Reference no: EM131098634

CASE STUDY: SCHIZOPHRENIA

Patient: Randy
Written by Elaine Cassel
Marymount University and Lord Fairfax Community College
Worth Publishers, 2004

Presenting Complaint:

Thirty-two-year-old Randy lives in a cabin in a remote rural area of Montana. He moved here 10 years ago after he left his parent's home in suburban Sacramento, California. The cabin has no electricity or running water. Randy considers himself a survivalist; he heats his house with wood and gets his water from a nearby mountain stream or from the rainwater he collects. He grows vegetables and kills game and birds. He has a 20-year-old truck that he uses to go into town, a 100-mile trip from his isolated home. He inherited $50,000 from an aunt several years ago. He keeps the money in a passbook savings account in town and withdraws cash when he needs it. He doesn't have a regular job, but people have found that he is good with his hands. He does odd carpentry jobs occasionally, if he is in the mood.

When Randy goes into town, it is usually to get a couple of hundred dollars of cash out of the bank, buy a few things from the grocery store, such as coffee, milk, and household items, treat himself to lunch at the diner, and go to the library. On these trips, he might pick up a job or two.

The people who know Randy refer to him as "odd" but harmless. He often talks to himself when he eats or works. Some say that if they listen closely he appears to be carrying on a conversation with one or two other people. Randy wears worn-out clothing and has long hair and a bushy beard. He is often dirty and disheveled, but he is not so different in that regard from other men in the area.

The diner where Randy eats lunch has a television that is always on. Randy appears agitated by the television and he mumbles something like, "Turn that thing off. It is messing with my head." One of the waitresses humors him and asks the other clients if she can turn it off. Most agree. When that waitress isn't working, the television stays on. Then Randy doesn't linger over his meal.

The librarian says Randy must be very bright, because he checks out history and philosophy books. In fact, she often orders books he wants from a large city library, as their library caters to the simple tastes of its rural populace.

One day, Randy came into the restaurant extremely agitated. He was pulling at his hair and talking loudly. He asked the waitress to give him something to stop the noise. What noise, she asked? He said, "The noise in my head. Since the television stole my brain I can't stop the noise." The waitress laughed and said, "Why don't you tell us what kind of noise is in your head? Maybe we want to listen, too." At this point, Randy reached over the counter and grabbed the waitress by the blouse and shouted, "Kill the noise or I will kill you."

A scuffle ensued as the patrons in the restaurant rushed to the waitress's defense. As they struggled with Randy he got more upset. He kicked, he bit, he threatened. Someone called the police and they came to arrest Randy. He actually calmed down and told the officers, "So, it's you. Go head and take me. You have been after me for years - putting arsenic in my garden plot, taking money out of my bank account. And stealing my brain - don't think I forgot that. But you will pay for this. The Chief is looking for you."

Randy was arrested and charges with assault and battery on the waitress and the patrons who tried to restrain him - both misdemeanors. Randy spent the night in jail before being brought before a judge the next day. During his night in jail he continuously banged on the bars demanding that the guards turn off the television (the closed-circuit television hung on the wall outside and across from his cell). He threw his metal dinner plate at the television, cursing it and yelling, "Why are you doing this to me? You stole my brain, what else do you want?" When he was taken in front of the judge, the officers reported on his comment at the restaurant and his behavior in jail. The jail superintendent reported that he wanted Randy charged with destruction of jail property (his metal dinner tray dented the side of the television). The judge ordered a psychological evaluation to see if Randy was suffering from a mental disorder of some kind. When the judge asked Randy if he knew what a psychological evaluation was, Randy said, "Sure. They want to get inside my head. But I'm telling you, they won't find anything. My brain is missing and I don't know where I left it."

Social and Family History:

Randy was the middle of three children. His father was an electrician and his mother taught elementary school. His older brother committed suicide at the age of 30 - having struggled with depression most of his adult life. His father was never diagnosed with a mental disorder, but he was known for his paranoia and eccentric behaviors. Randy's mother had learned to be quiet and passive in order to appease her volatile husband. They rarely communicated with one another, and when they did it usually ended up in an argument.

Randy was a star high-school student had a 3.8 GPA his first year in college. He was majoring in history. When a girlfriend broke up with him, his grades started to slip and everything about his seemed to change. He slept a lot, ate mostly junk food, and stopped going to class. He was placed on academic probation. He accused the Dean of being out to "get" him. He even suggested that the Dean took his girlfriend. Eventually Randy was expelled from the college.

He went home to his parents, where he became withdrawn and paranoid. Randy was angry with his father, who mostly ignored him. His mother was afraid of him, especially when he talked to himself and yelled at the television. Once when they were gone for the weekend, Randy pulled the cable box out of the wall and took a hammer to the television set, smashing in the sides. He told his parents that the cable box was taking thoughts from his brain sending them to the television for all to hear. "My thoughts belong to me, and to no one else. Whoever tries to take them is going to have to pay."

A neighbor of his parents suggested that Randy ought to go to the community mental health clinic. Randy's father forbid it, saying no son of mine is going to a shrink. Shrinks are for "sissies." When the neighbor asked Randy if he wanted to get some help, Randy's response was, "I don't need help. Just turn off the damn TV."

One day, Randy went to the police department and said he wanted to file a criminal complaint. "Against whom?" the officer on duty asked. "Against WJTA-TV," Randy said. Sensing that Randy was a "big off," he asked Randy, "What did they do to you?" "Larceny - grand larceny," Randy said. "They stole my brain, and I want it back."

The officer pretended to write up a complaint and told Randy he would give it to his supervisor for approval. That appeased Randy. When he left, the officer laughed and said, "Boy, it takes all kinds."

Shortly after this incident, Randy's aunt died and left him $50, 000. Randy bought an old truck, the same one he has now, packed up his clothes and books and took off. He left his parents a note reading, "Thanks for nothing." That was the last they heard from Randy.

Diagnosis:

Checklist - Schizophrenia

1. At least two of the following symptoms, each present for a significant portion of time during a one-month period:
a. Delusions
b. Hallucinations
c. Disorganized speech
d. Grossly disorganized or catatonic behavior
e. Negative symptoms

2. Functioning markedly below the level achieved prior to onset.

3. Continuous signs of the disturbance for at least six months, at least one month of which includes symptoms in full and active form (as opposed to attenuated form).

Diagnosing Randy:

1. Go to the DSM-IV checklist for schizophrenia and list each of Randy's behaviors that satisfy the symptom criteria for schizophrenia. Which of Randy's symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

2. How long has Randy been experiencing symptoms that meet the criteria for schizophrenia?

3. What type of schizophrenia does Randy display?

4. What phase of schizophrenia was Randy in during the days before the diner incident?

5. What phase was he in at the time of the diner incident that led to his arrest?

Explaining Randy's Schizophrenia:

1. What genetic factors may have played a part in Randy's schizophrenia?

2. What biochemical abnormalities might account for Randy's symptoms?

3. What might have been the role of family stress in Randy's disorder?

4. What sociocultural factors may have played a role in Randy's schizophrenia?

Treating Randy:

1. Assume that instead of being jailed for his offenses, Randy is referred to a community health center for treatment planning. You are assigned to be his caseworker. What kind of assessments will you need to do before you begin Randy's treatment planning?

2. What type of medication might you recommend for Randy?

3. What mental health treatment modalities would be helpful to Randy in addition to medication?

4. What services other than mental health treatment might be beneficial for Randy?