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A Patient with Delusions and Psychotic Behavior Related to Schizophrenia, Admitted to the
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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Case Study
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
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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Case Study
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
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.
with patients receiving many medications. Nicotine was given because the patient is a pack
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Case Study
per day smoker. Bisacodyl and Mg hydroxide are given PRN because of common med side effect
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
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
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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Case Study
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
History
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Case Study
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
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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Case Study
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
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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Case Study
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
Plan
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Case Study
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
Actual Diagnoses
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Case Study
Self-care deficit related to loss of contact with reality and concentration problems, as
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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Case Study
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:
Schizophrenia.html.
National Institute of Mental Health. Schizophrenia. The National Institute of Mental Health
12-2015/nih-15-3517_151858.pdf