Psychiatric Mental Health Comprehensive Case Study 1

Psychiatric Mental Health Comprehensive Case Study

Ariana L. Ormiston

November 30, 2023

Dr. Teresa Peck, RN, MSN, DNP

Elizabeth Sanford, BSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University's Centofanti School of Nursing

Psychiatric Mental Health Comprehensive Case Study 2

Abstract

BA a 31-year-old male patient that was admitted to the inpatient psychiatric unit after presenting

to the emergency department with concern for auditory hallucinations that developed into

command auditory hallucinations. He has a mental health diagnosis of antisocial personality

disorder and he also began showing signs and symptoms of acute psychosis and mood disorder,

unspecified. The staff have started him on medication treatments, including antipsychotics, sleep

aids, antidepressants, and mood stabilizers, and BA has resumed baseline daily functioning.

Hallucinations and other symptoms are becoming manageable. Nursing care provided on the unit

is focused on re-orientation to reality when hallucinations are noticed and symptom management

through pharmacologic methods, as well as nonpharmacological methods such as therapeutic

group therapy sessions and individual therapy sessions.

Keywords: antisocial personality disorder, mood disorder, mental illness, acute psychosis,

therapy, medication, treatment

Psychiatric Mental Health Comprehensive Case Study 3

Objective Data
Patient identifier BA

Age 31

Sex Male

Date of admission October 28, 2023

Date of care November 02, 2023

Psychiatric diagnosis Antisocial Personality Disorder

Other diagnoses Anxiety, depression, acute psychosis, suicide attempt, suicidal ideation, mood

disorder unspecified, medication noncompliance, and substance induced mood disorder

Behaviors on admission BA came into the emergency department due to the fear of his auditory

command hallucinations. He stated they were “all in his head” that someone was telling him to

shoot himself. BA told staff that someone needed to shoot him because he can not do it himself

and he fears he is “losing all hope”.

Behaviors on day of care BA participated in group sessions throughout the day and was the

lively one out of the bunch. He was laughing, calm, cooperative, listening and commending

others when they shared, and willing to share what he was thankful for. BA was not experiencing

any hallucinations but was having anxiety throughout the day. BA seemed to have a positive

outlook and stated that he wants to “live sober in Youngstown”. BA showed signs of

hyperactivity, had normal speech patterns, and answered all exam questions appropriately. He

showed an incongruent affect as it was mainly blunted and his mood was euthymic for most of

the day on day of care. After dinner and another group session mood swings set in.
 Psychiatric Mental Health Comprehensive Case Study 4

Safety and security measures In the emergency department safety checks are implemented

around the clock every 15-minutes and a constant observer is in place through Doctors orders.

The constant observer is with the patient at all times and accompanies them wherever they go.

Once admitted to the inpatient unit patients are not permitted off the unit, and staff is present in

the milieu activities at all times. All hazardous items such as shoelaces, razors, pencils, pens,

paperclips, staples, etc; were not permitted on the unit, and only markers are used for writing,

drawing, and other activities. Medications were administered to the patient by the medication

nurse, and the nurse must verify all medications given were consumed at the time of

administration. This can be done by oral checks to ensure they are not in cheeks or under tongue.

Laboratory results

Laboratory Value Result N/Ab & Normal Ranges

Potassium 4.1 mmol/L Normal 3.6 to 5.2mmol/L

Sodium 138 mEq/L Normal 135 to 145mEq/L

Glucose 115 mg/dL Abnormal 70 to 99 mg/dL

A1C 5.5% Normal <5.7%

Blood Urea Nitrogen 14mg/dL Normal 6 to 24mg/dL

Creatinine 0.7mg/dL Normal 0.7 to 1.3mg/dL

Red Blood Cells 3.95 million cells/mcL Abnormal 4.0 to 5.9 x 10*12/L

Hemoglobin 11.7g/dL Abnormal 14g/dl to 18g/dL

Hematocrit 35% Abnormal 41% to 50%

 Psychiatric Mental Health Comprehensive Case Study 5

White Blood Cells 10.2/microliters Normal 4.5 to 11.0 × 109/L

AST 30 U/L Normal 8 to 33 U/L

ALT 58 U/L Abnormal 7 to 55U/L

Urine Analysis Alcohol Level < 10 Normal <10

QTC/ECG 450 Borderline <450

Drug Toxicology Amphetamine, Buprenorphine, Abnormal Negative

Cannabinoid, and Fentanyl

Psychiatric medications

Generic Name Trade Name Classification Dose/Frequency Reasoning

Nicotine patch Nicoderm Nicotine 1 patch daily Tobacco dependence

CQ replacement

divalproex Depakote Anticonvulsant 350 mg BID Mood stabilization

olanzapine Zyprexa SSRI antidepressant 5mg HS Depression

haloperidol Haldol typical 5 mg Q4H PRN Agitation

antipsychotic

hydroxyzine pamoate Vistaril Antihistamine 50mg TID PRN Anxiety

melatonin Melatonin Hypnotic/Sleep Aid 3mg QHS PRN Sleep

dicyclomine Bentyl Antispasmodic 10mg QID PRN Abdominal cramping

 Psychiatric Mental Health Comprehensive Case Study 6

clonidine Catapres Antihypertensive 0.1mg TID PRN Withdrawal

Summary of psychiatric diagnoses

Antisocial personality disorder is a cluster b personality disorder that is characterized by

failure to conform to social norms and lawful behavior, irritability and aggressiveness. they often

engage in physical fights or commit assaults, they have trouble with impulsiveness, and have a

disregard for the rights, feelings, and safety of others; and disregard for their own safety and the

consequences of their behavior (Videbeck. S). The symptoms lead to a large number of those

with ASPD in jail. Those with ASPD used to be considered sociopaths, typically serial killers

(Videbeck. S) Their symptoms typically begin to show in early childhood. A few more

characteristics of ASPD is that their symptoms tend to be dramatic and erratic, they have trouble

maintaining relationships, and are often deceitful and manipulative in getting what they want.

Antisocial personality disorder is diagnosed when three or more of the following symptoms

are present after undergoing rigorous and detailed psychological assessment: repeatedly showing

unlawful behavior and being manipulative, trouble with impulsiveness, being overly aggressive

and irritable, consistently failing to be responsible, having lack of remorse, and not caring about

the rights, feelings, and safety of others (Anderson. J.L. al). BA exhibits impulsiveness,

irritability, and failure to be responsible regularly. BA has also been in jail and is currently on

probation for breaking the law.

Identification of stressors and behaviors precipitating current hospitalization

Prior to admission and during past admissions, BA was non-compliant with his

medication. He lives alone at home and does not see or speak to family. When asked about their

relationship, BA states that in his immediate family, his mother and brother are the only ones
Psychiatric Mental Health Comprehensive Case Study 7

living. BA states his mother is selfish and does not believe in mental illness and his brother has

not been in contact with him for years. BA stated that prior to admission he started to hear voices

in his head that became intensely commanding after a few days, and needed to seek help as he

began feeling hopeless. He feared listening to the voices and acting upon them. He stated that

upon admission, he could not think or remember straight due to the inability to fall or stay

asleep. On the day BA was admitted to the hospital, he told staff he was afraid to be honest about

his previous suicide attempts in jail and the voices he heard in fear of being put in a “turtle suit”,

referring to a straight jacket.

BA was reassured and gradually became open to emergency staff about his symptoms.

He was compliant with laboratory work involving blood and urine samples. After a few hours in

the emergency department awaiting a social work consult, BA did have outbursts on the unit. He

told staff that he needs someone to shoot him because he is unable to do it himself and when he

leaves he will go to “the streets and hopefully get my head blown off”. BA was placed on an

involuntary psychiatric hold due to being a danger to himself and others.

Patient and family history of mental illness

BA states that he does not have a familial history of mental illness. The family history

unrelated to mental illness that he provided was that his father died of pancreatic cancer. When

asked about details of when or how he feels about the death, he does not wish to answer and

changes the subject. His mother, still alive, deals with hypertension. BA has one brother with no

mental illnesses or health conditions. Extended family member histories were not obtained as BA

did not remember if they had any conditions or illnesses. BA did have a hernia repair two years

ago. He dropped out of high school after the 11th grade and does not have a general education

development diploma (GED). He currently lives alone in a Youngstown apartment, has one child
Psychiatric Mental Health Comprehensive Case Study 8

whom he does not see, has been in jail multiple times and is currently on probation for theft and

trespassing, and no family support. His brother does not speak to him and his mother is the

primary contact, but she does not wish to help. She states she cannot take him in and does not

want to visit, but hopes that he will figure it out by himself.

Psychiatric evidence-based nursing care provided

During his stay in the inpatient psychiatric unit, BA received nursing care from the unit's

mental health nursing staff. The registered nurses on the unit use the nursing process to assess,

diagnose, plan, implement, and evaluate their patients on a daily basis to ensure adequate care

and goals. For each shift, BA was assigned a nurse that built a rapport with him and encouraged

him to bring any concerns about his care. His nurse would administer his daily medications as

ordered and ensure that BA was consuming his medication and not pocketing it for later use or

throwing it away. While he was inpatient, BA was placed on mood stabilizing medication, an

SSRI antidepressant, as well as a typical antipsychotic for his symptoms. Each nurse on the unit

that provides care for the patients is educated on what antipsychotic medications are used for,

their side effects, and the signs and symptoms such as extrapyramidal symptoms, serotonin

syndrome, and of a rare but serious condition called neuroleptic malignant syndrome (NMS).

A newer approach to treating antisocial personality disorder called mentalization based

treatment (MBT) that was originally used for borderline personality disorder. This approach is

used to help those with ASPD gain new insight to own and understand their actions through

thoughts and feelings, in addition to what others have experienced (Bateman. W, 2022). This

approach of treatment is to help those with ASPD with mental processes that are out of balance

and easily disrupted due to their disorder. Abstraction, for example, is a mental process that MBT

helps those with ASPD work on and implement in their daily lives.
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Another aspect of the treatment that BA underwent was the unit's daily group sessions

including psychoeducation and community. He was encouraged to attend and participate in these

groups as they are kept track of to see where patients are with their implemented nursing goals.

The psychiatric unit has a structured schedule that includes when staff other than nurses come,

group sessions, meal times, phone calls, and personal visits. BA had trouble in the beginning

attending many of these group sessions, but as BA became more trusting and comfortable, he

started to attend. BA has shown a positive attitude on the unit and towards staff after attending

groups more often. BA states that he hopes to stay clean and comply with treatment to achieve

his goals upon discharge.

Ethnic, spiritual and cultural influences

BA is a middle-eastern, single male from an upper middle-class family. He is

unemployed, lives alone, and depends on state assistance. BA does not currently practice a

religion, but regularly talks about Allah (God) and his will. When asked about his spiritual

beliefs, he stated he was intune with his Islamic faith, but his condition has made it hard for him

to believe. He stated that in the Islamic faith, suicide is considered a cardinal sin and those who

commit will be forbidden from entering paradise. BA stated that he feels if he gets clean and

manages his psychiatric diagnoses, he will have a better connection to Allah (God). Upon

discharge he hopes to attend the Youngstown Islamic Center and or the Islamic Society of

Greater Youngstown to worship. Both are Mosques, places of worship, for those of the Islamic

faith.

Evaluation of patient outcomes

The outcomes that are desired for a patient with antisocial personality disorder include

learning how to maintain lawful behaviors, remaining compliant with treatments, free from
Psychiatric Mental Health Comprehensive Case Study 10

harming themselves or others, understanding the thoughts of oneself and others, and socializing

by communicating with others appropriately. On BAs day of care, he was showing empathy for

those in the group and understanding theory thoughts and feelings. BA would respond to other

group members and commend them for being open and agree with what they had to say. He also

shared his thoughts and feelings without being asked. He had remained free from any and all

hallucinations while he was on the psychiatric inpatient unit, he was not showing aggression

towards staff or other patients, did not appear irritable, had no outburst on the unit, and was

compliant with taking his medications as ordered.

Other outcomes that were only partially met on the day of care was BA’s ability to remain

free from anxiety. BA was anxious by the end of the day, but was able to speak to the appropriate

staff about his feelings. He would find his nurse for the day and ask about his anxiety

medications to help relieve it. BA’s mood disorder which contributed to anxiety and depression

became better managed on the day of care compared to when he was admitted due to better

communication. When BA is asked to appropriately rate his anxiety on a scale of 1 to 10, with

one being the lowest and ten the highest, he rated his anxiety at the time a 6. During the day,

BA’s anxiety was rated a 3. Both times he has denied any feelings of depression. BA remains

compliant with medications when they are due and uses the unit's group sessions as a way to

manage both the anxiety and depression symptoms as he feels the patients and staff are

understanding and empathetic.

Plans for discharge

When BA is discharged, he will go to a rehabilitation facility where he hopes to become clean.

BA and staff felt that upon discharge from the inpatient unit, Meridian on Chalmers Avenue in

Youngstown, Ohio, would be beneficial in achieving the goal of sobriety. Meridian does pick up
Psychiatric Mental Health Comprehensive Case Study 11

potential patients upon discharge, but they do not force them to stay as they are an at will facility.

BA will be discharged with a month's supply of his medication, and will be referred to and

encouraged to make an outpatient appointment with a mental health agency in his community.

BA will be referred to a psychiatrist in the community and encouraged to attend sessions with

them, and to stay compliant with his medications. Educational material will be provided to BA

about his medications, possible side effects, and adverse reactions that can occur.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for BA:

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

hallucinations.

2. Risk for impaired decision making related to reduced impulse control as evidenced by

psychiatric diagnosis of antisocial personality disorder and command auditory

hallucinations.

3. Anxiety related to multiple adverse situations and hopelessness as evidenced by Mood

Disorder, Unspecified.

4. Risk for suicide related to previous suicidal ideation and attempt, and hallucinations.

5. Risk for other and self directed violence related to ineffective impulse control and

command auditory hallucinations.

6. Risk for self-harm related to ineffective impulse control and command auditory

hallucinations.

Potential nursing diagnoses

1. Ineffective coping related to history of substance abuse and inadequate social support.

2. Impaired verbal communication related to psychiatric diagnosis of antisocial personality

Psychiatric Mental Health Comprehensive Case Study 12

disorder.

3. Deficient diversional activity related to mood disorder.

4. Ineffective health maintenance related to lack of health insurance and multiple coexisting

adverse situations.

5. Fear related to lack of support and command auditory hallucinations and ineffective

impulse control.

6. Hopelessness related to inadequate social support and dysfunctional family processes.

7. Impaired memory related to history of substance abuse.

8. Impaired individual resilience related to substance abuse.

9. Self-care deficit related to multiple coexisting adverse situations.

10. Impaired social interaction related to psychiatric diagnosis of antisocial personality

disorder.

11. Social isolation related to psychiatric diagnosis of antisocial personality disorder.

Conclusion

Antisocial personality disorder is a complex mental illness that is hard to treat but not

impossible to manage. Though it is hard for those with ASPD to manage their symptoms as they

suffer from non-compliance with therapy and medication as well as having impaired social

relationships, with the right support system it may be possible for some to overcome it. The

mood disorder exhibited along with a history and active substance abuse mixed with the patient's

ASPD becomes dangerous for the patient and others as he begins to feel hopeless and resorts to

noncompliance due to the command auditory hallucinations he experiences. BA has not been

violent during his stay, but has shown disturbed sensory perception, communication deficits, and

impaired thought processes during his admission that made hospitalization necessary until his
Psychiatric Mental Health Comprehensive Case Study 13

hallucinations and symptoms became manageable.

BA was exhibiting severe command auditory hallucinations that were present upon

admission that encouraged him to self-harm or find someone else to do it for him, putting him at

risk for reckless behavior leading to injury of himself or others. BA is still at an increased risk

for self harm, other directed self harm, and suicide attempts since these have occurred in the past.

Upon discharge including education, the goal for BA is to remain compliant with his medications

as he has failed to in the past and seek community therapy to avoid criminal behavior and

self-harm situations. If BA is regular and consistent with his treatment plans, his symptoms

should be manageable and easier to control. This is in hopes that BA does not seriously harm

himself or others and or commit more crimes. BA was encouraged to seek help immediately if

symptoms begin to become unmanageable.

Psychiatric Mental Health Comprehensive Case Study 14

References

Bateman, A. (2022). Mentalizing and Group Psychotherapy: A Novel Treatment for antisocial

personality disorder. The American Journal of Psychotherapy, 75(1), 32-37.

Anderson, J. L., & Kelley, S. E. (2022). Antisocial personality disorder and psychopathy: The

AMPD in review. Personality Disorders: Theory, Research, and Treatment, 13(4),

397–401. https://psycnet.apa.org/fulltext/2022-78256-020.html

Ackley, B.J., Ladwig, G.B., Makic, M.B.F., Martinez-Kratz, M.R., & Zanotti, M. (2020).

Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Twelfth

Edition. St. Louis, Missouri, Elsevier.

Videbeck, S. (2020). Chapters 17 and 18. In Psychiatric-Mental Health Nursing (pp. ).

Lippincott Williams & Wilkins.