SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 1

Comprehensive Case Study Schizoaffective Disorder

Kaitlyn Fitch

Youngstown State University

NURS 4842: Mental Health Nursing

Professor Teresa Peck

November 12, 2021

SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 2

Abstract

This case study follows a patient with schizoaffective disorder and bipolar while providing detail

about the patients’ history, stressors and medications. MW is a 24-year-old Caucasian male who

was admitted to the floor for making suicidal and homicidal ideations. MW has a moderate

intellectual disability and a past psychiatric diagnosis of depression and anxiety with no past

suicidal thoughts or attempts. The textbook, Psychiatric Mental Health Nursing and journals

from the Maag library search engine Academic Search Complete and EBSCO were used to

define and strengthen information in this study.

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Objective Data

MW is a 24-year-old Caucasian male who was admitted at Generations on November 6,

2021. He has a diagnosis of schizoaffective disorder and bipolar, with a history of depression,

anxiety and a moderate intellectual disability. His other medical history includes hypertension,

hyperhidrosis and gastroesophageal reflux disease. At the time of the interview, he was alert and

oriented to person, time, and place. His highest form of education is high school and his primary

language is English. He has allergies to cephalosporins, eggs, Suprax, Omnicef and loperamide.

His grooming and appearance seemed disheveled. His posture, height and weight were

appropriate for his age. He looked much older than 24 years old but it could seem that way

because of his unkept beard and hair. MW demonstrated minimal to fleeting eye contact

throughout the interview. He had no tics, tremors, rigidity, echopraxia or mannerisms. He did

seem restless and agitated when talking about certain topics. He had pressured speech, a stutter,

and an overall loud volume. He did seem depressed, despairing and anxious but was still

friendly, and cooperative and his mood matched his affect. He has no family history of mental

health issues. He is on suicidal and homicidal precautions for making threats. He states he feels

like he has nothing to live for. On November 5th, he went to Aultman hospital for making

homicidal threats toward people in his group home but was discharged shortly after. This

aggravated him even further and he began cutting his knuckles with scissors as an attempt to

bleed out. He was transported to St. Elizabeth hospital in Youngstown before coming to

Generations. The only other history of self-harm is an incident where he purposefully cut his

penis and had to have surgery. This incident was found in the chart and gave no date or age at

when this occurred. He does see an outside psychiatrist but states his medications are not

working and wishes to switch to a new doctor. MW lives in a group home and has a guardian,
SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 4

Susan. At the moment, MW is having problems with his guardian. He claims she does not let

him go anywhere or do anything. Per chart review, it was noted that Susan placed a restriction

that MW must stay in Stark County due to the recent suicidal and homicidal threats. Susan

exclaimed that she has never had to place restrictions on MW and does not know why he’s

saying she never lets him go anywhere. During the interview, MW stated that all the things he

likes to do are in Cleveland and Akron which is why he is upset. MW states he travels through

group home transportation as well as taking the bus. MW has a mother, father, and a brother. He

says they are supportive but do not want him to live in their home. The mother claims that MW

gave her post traumatic stress disorder (PTSD) and requested him to live elsewhere. According

to the chart, there is a history of physical and mental abuse from the father. This could contribute

to the complicated living situation, but the client does not seem to see it as an issue. He states

that he does want to move back in with his parents and he hates his group home. His brother

requested MW to not be placed with him as he has a busy work schedule and cannot watch over

his brother. MW states he has dogs who he loves to be around. It is evident that his dogs bring

him a lot of joy and stress relief, but he says he does not see them as much after moving out.

MW has a few other positive coping skills such collecting patches from fire stations, running and

drawing. He enjoys going to various fire stations on group home trips and talking to the

firefighters. He also expressed his love for traveling. He has been to multiple states on family

trips and group home activity days.

As stated by MW and chart confirmation, he has lived in multiple group homes, but none

have worked out due to his anger. His most recent group home is also causing some trouble. MW

does not get along with the staff at the group home or his fellow roommates. As stated by MW,

his roommates were “saying they were Jesus Christ” and MW became frustrated because this
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was not true. This was the only indication of a religious preference. It is assumed he is Catholic

since he became defensive toward his roommates. It was then confirmed in the chart that his

religious preference is Catholic. This argument led to MW making homicidal threats toward staff

and the roommates. According to the chart, he said he was going to fight people, which he took

as making a homicidal threat. The chart stated that he threatened a fight as well as the statement

“I want to kill people” which placed him on homicidal precautions. In some of these group

homes he was able to hold down a job before getting kicked out. He stated that these jobs were

within the group home and included chores like taking out the trash and cleaning. These jobs

were paid but MW was frustrated at how little his income was. This is the only job history of

MW and he does not currently have a job. MW is on Medicare, Supplemental Security Income

and Social Security Disability Insurance.

While the interview was going on, MW demonstrated multiple forms of disorganized

thought and speech. One form was flight of ideas. His sentences had little connection and were

all over the place. He was jittery, excited and anxious when talking about various topics. He also

demonstrated some associative looseness. A few of his sentences did not exactly line up but still

had a connection. At times, it was possible to connect his sentences to the topic at hand and other

times it was not so easy. Another form disorganized thought and speech is circumstantiality. This

is where when a question is asked, MW would go off on tangents that related to the question. He

would eventually get to an answer, but a long explanation always came before. He also had a

short attention span. At times, he was able to answer questions but would quickly jump to

another topic or repeat something that was already stated. The most prevalent form of

disorganized speech MW demonstrated was perseveration. This is constant repetition and getting

stuck on a certain topic. This can be seen in people with autism and those with intellectual
SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 6

disabilities. He would frequently mention his dogs and how he would dress them up for

Halloween. This could represent a safe memory he has and thinks about when he is stressed.

MW also repeatedly talked about his anger at the psychiatrist and the treatment team over his

medication. He claims that he has tried every combination of medication and nothing has

worked. MW stated that he has been telling nurses and staff that he wants to talk about his

medication since his admit date, but no changes have been made. He claims they just keep saying

they will look into in but never follow up. His frustration with this was clear. When talking about

his medication problems, he would get even more anxious and his volume would get louder.

MW was able to give a list of his past medications and why they did not work. He gave the

example of how Risperdal gave him gynecomastia, so he asked to switch medication. During the

interview, the psychiatrist and nurse practitioner were doing their rounds. When it was MW’s

turn, he explained how the staff was not doing anything about his medication issues and once

again, the psychiatrist replied with “we’re still looking into it”. MW said “okay” but was clearly

frustrated. This made it evident that he was active in his care and wanted to get the proper

treatment. It did seem like a lot of his medication issues stemmed from side effects he did not

like. It was unclear how long he was on his older medications, but it is a possibility that he didn’t

give enough time for the medication to fully work before stopping it. These forms of

disorganized thought and speech could be a result from not only his schizoaffective disorder but

also from his intellectual disability. The chart nor the patient stated what kind of intellectual

disability was present. The chart only stated that it was a “moderate” disability. The 2018 article,

Intellectual Disability co-occurring with Schizophrenia and other Psychiatric Illness: a

population-based study states,

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Overall, 31.7% of people with an intellectual disability had a psychiatric disorder.

Schizophrenia, but not bipolar disorder and unipolar depression, was greatly

overrepresented among individuals with a dual diagnosis: depending on birth cohort, 3.7–

5.2% of those with intellectual disability had co-occurring schizophrenia (Morgan,

Leonard, Bourke, 2018, pg. 372).

Those with an intellectual disability have an increased risk for developing schizophrenia or a

mental illness in general. As for perceptual disturbances and thought, MW did not exhibit any

hallucination, illusions, depolarization, magical thinking or delusions. He also did not talk about

any phobias, paranoia or obsessions nor does he have any history of any of these. He does have a

history of mania, as he has bipolar, and mood swings.

Schizoaffective disorder is broken down into two types, the bipolar type and the

depressive type. The bipolar type has both manic and depressive episodes whereas the depressive

type only has depressive episodes. MW was diagnosed with the bipolar type but has a separate

diagnosis of depression. A schizoaffective disorder diagnosis is made when a person has

schizophrenia symptoms, like delusions or hallucinations, as well as symptoms associated with

mood disorders like mania or depression. In the third edition of the Diagnostic and Statistical

Manual of Mental Disorders (DSM), schizoaffective disorder was separated from schizophrenia

and given its own category. In the article, The schizoaffective disorder diagnosis: a conundrum

in the clinical setting, the authors list the criteria for schizoaffective disorder as follows:

DSM-IV lists four diagnostic criteria for schizoaffective disorder (A–D). Criterion A

requires that the patient experience psychotic symptoms consistent with criterion A for

schizophrenia and that they co-occur with a major mood episode (major depression,

mania or a mixed state). Criterion B requires that the patient also experiences psychotic
SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 8

symptoms in the absence of major mood symptoms, for a period of at least 2 weeks.

Criterion C states that manic or major depressive symptoms must be present for a

substantial portion of the total duration of the illness. Finally, Criterion D excludes cases

with psychotic and mood symptoms that can be attributed to substance use or another

medical condition (Wilson, Nian, Heckers, 2013, pg. 30).

The laboratory results on this client came back normal and his QTC was 449. He was also

negative for drugs and alcohol and states that he does not use either of them. He is on a few

medications not related to his psychiatric diagnosis. He takes amlodipine besylate (Norvasc) 5

milligrams daily for his blood pressure. MW also takes omeprazole (Zegerid) 20 milligrams

daily for gastroesophageal reflux disease. As for his psychiatric medications, he is prescribed

fluoxetine (Prozac) 60 milligrams daily for his depression. It is important to monitor the QT

interval since this medication can prolong it. MW also takes quetiapine (Seroquel) 300

milligrams daily for his psychosis. This helps him concentrate, organize his thinking and speech

and decreases his mood swings. Lastly, MW takes divalproex sodium (Depakote) for his mood.

This medication helps settle his brain during a manic episode. Laboratory results to monitor

when taking Depakote are pancreatic enzymes, platelets and liver enzymes (AST/ALT).

Summarize the Psychiatric Diagnosis

The Psychiatric-Mental Health Nursing book defines schizoaffective disorder as, “a

mixture of psychotic and mood symptoms. The signs and symptoms include those of both

schizophrenia and a mood disorder such as depression or bipolar” (Videbeck, 2020, pg. 256).

Some expected and common behaviors with this diagnosis include paranoia, night eating

syndrome, hallucinations, delusions, disorganized thinking, lack of motivation (avolition),

inability to experience pleasure (anhedonia) and difficulty concentrating. There are also
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symptoms of mania and depression mixed in. These include rapid speech, inability to

concentrate, little need for sleep or sleeping too much, lethargy, overwhelming sadness and

feelings of worthlessness. This disorder has cycles of severe symptoms followed by periods of

improvement.

Identify the Stressors and Behaviors the Precipitated Current Hospitalization

The biggest reason for the hospitalization of MW was his anger. The frustration he felt

toward his guardian, family, doctors and group home kept building until it reached the point of

him making homicidal and suicidal threats. MW said how he felt trapped by his guardian and

started to lose hope. Another issue brought up was that his guardian wouldn’t allow him to

switch health care providers since he was having so many medication troubles with his current

one. He claimed he was not being heard or listened to by anybody. This turned into feelings of

worthlessness and despair. During the interview, he explained how he would rather die than go

to “prison” (referencing his group home) because of the people there and his restriction to Stark

County. MW also has started thinking about self-harm and participating in it to calm down. He

states he tries to “remember the fun times with his dogs and his traveling adventures but

sometimes, it just isn’t enough to stop the sadness”.

Discuss Patient and Family History of Mental Illness

Regarding mental illness, the patient has a history of depression and anxiety. It is

unknown how long ago these diagnoses were made. A possible contributing factor to both could

be the fact that he was psychically and emotionally abused by his father at a younger age. The

research article The Interaction Effects of Suicidal Ideation and Childhood Abuse on Brain

Structure and Function in Major Depressive Disorder Patients claims, “Studies have reported
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that childhood abuse is significantly associated with an increased risk of SI. There is a greater

likelihood for a person to think about suicide if he or she had suffered from severe trauma in

childhood” (Wang, Zhang, Guo, 2021, pg. 2). It is possible for MW to have repressed those

memories and they are now manifesting through anxiety and depression. He mentioned that he

always “tries to be normal” but his mental health gets in the way. As for history of mental illness

in his family, there is none documented.

Evidence Based Nursing Care Provided and Milieu Activities Attended

Due to client precautions of suicidal and homicidal ideations, anything that could be

dangerous was taken off the floor and out of the clients’ possession. This included removing

belts, shoelaces, glass and replacing normal writing utensils with markers. The tv was also

behind shatter proof plastic and the chairs on the floor were heavy enough to prevent patients

from picking them up. Before and after the interview, MW could be seen talking to other clients,

drawing, coloring and playing games. All of these activities seemed to lower his stress levels and

he remained calm throughout. There was one group that day and MW was eager to attend, asking

multiple times when group would start. During the group, MW often asked repeated questions

and was hyperverbal. His actions were almost childlike, but he was easily redirected and

distracted. He understood the instructions of the game and was able to complete his worksheet

with minimal help. When going through the chart, it was noted that he commonly acts this way

in group and it could be due to his intellectual disability. He never showed any aggression

toward group members and remained positive throughout. Family centered therapy is one

treatment that was not in the chart but could be helpful to this client. It seems there is some

tension between MW and his parents. Sitting down and talking could help this client better

understand why his parents say he gave them PTSD as this topic emotionally upset him when
SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 11

brought up in the interview. Setting the client up with a referral to a new psychiatrist could also

be counted as a treatment. In collaboration with his guardian, a switch in doctors would greatly

benefit MW and help him become more compliant with his medication.

Analyze Ethnic, Spiritual and Cultural Influences

MW is a Caucasian male. He does not have many ethnic, spiritual or cultural influences.

When religion was brought up in the interview, never gave a clear answer and simply stated he

“believed in God”. His chart stated he was Catholic but did not mention any specific influences.

The other thing that could hint his belief in God was when his roommates were pretending to be

Jesus Christ and MW became defensive.

Evaluate the Patient Outcomes

MW is active in his care and meeting his outcomes. He remained free from injury on the

floor and was able to control his temper. He did not harm anyone or become destructive. MW

said he is getting around eight hours of sleep at Generations which is more than what he got at

his group home. He said he likes it here and is afraid to leave, exclaiming he doesn’t know where

he will end up. His medication issues are still present but are being worked out. MW is eating

and maintaining his hydration status. He is finding activities to do on the floor that keep him

busy. Though he often interrupts, he does attend group and gets excited about it. He denies any

new hallucinations or delusions since being admitted and denies ever having any in the past. The

client’s depression has stayed at a manageable level, but he reports still being anxious. He is

physically restless with fleeting eye contact. MW worries about the medication he will be put on

as well as where he will be living once discharged.

Summarize the Plans for Discharge

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Despite being at Generations for multiple days, neither the patient nor the chart gave any

discharge information. It could be assumed that he would possibly be moved to a different group

home since homicidal threats were made toward staff and roommates at his current one. The

client wishes to be placed in a group home in Cleveland or Akron as he cites having activities he

likes to do in those areas. It does look like the guardian will keep the Stark County restriction in

place forever but at least until his medication issues clear up.

Prioritized list of Actual Diagnoses

Risk for self-directed or other-directed violence related to aggression as evidenced by verbal

threats, fighting with staff and acts of self-harm.

Risk for low self esteem related to feelings of hopelessness as evidenced by suicidal ideation,

past trauma and making negative statements about self.

Risk for inadequate treatment related to noncompliance with medications as evidenced by not

allowing enough time for the medication to fully work and stopping the medication due to

unwanted side effects.

Interrupted family process related to patient having a mental illness along with a disability as

evidence by a guardianship and family requesting patient to not live with them.

Ineffective impulse control related to anger management issues as evidenced by being kicked out

of multiple group homes for fighting with staff and other clients.

List of potential nursing diagnoses

Risk for loneliness Care giver role strain (guardian Susan) Self-care deficit
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Risk for suicide Impaired social interaction Disturbed thought process Ineffective

coping

Conclusion

Overall, MW was a good patient to write a case study on. His medication and anger

issues need to be worked on during and after his stay at Generations. One of the biggest things

that needs to happen is effective collaboration between MW, his family, his guardian and his

doctors. There are many unresolved issues and a lot of arguing going on. If everyone works

together then the patient can function at his highest potential.

SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 14

References

Morgan, V. A., Leonard, H., & Bourke, J. (2018, January 2). Intellectual disability co-occurring

with schizophrenia and other psychiatric illness: Population-based study: The British

Journal of Psychiatry. Cambridge Core. Retrieved December 1, 2021, from

https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/

intellectual-disability-cooccurring-with-schizophrenia-and-other-psychiatric-illness-

populationbased-study/E994104AE84058AFB15C89484104B151.

Videbeck, S. (2020). Psychiatric-Mental Health Nursing Eighth Ed. Wolters Kluwer.

Wang, W., Zhang, N., & Guo, X. (2021). The interaction effects of suicidal ideation and

childhood abuse on brain structure and function in major depressive disorder patients.

Neural Plasticity, 2021, 1–10. https://doi.org/10.1155/2021/7088856

Wilson, J. E., Nian, H., & Heckers, S. (2013). The schizoaffective disorder diagnosis: A

conundrum in the clinical setting. European Archives of Psychiatry and Clinical

Neuroscience, 264(1), 29–34. https://doi.org/10.1007/s00406-013-0410-7

SCHIZOAFFECTIVE MENTAL HEALTH CASE STUDY 15

Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format