B760 Assessment In Mental Health Nursing

Case formulation or clinical formulation encompasses a theoretical based conceptualisation or explanation of the information gathered from clinical assessment of an individual. This formulation offers a specific hypothesis about the nature and cause of the presenting complaints of the patient and is also considered an alternative or adjunct approach for psychiatric diagnosis (Rainforth & Laurenson, 2014). In clinical practice, these formulations are generally for communicating a specific hypothesis. The formulation also provides frameworks that helps in the process of developing suitable treatment approaches. Most commonly used clinical formulations that are utilised in by psychological schools include systemic therapy, psychodynamic therapy, cognitive behavioural therapy, and applied behavioural analysis. In other words, case formulation will inform a choice of psychological treatment that will provide a bridge between patient assessment and guiding treatment options. The essay will discuss in details the clinical formulation for a 60 year old patient Jim (pseudonym). This clinical formulation will help in gaining a deeper understanding of the difficulties faced by the patient, which in turn will be synthesised from a plethora of clinical data (Johnstone & Dallos, 2013). Thus, the formulation will not only synthesis relevant information from psychological, biological, spiritual and social domains, but will also facilitate the synthesis of theoretical perspectives based on biological, psychodynamic, psychospiritual and interpersonal domains.  The CBT case formulation will comprise of 5 components, namely, presenting problems, predisposing factors, precipitating factors, perpetuating factors, and protecting factors.

Presenting problem

A presenting problem refers to the initial symptoms that make a person seek help from a psychotherapist, psychiatrist, doctor or other healthcare provider. Most patients are capable of tolerating some amounts of psychological or physical discomfort, before seeking assistance from it. Thus, the tolerance levels varies across different individuals. The case study being discussed in this essay is that of a patient Jim (pseudonym), aged 60 years. A pseudonym is used for the patient with the aim of maintaining confidentiality. Some of the problems presented by the patient include intellectual disability. This presenting complaint generally encompasses problems that are related to impairments, thereby affecting the functioning of two major areas such as, adaptive functioning and intellectual functioning. This results in difficulties in learning, judgment, communication and problem solving. This was established by the fact that Jim faced difficulties in understanding. Presenting complaints of the patients also include the fact that he gets agitated when anyone touches his money and also grows suspicious of them. An analysis of the patient and his presenting problems, based on the DSM-V criteria indicates the presence of paranoid personality disorders (F60.0). Diagnosis of this disorder is primarily influenced by the presence of symptoms that relate to distrust and suspicion of others in the patient.

The DSM-V criteria, published by the American Psychiatric Association is a diagnostic and taxonomic tool, which serves as the main authority for diagnosing psychiatric illness (American Psychiatric Association, 2013).  Research evidences suggest that this disorder is primarily characterised by paranoia that refers to a thought process that is greatly influenced by fear or anxiety, often to an extent that results in irrationality or delusion among the sufferers (Triebwasser et al., 2013). This disorder is manifested by beliefs of conspiracy or persecution that are associated with perceived threats towards a person (Bateman, Bolton & Fonagy, 2013). There is mounting evidence to support the fact that patients suffering from paranoid personality disorder might become hypersensitive, get easily insulted and might also habitually relate to the outer world by conducting a vigilant scan of the environment (Anderson et al., 2014). This helps in providing them clues that validates their biases or fears (Bateman, Gundersonn & Mulder,2015). Furthermore, the fact that the patient Jim grows suspicious of people surrounding him, when they touch his money can be correlated with the symptoms of this disorder that makes the patients suspicious and guarded, which in turn results in a constricted emotional life. This reduced capacity for emotional involvement and isolated withdrawal results in schizoid isolation (Gunderson & Sabo, 2013). Thus, the DSM-V criteria recognises the condition as paranoid personality disorder.

Predisposing factors

These factors refer to risks that increase the susceptibility of an individual from suffering from specific mental disorders (Townsend, 2013). Thus, predisposition increases the likelihood of development of a mental illness. An assessment of the case study indicates that the patient does not have any familial history of any forms of personality disorders. Jim grew up in an orphanage, for ten years and was transferred to different foster homes. This disturbed childhood resulted in a broken trust. Evidences exist that establish a close association between mistrust, damaged relationships and mental illness (Keyes et al., 2013). This aggravates in the form of manifestation of psychiatric disorders and makes it difficult for the affected person to rebuild the trust. One major predisposing factor is related to incidents of bullying, harassment and vicitimisation that the student had faced at 6 years of age, in school. Childhood bullying can have severe impacts on the mental health of a person. Recent studies suggest that children who have suffered frequent bullying are more likely to develop psychiatric disorders, compared to their non-bullied counterparts (Kelleher et al., 2013). Scientists have provided strong evidence that being harassed or bullied as a child puts all the affected children at higher risks of depression in their adulthood. Victimisation or bullying have been suggested to significantly contribute to paranoid ideations among bullied people, who present an ultra-high risks of psychosis (Scott et al., 2014).

Furthermore, previous research studies also found that victims of bullying often suffer from suicidal thoughts, thrice more than other children (Litwiller & Brausch, 2013). The patient also did not have any formal schooling and no work experience. This can be correlated with evidences that establish strong correlation with family disruption and unemployment with onset of paranoid personality disorder symptoms (Hengartner et al., 2014). Thus, it can be stated that long-standing patterns of suspiciousness and mistrust of others, that occurred due to some childhood incidents made Jim more vulnerable to development of this disorder.

Precipitating factors

This is an umbrella term that results in the occurrence of a mental disorder. Thus, they refer to specific events that trigger the onset of the diagnosed mental disorder (Layous, Chancellor & Lyubomirsky, 2014). The paranoid symptoms get aggravated at instances when other people try to touch his money. This makes Jim agitated and he feels anxious of losing his money. This can be attributed to the fact that childhood instances of bullying and harassment resulted in the development of mistrust towards all people (Schuster et al., 2013). This signifies lack of engagement with the society. Failure to understand the motives of these people, due to the persistent intellectual disability also makes Jim manifest his paranoid symptoms. This shows consistency with previous findings that have suggested that paranoid personality disorders involve a negative social representation of the surrounding people. Furthermore, people suffering from non-clincial paranoid disorders have also been found to demonstrate biases in their social and cognitive functioning. This fact is established by supporting evidences that individuals suffering from this disorder often demonstrate more perceived blame and hostility towards ambiguous social situations that might have been experienced earlier. Such patients have also been found to report less social engagement and fewer social contacts, which in turn contributes to problems in their social skills and perceptions (Lopes, 2013).

In addition, the precipitating factor that Jim has poor communication skills can be related to evidences that have formed a strong correlation between ineffective communication skills, disordered thinking and this personality disorder. Owing to their lack of purposeful and meaningful communication, these people fail to develop and accurate impression of the way by which they get along with the individuals surrounding them (Ovejero et al., 2014). Thus, it can be stated that the bullying and harassment suffered at childhood, and multiple transfers across foster homes that resulted in developing mistrust, created a negative impact on the precipitating factors, which encompassed fear of having his money stolen. Thus, it can be suggested that the patient Jim met some of the DSM-V criteria that resulted in diagnosis of the disorder. The aforementioned precipitating factor can be related to the diagnostic criteria that these patients are reluctant to confide in others, owing to their unwarranted fear. Furthermore, the criteria that pertain to presence of suspects without basis related to suffering exploitation of harm from others, and being preoccupied with unjustified suspicions and doubts about the trustworthiness and loyalty of associates or acquaintances. A disturbed childhood, stay at foster homes and incidents of harassment all contributed to the development of the precipitating factors that further worsened the condition (Laulik et al., 2013).

Perpetuating factors

In the context of case formulation, these refer to factors that makes a condition endure such as, its severity, compliance issues and predisposing or precipitating factors that are unresolved (Treasure & Schmidt, 2013). Isolation has been identified as one of such perpetuating factors that aggravated his mental condition. Social isolation and detachment encompass the state of near-complete or complete lack of contact between an individual and the community or the society (Cacioppo & Cacioppo, 2014). This is quite different from loneliness, where the affected individual manifests a temporary lack of contact with others. Several researchers have confirmed the fact that people suffering from paranoid personality disorders often display a heightened sensitivity towards the words and actions of others that confirms their belief of being prone to imminent danger (Tyrer, Reed & Crawford, 2015). This is further associated with the tendency of isolating themselves from the community or society, followed by display of hostile attitudes towards people who threaten this isolation, such as, friends, family and partners. A distrust towards others and continuous suspicion towards the actions and intentions of the surrounding people eventually makes the sufferer or the patient appear distant and cold, constantly challenging the loyalties of the acquaintances (Hanafiah & Van Bortel, 2015). This subsequently results in social isolation, as the patient might stay at home, planning the way by which a perceived attack of danger can be confronted.

Thus, the fact that Jim is socially isolated and fails to understand other people makes him incapable of recognising his negative feelings. These perpetuating factors in turn, aggravate the mental illness and results in a failure of the patient to confide in others, due to fear of betrayal, or lack of trustworthiness. Inability to communicate properly with is another perpetuating factors that increases the severity of the paranoid symptoms (Sperry, 2014). Researches have been successful in stating that any attempts of communication are most often rejected by such patients as the sufferers become reclusive. This is generally manifested by the individual living in voluntary seclusion from the society and the public. Research studies state that people with such disorders are reclusive, and organise their lives in a way so as to avoid contact with other people (Boumans et al., 2015). Various researchers have identified insular paranoid features among such individuals that correspond to avoidant, reclusive, hermitical and self-sequestered features. Thus, it can be stated that isolation, and lack of communication have increased the severity of the diagnosed condition.

Protecting factors

These encompass characteristics that reduce likelihood of suffering from poor mental health, either on their own, or in the presence of several risk factors. These might be considered as strengths that provide assistance to the sufferers to maintain their mental wellbeing (Layous, Chancellor & Lyubomirsky, 2014). The protective factors in the case formulation of Jim are related to his adherence to the daily plan day structure. These activities are generally related to the self-care activities that commonly include feeding, bathing, grooming, and dressing. The daily plan structure also comprises of homemaking, leisure and cleaning oneself after defecating. The fact that the patient Jim is able to conduct these daily activities without any assistance help in establishing the fact that the intellectual disability and lack of understanding due to paranoid symptoms have failed to create any negative impact on activities of daily living. Persistence of paranoid symptoms for some time often makes these individuals to become disconnected and secluded from the general aspects of daily living (Jekel et al., 2015).

Though not intentional, such actions that stem from uncontrolled paranoid personality disorder can make the patients self-destructive and result in subsequent damage of all responsibilities. However, the fact that Jim shows compliance and consistency with his care plan and successfully executes daily activities, significantly contribute to preventing further deterioration of his mental health and wellbeing. Furthermore, research evidences suggest that such patients often show compliance and adherence to the instructions of the healthcare professionals, on reasonable request (Kane, Kishimoto & Correll, 2013). Thus, following the instructions suggest development of trust on the healthcare professional, thereby suggesting an improvement of the paranoid symptoms.

Recovery oriented process

The use of a structured day plan is one major step towards recovery of the patient that has proved effective in symptom stabilisation (Cavanaugh, 2014). Presence of a structured life style will support the activities of daily living and will also facilitate in reducing free time. Reduction in free time will directly result in a decrease in suspicious thoughts. Use of a simple language for communication is another recovery approach. This can be attributed to the fact that patients of paranoid personality disorder find it extremely difficult to express themselves, thereby failing to provide an insight into their experiences and feelings (Thomas et al., 2017). This also results in a rejection in communication attempts made by others. Use of simple communication language will help in the establishment of a general level of trust, and will also allow the patient to understand the intended meaning of the words being spoken. An effective communication that encompasses active listening and understanding of the patient’s point of view has also been found effective in reducing symptoms of hostility and suspicions towards others (Videbeck & Videbeck, 2013).

Use of pictures are an effective communication tool that will allow the patient to get a deeper understanding of the behaviour that is expected from him. Picture exchange conversation will provide Jim more opportunities to communicate (Amit, Wakslak & Trope, 2013). Assisting him with certain daily activities such as, showering and feeding will instil his faith in the surrounding people, thereby reducing the persistent symptoms of mistrust. Owing to the fact that Jim loves music, it should also be incorporated in his daily routine in the form of leisure activities. Jim will also be made to go to the café every day. This will increase his social interaction skills, and reduce long-standing isolation and mistrust. An engagement with activities that involve his favourite music will reduce ill feelings of paranoia. This can be established by the fact that there are strong implications for involvement in leisure activities with the personality of an individual (Bakker et al., 2013). Furthermore, the recovery process will also encompass evaluation of the primary objective of eliminating all chances of bullying or harassment, which were the main predisposing factors. Older adults are often subjected to abuse in their homes or healthcare settings, within relationship that involves an expectation of trust. A close surveillance will help in preventing all instances of being subjected to bullying, thereby reducing symptoms related to agitation or aggression. In addition to these, appropriate psychotherapy and antipsychotics should also be administered, when Jim becomes receptive to intervention.

Conclusion

To conclude, the patient Jim has a mental disorder that is characterised by pervasive suspicion and mistrust of others that have been triggered by instances of harassment and bullying in his childhood, in addition to a disrupted family life. Thus, efforts must be taken to formulate a recovery approach that focuses on effective communication, assistance with daily activities, recreation therapies and vigilant scanning to prevent clues in the environment that might validate his biases and fears. Thus, it can be concluded that there is a need to look for threats and signs that might be perceived as potentially dangerous by the patient.

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