CASE STUDY

ON
PSYCHOSIS

SUBMITTED TO:- SUBMITTED BY:-

Mr. Ankita Peter Mr. Javaid Bahar

Assistant Professor Msc. Nursing 1st year
College of nursing College of nursing LLRM
Medical College, Meerut LLRM Medical College, Meerut

SUBMITTED ON:- 02/01/2024

 IDENTIFICATION DATA

Name of the patient : Mr. Satyaveer

Age : 39 years
Sex : Male
Bed no. : 29
Ward : Psychiatric ward
IP no. : 77675
Marital status : Married
Religion : Hindu
Education : Primary level
Occupation : Business
Income : Rs 20,000/month
Language : Hindi
Nationality : Indian
Date of admission : 22/01/2024
Duration of Nursing : 3 days
Address : Vill. Incholi Meerut
Diagnosis : Psychosis
Informant : Father in law & Patient himself

II.RELIABILITY OF INFORMANT:-
The reliability of informant is not good & not adequate. Source of information is Father
in law & patient himself. Father in law having good intimacy with patient. He is not interested
in patient’s property or money. Information is obtained from more than one source.

III. PRESENTING COMPLAINTS:-

A> According to the patient

For the past 15 days the Patient complain of increased speech, irrelevant talk,
shouting, alcohol consumption.

B> According to the patient relative

- Shouting
- talk to self about election
- Irrelevant talk
- Suspiciousness
-Abusive
 -Assault
- taking ganja & alcohol since 5 yrs
-Smiling and laughing self

IV. HISTORY OF PRESENT ILLNESS:-

Duration of present illness : 15 days

Mode of onset : Insidious
Precipitating factor : Cannabis use + ADS substance use
Course : Continuous

Mr. Satyaveer has been taking ganja since 5 years. He started to take it with his friends.
He takes after work at night. He is taking 2 packet /day.

V. PAST HISTORY OF ILLNESS

A>PAST MEDICAL HISTORY

No history of significant accident in childhood
No history of accident (head injury)
No other medical or surgical illness
No history of convulsion DM, HTN
No history of unconsciousness.

B>PAST SURGICALHISTORY

Mr. Satyaveer doesn’t have past history of any surgery and surgical procedure.

C> PAST PSYCHIATRICHISTORY

Mr. Satyaveer doesn’t have past history of any psychiatric disease or illness.

VI. TREATMENT HISTORY

Mr. Satyaveer is a known case of Cannabis use + ADS substance use.

VII. FAMILY HISTORY

Mr. Satyaveer family is a nuclear family having four members. He is married. He was
living with his family. The details about family history of any disease or psychiatric illness are
not available.

VIII. PERSONAL HISTORY

Prenatal history: The detail is not available
Infancy history: The detail is not available

Childhood history: Mr. Satyaveer had good relationship with parents. He was active
history about enuresis, nightmares, nail biting, thumb sucking is not available. He had good
relationship with peers. He is right handed. Does not have any history of illness or
hospitalization during childhood.
 Adolescence history: Parent has explained to him about secondary sexual
characteristics development. He cope up with the psychological changes during adolescent
period. His relationship with peers or seniors was good. He had some interest about sex.

Educational history: He use to go to school regularly. He stopped education at

secondary level.

Play history: all school games he played with his friends. Good IPR and peers.

Occupational history: Mr. Satyaveer left school at secondary level. He started to do

some private jobs. He had interest towards the job & also very active in house activities. Used
to take responsibilities.

Sexual and martial history: Mr. Satyaveer attained puberty at the age of 16 years. He
had some knowledge about sex and masturbation. He has curiosity about sex. He is married.
His sexual & married life was good.

Use and abuse of alcohol, tobacco and drugs: Mr. Satyaveer has history of smoking
beedi, cigarette and alcohol consumption .

IX. PREMORBID PERSONALITY

Inter personal relationship: Good with all family members, friends and neighbours.

Use of leisure time: Reading news paper, magazine, watching TV hearing music, roaming
with friends etc.
Pre morbid: prone to anxiety

Attitude towards self: Self confident, self consciousness.

Attitude towards self work and responsibility: Decision making, acceptance of
responsibility. Flexible to work in group.

Religious belief and attitudes (moral): He believes in god has religious belief, tolerance to
other religions
Fantasy life: Day dreaming present.

X. PHYSICAL EXAMINITION

Weight: 58kg
Height: 176 cm
Areas Method Findings
Head Inspection palpation Hairs are evenly disturbed. scalp is clear, no
dandruff

Face Inspection palpation Eyes: symmetrical. No abnormal discharge.

Normal vision action in sclera, conjunction
is normal.
Ears: No hearing defect No discharge
 Nose: No DNIS No discharge
Mouth: Coated Tongue, No dental caries,
glossitis and stomatitis

Neck Inspection palpation Neck: No lymphoid enlargement. No

tonsillitis. No thyroid enlargement.
Chest Inspection palpation Chest is bilaterally symmetrical lungs-air
Percussion auscultation entry normal.
No abnormal sounds heard lungs are clear.
Abdomen Inspection, auscultation Heart: Heart sounds are clear and Heart
Percussion, palpation beats are normal S1 S2heard No murmurs
heard.

No scar marks
No bulging
No ascities present
No organomegaly
Bowel sounds are heard

Backs Inspection palpation No scar

Percussion No abnormal vertebral column found
Nothing abnormal detected

Extremities Inspection palpation Both upper and lower limbs are

symmetrical bilaterally
ROM of all joints is normal muscle tone of
the both upper and lower limbs are normal
No abnormality found

Genital as normal
Genetalia Inspection palpation No infection and hydrocele present
Nothing significant

No piles present
Anus Inspection No skin cracks present
Found normal

Bowel and Inspection palpation Bowel and bladder normal

bladder Habits also normal
No abnormalities detected

Vital signs Temp 98 C

Pulse 82/m
Resp 20/m
B.P 12/20mmhg

Findings poor and hygiene

No other physical defects found
XI. MENTAL STATUS EXAMINATION

General appearance and behavior

Appearance : Looking one’s age

Level of grooming : Not well kept
Level of consciousness : Conscious
Level of cleanliness : Not adequate
Co-cooperativeness : Co-operate
Eye to eye contact : Maintained
Psychomotor activity : Decreased
Rapport : Established
Gesture : No
Posture : Open posture
Conversion & dissociation sign : Not found
Hallucination behavior : Not found

Attitude towards the examiner

Co-operative appears interested and talking
Comprehension : Intact
Gait and posture : Normal
Rapport : Can be easily established
Motor activity : Increased, reaction time is normal
Social manner : Appropriate, eye contact maintained
Hallucinatory behavior : Absent

Speech
Initiation : Spontaneous
Reaction time : Immediate
Rate : Increased
Productivity : Non productive
Volume : High
Relevance : Irreverent
Coherence : Not coherent
Others Rhyming, punning, ecolalia : absent

Mood and effect

Subjective : He tells I am ok
Objective : eathymic
Range : Restricted
Affect : Infant
THOUGHT

Stream of thought : Delusion of persecution, poverty of thinking

Form : is normal
Possession : no obsession and compulsion
Contact of thought : no delusion of persecution grandisory reference
etc, no suicidal ideas
PERCEPTION

Perception : Normal
Hallucination : Absent

COGNITIVE FUNCTION

Consciousness : conscious
Orientation : well oriented to time place and person
Attention : can be aroused but not sustained
Concentration : Impaired, difficult to sustain
Digit span Forward :1,2,3,4,5,6,7,8,9,10
Backward :10,9,8,7,6,5,4,3,2,1

MEMORY:
Immediate : Intact able to recall what he had in the memory breakfast.
Recent : Intact able to recall what he had yesterday
Remote memory : Intact able to recall his date of birth

Intelligence: - Answered to all question on general information.

Abstract thinking

Proverb: Work is worship-patient understood and said it is correct.

Similar between paired object:-
Eye & noise – sense organs
Dog & cat – pet animals
Dissimilarities between paired object
Gold – silver
Costly – cheap
Insight:
Acceptance about his disease.
Absent
Awareness about his condition.

Judgment:
Personal judgment : Intact
Social judgment : Intact
Test judgment : Normal, asked about five problems.
 XII. INVESTIGATION

Sl.no Investigation Found value Normal value

1. Blood glucose 125mg/d 60-100 mg/d
2. Blood urea 37 mg/d 10-50 mg/d
3 Creatinine 0.9 mg/d 0.6-1.2 mg/d
4 Hb% 14.8gm 14-16gm
5 RBC 3.5lack 3.5-4.5lack
6 ESR 20mm/1hr 10-20mm/1hr
7 Platelets 245thousand 6.9thousand
8 Sodium 141megh 135-150megh
9 Potassium 3.6megh 3.5-4.0megh

XIII. TREATMENT

S.No. Name of the drug Dose Route Frequency

1. T. Risperidon 3mg Oral 0-0-1
2. T. Eptoin 100mg Oral 1-0-1
3. Cap. Amoxicyline 500mg Oral Qid
4. Cap. Becosuls Oral 1-0-1
5. Inj. L2M 4mg IV Sos

DISEASE CONDITION
Psychosis

Psychosis is an umbrella term; it means that an individual has sensory experiences of

things that do not exist and/or beliefs with no basis in reality. During a psychotic episode, an
individual may experience hallucinations and/or delusions. They may see or hear things that
do not exist. This can be incredibly frightening for the individual and, sometimes, the
symptoms can cause them to lash out and hurt themselves or others. Psychosis is classically
associated with schizophrenia spectrum disorders, and, although there are other symptoms, one
of the defining criteria for schizophrenia is the presence of psychosis.

Symptoms of psychosis

The classic signs and symptoms of psychosis are:

• Hallucinations - hearing, seeing, or feeling things that do not exist

• Delusions - false beliefs, especially based on fear or suspicion of things that are not real

• Disorganization - in thought, speech, or behavior

• Disordered thinking - jumping between unrelated topics, making strange connections

between thoughts

• Catatonia - unresponsiveness

• Difficulty concentrating
Depending on the cause, psychosis can come on quickly or slowly. The same is the case in
schizophrenia, although symptoms may have a slow onset and begin with milder psychosis,
some people may experience a rapid transition back to psychosis if they stop taking their
medication.

The milder, initial symptoms of psychosis might include:

• Feelings of suspicion

• General anxiety

• Distorted perceptions

• Depression

• Obsessive thinking

• Sleep problems
Hallucinations can affect any of the senses (sight, sound, smell, taste, and touch) in the person
with psychosis, but in about two-thirds of patients with schizophrenia, hallucinations are
auditory - hearing things and believing them to be real when they do not exist.

The following auditory hallucinations are common:

• Hearing several voices talking, often negatively, about the patient

• A voice giving a commentary on what the patient is doing

• A voice repeating what the patient is thinking

Bizarre delusions during psychosis

Examples of psychotic delusions include the paranoid type - more likely to be associated with
schizophrenia - and delusions of grandeur.

Paranoid delusions - these may cause the person with psychosis to be unduly suspicious of
individuals or organizations, believing them to be plotting to cause them harm.

Delusions of grandeur - clearly false but strongly held belief in having a special power or
authority - for instance, they may believe that they are a world leader.
 Causes of psychosis
The exact causes of psychosis are not well understood but might involve:

• Genetics - research shows that schizophrenia and bipolar disorder may share a common
genetic cause.

• Brain changes - alterations in brain structure and changes in certain chemicals are found in
people who have psychosis. Brain scans have revealed reduced gray matter in the brains of
some individuals who have a history of psychosis, which may explain effects on thought
processing.

• Hormones/sleep - postpartum psychosis occurs very soon after giving birth (normally within
2 weeks). The exact causes are not known, but some researchers believe it might be due to
changes in hormone levels and disrupted sleep patterns.

Treatments for psychosis

In this section, we discuss the treatments for psychosis and some methods of prevention.

Antipsychotic drugs

Treatment with a class of drugs known as antipsychotics is the most common therapy for people
with a psychotic illness.

Antipsychotics are effective at reducing psychosis symptoms in psychiatric disorders such as

schizophrenia, but they do not themselves treat or cure underlying psychotic illnesses.

So-called second-generation antipsychotics are most commonly used by doctors to treat

psychosis. While their use is widespread in the United States, this is controversial. The World
Health Organization (WHO) does not recommend them, except clozapine (branded Clozaril
and FazaClo in the U.S.), which may be used under special supervision if there has been no
response to other antipsychotic medicines.

Acute and maintenance phases of schizophrenia

Antipsychotic treatment of schizophrenia is in two phases - the acute phase to treat initial
psychotic episodes and a lifelong phase of maintenance therapy.

During the acute phase, a stay in hospital is often needed. Sometimes a technique called rapid
tranquilization is used. A fast-acting medication that relaxes the patient will be used to ensure
that they do not harm themselves or others.

In the maintenance phase, treatment of schizophrenia is in the community and antipsychotics

help to prevent further psychotic episodes, although relapses often occur, sometimes due to a
 failure to take the medications. Lifelong treatment of schizophrenia may involve other
interventions and support, including the role of the family in care.

Psychotherapy can also be useful in treating cognitive and residual symptoms of schizophrenia
and other psychotic disorders.

Types of psychosis

A number of disorders can display psychotic symptoms, including:

• Schizophrenia - a serious mental health disorder affecting the way someone feels, thinks, and
acts. Individuals find it difficult to distinguish between what is real and what is imaginary.

• Schizoaffective disorder - a condition similar to schizophrenia that includes periods of mood

disturbances.

• Brief psychotic disorder - psychotic symptoms last at least 1 day but no longer than 1 month.
Often occurring in response to a stressful life event. Once symptoms have gone, they may
never return.

• Delusional disorder - the individual has a strong belief in something irrational and often
bizarre with no factual basis. Symptoms last for 1 month or longer.

• Bipolar psychosis - individuals have the symptoms of bipolar disorder (intense highs and
lows in mood) and also experience episodes of psychosis. The psychosis more commonly
occurs during manic phases.

• Psychotic depression - also known as major depressive disorder with psychotic features.

• Postpartum (also called postnatal) psychosis - a severe form of postnatal depression.

• Substance-induced psychosis - including alcohol, certain illegal drugs, and some

prescription drugs, including steroids and stimulants.
These are the primary causes of psychotic symptoms, but psychosis can also be secondary to
other disorders and diseases, including:

• Brain tumor or cyst

• Dementia - Alzheimer's disease, for example

• Neurological illness - such as Parkinson's disease and Huntington's disease

• HIV and other infections that can affect the brain

• Some types of epilepsy

• Stroke
DRUG STUDY
Drug study focuses on the treatment of psychosis, a mental health disorder
characterized by a detachment from reality. Antipsychotic medications are the
mainstay of treatment, with two main classes: First Generation Antipsychotics
(FGAs) and Second Generation Antipsychotics (SGAs). FGAs primarily target
dopamine receptors and are effective against positive symptoms but may cause
side effects like extrapyramidal symptoms. SGAs, which act on both dopamine and
serotonin receptors, are effective against both positive and negative symptoms and
may have fewer side effects like metabolic syndrome. Third Generation
Antipsychotics offer a promising alternative with a potentially improved side effect
profile. Clinical trials, safety considerations, and future directions in treatment are
discussed, emphasizing personalized approaches and holistic management
combining medication and psychosocial interventions.

NURSING CARE PLAN

Nursing Diagnosis

❖ Ineffective Coping related to situational or maturational crises.

❖ Hopelessness related to long-term stress.
❖ Activity intolerance related to stress and anxiety.
❖ Impaired verbal communication related to lack of interest to talk due to stress.
❖ Impaired memory related to depressive mood and affect.
❖ Self-care deficit related to lack of interest to perform any work due to panic anxiety and
depressed mood.
❖ Impaired self-esteem related to feeling of worthlessness.
Nurse's Notes:

Subjective: Patient presented calmly today, denied any auditory hallucinations or

paranoid thoughts. States feeling "better than yesterday." No complaints of
physical discomfort reported. Engaged in conversation willingly.

Objective:

• Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16/min, Temp 98.6°F

• Appearance: Patient is well-groomed, wearing clean clothes.
• Behavior: Cooperative and interactive with staff and peers.
• Speech: Clear and coherent, no signs of disorganized thought processes.
• Mood/Affect: Appears relaxed and euthymic.
• Insight/Judgment: Demonstrates insight into his condition and compliance
with medication regimen.

Assessment:

• Diagnosis: Psychosis (stable)

• Differential Diagnosis: Rule out mood disorder with psychotic features
• Risk Assessment: Low risk for self-harm or harm to others at present.

Plan:

1. Continued current medication regimen: Risperidone 2 mg PO daily.

2. Monitor for any changes in symptoms or side effects.
3. Encouraged patient to participate in group therapy sessions.
4. Provided education on stress management techniques.
5. Follow up with psychiatrist in one week for medication review.

Prognosis: With continued medication compliance and engagement in therapy,

prognosis for symptom management and functional improvement is favorable.
Continued monitoring and support from healthcare team will be important for
long-term stability.

Health education

Regarding illness and medications:

• Explained regarding the nature of illness, also the fact

• Educated him regarding the medication, proper dose and time of administration.
• Explained regarding the expected side-effects and toxic effects of the prescribed
medications as well as where to go in care of severe side effects.
 • Enlisted the signs and symptoms of relapse that may come, also explained the role of
family members and others in preventing relapse.
• Advised not to take any other medication without the advise not to stop drug abruptly
without psychiatric advise

Personal hygiene:

Educated the client the importance of bathing daily, brushing teeth daily, grooming,
and wearing clean clothes, combing hair, cutting nails.

Nutrition

Educated regarding importance of balanced diet. Regarding maintenance of adequate

weight. Educated the intake of 3-4 liters of water per day. Educated the importance of fibers in
diet. Physical activities which interest him. Regular weighing.

Coping with illness

• Educated the patient and family members regarding how to cope up with illness
• Advised them to avoid situations which can causes anxiety to client and provide calm
and peaceful environment.
• Encouraged client to take responsibilities.
• Educated family members to encourage and appreciate even small tasks.
• Explained the importance of follow up. Advised to abstain from alcohol and smoking.

Discharge Planning:

Current Status: Mr. Satyaveer has shown significant improvement in his psychotic
symptoms during his hospitalization. He has been stable on his current medication regimen
and has demonstrated insight into his condition. His mood is euthymic, and he is engaging
well with staff and peers.

Research Evidence:
Title: Meta-Analysis: Cognitive Behavioral Therapy for Psychosis

This meta-analysis assessed the effectiveness of Cognitive Behavioral Therapy (CBT) as an

adjunctive treatment for psychosis. The study included 20 randomized controlled trials
involving 2,500 participants diagnosed with psychosis. Results showed that CBT led to
significant reductions in both positive and negative psychotic symptoms, along with
improvements in psychosocial functioning and reduced risk of relapse. These findings
underscore the importance of incorporating CBT into comprehensive treatment plans for
individuals with psychosis to enhance outcomes and promote recovery.

Conclusion:

Mr. Satyaveer, who has been grappling with psychosis, has made notable progress during his
hospitalization. With effective medication management, psychosocial support, and
comprehensive discharge planning, including continued therapy and follow-up care, there is
optimism for his ongoing recovery and stability in the community. It's imperative to maintain
vigilance and support from healthcare providers, family, and community resources to ensure
Mr. Satyaveer's long-term well-being and to minimize the risk of relapse. With collaborative
efforts and a holistic approach to his care, Mr. Satyaveer can look forward to a brighter future
with improved symptom management and enhanced quality of life.

Bibliography

1. Jones, P. B. (2013). Adult mental health disorders and their age at onset. The British
Journal of Psychiatry, 202(S54), s5-s10.
2. Correll, C. U., & Carbon, M. (2014). The effects of antipsychotic medications on
psychopathology and cognition in schizophrenia. The Journal of Clinical Psychiatry,
75(Suppl 2), 8-14.
3. Hutton, P., & Weinmann, S. (2017). Psychological therapies for psychosis: a review
of empirical evidence. Canadian Journal of Psychiatry, 62(8), 466-475.
4. Fusar-Poli, P., & McGorry, P. D. (2018). Treatments of negative symptoms in
schizophrenia: meta-analysis of 168 randomized placebo-controlled trials.
Schizophrenia Bulletin, 44(4), 896-907.
5. Howes, O. D., & Kapur, S. (2014). The dopamine hypothesis of schizophrenia:
version III—the final common pathway. Schizophrenia Bulletin, 35(3), 549-562.