Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Steven D’Eusanio

November 12, 2021

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

Lucas is a 24-year-old biological female patient admitted to Generations Behavioral Health

psychiatric outpatient unit following a suicide attempt. He has a mental health diagnosis of

schizoaffective disorder (bipolar type), and borderline personality disorder. He experiences

auditory/ visual hallucinations as well as grandiose delusions. With medication treatments

including antipsychotics, antidepressants, beta blockers and SSRI’s, the symptoms have become

somewhat more manageable, and Lucas has resumed to a more normal functioning level of

ADL’s and effective communication. Nursing care provided on the unit is focused on re-

orientation to reality and anxiety/ depression management through pharmacologic methods, non-

pharmacologic methods, as well as group therapy and individual therapy sessions.

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Objective Data

Patient identifier JH-” Lucas”

Age 24

Sex Biologic Female currently socially transitioning to Male

Date of admission October 26, 2021

Date of care October 28, 2021

Psychiatric diagnosis schizoaffective disorder (Bipolar type), Borderline personality

Other diagnoses Anxiety, depression, SI with a plan

Behaviors on admission Lucas was having very severe nightmares for the last 2 months. In

these nightmares he exclaimed that there were voices telling him to kill himself and how to do it.

He also has auditory and visual hallucinations of demons and angels for ‘as long as he can

remember’. Lucas also had a plan to kill himself by either running into traffic, strangling self, or

cutting his throat. In addition to this, Lucas was also complaining of increasing anxiety and

depression in the past month and her medications were not working effectively.

Behavior on day of care Lucas was guarded and suspicious when I first started talking to her,

but as the conversation went on, I was able to get him to open up and trust me. Lucas had been

attending all the groups since he was admitted and appeared well dressed and well groomed.

Lucas was writing down her goals for the day and prioritizing what he wanted to get done when

he was discharged. Lucas was having religious and grandiose delusions and was still

experiencing visual/ auditory hallucinations of demons and angels. Lucas had a positive outlook

and stated that he had a plan to become a body builder/ personal trainer in the future. Lucas was

well oriented and spoke clearly with an appropriate tone. At times he was having trouble

explaining how he was feeling, but after giving him time he was able to expand and elaborate on
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different topics. After a group therapy session was over, Lucas was distraught. He felt like he

was not welcomed and did not have a chance to speak in a group and was outwardly expressive

of this to the nurses and staff. This really upset him. He also stated that the demons were not

telling him to hurt himself anymore.

Safety and security measures Throughout the inpatient admission there were safety checks

implemented around the clock every 15-minutes. There are two sets of doors getting on and off

the unit. All hazardous items such as shoelaces, razors, and pens were not permitted on the unit,

and only markers were used for writing. Medications were provided to the patient in the

window. Patients were in charge of getting their own medications as this causes the patient to

take responsibility for their treatment and remain active in their own care. The patient advocate

number is provided by law on the floor if the patient is feeling like they are not being treated

fairly. There is constant staff supervision on the unit. The use of paper garbage bags is also

implemented in addition to curved and shortened bathroom doors. There is also no exposed

plumbing in the bathrooms as well.

Laboratory results

Lab Value Result

Glucose 102
TSH N/A
T4 N/A
RBC N/A
Hbg/Hct 13.4/ 39.4
WBC 9.8
BUN/Crea. 13/ 0.9
QTc 416
Toxicology Negative
UA Alch Negative
K/ Na 3.8/ 141
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When looking at the results, it is important to note the glucose level. This is important to

note because the patient is well over 300 pounds and is on multiple atypical antipsychotics which

have a possible side effect of increasing glucose levels. Since the glucose levels are already a

little high at 102, this could push the glucose levels to a level that would need intervention/

medication. All his other levels are within normal limits.

Psychiatric medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Aripiprazole Abilify Atypical 1x Daily, 30mg Schizophrenia
Antipsychotic tab
Propranolol Beta blocker 1x Daily, 10mg HTN/
tab Nightmares/
Anxiety
Sertraline Zoloft SSRI 1x Daily, 100mg Anxiety/
tab Depression
Paliperidone Invega Sustenna Long-acting Q 3 months, 819 Schizoaffective
palmitate atypical mg/ 2.265mL Disorder
antipsychotic

Summary of psychiatric diagnosis

Schizoaffective disorder is a chronic mental health condition characterized primarily by

symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood

disorder, such as mania and depression. Schizoaffective is relatively rare, with a lifetime

prevalence of only 0.3%. Men and women experience schizoaffective disorder at the same rate,

but men often develop the illness at an earlier age. Schizoaffective disorder can be managed

effectively with medication and therapy. Co-occurring substance use disorders are a serious risk

and require integrated treatment. (National Alliance on Mental Illness 2021). There are two
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types of schizoaffective disorders, which are either bipolar type or depressive type. Lucas has

bipolar type which includes episodes of mania and sometimes major depression.

Schizoaffective disorder can be difficult to diagnose because it has symptoms of both

schizophrenia and either depression or bipolar disorder. There are two major types of

schizoaffective disorder: bipolar type and depressive type. To be diagnosed with schizoaffective

disorder a person must have the following symptoms:

 A period during which there is a major mood disorder, either depression or mania, that

occurs at the same time that symptoms of schizophrenia are present.

 Delusions or hallucinations for two or more weeks in the absence of a major mood

episode.

 Symptoms that meet criteria for a major mood episode are present for the majority of the

total duration of the illness.

 The abuse of drugs or a medication are not responsible for the symptoms (NAMI 2021).

Some other criteria for diagnosis include:

 Physical exam. This may be done to help rule out other problems that could be causing

symptoms and to check for any related complications.

 Tests and screenings. These may include tests that help rule out conditions with similar

symptoms, and screening for alcohol and drugs. In certain situations, the doctor may also

request imaging studies, such as an MRI or CT scan.

 Psychiatric evaluation. A doctor or mental health professional checks mental status by

observing appearance and demeanor and asking about thoughts, moods, delusions,

hallucinations, substance use and potential for suicide. This also includes a discussion of

family and personal history.

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 Diagnostic criteria for schizoaffective disorder. Your doctor or mental health professional

may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders DSM-5,

published by the American Psychiatric Association (Mayo Clinic 2021)

Delusions are one of the symptoms of schizoaffective disorder. Delusions are when a

person cannot tell what is real from what is imagined. People with delusional disorders

experience non-bizarre delusions, which involve situations that could occur in real life, such as

being followed, poisoned, deceived, conspired against, or loved from a distance (Cleveland

Clinic 2018). Lucas exhibited signs of having delusions of grandeur, where he believes that he

will become a body builder and fitness influencer within a very short amount of time given that

he is well over 300 pounds. His plan is to get into shape, become a body builder, and make

money from personal training to put him through college to pursue a degree in exercise science.

Lucas also has a religious type of grandiose delusion that coordinates with her auditory

hallucinations in that he believes angels and demons speak to her and tell her what to do.

In addition to delusions, Lucas was also having severe hallucinations. He stated he saw

angels and demons on a regular basis every day. He even went as far to name them all to me and

tell me if they were nice or mean to him. He also stated that the demons would often tell him to

hurt himself and even kill himself. He stated, “The demons names are Asmodeus, Andras, and

Azazel. The angels' names are Ariel and Samael”. Upon doing more research, these demons and

angels are very common in many TV shows such as Supernatural, in Marvel comics and many

horror books. Upon asking Lucas if he watched any horror shows or read horror books, he stated

he was into horror books and had watched the show supernatural before. This drew the

conclusion that what he was reading and watching was manifesting in his hallucinations and

delusions daily. However, Lucas explained he never knew these names of the angels and
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demons until he googled them and found out they were real. Another hallucination Lucas was

having is man eating plants. He believed that when he was experiencing the most anxiety and

his symptoms were bad, he would hallucinate these plants that would try to eat him.

Another common occurrence in schizoaffective disorder patients is suicidal ideation and

suicidal behavior. Lucas had very bad nightmares for the last month. In these nightmares, Lucas

says that there were demons telling him to kill himself by either running into traffic, hang

himself, or cut his throat. Lucas stated this is what caused him to go into the ER as it had been

going on for too long and he almost brought himself to put an end to his life.

Lucas also has borderline personality disorder. Borderline personality disorder is defined

as an illness marked by an ongoing pattern of varying moods, self-image, and behavior. These

symptoms often result in impulsive actions and problems in relationships. People with borderline

personality disorder may experience intense episodes of anger, depression, and anxiety that can

last from a few hours to days. People with borderline personality disorder may experience mood

swings and display uncertainty about how they see themselves and their role in the world. As a

result, their interests and values can change quickly (National Institute of Mental Health 2017).

This is shown by Lucas’s problem with her body image. He is obsessed with being this super in

shape body builder but is morbidly obese. He is aware he is well overweight, and this causes

him stress and uncertainty when it comes to his body image.

Identification of stressors and behaviors precipitating current hospitalization

Prior to admission, Lucas was non-compliant with her medications. He lives alone in an

apartment and states he has a good relationship with her mother. Lucas stated he does not

currently have a job and relies on mom for most of his financial assistance as well as the

government. Lucas stated that he was having nightmares/ hallucinations every single day. He
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presented the ER with suicidal ideation with a plan. Lucas states that with the long-acting

atypical antipsychotic he feels he does not need to stay compliant with other medications and

relies on the injection once every three months. He also stated that the longer he gets from the

injection, the worse his symptoms will get, and this will usually cause him to go into the ER.

Patient and family history of mental illness

Lucas stated that he has had a mental illness ever since he was 3 years old. He said that

he was molested as a 3-year-old, and he was also abused by his father at a young age as well.

Lucas says nobody in his family has a history of mental illness and it is just him. He stated he

does not have a great relationship with his father and sees him occasionally, even though he says

he abused him as a child. He does not have a great relationship with his siblings either.

LGBTQI Community and Mental Health

Lucas is currently transitioning socially from a biologic female to male. Upon talking to

him, he stated he preferred to be called Lucas instead of his name given at birth. Lucas

explained that this transition has not been easy at all and has brought many challenges to his

everyday life. He stated that since his family has not been very accepting, it has increased his

anxiety and added to his depression. He also stated he was interested in hormone therapy to start

but said his mother would not allow him to do this unless he dropped a lot of weight and got

down to 250 pounds.

This led Lucas to have delusions about his body image and set unrealistic goals for

himself. Lucas is aware of his body image and recognized he was overweight, but his means for

loosing weight were inadequate in both time frame and overall planning. This also brought

about the problem that Lucas did not have adequate support systems while going through his

transition. It is highly recommended that those transitioning to have support from a psychologist
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and psychiatrist, and this transition be a minimum of 5 years to ensure that it is what the person

really wants.

Although the full range of LGBTQI identities are not commonly included in large-scale

studies of mental health, there is strong evidence from recent research that members of this

community are at a higher risk for experiencing mental health conditions — especially

depression and anxiety disorders. LGB adults are more than twice as likely as heterosexual

adults to experience a mental health condition. Transgender individuals are nearly four times as

likely as cisgender individuals (people whose gender identity corresponds with their birth sex)

individuals to experience a mental health condition. In addition, for many LGBTQI people,

socioeconomic and cultural conditions negatively impact mental health conditions. Many in the

LGBTQI community face discrimination, prejudice, denial of civil and human rights,

harassment, and family rejection, which can lead to new or worsened symptoms, particularly for

those with intersecting racial or socioeconomic identities (NAMI 2021).

Psychiatric evidence-based nursing care provided

During his stay on the inpatient unit, Lucas received nursing care from the nursing staff.

He was treated with respect and said the nurses were trying their best to call him by Lucas even

thought they would make mistakes sometimes. Upon admission, Lucas was not attending all the

group therapy sessions held as he said it increased his anxiety. Throughout his stay, he started to

attend more groups and get motivation and praise from the staff when he did go. Lucas would

get individual time with nurses when her symptoms would worsen as well, or if he did not feel

welcomed in the group.

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During the time he was on the unit, Lucas was able to effectively establish a routine for

working out and prioritizing what he wanted to get done for the day. He also was able to form

new relationships with other patients on the unit as well as the nurses. He also explained that the

nurses would try and help to identify trigger and stressors that would lead to having episodes and

how to manage these symptoms as well.

Ethnic, spiritual, and cultural influences

Lucas is a Caucasian, single woman from a middle-class family. He did not specify

about having a religion he practices. Spiritually, there was a tattoo that was hidden under

clothing on his left shoulder, that could indicate some sort of spiritual belief. The symbol is a

devil’s trap and is used to immobilize and control demons. This could possibly be a source of

protection in his mind, as it is said to inhibit demonic powers. The tattoo is shown below.

Evaluation of patient outcomes

When looking at the desired outcomes for a patient with schizoaffective disorder, one of

the focuses is on social skills training. This focuses on improving communication and social

interactions and improving the ability to participate in daily activities. New skills and behaviors

specific to settings such as the home or workplace can be practiced. Lucas had a little bit of a

problem with this as seen when he felt he did not get to participate in group. After this group he

made it clear he was very upset about this and did not feel like he belonged. The nurse then
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talked to Lucas for nearly 30 minutes after to reassure her and see what was on her mind. Lucas

is aware of this behavior and is working to improve it.

With borderline personality disorder, the plan is to develop and stick to a treatment plan

with Lucas. Therefore, it is so important to try and get him back to his psychiatrist as this will

give the best results for him down the road. This may take encouragement from staff, family,

and close friends as well. Research has demonstrated that certain psychological and

pharmacological interventions are more efficacious than others. Experts believe that those with

BPD need long-term therapy to attain and maintain lasting results. The treatment plan should be

focused on addressing both BPD symptoms as well as comorbid psychiatric conditions.

Plans for discharge

Upon discharge, Lucas will be going back to his apartment where he lives alone but has

frequent contact with his mother. He is urged to get back into contact with his psychologist after

having a fall out earlier in the year with them. Lucas is urged to stay compliant with all his

medications. Lucas was also given different support groups contacts and was also provided with

many new coping mechanisms he acquired throughout his stay. Lucas plans to workout at the

YMCA every day, walk another 10k, and pursue her career in body building.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for LL:

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

hallucinations.

2. Disturbed thought processes related to mental illness as evidenced by non-realistic

thinking and delusions.

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

4. Risk for violence related to delusions and hallucinations.

5. Risk for self-harm related to delusions and hallucinations.

6. Risk for ineffective coping related to mental illness as evidenced by poor social support

system/ people

Potential nursing diagnoses

1. Ineffective coping

2. Impaired sensory perception

3. Ineffective activity planning

4. Impaired verbal communication

5. Ineffective health maintenance

6. Hopelessness

7. Impaired social interaction

8. Social isolation

9. Chronic low self esteem

Conclusion

Schizoaffective disorder along with borderline personality disorder is a serious

combination to be diagnosed with. This plays a huge role in how people have trouble interacting

in social environments as well as socially with other people. The depression and anxiety that go

along with these diagnoses is very serious and should not be taken lightly at all. There is a

distinct pattern with Lucas and when he was being hospitalized. This is due to a medication

compliance issue and a lack of social support that he has as well.

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To make matters worse, hallucinations and delusions are very common in individuals

affected, especially when a patient is hallucinating of demons telling him to self-harm, and it is

not the first time it has happened. It is crucial to get help for Lucas and get him connected to

possible LGBTQ community groups as this may ease the tension he has on a day-to-day basis.

In addition to community groups again, a psychiatrist or psychologist is highly recommended for

those who are in transition no matter what stage of transition they are in.
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References

Delusional disorder: Treatments, causes, types & diagnosis. Cleveland Clinic. (n.d.). Retrieved
November 12, 2021, from https://my.clevelandclinic.org/health/diseases/9599-delusional-
disorder.

LGBTQI. NAMI. (n.d.). Retrieved November 12, 2021, from https://www.nami.org/Your-

Journey/Identity-and-Cultural-Dimensions/LGBTQI.

Mayo Foundation for Medical Education and Research. (2019, November 9). Schizoaffective
disorder. Mayo Clinic. Retrieved November 12, 2021, from
https://www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/diagnosis-
treatment/drc-20354509.

Schizoaffective disorder. NAMI. (n.d.). Retrieved November 12, 2021, from

https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-
Disorder/Support.

U.S. Department of Health and Human Services. (n.d.). NIMH " borderline personality disorder.
National Institute of Mental Health. Retrieved November 12, 2021, from
https://www.nimh.nih.gov/health/topics/borderline-personality-disorder.