Running Head: Psych Case Study 1

Psych Case Study

Brianna Wasylychyn

YSU Centofanti School of Nursing

Mental Health Nursing Clinical NURS 4842L

Mrs. D

October 20, 2023

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Abstract

The following case study explores the disease process of a patient who lives with

Mixed Bipolar II Disorder and the plan of care and evidence-based treatments utilized to

care for the patient. The subject of this case study is a 20-year-old female patient with

the initials D.S. She was admitted to the psych unit at St. Elizabeth’s Youngstown

Hospital following a suicide attempt at home. She also has accompanying diagnoses of

anxiety and depression. This case study will explore what bipolar disorder is, the

manifestations of bipolar disorder, the patient’s stressors and behaviors that led to the

hospitalization, family history of mental illness, the evidence-based care for bipolar

disorder, spiritual and cultural influences on the patient, and an evaluation of the

patient’s outcomes. Multiple research resources were utilized to enhance the subject of

this case study’s disorder and the manifestations.

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Objective Data

D.S. is a 20-year-old female Caucasian patient that was admitted to the

psychiatry unit at St. Elizabeth’s Youngstown Hospital on October 5, 2023 with a

diagnosis of Mixed Bipolar II Disorder which is also accompanied by other diagnoses of

anxiety and depression. She has no other medical diagnoses. D.S. was admitted to the

psych unit following a twelve hour stay in the emergency department at the hospital

following a suicide attempt at home. The date of care for D.S. was October 6, 2023.

While interviewing D.S. on the unit, she exhibited interest in conversation, was

friendly, attentive, interested, and cooperative towards me. She also displayed normal

affect, appropriate mood, appropriate actions, and did not struggle with concentration. In

contrast to the previously stated “normal” characteristics, D.S. also appeared

depressed, anhedonic, and hypomanic.

When I first approached D.S. in the milieu, I explained to her that I was a

Youngstown State University nursing student and that I wanted to spend some time with

her and talk to her. She responded in a very friendly manner and appeared interested in

the prospect of this. At the beginning of our interview, D.S. stated that she “slept great

last night” and ate her full breakfast tray that morning. D.S. also stated that she believed

her good night of sleep was because she “was finally out of the ER after being there

after her suicide attempt.” This served as a great turning point in conversation with D.S.

because we began to discuss what led to her suicide attempt.

On the evening of October 4, 2023, D.S. overdosed on 10-20 Benadryl pills at

home. D.S. reports recent stressors of beginning a new job, a recent argument with her
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brother, and a tumultuous relationship with her mother, both of whom she lives with. She

also reports recent feelings of being “depressed and suicidal” leading up to the suicide

attempt, but also reports the situation as “impulsive.” D.S. states that she took an

overdose of Benadryl mainly to “sleep more” but she also “would have been okay if she

died.” D.S. drove herself to the emergency room “not because she attempted suicide”

but because of the “side effects of the Benadryl and she felt sick.” After taking herself to

the emergency room and being there for twelve hours, she was then admitted to the

psych unit.

Although no longer experiencing suicidal thoughts or suicidal ideation, D.S. is on

suicidal precautions throughout the duration of the current inpatient stay due to her

suicide attempt. D.S. appeared to be mildly depressed. While she did seem to be

entering a positive mindset, she was still down about the recent events of her suicide

attempt, being on the psych unit again, and her troubled relationship with her mother.

She expressed being concerned about returning home after discharge because she

was “unsure of how her mother would react and where their relationship would stand.”

She also appeared to be rather anhedonic. While we were discussing finding things that

she could enjoy and finding something she is passionate about, D.S. stated that she

“finds it hard to be passionate about anything.” D.S. also exhibited signs of hypomania

throughout our day together. She was consistently focused on her issues with both her

mother and brother at home would often go on small rants about that situation.

D.S. is ordered a handful of different medications for the current inpatient stay.

Her only scheduled medication is a Nicotine (Nicoderm CQ) 24mg patch daily to help

with nicotine withdrawal symptoms. The rest of the medications ordered for D.S. are all
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scheduled as needed. She is ordered 5mg of the antipsychotic Haloperidol (Haldol)

every 6 hours for psychosis related to bipolar disorder. This is available both oral and

intramuscular. D.S. is also ordered 50mg of the antihistamine Hydroxyzine (Atarax)

orally every 3 hours for anxiety. She is also ordered 3mg of oral Melatonin every day

nightly as a sleep aid and for insomnia.

Routine labs were assessed upon admission to the emergency department

following D.S.’s suicide attempt. All her lab values were within normal range for

potassium, sodium, glucose/A1C, blood urea nitrogen (BUN), creatinine, red blood cells,

hemoglobin, hematocrit, and AST/ALT liver enzymes. Amongst psych patients, there are

often abnormalities with the previously listed lab values, which can be caused by either

the mental illness itself or by some of the medications that treat certain mental illnesses.

However, D.S. did have an elevated white blood cell count of 12.5 (normal range is 4.5-

11.5). Elevated white blood cell counts are commonly seen in patients with anxiety and

depression. D.S. tested negative for lithium, Depakote, Tegretol, any illicit drugs, and

alcohol. Her ECG was in normal sinus rhythm, and she had no prolonged QT interval

(QTC), which can commonly be seen with antipsychotic use.

Summary of Diagnosis

The primary psychiatric diagnosis for D.S. is Mixed Bipolar II Disorder. According

to Psychiatric-Mental Health Nursing by Sheila Videbeck, bipolar disorder is defined as

a mood disorder that “involves extreme mood swings from episodes of mania to

episodes of depression” (Videbeck, p. 306). In the case of patients diagnosed with a

mixed bipolar disorder, they can experience both depression and mania simultaneously.

Episodes of depression and mania can also occur in a very rapid sequence with no
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period of recovery in between each other. During depressed phases, according to the

text, patients with bipolar disorder reflect “the same mood, behavior, and thoughts as

those with major depression” (Videbeck, p. 306). In depressed episodes, these patients

will often experience a persistent feeling of loss of interest in previously enjoyed

activities and sadness. Manic episodes are characterized by clients being “euphoric,

grandiose, energetic, and sleepless” and are often also exhibiting “poor judgement and

rapid thoughts, actions, and speech” (Videbeck, p. 306). Manic episodes will manifest

as high energy, euphoria, and excitement over a sustained period.

Common signs and symptoms of bipolar disorder can vary. Each patient

diagnosed with bipolar disorder may manifest different, but the signs heavily depend

upon whether the patient is experiencing a depressed episode or a manic episode, or in

the case of mixed bipolar disorder like D.S., if they are experiencing both at the same

time. Some of the common signs of a depressed episode in bipolar disorder include

feeling sad and hopeless, loss of interest, decreased energy, pessimism, self-doubt,

feeling empty, decreased appetite, delusions, and suicidal thoughts. Common signs we

observe during manic episodes may include being very happy or elated, rapid speech,

high energy, grandiosity, easily distracted, irritable, delusions and hallucinations,

decreased sleep, and making risky decisions.

Stressors and Behaviors Precipitating Hospitalization

Throughout my interview with D.S., I identified multiple clear current stressors

that appeared to be directly correlated with her recent suicide attempt and subsequent

hospitalization. D.S. stated that she began a new job at a local clothing store within two

weeks prior to her hospitalization and that “she was struggling with the change” and that
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she “does not really like her new job.” She also explained to me that on the day of her

suicide attempt, she had gotten into an argument with her brother over him refusing to

do a favor for her. She went on to explain that she lives with her brother at home and

that they “have never gotten along.” She explained that a lot of the tension she has with

her brother is because of her mother’s “favoritism toward [her] brother over [herself].”

D.S. also detailed ongoing conflicts with her mother. She lives with both of her

parents as well as her brother, which was previously stated. D.S. feels that most of the

tension she has with her mother stems from her mother also being diagnosed with

bipolar disorder. She believes that her mother “does not understand [her] when she

should be the one who understands [her] the most.” She also explained to me that her

mother will often threaten to kick her out of the house and will “pick on her about little

things that she knows is triggering for her.” D.S. did also state that her father is very

supportive of her, and she can count on him, but he “avoids getting in the middle of her

and her mother’s arguments.”

Patient and Family History of Mental Illness

D.S. has a family history of bipolar disorder. Her mother also struggles with

bipolar disorder which is often the reason D.S. conflicts with her mother. D.S. did not

directly state how her mother’s bipolar disorder manifests. However, statements made

by D.S. point toward her mother experiencing manic episodes and during these

episodes she often lashes out at D.S. In turn, her mother’s manic episodes often

negatively affect D.S. and push her toward a depressive episode. She alluded to this

process being a constant cycle and this process continues over and over.
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Living with a parent with bipolar disorder can often present challenges, especially

if it is not managed properly. In the case of D.S. and her mother who also struggles with

bipolar disorder, it is substantially more challenging because they are both dealing with

similar issues. According to the article What Does It Mean to Have a Parent with Bipolar

Disorder?, the children of parents with bipolar disorder may experience “difficulty

[building] relationships, have excess responsibility, and have extreme levels of anxiety”

(Pointer, 2019). These issues are exacerbated for D.S. because of her own struggles

with bipolar disorder. The manifestations of both D.S. and her mother’s bipolar disorder

often piggyback off one another and are also heavily influenced by one another. This

creates a toxic environment to cope with the mental illness not just for D.S., but also her

mother.

Evidence-Based Care and Milieu Therapy

During my time with D.S. on the psychiatry unit, I witnessed her participating in

many milieu activities. When I first met her, she was sitting in the common area with

some of the other patients and was interacting with them. After our interview, there was

a group therapy session being held in the milieu. During group therapy, she listed her

goal for the day to the therapist, attentively listened to the therapist’s lesson on

grounding techniques, and participating in the activities encouraged by the therapist

during the lesson. A short time after the group therapy session, D.S. also attended a

psychotherapy session with some of the other patients and a social worker. After

psychotherapy, she was coloring in the common area with other patients.

All the current treatments in place for D.S. for her bipolar disorder are all

evidence-based practices that have been shown to treat bipolar disorder well. According
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to the WebMD article Medications for Bipolar Disorder, there are many medications

used to treat bipolar disorder because “some fight the extreme highs of mania and

others treat the lows of depression” (Bhandari, 2022). The article also states that the

“most common type of drug to treat bipolar disorder are mood stabilizers,” and that

“some of these drugs are known as anticonvulsants while others are antipsychotics”

(Bhandari, 2022). One of the medications ordered for D.S. is Haldol, which is an

antipsychotic known to treat bipolar disorder.

Psychotherapy is another proven method of treatment for bipolar disorder, which

D.S. is engaged in during this current inpatient stay. According to the article Bipolar

Disorder published by the Mayo Clinic, “psychotherapy is a vital part of bipolar disorder

treatment and can be provided in individual, family, or group settings” (Mayo Clinic).

While on the psych unit, D.S. has been attending group therapy meetings which is

proven to be effective for treating bipolar disorder. The article also cites family-focused

therapy as a beneficial treatment as it creates “family support and communication” to

“help [the] patient to stick to [their] treatment plan” (Mayo Clinic, 2022). I believe that

family therapy would be beneficial for D.S. as her family learns to better support her, it

may also benefit her mother and create a healthier environment for their entire family.

Ethnic, Spiritual, and Cultural Influences

D.S. did not state belonging to a specific religion or any spiritual practices. She

also did not state any ethnic traditions or considerations to be made aware of. However,

D.S. did state having some friends that she will sometimes talk to but “she does not

have any very close friends” that she sees frequently and socializes with. She is not

currently in a relationship. She discussed an interest in attending concerts of some of

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her favorite music artists, a love for reading, and enjoyment of watching her favorite

television shows. She also discussed work as being a good hobby, but, again, is

struggling with her new place of employment.

Evaluation of Patient Outcomes

Throughout the day with D.S. on the psych unit, she displayed many positive

improvements and great promise when regarding the outcomes of care. She was

placed on suicide precautions, made no attempts to harm herself or others, and

remained safe from injury. She has been sleeping well through the night and has had an

adequate appetite and has been eating her meals. Despite displaying a mild depressed

mood, she generally has a positive outlook when it comes to working through her recent

suicide attempt and how she will continue to move forward. She has been compliant

with medication regimen and is aware of which medications are available to her if she

feels they are needed. She has been in communication with the treatment team and is

attending group activities and therapy.

Discharge Plans

Currently, there is no clear discharge plan in place for D.S. The date of care was

her first day on the psych unit. The current plan in place is to continue with medication

regimen and therapy on the unit and discharge plans will be evaluated at a future point

in time. Although no discharge plans are currently in place, it is expected that D.S. will

return home with her mother, father, and brother. She also stated that she intends to

continue with outpatient treatment and try to work on her relationship with her mother.
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Prioritized List of Actual Nursing Diagnoses

Risk for Suicide related to depression as evidenced by recent suicide attempt of

overdosing on 10-20 Benadryl pills.

Interrupted Family Process related to mental illness of patient and other family member

as evidenced by strained relationship of patient and her mother.

Disturbed Thought Processes related to psychotic process as evidenced by impulse to

take an excessive dose of Benadryl.

Risk for Injury related to destructive behaviors as evidenced by suicidal tendencies and

nicotine use.

Potential Nursing Diagnoses

Potential nursing diagnoses for bipolar disorder include self-care deficit,

disturbed sensory perception, imbalanced nutrition, risk for other-directed violence,

impaired social interaction, risk for loneliness, risk for insomnia, risk for disturbed sleep

pattern, ineffective health maintenance, and risk for spiritual distress.

Conclusion

D.S. was an interesting patient to explore as a case study patient. Her complex

relationship with her mother who also has bipolar disorder was solidified as a true

stressor in her life which leads to exacerbations of her mental illness. I believe that

despite her struggles with bipolar disorder, I think that D.S. has a great amount of

potential to get control over her disorder and treatment to live a functional and fulfilling

life. I believe that with continuing outpatient treatment after discharge, adhering to a
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medication regimen, and engaging in family therapy with those she lives with will

improve her mental health and her functionality substantially.

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References

Bhandari, S., MD. Medications for Bipolar Disorder. (2022, August 12). WebMD. https://

www.webmd.com/bipolar-disorder/medications-bipolar-disorder

Bipolar Disorder – Diagnosis and Treatment – Mayo Clinic. (2022, December 13). https:/

/www.mayoclinic.org/diseases-conditions/bipolar-disorder/diagnosis-treatment/dr

c-20355961

Pointer, K. What Does It Mean to Have a Parent with Bipolar Disorder? (2019,

November 5). Healthline. https://www.healthline.com/health/bipolar-disorder/how-

to-deal-with-a-bipolar-parent#:~:text=It%20typically%20involves%20episodes%2

0of,in%20activities%20you%20typically%20enjoy.

Videbeck, S.L., PhD RN. (2022). Videbeck’s Psychiatric-Mental Health Nursing.