BENNY & JOON CASE STUDY 1

Transcription

1 BENNY & JOON CASE STUDY 1 Benny and Joon Case Study Elisabeth Drake Longwood University Pledge:

2 BENNY & JOON CASE STUDY 2 Introduction Juniper Pearl was TDO d to Emma Sherman Memorial Hospital for a psychotic episode on a local bus after her brother angrily broke the news to her about a consideration of putting her in a group home. She was restrained by paramedics on site and transported to the hospital via ambulance. The patient is taking medications and following the prescribed dosage. This following information lists all problems, diagnosis, and recommendations regarding the patient. Diagnosis and Problem List Axis I-IV Axis I: PTSD, Schizoaffective Disorder Axis II: Paranoid Personality Disorder Axis III: Deferred Axis IV: 35 Explanation for GAF score I gave the patient Joon a 35 on the GAF due to her auditory hallucinations, and impaired judgment in reality orientation, noting that her behavior does not seem to be influenced by the auditory hallucinations. She has no history or current signs of HI or SI though she is required to not be left alone due to her lack of appropriate judgment and impulsive behavior at times. An example of impaired judgment would be when the patient wore scuba goggles and used a ping pong paddle to direct traffic in the middle of a busy intersection. She can however lead a normal

3 BENNY & JOON CASE STUDY 3 life when at home with her brother, when there are no triggers for her bizarre behavior that could potentially be dangerous. Problem list Patient has no history of suicide but does seem to be suffering from various symptoms. The patient experiences auditory hallucinations as her brother says she hears voices and at times will talk back to them. She seems to have paranoia as expressed by thinking all people are cheating her (while in a conversation with one person after a miscount of points in a ping pong match), riding in vehicles with a helmet, and not being able to stay calm through hearing vehicle noises while on the bus. The patient has impulsive behaviors when she is stressed and engages in bizarre behavior when she is left alone such as an incident where she was wearing a scuba mask, holding a ping pong paddle, and stood in a busy intersection in an attempt to direct traffic. The patient does seem oriented to person place and time, but not always the situation (again referring to the attempt to direct traffic in a busy intersection in inappropriate clothing). Attention span of the patient does seem to be within normal limits though her attitude seems guarded and at times uncooperative. Her speech is typically normal and clear, but there are times where it appears pressured, such as with the ping pong game where she claimed everyone was trying to cheat her, her speech did become pressured and she broke a house lamp while running out of the room. This also shows that impulse control is poor, and her mood can be unstable at times. The patients eye contact does seem appropriate and judgment seems fair. Patient has congruent affect, she laughs when appropriate, and is upset when appropriate. This leads to a provisional diagnosis of schizoaffective disorder with paranoid personality disorder.

4 BENNY & JOON CASE STUDY 4 The patient also seems to be showing symptoms of suffering from PTSD as evidence by her witnessing the sight of her parents being treated by paramedics and covered up after being pronounced deceased following a fatal motor vehicle accident (MVA). The patient partakes in unusual behaviors around cars such as wearing a helmet when in a vehicle and bus noises trigger a panic or psychotic episode. These episodes are characterized by the patient rocking back and forth in her seat, head nodding, tapping on the bus seat, fidgeting with her hands, speaking words to herself that aren t actual words, and saying I am not to herself, crying, hitting, being non responsive to surrounding persons help, head shaking, pacing, shaking of the hands, expressing a belief that paramedics are going to hurt her, and physically lashing out at help provided. The patient does carry a medication alert card and is on medication. The patient does require supervision at all times. The patient s appearance is neat and clean, she is thin, but looks healthy and well nourished. The way the patient dresses on the every day basis is normal attire, but when left alone and engaged in bizarre actions such as wearing the scuba mask, her attire is inappropriate. Treatment Recommendations: Level of care/facility I recommend that this patient go to partial hospitalization care five days a week (from 8:00-4:00 no weekends) for 10 weeks at a local hospital due to showing signs of being borderline nonfunctional. The patient should then receive intensive outpatient care three days a week indefinitely. Patient can receive services from an outpatient mental health facility. The patient

5 BENNY & JOON CASE STUDY 5 will be living with her boyfriend as he has been deeply informed and included on the situation, and due to the patient expressing a need to live in a desirable situation (deemed safe) with the understanding that she needs to be in treatment during the day as she should not be left alone. The patient should be seeing her psychiatrist twice a week to check in on how her outpatient program is going, and to oversee the care and provide medications for the patient. A psychologist should complete any psych testing needed that was recommended by the psychiatrist. Therapeutic recreation program recommendations The patient should receive therapeutic recreation interventions such as anger management, reality orientation, relaxation therapy, art therapy, music therapy, CBT, and self-esteem multiple times a week depending on the level of need the patient has to each intervention. Length of stay The patient should receive partial hospitalization program care and therapeutic recreation services for 10 weeks, and at week five, only seeing the psychiatrist once a week if progress is being made. If progress is made after those 10 weeks, intensive outpatient care with therapeutic recreation interventions should be completed three days a week indefinitely as she is required to be supervised at all times, and her brother works full time, and her boyfriend works part time. Functional Summary: Patients strengths include:

6 BENNY & JOON CASE STUDY 6 Cognitive: Good memory Physical: Painting Emotional: Congruent affect Spiritual: Seems relaxed outdoors Patients weakness includes: Cognitive: Impaired judgment, auditory hallucinations, paranoid thinking Physical: Lack of various physical leisure activities Emotional: Impulsive behavior Spiritual: Lack of prominence Therapeutic Goals/ Outcomes: Patient will actively work on managing anger impulses. o Over the course of 10 weeks, the patient will attend an anger management session group, twice a week. o Over the course of 5 weeks, the patient will fill out a log identifying anger triggers whenever the patient feels angry, specifying that events preceded the emotion. Patient will demonstrate ability to stay relaxed. o Over the course of 10 weeks the patient will attend a group deep breathing relaxation session for 30 minutes, three times a week.

7 BENNY & JOON CASE STUDY 7 Patient will demonstrate orientation to reality. o Over the course of 10 weeks, the patient will attend a daily current event group and identify date, place, situation and time correctly 3 out of 4 times. o Over the course of 10 weeks the patient will attend a 1:1 session with a recreational therapist, practicing grounding techniques once a week. Patient will express emotions through art. o Over the course of 10 weeks the patient will attend a 1:1 art session, expressively painting how she feels at the end of each week. Patient will be introduced to music therapy. o Over the course of 10 weeks, the patient will attend a music therapy session for 45 minutes, twice a week. Patient will actively work on increasing self-esteem. o Over the course of 10 weeks, the patient will attend a self-esteem group session once a week. Patient will actively work on cognitive retraining. o Over the course of 10 weeks, the patient will attend a CBT program once a week Interventions: Anger management would be a good intervention for the patient because she has impulses that she cannot control. Focusing on identifying the triggers of her anger outbursts and practicing managing the impulses will greatly improve her quality of life. Reality orientation is important for the client because when triggered, she detaches from reality and acts in a bizarre manner.

8 BENNY & JOON CASE STUDY 8 With attending reality orientation sessions and practicing grounding techniques the patient will be able to have better control over her episodes where she detaches from reality, and may be able to shorten the period of the episode. Being able to ground the patient is also important for the patients safety considering that when she looses her reality orientation is when she partakes in potentially dangerous behaviors. Relaxation therapy is a good intervention for the client going along with reality orientation and anger management to develop a more sturdy overall sense of being able to relax. The patient does become agitated and currently has no skills to stop the progression of agitation and to relax her mood. With relaxation sessions and practicing deep breathing, the patient will be able to develop those skills to better control her feelings of agitation. Art therapy for this patient is a necessary intervention due to the client having a passion in art, and an occupation. Using art as an intervention will be a comfortable area for her to express how she feels at the end of each week. By the end of the weeks, the patient can look at her collected paintings and review how her feeling has changed from the first week to the last in areas of self-esteem, control, and quality of life. Music therapy will be a new intervention for the client but is expected to go well as she enjoys listening to music. With music therapy, the patient will be able to further express how she feels in her situation with her diagnosis, symptoms and in all areas of her life. Cognitive behavioral therapy (CBT) would be a good choice for the patient due to her experiencing symptoms of schizoaffective disorder. CBT can help the patient realize that the thoughts she has about herself having a mental illness does not have to be completely negative. The patient has referred to herself in third person as mentally ill multiple times. The label was used in negative context each time, and with using CBT sessions with this client could work on improving her sense of self.

9 BENNY & JOON CASE STUDY 9 It may also help her handle lessen the amount of psychotic outbursts she has due to the change in her thought process. Self-esteem would be a good intervention for the patient because she does seem to feel as though her diagnosis is who she is, and attending self-esteem sessions can help point out areas in her personality that are strong. Relating to these strengths in her personality could help improve her sense of self further. Evidence based practice Anger management has been shown to help the patient adapt to the community better and the rehabilitation program (Fassino et al., 2009). It also has been found to predict better social involvement in the community (Fassino et al., 2009). Relaxation therapy has been shown to help reduce feelings of distress in patients with psychosis (Vancampfort et al., 2012). Cognitive behavioral therapy (CBT) has been shown to improve symptoms on PTSD and schizoaffective disorder (Frueh et al., 2009). Evaluation: Effectiveness The patient will be evaluated upon admission to the recreational therapist in areas of leisure awareness, self-awareness, leisure satisfaction, leisure competence, cognitive ability, functioning

10 BENNY & JOON CASE STUDY 10 ability, and self-esteem. To evaluate the patient to see if the program is effective I would use a list of questions regarding the goals and objectives that have been set for the patient and ask the patient in an interview style. In collaboration with the interview questions, I would look at documentation from the patients stay and see the progression that has been made. Frequency & continuation Every two weeks the patient will be reassessed using an appropriate assessment tool determined after the initial assessments have taken place. If progress is not made in the goals set for the patient, then the goals will be modified to try a different intervention, and if there is progress being made but more time is needed, the patient s length of care with therapeutic recreation programs will be extended. If no progress is made, the treatment team will meet up and determine a better course of action for the patient. Recommendation/ Discharge/ Transition Clinical: I recommend that the patient see her psychiatrist twice a week, and if good progress is being made then dropping down to once a week. I recommend that the patient see her psychiatrist as above also for the continual management of medications. Therapeutic:

11 BENNY & JOON CASE STUDY 11 I recommend that the patient continue to receive the following therapeutic recreation interventions: o Anger management group sessions (1x a week) o Group deep breathing sessions (2x a week) o Reality orientation-grounding techniques (2x a week) o Art therapy (1x a week) o Self-esteem group session (1x a week) o CBT (1x a week) Conclusion Joon seems to be suffering from schizoaffective disorder as well as paranoid personality disorder. She will go through a initial 10 week period where she will see her psychiatrist, a psychologist if needed, and engage in therapeutic recreational programs. After that 10 week period, the patient should continue with specific interventions indefinitely. During this time the patient will be living with her boyfriend and medications will continue the same as previously prescribed.

12 BENNY & JOON CASE STUDY 12 References Arnold, S., Roth D. (Producer), & Chechik, J. S. (Director). (23 April 1993). Benny & Joon [Motion picture]. United States of America: Metro-Goldwyn-Mayer studios inc. Fassino, S., Amianto, F., Gastaldo, L. & Leombruni, P. (2009). Anger and functioning amongst inpatients with schizophrenia or schizoaffective disorder living in a therapeutic community. Psychiatry and Clinical Neurosciences, 63, pages Frueh, B.C., Grubaugh, A. L., & Cusack, K. J. (2009). Exposure-based cognitice-behavioral treatment of ptsd in adults with schizophrenia or schizoaffectice disorder: a piolet study. Journal of anxiety disorders, 23 (5) pages Vancampfort, D., Correll, C. U., & Scheewe, T.W. (2012). Progressive muscle relaxation in persons with schizophrenia: a systems review of randomized controlled trials. Clinical rehabilitation, 27 (4)