One of the merits of working in mental health has been working alongside each client as they pave the way towards their personal notion of recovery. The client being addressed today is one whom I supported throughout her two-month admission. Her diagnosis was schizoaffective disorder, after a preliminary diagnosis of bipolar disorder with a manic episode. Schizoaffective disorder represents an ‘intermediate position on the continuum of mental illness between schizophrenia and mood disorders… it involves an uninterrupted duration of illness of a major mood disorder as well as symptoms such as delusions and disorganised speech for at least one month’ (Wilson, Nian & Heckers, 2014). Interventions include antipsychotic therapy, either alone or in conjunction with mood stabilisers (Joshi, Lin, Lingohr-Smith, Fu & Muser, 2016).
I have chosen this client because there was a notable improvement in her mental state over the course of the two months. I was also interested in the gradual alteration of her diagnosis and its link to the phenomenon of interchangeability. Interchangeability is the evolution (changing) of diagnoses due to fluctuations in one’s functioning and symptoms that may contradict the original diagnosis (Hung, Yang, Kuo & Lin, 2017). This was relevant to my client as she was demonstrated various psychotic features in addition to manic episodes. In a seven year follow-up study it was demonstrated that those with schizoaffective disorder experienced approximately 12% more changes in their diagnosis compared to those with schizophrenia or mood disorders (Hung, Yang, Kuo & Lin, 2017).
My client, ‘Pat’ (who has been de-identified), is a 77-year-old Caucasian, single lady with no children. Pat lives on pension and is a retired personnel manager who worked in the fashion design industry. She reported that she is currently housing a homeless man. There are some conflicting accounts that Pat was married in the past, however, Pat denied this.
Pat presented to the hospital and was admitted to the ward after being brought in by police under section 351 (with no previous forensic involvement) due to her increased agitation and psychotic symptoms – screaming, armed with scissors and voicing beliefs that her grandparents were murdered by ‘the Germans’. According to collateral history provided by one of her brothers, Pat had for several weeks believed she was ‘a TV character’ or ‘Shirley Temple’. Pat allegedly bit a police officer and was handcuffed, consequently sustaining a fracture to her left wrist. During her admission, Pat was placed under a Treatment Order.
Pat stated that her reason for being admitted was that she was sexually harassed by a neighbour and that she wanted him to leave her house. She explained that she had been finding it difficult to cope since her mother’s death approximately six months ago.
Mental State Examination
Appearance: 77 year old, Caucasian female, petite frame, with short, blonde hair. Reasonably well-groomed and attending to her own hygiene. Wearing a red top and a yellow vest.
Behaviour: Distracted – observed looking through drawers and walking away from staff at times when attempting to engage. Using large, sweeping hand gestures. Minimal interactions with co-patients, guarded. Not accepting medications. Observed walking the entire perimeter of the garden and attempting to look over the fence.
Speech: Pressured, annoyed tone, mumbling and incoherent at times, responding to probing questions.
Mood: ‘Bloody awful’.
Affect: Congruent with stated mood, irritable.
Thought Form: Disorganised. Loosening of associations and tangential. Client was sometimes singing or reciting poetry during the conversation.
Thought Content: Pat reported that she did not feel mentally unwell and wanted to be discharged as she needed to ‘be there for the children and look after the homeless man in my house’. She elaborated that ‘the only reason why I’m here is because I lost my mother.’ Pat verbalised some litigious themes, including wanting to call her lawyer so they could ‘sue all of you for poisoning my system with these drugs’.
Pat referred to herself in the third person and commented, ‘You don’t want to mess with Pat. I have connections with people in high places.’ Pat denied current suicidal ideation or thoughts of injuring herself.
Perception: Observed talking to herself, responding to internal stimuli.
Cognition: Alert and oriented to time, place and person.
Insight: Poor, wanting to be discharged promptly, unwilling to receive treatment for her condition.
Judgement: Impaired. Limited decision making capacity at present; impulsive.
Risks: Overall high risk: high absconding risk given client’s impulsivity and previous attempts to leave the ward. Escalating in agitation and verbally aggressive towards staff, requiring PRN medications and de-escalation strategies.
Formulation: Pat has poor insight into her condition and remains impulsive. Whilst she denies risks to herself, her escalating agitation and limited engagement with her treatment may place her at risk of harm towards others.
Plan: Pat remains on 1:15 visual observations and is subject to an Inpatient Treatment Order. Pat is prescribed regular Olanzapine 5mg (nocte) and sodium valproate 800mg BD, with the view to crossover from Olanzapine to Paliperidone. 1:1 therapeutic nursing engagement and provide medication psychoeducation. Monitor Pat’s neurovascular observations for her wrist fracture, side effects of her medications and her Valproate levels. Supervise Pat in the garden area.
Medical History: Pat reported that ‘sometime in the 1980s I was hit by a car and had a concussion’.
Family History: Pat states that ‘my father had mental health issues’; she did not want to elaborate further.
Personal History: Pat was born in the UK and immigrated to Australia in 1964. She describes having a ‘happy childhood’ with ‘the most beautiful family’ of three brothers and one sister, and her parents. With regard to relationships, Pat mentioned that she ‘lived with a priest for forty-six years.’ Pat and her mother were close and Pat looked after her for approximately ten years before she passed away. Pat cites her siblings as her main social supports.
Significant events include Pat’s mother’s passing over six months ago, and the passing of some of her pets and ‘children’ whom she has looked after over the years. Pat has an extensive trauma history, including being subjected to childhood sexual assault, which she reports has made her distrustful of men. Pat stated that a neighbour attempted to sexually ‘entice’ her which triggered distressing memories.
Drug and Alcohol History: Pat states that she is a ‘social drinker’ and drinks ‘1 to 2 glasses of alcohol’ when she is at a social gathering every few months. Pat denies past or current drug use.
Specific dates for Pat’s mental health journey are unclear, as Pat was unable to recall dates (such as her admission to a private hospital for depression) and there was a ‘convoluted pathway of referrals’ as per her treating team. Pat did recall that she has been taking the antidepressant Paroxetine for ‘at least ten years’. Pat expressed that ‘Aropax is the best tablet’ and viewed it as the best treatment for her mood. Pat stated that she was ‘fed up’ with the fact that she was commenced on several new medications, believing that they ‘make me into a zombie’, and she reported increased sedation.
Pat stated that the best treatment for her is ‘being alone because I’m a loner, going for a walk and being out in nature’. She expressed that ‘thinking positive thoughts and talking to my family on the phone’ helps her in recovery.
Pat said that spending ‘my first Mother’s Day’ without her mother was a very negative experience. She voiced that ‘being caged and feeling like sleeping all the time’ made her feel more unwell.
After staff asked Pat’s brother about Pat’s baseline mental state, he reported that ‘even though she’s slowly improving, she still doesn’t have a clue that she’s getting better.’
Pat’s DSM formulation is schizoaffective disorder and she strongly disagreed with her diagnosis initially, stating that she is ‘not schizo or bipolar, just grieving’.
Pat’s aims in her recovery were ‘to get out of this place’, she expressed a desire to move to Queensland and to ‘start afresh’. She also reported that whilst on the ward she would be trying to ‘look after myself more’.
People involved in Pat’s care included her brothers, the social worker (in helping her to manage finances and other affairs), the occupational therapist (in assessing her daily functioning), neuropsychologist (assessing her cognition), the nursing and medical staff. Pat’s brother was her nominated person and she did not have an advance statement.
Formulation – 5Ps Framework
Predisposing Factors: Pat reports some family history of mental health issues; significant trauma history; past carer stress; previous struggles with depression.
Precipitating Factors: Pat expresses that the grief of losing her mother worsened her mental state, as well as the sexual harassment she received from a male neighbour.
Perpetuating Factors: Pat states that ‘taking away my rights’ and ‘keeping me caged’ makes her more distressed. Pat asserts that ‘putting me on these medications’ reduces her ability to concentrate and function normally.
Protective Factors: Pat states that remembering her ‘beautiful family and my dogs’ and ‘how good my life has been’ help her to cope when feeling unwell. She reports that ‘being outside in nature, looking after others and loving children and animals’ give her a sense of purpose.
Plan: Utilise Pat’s family network and family visits or meetings; actively involve her in care planning; advocate for feasible medication changes to the treating team. Collaborate with Pat and her family about a relapse prevention plan (including support people to contact when she feels unwell and symptoms to be aware of) prior to discharge. Continue to elicit Pat’s recovery goals, acknowledge the progress she has made, and ask what has worked for her in the past to stabilise her mood. Enquire what the nursing/medical staff can do to facilitate achieving her goals. Educate Pat about her medications as well as her rights as a patient under the Mental Health Act 2014 (Vic).
Word count: 1650 (1500 + 10%).
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