Rational: Episodes of strange behaviors for at least last three months with withdrawal from activities and relationships, undocumented behavior history among relationships and age period of 18-20 years, past episodes of psychosis may be undocumented. Delusion of being a member of CIA and able to communicate telepathically, and auditory hallucination of male voice telling not fulfilling mission, client is a shame to the country, and will be Presidentially reprimanded. Staff observed as “enemy agents” and fearful in interactions, blank stares at the wall, angry outbursts, and lack of emotional expression. Mother has noted client to be returning home smelling of alcohol and discovered “strange pills” in bureau drawer (Osterman, 2012).
Axis II: Deferred, pending further assessment.
Axis III: No medical problem stated by client or mother.
Axis IV: Problem related to: Primary support group: few friendships, shades are drawn. Educational problems: failing grades from not attending or completing assignments. Occupational problems: probation at employer for missed days. Primary support problems: discord with brother, break-up of four year relationship three months ago (Osterman, 2012) (American Psychological Association, 2000).
Axis V: 25-30, auditory hallucinations, delusions of grandeur, attempt to jump from third floor window, poor attendance of job or school (Osterman, 2012) (American Psychological Association, 2000).
Plan of Care
The plan for the client at this stage of presentation is an inpatient hospitalization and initiation of an antipsychotic medication. The underlying rational is that the client is a danger to himself and possibly others as proven by the attempt to jump from a third floor window, a perceived duty to country, and perception of others as enemy secret agents (Osterman, 2012). The long-term plan for the client is to decrease hallucinations and delusions while educating client and family on coping skills and illness, inclusive of assessment for best placement of client for self and family. Initial plan of care is: to hospitalize the client; start him on Zyrexa 20 mg daily, initial IM with change over to PO as compliance increases (Stahl, 2011); check blood chemistries through a CBC, Chem panel (electrolytes, BUN/Cr, Ca, Phos, TSH, LFT, B12, Folate), UA with urine toxicology screen; and initiate oral supplements of Thiamin/Folate/MVI to address possible deficiencies. Further, as the client’s mentation clears assessment will be made to investigate appropriateness for alcoholics anonymous referral, smoking cessation education with treatment of 14 mcg Nicoderm patch daily for 6 weeks, and intensive outpatient treatment services as manifested psychosis of hallucinations, delusions, breaks in reality, and catatonia may be symptoms of a clinical condition resultant from drugs or toxins (Jacobson and Tarraza, 2013). During hospitalization, the client’s home will be searched for access to weapons and all medications will be locked up, family counseling and anger management sessions are initiated, individual cognitive therapy sessions conducted to modify thought patterns, and therapeutic touch utilized to ground the clients mentation in the here and now. Discharge planning for the client should include intensive outpatient treatment inclusive of medication management, individual and group CBT sessions, and anger management sessions with arrangements for activities that reconnect the client with social supports including consideration of enrollment in online classes at the community college attending and modification of job expectations at place of employment.
The goals of this client should address short and long-term domains. The short-term goals for the client are hospitalization for safety, consistent attendance at inpatient groups with peers while hospitalized, attain daily medication compliance, increase engagement with others in the inpatient unit, manifest decreased delusions and hallucinations, and evidence decreased behaviors of self-harm. The long-term goals are to engage in activities with old friends, attend outpatient therapy at a minimum of three times weekly, sustained medication compliance in outpatient follow-up, maintain functionality at school and job, and return to living independently either at home or in a group home.
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The client’s short-term goals can be categorized into issues of safety and issues of disease management. First, issues of safety may be addressed through initiation and maintenance of hospitalization. Hospitalization allows for the daily administration and monitoring of medication providing a means for assessing the hallucinations and delusions in an environment that can provide safety from intentional self-harm or accidental harm from medication effects. Further, the establishment of a therapeutic relationship with a staff of caregivers during hospitalization provides a framework for the client to increase socialization with others among a system of daily therapy that teaches coping skills and reality testing for recognizing safety from actions of hallucinations. Second, issues of disease management are met through education about diagnosis, medications, and coping skills. Education about diagnosis provided daily empowers the client with an understanding of how hallucinations are manifest in delusions and allows the client security in building relationships with others. Medication education performed with all administrations builds an understanding by the client of how medications are controlling symptoms recognized as hallucinations and allows him to feel comfortable in engaging others in the milieu. Therapy provided in groups and individual sessions daily may address automatic thoughts, perception of thoughts, cognitive impairments, and behaviors manifest with thoughts to assist the client in learning coping skills and reality testing, inclusive of therapeutic touch for centering the consciousness within the self for unblocking of negative thoughts and grounding in immediate reality, for distinguishing what is real from what is a hallucination (Tusaie, 2013). Properly addressing issues of safety and disease management allows the clinician to assess a progression of evidence in decreased behaviors of self-harm and decreasing of hallucinations to meet the short-term goal of stabilization for determining proper discharge placement and monitoring.
The long-term goals for the client are categorized as issues of returning to normal functional activities of daily living and issues of disease management with symptom suppression. Primarily, issues of return to daily functional activity are the most important goals for the client in accepting and managing disease symptoms. The client will be coached by cognitive behavioral therapy at outpatient therapy appointments three times weekly in how to engage in activities such as basketball games, group outings with old friends, maintenance of work requirements, and attendance at school classes without manifesting assumptions or automatic thoughts. Staff will support the client in all therapy sessions to find the best living arrangement for his perception of safety, whether returning to living independently at home or in a group home, as evidenced by decrease in behaviors of self-harm in the setting. Family therapies will be conducted monthly to educate the client and family about disease and symptom management, as well as to train the family in skills of early detection with intervention and support. Second, issues of disease symptom suppression will be addressed through the client’s attendance of intensive outpatient treatment with therapy and medication education/management at a minimum of three times weekly with attendance at a minimum of 90% of sessions. Efficacy of interventions may be assessed by the clinician in evidenced sustained medication compliance and decreased symptoms of hallucinations and delusions in outpatient follow-up for a period of six months.
The outcomes of this client is anticipated to be a return to an individual living home environment with sustained disease symptom management manifest through lack of self-harm behaviors and consistent medication compliance. The goal of symptom management is reached over a three-month period of diminished hallucinations and delusions through consistent use of an antipsychotic that controls auditory hallucinations and daily utilization of therapeutic touch to ground the energy of negative cognitions among reality for distinction. Further, progression of placement in an environment of safety is followed in a pattern of most restrictive to least restrictive environment, typically manifest as hospitalization with transition to group home environment and then to a home environment with daily contact progressively lengthening between contacts as absence of symptoms or problems dictates. Additionally, the client will maintain a job and continue in education endeavors over a one-year period through utilization of newly acquired coping skills for symptom or hallucination reduction and reconnection with previous support system of friends and family. Finally, the client and family will understand the manifestation of disease with perceived hallucinations and symptom management through monthly family therapy sessions.
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