CASE STUDIES
Case study 1
Dorothy is 29 years old. She gave birth to her first child, Amy, four weeks ago. Dorothy had a protracted labour. After 35 hours the obstetrician decided to perform a forceps delivery. The birth was difficult, resulting in Dorothy requiring internal and external sutures. Dorothy had a previous miscarriage when she was 24 years old. She subsequently found it difficult to become pregnant and this pregnancy was a surprise to her.
From the time of Amy’s birth Dorothy experienced a lack of interest and “feeling” for her new baby. She was only agreeing to hold the baby following encouragement from nurses and pressure from her husband Alan, who is 30-year-old self-employed electrician. Alan presents as intolerant of Dorothy’s lack of interest and affection for the new baby.
Since Dorothy’s daughter was born four weeks ago, Dorothy has been consistently complaining of tiredness. She refuses to breastfeed the baby saying it was “gross, painful.”
Dorothy presents for admission to the postnatal unit with low mood. She displays irritability and lack of interest and motivation. She also expresses a lack of connection with her daughter and an inability to care or show affection towards her. Dorothy has a low tolerance level, with frequent episodes of panic, screaming, and shaking. She finds caring for Amy particularly distressing. She refuses to breastfeed her as she feels no connection, attachment or affection for the baby. Dorothy states that all she wants to do is to “shake her (Amy) until she stops crying.” Dorothy describes fantasising about shaking Amy when she cries but to date she has never acted on her thoughts.
When alone, Dorothy appears subdued, sitting for long periods of time. She appears disengaged from her baby, husband and mother-in-law, who is living with them to help Dorothy care for the baby. Dorothy feels that her husband and his family are not supportive of her. Since the birth of her daughter, Dorothy has experienced loss of
appetite with resulting weight loss. She is not sleeping well, maybe one to two hours a night at the most, but she lies awake in bed thinking about her life.
Although Alan and Dorothy have been together for 6 years, their relationship has been quite difficult. Alan sometimes drinks alcohol and often is angry and intolerant of Dorothy, speaking dismissively of her emotional needs and other requirements.
Dorothy and Alan live in a 3-bedroom rental accommodation in a low socio-economic working class suburb of Brisbane. Dorothy’s parents live in Gin Gin, where Dorothy grew up. They are both estranged from Dorothy since her marriage to Alan following an incident where they witnessed him shouting and pushing her around. She has 2 siblings, who both live in Cairns and are not supportive to Dorothy. One of Dorothy’s siblings has a history of depression.
Dorothy had lots of friends when she was young but she has lost contact with them since meeting Alan. She does not work but stays at home caring for Amy. Currently she has daily support from her mother-in-law whom Dorothy describes as “controlling” in her approach to Dorothy. Dorothy has no social interaction or contact with any other adults.
Dorothy is concerned that she will never feel different and that she will always hate her daughter. She worries that her parents will continue to be estranged from her.
Dorothy recognises she is in an abusive relationship. She can’t see a way out, and resents the fact that Alan can escape from the baby when he goes to work or out with friends. Dorothy is worried that Alan’s intolerance will result in escalating aggression towards her and that she will have no one to turn to.
She hopes to have a break from the stress of living with Alan and his mother, so that she can sleep. Dorothy is hoping that while she is in hospital, she will be able to contact her parents and have them visit her without Alan and his mother knowing.
Case study 2
Susan is a 56-year-old woman who has presented for admission to a Moods Disorder Unit in Brisbane. She has had numerous admissions to this facility in the past and has a diagnosis of Bipolar Disorder. Her last admission was six months ago, when she hospitalised for four weeks to have her mood stabilized and maintained.
Susan is an attractive woman, dressed in bright flamboyant colours, with long scarves draped around her neck and vivid makeup rather heavily and theatrically applied. Susan has been brought to hospital by her two sisters, who have advised the staff that she is reluctant to be here. Susan’s speech is pressured and loud. She leans on the table to engage with the nurse, patting her arm and calling her “Darling”. She frequently stretches her arms and makes reference to her body shape.
Previous admissions have involved Susan being reinstated on a mood stabilizer medication and being monitored for compliance with same. For the last few weeks Susan has refused to take her medication, insisting she is “on top of the world” and does not want to be “a zombie”. Historically Susan has periods of depression followed by “highs” and whilst in the middle of a “high” does not want her mood to be levelled, because she loses the feeling of exhilaration. Susan has not slept for more than a few hours over the last week. She has started smoking again, after abstaining for one year.
Susan receives a disability pension due to her longstanding history of Bipolar Disorder. Up until five years ago she was able to work part time in a newsagent’s shop, but as her illness increasingly impacted on her work, she was no longer able to sustain her position.
Susan lives alone in a rented unit, and her two married sisters live close by. She has never married, and was devoted to her mother who passed away two years ago.
She has several friends whom she meets regularly and enjoys going to a local club for a meal with them. She is also a keen shopper, which causes friction with her sisters who control her finances. When Susan’s illness is in a hypomanic stage, she overspends and is very extravagant.
Susan’s brother also suffered from Bipolar Disorder and suicided 10 years ago.
Susan has been scheduled twice to a public hospital under the Mental Health Act.
In the last few days Susan has been ringing her friends in the middle of the night and attempting to engage them in animated conversations, wanting to plan various trips and outings which are not practical. She has also been disinhibited whilst interacting with male neighbours. Susan is at risk of tarnishing her reputation and placing herself in a vulnerable position. It is vital that she recommences her medication and has adequate rest. She needs to be admitted to hospital and be monitored for compliance with medication.
Susan is currently prescribed 250 mg Lithium in the morning and 500mg at night. She also is prescribed 100mg Sertraline in the morning. Susan usually tolerates this medication with no reported side effects. However, Susan has a history of medication non-adherence.
Case study 3
Steve is a 21-year-old man who has presented for a first admission to an acute psychotic unit.
Steve is being assessed in an interview room by a registered mental health nurse. He has recently been diagnosed with schizophrenia. Steve has gained some weight, which is partly a side effect of his medication. He presents as unkempt, unshaven with soiled clothing. His eye contact is poor. He is restless, moving around the room, at times muttering to himself and nodding. He responds to questions in a monosyllabic fashion: “Yes” or “No”.
Steve attended an elite private school, where he excelled academically, and was a popular student. He commenced his Bachelor of Law last year. Four months ago Steve went away for the weekend with a group of friends and experimented with a variety of illicit drugs such as, ice, cocaine, and ecstasy. When he came home his demeanour was markedly changed. He became suspicious and withdrawn. He refused to go to university, and stated his parents were “imposters”. Since then he has attempted to attend university only once, but was unable to last even half a day. He spends his days in his room listening to music. Friends no longer come around because of his current mental state. He has no social contact outside the family home.
Steve has been verbally aggressive towards his parents and younger brother, Andrew who is 15 years old, causing the family great distress. His parents are fearful of having Steve at home as they are frightened his verbal aggression may turn into physical violence towards his brother or them.
Steve is observed responding to “voices” or auditory hallucinations. He tells his parents the voices belong to a group of two men and a woman. The voices kept telling him that he was “no good” and “everybody hated” him. Sometimes they told him to harm himself and sometimes to harm other people. Steve also believes that he has special powers and he is a spy working for the government. He is argumentative and sometimes becomes aggressive. Steve also tells his parents that the “voices” don’t want him to take
medication because it is poison. Prior to this the family relationship was very good and would be described as “loving and close”.
Steve’s doctor prescribed anti-psychotic medication for him approximately four months ago, however Steve is not always compliant. He complains they make him put on weight and make him feel “weird”. Typical “weird” feelings include tingling sensations and fuzzy headedness.
Steve is currently on anti-psychotic medication: Olanzapine 20mg twice a day (BD) Quetiapine 200mg twice a day. He is also prescribed Diazepam 10mg three times a day which is a sedative. Steve knows exactly what medication he is supposed to take.