Case 2: Paranoid Schizophrenia
- Outline the major symptoms of this disorder.
- According to the DSM-5, the overall symptoms of Schizophrenia include positive symptoms such as delusions (surreal beliefs), hallucinations (seeing or hearing things which are nonexistent), disorganized speech (impaired communication or answers to questions are unrelated), or catatonic or grossly disorganized behavior (a range of silliness to agitation and may include abnormal motor behavior) (American Psychiatric Association, 2013). Schizophrenia also includes negative symptoms such as avolition which includes diminished emotional expression, lack of eye contact, monotone speech, neglecting personal hygiene, and social withdraw among other symptoms (American Psychiatric Association, 2013). The DSM-5 declares two or more symptoms must be present for the majority of a one-month period and one of the symptoms must be delusions, hallucinations, or disorganized speech (American Psychiatric Association, 2013). Level of functioning in one or more areas of life must have a marked decrease that lasts for at least six months and during one month symptoms must be present (American Psychiatric Association, 2013).
In this specific case study, it is important to note the prominent feature is delusions. Delusions are fixed beliefs that are not amendable despite evidence and manifest in six types: Persecutory delusions (belief that the individual will be harmed by someone or something), referential delusions (gestures, comments, or environmental cues are directed toward the individual), grandiose delusions (the individual is exceptional and above others), erotomanic delusions (false belief someone is in love with them), nihilistic delusions (belief a catastrophe will happen), and somatic delusions (preoccupation of health and organ functioning) (American Psychiatric Association, 2013). Delusions can be classified as bizarre (belief that one has loss of control over mind or body) or nonbizarre (external influence brings about conviction such as police have the individual under surveillance) (American Psychiatric Association, 2013). Delusions can be difficult to separate from strongly held ideology and therefore is dependent upon the degree of conviction despite proposed evidence of its surrealism (American Psychiatric Association, 2013).
- Client’s background
- Valerie is a middle-aged Caucasian female who resides with her parents and maintains a full time position working with mentally ill individuals (McGraw Hill Higher Education, 2007). Valerie loves her work and finds solitude within her working structure. Her childhood consisted of many moves in several states due to her parents teaching church school. Valerie experienced a normal childhood close to her parents (McGraw Hill Higher Education, 2007). Although she felt like a social outcast, she did well in school and even went on college and graduate school. In college she dated a little and married in her, mid-twenties. However, her marriage was unstable and she began manifesting symptoms of delusions of persecution and grandeur around twenty-eight years old(McGraw Hill Higher Education, 2007). Her husband had her involuntarily committed to the psych ward where her delusional state led her to believe doctors were performing experiments on her for several months. Once medications took effect and reduced the delusional symptoms, Valerie was released, however, due to the side effects she experienced, she refused the medications which would increasingly exacerbate the symptoms and she would be reinstitutionalized (McGraw Hill Higher Education, 2007). Over an eight-year period, she was able to accept her diagnosis, remain medicated, and symptoms have subsided.
Throughout the interview, Valerie was coherent and answered questions accordingly. However, she exhibited little emotion, with only a couple smiles and giggles throughout the interview which seemed to occur during her recollection of times she stood up for herself (McGraw Hill Higher Education, 2007). She appeared comfortable in the setting and did not usher much movement, rather arms were raised and rested on back of furniture. When explaining her illness, she resorted to using her hands to speak as if to get the point across it was a gradual onset not recognizable until she told about the infiltration she had been hiding in her diary (McGraw Hill Higher Education, 2007).
- Predisposition to disorder
- Valerie indicated herself as the only individual suffering from mental health issues within her family leading to the belief that there is no direct genetic link or predisposition to the illness (McGraw Hill Higher Education, 2007). According to the “National Institute of Mental Health”, there tends to be a link between chronic substance use affects interpersonal relationships and other areas of daily functioning (2016), but there is no evidence of substance usage among Valerie, her ex-husband, or other family members. It is believed that unspecified psychosocial factors may have a part in the development of Schizophrenia (“National Institute of Mental Health”, 2016). Therefore, it is possible that during her travels, Valerie may have been exposed to a virus that may have inflicted the development, but Valerie herself attributes the development to her marriage (McGraw Hill Higher Education, 2007). According to Valerie, she chose to remain in her marriage despite the indifferences that arose (McGraw Hill Higher Education, 2007). During this time, she engulfed herself in religion and soon developed delusions based in the church that led to hospitalization causing her to fear she would be a martyr of religion for exposing the individuals she believed were infiltrating the church (McGraw Hill Higher Education, 2007). When she turned to the individuals she trusted and they committed her to the psychiatric ward, she probably began feeling abandoned which led to delusions that caused her to fear for her life and the lives of her family (McGraw Hill Higher Education, 2007). Ultimately it was difficult to pinpoint a definitive cause outside of speculation from her unhappy environment.
- Symptoms that support the diagnosis.
- Valerie spoke of many examples of typical delusion classifications. Her delusions actually took over her mind and caused her to isolate herself in front of the television and drive for hours (McGraw Hill Higher Education, 2007). At one point she believed doctors were using poison so they could take her breasts and use her body for experimental research (McGraw Hill Higher Education, 2007). Throughout the course of the interview, Valerie remained monotone and had very little expression consistent with avolition, a negative symptom of Schizophrenia (American Psychiatric Association, 2013). She spoke of experiencing only two hallucinations, both of which were of religious basis implying the possibility of grandiosity. In the couple segments she did have emotion, it was noted these were during her recollection of times she came off as winning or seemed to view herself as “superior” to others, giving the perception of her experiencing grandiose delusions in the moment.
- Symptoms or behaviors inconsistent with the diagnosis
- The manifestation of Schizophrenia altogether appears to be void of the diagnosis. There is no directly linked disposition, only environmental factors. This may be due to lack of research or unproven environmental factors.
- Development of this disorder.
- There was no familial connection to mental illness. However, Valerie stayed in her unhappy marriage due to her religious background (McGraw Hill Higher Education, 2007). After being married a few short years, her husband abandoned the notion of moving out of California and having children which is something she looked forward. Upon realization that her dreams were not going to come true, she was no longer happy and lost faith in her husband (McGraw Hill Higher Education, 2007). The stress of living in an unhappy, stressful environment may have cued the onset of delusions as she attempted to hide her emotions. As her illness continued, her husband abandoned her altogether and they divorced rendering her victim to having to move into her parents’ home.
- Medical conditions
- No observation of medical conditions that may contribute to Schizophrenia nor any medical conditions exposed in the interview. However, Valerie has done quite a bit of traveling opening her to the potential of contracting a virus that may have led to the development of Schizophrenia (American Psychiatric Association, 2013). Additionally, Valerie had mentioned a gradual onset of symptoms that had caused her to question if she was mentally ill before her initial major episode (McGraw Hill Higher Education, 2007).
- Psychosocial and environmental
- Valerie described an unstable marriage that eventually led to her spouse abandoning her in her illness (McGraw Hill Higher Education, 2007). After a few years into the marriage, the things they decided on as a couple were abandoned such as having children and moving to a different state which made her lose faith in her husband and created a resentment within her (McGraw Hill Higher Education, 2007). Having been raised in a religious household, turning to religion in her time of trouble with her husband, seemed to trigger the first major Schizophrenic episode (McGraw Hill Higher Education, 2007).
- Client’s overall level of safety regarding potential harm to self or others (suicidality or homicidality)
- Although Valerie does not present with suicidal ideations during the interview, she should be recognized as potential risk especially if symptoms come out of remission. According to the DSM-5, five percent of individuals diagnosed with Schizophrenia commit suicide, twenty percent attempt suicide, and many more have frequent suicidal ideations (American Psychiatry Association, 2013). Statistics implicate a high risk for those suffering from Schizophrenia, therefore best practice wold be to have an alert, especially is symptoms recur.
- Cross-cultural issues that affect the differential diagnosis
- Valerie’s manifested in her late twenties as consistent with the average of women developing the order (McGraw Hill Higher Education, 2007). The duration of Valerie’s illness has been more than eight years allowing the definitive diagnosis of Schizophrenia to hold true (McGraw Hill Higher Education, 2007). Statistically, individuals with schizophrenia have the potential to be readmitted to the hospital within two years of release such as Valerie experienced in the beginning of the symptoms onset (McGraw Hill Higher Education, 2007). Due to Valerie’s residing with her parents, she appears to satisfy the supportive environment necessary for recovery as paranoid schizophrenia tends to have a higher recovery rate from other subtypes (McGraw Hill Higher Education, 2007).
- Short-term goals of intervention
- Valerie should maintain her current status through the utilization of medication and therapy. Throughout her journey with mental illness, stability seems to be a major aggressor in the development of the disorder. She depended on those who love her to support her, but she was abandoned in her time of need and during those stressful periods, she regressed and opted out of treatment (McGraw Hill Higher Education, 2007). Additionally, Valerie should seek out external sources of support. Her support system is reportedly her parents and those who work with her which is great. However, it may benefit her to incorporate others into her life as a more rounded support team. Additionally, it appears that Valerie has unresolved issues from her marriage and these should be addressed and dealt with as soon as possible to help her rehabilitate.
- Long-term goals of intervention
- Valerie was happy at one point in her life. She described high lights such as traveling to Europe. If Valerie were able to travel she may feel a sense of freedom and “normalcy” as she does something she has enjoyed since she was a little girl. It may benefit Valerie to pursue her Ph. D. or even a second degree in mental health as she originally wanted. Attaining that goal will edify her self-worth and in turn create a sense of accomplishment that lets her know she is still capable of achieving her goals and dreams.
- Therapeutic strategy
- An article on the APA website explains new hope for Schizophrenia which integrates psychosocial rehabilitation, or a model consisting of the combination of medication, maintenance, and stabilization, to teach those with schizophrenia self-sufficiency via work skills, social integration via coping techniques that lead them to rehabilitation in their illness (MacGuire, 2000). Valerie should continue using antipsychotic medications. Pharmacological treatments block the dopamine D2 receptor which reduces psychotic symptoms such as hallucinations and delusions as well as potential relapse (Chien & Yip, 2013). Psycho-social interventions are utilized for ongoing treatment (Chien & Yip, 2013). Psycho-social interventions enhance functioning, reduce relapse and hospitalizations and facilitates rehabilitation and recovery (Chien & Yip, 2013). Psycho-social interventions are found in Cognitive Behavior Therapy which teaches the individual coping skills and diversion plans in the event of an “episode” (Chien & Yip, 2013). Additionally, psycho-social interventions include patient and family pseud- education increasing the knowledge of the illness allowing a reduction of stigma that may be experienced from the diagnosis (Chien & Yip, 2013).
- Therapeutic modality
- In the video, The Answered Patient: Schizophrenia Overview, posted in Dr. Cronin’s conclusion segment, Anthony Zipple, Sc. D. states that the “biggest misconception is that people don’t recover” from schizophrenia (2015). He goes on to claim looking at the data for over a five to twenty-year period, most people “do recover quite well” and others claim that the proper use of psychotherapy, medication, and group support systems increases the likelihood of positive relationships and independent life (The Answered Patient, 2015). The Clubhouse Model is a community program designed to create an atmosphere that helps individuals with mental illness find hope and opportunities to reach their maximum potential (“Clubhouse International”, 2016). Although Valerie works within the community of the mentally ill, it appears that should would benefit greatly if a Clubhouse was incorporated into her treatment. Valerie wanted to ern her Ph. D., but her illness caused her to abandon that goal. However, with the support of the model and education potential, external support may be what Valerie needs to attain her goal.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Brinkman, W. B., & Epstein, J. N. (2011). Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences. Patient Preference and Adherence, 5, 45–56. http://doi.org/10.2147/PPA.S10647
Centers for Disease Control and Prevention. (2016). Retrieved from http://www.cdc.gov/ncbddd/adhd/diagnosis.html
Chien, W. T., & Yip, A. L. (2013). Current approaches to treatments for schizophrenia spectrum disorders, part I: an overview and medical treatments. Neuropsychiatric Disease and Treatment, 9, 1311–1332. http://doi.org/10.2147/NDT.S37485
Clubhouse International. (2016). Retrieved from http://www.iccd.org/whatis.html
McGraw Hill Higher Education. (2007). Faces of Abnormal Psychology Interactive [Multimedia]. Retrieved from McGraw Hill Higher Education, Maladaptive Behavior & Psychopathology | FP6005 A01 website.
MacGuire, P. A. (2000, February). New hope for people with schizophrenia. American Psychological Association, 31(2), 24. http://www.apa.org/monitor/feb00/schizophrenia.aspx
The Answered Patient (2015). Schizophrenia overview [Video file]. Retrieved from BehaveNet.com website: http://behavenet.com/schizophrenia