The patient M. is a 26 year old married female who was brought to the ER by her husband after increased anxiety and depression worsened after a “spiritual attack” that lasted for over four days. While in the ER the patient admitted to hearing multiple distant male and female voices all around her head and outside of her head. She states not being able to make out the message but interprets them to be negative in nature. She told the ER Doc she felt people were trying to harm her and that “people in her life have used things against her.” She felt her extended family may have used witchcraft and “chakra dolls” to cast spells on her. She is cognizant of the strangeness of her claims but believes them to be real nonetheless. Past Medical/Psychiatric History
Her current hospitalization on 9/22/12 was preceded by her first ever admit to any psychiatric unit on 9/11/12. Worsening depression and anxiety with the arrival of psychosis: auditory, visual hallucinations and paranoid thoughts caused her to seek treatment on 9/11. Her first inpatient stay was cut short because a medical workup by HMS detected a pulmonary embolism. She was transferred to a medical floor, where she was treated with warfarin and coumadin until her INR levels reached a normal range of 2.4. She has since been transferred back to the inpatient psychiatry service for continued treatment of her psychosis. She has been treated for bipolar, anxiety and OCD. She has history of attending marriage counseling with her husband. M. has a history of chronic back pain that caused her to take leave from her job as a librarian. She has been unemployed for two years. Her pain was initially treated with opiod painkillers, which she later became addicted to. She attended rehab in 2008 and completed detox from opioid painkillers. She attributes her recent exacerbation of anxiety to an increase in her back pain. The current episode of paranoia and delusions that caused her to seek treatment on 9/11 is new for her. Nursing Focus
My overall impression was that she seemed anxious, apprehensive and highly fearful. The immediate priorities for her nursing care are environmental/physical safety nutrition/fluid intake, and psychosis symptom management. Once these are stabilized, we can move into working at acknowledging and normalizing her fear as well as identifying how she can develop new effective coping strategies. Epidemiology
According to the WHO World Health Report 2007 depression is very common and considered one of the oldest clinical mood disorders responsible for morbidity worldwide. Approximately 20.9 million American adults aged 18 or over experience depression at some point in their lifetime. Major Depression is the leading cause of disability in the United States for ages 15-44 (WHO, 2007.) It affects men women and children worldwide, while crossing all cultural and socioeconomic groups. Men are at lower lifetime risk for experiencing a major depression, 7-12% compared to women, 20-30% (Stuart, 2012, p.291). Pathophysiology
Depression is caused by multifaceted exchange between biology, psychological and sociological factors. A few different models define this dynamic. The biopsychosocial model explains depression through the interplay of biological, psychological and social factors which combine and together are responsible for causing depression. The stress model specifies that some people have preexisting genetic vulnerability, or tendency, towards depression that is activated by stressful life events. The Monamine Hypothesis suggests that depressed people have overproduction of the enzyme MAO-A which causes lower levels of monoamines (Porth 1371). Most agree that brain chemistry plays a significant role in depression as evidenced by neurological changes seen on the brains of depressed people. PET and MRI scans have shown a reduction in gray matter and decreased activity in the prefrontal...