CASE STUDY 1

CASE: Nicolette
Nicolette, a 20 year-old women, has been admitted in formally to an acute mental health ward; this is
Nicolette’s first admission. Nicolette was being treated for depression by her General Physician; prior to
her admission Nicolette attempted to kill herself by cutting her wrists. Subsequently a short admission
was arranged with the aim of devising a comprehensive care package.

After speaking about the circumstances leading up to her suicide attempt Nicolette became increasingly
tearful and distressed, and started demanding to see a doctor. After being told that the doctor was on
their way and would arrive in about 10 minutes, Nicolette became very angry demanding medication to
calm her down; she then proceeded to run towards the ward’s doors shouting that she wanted to go
home. At that moment the doctor arrived on the ward and Nicolette also immediately calmed down.

During the assessment process Nicolette disclosed that being angry if she did not get her way was not
unusual for her. She also mentioned that she felt awful after bouts of anger. She described herself as a
“terrible person who was out of control” and she wanted to die. After assessing Nicolette the nurse
started to formulate a plan of care

1. What type of psychological interventions would the nurse consider implementing?

Supportive psychotherapy

 Encourages the expression of emotions, validates the experiences of the individual, and offers
support through empathetic listening and encouragement, and provision of information.
Reflects on the strengths of the individual and encourages use of adaptive coping techniques.
Sometimes called supportive, existential or supportive-expressive.

 Improvement in mood, coping and physical and functional adjustment.

Cognitive behavioural therapy

 Includes cognitive, cognitive behavioural and behavioural therapies. Teaches skills in problem-
solving, reframing attitudes, e.g. challenging “black and white” thinking, coping with stress and
anxiety. Relaxation therapy, guided imagery or cognitive skills might be used in dealing with
stressful situations such as particular treatments, or to reduce nausea associated with
chemotherapy. Techniques to enable gradual adaptation might also be included.

 Improvement in emotional distress, coping, anxiety, depression and a psychiatric morbidity;

Decrease in nausea, vomiting and insomnia; increase in control over illness.
2. Currently Nicolette has been admitted informally to the ward. Due to Nicolette’s impulse control
difficulties this may change. On this basis what does the nurse professionally need to know when
managing Nicolette’s legal status?

- Unstable relationship, self-image, affect, impulsivity, self-mutilation

- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
- Identity disturbance; markedly and persistently unstable self- image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging
- Recurrent suicidal behaviour, gestures, or threats, or self- mutilating behaviour
- Affective instability due to a maked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress- related paranoid ideation or severe dissociative symptoms

3. Nicolette is subsequently diagnosed with a “borderline personality disorder”. What other types of
personality disorders are there?

1. Borderline personality disorder

This common personality disorder is characterized by self-harm, an extremely unstable mood, and a
tendency to view oneself or others as wholly good or bad. People with borderline personality disorder
(BPD) usually experience great difficulty engaging in (or sustaining) meaningful interpersonal
relationships. Chaotic behaviors, emotional instability, and fears of abandonment help to define BPD.

2. Antisocial Personality Disorder

People with antisocial personality disorder seem to thrive on conflict. They may get into verbal or
physical altercations with people they don’t even know, such as a clerk in a shop, because they don’t
care about the usual social conventions against that sort of behavior. They also tend to get into frequent
legal disputes and litigations. People with antisocial personality disorder can be abusive in interpersonal
relationships and show no remorse. Antisocial personality disorder also can lead to substance misuse.

3. Histrionic Personality Disorder

Histrionic personality disorder is marked by extremely emotional, overwrought or dramatic behavior in

situations that do not warrant such a response. The purpose of such dramatic behavior is to call
attention to the person. People with histrionic personality disorder often pay excessive attention to their
appearance and constantly seek others’ approval of them.

4. Narcissistic Personality Disorder

People with narcissistic personality disorder tend to experience feelings of great self-importance that
belie their underlying insecurity. In interpersonal relationships, narcissists tend to exploit the other
person without feeling remorseful. Narcissists tend to be extremely sensitive to criticism or failure.
People with this disorder often complain of physical aches and pains that cannot ultimately be
attributed to any medical cause.

5. Avoidant Personality Disorder

Avoidant personality disorder is marked by extreme fear of rejection and criticism that leads to an
inability to engage in meaningful relationships with other people. Avoidant personalities feel a strong
need to be liked by everyone and feel crushed if they believe they said or did something foolish in front
of others. As a result of their emotional fragility, they tend to avoid social situations as often as possible.

6. Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder (OCPD) is not the same thing as obsessive-compulsive

disorder (OCD). OCD is a more serious mental health issue that involves uncontrollable thoughts coupled
with repeated behaviors. OCPD, on the other hand, is a disorder characterized by perfectionism at the
expense of flexibility and inclusiveness. People with OCPD tend to take a “my way or the highway”
attitude toward work and life routines and tasks. OCPD usually involves very rigid systems of decision-
making that must not be deviated from.

7. Schizoid Personality Disorder

Schizoid personality disorder is not the same thing as schizophrenia—a very serious mental health
condition that usually includes hallucinations and extremely disordered thinking. A person with schizoid
personality disorder may be described as “withdrawn” or “solitary.” People with schizoid personality
disorder often appear emotionally cold and preoccupied with their own internal fantasies than with the
realities of life. They might be described as “dreamers” instead of “realists.”

8. Schizotypal Personality Disorder

Schizotypal personality disorder, a person may behave very eccentrically or express bizarre beliefs that
ostracize them from others. Schizotypal personality disorder often goes hand-in-hand with extreme
social anxiety. Some people with schizotypal personality disorder believe they can read other people’s
minds.

9. Paranoid Personality Disorder

People with paranoid personality disorder tend to be extremely distrustful of all other people. They view
every interpersonal interaction as a threat. This skewed viewpoint leads people with paranoid
personality disorder to behave in very guarded or secretive ways. Paranoid people also may turn violent
quickly if they perceive someone is ridiculing or threatening them.

10. Dependent Personality Disorder

The defining feature of dependent personality disorder is an unwillingness or inability to make your own
decisions or to actively participate in managing your own life. People with dependent personality
disorder tend to be very submissive or timid and rarely initiate relationships or projects. In dependent
personality disorder, even inconsequential decision-making can become an overwhelming task that
requires input and reassurance from multiple other people.

4. What specific psychological interventions would the nurse delivery?

- Promote safety
- Help client to cope and control emotions
- Cognitive restructuring techniques
- Structure time
- Teach social skills
- Dialectical behavior therapy (DBT) - DBT uses a skills-based approach to teach you how to
manage your emotions, tolerate distress and improve relationships.
- Schema-focused therapy - Therapy focuses on helping you get your needs met in a healthy
manner to promote positive life patterns.
- Mentalization-based therapy (MBT) - MBT is a type of talk therapy that helps you identify your
own thoughts and feelings at any given moment and create an alternate perspective on the
situation.
- Systems training for emotional predictability and problem-solving (STEPPS). - STEPPS is a 20-
week treatment that involves working in groups that incorporate your family members,
caregivers, friends or significant others into treatment.
- Transference-focused psychotherapy (TFP)
- TFP aims to help you understand your emotions and interpersonal difficulties through the
developing relationship between you and your therapist.
- Good psychiatric management. It focuses on making sense of emotionally difficult moments by
considering the interpersonal context for feelings. It may integrate medications, groups, family
education and individual therapy.

Nicolette has now been on the ward for over 6 months. Each time discharge has been arranged Nicolette
self-harms or threatens suicide. Nicolette has now agreed to go to a therapeutic community, a place has
been secured and Nicolette is now engaging in pre-therapy work

1. What other treatments besides a therapeutic community are recommended for individuals diagnosed
with a borderline personality disorder?

-Borderline personality disorder is mainly treated using psychotherapy, but medication may be added.

Types of psychotherapy that have been found to be effective include:

• Dialectical behavior therapy (DBT). DBT

• Schema-focused therapy

• Mentalization-based therapy (MBT)

• Systems training for emotional predictability and problem-solving (STEPPS).

• Transference-focused psychotherapy (TFP).

• Good psychiatric management.

2. While working with Nicolette the primary nurse has found the relationship at times to be quite
stressful. What are the signs of stress?

- Anxiety or panic attacks.

- A feeling of being constantly pressured, hassled and hurried.

- Irritability and moodiness.

- Physical symptoms, such as stomach problems, headaches, or even chest pain.

- Trouble sleeping or sleeping too much.

2. While working with Nicolette the primary nurse has found the relationship at times to be quite
stressful. What are the signs of stress?

Cognitive symptoms:

 Memory problems

 Inability to concentrate

 Poor judgment

 Seeing only the negative

 Anxious or racing thoughts

 Constant worrying

Emotional symptoms:

 Depression or general unhappiness

 Anxiety and agitation

 Moodiness, irritability, or anger

 Feeling overwhelmed

 Loneliness and isolation

 Other mental or emotional health problems

Physical symptoms:
  Aches and pains

 Diarrhea or constipation

 Nausea, dizziness

 Chest pain, rapid heart rate

 Loss of sex drive

 Frequent colds or flu

Behavioral symptoms:

 Eating more or less

 Sleeping too much or too little

 Withdrawing from others

 Procrastinating or neglecting responsibilities

 Using alcohol, cigarettes, or drugs to relax

 Nervous habits (e.g. nail biting, pacing)

3. What strategies could the nurse use to manage their stress?

 Manage your diet. Eating healthy foods — fruits and vegetables, whole grains, lean proteins —
boosts energy levels and aids digestion. It can also contribute to better sleep.

 Get plenty of sleep. Stress can lead to poor sleep, which in turn can contribute to more stress.
Eating healthy foods and exercising can help break the cycle.

 Exercise and stretch. Finding time to exercise can be difficult, particularly when nurses are
already working long hours doing work that is physically demanding, but the benefits are
substantial. Exercise releases endorphins and boosts serotonin levels, which can improve mood,
appetite, and sleep cycles.

 Practice meditation, mindfulness, or yoga. Practices that quiet the mind, focus awareness, and
regulate breathing can help reduce stress.

 Unwind by pursuing hobbies. Focusing on personal interests gives people something to look

forward to, provides a healthy outlet for stress, and keeps the mind distracted from work-
related concerns.

 Share your feelings. Venting to friends and family members about work challenges can help
relieve stress. Professional, community, and faith-based organizations can also provide outlets
for sharing experiences.
 Many people find that recording their thoughts and feelings helps clear their mind.

 Limit exposure to media, particularly social media. While it is important to stay informed

during health crises, setting parameters for the time and duration of media consumption
prevents fixation on negative events.