Psychiatric History and Mental State of Andy
PSYCHIATRIC INTERVIEWS FOR TEACHING
In order to create a mental health assessment of Andy, a three stage process is included. In first stage, a detailed description of familial and psychotic background of Andy is provided. It showed that he is very keen to his family and sudden departure from family made him insecure. Slowly, this sense of insecurity succumed him and led to excessive drinking and consuming cannabis. As a matter of fact, second part of mental state examination showed that he is suffering acute psychotic and thought disorder for the last 2 months. The third part suggested the medical intervention involve the drugs namely Clozapine, Quetiapine, Ziprasidone, aripiprazole, Risperidone. The psychosocial interventions include cognitive-remediation-therapy, training programmes and on. Nursing intervention include patient educations and self management of the patient.
A mental health assessment or psychiatric assessment or the psychological screening is a process of information gathering of a person who is within psychiatric service. In this report, in order to construct a report on intervention a psychiatric interview of the patient is conducted as suggested by his general practitioner. For this purpose, an assessment of the psychiatric history of the patient with family history is drawn. In the second and third part, examination of the mental state of the patient along with nursing, medical and psychosocial evidence-based-interventions of the patient is discussed.
Part A: Assessment of the client's psychiatric history and family or social environment
Andy was a 21 year old final year student of a renowned university and currently he lived with housemates in a shared house away from his family. Recently his mom observed that her son was having some sort of distressed experiences for the last two months. Hence, she decided to take him to the family general physician. Hearing distressed experiences stories of Andy, the GP referred him to the Dr Tylor, an eminent psychiatrist to handle the case. As per the conversation with Andy, it was noticed that he had not any past history or history related to mental health. He was not with any kind of severe medical or family history. His personal history showed and evidenced from Andy’s conversation with Dr. Tylor that he was close to his mum, he loved her mum very much and he did not want to make worry to her about the anything or about his mental health situation. He has not met with his mum for the last couple of months.
He admitted a fact to the psychiatrist that he had been hallucinating for last two months. Before that everything was fine. He was hearing sounds of three of his housemates making conspiracy with MI5 against him. Even he thought that his lecturer at university was also associated with MI5 and they were all against him. For this reason he had been keeping a baseball bat and a knife with him as he was very concerned about his protection. He could hear them all the time talking about him, his all kinds of actions and behavior. He was afraid about the fact the some sort of chip or device had been put into his head. Even, he had the physical sensation of something moving into his brain. It was understood from the patient’s statement that he did not drink too much but used to consume a lot of cannabis that is about ten bag of it which takes him a day or so.
Occupational history of Andy was not discussed in the interview session. However, incident of substance abuse was detected. As per his drug history he had done bit of Speed in group out with housemates at weekend and the last time when he took this was about a week ago. He even smoke weed worth 10$ daily and had 4-5 smokes in a day. He was not going through any kind of current treatments and so he did not have taken any pills referred by any doctor. However, he had the desire to take overdose of tablets but he has not done anything like this as he did not literally want to leave the house.
No records of criminal offense of Andy. He is not high temperament or aggressive kind of person. He is homesick person and feels safest in homely atmosphere. He had not any kind of crime history or any kind of agitating situation with his housemates as he did not ever want to hurt anyone. As there is strong familial bond, his mother went with him to the psychiatrist as she cared about him. It was clear from his conversation that if he had any kind of career responsibility or not. He was dependant mostly upon his mum. No detailed information of parental status, carer responsibility or siblings or other data was recorded.
Part B: Mental state examination
Assessing all kinds of history of the patient, he was diagnosed with having schizophrenia or extreme psychotic disorder. It was observed from his appearance, perception, mood and so many factors. His mental state examination conveys the following as per the
Diagnostic criteria of DSM 5-
Appearance: It was observed from Andy’s appearance was not that pleasant. It was observed that he was with lack of proper insights, and fidget body movement. He body build up was proper apparently however he was suffering from eating disorder. He was well groomed, properly dressed, blue sweatshirts and jeans but had shabby golden hair. Occasionally he had red face, especially during state of anxiety in middle of conversation. As per Boyle (2014), all of these characteristics match with the pattern of appearance of schizophrenics.
Behavior: His behavior was not properly like a normal person. He was observed that he had the willingness to answering questions or talk in first place. He was not even sitting steadily. He was noticed with distracting behavior like moving his eyes all around the room like he was searching for something or keeping busy with hands or nails. He did not even mad proper eye contact with psychiatrist during conversation. In words of Frith, (2014), the schizophrenic behavior matches all of these behaviors.
Affect: His response was appropriate because he was answering all the questions properly without hesitating. He straightforwardly accepted that he was hallucinating that three of his friend’s voices of his housemates. He thought they all were discussing, commenting on each of his behavioral movement. This has affected him negatively and he used to take lots of weeds or cannabis, the amount was such as ten bags in a day. He was addicted to this. He even consumed speed frequently and the last time he had this just a week ago. This has affected him on his mental condition (Ben-Zeev et al. 2014).
Mood: Andy was distressed and also had a feeling of isolation. He had the mood symptoms associating with the bigger real-world-disability in schizophrenia. He was diagnosed with general mania. This was due to the purpose of having the predominance of the psychotic features at the time of interview.
Speech: Though he was speaking in an inconsistent way, he had no difficulty in finding proper words. As the interview progressed, his tone became monotonous and tempo got reduced. As he was distreed and frustrated, he used minimum words to express thoughts. His verbal attitude was very confident while describing of those ‘talkings’ going into his head, as if it an ‘actual’ incident (Firth et al. 2015). His voice was normal and occasional sign of anxiety was expressed.
Thought form: his thought process or form did include any conflicting ideas or loosening ideas. All those stream of thoughts running into his head had logical flow, with no connection to real world. He had the delusion of his housemates working with MI5 and making conspiracy with him. Even, he thought that, his housemates could add poison to his food. He had the obsessiveness of this and hence his tough form was lack of circumstantialists. Also, he thought that three of his housemates was constantly discussing about him. He had the loosening of the association which was totally incoherent. All of these features proved his irrational behavior (Freeman & Garety, 2014).
Thought content: his thought content or subject of thought was filled with the delusions and each imaginative incident is linked with each other. For example, his delusion regarding his lecturer is conspiring against him leads to isolating Andy from housemates and thus are they might cause harm to him, like poisoning food. Hence, there is logical flow of thought (Townsend & Morgan, 2017). He expressed every incident properly, though sometimes, he lost concentration and looked around the room, again he refocused himself. During conversation, he expressed that once, he had in his mind of committing suicide by overdosing pills.
Perception: his knowledge of ability to thought or hears to something through the senses. Andy has experienced perceptual disturbances due to his disorder of auditory hallucinations as well as somatic hallucination. He manifested the somatic hallucination as he felt that his thoughts had been inserted by his surrounding housemates which haunts him day and night at every single time. He has faith that he requires of some protection for his survival and observed searching for a person during interview.
Cognition/intellectual functioning: He was well aware of time and place. Though, there is no such evidence of cognitive or intellectual or linguistics issue, his intellectual functioning level was rational because his narration has logical flow. In fact he showed good memory function and attention. As in his delusion he thought that his housemates are conspiring against them and wanted to harm him, he kept baseball bat and knife with him for self-defense. He manifested not only attention but also functions with good memory. He did not want to be caught, he hid those weapons. The greatest impairment that was associated with these was executive functions (Shonin, Van Gordon & Griffiths, 2014).
Judgment as well as insights: he had the aberrant pattern of judgmental level and lacked both insight as well as judgement. He has an intense belief that his housemates was the only reason for his disorder of hallucination. His perceptions to the real world became sometimes reduced and this was observed directly from the irrelevant thinking or delusions. Andy was reluctant regarding admitting his feelings with experiences of mental illness which was not fully agreeable in order to opt for treatment and provide support. His capacity in understanding the present situation was not rational.
Risk assessment: Andy feels so insecure and isolated and believes that his housemates kill him. He carried knife, baseball bat for his protection. He hallucinated that his food is being poisoned and having eating disorder. There were occasional thoughts of suicide by overdosing pills and his parent’s involvement in conspiracy but he restricted himself from those thoughts. Though he has no previous crime history.
Formulation: hence, the above analysis showed that Andy is suffering from Substance Induced Psychosis that resulted in acute psychotic disorder delusion and thought disorder, which are symptoms of schizophrenia due to excessive obsession for familial bond. As he scared and is being isolated from family and his insecurity grows to such extent that unfortunately he is succumbed into his world of delusion. For this he started drinking habits and consuming cannabis. He even started hallucinating housemates are poisoning his food and could hear 3 voices (Van Ameringen, Patterson & Simpson, 2014). Hence, he chose to stay in his room and barely goes out. In such scenario, as Andy reluctantly agreed to further health support and is not fully convinced with his mental health issue, his roommates might be at risk.
Provisional diagnosis: He was suffering from Substance Induced Psychosis. Primary symptoms were delusions, somatic and auditory hallucinations, initial thought disorder, isolation, and indifferent attitude, running commentary and thought insertion.
Need of referral: as Andy is suffering from delusion for 2 months, his mental health is worsening; hence immediate referral to Alcohol and other Drug counsellor (AOD) is needed.
Part C: Evidence-based interventions
Clinical Issue- Psychosis
Goal or expected outcome: the goal of medical intervention plays an important role in diminishing the effects of schizophrenia. It also aims at reducing perceptual disturbances like auditory hallucination, delusion by the fortnight. In this purpose, several drugs are relatable to this treatment.
Andy manifested signs and symptoms of psychosis which includes auditory hallucination, delusion and so on. According to the hypothesis of self-medication, that a person having schizophrenia can utilize the substance in order to alleviate the symptoms of distressing psychiatrist or any kind of uncomfortable side-effects of the antipsychotic medications. Antipsychotic drugs was commenced by him to mitigate his risks of signs for his disorder which consists of phenothiazines, butyrophenones, thioxanthenes and much more. These drugs have the ability to block histamine, muscarinic and receptors of alpha 1 present in brain. Another way of lessening the deficits is the use of substances like use of Clozapine. Another few contains antipsychotic agents of novel second generation such as Quetiapine, Ziprasidone, aripiprazole, Risperidone and as per the reports it was suggested that these are quite helpful in the controlling of the substance use in those patients having schizophrenia (Green, Noordsy, Brunette & O'Keefe, 2008).
Antipsychotics of second generation (SGA) consists of benzisoxazoles like paliperidone, diphenyl butyl piperidine like pimozide, benzamides such as amisulpride and so on. These helped in manifesting broader dopamine range and other subtypes of serotonin for example, Serotonergic, Glutamatergic receptors. SGA have less affinity to dissociate from D2 receptors.
Clinical Issues- Social Withdrawal
The psychosocial intervention in the patients with psychotic disorder or schizophrenia deals with the actions as well as therapies which are used for that particular person to make him reintegrating into the society in a healthy way and making some sort of connection with them. ]
In case of psychosis, medical intervention is insufficient to reduce signs of auditory hallucination. Therefore, psychosocial intervention consists of psychotherapy, CBT, psychoeducation and family intervention. Andy’s delusion thought indicates that his housemates working for MIS. Therapeutic CBT need clients to interact in open manner, relaxed mood for better conversation regarding its professional.
In the psychosocial treatment of that patient there are five main categories of the psychosocial treatment is present which are basically based upon the patient’s community-based-treatment. The five categories are like cognitive therapy like CBT and the cognitive-remediation-therapy. The other are training programs, coping up with some social skills, different types of psychoeducational programs (Mahone, Maphis & Snow, 2016).
Family intervention requires collaboration to maintain good results in order to reduce relapse risks which in turn helped to improve mental conditions. Services in early and advanced interventions includes CBT which minimize the severity symptoms and family participation.
Nursing Diagnosis: thought process with perceptual disturbances which related to alteration of neurochemicals such as dopamine, serotonin in brains. This was evidenced by thoughts of delusions.
The nursing interventions are important by the actions of nurses for the patient in order to ensure to the continuation of all kinds of medical treatments that has been prescribed to him. Patient will need to develop insights by considering minimum one disturbed thought within three weeks.
The nursing intervention of the schizophrenia patient involves initiation, and titration and lastly the switching of ongoing medications. Nurses use several strategies as the tool, of recovery. In this context, shared decision-making is important. The nurses provide the holistic care which involves the patient educations and self management of the patient along with enhancing the spiritual support (Chien, Leung, Yeung & Wong, 2013).
Out of three steps of intervention, first one includes trust establishment to determine interpersonal relationship via proper communication system. During communication, active listening is essential to explore delusion feelings. Second include psychoeducation with respect to family members, friends, patient it is important to understand health conditions for developing insights in patient. This will offer teachings of nursing with personal experiences to encourage patient in order to identify delusional thoughts of belief to improve reality testing. Third one contains engagement of persons to promote social network and provide support by the means of valued and recreational activities. Administration regarding antipsychotic drugs is needed to manage and reduce imbalances of neurochemicals.
Evaluation: development of patient insight by accepting delusion thought of one’s person.
Health assessment is carried out with the sole purpose of diagnosis. This is the 1st step of treatment. In this report, it was known that Andy was going schizophrenia having delusional thinking, imagination and hearing voices. His medical examination was carried out. After that various medical interventions, psychosocial therapies and proper nursing interventions is be followed.