ADULT PSYCHOPATHOLOGY CASE STUDY

CHARACTERISTICS SYMPTOMS:

Symptomology (Accor Examples

to DSM-5)
A-1.Delusions 1. Bill realized that something strange was happening. He noticed
that people were taking special interest in him and often felt that
they were talking about him behind his back. (for several weeks)
2. Bill suddenly came to believe that a group of conspirators had
secretly produced and distributed a documentary.
3. Bill believed that the film had grossed over $50 million at the box
office and that this money had been sent to the Irish Republican
Army to buy arms and ammunition. (delusion of reference)

2. Hallucinations 1. Bill called the thoughts and his corrective incantations as

“scruples.”
2. He often mumbled and day dream about his intrusive thoughts.
3. Bill had recently talked extensively about some of Bill’s unusual
idea.
4. When Bill was sitting alone in his bedroom at Colleen’s home, he
thought he overheard a conversation in the next room. It was a
heated argument in which one voice kept repeating “He’s a
goddamned faggot, and we’ve got to kill him!”
3. Disorganized Stammered speech. Couldn’t understand his mumbling sometimes
speech
4. Grossly 1. Sat motionless in his room (catatonia)
disorganized or
catatonic behavior
5. Negative symptoms, Bill’s denied behavior.
such as affective
flattening, alogia (a Cousins met, then he met the elevator operator at his mother’s
apartment building as further evidence for the existence of the film.

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poverty of speech), or He remembered stepping onto the elevator one morning and having
the operator give him a puzzled, prolonged glance. The man asked
apathy(anhedonia)
him if they knew each other. Bill replied that they did not.
2. Bill could not remember having any close friends as a child. Most
of his social contacts were with cousins, nephews, and nieces. He
did not enjoy their company or the games that other children played.
(anhedonia)
B. Social/occupational 1. Bill’s Peculiar behavior and social isolation.
dysfunction: 2. His social contacts and lack of friends.
3. He won’t go out, stay in his room.
4. Bill had some limited and fleeting sexual experiences. These had
been both heterosexual and homosexual in nature.
C. Duration These all signs were persisted for 6 months.

Specifier Paranoia
1. He was visibly moved as he described his guilt concerning the bombings.
He was also afraid that serious consequences would follow his
confession.
1. Bill believed that the conspirators had agreed to kill him if he ever
found out about the movie. This imagined threat had prevented Bill
from confiding in anyone prior to this time. It was clear that he now
feared for his life. (suspiciousness)

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 Code Diagnosis
ICD-10(F20.0) DSM-4TR(295.3) Schizophrenia paranoid type

Etiological Considerations:

Genetic factors:

The development of the disorder must therefore depend on a dynamic interaction between

a genetically determined predisposition and various environmental events (Gottesman & Hanson,

2005). We do not know how genetic factors interact with environmental events to produce

schizophrenia. This problem is enormously complex because the environmental events in

question might take any of several different forms (Walker,Kestler, Bollini, & Hochman, 2004).

Some investigators have focused on factors such as nutritional deficiencies or viral infections.

One hypothesis suggests that prenatal infections increase vulnerability to schizophrenia by

disrupting brain development in the fetus (Brown & Derkits, 2010).

Genetic factors are clearly involved in the transmission of schizophrenia (Mitchell &

Porteous, 2010). The most persuasive data supporting this conclusion come from twin studies

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and investigations following various adoption methods. Based on the assumption that both forms

of twins share similar environments, monozygotic twins should manifest a higher concordance

rate (i.e., more often resemble to each other) for traits that are genetically determined. This is, in

fact, the pattern that has now been reported for schizophrenia over a large number of studies

(Pogue-Geile & Gottesman, 2007). For example, one study conducted in Finland reported a

concordance rate of 46% for monozygotic twins and only 9% among dizygotic twins (Cannon,

Kaprio, Loennqvist, Huttunen, & Koskenvuo, 1998). This substantial difference between

monozygotic and dizygotic concordance indicates the influence of genetic factors. On the other

hand, the absence of 100% concordance among the twins also indicates that genetic factors do

not account for all of the variance to environmental events and vulnerability to schizophrenia has

focused on interpersonal relations within the family.

Childhood isolation:

Adverse family circumstances during childhood may increase the probability of

subsequently developing schizophrenia among people who are genetically predisposed toward

the disorder (Schiffman et al., 2001). Bill was always much closer to his mother than to his

father, whom he remembered as being harsh and distant. When his parents fought, which they

did frequently, Bill often found himself caught in the middle. Most of bill’s social contacts were

with cousins, nephews, and nieces. He did not enjoy their company or the games that other

children played. He remembered himself as a clumsy, effeminate child who preferred to be alone

or with his mother instead of with other boys.

Family environment:

A considerable amount of research has also stressed the family’s influence on the course

of the disorder. These studies follow the progress of patients who have already been treated for

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schizophrenia, and they are concerned with expressed emotion, or the extent to which at least

one family member is extremely critical of the patient and his or her behavior. The patients are

typically followed for several months after discharge from the hospital, and the outcome variable

is the percentage of patients who return to the hospital for further treatment. Relapse rates are

much higher for patients who returned to high EE homes (Aguilera, Lopez, Breitborde,

Kopelowicz, & Zarate, 2010; Hooley, 2007).

The data regarding expressed emotions are consistent with Bill’s experience. Bill

remembered that when he and his mother were living together, they made each other anxious.

His descriptions of her behavior indicate that her emotional involvement was excessive, given

that he was an adult and capable of greater independence; she was always worried about his

job, his friends, or what he was doing with his time. Her constant intrusions and coaxing finally

led him to seek refuge with his sister’s family. When he came to home after he was fired from

the job, he came home to live again with his mother. This is known as “Boomerang child”.

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Case Conceptualization:

Bill had a paranoid schizophrenia. It’s a severe disorder that is often associated with considerable

impairments in functioning. The disorder is characterized by an array of diverse symptoms,

including extreme abnormalities in perception, thinking, action, sense of self, and manner of

relating to others. The hallmark of schizophrenia is a significant loss of contact with reality,

referred to as psychosis. In this disorder, there is a split within the intellect, between the intellect

and emotion, and between the intellect and external reality.

FIGURE 1 Simple linear models of disease and discrimination paradigms that outhne their impact on severe mental illness

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SPECIFIC TO BILL

Biological vulnerability: He was the youngest child so his father of old age.

Psychiatric symptoms: Psychiatric symptoms “She was concerned about his peculiar behavior

and social isolation. He spent most of his time daydreaming, often talked to himself, and

occasionally said things that made little sense.” bill’s sister

Misconception: Persons who are plagued by psychiatric symptoms and who lack social skills

soon find they are missing a supportive social network. Few people are willing to befriend them

or help them with their problems (Meeks & Murrell, 1994). As a result, many persons with

severe mental illness do not attain age-appropriate social roles: They do not finish school, enter a

vocation, or get married. This chain of events leads to a loss of social opportunity.

As a result nobody befriended him. “Bill could not remember having any close friends as a

child”

Stigma and discrimination: Proponents of a stigma and discrimination model acknowledge

that biological agents cause psychiatric symptoms; the combination of symptoms and

vulnerabilities, in turn, leads to diminished social skills and support networks. However,

proponents of the stigma and discrimination model suggest stigmatizing attitudes about these

symptoms have an equally damaging effect on social functioning (Corrigan & Penn, 1998;

Fisher, 1994; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989; Penn et al., 1994).

Bill faced 2 stigmas: of being mentally ill and of being a homosexual. A man in his middle

forties who often did business at the bank invited Bill to his apartment for a drink, and they

became intimate. The experience was moderately enjoyable but primarily anxiety provoking.

Bill decided not to see this man again.

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 Loss of social opportunities: Members of society withhold opportunities related to housing,

work, and income (Monahan, 1992; Nagler, 1994; Riger, 1994; Stephens & Belisle, 1993).

Bill’s was fired from operator elevator job and due to his loss of job his mother was also

concerned about him.

Poor Quality life: Bill wasn’t a good decision maker in everything.

TREATMENT: Antipsychotic drug treatment:

The most recent medications typically prescribed for schizophrenia include a class of drugs

called “atypical antipsychotics.” Atypical means they work in a manner that is significantly

different than the previous class of antipsychotic medications.

There are seven commonly prescribed atypical antipsychotic medications for schizophrenia:

 Abilify (aripiprazole)

 Risperdal (risperidone)

 Zyprexa (olanzapine)

 Seroquel (quetiapine)

 Cloazril (clozapine)

 Symbyax (olanzapine/fluoxetine)

 Geodon (ziprasidone)

Common side effects of these medications include weight gain and drowsiness. Weight gain

can be a significant issue — most people taking an atypical antipsychotic can expect to gain

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weight. Because weight gain is also associated with an increased risk for Type II diabetes,

individuals taking an atyptical antipsychotic should be carefully monitored by their physician.

Exercise and a nutritional, balanced diet are also important.

2. Cognitive Remediation Therapy:

Cognitive Remediation Therapy (CRT) is a treatment option for people with

schizophrenia to improve cognitive abilities essential to functioning in social or professional

settings, such as attention, memory and planning. The treatment would be carried for 3 months

as no statistically significant difference was found between 3 month and 6 month treatment

groups (Iwata, 2017). Two studies that support this recent treatment are highlighted in the next

2 paragraphs.

The first study focused on working memory and also involved biological tests.

Participants with schizophrenia were then randomly assigned to the computerized cognitive

training (SZ-AT) or to a control condition of commercial computer games for 80 hours of training

sessions over 16 weeks. While the computer game condition group did not have significant

improvements, SZ-AT had improved verbal working memories, occupational functioning and a

decrease in disorganized symptoms. This was correlated with an increased efficiency in the

right middle front gyri and enhanced connectivity in the prefrontal neural networks. In the time

between the end of treatment and the six-month follow up, participants did not practice the

cognitive tasks, but continued with other, existing treatment such as medication. However, these

cognitive and neurological improvements remained strong at the six-month follow up and imply

permanent repairs in their neurology (Subramaniam, 2014).

Another study, took schizophrenics as controls rather than healthy patients. The TAU

group received standard outpatient treatment, consisting of medication and voluntary programs

like psychoeducation, social skills training, work therapy and group activities in the same six

hospitals offered six hours a day, five days a week. The sample was improved as it took place

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at six different psychiatric facilities throughout Japan, consisted of 60 participants with

schizophrenia, not currently taking first generation antipsychotics, being randomized into the

cognitive remediation group or the treatment as usual group (TAU). The CRT group participated

in 24 cognitive training sessions for 45 to 60 minutes twice a week, as well as a weekly group

session that applied the skills they learned to practical applications, which was again different

from the first experiment that focused on memory training. The CRT group showed significantly

greater improvement than the TAU group, especially in the domains of general cognitive

functioning, processing speed, executive functioning, interpersonal relationships, work skills and

overall psychiatric symptoms. There was a significant correlation between increased cognitive

functioning and social functioning, suggesting computer-assisted therapy paired with group

rehabilitation may provide an opportunity for individuals to practice and integrate new skills

(Buonocore, 2017).

Bill had a problem in working memory due to which he couldn’t be able to perform to his

full potential. “He forgot his due assignments and On occasion he seemed to mumble to himself,

and he often forgot floor numbers to which he had been directed. After he was fired from the job

as an elevator operator, Bill moved back into his mother’s apartment.”

3. Family therapy:

Meta-analyses pooling data across studies have consistently shown reductions

in relapse rates (157, 158, 1232) and also reduced family burden (1233). The control
treatments have included individual supportive therapy, intensive case management, and medication
alone. The one consistent finding
is that brief interventions lasting less than 9 months have little effect and are therefore inferior
to programs lasting 9 months or longer (157).

The goal of treatment is to help patients achieve remission. Some people have long

periods of remission with quite stable disease and minimal impairment. Other people have

worsening symptoms and functioning and do not have a good response to available therapies. It

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is hard to know how a specific person will do after diagnosis. But the outlook for people with

schizophrenia has improved over recent years, with better psychiatric medications and more

comprehensive psychological and social support.

Unfortunately, people with schizophrenia have a much higher risk of suicide than people

without the disorder. But this risk can be reduced if affected individuals receive high-quality

treatment and keep taking the medications that they need. People with schizophrenia also have a

higher risk of certain other medical conditions, like cardiovascular and respiratory

diseases. Additionally, people with schizophrenia also have a higher risk of certain other

psychiatric problems, like substance-related disorders, panic disorder, and obsessive compulsive

disorder.

Most people will continue to need some form of support after their diagnosis. However, many

people are able to live independently and actively participate in building their lives.

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Reference:

Aguilera , A. , López , S. R. , Breitborde , N. K. , Kopelowicz , A. , & Zarate , R. ( 2010).

Expressed emotion and sociocultural moderation in the course of schizophrenia . Journal of

Abnormal Psychology , 119 , 875 – 885 .

Brown, A.S. and Derkits, E.J. (2010) Orenatal infection and schizophrenia: A review of

epidemiologic and translational studies. American Journal of Psychiatry, 167, 261-280. doi:10.

Cannon , T. D. , Kaprio , J. , Loennqvist , J. , Huttunen , M. , & Koskenvuo , M. ( 1998 ).

The genetic epidemiology of schizophrenia in a Finnish twin cohort: A population-based

modeling study . Archives of General Psychiatry , 55 , 67 – 74 .1176/appi.ajp.2009.09030361

Corrigan, E W., & Penn, D L. (1997) Disease and discrimination. Two paradigms that

discrete severe mental illness Journal of Mental Health, 6, 355-366

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 Corngan, E W, & Penn, D L (1998) Stigma-busting and stereotype Lessons from social

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Grohol, J. (2016). Atypical Antipsychotics for Schizophrenia. Psych Central. Retrieved

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 Walker, E., Kestler, L., Bollini, A., & Hochman, K. M. (2004). Schizophrenia: Etiology

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