Transcript OBP II: Mental Health Case Study - Angela

OBP II: Mental Health
Case Study - Angela
Jeffrey 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 History
 Preoccupation
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
 Attend

between size, color, and form
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
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Medication
Name/Dosage
A.M./P.M
Mood Scale
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.