Clinical Case Study: BA

Introduction

This assessment looks at the case of BA, an individual presenting with symptoms that span from mood disturbances and psychotic experiences to potential delusional beliefs. This evaluation discusses BA's diagnoses, the underlying etiology, and the most effective treatment modalities. It also considers the significance of her personal history and presentation.

Disease Process or Patient Problem with Presenting Signs and Symptoms

BA is a 36-year-old African American female who was BIBA to the MER with chief complaints of chest pain and SOB. Additionally, she exhibited signs of mental distress, as she verbalized suicidal ideations and displayed bizarre behavior while in the MER. Her psychiatric history reveals a diagnosis of schizoaffective disorder. During her stay in the CPEP, she demonstrated a flat affect and an excessive preoccupation with hygiene, evidenced by her showering four times. She also made illogical and delusional statements, such as claiming to be pregnant without any supporting evidence, stating she is married and owns three houses, and providing a contact number for her husband that staff were unable to verify.

Demographics and Background of the Individual

BA is a 36-year-old African American female. Her past medical history is significant for HTN, TBI following a motor vehicle incident, subsequent brain surgery, asthma, and a mechanical thrombectomy for which she is on the anticoagulant, Eliquis. Her psychiatric history includes a diagnosis of schizoaffective disorder. She was previously administered Abilify Maintena at Jacobi Medical Center on 10/3 and was started on Abilify 30mg orally daily while in CPEP. BA denies any alcohol (EtOH) or substance abuse.

The patient's presentation includes both physical and psychiatric symptoms. The combination of her medical and psychiatric history, along with her current presentation, necessitates a comprehensive evaluation and a multidisciplinary approach to her care (Patel & Jafferany, 2020).

Diagnosis - Diagnostic Work-up and Rationale for DSM-5 Diagnoses

The diagnostic work-up for BA's schizoaffective disorder began with a clinical interview. During this session, there was an assessment of the presence of mood episodes that occurred concurrently with psychotic symptoms. Observations made during BA's time in the CPEP yielded further information, such as her bizarre behavior, illogical thinking, and delusional statements. A review of her past psychiatric history solidified the diagnosis of schizoaffective disorder. According to the DSM-5 criteria, a diagnosis of schizoaffective disorder necessitates that an individual undergoes a period where there's a major mood episode, either depressive or manic, that coincides with Criterion A of schizophrenia (Perrotta, 2020). An essential criterion is that delusions or hallucinations must be present for a minimum of two weeks when a major mood episode is not evident.

The etiology of schizoaffective disorder remains somewhat ambiguous. However, prevailing theories suggest that a blend of genetic, chemical, and environmental factors might be at play (Mallard et al., 2023). The brain's inherent chemistry and structure could also be influential. In terms of epidemiology, schizoaffective disorder is not widespread, as it affects only approximately 0.3% of the population (Gynther et al., 2019). Notably, it is slightly more prevalent in women and typically emerges in late adolescence or early adulthood (Gynther et al., 2019).

BA's suicidal ideation came to the fore when she verbalized these thoughts during her stay in the MER. A subsequent clinical interview focused on the severity, frequency, and intent behind these ideations. The DSM-5 does not classify suicidal ideation as a distinct diagnosis; however, it is acknowledged as a symptom commonly linked with psychiatric disorders. The etiology of suicidal ideation is usually rooted in a combination of biological, environmental, and psychological factors. From an epidemiological standpoint, suicidal ideation is a pressing public health concern. Current research suggests that approximately 12.3 million adults in the U.S. have grappled with suicidal thoughts in the past year (CDC, 2023).

The diagnostic work-up for BA's potential delusional disorder involved a clinical interview aimed at discerning the presence and duration of her delusions. Observations reinforced BA's claims, such as her belief in being pregnant, her ownership of three houses, and her marital status. According to the DSM-5, a diagnosis of delusional disorder requires that an individual maintains one or more delusions for at least one month. It is important to highlight that these individuals do not meet the criteria for schizophrenia (Perrotta, 2020). Beyond the direct influence of the delusion(s) or its implications, their overall functionality is predominantly intact. The etiology of delusional disorder remains speculative, but its theorized that genetic, biochemical, and environmental factors might be contributory. In terms of epidemiology, delusional disorder is a rarity, with a prevalence rate of about 0.02% in the general populace (Gynther et al., 2019).

Planning - Treatment Plan and Therapy Modality, Referrals

For BA's schizoaffective disorder, the main focus is on medication management. Continuing with Abilify 30mg orally daily is recommended, with monitoring for side effects and assessing therapeutic response. Regular reviews should...…or improved social interactions, could indicate change in the right direction. Also, it would be important to monitor BA's adherence to her medication regimen and evaluate her response to the medications to make sure there are no negative side effects.

Reflection on Approach

In retrospect, there might be considerations for alternative or additional therapeutic modalities. For instance, it might help to start family therapy earlier, if BA's family could be verified, as it could be a way to have additional support for and for her to have a more holistic approach to care. Additionally, considering BA's history of TBI, more frequent consultations with a neurologist or neuropsychologist might have been beneficial to better understand any potential interplay between her TBI and psychiatric symptoms.

Treatment Plan Evaluation

For BA's diagnoses, the treatment plan's emphasis on both psychopharmacology and therapy was appropriate. Schizoaffective disorder, in particular, often requires a combination of antipsychotic medications and mood stabilizers or antidepressants (Holt et al., 2019). The choice of Abilify seemed to align with standard treatment protocols for schizoaffective disorder. Its dual action, both as an antipsychotic and mood stabilizer, would address the spectrum of BA's symptoms.

Plus, the integration of CBT and DBT made sense, as they focus on addressing distorted beliefs and provide her with coping mechanisms. Given BA's delusional claims and suicidal ideations, this combination is appopriate. However, the true measure of the treatment plan's efficacy would be BA's symptom reduction, improved functionality, and enhanced quality of life over time.

Advanced Nursing: Psychopharmacology Rationale & Therapy

From an APN perspective, understanding the rationale behind psychopharmacological choices is paramount. Abilify (aripiprazole) functions as a partial dopamine agonist, which can help regulate dopamine levels in the brain, addressing both psychotic and mood symptoms (Azorin & Simon, 2019). Its side effect profile, especially regarding metabolic disturbances, would need regular monitoring. Therapeutically, the combination of individual and group sessions offers BA a balanced approach. Individual sessions provide personalized care, while group sessions offer peer support and validation. The choice of CBT and DBT is grounded in evidence-based practice, with both modalities showing efficacy in treating schizoaffective disorder and suicidal ideations, respectively.

Conclusion

BA's case began with her presentation of schizoaffective symptoms, suicidal ideations, and potential delusional beliefs. Through the integration of insights from her history, clinical observations, and established diagnostic criteria, a tailored treatment plan was developed for BA. The plan included pharmacological and therapeutic interventions to address BA's needs.…