Drug induced psychosis case study

SAN PEDRO COLLEGE

A case study on

DRUG INDUCED PSYCHOSIS In partial fulfillment of the Requirements in NCM105-RLE

PSYCHIATRIC NURSING ROTATION Submitted to: Elinor B. Marcelino, RN, MN CLINICAL INSTRUCTOR Ogiene Q. Abril Aurora Faye A. Nabua Janell Jan V. Rodriguez PRACTICING CLINICAL INSTRUCTORS Submitted by: James Edward Amazona Kirk E. Batomalaque John Joemel Jimenez Maricon Cita alberca Kristine Princess Alga Faye Alyssa Alcoberes Rhiesa Marie Caneta Joyce Candido Michelle Cruz Ivy Morales Janine Udin BSN 3B group 1 March 1, 2013 1

CRITERIA

INTRODUCTION & OBJECTIVE

5%

ANAMNESIS

20%

COURSE IN THE HOSPITAL

5%

PSYCHODYNAMICS

15%

MEDICAL MANAGEMENT

10%

NURSING CARE NURSING CARE PLANS

20%

DISCHARGE HEALTH TEACHINGS

5%

PROGNOSIS

5%

REFERENCES

5%

PROMPTNESS

5%

NEATNESS AND FORMAT

5% 100%

2

TABLE OF CONTENTS

Criteria.....................................................................................................................2 Table of contents .....................................................................................................3 Introduction .............................................................................................................4 Goal and Objectives ................................................................................................6 ANAMNESIS Personal Data ............... ............................................................................... 7 Genogram .................................................................................................... 9 Informants .................................................................................................... 10 COURSE IN THE HOSPITAL Mental Status Examination .......................................................................... 16 Progress Notes ............................................................................................. 40 Psychodynamics ..................................................................................................... 41 Definition of Diagnosis............................................................................................. 42 MEDICAL MANAGEMENT Drug Studies ................................................................................................. 45 Diagnostics .................................................................................................. 54 Nursing Care Plans ................................................................................................. 57 Prognosis ................................................................................................................ 57 Health Teachings .................................................................................................... 60 References ----------------------------------------------------------------------------------------62

3

Introduction Psychiatric nursing, also sometimes called mental health nursing, is a branch of the nursing profession which revolves around caring for people with mental illness, psychological disorders, and emotional distress. People at all stages of life can be cared for

by

psychiatric

nurses.(Reference:

retrieved

on

February

23,

2013,

at

http://www.wisegeek.com/what-is-psychiatric-nursing.htm)

Mental illness is a medical condition that disrupts a person's thinking, feeling, mood, ability to relate to others and daily functioning. While, Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality". People suffering from psychosis are said to be ''psychotic”. (Reference:

retrieved

on

February

23,

2013,

at

http://www.news-

medical.net/health/Psychosis-What-is-Psychosis.aspx)

Psychosis can be induced by drugs or can be "drug assisted". Some stimulating drugs, like amphetamines, can cause psychosis, while other drugs, including marijuana, can trigger the onset of psychosis in someone who is already at increased risk because they have "vulnerability". The risks associated with drug use for a person with psychosis include an increased risk of relapse, the development of more secondary problems (including depression, anxiety or memory problems), a slower recovery and more persistent psychotic symptoms. Prominent psychotic symptoms (i.e., hallucinations and/or delusions) determined to be caused by the effects of a psychoactive substance is the primary feature of a substance-induced psychotic disorder. A substance may induce psychotic symptoms during intoxication (while the individual is under the influence of the drug) or during withdrawal (after an individual stops using the drug). (Reference:

retrieved

on

February

23,

2013,

at

http://www.psychosissucks.ca/substanceuseandpsych.cfm, http://www.minddisorders.com/Py-Z/Substance-induced-psychotic-disorder.html,)

4

According to Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health, there are 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem in 2009 (9.3 percent of persons aged 12 or older). While in the Philippines, there are believed to be as many as 1,268,260 drug abusers according to figures from 2010, (Philippine Drug Prevalence). In Davao City, CADAC reports that they have filed 156 cases against a number of individuals involving illegal drugs. In their rehabilitation program, they have 31 admissions and have discharged 29 individuals from the program, (Sunstar: Trinidad, 2012). (Reference:

retrieved

on

February

23,

2013,

at

http://www.drugabuse.gov/publications/drugfacts/treatment-statistics)

This case study about substance induced psychosis is significant to nursing research because through this case study, nurses can be updated of the new treatment, medical management and possible therapies that could help alleviation of the disorder. The function to support the patient and family by providing nursing care that they cannot perform, educating and supporting them to maintain their normal caring activities and actively viewing in the care process. In practice, this means that the nurse should seek to engage with the person in care in a positive and collaborative way that will empower the patient to draw on his or her inner resources in addition to any other treatment they may be receiving. Through practice we learn fast, we develop our skills and we gain knowledge. Our client A.A. 23 years old male, a resident of Dela Rosa Psychiatry Clinic and Rehabilitation Center, was diagnosed with substance induced psychosis. We choose him as the subject for the study, to determine underlying causes, and risk factors, and learn to manage clients with the above said disorder.

5

General Objective: That within our two weeks of exposure in the Dela Rosa Psychiatry Clinic and Rehabilitation Center, we, will be able to apply skills, knowledge and attitudes learned from psychiatric nursing concept applicable to condition of the patient through nursing process. Specifically we aim to: a. Gather client’s data thoroughly; b. identify client’s need as perform complete assessment; c. discuss client’s present condition; d. construct a plan for client that are specific, measurable, attainable, realistic, and time bounded goal of care and interventions; e. formulate priority interventions or plan of care; f. implement the plan of care; g. conduct an evaluation if the plan of care have been met, partially or not met; h. emphasize the value of life, respect and privacy during the care of the patient.

6

A. PERSONAL DATA Name: A.A. Address: Buhangin, Davao City Age

: 23 years old

Gender : Male Birth date: March 11, 1989 Birth Place: Jose Abad Santos, Davao Del Sur Ordinal Rank: 1st child Nationality: Filipino Civil Status: Single Religion: Roman Catholic Educational Attainment: Elementary Undergraduate Occupation: Driver

Father’s Name: E.A. Occupation: N/A Mother’s Name: E.A. Occupation: Housewife

7

B. CLINICAL DATA Agency: Dela Rosa Psychiatry Clinic and Rehabilitation Center Date of Admission: January 26, 2013 Came in due to: Behavioral changes Attending Physician: Dr. Benjamin Molina Diagnosis: Drug Induced Psychosis

8

Maternal Side

?

?

?

Paternal Side

?

?

H.L.

P.R.

L.L.

A.A.1

M.L.

M.L.

E.L.2

E.L1

E.A.

A.A.2

Legends Deceased

Cardiac Arrest

Male

Diabetic

Female

Foster Parents

9

10

The family genogram is a pictorial display of a person's family relationships and medical history. It goes beyond a traditional family tree by allowing the user to visualize hereditary patterns and psychological factors that punctuate relationships. It can be used to identify repetitive patterns of behavior and to recognize hereditary tendencies. From the maternal side, E.L. and E.L., has diabetes, but this is due to their lifestyle, this is not hereditary. There were no history of any drug abuse, or mental illness in the family, their father E.L., is already 92 years old, and is currently living with them. From the paternal side, E.A. died, due to old cardiac arrest. And his parents died due to old age. The twins, A.A.1 and A.A.2 are adopted children, E.L and E.A are not their biological parents. The twins are the children of E.L.2 the brother of E.L.1 The pregnancy was unwanted, that the parents decided to stop the pregnancy, but the foster parents encouraged them to continue it, and they will adopt the child. And they just know that it was a twin. So the foster parents decided to adopt them both. One of the reason why they voluntarily adopt the child is that, they are too many in the family, another is that, the foster parents cannot bear or make a child.

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Anamnesis Informant 1 Name: EA,60 Relationship to Patient: Foster Mother Address: Panorama Homes, Davao City Educational Attainment: College Undergraduate Occupation: Businesswoman Length of Time being with Patient: Since birth

Apparent Understanding of the Disease: The mother understands her son’s condition as a problem in behavior and mental process caused by over-usage of drugs specifically, Shabu. She said that it can still be cured with proper counseling, presence of support groups and medication therapy. She also added that behavioral modification is of vital importance in this condition. Observed Behavioral changes of the Informant to the Patient: According to the informant, the client rarely shares his feelings, thoughts and personal activities with the family since his childhood days. She stated that the client’s behavior began to change after the death of his cousin due to vehicular accident, which happened last 2010, wherein the client was said to be the driver of the van at that time. From then on, the informant started to notice that the client begins to show

12

aggressiveness on others. Client seemed to be angry and impatient all the time. Paranoia and feeling of guilt was also observed by the mother. She stated that during the teenage years of A.A, he always spends time with his barkada and cousins. The mother verbalized that A.A usually goes out at night and returns home by 5 or 6 in the morning smelling like alcohol. By year 2007, his foster dad – the only family member whom the client is very close with – died. The informant observed that A.A had lost his appetite. He became impulsive, violent and never listens to his mother. Sometimes, he goes home very hyperactive and alert. He kept on asking for money for the reason that he would get his motorcycle repaired. He got more attached with his cousins and friends whom she said were also drug addicts. He seemed to be anxious all the time and keeps on telling his mother that someone was chasing him and wants to kill him. After his first rehabilitation, the negative behaviors temporarily disappeared. But a few months later, the behaviors returned. This time, the c` `lient’s condition became even worse. He was already very violent and kept on blaming others of his own acts. He kept on reasoning out with other people and the severity of his aggressiveness grew bigger. He asks for money more frequently to buy a pistol and displaces his anger on one of his cousins all the time. The informant stated that the client had grown wild already.

Other characteristics of the informants: The interview was conducted at the family’s residence last February 23, 2012 at around 1 pm. During the interview, the informant looked tired and hesitant but still

13

managed to answer the questions spontaneously. She speaks in a clear, loud voice. There were no mannerism and unusual gesture noted during the interview.

Her

narration of the client’s background seemed to be dependable but, her narration on her responsibility as a parent was doubtful and biased.

Informant 2 Name: VA, 42 Sex: Female Address: Panorama Homes, Davao City Educational Attainment: College undergraduate Occupational: Domestic Helper Relationship to the patient: Aunt Length of time the informant has known the client: since client was born Apparent understanding of the client’s present illness: According to her client AA has a twin brother. She knows that the twins are adopted sons of his brother. She knows that client AA was engaging drugs like shabu because of the behavioral changes client manifested and rumors came from other relatives. Observed Behavioral changes of the Informant to the Patient: Even though she was not able to witness the start of the client’s mental illness, she can say the changes of client AA before when he was still young. She also said that client AA before was behave and quiet child and was not able to continue his secondary education because client was not motivated until such time that she just

14

know client was already engaging illegal activities. The reason why she didn’t know well the life of client is because she went to Dubai to work as Domestic Helper. The informant told us that she came back in the Philippines when it was the second rehabilitation of client AA because of the maladaptive behavior manifested such as talking by himself and becoming violent to other member in the house.

Other characteristics and attitude of the informant: The informant was very accommodating as she allowed us to interview her without hesitation and she even offered seats for us to be comfortable while interviewing her. The informant answered the questions willingly. She was cooperative and confident in answering our questions. She had been patient to us. She was interested in giving information.

Informant 3 Name: JC, 68 Sex: Male Address: Panorama Homes, Davao City Educational Attainment: College graduate Occupational: Sales Agent Relationship to the patient: neighbor Length of time the informant has known the client: client was still young Apparent understanding of the client’s present illness:

15

We asked him about the family of AA, he told us that the father of the twin was a Barangay Captain in one of the barangay of Davao del Sur. He said that client’s father is a good person until died last 5 years ago. He knows the family because they were neighbors since then. According to him, although they were not that close, they maintain the essence of having a good neighborhood. He also talked about client AA and his twin brother. Although he doesn’t know about the activities or educational background of the twin, he pointed out to us the incidence happened last January, in which, there were many policemen surrounds the entire house of client AA. According to him, this was due to illegal activity involving client AA. From the statement given, he said that AA is drug addict

and

becoming

wild

and

violent.

Other characteristics and attitude of the informant: JC was sitting near the gate of their house. His house is located in front the house of the client. He was good to us students, lessons and advices about life. He was also open to our questions and understood our circumstance. JC is the father of the one of the childhood twin’s friend.

Informant 4 Name: RM,48 Sex: Female Address: Panorama Homes, Davao City Educational Attainment: College graduate

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Occupation: Businesswoman Relationship to Patient: Neighbor Length of Time being with Patient: Since childhood (15 years)

Apparent Understanding of the Disease: The informant stated that drug abuse has been very rampant nowadays. In her point of view, drug abuse is the too much intake of illegal drugs leading to psychosis and manifestation of abnormal behavior. She said that it can still be cured once the person is sent to the rehab center. Observed Behavioral changes of the Informant to the Patient: The informant said that she had known the client since childhood. According to her, the client was a playful child. When AA was still young, she would often see him play outside with his friends. He was a jolly, active boy and can easily make friends. Until he grew up as a teenager, she often sees AA riding his motorcycle, sometimes with his barkada. The informant already had a clue that the client was on drugs due to the violent behaviors he manifested. She stated that AA always gets into a fight with his cousin and had been wild lately. The last time she saw the client was last January. Other characteristics of the informants: The interview was conducted outside the informant’s residence last February 23, 2012 at around 4 pm. During the interview, the informant seemed relaxed. She speaks in a low-modulated voice. There were no mannerism and unusual gestures noted during the interview. Her narration of the client’s background was somewhat helpful but still insufficient because details were broad and general.

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A. MENTAL STATUS EXAMINATION February 11, 2013 (Orientation Phase) I. PREEXAMINATION A. GENERAL APPEARANCE Our client is 23 years old, has long hair about the length of 4 inches, wears gray shirt and cargo pant and black sleepers, and has clean fingernails and toenails. Have tattoos at right deltoid a picture of skulls, an octopus at the left deltoid, a half woman half skull at left neck, a D-A-N-G on left fingers it is his nickname. He looks as if it was just the time he woke up. He’s manifesting anxiety as tense posture and can’t have direct eye contact. He keeps on looking at sides and other person surrounds us. B. GENERAL MOBILITY 1. Posture & Gait: He stands erect able to walk properly with normal pace but with unusual mannerism like stamping right leg while sitting on chair which indicates our client is anxious. 2. Activity: ( / ) Normoactive ( ) Hyperactive

( ) Psychomotor retardation ( ) Agitated

He is normoactive during the activity. During the games he participated well to the group. 3. Facial Expression:

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The resident Smiles during the interaction, and sometimes have flat affect and cannot have direct eye contact. C. BEHAVIOR (  ) friendly

( ) impulsive

( ) embarrassed

( ) negativistic

( ) seductive

( ) indifferent

( ) angry ( ) evasive ( ) withdrawn

He is friendly towards us, and showed interest when asked, even though he manifested anxiety he is still willing to answer questions and waited until the program has ended. D. NURSE-PATIENT INTERACTION (  ) cooperative ( ) initially ( ) uncooperative

( ) all throughout

Quality: (  ) warm

( ) distant

( ) dependent

( ) hostile

( ) suspicious

( ) talkative

During the interaction with him he is cooperative and immediately answers questions without any hesitation. He is warm and willing to give information about him and about the situation he has with. He even told when he started using marijuana and shabu. He is cooperative all throughout the interaction.

II – STREAM OF TALK: A. CHARACTER (  ) spontaneous

( ) deliberate

( ) pressure

( ) blocking

19

Talking spontaneously every time I have questions and in organized manner, even if I will ask again same question after a while still he has same answer as the previous questions. Talks smoothly about his family, brothers and sisters.

B. ORGANIZATION OF TALK (  ) relevant

( ) loose of association

( ) tangentiality

( ) irrelevant

( ) flight of ideas

( ) neologism

( ) incorrect

( ) circumstantiality

( ) others ____

He doesn’t have any problem with organization of talk since all the things he said were relevant with the questions I have for him. C. ACCESSIBILITY ( ) good

( ) self-absorbed

( ) defensive

( ) fair

( ) mute

( ) inaccessibility

He has good accessibility since he answers immediately and openly shares about his condition and the things that he has been doing since he is using prohibited drugs. III. EMOTIONAL STATE & REACTIONS: A. MOOD ( ) euthymic

( ) depression

( ) euphoria

When ask how he feels that day, he said he feels good since he joined in the activity and he saw Ms. A one of the resident a pretty one which he keeps on looking at. He is euthymic.

20

B. AFFECT () appropriate

( ) inappropriate

Quality: ( ) flat

( ) elated

( ) histrionic

( ) blunted

( ) labile

( ) angry

( ) hostile

() anxious others _______

He has inappropriate affect sometimes he has flat affect and anxious.

C. DEPERSONALIZATION & DEREALIZATION (  ) absent

( ) present

He never manifested any depersonalization and derealization since he never had subjective sense of being unreal, strange or unfamiliar and strange sense of environment since he knew that he is at dela Rosa Rehabilitation Center. D. SUICIDAL HOMICIDIAL ESCAPE POTENTIAL ( ) present

( ) absent

Our client doesn’t have suicidal but he has homicidal attempts before he was admitted in the institution.

IV – THOUGHT CONTROL: A. PERCEPTION ( ) present

( ) absent

21

During that day the client never manifested any hallucination and illusion, but reported he cannot sleep straight at night or he has an interrupted sleep because of auditory hallucination. B. DELUSIONS ( ) present

(  ) absent

This day he doesn’t have any delusions. C. IDEAS OF REFERENCE ( ) present

(  ) absent

Doesn’t have any ideas of reference. D. PREOCCUPATIONS & RUMINATIONS Client doesn’t have preoccupations and ruminations. D. DEJAVU & JAMAIS VU ( ) present

(  ) absent

When as if he has any familiarity and strange feeling about the activity that day he said he never had any of the two.

V – NEUROVEGETATIVE DYSFUNCTION: A. SLEEP As we talk about sleep pattern he is complaining of interrupted sleep since he could not have continuous sleep pattern. He had midnight awakening due to Auditory hallucination B. APPETITE: He has good appetite and could finish immediately his food.

22

C. DIURNAL VARIATION: When ask what he is doing everyday he said he just watch tv, talk with coresidents pacing every morning (three to four times) D. WEIGHT We never had the chance to weigh our resident. E. LIBIDO As what I have observe client is have energy to participate with the activity and able to do his ADL’s. He did not show any sexual desires.

VI – GENERAL SENSORIUM & INTELLECTUAL STATUS: A. ORIENTATION: When ask about the date, place and person he was able to answer appropriately. B. MEMORY: Client’s memory is not impaired. When ask again who I am he is able to say I am Michelle which belong to his recent memory When ask about what do they have during the new year he was able to enumerate foods they have during the new year, and when ask when he was admitted he said January 26, 2013. He said he was locked up last February 10, yesterday. D. ATTENTION SPAN: (  ) good

( ) fair

( ) poor

He has good attention span and able to finish the program before leaving the area.

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D. GENERAL INFORMATION When ask about his personal data he is able to give appropriate information. E. ABSTRACT THINKING ABILITY He has fair abstract thinking ability. He knew two different things like a student nurse and a psychiatrist doctor of mental health. E. JUDGEMENT & REASONING (  ) unimpaired

( ) impaired

He has unimpaired judgment and reasoning ability since he knew what he did was wrong and that all the things he has done was because he is high with shabu.

VII - INSIGHT (  ) unimpaired

( ) impaired

He doesn’t have impairment when it comes with insight. He is willing to do things that is good for himself.

VIII – SUMMARY OF MENTAL STATUS EXAMINTATION: A. Disturbance in: ( / ) Presentation

( ) Insight

( ) Stream of talk

( / ) Neurovegetative Dysfuntion

( / ) Thought Control

( ) General Sensorium & Intellectual Status (  ) Emotional state and reaction

24

B. Diagnosis Category

() Psychotic

(

)

Non psychotic

He is functional since he could do ADL’s alone every day without the help of other person and still psychotic since he was still have auditory hallucination that manifest anytime in the rehabilitation center

.

C. DSM IV-TR Diagnosis Axis 1- Substance Induce (Clinical Syndromes) Axis ii- none (Personality and development disorder) Axis iii- none (Physical disorders and conditions) Axis 1V- none (Psychosocial and Environmental problems)

25

B. MENTAL STATUS EXAMINATION

(Working Phase)

DATE: February 13, 2013 I – PREEXAMINATION A. GENERAL APPEARANCE Our client is 23 years old, has long hair about the length of 4 inches, wears gray shirt and cargo pant and black sleepers, has clean fingernails and toenails. Have tattoos at right deltoid a picture of skulls, an octopus at the left deltoid, a half woman half skull at left neck, a D-A-N-G on left fingers it is his nickname. He looks as if it was just the time he woke up. He’s manifesting anxiety as tense posture and can’t have direct eye contact. He keeps on looking at sides and other person surrounds us. B. GENRAL MOBILITY 1. Posture & Gait: He stands erect able to walk properly with normal pace but with unusual mannerism like stamping right leg while sitting on chair. 2. Activity: () Normoactive ( ) Hyperactive

( ) Psychomotor retardation ( ) Agitated

26

He is normoactive during the activity. During the games he participated well to the group. He is physically and mentally capable in daily activities. 3. Facial Expression: Smiling during the interaction, and sometimes have flat affect and cannot have direct eye contact. C. BEHAVIOR (  ) friendly

( ) impulsive

( ) embarrassed

( ) negativistic

( ) seductive

( ) indifferent

( ) angry ( ) evasive ( ) withdrawn

He is friendly towards us, and showed interest when I am asking questions from him, He also accommodating with the questions given during the coversation D. NURSE-PATIENT INTERACTION (  ) cooperative ( ) initially

( ) uncooperative

( ) all throughout

Quality: (  ) warm ( ) distant ( ) dependent ( ) hostile

( ) suspicious

( ) talkative

During the interaction with him he is cooperative and immediately answers questions without any hesitation. He is warm and willing to give information about him and about the situation he has with. He is cooperative all throughout the interaction.

27

II – STREAM OF TALK: A. CHARACTER  ) spontaneous

( ) deliberate

( ) pressure

( ) blocking

Talking spontaneously every time I have questions and in organized manner, even if I will ask again same question after a while still he has same answer as the previous questions. Smoothly talk about his family, his twin brother and sisters

B. ORGANIZATION OF TALK (  ) relevant

( ) loose of association

( ) tangentiality

( ) irrelevant

( ) flight of ideas

( ) neologism

( ) incorrect

( ) circumstantiality

( ) others ____

He doesn’t have any problem with organization of talk since all the things he said were relevant with the questions I have for him. C. ACCESSIBILITY ( ) good

( ) self-absorbed

( ) defensive

( ) fair

( ) mute

( ) inaccessibility

He has good accessibility since he answers immediately and openly shares about his condition and the things that he has been doing since he is using prohibited drugs. III. EMOTIONAL STATE & REACTIONS: A. MOOD 28

( ) euthymic

( ) depression

( ) euphoria

When ask how he feels that day, he said he feels good since he joined in the activity and he saw Ms. A one of the resident a pretty one which he keeps on looking at. He is euthymic. B. AFFECT (  ) appropriate

( ) inappropriate

Quality: ( ) flat

( ) elated

( ) histrionic

( ) blunted

( ) labile

( ) angry

( ) hostile

( ) anxious

others _______

He has appropriate affect that react according to stimuli.

C. DEPERSONALIZATION & DEREALIZATION He never manifested any depersonalization and derealization since he never had subjective sense of being unreal, strange or unfamiliar and strange sense of environment since he knew that he is at dela Rosa Rehabilitation Center. D. SUICIDAL POTENTIAL Our client doesn’t have suicidal and homicidal attempts or even thoughts.

IV – THOUGHT CONTROL: A. PERCEPTION ( ) present

(  ) absent

During that day the client never manifested any hallucination and illusion. 29

B. DELUSIONS (  ) absent

( ) present

This day he doesn’t have any delusions. C. IDEAS OF REFERENCE ( ) present

(  ) absent

Doesn’t have any ideas of reference. D. PREOCCUPATIONS & RUMINATIONS Client doesn’t have preoccupations and ruminations. E. DEJAVU & JAMAIS VU ( ) present

(  ) absent

When as if he has any familiarity and strange feeling about the activity that day he said he never had any of the two.

V – NEUROVEGETATIVE DYSFUNCTION: A. SLEEP As we talk about sleep pattern he is complaining of interrupted sleep since he could not have continuous sleep pattern. B. APPETITE: He has good appetite and could finish immediately his food. C. DIURNAL VARIATION: When ask what he is doing everyday he said he just watch tv, talk with coresidents pacing every morning. 30

D. WEIGHT We never had the chance to weigh our resident. E. LIBIDO As what I have observe client is energetic to participate with the activity and able to do his ADL’s. Never had the chance to ask about his sexual drive.

VI – GENERAL SENSORIUM & INTELLECTUAL STATUS: A. ORIENTATION: When ask about the date, place and person he was able to answer appropriately. B. MEMORY: When ask again who I am he is able to say I am Michelle. When ask about what do they have during the new year he was able to enumerate foods they have during the new year, and when ask when he was admitted he said January 26, 2013. He said he was locked up last February 10, yesterday. C. ATTENTION SPAN: (  ) good

( ) fair

( ) poor

He has good attention span and able to finish the program before leaving the area. D. GENERAL INFORMATION When ask about his personal data he is able to give appropriate information.

31

E. ABSTRACT THINKING ABILITY He has fair abstract thinking ability since he was not able to graduate elementary years but knew two different things like a student nurse and a psychiatrist doctors of mental health. Student nurse are still students and F. JUDGEMENT & REASONING (  ) unimpaired

( ) impaired

He has unimpaired judgment and reasoning ability since he knew what he did was wrong and that all the things he has done was because he is high with shabu.

VII - INSIGHT (  ) unimpaired

( ) impaired

He doesn’t have impairment when it comes with insight. He is willing to do things that is good for himself.

VIII – SUMMARY OF MENTAL STATUS EXAMINTATION: A. Disturbance in: ( /) Presentation

( ) Insight

( ) Stream of talk

( ) Neurovegetative Dysfunction

( ) Thought Control

(/) General Sensorium & Intellectual Status (/) Emotional state and reaction

B. Diagnosis Category

32

( /) Psychotic

(

)

Non psychotic

He is functional since he could do ADL’s alone every day without the help of other person and still psychotic since he was still have auditory hallucination that manifest anytime in the rehabilitation center

.

C. DSM IV-TR Diagnosis Axis 1- Substance Induce ( Clinical Syndromes) Axis ii- none (Personality and development disorder) Axis iii- none (Physical disorders and conditions) Axis 1V- none (Psychosocial and Environmental problems)

33

(Termination)

DATE: February 20, 2013 I – POSTEXAMINATION A. GENERAL APPEARANCE The client had an endomorphic type of body. He already performed his ADL and appears well-groomed. He has fair complexion all over the body and has tattoos on his right and left deltoid as well as on his neck part and fingers. He wears white sando and checkered pants with a pair of black slippers. The client looks anxious and keeps on pacing but still he is eager to join the activity and excited to join the games.

B. GENRAL MOBILITY 1. Posture & Gait: Client was in an upright position most of the time when standing and siting. He is able to walk without difficulty. His body position seemed to be open to queries and conversation as he had an open body position but mannerism noted like stamping of leg noted at times during our conversation. 2. Activity: He was normoactive and he likes to participate in the exercise, games like the showing of talents in the culmination activity. While doing the

34

He did not exhibit any abnormality pertaining to the level of activity, which was constant all throughout the duration of the program. But constant washing of hands during the activity was observed. 3. Facial Expression: He can now establish eye to eye contact during conversation conversation. He is frowning quite sometimes but when you catch his attention he will smile. He did not exhibit any outward or receding behavior when conversing with the student nurse. He was very accommodating with the student nurse and was showing interest with the nurse interaction. C. BEHAVIOR (  ) friendly

( ) impulsive

( ) embarrassed

( ) negativistic

( ) seductive

( ) indifferent

( ) angry ( ) evasive ( ) withdrawn

During the course of interaction client is approachable and friendly. He was very cooperative, and shares his insights, ideas and feelings. When ask with different questions he immediately answer and expound his ideas. He elicits positive outlooks in life. While conversing with the student nurse client seemed to be comfortable. D. NURSE-PATIENT INTERACTION (  ) cooperative ( ) initially

( ) uncooperative

( ) all throughout

Quality: (  ) warm ( ) hostile

( ) distant

( ) dependent

( ) suspicious

( ) talkative 35

During the interaction client speaks openly and very cooperative all throughout. Client was warm and accommodating toward the student nurse. Along the way, client was still interested with the conversation and gladly shared his ideas, insights and feelings. When ask, he answers all questions without hesitation.

II – STREAM OF TALK: A. CHARACTER  ) spontaneous

( ) deliberate

( ) pressure

( ) blocking

Client was spontaneous in answering and delivering his ideas. There are times that he only answers what was being ask. At times, client initiates to open a topic and exchanges ideas with the nurse intuitively. He is able to elaborate his ideas and feelings when asked to do so. B. ORGANIZATION OF TALK (  ) relevant

( ) loose of association

( ) tangentiality

( ) irrelevant

( ) flight of ideas

( ) neologism

( ) incorrect

( ) circumstantiality

( ) others ____

During the nurse-client interaction client had a relevant stream of talk. He has organized thoughts and his ideas were also relevant of the questions that were asked to him. C. ACCESSIBILITY ( ) good

( ) self-absorbed

( ) defensive

( ) fair

( ) mute

( ) inaccessibility

36

Client has good accessibility since he can answer the questions immediately. He can open up topics to talk about and can penetrate to the topic initiate by the student nurse. III. EMOTIONAL STATE & REACTIONS: A. MOOD ( ) euthymic

( ) depression

( ) euphoria

Client verbalized that he feels good and happy. He was euthymic. He had an appropriate reaction and mood to the nurse-client interaction. No noticeable depression present during the course of the conversation. B. AFFECT (  ) appropriate

( ) inappropriate

Quality: ( ) flat

( ) elated

( ) histrionic

( ) blunted

( ) labile

( ) angry

( ) hostile

( ) anxious

others _______

Client had an inappropriate affect sometimes like being anxious. He looks tense and worried because according to him he is conscious with his appearance because of his crush Ms. A. Client also cannot maintain eye contact. C. DEPERSONALIZATION & DEREALIZATION Depersonalization and Derealization were absent during the course of interaction. D. SUICIDAL POTENTIAL During the course of interaction, there were no noticeable verbal and nonverbal cues and gestures that suggested a suicidal and escape potential. 37

IV – THOUGHT CONTROL: A. PERCEPTION Client exhibited orientation to reality there were no hallucinations and illusions observed during the course of interaction. B. DELUSIONS ( ) present

(  ) absent

There is no delusion noted. C. IDEAS OF REFERENCE During the course of interaction ideas of reference were not observed. D. PREOCCUPATIONS & RUMINATIONS ( ) present

(  ) absent

Pre-occupation and Rumination were not observed during the course of interaction. E. DEJAVU & JAMAIS VU Déjà Vu and Jamais Vu were not observed during the course of interaction.

V – NEUROVEGETATIVE DYSFUNCTION: A. SLEEP When ask about his sleeping pattern we said that he sleeps early but he was awaken at dawn because there is a voice that others him but later he ignored. Client can rest and sleep normal during siesta. 38

B. APPETITE: Client has good appetite and consumes food immediately. C. DIURNAL VARIATION: Client verbalized that his mood was good from the time he awakes. The client said that he does not have mood swings in the course of the day. D. WEIGHT The clients weight was not able to be obtain. E. LIBIDO Client is energetic and eager to participate with the activity and able to perform his ADL’s. Client did not show his sexual desires

VI – GENERAL SENSORIUM & INTELLECTUAL STATUS: A. ORIENTATION: Client was able to answer appropriately when ask about the date, place and person. B. MEMORY: For the remote memory, client was able to recall his past experiences like how he harassed his family, when was his father died. He was able to recall recent times, the activity we conducted yesterday; he enjoyed one of the games which is the singing bee. For the immediate memory, client was able to remember their food for breakfast which are corned beef and ampalaya. C. ATTENTION SPAN: (  ) good

( ) fair

( ) poor

39

Client has good attention span as he was able to maintain conversations with the student nurse for long periods and able to finish the program before leaving the area. D. GENERAL INFORMATION Client was able to state personal data like name, age, birthdate, address, name of mother, father, siblings, and his educational background. E. ABSTRACT THINKING ABILITY His abstract thinking was not impaired and he was able to explain the thought of the day with correct reasoning.

When ask about what’s the

significance of the clay he molded during the activity, for him it signifies love for his mother and girlfriend. F. JUDGEMENT & REASONING (  ) unimpaired

( ) impaired

He has unimpaired judgment and reasoning ability since he knew what was his condition and according to him it was the effect of using prohibited drugs.

VII - INSIGHT (  ) unimpaired

( ) impaired

Client has unimpaired insights. He had consistent answers to each question and always had a good trail of thought and reasoning

40

VIII – SUMMARY OF MENTAL STATUS EXAMINTATION: A. Disturbance in: ( ) Presentation

( ) Insight

( ) Stream of talk

( ) Neurovegetative Dysfuntion

( / ) Thought Control

( / ) General Sensorium & Intellectual Status ( / ) Emotional state and reaction

C. Diagnosis Category ( ) Psychotic

(

)

Non psychotic

He is functional since he could do ADL’s alone every day without the help of other person and still psychotic since he was still have auditory hallucination that manifest anytime in the rehabilitation center

.

D. DSM IV-TR Diagnosis Axis 1- Substance Induce (Clinical Syndromes) Axis ii- none (Personality and development disorder) Axis iii- none (Physical disorders and conditions) Axis 1V- none (Psychosocial and Environmental problems)

41

Progress Notes Acquaintance Party (February 11, 2013) This was our first day of meeting with our client AA. As he was approached, he was quite but he managed to smile towards us. At that time he was wearing a pair of gray shirt and short. During the VS taking we observed that he appears untidy and with messy hair. There was no presence of bad odor. The client was asked about his age which is 23 years old and he look just appropriate to his age and sex. The group also noticed that he remains silent in his sit, observant, behave and responsive only when asked. He only answers the questions that was asked and open up any subject in relation to the questions. As for the physical appearance he has an endomorphic body. He has a fair complexion with tattoos noted on his neck part, left metacarpal and both deltoid. The client was observed to have a good posture and gait. He can walk, sit, stand and move even without assistance. The client is participative in all the prepared activities for the day. He remained normoactive all of the time however he kept on going back and forth to residents room and activity proper. The client smiles most of the time. This may be because he enjoys the activities. During the course of our activity, the client always smiles and can easily be acquainted to other student nurses. With regards to his level of awareness on his condition, he was oriented about it. He showed independence during self care activities. He was already aware with the thing to be done. He didn’t manifest any signs of hallucinations and social isolation.

42

Music and Art Therapy (February 12, 2013)

On this day our client wears gray sando, plaid short pants and a pair of black slippers. There was no presence of bad odor noted. He was well-dressed and clean. Our client manifests presence of interest in his attitude as the activity starts. He asked questions such what he understand on the motto presented for today’s activity and what will be the activity for this day and was able to answer back appropriately. During the therapy, he participated to the games by group. He molded a heart- shaped and he according to him it was a symbol of love for his girlfriend and family. We observed that he keep on standing and after awhile he will do pacing. During break time, he answers all the questions being asked especially his experiences using drug substances and behavioral changes that he observed during the course of drug addiction. According to client , he told that his cousins are one who influenced him to used drugs such as shabu ,marijuana and even smoking. He said also that he used to manipulate his foster mother to have money to buy drugs.

Occupational Therapy (February 13, 2013) During this day our resident was wearing white sando, short pants and slippers. He was well-groomed and clean. His hair was newly trimmed. Before the actual program starts, we observed that he keep on pacing back and forth. He is cooperative in the games and activities however he kept on yawning and blinking. He said he enjoyed the games especially “ Pinoy Henyo” . Also, he enjoyed making pastil which is 43

the main part of our activity .During interactions, he talk openly, he even mention that some of the residents he knew already and give comments to them on what they are doing. We learned also why he do pacing back and forth, in which, according to him it will help him to relieve from tension he experiences. He was still open to the questions about his personal life and experiences outside until such time he went to Dela Rosa Institution.

44

PSYCHODYNAMICS Tabular presentation Predisposing Factors Age

Presence 

Rationale According to WHO, it is common among the age groups of 15-35 years old. According to Videbeck, the onset of intoxication is between 15 and 17 years of age. In men, 15-25 years old and 25-35 in women. It seldom occurs in childhood and is frequently diagnosed during the late adolescence.

Gender



Male and female are prone to be influenced in taking illegal drug for substance abuse. However, it is common that in males at their early age they are influenced to use.

Genetics



Children of alcoholic parents are at higher risk for developing

45

alcoholism and drug dependence than are children of non-alcoholic parents. Physiological trauma



Some mental illness may be triggered by physiological trauma suffered since childhood such as emotional abuse, severe physical abuse or sexual abuse; even a significant other loss such as loss of the parents and neglect.

Precipitating Factors Peer pressure

Presence 

Rationale Peer influences have been found to

be

among

the

strongest

predictors of drug use during adolescence. It has been argued that peers initiate youth into drugs,

provide

drugs,

model

drug-using behaviors, and shape attitudes about drug. The first big transition for children is when they leave the security of the family and enter school. 46

Later, when they advance from elementary

school

to

middle

school, they often experience new

academic

and

social

situations, such as learning to get along with a wider group of peers. It is at this stage—early adolescence—that children are likely to encounter drugs for the first time. When they enter high school, adolescents social,

face

additional

emotional,

and

educational challenges. At the same time, they may be exposed to greater availability of drugs, drug

abusers,

and

social

activities involving drugs. These challenges can increase the risk that they will abuse alcohol, tobacco, and other substances. Stress



Some

people

substances

as

use

illegal

a

coping

47

mechanism or to relieve stress and tension. Family Problem



Most children with poor family support usually end up lack of emotional and moral attention. They find this attention to their psychosocial

environment.

Almost 5 out of 10 children with broken families has vices.

48

SCHEMATIC DIAGRAM

Father

Mother

EA

EA

Age: 63 years old

Age: 60 years old

Occupation: Barangay Captain

Occupation: Businesswoman

> Closed with the twins

>Always busy with the business

> Always busy and has short time

>Loud personality

with the his children > Died last 2007 due cardiac arrest

>Do not usually communicate with her children >Doesn’t care about her children’s way of

life Abad Santos Davao del Sur. They EA and EA got married on the year 1980 at Jose never had any child that is why they decided to>Vocal, adopt the twins brother. Their strict andfrom thriftyEA’s woman marriage conflicts were only minimal because they try to talk it over whenever they have an argument. The couple made sure that they will provide their children proper education and they did with the financial support of their business which is sari-sari store. Both EA & EA are thrifty and does understand each other that made their relationship last.

A1.A 21 Y.O.

A2.A 21 Y.O.

Psychologist as Dubai

Driver

49

PRE-NATAL ASSESSMENT They were unwanted because their biological parents have a lot of children and they don’t have enough money to feed them all. So the biological mother wanted to abort the twins but since the aunt offer to adopt the children after birth, the biological mother did not continue her plan of abortion. According to his foster mother, patient’s biological mother does pre-natal check up at their health center. During pregnancy, she does drink alcohol and does always quarrel with her husband. She believes in albularyo and hilot. She did not visit a doctor and did not undergo ultrasound that’s why she did not recognize she have twins.

BIRTH They were born on March 11, 1989 via Normal Spontaneous Vaginal Delivery at Home at Jose Abad Santos Davao del Sur. It took for about less than 1 hour for the twins to be delivered. Patient’s twin was the first one who got out, followed by the patient after 3 minutes. There were no complications and difficulty in labor noted. The twins were given to their aunt and uncle right after the delivery. Infancy (0-12months) Erik Erikson’s psychosocial theory: TRUST vs. MISTRUST During the first stage of life, infants depend on their parents for their physiological and psychological needs. Fulfillment of these needs is required for the infants to develop basic sense of trust. Parents can enhance this trust by respond consistently to infant’s needs. Another is by providing a predictable environment in which routines are established and lastly being sensitive of the infant’s needs and meeting them skillfully and promptly. An indicative good result in this stage is when the infant learns to trust others but would be in vain if the child exhibits mistrust, withdrawal and estrangement to others.

50

Sigmund Freud’s Psychosexual theory: ORAL STAGE In the oral stage, the development begins at birth, extending about 18 months. During this stage, stimulation of the mouth, such as sucking, biting, and swallowing, is the primary source of satisfaction. Not getting needs met at this stage may produce problems with eating and habits such as smoking and biting nails. A wide range of adult behaviors, from excessive optimism to sarcasm, cynicism and pessimism, has been attributed during this stage. Fixation at this stage is characterized by narcissism and incorporation loved objects.

Significant persons: Mother and Father, Primary caregiver Critical experience: weaning Developmental Task: establishing trust Developmental Task:  Viewing the world safe and reliable  Viewing the relationships as nurturing, stable, and dependable

51

Psychosocial Developmental Theory: I.

Trust vs. Mistrust

At this stage of the client’s life, he formed mistrust instead of trust. Presently, he manifests behaviors such as suspiciousness, withdrawal from others etc. According to the mother, weaning was not done, the client just stopped drinking in a bottle at the age of 5. Since she just let her twins do what they want like drinking in a bottle until they stopped. But she also stated that during the infant years of the client, he was not a cry baby. He only cries if he is hungry, and the babysitter would provide a bottled milk to be fed to the baby. Psychosexuall Developmental Theory I. Oral Stage (Birth-18 mos.) Her mother is the primary caregiver during the infancy stage. She feds AA and his twin every 4 hours or whenever feeling hungry. AA was cuddled during feeding and crying. Weaning was not done by his mother because according to her she doesn’t want to force them to stop feeding in the bottle. So our client stops feeding in the bottle at the age of 5 years old during his kindergarten years. He never experienced to be breastfed because after his birth he was directly given to his foster mother. At 7 months, semi-solid foods were already introduced to him such as “lugaw” and cerelac. Early weaning can cause personalities like narcissism, dependence, talkative and orally fixated; late weaning causes smoking and alcoholism 52

Toddlerhood (1-3 years old) Erik Erikson’s Psychosocial theory: AUTONOMY vs. SHAME and DOUBT If the caretaker permits the child, now a toddler to explore and manipulate environment, the child will develop a sense of autonomy or independence. Sigmund Freud’s Psychosexual theory: ANAL STAGE Sexual gratification during this stage shifts to the anus. This occurs during the period of toilet training. The child is concerned with retaining and letting go of feces. Problems occurring in resolution of this phase may result in rebelliousness and an exaggerated need to in control across the life span. If the fixation is with retention or holding in, the adult may be excessively neat, clean and compulsive. If however, expulsion is the problem, the adult may be dirty, wasteful and extravagant. Significant persons: Parents/ Basic Family Type of Play: Parallel Play Critical Experience: Toilet Training Developmental Task: development of sphincter, autonomy Developmental Tasks: 

Leaning to walk.



Learning to take solid food.



Learning to walk.



Learning to control elimination of body waste.



Learning sex differences.



Learning to relate emotionally to significant others.



Learning concepts and learning language to described social and physical reality.



Learning to distinguish right or wrong.



Developing a conscience.

53

Psychosocial Developmental Theory: II.

Autonomy vs. Shame and doubt

According to the client’s foster mother, when he was still a toddler, they would provide all the toys for them and let them play as much as they want, but she would leave the twins to their babysitters. She said she doesn’t encourage much, since doesn’t talk much to her children. She would just let her twins do what they want. According to her, she didn’t discipline them when they were still a child, since for her they were behave. He developed shame and doubt. Presently, he has no self-control, especially when it comes to his vices, and he feels that he is always attacked and the sense of being out of control. He doubts almost everything even himself on what he can do to improve his life. And he depends on his “barkadas” on what to do, he cannot decide by himself. He is also exhibiting obsessive compulsiveness, like when he gets dirty even just a little bit, he would wash it. Psychoanalytical Developmental Theory: II. Anal Stage (18 mos.-3 yrs.) His toilet training started at the age of 1 and a half years old and progress until three years old. The mother, being the primary caregiver in this age, taught AA this skill and eventually became successful. He had a sense of control in his elimination. According to his mother our client can easily catch up instructions that were given to him like going to the bathroom whenever there’s an urge to urinate or defecate. It was also mentioned by the mother that the twins usually takes a bath 8x a day especially every after playing. It was stated that rigid toilet training causes obsessive- compulsive behavior.

54

Preschool (3-6 years old) Erik Erikson’s Psychosocial theory: INITIATIVE vs. GUILT Initiative means a positive response to the world challenges, taking on responsibilities, learning new skills and feeling purposeful.

Sigmund Freud’s Psychosexual theory: PHALLIC STAGE Phallic stage occurs at the end of the third or fourth year, erotic gratification shifts to genital region. The child becomes sexually attracted to the parent of the opposite sex and fears the parent of the same sex, who is now perceived as a rival. The child overcomes this conflict by identifying with parent of the same sex. Object love at stage is ambivalent and may affect object relations in adult life. Significant person: Basic family. Type of Play: Parallel and Associative Play Critical experience: oedipal complex (attaches with opposite sex parent and be rid of same sex parent) Developmental Task: establish sexuality identity, beginning socialization repression and identification Developmental Task: 

Learning sex differences and sexual modesty.



Achieving psychological stability.



Forming simple concepts of social and physical reality.



Learning to relate emotionally to parents, siblings, other people.

55

Psychosocial Developmental Theory: I.

Initiative vs. Guilt

AA achieved guilt, since he manifest excessive guilt, passivity and underachievement of his potentials. According to the foster mother, she doesn’t see the twins do household chores that much. They don’t study much, but they were more on to playing. They cannot take a bath on their own until their elementary years, since they have their own babysitter. She even stated that they would even take a bath up to 8 times a day since their babysitter gives them a bath if they would be dirty. She would let them do what they want and play as long as they want. He doesn’t initiate to do things unless he is told so. And the foster mother stated, didn’t discipline them when they were still a child, since they are good children. Psychosexual Developmental Theory: III. Phallic Stage/ Oedipal (3-6 yrs.) Our client was said to be more close to his father rather than his mother. They have lots of moments together which AA cherishes most. He plays with his twin brother and with their friends in the neighbourhood. They usually play toy guns, toy cars and the like. The mother also noticed AA playing with his genitals especially while urinating.

56

School Age (6-12 years old) Erik Erikson’s Psychosocial theory: INDUSTRY vs. INDFERIORITY

At this time children begin to create and develop a sense of competence and perseverance. School age children are motivated by activities that provide a sense of worth. They compete on mastering skills that will help them function in the adult world. Although children of this age work hard to succeed, they are always faced with the possibility of failure, which can lead to a sense of inferiority. If children have been successful in previous stages, they are motivated and to cooperate with others toward common goal. Sigmund Freud’s Psychosexual theory: LATENCY The child begins to submit to the demands of the superego and sublimate in instincts. The way the person handles the internal and external demands, for better or for worse, becomes consolidated during this time. Type of Play: Competitive Play Significant persons: School Acquaintances Critical experience: peer group experience & intellectual growth Developmental Task: group identification Developmental Task: 

Learning physical skills necessary for ordinary games.



Building wholesome attitudes toward oneself as a growing organism.



Learning to get along with age-mates.



Learning an appropriate masculine or feminine role.



Developing concepts necessary for daily living.

57

Psychosocial Developmental Theory: I.

Industry vs. Inferiority

In this stage, he developed inferiority. He was just an average student, he only participates in basketball games at school, and during his 6th grade in elementary, according to the foster mother, AA was not able to graduate elementary, since he was always absent. Then one time, he punched a classmate for the reason that his classmate destroyed his plant in their school garden, he was called to the guidance office. Thus he was failed, from then on, he didn’t continue his studies. His foster mother encouraged him to continue studying even after all that happened. But then he lost his motivation to continue his studies Psychosexual Developmental Theory: IV. Latency/School Age (6-12 yrs.) He likes to play basketball with his friends. He was able to follow simple rules and avoids conflict with his peers by playing fair. He did not exhibit difficulty in learning basic lessons thereby giving him with good. There was no failure in developing personal independence as evidenced by ability to take care of basic needs of self because since then they were trained and raised to be independent. His physical skills are fully developed and he is capable of playing with other kids. At this stage, AA was able to gain lots of friends and did establish a good relationship with them. He was already able to initiate personal grooming like taking a bath, which signifies development of independence and there were no further fixations noted. He was circumcised at the age of 9 and he was accompanied by his mother. His secondary male sex characteristic started to appear at this stage. 58

Adolescence (12-19 year old) Erik Erikson’s Psychosocial Theory: IDENTITY vs. CONFUSION In this stage, the individual learns to develop a coherent sense of self. Planning for actualization of one’s abilities is also vital in this stage. Indicators of negative resolution include feeling of confusion, indecisiveness, and possible antisocial behavior Sigmund Freud’s Psychosexual Theory: Genital Stage At the start of adolescence, the final stage, called the genital stage, begins. Heterosexual behavior is evident, and the person undertakes various activities in preparation for marriage and family. Significant person: PEERS Critical Experience: establishes heterosexual relationship and sexual maturity Developmental Task: development of social control over instincts Developmental task: 

Achieving new and more mature relations with age-mates and both sexes.



Achieving a masculine or feminine social role.



Achieving one’s physique and using the body effectively.



Achieving emotional independence from parents and their adults.



Achieving assurance of economic independence.



Selecting and preparing for an occupation.



Preparing for marriage and family life.



Desiring and achieving socially responsible behavior.



Acquiring a set of values and an ethical system as a guide to behavior.

59

Psychosocial Developmental Theory: I.

Identity vs. Role confusion

During his adolescent years, he stopped going to school since he did not graduated in elementary and lost motivation to conitue his studies. Instead he stays at home, sleeping, eating, or most of the time going outside with his “barkadas”. According to his mother, he doesn’t bring his “barkadas” at home, but sometimes, she sees him with them, and she said they look like addicts. The foster mother was not aware that AA used drugs at the age of 15 until she read it from the chart. She is not also aware when did AA start smoking, but she says he would go home drunk at dawn and their home smells smoke. AA developed role confusion, presently, he exhibited behaviors such as lack of goals like finishing his studies, beliefs such as not going to church at his teenage years, values, productive roles such as being responsible. He also had short term relationship with his girlfriends. And lastly, the influence of his peers and cousins to alcohol, smoke and substance abuse. Psychosexual Developmental Theory: V. Genital Stage/Adolescence (12-18 yrs.) His voice started to lower down in tone at the age of 16. Secondary male characteristics were evident and he was starting to get mature in his looks. He started to have group of friends or barkada. According to his mother he already had girlfriends but was not introduced to her personally. 60

YOUNG ADULTHOOD (19-35 years old) Erik Erikson’s Psychosocial Theory: INTIMACY vs. ISOLATION This stage covers the period of early adulthood when an individual begins to have an intimate relationship with another person and shows commitment to work and relationships. Indicators of negative resolution include impersonal relationships, avoidance of relationships, career, or lifestyle commitments. Sigmund Freud’s Psychosexual Theory: Genital stage Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment. Implications on this stage include encouragement to separate from parents, achievement of independence, and decision making.

Psychosocial Developmental Theory: I.

Intimacy vs. Isolation

According to his mother, AA has many girlfriends. He just bring these girls at home, she doesn’t know when AA started having a girlfriend, and sometimes AA let the girl sleep in their home. At times, his mother scolded him for having sex with his drug-user cousins. AA is currently in this stage, as of now AA manifests behaviours such as Seeking intimacy through casual sexual encounters such as with his cousins and other girls. Emotional distance in relationships, like he doesn’t communicate that much with his family, instead he goes out with friends most of the time

61

Predisposing Factor:

Precipitating Factor:

 Age

 Peer pressure

 Gender

 Lack of attachment & nurturing

 Genetics  Physiological trauma

by parents or caregivers  Drug Availability

YEAR 2001 When he was grade 6, he punched his classmate for the reason that his classmate destroyed and kill his plant at their school garden. After that he was send to guidance office. The teacher and his parents scolded him and after that he never wanted to go to school anymore. His parents encouraged him to go to school but he never listen that’s why he failed his subjects and did not graduate. He lost his interest at school and don’t want to continue since his twin brother graduated. According to his foster mother he did not want to go to school anymore because he doesn’t want his brother to be ahead of him.

YEAR 2004 He was influenced by his cousins and peers in using drugs. YEAR 2007 His foster father where he was much closed to died due to cardiac arrest and he was very sad that time. YEAR 2010 He had encountered a car accident where his cousin died and he was the one driving that’s why he felt guilty and he blamed himself for the accident.

62

November 2011 He was asking money from her mother because he wanted to buy a gun and wants to kill someone. He had auditory hallucination telling him that he was being trace by someone and that someone wants to kill him. That’s why also his family hides the sharp utensils because AA was going to get those and hide them to guard himself. So they got alarmed and admit the patient to rehabilitation center for 2 months. January 2012 The patient released from Dela Rosa Psychiatry and Rehabilitation Center by his eldest brother. He was acting like he was changing for the better and starts his job as a factory worker in his aunt’s company. May 2012 His biological eldest brother went abroad and he returned to his bad attitudes and using drugs again. June to November 2012 He started to lie from his foster mother and is always asking money from her. His excuse is to repair the damages on his motorcycle. His mother asks for a receipt as a proof but he never gives it because the truth is he was buying it for shabu. December 2012 He poisoned all the fishes in their aquarium using solignum and baygon because he was very angry to his cousin JM and displaced it to the fishes. He was jealous to him and accusing him being “sipsip” to his aunt. In addition to that, one night, he sprayed gasoline all over his room. Then his foster mother was awakened by the smell and stop AA for burning the house.

63

December 2012 He poisoned all the fishes in their aquarium using solignum and baygon because he was very angry to his cousin JM and displaced it to the fishes. He was jealous to him and accusing him being “sipsip” to his aunt. In addition to that, one night, he sprayed gasoline all over his room. Then his foster mother was awakened by the smell and stop AA for burning the house.

January 2013 He apologized from all he had done and promised not to do it again.

January 26, 2013 He attempted to throw rocks to his cousin JM but his foster mother stopped him saying “Buhii na, ayaw pagpalaban ug bato lakaw pagsinumbagay mo didto” But he did not listen and still continued and threw rocks to their ceiling. That’s why his MEDICATIONS: foster mother call 911 and put him back to Dela Rosa again. 

Exulten



Laractyl



Vaneular



Solian

64

If treated: Medical management Therapies: - Music & Dance - Art

Other

Possible

Medical

Management

If not treated:

-

Group therapy

- Exacerbation

of

-

Cognitive therapy

unusual

or

-

Dream Analysis

maladaptive

-

Free Association

behaviors - Recurrence

- Occupational (cooking) - Sports

of

manifestations - Difficulty coping

GOOD PROGNOSIS - Recreational

POOR PROGNOSIS

65

Definition of Diagnosis

Drug induced psychosis has typically has hallucination and delirium. Often hallucinations are visual, tactile and gustatory. It is not associated with gross physical abnormalities. It is also known as substance-induced psychosis. Its mean criteria are the absence of delirium. (Keltner et. Al. (2012) Psychiatric Nursing(6th Ed.)Elsevier Substance-induced mood disorder is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of ingested substances such as alcohol, other drugs, or toxins. (Videbeck, S. (2011). Psychiatric Mental Health Nursing, (5thEd).Philadelphia. Lippincott Williams and Wilkins)

Drug induced psychosis has prominent hallucination and delusion. Not better accounted for other mental disorders. Not occurring during delirium. (Boyd, M.A. (2010) Psychiatric Nursing (4thEd.) China. Lippincott Williams and Wilkins) Drug Induced Psychosis Drug induced psychosis is considered a form of psychosis that occurs due to chemical means. While most cases of this psychiatric condition refers to psychosis brought about from the use of illegal drugs, some patients undergoing pharmacological therapy for other psychiatric conditions may also suffer from psychosis that is a marked side effect of certain prescribed medications. Therefore, illegal drug use is not always to blame and basing the definition on this criterion can be presumably false. (Stonecypher, L. (2010) Types of Drug Induced Psychosis, Symptoms, and Treatment. February 2013. Brighthub article # 62293) The

risk

of

developing

psychotic

symptoms

increases

during

periods

of

methamphetamine use among long-term users, new research suggests. Such

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symptoms included suspiciousness (71%), delusions or unusual thought content (35%), and hallucinations (51%). (Lawry F. (2013 ) Strong Dose-Dependent Effect With Meth and Psychosis. February 2013. http://www.medscape.com/viewarticle/777741) Substances with psychotomimetic properties such as cocaine, amphetamines, hallucinogens and cannabis are widespread, and their use or abuse can provoke psychotic reactions resembling a primary psychotic disease. The recent escalating use of methamphetamine throughout the world and its association with psychotic symptoms in regular users has fuelled concerns. ( Dragogna F. Rovera C, Maffini M, Mauri M.C, Altamura CA, Fiorentini A, Volonteri LS, Dragogna F, Rovera C, Maffini M, Mauri MC, Altamura CA Substance-induced psychosis: a critical review of the literature.Curr DrugAbuseRev.Dec;4(4):22840.February 2013. http://www.ncbi.nlm.nih.gov/pubmed/21999698)

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Diagnostic and Statistical Manual IV Criteria (DSM IV Criteria)

Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

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(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

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Generic Name: Amisulpride Brand Name: Solian Classification: Antipsychotic Mode of Action: Binds selectively to dopamine D(2) and D(3) receptors in the limbic system. Low doses of amisulpride preferentially block presynaptic D(2)/D(3)-dopamine autoreceptors, thereby enhancing dopaminergic transmission, whereas higher doses block postsynaptic receptors, thus inhibiting dopaminergic hyperactivity. It may also have 5-ht7 antagonistic effect, useful in depression treatment. Date Ordered: January 26, 2013 Ordered Dose: 400 mg ½ tab OD Suggested Dose: ≤ 400 mg daily dose, single intake. >400 mg, in 2 divided doses. Predominant negative episode 50-300 mg/day. Dosage should be adjusted individually. Optimum dosage: 100 mg/day. Mixed episodes with positive & negative symptoms 400-800 mg/day. Dosage should be adjusted individually according to patients' response, so as to maintain min effective dose. Acute psychotic episodes IM

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max dose of 400 mg/day w/ follow-on treatment by the oral route. Oral dose: 400-800 mg, max dosage: 1200 mg. Indication: Treatment of acute & chronic schizophrenia characterized by positive symptoms (eg delusions, hallucinations, thought disorders) &/or negative symptoms (eg blurred effects, emotional & social withdrawal). Contraindication: Pheochromocytoma, known or suspected prolactin-dependent tumors. Children