cigarettes, smoking marijuana to

calm him down which was counteracted by his statement that marijuana gives him paranoia.

Alcohol abuse is another coping mechanism for him. He acknowledges poor judgement with

drinking and blacking out from drinking but still sees no issue with it. Patient primarily uses two

ego defense mechanisms including denial and repression. Denial is the refusal to accept an

external reality because the threat is too big. This is when someone refuses to acknowledge the

unpleasant aspects of reality because it’s too overwhelming to deal with. G.S. demonstrates

denial with his alcohol abuse problem. G.S. was able to admit that alcohol impairs his

judgement, that he blacks out because of it, that he lost his job and friends due to alcohol, and

that after drinking he becomes shaky and experiences ringing in the ear. Although he was able to

admit this, he still does not see drinking as a problem and feels that he would have more

problems if he did not drink. Repression is the attempt to repel unpleasant thoughts to one’s

subconscious to protect self from threat of suffering. G.S. does this because he blocks out his bad

memories from his childhood and does not allow himself to acknowledge his feelings about that

time.

Patient’s Lab Values

When assessing the patient’s data, his lab values were observed, and the following

abnormalities were noted. The patient’s BUN indicates kidney function, his value was 20 and

normal range is 7-18. This means his value was only slightly elevated, but caution should be

taken because the patient is on lithium which can be nephrotoxic. Hemoglobin was elevated at

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16.4, normal range is 12-15.5. This is monitored because hemoglobin can alter level of oxygen

perfusion and if low can cause psychiatric symptoms. AST indicates liver function; the patients

was high at 46 and normal is 10-37. AST is extremely important to monitor in this patient

because alcohol and substance abuse can damage the liver as well as his prescribed medications.

Lithium level’s ran low at 0.2 indicating that this drug is not therapeutic to patient yet. The

therapeutic level for lithium should be between 0.6-1.2. Lastly the patients QTC came back high

at 477 with an abnormal ECG. The normal level for QTC should be between 350-420. This high

value needs monitored closely because patient is on Risperidone which increases QTC and can

cause fatal heart dysrhythmias.

Patients Medications

G.S. was ordered 4 psychiatric medications including following:

Lithium (Anti-manic drug)

600mg PO, B.I.D. for Bipolar Disorder

Side effects: headache, fatigue, lethargy, memory loss, dry mouth

Nursing Implications: monitor sodium, lithium, creatine, and BUN values

Risperidone (Anti-psychotic, atypical)

2mg PO, Daily for Delusions

Side Effects: weight gain, sleepiness, dizziness, constipation

Nursing implications: monitor blood sugar and QTC, hold if QTC is over 440

Haloperidol (Anti-psychotic, typical)

5mg PO, every 4hrs PRN for acute agitation

Side effects: dizziness, drowsiness, sleep disturbance, anxiety

Nursing Implications: increased fall risks, don’t stop abruptly, monitor blood sugar

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Ativan (Benzodiazepine/ Anxiolytic)

Per orders of CIWA scale, oral for severe agitation

Side effects: drowsiness, sedation, dizziness, blurred vision

Nursing implications: assess CBC, liver function, monitor ambulation

Librium (Benzodiazepine/ Anxiolytic)

10mg PO, every 6 hours for alcohol withdrawal and anxiety

Side Effects: drowsiness, lethargy, dizziness, respiratory depression

Nursing Implications: monitor for orthostatic hypotension, check blood pressure, pulse

and for signs and symptoms of paradoxical reaction

Nursing Diagnosis

The following are nursing diagnosis for G.S.:

1.) Disturbed sensory perception related to psychological stress as evidenced by auditory,

visual, and tactile hallucinations.

2.) Disturbed thought processes related to mental illness as evidenced by grandiose and

somatic delusions.

3.) Substance abuse related to ineffective coping as evidenced by alcohol abuse, loss of

friends and jobs due to alcohol abuse and marijuana use.

4.) Ineffective sleeping pattern related to mental illness as evidenced by mania, stating he

only sleeps three hours a night because he does not have time for sleep, and he has too

much to do.

Potential Nursing Diagnosis

Risks for loneliness

Risks for ineffective health maintaince

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 Risks for care give role strain

Risks for imbalanced nutrition

Risks for self- or other-directed violence

Recommendations and Plans After Discharge:

Patient will return home with aunt and will need continued monitoring to ensure he takes

his medication as ordered daily. Patient will need to remain free of alcohol and marijuana by

attending AA meetings multiple times a week. He will need to get lithium lab levels drawn

weekly and then monthly to prevent lithium toxicity. He should also have his QTC checked

regularly due to being on Lithium. To do this, he needs to make regular follow up appointments

and attend them. Patient should continue individualized outpatient therapy. Patient should be

encouraged to look for low stress job and work on repairing relationship with his friend.

Conclusion

G.S. may never fully recover from his hallucinations and delusions, however there are

some things he may be able to do to be able to live with higher functioning and fewer

exacerbations. He can learn to follow his treatment regimen at home, sustain from using drugs

and alcohol to cope with stress, gain adequate support and rebuild his relationship with his aunt.

He may be able to gain more adequate support by going to group therapy where social norms can

be enforced by peers. Group therapy can also help him gain a support system of people who are

experiencing similar mental illnesses and substance abuse disorders. To rebuild his relationship

with his aunt he needs to follow his prescribed medication regimen to help stabilize his moods. If

he can stay on his medication regimen, he may even be able to help his aunt around the house,

allow her more freedom to do what she enjoys and possibly get a job to help financially.

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 References

Cherry, K. (2021, July 18). Understanding Erikson's stages of psychosocial development.

Verywell Mind. Retrieved November 10, 2021, from https://www.verywellmind.com/erik-
eriksons-stages-of-psychosocial-development-2795740

The National Institute of Mental Health. (2020, January). NIMH bipolar disorder. National
Institute of Mental Health. Retrieved November 10, 2021, from
https://www.nimh.nih.gov/health/topics/bipolar-disorder

Thomas, & Ruth. (2013, March 10). Ego defense mechanisms - freudian psychoanalytic theory.
Captain Tom’s Treasure Chest. Retrieved November 10, 2021, from http://thomas-n-
ruth.com/misc_articles/ego-defense-mechanisms.html

Wilson, B. A., Shannon, M. T., Stang, C. L., & Shields, K. M. (2006, June 20). Prentice Hall
Nurse's Drug Guide. Retrieved November 10, 2021, from
http://www.robholland.com/Nursing/Drug_Guide/

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