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PSYCHOSIS AND BIPOLAR CASE STUDY

Psychosis and Bipolar Case Study

Kayla Wrasman

Nursing Department, Youngstown State University

NURS 4842: Mental Health Nursing

Dr. Teresa Pack

April 5, 2023
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Abstract

A.L. is a 62-year-old female patient admitted to the inpatient psychiatric unit for a diagnosis of

psychosis. This case study will describe her diagnosis along with bipolar disorder and

treatments and interventions for both disorders. In addition to her psychosis, she has a history

of bipolar disorder, diabetes, hypertension, hypothyroidism, hyperlipidemia, vitamin D

deficiency, and obesity which could contribute to some of her symptoms and lab values.

Numerous academic journal articles were found to complete this patient’s diagnoses and data.

This paper highlights the manifestations of psychosis and bipolar disorder and that factors that

lead to the development and exacerbation of these psychotic episodes.

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Psychosis and Bipolar Case Study

Objective Data

A.L. is a 62-year-old female patient admitted on March 20, 2023, to Trumbull Regional

Medical Center with a diagnosis of psychosis. She had threatened to blow up her neighbor’s

house when he called the cops and she was brought here involuntarily. When she came into

the ER, she was all over the place within her psychotic episode that they actually had to B52

her.

I had the opportunity to talk to A.L. on March 28, 2023. She is currently experiencing a

psychotic episode. At first when she started talking, she seemed to be okay, but once she got

talking more you could see all of the characteristics of psychosis. Her main characteristic was

religious delusions. She is very into God and believes that God is everything. She says God talks

to her and tells her things she should write down. God had told her that she will get shot, but

she is okay with that because she will come back since God raises people from the dead. She

also believes that the storm we recently got in Ohio was “the end of the world”. She has a birth

mark on her foot that when she presses on it, it goes away which she seems to think means

something and since it’s in the shape of an “e” it means end. She made a comment that her

birth mark is also what symbolized her bipolar and that is “the last puzzle piece of the world”.

She also doesn’t claim that she has disease, for instance bipolar, because if you claim you have

a disease you are agreeing with satin, which you shouldn’t do.

Some other symptoms she has include flight of ideas. When she talks, she goes all over

the place with her stories. She will be telling us one story then go to a different one but then
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come back to the first one, and sometimes the stories would not be connected in any way. So,

this sometimes made it hard to keep up with the stories and really understand what she was

saying. She had circumstantiality, in that she would take a long way around getting to the

answer and sometimes had tangentiality where she just never actually got to the answer of the

question. It took her also the whole time we were talking to her to get to what brought her in

and even then, she didn’t really quite get to the answer. She also showed some impulsivity, she

told us that one day she went out and bought 600 dollars’ worth of chocolate just because she

wanted to.

Another psychotic symptom she presents with is paranoia. When we were sitting there

talking to her, she looked behind her and there were other students who were writing on their

papers and she believed that they were taking notes on her, when in reality they were minding

their own business. She says that people in her neighborhood are out to get her. In addition,

when she was in the PICU she barricaded the doors to get in with chairs so the staff was unable

to get into the area, when asked why she did this, she yelled and said she wanted to go home.

She also does not trust health care workers; she believes that the medications they try to give

her are poisonous and that they make her very drowsy. Lastly, she told us a story of why she

quit her job. She was saying that all her coworkers thought she was crazy and were playing

mental games on her to make her look even worse. They were trying to get her fired and she

knew this, so instead of them firing her she decided to quit herself.

I had another opportunity to talk to A.L. on April 4, 2023. When I saw her, I thought she

looked a lot better. She was well groomed and seemed to have recently had a shower,

compared to the week before. I asked her how she was and how she was doing, she said she
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was doing a lot better. When I started talking to her, you could tell she was still having

religiosity and delusions and was not much better. She told us that it doesn’t matter where she

ends up because “I am safe no matter where I go because I am God’s child”. She is also not

worried about the bills she hasn’t paid because God will take care of them. Lastly, she said that

“if you don’t confess your love to God, you will not be going to Heaven”. We also saw her being

paranoid. She said “someone is out there trying to kill me” and that they are holding her

hostage here. Looking back at her notes, on March 31, she had a code violet called against her

involving another patient and the next day they took her back to the PICU where all she wanted

to do was talk to other patients and tell them that she will take them home with her.

The patients’ labs were taken on March 21, 2023, the day after she was admitted. They

didn’t recheck any of her levels since she got there besides her glucose and Depakote level.

When she came in, her glucose was at 294 and her hemoglobin A1C was 11.8. On April 4, 2023

they rechecked her blood sugar and it was 258. Both of these numbers are very high, she is

diabetic so that is what is contributing to this. But, Haldol and Invega which she is on also has a

tendency to increase glucose as well. Her hemoglobin was a little low at 11.7 which isn’t too

concerning. When she first came in her QTC was 522, the rechecked it the next day and it was

468. This is still high as we want it to be under 440. This could be from all of the B52 injections

she received as well as from the Haldol, Invega and Depakote she is prescribed. Lasty, they

checked her Depakote level to make sure she was in the therapeutic range, when she first came

in it was 54.1 and when they rechecked it on the 1st was 75. So, this is good and means she is

therapeutic. All of her other lab values were normal.

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Treatments for A.L. include Clonazepam (Klonopin) 0.5 mg for her anxiety, Divalproex

Sodium (Depakote) 500 mg as a mood stabilizer for her bipolar, Haloperidol (Haldol) 5 mg for

acute psychotic behaviors, Hydroxyzine HCl (Atarax) 50 mg for anxiety, Paliperidone (Invega) 3-

6 mg for psychotic symptoms and Trazadone HCl for her sleeping. Also considering her other

medical diagnoses of hypertension, hypothyroidism, hyperlipidemia, Vitamin D deficiency,

diabetes, and obesity; she is given Hydralazine for her blood pressure, Vitamin D supplement,

and Synthroid for her hypothyroidism. Out of all these medications she is prescribed, she only

takes her Depakote, thyroid, and vitamin D supplement. She will not take any of her other

psych meds. The only reason she takes her Depakote is because she believes it’s what gives her

hair is waviness.

Other treatments for A.L. include safety from her and the other patients on the floor.

So, making sure there is nothing around that is hazardous or has the potential to be used to

harm someone. She was in the PICU and given B52 multiple times, so this is a huge concern

with her. She even said herself “I am like Godzilla when I get mad”.

Summarize the psychiatric diagnosis

“In the early editions for the APA’s DSM, psychosis was defined broadly as ‘gross

impairment in reality testing’ or ‘loss of ego boundaries’ that interferes with the capacity to

meet the ordinary demands of life” (Arciniegas, 2015). “The term ‘psychosis’ still lacks a unified

definition, but denotes a clinical contrast composed of several symptoms. Delusions,

hallucinations, and thought disorders are the core clinical features. The search for a common

denominator of psychotic symptoms points towards combinations of neuropsychological

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mechanisms resulting in reality distortion” (Gaebel & Zielasek). A.L. has presented with these

symptoms. She has persecutory, grandiose, and religious delusions; she has auditory

hallucinations; and also presents with flight of ideas, circumstantiality, tangentiality,

perseverance, and paranoia.

“Bipolar, or manic-depressive, disorder is a frequent, severe, mostly recurrent mood

disorder associated with great morbidity. The clinical manifestations of the disease are

exceptionally diverse. They range from mild hypomania or mild depression to severe forms of

mania or depression accompanied by profound psychosis” (Müller-Oerlinghausen et al., 2002).

We saw that A.L. has had many recurrences with her manic or psychotic phases as evidenced by

all of the times she has been hospitalized in the past. For the most part, she does not exhibit

much depression. “The choice of treatment for bipolar disorder is constantly being revised, as

new drugs become available and anticonvulsants take on and increasingly important role”

(Müller-Oerlinghausen et al., 2002). A.L. is prescribes the anticonvulsant, Depakote to try and

help her with her mood stability and with her bipolar diagnosis. Luckily, she is taking this

medication, so it is helping in some way.

Identify the stressors and behaviors

A.L. has had some stressors in the past that have contributed to this admission. She told

us that she has been hospitalized before for this same thing, so at least she recognizes that

there is something going on. She said that her first hospitalization was due to anxiety that

triggered her. From hearing all of her stories, it seems like most of her admissions now are

because of anger and psychotic breaks. As I said earlier, she stated “I am like Godzilla when I get

mad”. This seems like a pretty accurate statement from what I understood. She has difficulty
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controlling her anger. After she had said she was going to blow up her neighbor’s house, she

went back to hers and started throwing all of her stuff out her front door into her front lawn.

She also stated when the cops came to get her that they put her in hand cuffs and was hurting

her, so this was a big stressor for her to experience. To go along with this, she doesn’t take her

medications that are to help her and her behavior. So, not taking her medications and her

history of bipolar disorder are factors that contribute to her mood swings and her psychotic

episodes.

Discuss patient and family history of mental illness

A.L. seems to have a little bit of family history of mental illness. She states that her

mother had bipolar disorder and she also has a diagnosis of bipolar disorder. In addition, she

stated that her sister does not have an actual diagnosis of a mental illness but that she does

have some sort of mental issues. A.L. also has had a history of mental illness since she was first

admitted to a Psych floor when she was 18 years old. She believed it all started from having

anxiety. Since then, she has been admitted to the Psych unit about 9-10 times.

Describe the psychiatric evidence-based nursing care provided

“Treatment should proceed in a stepwise fashion depending upon safety, response, and

progression” (McGorry et al., 2008). Safety is one of the most important care one can provide

for a patient going through a psychotic episode. When the patient was brought to the unit, they

removed any sort of hazardous items they might have, strings, belts, glass, etc. In addition to

removing objects they might have, the floors are also removed of anything dangerous including,

pens and pencils, metal utensils, they don’t have glass windows or mirrors, their call buttons

have short strings, they have heavy furniture and Velcro on the bathroom doors. Along with
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removing all unsafe objects from the patients and surroundings, it is good to keep an eye on

these patients. Frequently contacting and spending time with someone during a psychotic

episode is important, even if the patient doesn’t even know you are there.

Another treatment available for A.L. to attend was group therapy. At the hospital, the

provide a couple sessions per day. The morning group is usually a meditation, this helps the

patients get into a good mindset and starts their day off right. The next one is usually the ones

where these patients do activities and really get involved. “Group therapy is a treatment

modality involving a small group of members and one or more therapist with specialized

training in group therapy. It is designed to promote psychological growth and ameliorate

psychological problems through the cognitive and affective exploration of the interactions

among members, and between members and the therapist” (Barbender et al., 2014). Group

therapy is supposed to help these patients produce some sort of positivity, whether that be will

coping skills or being able to recognize behaviors that are not appropriate and be able to find

ways to change them. A.L. was able to list some positive coping strategies she uses. She also

mentioned that she gets very angry but that will never change. She has acknowledged this

negative behavior but she didn’t come up with ways to try and fix that, she just gave up and

said that it wasn’t going to change. This is something that she could talk more about during an

individualized session with a therapist to figure something out to help this negative behavior.

Analyze ethnic, spiritual, and cultural influences

A.L. is a 62-year-old Caucasian female. She never stated a specific religion but she does

strongly believe in God. She believes that God talks to her frequently and tells he what to do

and what she should write down. She said that God told her she was going to get shot but that
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it would be okay because God will raise her from the dead. It could be concluded that A.L. is in a

lower socioeconomic class. She doesn’t have a job, she lives alone with no husband or children,

and stated she has a car but it has been broken for a while and needs fixed.

Evaluate the patient outcomes

I had the opportunity to talk to A.L. two weeks in a row. From the first week to the

second week, she seemed to look better physically. She was more put together and was better

groomed. But, as for her mood and psychotic symptoms she seemed to be the same with not

much improvement. A big factor to this is because she is not taking her medications which are

there to help her with this. She again stated that she doesn’t care where she goes because she

is safe anywhere since she is God’s child. Compared to the first week, she did seem to be more

active within group therapy. It sometimes would take her a while to get to her ideas, but she

was able to come up with some positive coping skills. But she did state that she gets angry

easily and that will not change. So, this was not good, but I guess at least she is being honest

and recognized these actions.

Summarize the plans for discharge

A.L. states that it doesn’t matter where she goes and that she would be okay staying at

the hospital because she knows she is safe there. If she does get discharged, she will be going

home where she lives alone. There she will be required to take all of her prescribed

medications. Since she is noncompliant in taking her medications at the hospital, she may need

a lot of education. They will also educate her on some of the side effects and adverse reactions

that may occur when taking her medications. Since she is taking Depakote, she will need to

come in to get her levels checked to make sure she is taking it and that she is within the
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therapeutic range. In my opinion, it may not be in her best interest to go home to live by

herself, I think that an assisted living facility would do her good. They could keep an eye on her

and make sure she is taking her medications.

Prioritized list of all actual diagnoses

Risk for injury to self or others related to psychotic episodes of uncontrolled outburst as

evidenced by receiving B52 injections multiple times and getting the cops called on her and

them putting her in hand cuffs.

Impaired though process related to mental illness as evidence by auditory hallucinations

and delusions.

Anxiety related to paranoia as evidence by barricading self in the PICU, saying “someone

out there is trying to kill me”, thinking that other students are writing notes about her, and

believing that the health care workings are poisoning her with the medications.

Risk for violence related to delusions and hallucinations and psychotic episodes.

List of potential nursing diagnoses

Ineffective coping

Self-care deficits

Risk for loneliness

Ineffective health maintenance

Ineffective impulse control

Impaired social interaction

Disturbed sensory perception

Risk of lack of sleep

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Risk for depression

Conclusion

In conclusion, I had never talked to a patient will all these different delusions and

symptoms of psychosis, so it was very interesting to talk to her and see what she had to say. It

was hard to know at times if the stories she was share were true or not. A.L. experiences many

psychotic episodes. During these episodes she get very mad and angry and has a hard time

controlling her emotions. If she follows her medication regimen it can help with these

symptoms and psychotic breaks and can help decrease her rate of hospitalizations.
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References

Arciniegas, D. B. (2015, June). Psychosis. Continuum (Minneapolis, Minn.). Retrieved April 11,

2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455840/

Brabender, V., Fallon, A., & Smolar, A. I. (2004). Essentials of Group therapy. Wiley. 

Gaebel, W., & Zielasek, J. (n.d.). Focus on psychosis. Taylor & Francis. Retrieved April 11, 2023,

from https://www.tandfonline.com/doi/full/10.31887/DCNS.2015.17.1/wgaebel?

scroll=top&needAccess=true&role=tab 

McGorry, P. D., Killackey, E., & Yung, A. (2008, October). Early intervention in psychosis:

Concepts, evidence and future directions. World psychiatry : official journal of the World

Psychiatric Association (WPA). Retrieved April 11, 2023, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2559918/ 

Müller-Oerlinghausen, B., Berghöfer, A., & Bauer, M. (2002, January 21). Bipolar disorder. The

Lancet. Retrieved April 11, 2023, from

https://www.sciencedirect.com/science/article/abs/pii/S0140673602074500