Mental disorder, as well as mental health, is a broad concept that is difficult to precisely define. However, for the purposes of academic discussion, we shall utilize the definition of renowned associations in the world. Mental disorder, as defined by the American Psychological Association (APA, 2000), is “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (p.xxxi). Mental Health, on one hand, is defined by the World Health Organization as a “state of emotional, physical, and social well-being wherein one is able to fulfill life responsibilities, function effectively in daily life, and is satisfied with interpersonal relationship and oneself”
One key skill used in dealing with psychiatric patients is therapeutic communication. It is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information (Videbeck, 2011). All nurses and other professionals in the health care team need skills in therapeutic communication to effectively apply the nursing process which will contribute to meet the standards of care. The skillful nurse utilizing therapeutic communication techniques is led to the proper understanding of the client’s experience (Videbeck, 2011).
Nurses listen carefully for cues throughout the interaction because they provide a window for the understanding of the client’s thoughts. Moreover, the nurse watches for themes or topics around which the client composes his words. The theme is then used to assess the nonverbal behaviors that accompany the client’s words and build responses based on the cues.
Thus, this academic paper aims to provide an in depth analysis of the theme/s of the student nurse’s interaction with a client diagnosed with Brief Psychotic Disorder. Understanding the behavior of an individual entails focusing on the situation and looking at it on a holistic perspective, in detail and without any distortion. Human behavior is a complicated phenomenon influenced by various factors all interacting together in such a way that everything else affects one another (Brown and Fower, 1961). Because of this, analysis must entail going deep down into the client’s lived experiences and to his here and now; and going outside the totality of the client assuming a third person point of view.
GMR, 14 year old male, was admitted on August 20, 2014 at the University of the Philippines – Philippine General Hospital Ward 7 Department of Psychiatry and Behavioral Sciences. Data on his nursing health history were taken on August 29, 2014 at PGH’s Ward 7 at around 9 in the morning. The information was primarily provided by his mother. The place was well-lighted and warm. The student nurse was 1 foot away from the patient and the interviewee. The health history taking lasted 45 minutes.
GMR is a 14 year old young man who lives with his family at #1661 Estrada Street, San Andres Bukid, City of Manila. GMR, a Roman Catholic, was born on May 15, 2000 via Spontaneous Vaginal Delivery at the Ospital ng Maynila without fetomaternal complications. He is the youngest among the 3 children. He has 1 younger adopted sister. His health care expenses are currently shouldered by his immediate family and other relatives. The patient grew up under the care of his mother, a housewife. His father is an Overseas Filipino Worker (OFW) at Saudi Arabia
Chief complaint on the day of consult was difficulty sleeping.
HISTORY OF PRESENT ILLNESS
According to the mother, the patient was apparently well and functional without any manifestations of depression, mania, etc. Four days prior to consult, the patient went out with his friends to attend a computer game event or tournament called “Rampage” at the World Trade Center in Pasay City. The patient stated that he was consistently being bullied by his companions as gay. The patient came home crying, sad, and looked depressed. He constantly asked his mother questions and told statements such as: “bakit ganun ma? Sana hindi ko na lang itinago. Sana matagal ko ng inamin na bakla ako”. He was noted to have auditory hallucinations saying, “ayan na naman sila. Pinag-uusapan nila na bakla ako”, and “ayaw ko sa apoy, gusto ko kay Jesus”. He told that he saw hell and heaven.
He began to experience persecutory and paranoid delusion. He did not eat or drink because of the thought that he was being poisoned and that people want him gone. He confessed and apologized to his mother for his past mistakes. He told his mother “ayaw ko na ma. Hindi ko na kaya. Parang mawawala na ako.” The patient, according to the informant, would sometimes stare blankly into space. One day prior to consult, the family consulted a physician at a local clinic. Iterax was prescribed but the patient still experienced difficulty sleeping. The family then resorted to consult an “albularyo” and they noted sudden behavior change: “parang lumakas siya at ayaw niyang lumapit sa apoy”
The night prior to latest consult, the family brought the patient to the PGH Emergency Department and was given diphenhydramine. The patient was able to sleep but experienced loss of appetite. The persistence of symptoms prompted latest consult, hence the present admission to Ward 7.
The patient is currently not diagnosed with any other health condition. He does not have any known allergy to food, drug, or environmental allergens. He did not undergo any surgery in the past. No other previous admissions were noted.
FAMILY HISTORY OF ILLNESS
There are familial incidences of Diabetes Mellitus (paternal side) and Hypertension and Cardiovascular Diseases (maternal side). No family history of Pulmonary Tuberculosis, goiter, cancer, allergies. There is also no known familial incidence of any psychiatric illness.
Diphenhydramine 50mg/cap, 1 cap PRN for insomnia
Biperiden 2mg/tab, 1 tab PRN for EPS po
Risperidone 1mg/tab, 1 ½ tab HS po
Olanzapine 10mg/ODT, 1ODT prn for refusal to take meds
Clonazepam 2mg/tab, ¼ tab prn for sleep
FUNCTIONAL HEALTH PATTERNS
1. Health Perception and Health Management
The patient is nonsmoker, nonalcoholic and denies illicit drug use. He does not have any exercise routine. However, he plays basketball with his friends especially on weekends. He seldom catches cough and colds. He is said to be compliant to any therapeutic regimen. He loves to spend his time alone even at home.
2. Nutritional and Metabolic Pattern
The patient is on DAT (diet as tolerated). The patient usually eats 1 cup of rice. Usual viands include fish and vegetables, seldom meat. He does not experience any difficulty eating. He recently experienced loss of appetite. However, no sudden loss of weight was noted.
3. Elimination Pattern
He used to defecate daily and does not experience any difficulty. However, the patient stated that he is currently experiencing difficulty in defecating since admission. He is also on input-output monitoring every shift. His urine is straw-colored. He did not verbalize any difficulty when voiding.
4. Activity-Exercise Pattern
The patient is ambulatory with bathroom privileges. As stated earlier, he does not have any exercise routine. Presently, he is actively involved in ward group activities every morning.
5. Sleep-rest pattern
The patient experienced difficulty sleeping in the previous weeks. In the hospital, the patient, according to the mother, sleeps for about 7 to 9 hours daily. There were no reports of night terror or nightmare.
6. Cognitive-perceptual pattern
The patient was able to finish 6th Grade with honors. He is currently a 3rd year high school student with average to below average grades. He does not have any eye or ear problems that may affect sight and hearing. He loves Mathematics and verbalized that he wanted to go back studying but in another school away from those who bullied him.
7. Self-perception and self-control pattern
The patient admits that he is shy especially to people he barely knows. He claims that he is obedient. These were confirmed by his mother during the interview. Add to that, he likes to be alone especially at home.
8 Role-relationship pattern
The patient has good interpersonal relationship with family and friends. There was no other history of bullying but had some petty quarrels with his siblings which led him to threaten his brother with a knife.
9. Sexuality-Reproductive Pattern
The patient did not verbalize anything about this pattern.
10. Coping-Stress Tolerance
The patient does not usually experience stress. But when he does, he usually sleeps it off. During the times he was apparently bullied, he would simply turn his back and move away from the people involved in the bullying. He would cry and share his thoughts and feelings to his closest friends, seldom his mother and siblings.
The patient and his family are Roman Catholics. The patient stated that religion is an important part of his life and that it is where he gets his strength. “Madasalin ako”, he said. He values his religion so much.
There were no further statements.
MENTAL STATUS EXAMINATION
The patient was seen sitting on bed, well-kempt, looks and dressed appropriate for age and gender. The patient was cooperative and responsive with fair eye contact. Patient was anxious. Patient’s affect was appropriate to situation. His affect, in general, was blunted. During the encounter, the patient appeared to be shy and at the same time suspicious.
At the latter part of the encounter, the patient was more open and cooperative. The patient appeared sad with mild anxiety; consistently saying that he wanted to go home. Rate of speech was slow and spontaneous, sometimes with long pauses. The patient was speaking in a soft or whisper voice, uttering words clearly. He was dull rather than monotonous. Patient responds adequately to most questions.
The patient has short attention span, relatively adequate concentration. He was able to do the Serial 7s test with ease as well as other mathematical equations. He has average memory or recall of recent events as well as remote events in the past year. He is able to remember birthdays, address, age, among others. Patient has concrete thinking but dismisses questions sometimes. Patient was oriented to time, person, and place and able to come to appropriate conclusions/answers to most questions (insight/judgment). The patient was responsive to verbal stimuli. The patient’s thoughts were coherent and not necessarily confused. He answers logically and relevantly to most topics discussed. The patient had slow reactions to questions. He sometimes exhibited blocking or the sudden interruption of speech or thought. Also, he exhibited circumstantiality or being incidental and irrelevant in stating answers or details.
Persecutory and paranoid delusions were noted with the patient saying that he is being “set up” by the people around him. Moreover, he stated that the nurses and other staff in the ward were putting cockroaches and mosquitoes around him in order for him to acquire other diseases. No auditory, visual, olfactory, tactile, kinesthetic, and gustatory hallucinations were noted.
DELUSIONS AS MALADAPTIVE COPING
The essential feature of the Brief Psychotic Disorder is the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month, and there is an eventual full return to the premorbid level of functioning (APA, 2000). The individual experiences emotional turmoil or overwhelming perplexity or confusion. Evidence of impaired reality testing may include incoherent speech, delusions, hallucinations, bizarre behavior, and disorientation (Townsend, 2008). These were observed in the client with said disorder.
Throughout the nurse-client interaction, the client appeared to be pre-occupied with the thought and desire to go home and go back to school. This was clearly reflected in the Process Recording No. 1. An excerpt of the recorded conversation is presented below:
Student Nurse: Ano ulit yung pangalan ko?
Client: Mr. Tamayo
Student Nurse: Tama. Mr. Tamayo ang pangalan.
Client: Gusto ko nang umuwi. Uwi na tayo
Student Nurse: Anong year mo na sa high school?
Client: 3rd year. Gusto ko nang umuwi.
Student Nurse: Kailan pala ang birthday mo?
Client: May 15, 2000
Student Nurse: Ilang taon ka na sa kasalukuyan?
Client: 14 po
Student Nurse: Glen, saan ka pinanganak?
Client: Ospital ng Maynila
Student Nurse: Saan ka naman nakatira ngayon?
Client: San Andres Bukid
Student Nurse: Ahh. Sa San Andres Bukid, Manila.
Client: Gusto ko nang umuwi
The reason for this pre-occupation to go home and be in school was not totally explored by the student nurse. However, it may have led the patient to think of persecutory delusions. Persecutory delusions, according to Videbeck (2011), involve the client’s belief that others are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Sometimes, the client cannot define who these others are (Videbeck, 2011). However, this client was able to identify the “others” he was referring to as the ones who have persecutory plans against him. Another excerpt showing these thoughts is stated below:
Student Nurse: Aktibo ka bang sumasali sa mga aktibidad dito?
Client: Nilalagyan nila ng ipis ito. Naglalagay sila ng lamok dito.
Student Nurse: Sino sa tingin mo ang gumagawa niyan sa iyo?
Client: Kayo. Yung mga nurse. Para magkasakit ako lalo at tumagal rito. Gusto ko nang umuwi.
Student Nurse: Naiintidihan ko na gusto mo nang umuwi. Pero Glen, wala sa mga tao sa ward na ito ang nakita kong gumagawa nun sayo
Townsend (2008) explains that clients with persecutory delusions/thoughts may believe that they are being malevolently being treated in some way. Frequent themes include being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of goals (APA, 2000). The individual may obsess about and exaggerate a slight rebuff (either real or imagined) until it becomes the focus of a delusional system. Repeated complaints may be directed at authorities, lack of satisfaction from which may result in violence toward the object of the delusion (Townsend, 2008). Further, it was revealed by the client’s mother that the former avoided food offered in the Ward because the client believed he was being poisoned. This could also be considered paranoia where one has extreme suspiciousness of others and of their actions or perceived intentions (Townsend, 2008).
Delusions are considered false beliefs or misinterpretations of reality in order to meet one’s needs and to preserve the self. They are understandable interpretations of abnormal perceptual experiences. According to the Karl Jaspers, in the book General Psychopathology, delusions form after a ‘direct experience of meaning’, whereby the ‘awareness of a meaning undergoes transformation’. In the same book, he identified three criteria for a belief to be considered delusional— certainty, or held with absolute conviction; incorrigibility, or not changeable by compelling counterargument, and; implausibility of content. Sigmund Freud, on one hand, explains that delusions are extreme forms of projections which are applied by directing the issue towards the non-self, thereby preserving the self through provision of its unmet need/s. Since it is a form of maladaptive coping, it is important to know and understand contributing factor/s which to properly address the issues faced by the client. There are several biologic, psychosocial, and cognitive factors that result to delusions.
The prefrontal lobe of the brain is responsible for one’s emotions, judgment, sympathy, and empathy. It also is responsible for humour, sarcasm, and irony. Aside from these, it is the one we use for mentalizing, the process we use when we socialize, as it enables one to understand the behaviour of others and the rationale behind it. More importantly, it provides one the flexibility to think, analyze, and control our behaviors. Damage to this area can precipitate delusions, as the ability to process information correctly is altered. The neuroanatomical pathways which process and send information contribute to the false interpretation of the reality. (McMurtray, 2008)
Another is that it has been established that organic brain damage contributes to the presence of psychiatric symptoms. A study conducted by Selvi in 2010 has developed that brain lesions may lead to sequelae of executive dysfunction. Cutting, in 1985, has proposed that left temporal brain lesions are correlated with delusional and hallucinatory states.
Relating all these to the client, it is inconclusive since there was no hold of any brain imaging scans; however, it is highly probable that given his diagnosis, the neurotransmitter imbalance is one of the underlying causes of his delusions. This is why the client is prescribed medications to correct the said imbalance.
According to Freud, defense mechanisms function to preserve the ego. He conceptualized personality structure as having three components – id, ego, and superego (Freud, 1923/1962). The id is considered to be the pleasure-seeking aspect, where a primitive and instinctive self is powered by the desire to experience pleasure. It reflects basic or innate desires such as pleasure-seeking behavior, aggression, and sexual impulses. Videbeck (2011) further states that the id seeks instant gratification which causes impulsive unthinking behavior, and has no regard for rules or social convention. The super ego is the component which aims for perfection. In simpler terms, it is the most ideal among the three. It is the part where moral and ethical concepts, values, and parental and social expectations are reflected and taken into consideration. Therefore, it is the direct opposition of the id. The balance between the two is the ego, where both the id and the super ego meet to form the self. It represents mature and adaptive behavior that allows a person to function successfully and appropriately in the world (Videbeck, 2011). Freud believed that the three uses ego defense mechanisms, which are methods of attempting to protect the self with basic drives or emotionally painful thoughts, feelings, or events (Videbeck, 2011). Delusions are produced when one’s super ego overpowers the two, creating another set of reality to preserve the self and compensate for any lack. Its basis is actually from the client’s past experiences. It was apparent that the patient was exhibiting projection. Further, he was also resistant to counterarguments. Delusions are extreme form of projection, a mechanism where one denies the existence of an undesirable quality by directing it towards the outside world. Delusions are resistant to counterarguments because the changes in these fixations require a change in personality and upheaval of principles. Intense trauma or unwanted emotions are probable causes of such, and it would require us to go back to the Freudian concept of defense mechanisms. Delusions are created to avoid facing uncomfortable realities.
Maher (1974) has conceptualized that delusions are disturbances of perception. They are perceptual anomalies which involve vivid and intense sensory input. Due to the overload, there is lack to process the stimuli effectively, so the individual seeks an explanation developed through normal cognitive mechanisms, which makes delusions as strong as any other belief, and delusional clients to be as resistant to counterarguments. They are also reinforced by anxiety reduction and repaired levels of self-esteem from each delusional episode. Delusions are built to make sense for the individual and explain the events in their environment.
Another theory is proposed by Garety, and coined it as the Probabilistic Reasoning Bias. He claims that delusions have different causes, although the factors which contribute to its formation and maintenance may be similar in nature. He has identified past experiences, affect, self-esteem, and motivational play as parts of a delusion. To correctly identify what, it requires an extensive assessment of the case to see what activated the maladaptive coping technique. Applying this to the client, self-esteem and self-image issues may have been a great contributor to his delusions. One of the most prominent reasons for his low self-regard is the consistent bullying he received from his peers.
Bentall explains persecutory delusions as self-serving— maintain self-esteem, and avoid discrepancies between how they perceive themselves and how they would want to be perceived. Initially, they feel threatened by their negative self-representations. With the protective externalizing attributional bias at play, the individual proceeds to blaming the non-self.
EVALUATION AND CONCLUSION
Indeed, there are several contributing factors present in a client with delusions. It is believed that these delusions are rooted within the client’s personality which makes him resistant to logical arguments.. As a nurse, it is important to help the client recognize and put into practice proper and effective coping strategies and that this could only be done when his personal issues are adequately addressed. One way to address these issues is by providing the client some positive regard towards self while maintaining a harmonious, trusting nurse-client relationship.