HoNOS case study written vignette - Shirley

Shirley is a physically fit 37 year-old woman. She exercises regularly and usually eats well. She lives in a comfortable middle-class suburb with her husband who travels a lot with work. Her daughter lives close by. Occasionally, she is impatient with others leading to verbal, but not physical, arguments. On several occasions over recent days, she has shouted at and abused her son over the telephone, and latterly some of her friends. Her recent overactive and inappropriate behaviour led Shirley’s son to come home from university. Following his arrival home, he called the crisis team for an assessment of her mental state. As a result Shirley has agreed, albeit reluctantly, to be admitted to the local psychiatric unit. Shirley stated to the crisis team that all the top models need a period of convalescence and recuperation and this is hers.

Shirley is currently expressing the belief that she is an 18-year-old catwalk model. Over the past week, she spent all of her money on clothing, makeup and fashion accessories, and considerable time telling everyone about her latest modelling assignments. Her friends describe her as being in “full flight'' and almost incoherent at times, although they said at other times she was “quite normal”.

Up until three weeks ago, she was able to undertake basic self-care and more complex activities such as the running of the household, but this has not been the case recently. Her husband and daughter have had to take over the jobs normally done by Shirley. Shirley does not have a paid job, but is normally fully occupied looking after the house, gardening, and participating in tennis and swimming at the local clubs.

Her friends from these clubs report that normally Shirley is sociable and fun to be with, but in her present state they are unable to communicate with her. Although normally a non-drinker and nonsmoker, she has, on two occasions, arrived at the club intoxicated. Her friends have been supportive but are now saying that they are getting tired of Shirley’s unpredictability and abuse. Shirley says that her friends are all “old fogeys” and won’t have anything to do with them. She says she feels the same about her own family, saying that they are small minded and boring. She would prefer to have nothing to do with them.

On admission, Shirley was talking incessantly. She was unable to recall a simple address after a few minutes, but knew the date and time. She had not slept for two days but she does not think that this is problem because “I don’t have time to sleep”. Although, her son says that not being able to sleep has, at times, distressed her over the last week. The registrar noted that on examination she had an offensive odour and appeared to have not washed for several days.

Shirley - Progress notes

Day 1

Shirley admitted to the ward at 9 am this morning, accompanied by her son and Julie Harris (CMHN Crisis team) following several days of reported manic behaviour. She was dressed in track suit pants and dressing gown that she dramatically threw off during the interview. Exhibits grandiose ideas – believes she is an 18-year-old fashion model and will be off to Paris very soon. Extremely restless – paced non-stop around the admission office. Speech pressured – talks incessantly about her modelling career. Oriented in time and place. Attention poor – easily distracted, unable to recall a simple address three minutes later. Sian O’Reilly MBBS

Day 1, 8pm

Shirley’s mood remains elevated. Behaviour continues to be disinhibited, removes clothing and walks around ward in her underwear. Discussion with son this evening who confirms that his mother has not been taking her tablets for some weeks. Paula Griffin RN

Information relevant for Focus of Care only.

Day 17, 2pm

Shirley appears to be settling well. Has been attending day program activities in preparation for community follow-up. Mood appears euthymic, behaviour appropriate, although remains a little impatient; constantly asking other people’s opinions of her appearance, and becoming irritable if she does not receive an answer immediately. Also offering fashion advice to both staff and fellow service users in the day program.

Provisional discharge date set for Friday (end of this week). Community mental health nurse has visited and spent some time with Shirley. Family meeting date set with CMHT. Going on leave this evening until tomorrow, attending barbeque function at the tennis club with her son and some friends and apprehensive about this but feels she ‘should’ attend for the sake of her husband. Paula Griffin RN