Running Head: MENTAL HEALTH NURSING CLINICAL CASE STUDY

Mental Health Nursing Clinical Case Study

Abby Stein

Youngstown State University

MENTAL HEALTH NURSING CLINCIAL CASE STUDY

Abstract

There is a growing body of research suggesting a correlation between cluster B personality

disorders and substance abuse. The DSM-V defines a personality disorder as, “an enduring pattern of

inner experience and behavior that deviates markedly from the expectations of the individual’s culture,

is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time, and leads to

distress or impairment.” Cluster B personality disorder is a subset of personality disorders characterized

largely by unpredictability and instability in personal functioning, relationships, and behaviors.

Personality disorders falling under the category of cluster B include antisocial, borderline, histrionic, and

narcissistic personality disorders. The client I have chosen for my case study has been diagnosed with

cluster B personality and substance abuse, among other psychiatric and medical diagnoses. In my case

study, I will attempt to correlate the body of research on cluster B personality disorder and substance

abuse to the diagnoses of my client.

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MENTAL HEALTH NURSING CLINCIAL CASE STUDY

Section I. Objective Data

My client, AB, is a 35 year old female who was brought to the emergency department on March

8, 2018 at Trumbull Memorial Hospital by her sister. AB describes drinking about three pints of vodka

and taking “about 400 pills” to the clinician in the emergency department. These pills include Topamax

(topiramate), Remeron (mirtazapine), and Neurontin (gabapentin). She says that she had taken the pills,

and then was later found half-conscious on the bathroom floor by her sister. In the emergency

department, AB’s chart describes that she was weak and tachycardic. She was transferred from the

emergency department to the ICU, where she was sedated with Ativan during almost the entirety of her

stay. From the ICU, AB was transferred to the psychiatric unit, where I performed an interview on March

13, 2018.

The psychiatric diagnoses of my client include polysubstance abuse, bipolar I, depression, PTSD,

and cluster B personality disorder. The DSM-V describes a diagnosis of substance use disorders as being,

“based on a pathological pattern of behaviors related to use of the substance.” This client’s substance

abuse includes alcohol, specifically. Upon admission to the emergency department, AB’s blood alcohol

level was 0.14. At a blood alcohol level of 0.14, the website brad21.org describes effects such as, “gross

motor impairment and lack of physical control, blurred vision, major loss of balance, reduced euphoria,

increasing dysphoria, and seriously impaired judgement and perception. For reference, the legal alcohol

limit is 0.08. The client also describes past use of “harder” drugs in our interview, including injectable

drugs like cocaine and heroin.

As I had described in the abstract section, Cluster B personality disorder is a subset of

personality disorders characterized largely by unpredictability and instability in personal functioning,

relationships, and behaviors. Personality disorders falling under the category of cluster B include

antisocial, borderline, histrionic, and narcissistic personality disorders.

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MENTAL HEALTH NURSING CLINCIAL CASE STUDY

The DSM-V outlines specific criteria to be met for a diagnosis of bipolar I disorder. Criteria for an

episode of mania must be met, which includes in part, “a distinct period of abnormally and persistently

elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity

or energy, lasting at least one week and present most of the day, nearly every day (or any duration if

hospitalization is necessary).” Other criteria for a diagnosis of a manic episode include mood

disturbances (i.e. grandiosity, decreased need for sleep, flight of ideas, distractibility, and engagement in

high-risk behaviors).

Depressive disorders are defined by the DSM-V as being characterized by, “discrete episodes of

at least two weeks’ duration (although most episodes last considerably longer) involving clear-cut

changes in affect, cognition, and neurovegetative functions and inter-episode remissions.” Anxiety

disorder is separated by the DSM-V into distinct categories of anxiety, but anxiety disorders as a whole

share feature of excessive fear. Posttraumatic stress disorder (PTSD) falls under the DSM-V category of

“trauma- and stressor-related disorders.” Criteria for a diagnosis of PTSD includes, “exposure to actual

or threatened death, serious injury, or sexual violence in one (or more) ways […] and presence of one or

more intrusive symptoms associated with the traumatic event(s), beginning after the traumatic event(s)

occur.”

Medical diagnoses for my patient include hepatitis C, gastroesophageal reflux disease (GERD),

hypertension, and morbid obesity. The hepatitis C, presumably, is a result of the years of described

“hard drug” use. The GERD is possibly a complication of the years of alcoholism, and the hypertension

possibly a result of a combination of morbid obesity and alcoholism. In the ICU, AB was treated with

nutrition replacement and treated for elevated ALT, AST, and other indicators related to her overdose

and chronic alcoholism. She was also kept on constant heart monitoring, and constant sedation.

This client is on a long list of medications, both psychiatric and non-psychiatric. She is prescribed

Neurontin (gabapentin), a nerve pain medication and anticonvulsant, 400 mg TID for mood stabilization.

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MENTAL HEALTH NURSING CLINCIAL CASE STUDY

She is prescribed lithium, a mood stabilizer, 300 mg BID for mood stabilization. It is worth noting that

AB’s blood lithium level on admission to the emergency department was less than 0.20. A normal

lithium range is 0.6 – 1.2. I believe the client’s low lithium levels could be due to noncompliance with her

prescribed medication regimen. The client is prescribed Cozaar (losartan), an anti-hypertensive, 100 mg

daily for hypertension treatment. Protonix (pantoprazole), a proton-pump inhibitor, 40 mg daily is

prescribed for GERD treatment.

Risperdal (risperidone), an antipsychotic, is prescribed at 1 mg daily for bipolar disorder. Zoloft

(sertraline), an SSRI anti-depressant, is prescribed at 150 mg daily for treatment of depression. Hytrin

(terazosin), an anti-hypertensive, is prescribed at 3 mg daily for hypertension treatment. Desyrel

(trazodone), an anti-psychotic, is prescribed at 100 mg daily for depression and use as a sleep-aid.

Medication prescribed as needed, or “PRN,” for sedation include Haldol (haloperidol), an anti-psychotic;

and Vistaril (hydroxyzine), an antihistamine.

AB was admitted to the psychiatric unit voluntarily from the ICU. She has a history of suicidal

behavior, which I will explore deeper in later sections. She is being monitored as part of the unit’s

patient self-harm precautions. As far as appearance and behaviors that I observed, she appeared sad

and depressed during our interview. Her dress was neat, but hair was unkempt and brittle. I did not note

any inappropriate motor activity, akathisia, akinesia, tardive dyskinesia, or acute dystonic reaction from

this client. She seemed relatively friendly, and answered questions appropriately.

I think it is interesting to note that during our interview, AB spoke softly and slowly. She was

obviously upset over the events of the past week or so, and described her past situation using the same

depressed tone. That being said, during group therapy about an hour later, she became more animated

and somewhat manic when describing an episode from her past where she had been drinking too much

and “cold-cocked” a close friend in the face during a disagreement. I thought it was interesting and

notable to see how her moods could change in such a relatively short amount of time.

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Section II: Client Summary

In total, my client has six diagnosed mental illnesses: bipolar I, anxiety, depression, PTSD, cluster

B personality disorder, and polysubstance abuse. Her first diagnosis that I will attempt to summarize is

bipolar I. Bipolar I disorder is a diagnosis given to a patient who is experiencing or as a history of one or

multiple manic episodes. The patient receiving a diagnosis of bipolar I disorder may also experience

episodes of depression, along with the episodes of mania defined in the diagnosing criteria. Different

descriptors of episodes of mania include hypomanic, mixed, or depressed. A manic episode must meet

certain defined criteria by the DSM-V, and includes periods of abnormally elevated mood, increased

energy, risk taking behaviors, etc.

AB also has a diagnosis of an unspecified anxiety disorder. Anxiety, in relatively low levels, is

considered to be a regular human emotional response to realistic danger perceived danger. Part of what

defines abnormal anxiety is the societal context in which the person experiencing the anxiety exists. An

important diagnostic criterion of an anxiety disorder is that it interferes with everyday functioning.

During my interview with AB, she described having “night terrors,” which produced sleeplessness many

nights. Generalized anxiety disorder (GAD) is defined as, “persistent, unrealistic, and excessive anxiety

and worry, which have occurred more days than not for at least six months.” Behaviors associated with

GAD include restlessness, pain in muscles, and procrastination of tasks.

Depression is another of AB’s mental illnesses. The DSM-V describes diagnostic criteria for major

depressive disorder as depression that is, “present nearly every day […] with the exception of weight

change and suicidal ideation. Depressed mood must be present for most of the day, in addition to being

present nearly every day.” Sleep disturbances often accompany major depressive disorder. Major

depressive disorder is associated with a high mortality rate due to patient suicide. The suicide risk, as

written in the DSM-V, and is elevated with the number of suicide attempts and is also increased in

males, those who live alone, and persistent feelings of hopelessness.

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MENTAL HEALTH NURSING CLINCIAL CASE STUDY

Posttraumatic Stress Disorder (PTSD) is possibly most commonly associated in our society with

persons who have served in combat roles. But, it is not only service people who are diagnosed with

PTSD. PTSD falls under the category of trauma- and stressor-related disorders in the DSM-V, along with

acute stress disorder. PTSD involves the exposure of an individual to real or threatened danger. These

major events are considered to be so traumatic that they would cause distress to almost anyone who

could be involved. Victims of rape, torture, and terrorism all have the potential of the development of

PTSD, and other precipitating stressors may include man-made or natural disasters, witnessing the

violent death of others, or similar traumatic events. AB described the suicides of her father, two

brothers, and grandfather. I believe these events, and the patient’s lingering reaction to them, justify

her diagnosis of PTSD. Sleeplessness and flashbacks are common behaviors of PTSD.

Cluster B personality disorder includes antisocial personality disorder, borderline personality

disorder, histrionic personality disorder, and narcissistic personality disorder. These personality

disorders are often characterized by dramatic, erratic, and/or emotional features. The traits

accompanying these personality disorders are pervasive enough that they interfere with the everyday

functioning of the individual receiving the diagnosis. The specific personality disorder under cluster B

which I believe AB experiences is borderline personality disorder. This personality is believed to be built

around a fear of abandonment. As with all personality disorders, cluster B disorders are difficult to treat.

Last, AB has a diagnosis of polysubstance abuse. She describes a history of “hard drug” use (i.e.

cocaine and heroin), and is an alcoholic who has been to rehab for drugs and alcohol twice. She

describes drinking a significant amount of vodka on a daily basis, and her blood alcohol level was 0.14 on

arrival at the emergency department. The DSM-V describes the some individuals as being more prone to

substance abuse disorders than other clients. Associated with alcohol use disorder is alcohol withdrawal,

which is a medical condition with undesirable and sometimes deadly effects on the user.

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Section III: Identified Precipitating Stressors

My client has many precipitating stressors in her life which, compiled, describe a lengthy mental

health history. A great deal of trauma can be traced back to her childhood, according to her own

personal account. AB describes her mother as having always been an, “alcoholic crack-head.” She was

one of five children, born to a family low on the socio-economic ladder. Her father, two of her brothers,

and her grandfather all committed suicide during her lifetime. She describes life with her mother as

being very traumatic. Her sister, who happens to be her twin, is AB’s closest relative. AB’s twin sister is

also a recovering alcoholic, but AB describes her as being, “my greatest support system.”

AB has another brother who is still living, but describes him as being an alcoholic and

methamphetamine addict. AB and her brother are somewhat estranged, although AB’s brother lives

with their mother. AB’s mother is in poor health, is on dialysis several times a week, and still is addicted

to cocaine. Neither AB nor her sister has a relationship with their mother or living brother. AB has,

herself, been married and divorced twice. She has four daughters, ages 17, 16, 14, and 5. The three

older children live with their father, her first husband. AB has partial custody of these children. AB’s

youngest child, from her second marriage, lives with AB in subsidized housing in Warren. She describes

being on a fixed income, and is unemployed.

AB has been to rehab for drugs and alcohol on two separate occasions at Riverbend, a private

rehab and mental health center in Warren. She described consuming a considerable amount of vodka

on a daily basis, or about three pints. AB talks about having being an Alcoholics Anonymous (AA)

member. She says she has gone through all ten steps of the program all three times, but always

relapsing. She has had 3 sponsors. AB describes being hospitalized, “at least 15 times since 2013.” Her

plans upon discharge from Trumbull Memorial Hospital include further treatment with Riverbend.

In our interview, AB describes being, “debilitatingly [sic] depressed.” She describes her

depression as being so debilitating that she sometimes stays in bed for days at a time. She says that it is,

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“painful” for her to be sober. The longest period of time she describes being sober is about three

months. Night terrors plague her during the night, and she describes days as being “painful to deal

with.”

Precipitating this hospitalization was a drug overdose. AB describes taking, “about 400 pills

washed down with a bottle of vodka.” In her chart, the notes say that she called her sister after ingesting

the combination of pills and alcohol. In my interview, the patient describes her sister finding her

unconscious on the bathroom floor. Her sister brought her to the emergency room, and from the

emergency room she was transferred to the ICU and monitored for a few days. When AB was well

enough, she was transferred from the ICU to the psychiatric unit.

Section IV: Discussion

I suspect that this particular client has a long history of familial mental illness. As I mentioned in

the previous section, AB is one of five siblings. Two of her brothers, her father, and her grandfather all

committed suicide. I believe this is a very significant bit of information in relation to AB’s current mental

state. When I asked AB about the psychiatric history of her relatives, she could not say with certainty if

any of her relatives who committed suicide had had any psychiatric diagnoses. She said, “I think they all

had depression, but I don’t know anything more than that.”

A group of mental health researchers from Hungary conducted a study examining relationships

between familial history of suicide attempts, individual suicide attempts/suicidal ideation, depression

and bipolar disorder. The researchers, Rihmer et. al, attempt to make connections between these

variables in their research. They found that among those who answered affirmatively to questions about

a history of suicide attempts, 9.1% reported a family history of suicide (Rihmer et al, 2013). They also

said that, “untreated unipolar or bipolar depressive episode is the main clinical substrate of completed

suicide, accounting for 56-87% of cases [of suicide]” (Rihmer et al, 2013).

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This research is significant to my client in the span of mental illnesses it correlates with

suicidality. The researchers present that suicidality is related to many of the same personality traits as

mania, including irritability and impulsivity. Depression and hopelessness are hallmarks of suicidality,

and are the same traits characterized by depression. AB has both bipolar I and depressive episodes.

From AB’s familial history of suicide, along with her mental illness diagnoses, one would hypothesize

that she is at a high risk for death by suicide. Further in their research, Rihmer et al. describe a possible

genetic link to depression. They conclude, ultimately, that, “patients with a positive family history of

completed suicide made significantly more frequent suicide attempts than those with a negative family

history of suicide” (Rihmer et al, 2013).

Also significant is the research correlating substance abuse and cluster B personality disorders.

Research by Tatari et al describes the comorbidity of substance dependency in patients with cluster B

personality disorders. In their cross-sectional study, the researchers attempt to show that individuals

with cluster B personality disorders are at risk for substance dependency. I would tend to believe it has a

great deal to do with the attention-seeking, impulsiveness, and instability that accompany cluster B

personality disorders. The researchers did indeed find a correlation in cluster B personality disorders

and substance abuse. Suggested for these individuals are medication, psychological intervention, and

psychiatric intervention in treatment centers.

Lastly, I want to go back to the correlation between suicidality and familial history. AB has an

extensive history of completed suicides in her family. This is likely the cause of her PTSD, I believe. One

of the diagnostic criteria, as I had mentioned earlier, is that the individual directly experienced traumatic

events. The untimely death of a loved one by suicide is, objectively, a traumatic event. The lasting

trauma endured by AB likely is the reason for her diagnosis of PTSD. The trauma related to these events

likely is the cause of long-lasting inability to cope with events, and the familial history of suicide suggests

that AB has not been modeled appropriate coping mechanisms.

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Section V: Psychiatric Evidence Based Nursing Care

A variety of psychiatric evidence-based nursing care modalities are being performed on my

client. AB is afforded the opportunity to attend therapeutic groups during her time in the psychiatric

unit at Trumbull Memorial Hospital. These therapeutic groups include many important functions,

including socialization and support of clients. These skills are beneficial, if not crucial, to life outside of

the psychiatric unit. As I had mentioned before, it is unlikely that AB has been modeled good coping

mechanisms. The primary focus of therapeutic groups, after all, is to teach participants effective ways of

coping with developmental and emotional stresses in a healthy and productive way.

AB is also being kept on patient self-harm precautions during her time at Trumbull Memorial.

Self-harm precautions include measures nurses periodically monitoring the individual on an irregular

schedule. The irregularity prevents staff monitoring from becoming predictable. AB was likely screened

for suicidality upon admission to the emergency department, and screened periodically during her time

at Trumbull Memorial. A safe, quiet space is likely being maintained for the client during her stay on the

psychiatric unit. This is for AB’s safety, as well as the safety of other patients. Nurses and other clinicians

likely speak to AB using clear, concise, statement. She is likely spoken to in a low, calm tone of voice.

Medication administration is likely also monitored closely, to avoid the patient “pocketing” medication

to overdose with at a later time.

Milieu therapy combines assessment, outcome identification, planning, and implementation. In

nursing therapeutic milieu, patient physiological needs are met. The nurse on the psychiatric unit most

likely encourages patient self-reliance and self-sufficiency, while performing basic nursing duties. A

trusting relationship between the nurse and client is vital to successful hospitalization.

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Section VI: Analysis

AB is a white female, age 35. She describes no religious affiliation, nor cultural ties. In her family,

the behaviors modeled for her are likely the culprit for many of her maladaptive behaviors and mental

illnesses. As a woman, she is statistically more likely to experience mental illness. AB’s family dynamic is

largely dysfunctional.

Section VII: Evaluation

Statistically speaking, things look pretty bleak for AB. As I had mentioned before, her familial

history of suicide combined with her prior attempts at suicide suggest that there may be future

attempts at suicide. As that study outlined, the greater number of immediate family members who had

attempted or completed suicide had an impact on other family members’ suicidality if those family

members also suffered from mental illness.

By all appearances, AB’s time on the floor has been beneficial. According to her chart, she has

attended many (if not all) therapeutic groups. She describes making friends with a few people on the

floor, and is social and talkative. Notes describe her taking her medication as prescribed, and there are

no noted instances of patient unruliness while she has been on the psychiatric unit.

While attending a group session on my day of care, AB participated in groups on good coping

skills and positive/negative influence. She was vocal in group participation, although she seemed a bit

manic during the second session. During the second session, while discussing positive/negative

influences, she described a night in which she became, “black-out wasted” on alcohol and cocaine, and,

“cold-cocked” a friend in the face. The group reacted to this with raucous laughter, but AB eventually

settled herself. In the group on coping mechanisms, AB was able to name three coping mechanisms

better than using alcohol, but admitted that these coping mechanisms hadn’t been successful in the

past.

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Section VIII: Discharge

As described both in the patient’s chart and earlier in this study, AB’s discharge plans involve

further treatment at the Riverbend mental health center in Warren. She has been there once before,

but believes that this time she will more successfully confront her own alcoholism. AB is uncertain how

she will handle childcare as she participates in programs at Riverbend. Her five-year-old daughter, whom

she lives with, is staying with AB’s twin sister. AB says that her sister loves her daughter, and doesn’t

seem to have any issue with keeping the young girl while AB is away.

According to a 2011 study, the most effective treatment for patients with cluster B personality

disorder is inpatient treatment (Bartak et al, 2011). In their study the researchers compare inpatient,

outpatient treatment, and day-hospital treatment. For the participants who followed through without

deviation from their prescribed treatment plans, the patients who spent time as inpatients had the best

outcomes (Bartak et al, 2011). If AB is anything like any of the participants in this study, her time spent

in the psychiatric unit at Trumbull Memorial Hospital will not be in vain.

Section IX: Actual Nursing Diagnoses

1. Risk for suicide r/t feelings of hopelessness and worthless as evidenced by patient statements

such as, “I don’t want to be alive anymore.”

2. Imbalanced nutrition: less than body requirements r/t chronic alcoholism as evidenced by the

consumption of alcohol instead of necessary nutrition.

3. Ineffective impulse control r/t chronic alcoholism as evidenced by patient consuming three pints

of vodka per day.

Section X: Potential Nursing Diagnoses

 Imbalanced nutrition, less than body requirements

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 Anxiety

 Risk for suicide

 Hopelessness

 Ineffective denial

 Powerlessness

 Fear

 Social Isolation

 Ineffective coping

 Ineffective role performance

 Disturbed body image

 Ineffective impulse control

 Risk for injury

 Risk for violence: Self-directed or other-directed

 Disturbed thought processes

 Impaired social interaction

 Insomnia

 Risk for self-mutilation

 Complicated grieving

 Disturbed personal identity

 Chronic low self-esteem

 Spiritual distress

 Self-care deficit

 Post-trauma syndrome

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Conclusion

There are quite a few things to consider about AB. The trauma related to the suicides of

immediate family members, the alcoholism, the dysfunctional relationships with living family members,

the drug abuse, and the myriad of mental illnesses, to name a few. Her pattern of risky behavior,

coupled with history of trauma leave much to be desired in the way of a typical “healthy” individual.

That being said, the fact that she has sought treatment for her addiction and mental illnesses says a lot

about her willingness to change her ways.

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References

 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: American Psychiatric Publishing.

 Bartak, A., Andrea, H., Spreeuwenberg, M.D., Ziegler, U.M., Dekker, J., Rossum, B.V., Hamers,

E.F.M., Scholte, W., Aerts, J., Busschbach, J.J.V., Verheul, R., Stijnen, T., & Emmelkamp,

P.M.G. (2011). Effectiveness of outpatient, day hospital, and inpatient

psychotherapeutic treatments for patients with cluster B personality disorders.

Psychotherapy and Psychosomatics, 80(na), 28-38.

 Rihmer, Z., Gonda, X., Torzsa, P., Kalabay, L., & Akiskal, H. (2013). Affective temperament,

history of suicide attempt and family history of suicide in general practice patients.

Journal of Affective Disorders, 149(1-3), 350-354.

 Tatari, F., Mousavi, S.A., Shakeri, J., Zavaleh, V.M., & Zarafshani, K. (2015). Comorbidity of

substance dependency in patients with cluster B personality disorders. University

Medical Science, 19(6), 365-373.

 Townsend, M.C. (2015). Psychiatric mental health nursing. Philadelphia, PA: F.A. Davis Company.

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