Mental health articles

Case study: Martha – a study to illustrate risk categories and factors

Personal history

Martha is 71 years of age, white British, and was born in Scotland. She experienced physical, sexual and emotional abuse from the age of 4 by her aunt who brought her up as her mother and father were unfit to look after her due to chronic alcoholism. Martha did reasonably well at school despite the severe problems at home and subsequently obtained a job in a local bakery. She worked in various bakers’ shops between 16 and 35 years of age. At 25, Martha married someone she met during one of her inpatient spells in hospital but unfortunately he was physically and emotionally abusive towards her and they eventually divorced when she was 36. Approximately a year before the divorce, Martha was pushed down the stairs by her husband, through which she acquired a head injury leading to a mild learning disability.

This incident also left her with epilepsy and she tends to get an attack every couple of months although she manages to cope with this quite well. Residing in the Leeds area since the age of 23, Martha now lives alone in a 24-hour warden-assisted ground-floor flat where she normally copes reasonably well, receiving weekly support through her community psychiatric nurse (CPN) from the elderly service.

Psychiatric history and associated factors Martha experienced her first episode of what is now known as bipolar disorder at the age of 19 and she had numerous hospital admissions up to 30 years of age. Fortunately, she was able to gain an immense degree of insight and applied herself to managing her illness and this led to dramatically reduced hospital admissions. Following the head injury she sustained at the age of 35, Martha was admitted to Rampton High Security Hospital as she was considered too difficult to manage within her local hospital and, at that time, there were no other appropriate services to deliver her care. She was discharged from Rampton Hospital at the age of 40 to her local hospital in Leeds where she spent two months before being resettled into the community. Three years ago, Martha had a major stroke that has left her right side very weak. Although she has responded well to physiotherapy, she still needs the aid of a stick when walking and she can be quite unsteady on her feet. In addition, it is impossible for her to climb stairs or walk much more than three-quarters of a mile without having to have a long rest.

The following are some of the main risk factors that have been present at various times during the past ten years:

Self-harming behaviour: Martha has been known to insert objects in her arm, swallow batteries and also cut herself when she is distressed.

Alcohol misuse: She often drinks excessive amounts of gin when feeling depressed/not coping.

Exploitation: Martha usually becomes very free and loose with her money when high and/or when she feels lonely and wants company.

Self-neglect: When depressed and/or drinking heavily she usually doesn’t wash or take a shower and fails to eat properly.

Aggression/violence: During periods of psychosis, Martha has been known to lash out with her hands at various people who come into contact with her. Martha has a standing agreement (by way of a ‘contract’ with her clinical team) to notify them when her clinical management requires inpatient care. This arrangement usually works well and short admissions of three weeks or so are usually sufficient to get her stabilized. She has the support of an advocate from the local advocacy service in relation to this set-up as well as for other issues which arise from time to time. Relationships She enjoys an excellent relationship with her CPN who previously worked in a challenging behaviour unit and is, therefore, well experienced in dealing with how she presents sometimes. As well as a good relationship with her advocate, Martha enjoys a close friendship with a fellow woman resident who lives upstairs – they usually have tea and biscuits with each other at least twice a week.

Current situation

Martha’s cousin passed away three days ago and this has led to a difficult period for her. Since receiving the awful news, Martha has been drinking heavily in order to escape from the intolerable reality and this has led to the usual problems of self-neglect. In addition, she has been cutting her arm again and inserting objects into it as part of her coping strategy. On today’s visit of the CPN, there were signs of psychotic symptoms in that Martha was talking rapidly and not making much sense at times. In addition, she became quite distressed twice during the visit and shouted abusively at her CPN. The environment of the flat appeared to be extremely untidy with cigarette ends, ash, empty bottles and other items scattered around. Martha was also dishevelled and has been ignoring personal hygiene. Finally, as the CPN left the flat, he thought he heard Martha mumbling something about ‘bringing an end to it all’. However, when he asked her if she was suicidal she said ‘no’.

Tags: categories, risk