Cat Is A 21-Year-Old Woman Who Is Superficially Known To Mental Health: Physical Health Care In Mental Health Case Study, CSU, Australia

Cat is a 21-year-old woman who is superficially known to mental health and emergency services for self-harm and suicide attempts. She is estranged from her family and is currently living in a share house with other young people. Cat presents with a diagnosis of borderline personality disorder. It has occurred in the context of Cat smoking methamphetamine most weekends over the last six months, which has led to poor sleep and her engaging in casual, unprotected sex.  She states that she is not worried about pregnancy because she has not had her period for over a year.

It is based on having experienced sexual abuse during childhood, which has triggered a response to interpersonal stress, and in her mid-teens started self-injuring.  She states that she used to be fat (around 60kg ~ last year). Her current weight is 43kg (height 159cm). She states that she does not think about food when high, and about mid-week, she sometimes becomes ravenous and binges on McDonald’s. She then feels guilty and induces vomiting. She often feels quite dizzy when she stands up, and she feels her heart pounding in her chest. Her flatmates are worried about her as she has fainted on a couple of occasions.

An extensive history is unavailable currently, although perpetuating factors include ongoing and increase the use of methamphetamine, poor sleep, engaging in unprotected sex, binging on take away food and purging, amenorrhea and postural drop when standing. Cats strengths are that she is currently living in a share house with peers her age who are concerned and can support her. The gaps include Cat having no insight into the sexually transmitted disease and unwanted pregnancy regarding her casual, unprotected sex; how the lack of sleep, binging and purging can affect mental and physical health and the fact that she suffered sexual abuse during childhood has led to her low self-worth. Cat’s risk status is high for suicide due to no active safety plan, limited reasoning ability and self-control when distressed. Her vulnerability and lack of judgement due to methamphetamine use leading to impulsive behaviour of casual, unprotected sex and the fact that she is underweight due to her eating and purging habits which is a concern that she is developing an eating disorder. Her self-care is deteriorating due to her increase in methamphetamine use, poor sleep leading to mood intolerance and impulsivity, and nutrition intake along with her purging.

The focus would be to treat Cat’s eating disorder first due to her BMI being 17 and placing her in the underweight category. A full pathology to view serum electrolytes that can precipitate the re-feeding syndrome can cause arrhythmias, seizures and potentially death. A dietitian can provide education for meal planning and nutritional care in the re-feeding phase. The choice of treatment would be to use a family-based approach to the eating disorder. Due to family dynamics, cognitive behaviour therapy could address eating behaviour and poor self-image. Alcohol and other drug services (AODS) to assist Cat with her methamphetamine use and a referral for Cat to have a dental check-up.

The outcome of the assessment was discussed with Cat.  She accepted that referrals would be made to the following: a dietitian (which would allow for 20 sessions at Medicare rebate, one session per week); individual cognitive behaviour therapy to begin with (5-20 sessions over 12-20 weeks, the GP has requested the full 20 sessions); alcohol and other drug services (AODS) and regular follow-ups with her GP; encourage Cat to see a dentist due to the damage the methamphetamine use, and purging can have on teeth and mouth hygiene. Cat stated that she was willing to engage.

A dietitian prescribed a gradually increasing diet for Cat, and she is receiving ongoing support in increasing her dietary intake to improve her physical health and weight. Weekly weighs, physical assessments, and follow-up with the dietitian has led to an increase in Cat’s weight. Her current weight has moved her out of the underweight category of the BMI. Cat has attended six sessions with 14 sessions that she will continue.

Cat has attended cognitive behaviour therapy during her re-feeding regime and focuses on formulating a safety plan. She has discussed ways to increase her self-image and improve relationships with the possibility of restoring her relationship with her family. Dealing with her mood changes, Cat has since joined an aerobics class at her local gym. There has been positive feedback from Cat after her fourth session regarding CBT; although they have been challenging and confronting, Cat stated that she would continue to engage.

Cat has contacted AODS, psychoeducation was provided, and she is currently working on her methamphetamine use. Although she has not ceased the use of this, she has cut down; she continues to have ongoing contact. Cat informed her GP her moods and sleep have improved since she has joined her local gym. Cat has had a screen done for sexually transmitted disease by her GP, which returned clear, and her GP has had an in-depth conversation with her regarding sexually transmitted diseases and the high risk of pregnancy; to which Cat agreed to use protection when engaging in sexual activities and was commenced on contraception. Cat advised the GP that she has been to see a dentist and no permanent damage has been done to her teeth enamel, and she will continue with regular follow-ups, her next one being due in 6 months.

Dion is a 55-year-old man who feels his life has not gone to plan. He has spent most of his life working laying concrete and had a reasonably successful concreting business. He employed a couple of labourers, and his wife Joan of twenty years managed the office and kept the books. A construction downturn and poor management meant he has recently had to close his business, and he has sold it for less than he believes it is worth. Dion does not know where to start or what to do.

Dion has presented to his general practitioner (GP) post a liver function test with elevated AST & ALT, triglycerides are up, and hypertension. It has been explained to him that further diagnostic testing is required to determine the exact condition, for the present he has been advised to stop smoking (20 per day) and drinking due to the induced organ damage (Kong et al., 2019). This is based on a history of depression and various comorbidities, including smoking, alcohol consumption, impotence, gambling, a decline in nutritional intake, and relationship breakdown.

He was physically active for most of his life – playing footy as a young adult and going fishing on weekends. His last few years of work were tough as he acquired a lower back injury which confined him to the office. Always a drinker at the end of the day, he began starting the day with a beer and would consume a cartoon of beer before “knock off” time. He visited his GP, who prescribed him Zoloft 150mg mane. He does not feel any better, and no longer goes fishing. Dion has reduced his alcohol intake somewhat at Joan’s request as she thinks it is affecting his sexual performance.

Dion cannot seem to get an erection at all. Joan says that she has had enough of him moping about the house. She has decided to take “time out” from the relationship and stay with her sister in another town until Dion sorts himself out. Dion is quite depressed and spends most of his day at the pub playing pokies. Since Joan had left two weeks ago, he has not had a home-cooked meal.

Treatment for Dion at this time would include education and support through alcohol and other drugs services for his alcohol consumption and tobacco use. As alcohol and drug use assessment show that Dion’s pattern is binge drinking rather than regular drinking, it is recommended that he be treated as an inpatient during this time due to the life-threatening nature of its effects of seizures and delirium (AIHW, 2020).

He is also a heavy smoker (20 per day), and his efforts to discontinue tobacco use have been futile; a quit pack has been given to him, and the use of pharmacotherapy such as nicotine patches and gum have been discussed and agreed upon for use(Zwar et al., 2014). He was prescribed Zoloft 150mg mane by his GP for depression but did not feel better, and it has affected his sexual performance, which is a common complaint with some antidepressants; the GP has since changed the medication to Mirtazapine and explained this to Dion (Shoshany et al., 2017).

This has occurred on the background of an acquired lower back injury which prevented him from performing his usual activities of employment as a concrete layer (Fenner, 2013); the close and sale of his business due to a construction downturn and poor management, and a situational crisis of his wife leaving him until he has sorted himself out.

The GP discussed the above outcome in the presence of Dion and explained that the following referrals would be made for him: alcohol and other drugs services to address his alcohol intake and tobacco use; contact information to reach out to Gambling Queensland for education and support regarding his recent involvement in the pokies; a 5 x 60-minute sessions with a Pilates instructor to assess and assist Dion in the way forward with exercise for his lower back injury; and request that Joan attend Dion’s next GP appointment for a meeting to offer education to Joan regarding Dion’s mental health and how she can be supported; 5 sessions for CBT, which can be extended as/when required (Berends et al., 2013).

Dion has been engaging with alcohol and other drug services and his GP and has since stopped his alcohol consumption alongside the use of Diazepam for the withdrawal; he has not ceased smoking although he is making use of the nicotine patches and gum and is receiving support to identify triggers and discuss coping skills(Mendelsohn et al., 2016); he has not been in touch with Gambling Queensland as yet as he has just felt overwhelmed with everything that has been going on, although it has been a distraction that Joan is back at home and they are spending more time together going for walks in the afternoon when he would have been going to the pub; he has made use of 2 of the Pilates sessions and has stated that along with the afternoon walks he has less back pain and feels he is able to do more physically;

Joan did attend a GP appointment with Dion and was offered education regarding depression and how this can affect a person’s physical and mental health – Joan was very thankful for this information and apologetic towards Dion for not being understanding and supportive when required; Joan advised that since she had moved back home there would no longer be concerns with Dion’s nutritional intake; he has attended 2 sessions for CBT to assist with moving on and dealing with the loss/grief of having to sell his business – he is feeling more positive now and is better managing his emotions.

There has been an overall improvement in Dion’s demeanour since Joan has returned home and understands what he is going through; this has made treatment easier for him, and he has agreed to continue to engage in the referred services. Dion will continue with regular appointments with his GP at this stage every two weeks to ensure everything is on track and assess if anything needs to be changed.