Mental Health Case Study

This case study explores the mental health of a patient named Calvina who suffers from mental breakdown and depression. It covers her demographic profile, mode of referral, presentation, past psychiatric history, forensic history, substance abuse history, family psychiatric history, medical history, social history, physical assessment, mental status examination, formulation, and management.

MENTAL HEALTH CASE STUDY
Introduction
The study is a mental health of a patient by the name Calvina (not real name for purposes of
protecting the patient’s identity and ensuring privacy) who suffers from mental breakdown and
depression.
Demographic profile
Ms. Calvina is 31-year old, recently unemployed after suffering mental breakdowns at her work place
repeatedly. She lives alone at Baltimore country penthouse after severing ties with her partner of 6
years.
Mode of referral
Ms. Calvina was working a consulting and logistics company, before she was fired due to her
psychotic characters. She started making lots of errors with her work and get depressed while at work
which led to her output reducing considerably. Her family and friends took her to Baltimore county
Hospital for Mental Therapy where she has been receiving immense help.
Presentation
Since Calvina was taken to the county mental health hospital by family and friends, she has been
staying there receiving the treatment required. She was diagnosed to be suffering from borderline
personality disorder (BPD). Calvina exhibited various symptoms including anger, anxiety, difficulties
in concentration, emotional impulsivity, suicidal thoughts, mood swings and self-injuries.
Past psychiatric history
Ms. Calvina has no history of suffering from mental illnesses. As family members have reported she
has never been diagnosed with any mental related illnesses. The only history the hospital of Baltimore
has is that mother died by killing herself, when Calvina was 12 years old. She had been suffering from
Schizophrenia and had been taking medication. Her mom died of drug overdose. The psychologists at
the mental hospital concluded Calvina might have inherited the mental disorder from his mother.
Forensic History
There is no forensic history of Ms. Calvina available.
Substance abuse history

Calvin has never used narcotics in her life. But it was reported that a few weeks ago she started taking
antidepressants.
Family psychiatric history
Ms. Calvina’s only reported mental illnesses in her family tree is her mother. Her mother suffered
from schizophrenia for a very long time as reported. She used to indulge in binge drinking and
inflicted injuries to herself. Calvina’s father is reported to have been missing in action throughout
Calvina’s life. It is reported that her mother and father parted ways while her mother was still
pregnant and never came to see his daughter.
Medical history
Calvina has no medical history since she has never been diagnosed with any mental disorder before.
She’s been taking antidepressants bought from the local drug sellers.
Social History
Calvina has no siblings since she was the only child of Mary Routledge and Elvis Chandler. It is
reported the Calvin has a normal and happy relationships with people surrounding her including her
maternal granny, best friend, Clara and co-workers. She spent her childhood staying with her mother
and grandmother and so it is reported that she must have watched her mother’s psychotic behaviors
including binge drinking, self-cutting her hands and wrists. At the age of 12 she witnessed the death
of her mother after taking an overdose of ecstasy drugs.
Physical assessment
Some of the physical signs observed by doctors at the Baltimore Hospital includes; increased heart
rate and blood pressure. This was because of emotional imbalance which triggered overreaction and
thus increased heartbeat rate and blood pressure. She also exhibited mood swings where at one time
she could be nice and cool and at other times she could get so angry at anybody and anything for no
reason. Doctors conducted various tests. They took her urine and blood samples for comprehensive
screening.
Mental status Examination
Appearance: slim Caucasian female looks her age, wearing blue denim tight denim jeans with
maroon top, nicely kempt long hair held in ponytail shape. Her face her no make-up, showing some
mosquito bites.
Behavior: Calvina wore a calm facial look. Other than showing restless behaviors at times, she
displayed no abnormal tendencies usually associated with mentally people. Was very engaging and
observant while talking to doctors.
Speech: She sounded calm and composed when talking and answering questions to doctors.

Mood or Affect: She looked depressed and uneasy at times.
Thought form: Disorder was evident due to her mood changes and restlessness.
Thought content: She seemed angry but at no one in particular, sometimes.
Perception: Calvina said that she could hear voices urging her to throw her herself through the
window at her now former workplace, jump in front of moving vehicles and had conflicting reactions.
Cognition: she had no problem with cognition abilities.
Insight or Judgment: she had experienced poor situational judgement tendencies.
Risk issues: from her assessment she sounded danger to self and risk of worsening of her
psychological state.
FORMULATION
Awarding problems
Ms. Calvina was released and a team of doctors and mental health practitioners was formulated to
monitor his behavioural and mental state for a period of one month.
The doctors observed that Calvina was showing tendencies of being an introvert. This character was
disputed by his peers, co-workers and grandma. Her introvert behaviours, were consistent with other
studies done throughout the whole of the United States. Patients who were suffering from BPD
disorder seemed to dislike company and kept to themselves.
It was also established that Calvina had developed poor eating character. She seemed never to mind
her dietary needs. This is brought by depression which reduces one’s appetite.
Calvina also seemed to be fond of injuring herself. Her hands and wrists had marks and scars of cuts
probably caused by herself.
Predisposing factors
Calvina was thought to be a health kid who had grown in a very conducive environment in the care of
her mother and grandmother. It is established that she has never had a chance to meet her biological
father but her mother introduced her to a few partners of hers while alive. She must have witnessed
problems her mother passed through while tackling schizophrenia.
Precipitating factors:
Calvina started suffering from the Borderline Personality Disorder while working in the consulting
and logistics company in Baltimore. She lost concentration and focus while at work and had thoughts
of jumping through the window of her working place.
Perpetuating factors:

She has been using antidepressants when she got depressed which have impacted her negatively
health wise.
Protective/Positive factors
Calvina has never experienced this BPD symptoms, they started when she broke up with her long
term boyfriend. She started becoming depressed, angry at herself, restless and become hostile to co-
workers and friends both at work and home. She was advised by friends to seek mental psychological
assistance but instead opted to use over the counter antidepressant drugs. This might have worsened
his condition.
Management
Pharmacological management: Calvina’s was managed by various treatments and physiotherapy
and psychological applications. Jon pharmacotherapy comprised of Omeprazole 20 mg mane,
Clozapine 450 mg nocte, Gliclazide 60 mg mane, Vitamin D 1000 IU and Metformin 500 mg BD.
Psychological management: Thereafter Calvina seemed responsive to this drugs and her condition
greatly improved. She was even motivated to take yoga lessons in order to improve his physicality
and appetite. She was also motivated to become a community organiser for people with mental
disorders.