Case Study Description
The patient in question, whom we will call Mrs. Renfrew, was a 72 year old woman who presented to the emergency department following the onset of various psychiatric symptoms. These included both auditory and visual hallucination. These hallucinations generally had a religious preoccupation, involving Mrs. Renfrew’s role as a “judgement maker” and giver of punishment. Her hallucinations most commonly involved adult male child molesters, for whom she had to stop. Additionally, she had various hallucinations involving seeing bugs or oil in her room, which she would attempt to clean. Mrs. Renfrew had incredible insight into these hallucinations when looking at them in retrospect. She was able to identify logical inconsistencies (such as being unable to touch her hallucinations) which would allow for her to identify situations as legitimate or false.
However, when Mrs. Renfrew was in the depths of a hallucination, she had a difficult time determining the legitimacy of the situation. At that point, she would become aggressive, believing that she needed to handle the situations put before her. She would then proceed to wander around her current living situation (or hospital ward), attempting to stop the actions occurring in her hallucinations. This would lead to increased risk of Mrs. Renfrew getting disoriented and potentially venturing into an unsafe environment. Also, she would confuse real individuals with those of her hallucinations, leading her to physically and verbally lash out at caretakers and hospital staff. This situation was all compiled atop a previously existing history of significant short-term memory loss (Barnes, 2014).
Social Significance
Due to the patient’s abnormal behavior, it became difficult for her to interact socially with strangers. Her behavior put a strain on her relationship with her husband and children, as they were less understanding of her psychiatric diagnoses. Even in cases where people knew of her condition, Mrs. Renfrew’s aggression and hostility made it increasingly difficult for her to achieve significant human interaction.
Target Behavior Definition
The target behavior in this case is that of Mrs. Renfrew’s continued interaction with her hallucinations. The presence of her hallucinations may cause her distress, but in her attempts to interfere with the actions of these situations, she makes it increasingly difficult for those around her to properly manage her care. Her specific behaviors which need to be addressed include primarily aggression towards individuals present at the time of her hallucinations. She is verbally threatening to caretakers and staff as she is unable to discern reality from fantasy. Secondly, her high levels of functional mobility and spirited enthusiasm make her more likely to venture into unknown areas in an attempt to interfere with her hallucinations. Mrs. Renfrew’s care needs to focus primarily on discerning reality from hallucination, providing appropriate redirection, and giving her adequate memory cues to function until her hallucinations end (Weinberger, 1993).
Outcome Criteria
In order to properly manage Mrs. Renfrew’s care, we must outline a functional plan that can be put into place in any living situation she may be involved in. First, it is key to notice Mrs. Renfrew’s degree of retrospective insight. She is accepting of the suggestion that things she sees may not be real. She admits to seeing things, then following her statement with, “but that might just be a hallucination.” This leads us to believe that a social companion may benefit Mrs. Renfrew’s overall functionality. In order to put this in place, we must arrange for Mrs. Renfrew to have either a hired sitter/caretaker that can be present at all times. This caretaker would be responsible for noting abnormal behavior in the patient, and pointing that out to the patient actively. Based on past reactions, we can assume Mrs. Renfrew would be accepting of an individual identifying her hallucinations, decreasing the amount of time in which she would attempt to discern the level of reality of what she was seeing. Also, with a caretaker present, it would be substantially less likely for Mrs. Renfrew to wander off, as she is easily redirectable.
On previous attempts, it is relatively easy to direct the patient into a certain physical location, leading with an explanation of her current situation. This also is in addition to her significant memory issues, which need to be addressed. Because the patient has short-term memory loss, she continuously forgets her logical reasoning that is used to discern hallucination from reality. She commonly confounds her stories in order to make her memory loss seem less substantial. Therefore, it would be helpful for Mrs. Renfrew’s caretakers to provide her with memory cues which she can frequently access. For example, it would be helpful to provide the patient with a notepad and pen.
This would allow the patient to physically write down realizations she has come to, such as writing, “the bugs are not real.” In addition to the finite existence of these notes, she can be reassured by the fact that her memory cues will have been written in her own handwriting, thus confirming that these notes came from a reliable, trustworthy source. Overall, Mrs. Renfrew’s treatment plan needs to focus mostly on providing frequent, consistent reassurance (Desai, 2001). Therefore, she must have a constant companion that is able to communicate with her and is open to discussing her psychiatric issues. This person would be key in both reassurance, safety, and providing help in implementing her memory cues (Dobbins, 2012).
