Comprehensive Case study review of a patient's experience: Mental Illness

Dora's mother reported that she has been noticing changes/symptoms in her behaviour in the past 2 months. On the other hand, Dora herself accounted that she started visualising things since 6 months. The patient was followed-up quite quickly after the initial check-up. The follow-up involved consultation with a psychiatrist for about a week. In case the occurrence of delusions and hallucinations increase, the patient has to be immediately hospitalised (Bortolon, Capdevielle and Raffard, 2015).

PHYSICAL ASSESSMENT

Before the doctor prescribes any sort of tests or medicines, there is a physical assessment conducted (Khademvatan and Yousefi, 2014). For Dora, this assessment included general check-up of the vitals which included blood pressure, weight, eye movements and pulse rate. The involuntary movements of body and diverging actions, repetitive motions, check up of twitches and tics are some of the parameters that are considered during the physical examination (Rasic and et.al., 2014). The doctor identified that Dora blinked her eyes very less while swung her leg in a pendulum motion continuously. It was also recognised that Dora's weight was normal but she kept her head tilted towards one direction as if continuously listening to some other person's talks.

The physical assessment conducted by medical practitioner describes very abnormal social behaviour of the patient. Physical abnormalities portray that patient's mental state is not stable and there are some mental barriers which are causing the patient to behave in such a mysterious manner (Physical Exam for Schizophrenia, 2015).

MENTAL/EMOTIONAL ASSESSMENT

The state of healthiness is a combination of physical, mental and emotional well-being (Demjaha, MacCabe and Murray, 2012). Dora's condition was not well as per the physical examination. The psychiatrist performed mental/emotional assessment for getting an overview regarding the internal situation. This mental examination was witnessed by Dora's parents also. The attributes that were assessed include appearance, changes in mood, thinking styles, reasoning in different situations, behaviour and lastly memory (Baker and et.al., 2014). The abilities of patient to express herself are also tested (Schizophrenia, 2017). The psychiatrist conducted verbal and written test on the scale of aforementioned parameters.

From this mental/emotional assessment, the psychiatrist inferred that Dora was experiencing severe difficulty in thinking and managing her emotions. She was quite confused when asked about herself talking with an invisible person, etc. In the initial stage of test, she was reluctant to talk and interact with the doctor but later on she communicated that her “friend” (hallucinations that are not real) stated to initiate a conversation. Dora stated that her friend is here to protect her from the upcoming danger that might kill her. These statements reflected towards a risk or threat of danger to her own life which is hypothetical for others but realistic for Dora. Schizophrenic patients have been reported to kill themselves just to safeguard themselves from such kind of assumed deaths (Larsson and et.al., 2013). These symptoms led the doctor to indicate that Dora was suffering from incurable disease i.e. schizophrenia.

BIOGRAPHICAL HISTORY

The biographical history depicts a patient's overall history from childhood to the present state. This helps in providing appropriate interventions to the patients that are suffering from mental illness like schizophrenia (Correll and et.al., 2015). Dora's early childhood was very natural and just similar to that of normal kids till the age of 14. her father died in a brutal mishap when he was coming to pick her up. This situation had a deep scar over Dora's emotional health. She withdrew from her friends and had restricted conversations with her mother. This particular attribute is a severe indication towards the onset of a mental illness (Whitton, Treadway and Pizzagalli, 2015). Dora's school performance declined and the initial stages of adolescent also led to depression and loneliness. There was no inclusion of drugs and alcohol in her lifestyle. But her mother was quite worried regarding her behaviour with other family members because it was quite harsh and storming.

The absence of a sibling also led to increase in these mental conditions. The high school performance was quite average and Dora somehow managed to get a degree in Arts with literature as the specialisation. There were no spiritual practises conducted by her mother and herself. However, her paternal grandmother is said to have schizophrenia. There was a probability of transfer of this genetic defect to the next generations which can be witnessed in Dora. The age time period from 19-21 was very smooth for both Dora and her mother. She did not indulge in any sort of violent activity which may harm herself or any other person. But after her disturbed sexual relationship with her senior in the college, the onset of past metal issues was witnessed. The occurrence of hallucinations increased and this further led to development of inner anxiety and highly disturbed social behaviour.

PAST PHYSICAL AND MENTAL HEALTH HISTORY

The consultation of primary health care doctor by the patient includes accumulation of information relating with the medical history. Dora's history depicts following facts:

• Inability in sleeping.
• Loss of appetite in some situations and over eating in some.
• Dora did not feel good when asked about friends or family members.
• She had experienced death of her father at an early age and also had a disturbed relationship with her boyfriend during college.
• Had been hospitalised once for 5 days due to acute jaundice.
• No exposure to drugs and alcohols.
• Paternal grandmother had schizophrenia.
• Severe hallucinations from 6 months.
• Hears whispering sounds and visualises a “friend” who is same as the age of Dora and a male.
• Dora often experiences that she is in danger and somebody will harm her.
• Continuous talking to herself.
• Often gets confused when asked about day and night or the present time.
• No operations or surgeries have been experienced by the patient till date.

Schizophrenia is often confused with depression and anxiety (Jónsdóttir and et.al., 2013). The health practitioner has to perform respective question answer sessions so that in-depth history of the patient is acquired and then necessary conclusions can be made. The biographical history of Dora presents that her hospitalisation experience is only one in number but she has been subjected to mentally ill conditions throughout major part of her life. The presence of schizophrenia is prevalent in her genes because her paternal grandmother also experienced the same. Physical relationships were not so productive or soothing for Dora's conditions. She had been emotionally disturbed because of her father's death and boyfriend's abusive behaviour. All these conditions indicate her probability of getting diagnosed with schizophrenia.

COLLABORATIVE/CORROBORATIVE HISTORY

The collaborative and corroborative evidences or history help in reaching a conclusion whether proposed doubt is appropriate or not (Demjaha, MacCabe and Murray, 2012). The collaborative history was confirmed by collection of findings of both psychiatrist and the primary health practitioner in Dora's case. The primary doctor was family doctor for Dora since her childhood. Hence, familiarity with patient's conditions is quite high. The assessments conducted by both these practitioners led to similar conclusions that there is a prevalence of mental illness for Dora. She is experiencing severe schizophrenia because of her increasing hallucinations and minimal interaction with people in the social set up.

To support this claim, the medical practitioners recognised existence of loneliness and talking to herself in adulthood were primary conditions. Further, she experienced hallucinations at a stronger level which was confirmed in her description of a male friend who stays with her throughout the day and everywhere. Her physical structure is quite shabby in appearance and she twitches continuously. These symptoms and biographical history are the evidences of corroborative history which depict and strengthen the fact that Dora is not a patient of severe depression or anxiety but schizophrenia.

DIAGNOSIS

Unlike other biological disorders or diseases that can be diagnosed by conducting laboratory tests or technical examinations, schizophrenia doesn't have a particular test. Medical practitioners have to rely on certain criteria for the diagnosis of this mental illness. The various assessments like physical examination, psychiatric evaluations and screenings, MRI and CT scan tests are helpful in gathering evidences for the detection of right disease (Vöhringer and et.al., 2013). The primary doctor listed a series of tests like blood test, sugar, quantification of alcohol and drugs, MRI scan and electrocardiogram readings. These were a part of the physical examination for diagnosis.

The psychiatrist consultation included mental examination of patient for substantiating the level of mental illness that is visible in Dora's behaviour. The diagnosis also included consultations from family members and the close friends of patient (Sasayama and et.al., 2013). Their opinions and reviews helped in acquiring knowledge regarding stimulation of the disorder in sufferer. The criteria for diagnosis of the mental illness is produced in the DSM-5 i.e. Diagnostic and Statistical Manual of Mental Disorders (Raffa and et.al., 2012). It is a manual published by APA i.e. American Psychiatric Association for consultation by the doctors and healthcare practitioners in the field of mental disorders.

About 1.1 % of the entire population that is categorised in the adult category i.e. above 18 years of age is said to be suffering from schizophrenia (About Schizophrenia, 2014). This is also known as the prevalence rate. The Australian researches have inferred over the fact that people suffering from this mental illness can experience either a no disability state or experience major disabilities and disorders in assistance (Schizophrenia – Diagnosis, 2017). The age group 15 to 30 is considered to be more vulnerable in onset of this illness. The risk factors associated with people developing this illness include a family history and indulging in drugs that alter mental balance (About Schizophrenia, 2014). Teenagers are highly subjected to drugs which are also known as psychoactive or psychotropic because they fluctuate the mental balance. Furthermore, the complications experienced by mother in pregnancy also leads to development of such a disease (Whitton, Treadway and Pizzagalli, 2015).

The predisposing factors linked with the development of schizophrenia in general audience include presence of schizophrenic genes in parents or the family history (Baker and et.al., 2014). If there are more number of blood relatives with this illness then next generation is highly vulnerable simultaneously. Additionally, the socio-cultural aspects associated with life of a person are also contributing to the mental disharmony. This further inclines them to become schizophrenic and seek medical intervention (Schizophrenia – Diagnosis, 2017). Psychological disturbances caused to a person's mental orientation also lead to occurrence of this disease. In Dora's situation, loss of her father had a tragic impact over her psychological balance.

The common co-morbidities linked with schizophrenia include development of pre-existing symptoms like depression and anxiety (Rasic and et.al., 2014). There is also an increase in the psychiatric co-morbidities of this disease which is further increased by consequent abusive activities. This implies that there are chances that the patient might harm him/herself.

COMMON INTERVENTIONS AND RECOVERY PLAN

The common interventions that are provided to patients with schizophrenia for reducing their pain and suffering include use of antipsychotics which are specialised tranquillisers given to patients when their physical behaviour goes out of control (Everybody matters 3: engaging patients and relatives in decision making to promote dignity, 2010). These are termed as pharmacological interventions. A care program is launched in which the service providers address the basic needs and requirements of patient and appoint a professional care provider to look after each and every need of the patient with keen monitoring (Schizophrenia, 2017). The psychological treatment includes therapeutic measures which engage arts, family and cognitive behaviour therapy.

Dora is receiving psychological intervention with her mother's support and strict supervision of her psychiatrist. Since, she is not involved with drugs and alcohol, there is a scope of improvement. In case of violent behaviour or situation of harming herself, Dora shall be provided antipsychotics. Currently, there are no medications provided to the patient which directly implies that there are no side-effects. The multidisciplinary team active in providing care to the patient have certain roles in providing the intervention without any barrier. These are depicted as follows:

• Doctor has to prescribe right treatment according to mental conditions of Dora.
• Nurse monitors the patient continuously and restricts activities that can increase the potentiality of schizophrenia.
• Support Group must look after the fact that every patient whose is being treated with this disease doesn't get subjected to abuse or exploitation in any manner.
• Community organisation should provide support to Dora and her family in a way that socio-cultural barriers do not hinder her treatment.

Following recovery plan has been developed for Dora:

• Goals: To improve Dora's mental condition and reduce impact of schizophrenia.
• Activities: The entire treatment is divided into following activities:
• Activity 1 Recognising different positions and places where the patient visualises herself. This should be followed by listing of events Dora participates in so that she feels good. Further, she has to prepare her own timetable on a weekly basis.
• Activity 2 (Relapsing triggers) Management of highs and lows with thoughts that are triggering and the listing of actions that will be taken by patient for reducing the impact of trigger. It also involves self-realisation of warning signals that affect mental situation.
• Activity 3 Listing of activities in which patient requires help and developing healthier relations with associated individuals (Schizophrenia – Symptoms, 2017).
• Activity 4 Planning to achieve hopes and dreams.

ENGAGEMENT

As a Registered Nurse, I would provide my care services in an empathetic manner. Dora's condition is quite critical, hence, there is a requirement of psychological treatment rather than physical one. Furthermore, I would assure her mother for quick recovery so that her will power shall support the patient to come out of the dreadful situation easily. Engagement with extended family members that are supportive in nature and would understand the situation in a better way shall also be ensured by my side so that collective efforts shall speed up the process of recovery. Patient centred communication shall be initiated by myself so that Dora doesn't experience loneliness or deserted due to her illness or mental disability.

REFLECTION

Through this entire unit, I have developed knowledge regarding schizophrenia which is a dangerous and serious mental illness. The case study of Dora has supported the development of my knowledge regarding conditions that revolve around the patients of schizophrenia. I have also acquired a skill to provide intervention and tackle a patient that has certain type of psychological disturbances. Being a Registered nurse, it is my prime responsibility to ensure that both family and the patient are not in a state of trauma due to the unhealthy atmosphere. Lastly, I would like to infer that the production of recovery plan and implementation of basic diagnostic knowledge helps in reducing the trigger factors which can reverse the recovery process. This aspect has been acquired by myself through this assessment.

REFERENCES

Books and Journals

• Baker, J. T. & et.al., (2014). Disruption of cortical association networks in schizophrenia and psychotic bipolar disorder. JAMA psychiatry, 71(2), 109-118.
• Bortolon, C., Capdevielle, D., & Raffard, S. (2015). Face recognition in schizophrenia disorder: A comprehensive review of behavioral, neuroimaging and neurophysiological studies. Neuroscience & Biobehavioral Reviews, 53, 79-107.
• Correll, C. U. & et.al., (2015). Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry, 14(2), 119-136.
• Demjaha, A., MacCabe, J. H., & Murray, R. M. (2012). How genes and environmental factors determine the different neurodevelopmental trajectories of schizophrenia and bipolar disorder. Schizophrenia bulletin, 38(2), 209-214.
• Jónsdóttir, H. & et.al., (2013). Predictors of medication adherence in patients with schizophrenia and bipolar disorder. Acta Psychiatrica Scandinavica, 127(1), 23-33.
• Khademvatan, S., & Yousefi, E. (2014). Investigation of anti-Toxocara and anti-Toxoplasma antibodies in patients with schizophrenia disorder. Schizophrenia research and treatment, 2014.
• Larsson, H. & et.al., (2013). Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder. The British Journal of Psychiatry, 203(2), 103-106.
• Raffa, M. & et.al., (2012). Reduced antioxidant defense systems in schizophrenia and bipolar I disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 39(2), 371-375.
• Rasic, D. & et.al., (2014). Risk of mental illness in offspring of parents with schizophrenia, bipolar disorder, and major depressive disorder: a meta-analysis of family high-risk studies. Schizophrenia bulletin, 40(1), 28-38.
• Sasayama, D. & et.al., (2013). Increased cerebrospinal fluid interleukin-6 levels in patients with schizophrenia and those with major depressive disorder. Journal of psychiatric research, 47(3), 401-406.
• Vöhringer, P. A. & et.al., (2013). Cognitive impairment in bipolar disorder and schizophrenia: a systematic review. Frontiers in psychiatry, 4, 87.
• Whitton, A. E., Treadway, M. T., & Pizzagalli, D. A. (2015). Reward processing dysfunction in major depression, bipolar disorder and schizophrenia. Current opinion in psychiatry, 28(1), 7.

Online

• Everybody matters 3: engaging patients and relatives in decision making to promote dignity (2010). [Online]. Available Through:<https://www.nursingtimes.net/roles/nurse-managers/everybody-matters-3-engaging-patients-and-relatives-in-decision-making-to-promote-dignity-/5015609.article>. [Accessed on 9th June, 2017].
• Physical Exam for Schizophrenia (2015). [Online]. Available Through:<http://www.webmd.com/schizophrenia/physical-exam-for-schizophrenia>. [Accessed on 9th June, 2017].
• Schizophrenia – Diagnosis (2017). [Online]. Available Through:<http://www.nhs.uk/conditions/Schizophrenia/Pages/Diagnosis.aspx>. [Accessed on 9th June, 2017].
• Schizophrenia – Symptoms (2017). [Online]. Available Through:<http://www.nhs.uk/Conditions/Schizophrenia/Pages/Symptoms.aspx>. [Accessed on 9th June, 2017].
• Schizophrenia (2017). [Online]. Available Through:<http://bestpractice.bmj.com/best-practice/monograph/406/follow-up/recommendations.html>. [Accessed on 9th June, 2017].
• About Schizophrenia. (2014). [Online]. Available Through:<http://www.schizophreniaresearch.org.au/schizophrenia/about-schizophrenia/>.

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