Holistic Care for Neuro Disorders

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 be conducted to determine the need for dose adjustments. Alongside medication, Cognitive Behavioral Therapy (CBT) can be introduced. CBT is beneficial in addressing distorted thought patterns and enhancing coping mechanisms. It is also important to provide BA with psychoeducation about her condition. This would include teaching her about the nature of her disorder and informing her about potential triggers to avoid. This is a common approach in CBT as well. In terms of therapy modality, individual therapy sessions, complemented by group therapy, could be helpful. This dual approach would give BA personalized attention and the support of peers who share similar experiences. Referrals for BA should include outpatient psychiatric follow-ups for both medication management and therapy. It would be beneficial to be part of support groups specifically tailored for people with schizoaffective disorder, too (Holt et al., 2019).

Addressing BA\\\\\\\'s suicidal ideation requires immediate crisis intervention. An assessment of risk should be conducted along with the creation of a safety plan. It would help to have a review of BA\\\\\\\'s current medications to verify that none increase the risk of suicidal ideation. Dialectical Behavior Therapy (DBT) is a recommended psychotherapy approach, given its efficacy in addressing suicidal ideation and self-harming behaviors. Individual and group therapy sessions would also be recomended. Referrals should include crisis helplines like the National Suicide Prevention Lifeline and outpatient therapy that emphasizes DBT techniques.

Given BA\\\\\\\'s delusional claims, a treatment plan should involve considering antipsychotic medications to address the delusional thoughts. Also, CBT can be employed to challenge and restructure these delusional beliefs (Cox, 2022). BA should receive regular, reality-oriented feedback from trusted people to help her differentiate between delusional and real experiences. The therapy modality should be individual sessions to provide focused attention on BA\\\\\\\'s specific delusions. Referrals for BA in this context should involve outpatient psychiatric follow-ups for the continued assessment and treatment of her delusional symptoms. Again, support groups for individuals grappling with delusional disorder or psychosis would also help.

General Recommendations

Collaboration among psychiatrists, therapists, social workers, and possibly neurologists (given BA\\\\\\\'s history of TBI) will provide a comprehensive care strategy. If BA\\\\\\\'s family can be verified, their involvement in her treatment plan is recommended. They should be provided with education and support to assist BA effectively. Considering BA\\\\\\\'s claims about housing and marital status, a social worker\\\\\\\'s assessment of her living situation should be had. They can then provide the necessary resources or referrals based on their findings.

Implementation - Sessions and Treatment Execution

For schizoaffective disorder, the commencement of therapy would prioritize establishing a trusting relationship with BA. The initial sessions would be dedicated to ensuring BA feels understood, safe, and comfortable discussing her experiences. There should be an assessment of her current mood and any potential medication side effects. As the therapeutic relationship strengthens, the focus would shift to integrating CBT techniques. These techniques would help BA identify and challenge distorted thought patterns and beliefs. Role-playing might be introduced as a practical tool, to help BA to rehearse coping strategies for real-life situations. Psychoeducation would also give BA needed knowledge about her condition, the importance of medication adherence, potential triggers, and how support networks can help. Once BA is settled into individual therapy, the introduction to group therapy could be started, so that she has a platform to share (Holt et al., 2019).

Suicidal ideation requires immediate attention. The very first session would be centered around a comprehensive risk assessment, with attention given to severity, frequency, and intent behind BA\\\\\\\'s ideations. A safety plan should focus on pinpointing warning signs and delineating steps BA should take if she feels endangered. As therapy progresses, the sessions would pivot to incorporate DBT techniques. Focus would be on skills training, encompassing mindfulness practices, distress tolerance techniques, emotion regulation, and interpersonal effectiveness strategies. A consistent element of each session would be regular check-ins regarding any emergent or persistent suicidal thoughts (Holt et al., 2019).

For the delusional disorder considerations, the initial sessions would be geared towards understanding the nature of BA\\\\\\\'s delusions (Holt et al., 2019). It would be important approach her delusions with sensitivity, avoiding direct confrontation, and ensuring she feels her experiences are validated. As therapy progresses, sessions would employ CBT to gently challenge these delusions, guiding BA to discern between her beliefs and objective reality. Feedback would be a stepping stone with perhaps some Socratic questioning to help BA assess the validity of her beliefs. If feasible, and once BA\\\\\\\'s family is verified, family therapy sessions could be introduced. These would serve a dual purpose: educating the family about BA\\\\\\\'s conditions and equipping them with strategies to support her, especially in providing reality-oriented feedback outside the therapy setting (Patel & Jafferany, 2020).

General implementation strategies should focus on consistency. Regular, or ideally weekly, sessions would help to keep the therapeutic rhythm and close monitoring of BA\\\\\\\'s progress should be done. Collaborative efforts would be helpful, with routine meetings involving the multidisciplinary team, i.e., psychiatrists, social workers, and potentially neurologists. This cohesive approach would allow BA\\\\\\\'s care to be holistic. Feedback would be a continuous loop in this process. Actively seeking BA\\\\\\\'s feedback is a big part of therapy as it helps it to stay patient-centered (Holt et al., 2019).

Evaluation - Advanced Practice Nurse Perspective

As an Advanced Practice Nurse (APN), evaluating progress in a patient like BA requires clinical observations, feedback, patient self-report, and monitoring of medication adherence and response. A reduction in the frequency and intensity of BA\\\\\\\'s delusional beliefs, improved mood stability, and a decrease in suicidal ideations would be primary indicators of progress. Collaborative feedback from therapists and other healthcare professionals involved in BA\\\\\\\'s care would give a comprehensive view of her progress. Regularly checking in with BA about her perceptions of her progress and her experiences with medications would help to give a view of how she is doing. Patient-reported outcomes, like improved sleep 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.