Schizophrenia
While Frank continued to talk to the man, Jerry moved very slowly to work his way behind the now much calmer man. Frank moved to stand directly in front of the stranger and looked him right in the eye. The human contact with-out touching seemed to calm the man even more. While he continued to fix his gaze on the man, Jerry moved in behind him.
Frank explained what they were going to do. “We’re going to put handcuffs on you now,” he began. “To help keep the bugs away we’re going to take you somewhere safe. But to do that, we have to put handcuffs on you. Do you under-stand?” Frank never broke his connection with the man’s still-frightened eyes.
The man seemed about to protest, then simply dropped his chin to his chest and put his arms behind his back. Jerry took the signal and very gently placed hand-cuffs on the now unmoving man’s wrists. The officers helped the man into the cruiser and headed for the hospital. Given the state the man was in when they first confronted him, it seemed wise to have him checked out before they took him to the station.
The Diagnostic Interview
After his vital signs were checked by emergency room personnel, Ricky was escorted to a tiny office near the psychiatric section of the emergency room. He waited quietly until two women appeared at the door, gave a perfunctory knock, and entered. The younger one introduced herself:
“Hello. I’m Dr. Morgan, a psychiatry resident here. This is Ms. Johnstone, a nurse’s aid.” Then, after a brief pause, “What is your name?” Ricky said nothing.
Dr. Morgan carefully noted Ricky’s appearance: He was dirty and disheveled.
He sat stiff ly and abruptly looked away when she tried to make eye contact. He seemed to pay little attention to his surroundings.
Dr. Morgan’s formal assessment of Ricky began in a slow, sincere tone of voice: “Do you know what place this is?”
Ricky mumbled, “Hospital.”
“That’s right, Memorial Hospital. Do you know what day it is?”
After a pause of several seconds, “Tuesday.”
“Actually, it’s early Wednesday morning, but you’re close.” From this part of the mental status exam (Siassi, 1984) she concluded that Ricky was oriented to place and time, meaning that he knew where he was and approximately what time it was. Her low-key manner relaxed Ricky slightly, and he began to give brief, cau-tious answers to her questions. Finally he told her his name. She then asked, “Can you tell me what happened that caused the police to bring you here?”
Ricky’s responses were guarded and hesitant, but over the next hour he revealed bits of information that when pieced together indicate he has been in New York for less than 2 weeks, having abruptly left his hometown after his parents tried to obtain a court order committing him to inpatient treatment at a
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state psychiatric hospital. Using most of the money he had for his bus ticket, he arrived at the Port Authority terminal and managed to find a run-down room-ing house in which to stay.
The rooming house was noisy and Ricky was very uncomfortable there. He spent most of the time in his stuffy little room, and as the days passed he began to hear messages coming from the television, even after he unplugged it. When police cars came down the street or a helicopter f lew by overhead, Ricky believed they were trying to photograph him. Once he even telephoned the police to tell them that he knew they were working with the CIA to control him.
A CRITICAL THINKING AND QUESTIONING PAUSE Given the brief description of this case thus far, what questions might you want to ask Ricky in order to pursue a diagnosis? Generate at least three questions (such as, “What do you think you know that the CIA would find so important that they want to control you?”). Keep these questions in mind as you consider the initial diagnosis and suggested treatment options that follow.
A Tentative Diagnosis
Ricky clearly had several symptoms. Among his cognitive disturbances were delu-sions, which are irrational beliefs (for example, that others are trying to control him and his thoughts), and disturbed patterns of thinking that resulted in Ricky having a difficult time keeping his thoughts “on track” and connected. These cognitive symptoms suggested a serious mental disorder, but they could also have been caused by acute intoxication from substance use or (less often) a nutritional deficiency.
In her initial interview, Dr. Morgan asked Ricky about his appetite and his use of alcohol and other substances. He refused to answer these questions, so she decided to wait, rather than press him, knowing that the toxicology screens would suggest if substance use or nutritional deficiencies might account for Ricky’s symptoms.
To evaluate other more remote possibilities, such as cerebral stroke or tumor, she asked Ricky if he had had any noticeable feelings of nausea, headaches, recent falls, or blows to the head. She also asked him for his parents’ phone number so she could contact them right away. Dr. Morgan expected that enlisting their help would make it much easier to arrange adequate care for Ricky once he left the hospital. However, Ricky refused to give her any information about his family.
Ricky also appeared to be experiencing hallucinations that were at least visual and auditory in nature. You will recall that Ricky was making statements about
“bugs eating his skin” if he did not do the bad things the voices told him to do. Although these symptoms appeared quite dramatic and unusual, they may have indicated a broader problem that Ricky was having with processing sensory information. This possibility will be covered more thoroughly in the Biological Perspective section later in this case.
Let us examine Ricky’s delusions in more detail. A key feature of Ricky’s delusions were their suspicious quality, including “ideas of reference.” With ideas of reference, everyday occurrences and situations are assumed to have special meaning. One such example might be having someone assume that a Coca-Cola commercial proclaiming, “Coke—It’s the real thing” means that the people in the room can be trusted but others cannot. An example of this in Ricky’s case was his belief that police cars and helicopters were in the neighborhood because of him. Dr. Morgan questioned the evidence for these beliefs, testing whether Ricky’s thinking is sufficiently chaotic that he would abandon these ideas in favor of other completely different notions. Ricky stuck by his story, however, and as she waited for the medical results, Dr. Morgan decided to evaluate the appropriateness of schizophrenia as a diagnosis.
For a diagnosis of schizophrenia, the patient must show continuous signs of disturbance for at least 6 months and demonstrate two or more of the follow-ing: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms, and social or occupational dysfunction. At least one symptom must be delusions, hallucinations, or disorganized speech. Ricky described hallucinations, and his beliefs about strangers trying to control him are almost certainly delusional. Although Ricky’s responses were guarded, Dr.
Morgan was able to infer that he had been gainfully employed in the past but had not worked for some months, suggesting social and occupational function-ing markedly below the level he achieved previously.
Although Ricky’s account of his problems at home and difficult time in New York suggest recent episodes of intense anxiety and agitation, there was no evidence that he experienced major depression, manic episodes, or mixed bipolar symptoms or f luctuating moods. From all of this information, Dr. Mor-gan arrived at a tentative diagnosis of schizophrenia based on Ricky’s frequent auditory hallucinations and his preoccupation with delusions of external control over his thoughts and behavior. Following DSM-5, she rated the severity of each of these symptoms as 3 on a scale of 0–4, and also noted that at this point there is very little evidence of severely disorganized speech, disorganized or catatonic behavior, or f lat or inappropriate affect. From what Ricky has told her, Dr. Mor-gan infers that his symptoms have persisted for at least 6 months.
When using DSM-5, it is important to try to understand the person’s cultural background and identity as these might be related to the symptoms. Ricky’s race and ethnicity appeared similar to her own, so Dr. Morgan decided to ask him whether his thoughts and perceptions have anything to do with his reli-gious and spiritual beliefs, or those of his family. Again, he refused to answer.
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Finally, having insufficient information from Ricky about any past episodes of schizophrenia, she completed her tentative diagnosis of schizophrenia by adding the term “acute,” but did not indicate whether this was Ricky’s first episode or instead the latest of multiple episodes he has experienced. In Dr. Morgan’s mind, Ricky’s symptoms were serious enough, and the nature of his illness was clear enough, that she did not need to keep him off of medication. She asked him what medications he had used in the past, and with her help, he identified some antipsychotic medications. He accepted her decision to have him resume one of these medications.
Ricky’s symptoms fit the diagnosis of schizophrenia very clearly, but it was important that Dr. Morgan get to know him as an individual. With this in mind, she renewed her efforts to contact Ricky’s family, hoping to pave the way for Ricky’s return home. Again, Ricky refused to provide any useful information.
A few days later, Dr. Morgan had no choice but to have Ricky transferred to the Creedmoor Psychiatric Center, one of New York’s state hospitals for people with mental illness.
Ricky’s History
As Ricky’s parents would later explain, he had a normal childhood and everyone in the family got along well. Ricky was involved in all the things that boys do, such as Little League baseball and Scouts, and was a solid B student all the way through high school. He played the clarinet in the high school band, had several after-school jobs, went to dances, and seemed to enjoy friends in a normal way for a teenager. Toward the end of high school, his parents noticed some problems but thought it was just typical teenage anxiety. During the second semester of his senior year of high school, his parents noticed some suspiciousness and odd statements, but they dismissed these signs also, believing that Ricky was simply anxious about graduating from high school and nervous about going to college.
Ricky went to college in another state and did not know anyone at the school when he arrived. The first month there, he seemed a little mixed up and called home frequently, but again his family thought it was just an adjustment prob-lem and he would get over it. Before long, he became good friends with his roommate, Chris, who was from India. However, Chris introduced him to LSD, marijuana, hashish, mescaline, and other drugs. Ricky tried LSD, had a terrify-ing experience, and was placed in the university infirmary. His friends assured him that the best way to get over a bad trip would be to try LSD again. However, he tried it again and once again had a psychotic episode and was placed in the infirmary.
Ricky managed to complete his freshman year, but when he came home in June, he was extremely thin and quite nervous. After much questioning, he finally told his mother about the drugs and confided that he was worried about losing his mind. They first approached their family physician because, as Ricky’s
mother often explained, “We are the kind of people who always start by con-sulting our doctor.” The doctor talked to Ricky and, unable to learn much from him, referred the family to a neurologist. The neurologist examined Ricky but found nothing wrong, so he suggested seeing a psychiatrist.
Ricky couldn’t get an appointment with the psychiatrist for 6 weeks, so he sat around the house and slept a lot. After the psychiatrist had interviewed him for about an hour, he recommended that Ricky be evaluated at the local general hospital, which had a wing for the treatment of psychiatric patients. His mother thought the doctors would prescribe a medication and he would be better in a few weeks or even a month.
Ricky stayed for only a week, and although he showed little response to treatment, the staff did not believe he was psychotic enough to require hospi-talization. When he returned home, Ricky insisted there was nothing wrong with him and refused to take any medication. When his mother went to do his laundry, she found that Ricky had been hiding much of the medication he was supposed to have taken in his dirty laundry. In addition, he either ate ravenously or refused to eat anything. He withdrew socially, spending less time interacting with friends and family, and more time in his room playing his stereo. He often slept during the day and stayed awake most of the night listening to loud music.
Sometimes his family could hear him scream at someone, but they were sure there was no one else in the room.
His sisters’ friends wondered what was wrong with him; their brothers, who were the same age, were out doing things. Once in a while, Ricky would sit with them and try to participate in their conversations, but he couldn’t keep up.
It seemed that it took him too long to grasp what people would say and then think of something to say back. It was as if he were playing a tennis game in slow motion, but everyone else was playing at regular speed. The conversation just went too fast. His inability to participate in conversations added to the embar-rassment his sisters felt.
As time passed, Ricky behaved more and more strangely. When he went out, he would dress “incognito,” he would say, wearing sunglasses and a hat and sit-ting very low in the seat of his vehicle. He wore golf gloves even though he never played golf—and, in fact, he slept with the gloves and his socks on. At times, members of the family would find him standing in front of the mirror patting different places on his face. When he had a chance at the full length mirror in his sisters’ room, they would see him look into the mirror and pat different parts of his body.
At home, he would sit in the living room and stare right past everyone. He had very little contact with former friends and became more and more argumen-tative with his parents. As these arguments became more heated, Ricky’s younger sister feared that he might injure one of their parents or even perhaps kill them.
Once he called her down into the basement where his bedroom was, and told her that he quit skydiving lessons (which in fact he had never taken) because he
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knew his mother and sister were trying to kill him and he thought they would pay someone to damage his parachute.
Eventually Ricky began to look for a job, but couldn’t seem to find anything satisfactory in his home town. He decided to move to California, where he knew someone who was attending a university there. Ricky found work as a janitor, and later worked in a fast-food restaurant, but after 6 months, he returned home saying that some people out there were after him.
Ricky decided to reapply for college and was accepted at an in-state university.
He enrolled there, but seemed to have a lot of difficulty. Soon his family stopped hearing from him, and there was no answer when they phoned his apartment.
After they left urgent messages at various university offices, an official from the school called them to say that Ricky had been arrested and that he was in jail. He had fired a gun in his apartment. He didn’t fire it at anyone, but fired it into the ceiling, saying that the planes overhead were buzzing him and bothering him.
The police, realizing that this was probably a psychiatric problem, decided to take him to a psychiatric clinic in town, but on the way, he assaulted one of the guards by biting him on the hand. Because of this, when they got to the clinic, the intake staff said he was too dangerous in his present state and refused to see him. The police had no choice but to put Ricky in jail.
Ricky’s father accompanied him to court and got the charges dismissed on condition that Ricky return home and receive psychiatric treatment. He was admitted to a state psychiatric hospital 2 weeks before Christmas. Christmas that year was very hard on the family. Ricky’s sisters didn’t want to go see him because they were frightened by all that he had been doing and what was happening to him. At that time, the typical medication regimen initially entailed high doses of powerful medications that were gradually tapered over time. When his par-ents visited, Ricky didn’t look or act like the son they knew. He was hospitalized for 3 months. He was somewhat improved after 6 weeks of hospitalization, at which time the staff psychiatrist told the family that Ricky’s diagnosis was acute schizophrenia.
The family felt terrified about this diagnosis. What was schizophrenia? They looked for books about it at the library. Unfortunately, much of what they found was old and featured outdated theories that schizophrenia was caused by bad parenting. The family not only felt overwhelmed with the suffering that Ricky was experiencing, but also tremendously guilty and inadequate.
After 3 months at the state hospital, Ricky returned home. He was supposed to continue taking powerful phenothiazine medications to blunt his delusions, but he disliked their troublesome side effects (dry mouth, constipation, blurred vision, and fatigue) so he stopped taking them without telling his parents. Within 2 months, his psychotic symptoms began to return. He believed the doctors, and even his family, were plotting against him and helping the CIA to control him;
his family was trying to poison him, he thought, and he would eat only things from cans he had seen opened.
One time there was a dishcloth lying on the sink with some food on it. When he saw it, he said, “Those are bugs! Those are giant bugs!” He took the family dog and ran upstairs, refusing to eat with the family. He took plastic from dry-cleaning bags and covered up his bed because he thought his mother was putting poison in the washing machine instead of detergent. He thought that she was not only putting poison in his food, because it tasted different, but also he thought she was poisoning the dog by putting poison in the dog food. He believed that he was designated to save the dog. He became very delusional, was afraid to be around people, and started carrying large rocks in his car in case he had to con-front someone.
Things came to a head when one day Ricky told his mother he’d have to kill her because people driving by knew that she was a bitch and was poison-ing him and his dog. He told his mother that the people in the car said that he was worthless crap, but he could really be somebody important if he killed his mother. He put his hands around her neck. She ran out the door and was able to get away from him. After a long time, she was able to get him to leave the house. This unfortunate incident illustrates an important finding of research on the relationship between schizophrenia and violence: People who are acutely ill with schizophrenia and other serious mental disorders are sometimes dangerous to themselves or others, especially if they have histories of past violent behavior and have been abusing alcohol or other drugs (Elbogen & Johnson, 2009), but the people who are most at risk besides themselves are their own family members or friends, not members of the general public (Steadman et al., 1998).
Mental illness, in and of itself, does not make someone violent who would not normally be violent. In addition, most persons with mental illness never become violent. So, how do we reconcile this information? If someone is hearing voices telling them to do bad things, it is possible this person would, ultimately, do such things. Many persons without diagnosable mental illnesses are or become violent. It is important to keep such things in perspective in order to avoid the temptation to assume that persons with mental illness who are exhibiting symptoms that could be labeled as “unusual” are, by definition, dangerous. Clearly, this is not the case. Research suggests individuals with men-tal illness who are in treatment are no more violent than the general population.
In fact, people who are mentally ill are far more often the victims of violence than perpetrators of violence.
Given the extremity of Ricky’s behavior, and believing that Ricky must have medication in order to improve, the family obtained a court order to force treat-ment. Two police cars and one state trooper arrived at the family home. The police read him his rights and had him empty his pockets. Ricky made a weak attempt to resist, and the officers immediately threw him to the ground and pinned his arms tightly behind his back. Ricky was terrified and began scream-ing as they tied him up and pushed him into the police car. This ordeal was traumatic for everyone, including the police.