HoNOS case study written vignette - Terry

Admission:
Terry is a 25-year-old New Zealand Pakeha man. This is his third admission to the acute inpatient unit in the last 18 months. He presents with an increase in auditory hallucinations – saying his voices call him names or tell him to do things to himself or others which he finds very distressing. He has recently been arrested twice for unprovoked assaults on people who were strangers (the last time was two weeks ago, he is facing charges for these assaults and had been remanded on bail). Today he was arrested again for a similar assault; however, he was intercepted by the forensic nurse at his court hearing and now has been bailed to the mental health unit (or such other place as decided by the treating psychiatrist) and is on a curfew.

He was born in Wellington. He moved around the country with his family having to change schools every three years because of his father's job. He is estranged from his family because at age 14 he accused an uncle of sexually molesting him. This was found to be untrue; it was at this time that he started his involvement with mental health services as Terry experienced severe depression related to the estrangement and change of schools. He was in CYF care until he turned 18 years old. Since that time he has been crashing at other people’s flats or staying in night shelters or halfway houses. He has never had any long-term accommodation due to his antisocial behaviour when stoned.

Terry is a daily user of marijuana and over the past few weeks, reported he has also used synthetic cannabis and other psychoactive substances when available. Other people in the places he has been living have reported to mental health staff that he gets more paranoid and is prone to impulsive violence when using synthetic cannabis. His arrest today was the result of such violence. When asked about this, Terry states that he has no memory of his actions at these times. He was "done over" by some younger men last week but didn't seek medical attention, despite being kicked in the back and head. He said he was ‘out of it' at the time and could not defend himself.

Terry reports feeling angry and ‘a bit down’ over the past month but denies any self -harm or suicidal intention. There have been no reports of Terry using alcohol, but he states that he does drink up to twenty cups of coffee a day. In previous admissions Terry had been assessed as suffering from caffeine withdrawal symptoms.
When asked about the medications he was prescribed when he was last discharged from the unit he says he only took a few, sold some on the street as downers, and forgot where he left the remainder as he started moving about when he was stoned and couldn’t remember where he had been.

When you talk with Terry you notice that he takes a long time to respond to your questions. He is willing to cooperate, but he does not seem to notice anything is wrong with the time it takes him to respond. He appears confused by questions, saying he can’t remember what the question was, and changes his answer several times. The only thing he seems unwilling to discuss are the voices. He will only say that the voices are worse but not what they are saying to him.

Terry can tell you where he is, and can remember your name from his last admission to the acute inpatient unit. He doesn't know the day of the week, but does know the month and year. He also knows that its election year, but does not know who the Prime Minister is, nor the governing political party.

He has not been eating over the past month and has lost 3kg since his last admission six months ago. He says that food hasn't been a priority for him, and he spends most of his money on drugs. He has a bad wheeze and has borderline oxygen saturation levels. This limits the amount of physical activity he can sustain. He states that “I can’t fight like I used to, I get stuffed really quickly”. He denies cigarette (tobacco) use. At present he is living on the street and he has been living this way for the last six weeks. His support worker stated that over the past two weeks Terry’s self-care (eating, washing, dressing) has diminished noticeably.

Terry reports that he collects a benefit on a regular basis and while accommodation options have been presented by his support worker he stated he is not going to spend his money on this.

Following two previous admissions Terry has not maintained contact with local activity programmes set up while he was in hospital. He said this was because he could not remember what days they were held and which bus to catch to get there, and added that he also doesn’t like mixing with the people who go to the programme.

On the last admission to IPU it was noted that Terry failed to engage with others and stayed in his room except for meal times. During the interview Terry confirmed that he keeps to himself, and reports that he has no friends and feels isolated most of the time.