OBP II: Mental Health

Case Study - AngelaJeffrey Arnold, Danielle Nester, Hannah Reed, Anne-Marie

Wadlington, Shelby Berthelot, Tatiana Caldera

Client History

Diagnosis: Paranoid Schizophrenic Angela is a 36 year old woman of mixed ethnicity, French and

African American, who grew up in household of mixed practices of Catholicism and VooDoo

Estranged marriage, with two sons ages 14 and 16

History of multiple psychotic episodes, beginning when she was 30

Pattern of discontinuing medications due to belief that she has no illnesses

3 voluntary hospitalizations between LSUHSC Shreveport and New Orleans within 3 years

Client History

During second hospitalization, client was prescribed haloperidol and lithium, but was discharged on lithium alone

Lithium: bipolar disorder, mania

Haloperidol: schizophrenia, antipsychotic, delirium

Because she presented as psychotic, haloperidol was prescribed to calm her. Once calm, doctors believed she was affected with bipolar disorder so they discharged her on lithium alone

Two weeks later, Angela was re-hospitalized. It was then established that she indeed had schizophrenia rather than bipolar disorder, which is why the lithium did not help her

Client History Client’s third hospitalization, in New Orleans, was as a result

of her showing up to the ER with this note pinned to her dress:

“No visitors allowed. I was fired. I do not feel very well. May I please speak to Dr. Mark Adams. In Shreveport, I am considered a chronic paranoid schizophrenic. I have no interest in answering questions, especially about my religion. I have nothing to say except to request a transfer to a professional health care facility in New Orleans. This is known as racketeering comrade. There is probably going to be another hospitalization. It is yet to be determined it there is going to be a pseudonym and no insurance. Happy anniversary.”

After several hospitalizations, Angela was court ordered to move to the Evangeline House for long term treatment

Evangeline House- provides psychiatric, psychological, psychosocial, and rehabilitative services in a therapeutic atmosphere

Client History

Evangeline House MSE Results Overview Cooperative in answering questions, but very guarded

No eye-contact established, constantly looking around the room

Poor insight into current illness, believing that she had a headache from probes placed in her head by the CIA, but was not crazy

Noted palilalia (rapid repetition of sounds, words, or phrases)

Oriented to person and place, but not date

History of suicidal ideations/attempts and sexual trauma

Client HistoryPreoccupation with conspiracy theories

Believes “men in black” and the CIA have been following her for years because of the special knowledge she has gained in dreams

Believes the film “Men in Black” was created to give her secret information on how to avoid government agencies

Believes that agents placed probes in her brain to allow them to read her thoughts and control her mind

She stated that she must starve her brain in order to ward off voices

States that she often sees agents lurking in the shadows, indoors and outdoors

Current Medical Report (Pre-OT) Symptoms of schizophrenia:

Positive: delusions, hallucinations, behavioral dyscontrol, thought disorder

Negative: attention impairment

Smoker

Nicotine normalizes medication and makes voices in head seem like they are her own; also known to reduce stress and anxiety

Current medication: Chlorpromazine Hydrochloride-Schizophrenia, Mania, Behavior Problems

Risperidone- Schizophrenia, Mania, Behavior Problems

Global Assessment Functioning (GAF) score: 30 Behavior is considered influenced by delusions, hallucinations, or

serious impairment in communication or judgment or inability to function in all areas

Angela’s Self Collage

Before therapy can begin…

LOTR Initial Assessment Findings Client needs multiple verbal cues to stay on task

Slow initiation of tasks, slow to complete

Poor sense of self-awareness (strengths and weaknesses)

Little to no ability to generate an adaptive response, cannot meet expectations of self or environment (OA)

LOTR Initial Assessment Findings Noted strengths

Motivated by hobby- gardening

Self-expression on collage, sense of identity

Can problem solve, but slow cognitive processing

Noted weaknesses Needs verbal cues to stay on task, poor attention span

Closed off; weary of interaction with other people; guarded

Lack of safety/good judgment

OT Accommodations and Precautions Accommodations:

Do not work in group setting, client is very uncomfortable with social interaction

Avoid approaching client suddenly, from behind, or in a manner that may be perceived as threatening

Do NOT whisper!

Avoid dark clothing, as client may associate this with hallucinations of the “Men in Black”

Do not argue or insinuate that the client is unintelligent

Prepare client for any anticipated environmental changes in advance, such as rearrangement of furniture

OT Accommodations and Precautions Precautions:

Suicide precautions

No sharp objects in vicinity of treatment

Address suicidal ideations and experiences if client is comfortable, never avoid having related conversations

Medical non-compliance

Client is estranged from family and has no form of personal support system

Client has impaired memory

Theory Behind Interventions Occupational Based Model:

MoHo Uses occupation to provide increase of personal causation, reorganize

habits and routines, and improve occupational performance capacity

Change occurs when there is a shift in one part of the person’s open systems cycle

Motivation is influenced by a person's interests, values, and a sense of personal causation.

Frame of Reference Acquisitional- Toglia

Focus is to improve cognitive function: orientation, attention, visual, processing, motor planning, cognition, occupational behaviors and effort

Change occurs when self-awareness is increased and through practice of cognitive strategies within multiple contexts

Assessments TCA: Toglia Category Flexibility Assessment

Requires that client is able to:

Follow two step directions

Discriminate between size, color, and form

Attend to a task for minimum of 15 minutes

Contextual Memory Test

Helps address memory capacity, strategy of use, and recall in adult clients with memory dysfunction

OT Therapeutic Goal: 1

In order to improve client’s medication adherence, client will verbalize three reasons why she wants to stay on her medication by discharge.

OT Therapeutic Intervention: 1 Complete a life time line of past (not on medication)

and present (on medication) occurrences

Client must recall past occurrences that were maladaptive due to poor medication adherence, and then compare them to present functional occurrences in order to gain an understanding of the benefits of taking her medication.

OT Therapeutic Intervention: 2 Client will work with OT to develop medication

schedule. The schedule chart will have spaces for the client to check off each time the medications are taken.

The chart will also have a section for the client to document her emotional status each time she takes her medication.

 Weekday Medication 

Name/Dosage

 A.M./P.M Mood Scale

 

Monday          

Tuesday          

Wednesday          

Thursday          

Friday          

Saturday          

Sunday          

OT Therapeutic Goal: 2

In order to increase self-awareness, client will demonstrate ability to follow a 5 step checklist to complete a moderately difficult task by discharge.

OT Therapeutic Intervention: 3

Client will use the OGI program to complete the appropriate steps to plant flowers in the Evangeline house garden.

Client must use the 5 step OGI checklist to assist her in monitoring her performance during the activity.

5 Step Checklist

1. Stop and think! Orienting and alerting to task

Initial discussion of interests and tasks the individual wants to work on; raises awareness of individual meaningful activities that will direct the choice of the task

2. Define the main task Define the specific goal. This stage includes choice, definition,

and goal setting

3. List and Partition goal into subgoals Setting the steps to achieve the goal

Recording the process, steps, and required material

Estimating duration of performance

5 Step Checklist (cont.)

4. Learn Steps Encoding and retention, say the process by heart (the subgoals)

Perform the task

5. Monitor Check and evaluate the outcome and the process

Compare the outcome with the goal definition

What kind of problems and difficulties did you meet or encounter?

What factors promoted or interrupted goal achievement (task completion)?

Are there alternative ways to carry out the task?

Schizophrenia Resources National Alliance on Mental Illness

https://www.nami.org/

www.namilouisiana.org : (225) 291-6262

Peer-to-Peer Support Groups

Family-to-Family Support Groups

Recovery Support Groups

Schizophrenia Health Center

http://www.webmd.com/schizophrenia/default.htm?names-dropdown=OR

News, references, videos

Symptoms & Types

Diagnosis & Tests

Treatment & Care

Living & Managing

Support & Resources

Schizophrenia Resources

Substance Abuse and Mental Health Administration

http://www.samhsa.gov/

Journal articles

Early, M. B. Mental Health: Concepts and Techniques for the Occupational Therapy Assistant. Lippincott Williams and Wilkins, 2008.

Toglia, J. P. (2011). The Dynamic Interactional Model of Cognition in cognitive rehabilitation. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 166-186). Bethesda, MD: AOTA Press.

Toglia, J. P. (1993). The Contextual Memory Test. Tuscon, AZ: Therapy Skill Builders.

Cole, M, & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: Slack.

Peer Reviewed References:

 

Bejerholm, U., & Eklund, M. (2007). Occupational engagement in persons with schizophrenia: Relationships to self related variables, psychopathology, and quality of life. American Journal of Occupational Therapy, 61, 21– 32.

Katz, N., & Keren, N. (2011). Effectiveness of occupational goal intervention for clients with schizophrenia. American Journal of Occupational Therapy, 65, 287-296. doi: 10.5014/ajot.2011.001347

Gutman, S.A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C.A. (2009). Supported education for adults with psychiatric disabilities:

Effectiveness of an occupational therapy program. American Journal of Occupational Therapy, 63, 245-254.