OBP II: Mental Health Case Study - Angela

1. OBP II: Mental HealthCase Study - Angela Jeffrey Arnold, Danielle Nester, Hannah Reed, Anne-Marie Wadlington, Shelby Berthelot, Tatiana Caldera

2. Client History • Diagnosis: Paranoid Schizophrenic • Angela is a 36 year old woman of mixed ethnicity, French and African American, who grew up in household of mixed practices of Catholicism and VooDoo • Estranged marriage, with two sons ages 14 and 16 • History of multiple psychotic episodes, beginning when she was 30 • Pattern of discontinuing medications due to belief that she has no illnesses • 3 voluntary hospitalizations between LSUHSC Shreveport and New Orleans within 3 years

3. Client History • During second hospitalization, client was prescribed haloperidol and lithium, but was discharged on lithium alone • Lithium: bipolar disorder, mania • Haloperidol: schizophrenia, antipsychotic, delirium • Because she presented as psychotic, haloperidol was prescribed to calm her. Once calm, doctors believed she was affected with bipolar disorder so they discharged her on lithium alone • Two weeks later, Angela was re-hospitalized. It was then established that she indeed had schizophrenia rather than bipolar disorder, which is why the lithium did not help her

4. Client History • Client’s third hospitalization, in New Orleans, was as a result of her showing up to the ER with this note pinned to her dress: “No visitors allowed. I was fired. I do not feel very well. May I please speak to Dr. Mark Adams. In Shreveport, I am considered a chronic paranoid schizophrenic. I have no interest in answering questions, especially about my religion. I have nothing to say except to request a transfer to a professional health care facility in New Orleans. This is known as racketeering comrade. There is probably going to be another hospitalization. It is yet to be determined it there is going to be a pseudonym and no insurance. Happy anniversary.” • After several hospitalizations, Angela was court ordered to move to the Evangeline House for long term treatment • Evangeline House- provides psychiatric, psychological, psychosocial, and rehabilitative services in a therapeutic atmosphere

5. Client History • Evangeline House MSE Results Overview • Cooperative in answering questions, but very guarded • No eye-contact established, constantly looking around the room • Poor insight into current illness, believing that she had a headache from probes placed in her head by the CIA, but was not crazy • Noted palilalia (rapid repetition of sounds, words, or phrases) • Oriented to person and place, but not date • History of suicidal ideations/attempts and sexual trauma

6. Client History • Preoccupation with conspiracy theories • Believes “men in black” and the CIA have been following her for years because of the special knowledge she has gained in dreams • Believes the film “Men in Black” was created to give her secret information on how to avoid government agencies • Believes that agents placed probes in her brain to allow them to read her thoughts and control her mind • She stated that she must starve her brain in order to ward off voices • States that she often sees agents lurking in the shadows, indoors and outdoors

7. Current Medical Report (Pre-OT) • Symptoms of schizophrenia: • Positive: delusions, hallucinations, behavioral dyscontrol, thought disorder • Negative: attention impairment • Smoker • Nicotine normalizes medication and makes voices in head seem like they are her own; also known to reduce stress and anxiety • Current medication: • Chlorpromazine Hydrochloride-Schizophrenia, Mania, Behavior Problems • Risperidone- Schizophrenia, Mania, Behavior Problems • Global Assessment Functioning (GAF) score: 30 • Behavior is considered influenced by delusions, hallucinations, or serious impairment in communication or judgment or inability to function in all areas

8. Angela’s Self Collage

9. Before therapy can begin…

10. LOTR Initial Assessment Findings • Client needs multiple verbal cues to stay on task • Slow initiation of tasks, slow to complete • Poor sense of self-awareness (strengths and weaknesses) • Little to no ability to generate an adaptive response, cannot meet expectations of self or environment (OA)

11. LOTR Initial Assessment Findings • Noted strengths • Motivated by hobby- gardening • Self-expression on collage, sense of identity • Can problem solve, but slow cognitive processing • Noted weaknesses • Needs verbal cues to stay on task, poor attention span • Closed off; weary of interaction with other people; guarded • Lack of safety/good judgment

12. OT Accommodations and Precautions • Accommodations: • Do not work in group setting, client is very uncomfortable with social interaction • Avoid approaching client suddenly, from behind, or in a manner that may be perceived as threatening • Do NOT whisper! • Avoid dark clothing, as client may associate this with hallucinations of the “Men in Black” • Do not argue or insinuate that the client is unintelligent • Prepare client for any anticipated environmental changes in advance, such as rearrangement of furniture

13. OT Accommodations and Precautions • Precautions: • Suicide precautions • No sharp objects in vicinity of treatment • Address suicidal ideations and experiences if client is comfortable, never avoid having related conversations • Medical non-compliance • Client is estranged from family and has no form of personal support system • Client has impaired memory

14. Theory Behind Interventions • Occupational Based Model: • MoHo • Uses occupation to provide increase of personal causation, reorganize habits and routines, and improve occupational performance capacity • Change occurs when there is a shift in one part of the person’s open systems cycle • Motivation is influenced by a person's interests, values, and a sense of personal causation. • Frame of Reference • Acquisitional- Toglia • Focus is to improve cognitive function: orientation, attention, visual, processing, motor planning, cognition, occupational behaviors and effort • Change occurs when self-awareness is increased and through practice of cognitive strategies within multiple contexts

15. Assessments • TCA: Toglia Category Flexibility Assessment • Requires that client is able to: • Follow two step directions • Discriminate between size, color, and form • Attend to a task for minimum of 15 minutes • Contextual Memory Test • Helps address memory capacity, strategy of use, and recall in adult clients with memory dysfunction

16. OT Therapeutic Goal: 1 • In order to improve client’s medication adherence, client will verbalize three reasons why she wants to stay on her medication by discharge.

17. OT Therapeutic Intervention: 1 • Complete a life time line of past (not on medication) and present (on medication) occurrences • Client must recall past occurrences that were maladaptive due to poor medication adherence, and then compare them to present functional occurrences in order to gain an understanding of the benefits of taking her medication.

18. OT Therapeutic Intervention: 2 • Client will work with OT to develop medication schedule. The schedule chart will have spaces for the client to check off each time the medications are taken. • The chart will also have a section for the client to document her emotional status each time she takes her medication.

20. OT Therapeutic Goal: 2 • In order to increase self-awareness, client will demonstrate ability to follow a 5 step checklist to complete a moderately difficult task by discharge.

21. OT Therapeutic Intervention: 3 • Client will use the OGI program to complete the appropriate steps to plant flowers in the Evangeline house garden. • Client must use the 5 step OGI checklist to assist her in monitoring her performance during the activity.

22. 5 Step Checklist 1. Stop and think! • Orienting and alerting to task • Initial discussion of interests and tasks the individual wants to work on; raises awareness of individual meaningful activities that will direct the choice of the task 2. Define the main task • Define the specific goal. This stage includes choice, definition, and goal setting 3. List and Partition goal into subgoals • Setting the steps to achieve the goal • Recording the process, steps, and required material • Estimating duration of performance

23. 5 Step Checklist (cont.) 4. Learn Steps • Encoding and retention, say the process by heart (the subgoals) • Perform the task 5. Monitor • Check and evaluate the outcome and the process • Compare the outcome with the goal definition • What kind of problems and difficulties did you meet or encounter? • What factors promoted or interrupted goal achievement (task completion)? • Are there alternative ways to carry out the task?

24. Schizophrenia Resources • National Alliance on Mental Illness • https://www.nami.org/ • www.namilouisiana.org : (225) 291-6262 • Peer-to-Peer Support Groups • Family-to-Family Support Groups • Recovery Support Groups • Schizophrenia Health Center • http://www.webmd.com/schizophrenia/default.htm?names-dropdown=OR • News, references, videos • Symptoms & Types • Diagnosis & Tests • Treatment & Care • Living & Managing • Support & Resources

25. Schizophrenia Resources • Substance Abuse and Mental Health Administration • http://www.samhsa.gov/ • Journal articles • Early, M. B. Mental Health: Concepts and Techniques for the Occupational Therapy Assistant. Lippincott Williams and Wilkins, 2008. • Toglia, J. P. (2011). The Dynamic Interactional Model of Cognition in cognitive rehabilitation. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 166-186). Bethesda, MD: AOTA Press. • Toglia, J. P. (1993). The Contextual Memory Test. Tuscon, AZ: Therapy Skill Builders. • Cole, M, & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: Slack.

26. Peer Reviewed References: • Bejerholm, U., & Eklund, M. (2007). Occupational engagement in persons with schizophrenia: Relationships to self related variables, psychopathology, and quality of life. American Journal of Occupational Therapy, 61, 21– 32. • Katz, N., & Keren, N. (2011). Effectiveness of occupational goal intervention for clients with schizophrenia. American Journal of Occupational Therapy, 65, 287-296. doi: 10.5014/ajot.2011.001347 • Gutman, S.A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C.A. (2009). Supported education for adults with psychiatric disabilities: Effectiveness of an occupational therapy program. American Journal of Occupational Therapy, 63, 245-254.