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RUNNING HEAD: Case Study

Psychiatric Case Study

A Patient with Delusions and Psychotic Behavior Related to Schizophrenia, Admitted to the

Behavior Health Unit

Josh Lyder

November 18th
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Case Study

Abstract

A patient named Tyler reports to the ED brought in by police with behaviors resulting

from pre-diagnosed with paranoid schizophrenia. This study examines this patients

medical/psychiatric history of this patient, as well as his behaviors leading up to and throughout

his stay in the behavior health unit. It also includes a breakdown of the pathology and

presentation of the patients schizophrenia and associated psychotic delusions. The patient had

been on the unit for 4 prior days, 2 spent in the PICU. His delusions were extremely inconsistent,

stating that he knew that he had problems on multiple occasions, then altering his story to blame

his mother entirely, and becoming extremely paranoid. The patient also discusses a long history

of depression and multiple instances of having suicidal thoughts. He was spending his 3rd stay on

the floor in a matter of 2 months and at one point made the statement that he enjoyed being on

the floor also stating that it was much better than being at home with his family.
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Basic Assessment

The subject is a 23-year-old male named Tyler. He was diagnosed with paranoid

schizophrenia for about 3 years. Paranoid schizophrenia is characterized by at least a one month

period of positive and negative associated symptoms, possibly including; delusions,

hallucinations, disorganized speech, frequent derailment or incoherence, grossly disorganized or

catatonic behavior, affective flattening, loss of speech, or lack of any motivation (DNA Learning

Center). His other axis diagnoses are II. Deferred III. See patient medical records IV. Social.

Environmental V. 25. Tyler was admitted through the ED on October 27th and the day of care was

November 2nd.

Tylers behavior while on the unit was always shifting from a calm, seemingly logical

mindset to a clearly delusion, at times psychotic, behavior pattern. Before coming into the ED

the patient was at home with his family and became very paranoid. His mothers friend was over

talking to his mom which triggered him to believe that they were teaming up against him, taking

his freedom away. Once in this mindset, he grabbed his crossbow and began to threaten both his

mother and her friend. After a short standoff, he proceeded to run to his room talking about

killing himself. Once in his room he grabbed a knife and put both the knife and his crossbow to

his neck threatening to kill himself. The police were called and eventually were able to stop him

and bring him into the hospital. Once in the hospital the patient continued to say that the fit was

caused by the mother plotting against him and being determined to ruin his life. He claimed

that the friend comes over often and often helps the mother conspire against him. He also reports

hearing voices in this instance, and on a regular basis. These voices supposedly tell him to hurt

himself and occasionally other people, in this case his mother and her friend.
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Once on the floor the patients mood became much calmer. He admitted to be very

comfortable on the floor. Even though he was still paranoid about many things, and appeared to

still have delusional thoughts, he no longer had suicidal thoughts and his behavior normalized.

On multiple occasions Tyler spoke with the nurses and therapists about his beliefs in the dark

magic and his regular worshiping of Satan. At certain points he would go as far as talking about

spells, and summoning dark portals to the underworld, however at other points he was hesitant to

discuss this at all and even attended the units spirituality group. His paranoid thoughts seemed to

be mainly based around his family. He did not appear paranoid of anyone on the floor, he was

extremely cooperative with the nurses and was very comfortable and social with the other

patients. His thoughts about his family included his mother trying to destroy his life and

happiness and everyone in his family at some point attempting to kill him. Tyler also discussed at

length being come on to sexually and at times even raped by his mother, father, step-father,

step-sister, step-brother, and uncle. The only other mention of paranoia was a nurse that had

reported the patient talking about the CIA being out to get him, although this was not mentioned

in the original assessment or day of care assessment.

Tyler seemed to be safe on the units standard self-harm precautions and was very well

behaved, cooperating with both staff and other patients. As far as treatment goes, he underwent

general Milieu therapy on the unit, as well as attending almost every group session. When talking

with the patient, the staff was focused on exposing delusions and trying to steer his thought

process into a more functional one. He was put on multiple medications once he reached to unit.

Tyler was put on ariprazole, nicotine, pantoprazole, bisacodyl, diphenhydramine, haloperidol,

Mg hydroxide, and trazadone. Pantoprazole is given to virtually all patients as a GI precaution

with patients receiving many medications. Nicotine was given because the patient is a pack
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per day smoker. Bisacodyl and Mg hydroxide are given PRN because of common med side effect

of constipation. Diphenhydramine is given in conjunction with many psychiatric meds as a

preventative measure for extra-pyramidal symptoms. Haldol is ordered PRN in case something

triggers another psychotic episode. Ariprazole is given as an antipsychotic stabilizing agent for

the patients schizophrenia. Finally, trazadone is given to combat associated depression and

insomnia, both linkable to the patients underlying diagnosis. The patient was not diagnosed with

any additional medical diagnoses.

Paranoid Schizophrenia

This patient is in his early twenties and has been diagnosed with the disorder in the last

few years. This is typical of paranoid schizophrenia, as the normal appearance of symptoms

often first occurs in the early twenties (NIMH). The patient exhibits many key attributes of the

schizophrenic condition including; auditory hallucinations, delusions, at times frantic speech,

frequent deviation in conversation, disorganized or catatonic behavior, affective flattening, and

lack of motivation (Ayano, 2016). The patient often claims to hear voices telling him to harm

himself and others, often his mother. He is delusions are predominantly paranoia based and

revolve around people, especially his family, being out to get him. When he enters a positive

symptom state he tends to have more pressured speech and a very jumpy pattern of conversation.

Also, during these stages he has very catatonic behavior as shown by the actions that brought

him into the hospital. He also experiences some negative symptoms including a flattened affect

and a lack of motivation (Ayano, 2016). The patient has never had a real job and the most that he

does on a regular basis is some routine chores around the house, and from his discussion even

that is not common. Also, at times he becomes very flat and unexpressive. The only commonly

seen symptom that was not at any point was visual hallucination.
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Triggers

Tyler seemed to have very recurrent factors that appear to precipitate these worst

episodes. He often complains about his entire family, it is clear that he cannot get along with

them. He states that his family is out to get him in many different ways. He consistently claims

that they are trying to destroy his life and occasionally he will mention them attempting to kill

him or sexually assault him. At the center of this paranoia seems to be the mother. Tyler resents

the fact that she yells at him and tells him to do things to the point where he perceives himself as

being the stability of the household and his mother being the problem. Stress can be a consistent

trigger of his symptoms (Corcoran, Walker, Huot, Mittal, Tessner, Kestler, Aalaspina, 2003).

Although, based on all information given it seems as though what Tyler contributes is virtually

nothing. He often mentions taking out the trash and helping move couches for his mom.

Whenever his mom or family begin to confront him or even exclude him from something it

triggered severe paranoia that he then placed into verbal and at times physical confrontation. He

also claims that his mother is taking all of his SSD for herself and using it to buy cigarettes and

alcohol. In the case of this event, it was precipitated by the mother having her friend over and

them talking on their own. This exclusion makes the patient feel as though they are conspiring

against him, which is what lead to the patient losing control. When the patient is triggered the

voices in his head becomes stronger and he acts in a way that he believes to be his only option, in

this case using a crossbow to assert himself. After he does this the weight of the situation is too

hard for him and he turns suicidal.

History
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In this case there was not very much information to work with. Since the patient is young

and the disease has only been affecting him for a few years. The majority of his personal history

is simply the acts of paranoia and acting out toward his family. He has experienced multiple

cases of these delusional states of paranoia, hallucinations, and homicidal/suicidal ideations.

Tyler did not present with any real previous medical history, therefore there was no analysis that

could be done with the patients medical history. There was also not any information that could

be found about the medical or psychiatric health of the patients family. The only information

that could be given about them is the way in which Tyler describes them. These thoughts are

easily considerable to be delusional, so there is little to no objective data to take away. The

patient claims that his mother, father, and all 3 siblings have all been abusive to him in the past,

but does not in any way substantiate these claims or give any medical or psychiatric conditions.

Care

The care that was provided to Tyler while on the unit was straight forward Milieu therapy,

with delusion reorientation. The patient was extremely active on the unit; watching TV with

other patients, participating in board games/coloring, talking with nurses and other staff, and

actively participating in pretty much every group session. Tyler was extremely engaged during

his stay on the unit and participated in all of the previously listed therapy. As mentioned early the

patient even made statements saying that he enjoyed being on the unit, and that it was a lot better

than home for him. The only instances in which the patient may not have fully participated

would have been when he entered certain states of flat affect and became noticeably less social.

These negative symptoms are common reversals of psychotic phases. Evidence based practice

may suggest to us that in this situation the patience is given a sense of psychological security in

the unit, whether it be the people, the stability, the lack or responsibility, or just the overall goal
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of supportiveness. It seemed to be clear that the patient was very much triggered by stressors in

his life, which is common among the schizophrenic community (Corcoran, et al. 2003).

Background

This patient did not come from a very diverse background in terms of ethnicity or cultural

background. The patient is a white main from an entirely white family, raised in a lower middle

class formerly working class family. His family now, according to the patient, just lives off of

social security and his disability income. Tyler did not express any specific cultural beliefs that

he or his family holds. In terms of spiritual beliefs, Tyler has a much more unique view of things.

He claims to be a practicing Satanic worshiper and practitioner of the dark arts. These beliefs

were not openly brought up on a consistent basis by the patient. He seemed to only bring it up at

random occasions or when he was pressed into doing so. He even attended the units spirituality

group and was a cooperative participant. While on the unit, he did draw a couple pages worth of

satanic drawing and what appeared to be symbols of some sort. He also wrote down a couple

raps that center around the premise of hell and Satan. He talks about using these spiritual

beliefs to summon dark forces and passages to the underworld. However, he does not seem to

attach any daily beliefs or practices into the holding of these beliefs. He does not speak of any

moral or behavioral qualifications of these beliefs.

Outcomes

When planning care for Tyler on the unit the primary goals included the basic safety

precautions, orientation to reality and correct thought processes, honest communication, and

open socialization with other patients. In this case, the goal of maintaining patient safety was
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most certainly achieved and it did not appear difficult. The patient was extremely cooperative

once on the unit and did not remotely pose a threat to hurt himself or anyone else. Orienting

Tyler to reality poses a much different challenge. Firstly, the patient is the only major source for

any events happening within his home leading up to the events that bring him in to the hospital,

therefore it is near impossible to determine what is really and what could be delusional.

Secondly, the patients day-to-day behavior and comments do not appear to be very delusional or

misguided. The only times in which these thoughts seem to surface are when he is either taken

deep into conversation, or when he is sent into one of his psychotic exacerbations. These factors

make it very difficult to isolate and address the particular delusional thoughts of the patient. In

terms of honest communication, it was also difficult to determine if the patient was being

truthful. For the previously listed reasons, it is difficult to distinguish between a delusion, the

truth, and a lie. Tyler did seem to be very willing to get into real conversation and did want to

share as much as he could about his life and situation. This could be construed as honesty, which

is why much of what he said was accepted as paranoia or a delusion. In terms of the patients

sociability, as mentioned earlier, he was very successful. He was not only willing, but he seemed

legitimately happy to be around other patients and to engage with them in any way possible. It

did not matter whether it was sitting around at the table, drawing, playing games, in group,

watching TV, or even talking to staff or students. Therefore, this was a very easily achieved goal

and certainly created a comfortable, therapeutic atmosphere for the patient. Overall, along with

the medication therapy managing his psychotic episodes, the therapeutic environment making

him happy and comfortable created successful care outcomes.

Plan
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Possibly the most difficult part of this case boils down to the plan for the patients

discharge. There are not many options outside of sending the patient home. This presents a

problem, because, as was previously identified, the patients single biggest stressor that sets off

his episodes is his family. His mother represents the largest identified stressor in his life and

interaction with her is unavoidable at home. However, being separate from her does not appear to

be an attainable goal due to the patient never being able to handle a job focus enough to provide

day-to-day care for himself. This being said, the plan of action was simply to adjust meds to a

point where the patients psychoses could be controlled and work with him therapeutically to

enable him to better understand what is happening with his thoughts and how to re-think them.

At times it seem as though some of his delusions may have been lifted when he admitted that he

does not react in a way that makes sense and he needs to have some self-control. However, just a

couple sentences later he will state that he did the only thing that he could and would do it again

if he was forced to. Medication compliance is another piece of the plan that is a focus for

future care. In the past he is not entirely reliable to stick to his medication regimen. He has not

been very reliable in the past with the medications, whether it be for financial reasons or access.

This makes finding the right medication and emphasizing the importance of continuing to get

and take these meds. Between Medicaid and SSD the patient should be able to obtain the

medication. However, since Tyler has no mode of transportation he is completely reliant on his

mother to obtain these prescriptions. Because there has been no communication with the mother,

it is difficult to determine her willingness to do this. Especially since the patient states she does

not help him and is trying to ruin his life.

Actual Diagnoses
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Self-care deficit related to loss of contact with reality and concentration problems, as

evidenced by joblessness, requirement of mother to perform some needs.

Risk for suicide related to psychosis as evidenced by commanding auditory halucinations.
Depressive symptoms related to conflict, insecurities, and psychiatric history, as

evidenced by poor concentration and depressed affect.

Nursing Diagnoses (Ackley, 2014)

Social isolation
Caregiver role strain
Interruption of family process
Ineffective self-care
Impaired social interaction
Risk for injury
Risk for self-mutilation/suicide
Risk for others-directed violence
Ineffective activity planning
Ineffective health maintenance
Disturbed sensory perception

References

Ackley, B.J., Ladwig, G.B. (2014). Nursing diagnosis handbook: an evidence based guide to
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planning care (10th ed.). Elsevier Publishing. Maryland Heights, MO.

Ayano, G. (2016). Schizophrenia: a concise overview of etiology, epidemiology, diagnosis, and

management. Austin Publishing. The Journal of Schizophrenic Research. 3(2).

Corcoran C, Walker E, Huot R, Mittal V, Tessner K, Kestler L, Aalaspina D. (2003). The stress

cascade and schizophrenia: etiology and onset. Oxford Journals: Schizophrenia Bulletin.

29(4).

DNA Learning Center. DSM-IV criteria for schizophrenia. Cold Spring Harbor Laboratory:

DNA Learning Center. dnalc.org. https://www.dnalc.org/view/899-DSM-IV-Criteria-for-

Schizophrenia.html.

National Institute of Mental Health. Schizophrenia. The National Institute of Mental Health

NIMH. NIH.gov. https://www.nimh.nih.gov/health/publications/schizophrenia-booklet-

12-2015/nih-15-3517_151858.pdf