Psychiatric

In-Class Case Study 2

Mr. and Mrs. Lahud have come to the clinic to initiate family therapy. The whole family is under stress because their youngest daughter, 10-year-old Elia, loses her temper "almost constantly," the parents say.

 

"In fact, she seems to be always seething under the surface, even when she's laughing and seeming to have a good time, just waiting to explode. She argues about the simplest things you can try to give her choices, like, instead of saying, 'time to get dressed for school,' you might say, 'Elia, do you want your green sweater or your yellow one today?' She just starts screaming and says, 'You can't tell me to get dressed!' And she's ten."

 

Jaival, their new therapist, asks, "Can you tell me how often, on average, you'd say Elia loses her temper? Can you make an average guess at, say, how many times a week?"

 

Elia's mother says, "It would be easier to estimate how many times per day."

 

Mr. Lahud nods, "Yes, I'd say about 18 times a day, at least once for every hour that she's awake."

 

"And that's on a daily basis?" says Jaival.

 

Both parents nod without hesitation.

 

"How long has it been like this?"

 

"Well," Mrs. Lahud tilts her head. "She was always kind of a fussy baby. She's never slept much and has just kind of always thrown tantrums and never stopped."

 

Jaival takes some notes and then asks, "Is there anything else about her behavior that fits a pattern that's fairly long-standing?"

 

Mr. Lahud sighs. "It just feels like she wants a big fight, then blames everyone else for something that she started-even when it's clear no one else is even participating in the fight. It's getting to be really hard on the other two kids because she just never lets up from the time she wakes up until late into the night; she tries to annoy us and them pretty equally, and now they're having trouble with her at school too. She's not getting along with other kids there either.

 

"We've tried positive reinforcement, like a sticker chart for good behavior—"

 

"-but after a while," Mrs. Lahud adds, "We just took it down. The other two kids would have rows of stickers, but she defies even the simplest of rules, so she'd have maybe one or two stars to their eight or ten. It started to feel like the sticker chart was just making her feel worse about herself. Her teachers say the same thing."

 

Mrs. Lahud's eyes fill with tears. "We don't know what to do anymore. I feel sorry for her. We can't help feel that this is not the 'real' her if you know what I mean."

 

She looks at her husband, who nods and squeezes her hand.

 

"She does some pretty mean, spiteful things to 'get even with everyone.'" Mrs. Lahud continues, "but then the other night, she was quiet and thoughtful when I cuddled with her at bedtime, and while we were alone, she whispered, 'Mom, why does it have to be so hard to be good? It's really hard.'"

 

She breaks down and cries, and her husband hugs her.

1. Jaival meets with Elia subsequently, and though she is very charming and intelligent at first, she does make an effort to annoy him, but he doesn't take the bait. The next day, with her parents' permission,      the school counselor also calls Jaival, asking if she can share some concerns of her own, which confirm for Jaival that Elia's parents have pretty accurately described her behavior. Subsequent testing does not      reveal a psychotic or mood disorder, and Jaival initially makes a      tentative diagnosis of "oppositional defiant disorder." Do you agree or disagree? What criteria would you cite to support your opinion?


2. What can cause oppositional defiant disorder?


3. Over a period of years, Elia continues to see therapists; and as adolescent hormones are added into the mix, times get a little rougher for her and her family. What kinds of comorbidity might she be at risk for?

 Case Study # 3 with Rubric

Evan is a psychiatric nurse working on an inpatient floor in a general community hospital. Mr. Girardi has been in a car accident, which has landed both him and his daughter in critical care. Because of Mr. Girardi's extensive injuries, his physicians prescribe that he be put on light sedatives that do not induce coma but keep him sleepy and calm. They simultaneously decide to not immediately inform him of his daughter's critical condition. The rationale for both decisions is their concern that he not cry, which would cause extended damage to his perforated lung. Mr. Girardi is kept drowsy and motionless and as pain-free as possible. He has asked about his daughter, but when told that the staff will check on her, he is satisfied with that and drifts back to sleep.

 

Mr. Girardi's wife arrives to stay with him. It is 3:18 a.m., and Evan has just administered Mr. Girardi a sedative through his IV set. Mrs. Girardi tells Evan that her husband took his last "kidney stone pill" at 6 p.m. with his dinner before he and his daughter left the house. "He's overdue for that kidney stone pill," Mrs. Girardi says. "He's not supposed to skip that."

 

Evan says, "He shouldn't take anything else right now, but I'll check that out." She assures Mrs. Girardi that she'll ask the doctor about that and leaves the room.

 

Fifteen minutes later, Evan returns, explaining that she consulted with the hospital surgeon, who checked with Mr. Girardi's urologist. The urologist confirmed that the "kidney stone pill" was a painkiller, which, under the circumstances, should be discontinued as long as Mr. Girardi is on the more powerful IV sedatives.

 

"Oh, that's okay," Mrs. Girardi tells Evan. "He woke up a bit while you were gone, and I was able to give him his pills."

 

Mr. Girardi suffers moderate complications from the IV sedative and oral analgesic combination, which extends his hospital stay by 2 days. The Girardis feel the hospital should have been in better control of the overdose, saying that if the staff had been on top of things and supervising more closely, this would not have happened.

1. In the case of Mr. Girardi, do you think this case is most concerned with a cause, in fact, proximate cause, or foreseeability of harm? 


2. Explain your rationale for your answer to Question      1. Include scholarly evidence to support your answer.