Alex's Schizophrenia
I wrote this diagnosis and intervention case study for a problem identification class at the University of Rochester. The professor asked us to use material from a particular fictional case study. I have included my reflection below.
Alex's Schizophrenia
Case Study
Alex is a 20-year-old White college student who visited the college counseling center at the urging of his parents. Alex lives with his parents, who take care of his basic needs because over the past year or two he has become increasingly unable to care for himself. Similarly, although he functioned adequately during his first year in college, his ability to complete assignments has steadily decreased over the past year. During the course of your conversation with him, he discloses that he believes he can control the behavior of others, and that others can read his mind. He constantly has the feeling of being watched. He lets you know he hears multiple voices that are threatening in nature. He experiences low energy, has low motivation, feels listless, and is unable to think or concentrate. His thoughts sometimes “stop midstream.” He reports poor appetite and difficulty sleeping. He says he has a romantic partner, but that they’re been spending less and less time together – he’s not sure why.
Question A
What additional 5 questions do you think would be important to ask in order to complete your assessment of Alex? Indicate how the answers to these questions will provide you with greater diagnostic clarity or be useful in treatment planning.
Answer A
Important Facts
Before providing five questions, I wish to describe important facts of the case that I consider relevant to constructing a biopsychosocial conceptualization.
The case study tells us that Alex is 20 years old and living with his parents, who provide for his basic needs. It does not tell us if his parents are biological, adoptive, or otherwise, who else he lives with, or give details about the living situation or his socioeconomic status.
The case content makes a biased judgment, claiming Alex is "White." Nobody "is White." A case study description should not equate a person directly with a racial construct; the person exists independently of the construct. A person may identify as belonging within a construct if they choose. I would have preferred the case study to state that Alex appears to have white skin or that Alex told us he identifies as being "White" or preferably something more specific like "White American." It could be that Alex is part of another culture that is very different from "White" yet still may have white skin, for example, African, Middle Eastern, or European. Potentially, Alex grew up in America with white skin yet identifies as part of a culture other than "White." Probably, Alex is mixed-race generically; very few of us are genetically pure. For example, I am Australian; I grew up in "Outback Australia" and was in a similar socioeconomic class and lived geographically alongside many Indigenous aboriginal Australians who have brown skin. I also contain genetic parts from Asian and Jewish cultures. I do not like it when people look at me and judge me as "White" at a construct level.
Similarly, the case study tells us Alex lives with "his" parents. How was this judgment derived? I would have preferred language, such as Alex, who was born biologically as a man and identifies as a man in his gender expression. The case study also does not give us any information regarding Alex's sexuality. The case study tells us that Alex does have a romantic partner. The case study does not describe details, except that Alex may be drifting away from this romantic partner; we do not know if there is a valid reason for this drift or if symptoms of asociality within Alex's condition are causing this drift.
The case study tells us that Alex's parents care for his basic needs, and then we are told that he was functioning adequately in his first year of college. Still, his ability to complete his assignments has decreased steadily over the past year. It appears Alex does not have an intellectual developmental disorder because the college has accepted him. Presumably, the level of care his parents provide does not necessitate helping him put on his clothes or take care of biological functions; the extent of Alex's inability to self-care needs further confirmation.
An important fact is that Alex tells us that he believes he can control the behavior of others with his mind and that others can read his mind. We do not know if these beliefs are part of a religious practice or if they are bizarre delusions. He also tells us that he hears aggressive voices. It is unlikely that these voices are real people; we do not know if they are part of any cultural or religious practice or if they are auditory hallucinations. Alex tells us that he feels like people are constantly watching him. We do not know if this is because he is actually under surveillance or if he is experiencing paranoia. Alex also tells us he feels avolition (low energy and motivation). He also says he is experiencing cognitive symptoms with problems thinking, concentrating, and stopping thoughts. He also is experiencing trouble sleeping and has a poor appetite.
To summarize these important facts for a biopsychosocial conceptualization:
Alex, 20 years old, lives with his parents; his parents meet his basic needs.
Appears male, must confirm biological sex, and discuss gender or sexual preferences.
Lacking detail on socioeconomic status or family system dynamics.
Lacking relational details other than parents and a romantic relationship.
Lacking medical information, either historical or current.
Lacking detail on substance use, current or former.
Lacking detail on traumatic events in the past or ongoing.
Lacking cultural identifications other than the potential of identifying as or being judged as "White."
Lacking information on any religious affiliations or spiritual beliefs.
Potential asociality (seen in drift away from romantic relationship).
Potential cognitive decline (difficulty thinking, schoolwork declining).
Potential bizarre delusions (mind control, mind reading).
Potential auditory hallucinations (hearing voices).
Potential paranoid thoughts (being watched).
Potential avolition (low motivation).
Poor sleep.
Poor Appetite.
Biopsychosocial Conceptualization
From these important facts, we can attempt to formulate a plausible biopsychosocial conceptualization of the case. At a biological level, we lack much information about medical history or substance use, so we do not know how these factors are incorporated. However, they will be crucial for our diagnosis. Alex is potentially experiencing psychotic features of bizarre delusions, as seen by his belief in mind reading, mind control, and paranoia of being watched. He also is experiencing auditory hallucinations (hearing voices) and disorganized cognition, which, at a biological level, can come about due to a neurochemical imbalance in the brain, potentially a dopamine imbalance in the mesolimbic pathway. We can see symptoms like this in Schizophrenia but also in other disorders. In Schizophrenia, the DSM terms these "positive symptoms" because they add something to the individual, something psychotic. Alex's poor sleep and poor appetite could be due to stress of the positive features and the neurochemical imbalance as "associated features"; alternatively, the sleep and appetite issues could be caused by separate neurochemical imbalances, for example, with the Serotonin system or the Norepinephrine system and classified as part of a mood disorder or depression.
At a psychological level, we can see Alex has avolition (low motivation) and cognitive difficulties (difficulty thinking or concentrating), both of which are negative symptoms of Schizophrenia. Negative means that the symptom takes something away from the individual. Positive symptoms such as hearing voices and feeling paranoid about being watched can contribute to a feeling of internal isolation and confusion for Alex, which then leads to trouble sleeping, poor appetite, or even depression. Problems at school and the stress this brings can make symptoms worse. Alex is going through a major life transition at the social level, moving from being part of his family system to college. If society expects Alex to conform to a construct of "White" or "White American," or even if he identifies with this construct consciously or unconsciously, there may be much pressure for him to become independent at this age or even more masculine at this age, relinquishing his role in his family system as he moves to become more self-sufficient in his society and his individualistic western culture.
The case study does not give us much information regarding Alex's social support systems outside his parents and Alex's romantic relationship. We see him drifting from his romantic partner (avolition). The case study mentioned no other friendships. The case study does not give us information about Alex's sexuality or gender expression, which can play a big role in social connection. The case study claims that Alex has his basic needs met by his parents; we do not know if his socioeconomic status is problematic. We are also not given any information on a history of trauma. Was Alex abused as a child? Did he experience any traumatic events, such as bullying or gun violence? We have now created a fuller biopsychosocial conceptualization of this case by synthesizing facts thematically across the biological, psychological, and social dimensions.
Five Questions
Can we obtain a thorough medical history and a new medical workup?
Can you describe any substances you use, and can we do a test for substance use? For example, alcohol, cannabis, or other drugs?
Can you tell me about your relationships, such as family and friends, and your key identifications, such as sexual and cultural, both now and how these have developed over time?
Have you ever experienced anything very stressful or traumatic, either in your life or recently? Was it a single event or an ongoing problem?
Of the symptoms you are experiencing, cognitive decline, mind control/mind reading beliefs, hearing voices, the feeling of being watched, low motivation, poor sleep, and poor appetite, when and how did these begin, and how have they developed over time?
The answers to these questions will provide us with greater diagnostic clarity. Beginning by ruling out any underlying medical conditions, for example, brain injury, thyroid dysfunction, medication side effects, or others that may mimic these symptoms. We then attempt to rule out substance use, which also could induce these symptoms. We then move on to Alex's relationships, both immediately and socially; if we see a weakening of social connections over the past years, it may build a case for a prodromal phase of Schizophrenia. We can also better understand any abusive or particularly protective relationships. We can screen for large-scale social problems that may be causing stress, such as race or gender issues or isolation due to COVID-19. We then screen for traumatic events to make sure that these symptoms have not come about due to trauma. Lastly, we get as much detail as possible on specific symptom onset to map these to the typical development pathways of known pathologies.
Question B
Provide a full diagnosis for Alex along with a brief rationale for your decision. (Be sure to use the current version, DSM-5-TR.
Answer B
Assessment Tools
Before making a diagnosis, I would consider applying a battery of assessment tools. Below are a wide array of tools that could be considered.
SCID-5-CV (Structured Clinical Interview for DSM-5 Clinical Version) - A good starting point may be the SCID-5, which screens for a wide array of conditions, including Mood Disorders, Psychotic Disorders, Substance Use Disorders, Anxiety Disorders, Obsessive-Compulsive and Related Disorders, Trauma and Stressor-Related Disorders, Eating Disorders, and more.
SCID-5-PD (Structured Clinical Interview for DSM-5 Personality Disorders) - This is an addition to the SCID-5-CV. It screens for personality disorders, specifically for Alex. It may help as it screens for Paranoid, Schizoid, Schizotypal, and Avoidant Personality Disorders, which may be relevant.
Positive and Negative Syndrome Scale (PANSS) - As many of the symptoms Alex has mentioned align with positive and negative symptoms of the Schizophrenia Spectrum of disorders, the PANSS would be a good tool to gain more confirmation towards a Schizophrenia diagnosis.
Brief Psychiatric Rating Scale (BPRS) - Similar to the PANSS but focuses on just psychotic symptoms. BPRS is a good adjunct to the PANSS.
Mood Disorder Inventory (MDI) - This instrument screens for mood disorders, such as depression or mania. MDI may be valuable for Alex's depressive symptoms, such as insomnia, poor appetite, lack of motivation, and isolation alongside psychotic ones.
Patient Health Questionnaire-9 (PHQ-9) - PHQ-9 is a short specific screener for depressive symptoms often used alongside the MDI.
Beck Depression Inventory (BDI-II) - A more detailed depression instrument to get more details on depressive symptoms.
Insomnia Severity Index (ISI) - This is used to assess insomnia symptoms.
Eating Attitudes Test (EAT-26) - For assessing poor appetite.
Mini-Mental State Examination (MMSE) - This examination will examine Alex's cognitive decline to rule out Intellectual Disability.
Posttraumatic Stress Disorder Checklist - The PTSD Checklist is used to screen to see if Alex's life has exposed him to any traumatic stressors.
Alcohol Use Disorders Identification Test (AUDIT) - AUDIT screens for alcohol use disorders.
Drug Abuse Screening Test (DAST-10) - Screens for substance use disorders, including marijuana and cocaine.
Diagnosis Facts
Before diagnosing, I would consider applying a battery of assessment tools. Below are a wide array of tools that I would consider:
Age of onset appears 19-20.
Onset appears gradual (over at least 12 month period).
Positive Symptom: Presence of Delusions for > 1 month (mind reading/control and surveillance).
Delusions are of the persecutory type (being watched) and are bizarre.
Positive Symptom: Presence of Auditory Hallucinations for > 1 month (aggressive voices).
Negative Symptoms: Avolition (reduced motivation), asociality (social withdrawal).
Associated Symptoms: Cognitive deficits, trouble thinking clearly.
It appears to be the first episode, currently in an acute episode.
Potential presence of depressive symptoms (insomnia, poor appetite, low motivation, isolation).
Increasingly unable to care for himself.
Disturbance in college and romantic relationship.
No presence of manic episodes.
There is no presence of other negative symptoms, alogia (poverty of speech), anhedonia (reduced pleasure), or affective flattening (reduced emotional expression).
There is no presence of markedly impaired behavior or catatonia.
There is no presence of grossly disorganized speech.
Presuming no underlying medical cause.
Presuming no underlying substance use disorder.
Presuming no underlying trauma.
Plausible Diagnosis
A candidate for an initial diagnosis is Schizophrenia, first episode, currently in acute episode. First-episode Schizophrenia is known to have onset in the late teens or early twenties in males (18-25). The severity specifier of the diagnosis should align with the severity measurements obtained by our assessments. The DSM-5-TR requires the following for this diagnosis:
Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
Delusions - present, in the form of mind control / reading and paranoia.
Hallucinations - present, auditory.
Disorganized speech - not present.
Grossly disorganized or catatonic behavior - not present.
Negative symptoms - present, avolition, asociality (not seen, alogia, anhedonia or affective flattening.
For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning) - Appears to be accurate as reported by parents, Alex is increasingly unable to care for himself, he is also struggling at college and his interpersonal relationships, especially with his romantic partner seem affected.
Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences) - To be confirmed with Alex. However, it appears these symptoms have been present over the last 12 months, meeting the 6-month requirement in the DSM.
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness - It does not appear as though Alex has encountered bipolar symptoms as no mania has been present, although he may be expressing depressive symptoms. So, we cannot yet rule out Schizoaffective disorder.
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition - We have yet to rule out substance abuse or physiological effects of a medical condition. We will use information from our interviews and assessments alongside medical reports.
If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of Schizophrenia, are also present for at least 1 month (or less if successfully treated) - Our SCID-5 and additional medical history and clinical interviews should be able to determine if an autism spectrum disorder or a communication disorder is present; then, we can rule this out.
So, in this case, to summarize, we do have two or more symptoms from criteria A, those being delusions, hallucinations, and negative symptoms. Criteria B has been affecting different parts of Alex's life, from home to relationships (romantic) and academic, to a significant degree. For criteria C, symptoms appear present for at least 6 months. For criteria D, we can rule out bipolar due to no manic periods, yet we should also make a differential diagnosis before we can rule out Schizoaffective disorder. We shall determine the pending results of our medical and substance use workups and assessments for Criteria E.
Differential Diagnosis
Schizoaffective Disorder, Depressive Type - Alex's insomnia, poor appetite, low motivation, social isolation, and inability to care for himself may be features of depression, but Alex has not reported sadness. It seems that in this case, Alex is primarily facing psychotic symptoms, and whilst having some features of depression, he does not currently claim sadness, so we are leaning towards a Schizophrenia diagnosis. Results of our interviews, assessments, and workups will help inform this further.
Substance/Medication-Induced Psychotic Disorder - If Alex is using substances such as cannabinoids or cocaine, it may mimic the symptoms he is experiencing now. If Alex is using certain medications, for example, Adderall, Prednisone, Prozac, or Benadryl, they could be contributing to his symptoms. If Alex has a medical condition, for example, thyroid dysfunction, vitamin deficiency, brain tumor, or neurological condition, these could be causing these symptoms. A complete medical and substance use workup, and history will aid in ruling this out.
Major Depressive Disorder with Psychotic Features - Again, the primary complaint of Alex seems to be the psychotic features, and these seem to be universally present, not only emerging during depressive episodes. Again, it is uncertain if Alex is experiencing depression or just some symptoms of it, as the case study did not mention sadness.
Brief Psychotic Disorder - If we found that Alex's symptoms were persistent for less than one month in complete form, we could consider a brief psychotic disorder, yet as it is currently, it appears his symptoms have been present for around 12 months.
PTSD with Psychotic Features - If we learn that Alex has had a history of trauma, we could consider PTSD with psychotic features. We need his trauma history to determine this.
Paranoid Personality Disorder - Alex persistently feels people are continually watching him. Feelings of being watched could be a symptom of Schizophrenia or something more pervasive in the form of Paranoid Personality Disorder. In this case, since his paranoia with other Schizophrenic symptoms, we can likely rule out Paranoid Personality Disorder.
Question C
C) What would you suggest would be the next steps in Alex’s treatment plan? Include a biopsychosocial case conceptualization, and provide a reasonably detailed problem list, as well as short-term goals, long-term goals, and possible interventions related to each.
Answer C
Treatment Plan
The treatment plan consists of the biopsychosocial case conceptualization (as shown above) and the next steps, problem lists, goals, and interventions shown below.
Immediate Next Steps
The immediate next steps for Alex are to share a complete medical history and workup, conduct clinical interviews and assessments, and determine with more certainty a diagnosis of Schizophrenia with the help of a psychiatrist.
Problem List
This report includes a biopsychosocial case conceptualization above. A list of current problems for Alex include:
Delusions of mind control/reading.
Auditory hallucinations of an aggressive nature.
He is increasingly unable to care for himself, including issues at home (self-care), at school (academic decline), and socially (romantic relationship drifting away).
Cognitive issues, inability to think clearly.
Low motivation.
Sleep and appetite disturbances.
Short Term Goals (within 4-12 weeks)
Short term goals include:
Within two weeks, establish a relationship with a psychiatrist for evaluation, confirmation of diagnosis, and recommendation of medication(s) where appropriate.
Within one month, Alex should communicate with the college regarding his situation and request accommodations.
Commit to meetings at regular intervals with the care team, including the counselor, psychiatrist, and others.
Commit to adherence to the medication regime, for example, missing no more than four monthly doses.
Reduce the frequency and intensity of psychotic episodes (delusions and hallucinations), for example, from 5 times a week to 2 times a week.
Commit to self-care activities, such as agreeing to shower and groom independently at least once daily.
Commit to social activities, such as agreeing to at least one social outing weekly.
Stabilize sleep and appetite, commit to a sleep schedule, aim for 6 hours of sleep a night, and commit to at least two healthy and substantial meals daily.
If Alex feels oppression due to his sex, gender expression, sexuality, race, or culture, connect with like-minded community groups at least once a month to advocate against oppression.
Medications
While only authorized individuals should prescribe medications, such as psychiatrists, we, as counselors, should be familiar with the medicines Alex is taking. For cases of first-episode Schizophrenia, a psychiatrist may prescribe an atypical antipsychotic to attempt to control and minimize psychotic features. A first-line choice may be Risperidone (Risperdal), beginning at around 1mg per day and then titrated up as needed, for example, up to 6mg. Risperidone will impact the dopamine system by blocking activity and help reduce positive symptoms of Schizophrenia. It may also help with negative symptoms such as low motivation and social isolation due to the removal of psychotic features, encouraging Alex to feel more motivated and a desire to be more connected. We should stay with this medication and monitor progress and side effects before trying to add additional medications or switching to others, such as Trazodone, Olanzapine (Zyprexa), or Lorazepam (Ativan). An exception may be if we find Alex's insomnia, poor appetite, and low motivation are related to depression, in which case we may consider an initial prescription of Fluoxetine (Prozac), which is an SSRI that can work alongside Risperidone to assist in managing the depressive symptoms. An alternative to Fluoxetine could be Bupropion (Wellbutrin XL), which may help the depressive symptoms as well as the cognitive deficits.
Long Term Goals (6 months to 1 year)
Long term goals include:
Establish a strong therapeutic alliance with a counselor and psychiatrist, as indicated by a score of over 100 on the Working Alliance Inventory (WAI).
Commit to medication adherence, as measured by Alex, missing less than three medications per month.
Alex hopes to report a reduction in the frequency of psychotic symptoms to less than once a month for delusions and hallucinations.
Alex hopes to see a reduction in the severity of positive symptoms as measured by improvements in the Positive and Negative Syndrome Scale (PANSS - Positive Symptoms Subscale).
Commit to increase self-care by daily showering, grooming, and dressing independently.
Improvement in academic performance with grades reaching 80% of high school level and showing improved performance compared to lower grades seen during the initial first episode of Schizophrenia.
Self-reported improvements in the ability to concentrate, find time for study, and clear thought at least three hours per week in 30-minute blocks.
Increase social connectivity to having at least two friends whom Alex contacts at least twice weekly.
Sleep pattern improved to 7-8 hours per night with a regular sleep-wake routine.
Improve appetite by having three healthy meals a day each day.
Feeling connected to at least one community organization that is working to address the social impacts Alex experiences.
Additional Interventions & Ecological Strategies
In addition to the information provided above, we recommend that Alex meet with his psychiatrist every 1-2 weeks at first and then tapering down as needed. We recommend weekly sessions with his counselor. We recommend that the counselor build a therapeutic alliance with Alex via humanistic techniques such as unconditional positive regard, empathy, and authenticity. Within this relationship, we recommend using techniques of cognitive behavioral therapy (CBT) to help Alex, specifically by assisting him in rationalizing his delusional beliefs and recognizing the biological nature of his hallucinations.
In addition, Alex may have many ecological support structures available. Both informal and systemic. As mentioned above, Alex is working with his college, where there may be school counselors and additional programs for people with mental health issues. We described Alex reaching out to community organizations who advocate for individuals in his condition and applicable organizations related to other religious, cultural, gender, or sexual parts of Alex's identity. Group therapy may be a good choice for Alex, specifically if we can find a group specializing in Schizophrenia. From this group or otherwise, Alex may be able to obtain peer support or peer mentoring from those who have similar problems and have achieved good results, for example, individuals with Schizophrenia who are in remission. Continued psychoeducation would be helpful for Alex, giving him more information about his diagnosis and general mental health overall, and psychoeducation for his family so that they can better understand his situation and support him.
