The following analysis is concerned with a case study (appendix i) of a 32 year-old Irish male named Sean Murphy. He has been referred for clinical assessment by his solicitor, in order to receive treatment and in aid of an upcoming court case for arson and burglary. The aim of this case study is to identify the key problems with Sean’s behaviour and how these problems affect his life, to produce a tentative diagnosis and to suggest relevant treatment programmes to improve Sean’s behaviour. To maintain confidentiality, Sean will be referred to as ‘the client’ throughout the following case study.
SECTION A: DIAGNOSIS
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The client is clearly suffering with psychotic episodes in which he believes a hidden force called ‘the organisation’ is controlling his thoughts and sexual feelings. He demonstrates cognitive dysfunctions as he holds implausible beliefs about himself and the world around him (i.e., that his mind is being controlled) and is extremely suspicious of others. He believes that external forces (mainly ‘the organisation’) “manipulated” him to commit previous crimes, which shows he lacks a real grasp of reality and is unaware of his own actions. The client is also socially withdrawn; he lives alone, rarely contacts his mother and it appears that he does not have any close friendships. In addition to this, the case study presents the client as an individual at the bottom of the social ladder; he spent his adolescence homeless, has been imprisoned on more than one occasion, and is unable to maintain close relationships. All of the above characteristics displayed by the client are presented by Davey (2008) and NHS Choices (2010a) as typical of Schizophrenia.
His maladaptive behaviour appears to meet the requirements of criterions A, B and C of the DSM-IV’s diagnostic of ‘Schizophrenia’ (American Psychiatric Association 1994) (see appendix ii) as he suffers bizarre delusions, lives alone, lacks the ability to maintain relationships, is unemployed and believes he has been the subject of psychological manipulation for over six months. However, the case study lacks detail regarding criterions D, E and F (appendix ii). To establish whether the client fully meets the ‘Schizophrenia’ requirements, further questioning is required about; other mental illnesses, medication/ substance abuse history, and family background of mental illness. Further to this, the client’s behaviour largely displays characteristics of ‘Paranoid Schizophrenia’ (appendix iii) as he experiences delusions of persecution in which he lives in “continual fear” and is “extremely suspicious of others and their motives”. Conversely, he does not show any characteristics of the ‘Catatonic’ (appendix iv), ‘Disorganised’ (appendix v) ‘Undifferentiated’ (appendix vi) or ‘Residual’ (appendix vii) subtypes. With this in mind, the client can be tentatively diagnosed as ‘Paranoid Schizophrenic’. It is interesting to note that when the DSM-V is released in May 2013 as an upgrade of the DSM-IV, the criteria of Schizophrenia diagnosis will be revised (American Psychiatric Association 2010). The subtypes of Schizophrenia are proposed for removal, and will be replaced by one revised continuum of ‘Schizophrenia’ (appendix ii). The dimensions of the disorder (i.e hallucinations, delusions, avolition and impaired cognition) will be assessed on a 0-4 scale based on the severity of the symptoms (appendix viii); whereby individuals will be diagnosed as mild or severe schizophrenic. Also, due to the fact that many Schizophrenics suffer from mood pathology (Bowle et al 2006; Crumlish et al 2005), for example, the client reports a ‘depressed state of mind’, the DSM-V proposes to include criteria for Depression and Mania in the process of diagnosis, in order to reduce the prevalence of depression with antidepressant-based treatment (Addington, Addington and Patten 1998; Peralta and Cuesta 2009). It is important to note that these changes are likely to affect the client’s diagnosis and will pose problems with his proposed treatment programme in the long-term.
Street drugs such as LSD, amphetamines and cannabis have been significantly linked with a likelihood of developing psychosis (Arendt et al 2005; Henquet et al 2005; Maki et al 2005). The NHS reports that cannabis “can cause anxiety, paranoia and loss of motivation” (NHS Choices 2010b) which appears to reflect the presenting client’s paranoid state. Prolonged use of these drugs prevents reuptake of the neurotransmitter dopamine; resulting in excess levels of dopamine in the brain (Mathias 2008). These excess levels have been found more often in Schizophrenic individuals compared to non-Schizophrenics, as seen in post mortems (Seeman and Kapur 2001). This phenomenon is known as the ‘dopamine-hypothesis’ (Davey 2008) and indicates that dopamine plays an important role in the development of Schizophrenia. For this reason, it is imperative that the client’s history of drug habits is sought to establish if drug abuse is a possible cause of his behaviour. Although the dopamine-hypothesis is plausible, antipsychotic drug trials do not display improvements in behaviour until several weeks after consumption of medication (Sanislow and Carson 2001) despite the fact that they reduce dopamine levels within minutes. If dopamine was a key trigger of psychosis, then the psychotic episodes should also reduce within minutes.
It is reported in the literature that the “highest rates of schizophrenia diagnosis are found in poor inner-city areas and those of low socioeconomic status” (Davey 2008: 231). This could be due to the fact that these areas present more life stresses to their inhabitants; thus act as ‘psychosis risk factors’ (Byrne et al 2004), known as the ‘sociogenic hypothesis’ (Davey 2008). The client is presented as someone from a low social status; as he left school with no qualifications, is unemployed, and is often involved in crimes of arson/burglary, therefore this social theory could help to explain his case. However, the ‘sociogenic hypothesis’ may be just a political bias. Lower class individuals may be diagnosed more as Schizophrenic because they “fit” the stereotype that Schizophrenics are poor and unintelligent (Angermeyer and Matschinger 2004). In addition, the theory’s prominent argument is that individuals from lower social classes are more often diagnosed as Schizophrenic, however it fails to acknowledge that one of the main symptoms of Schizophrenia is in fact ‘social dysfunction’ (American Psychiatric Association 1994) (see criterion B in appendix ii), therefore the lower class status is most likely a product of the illness itself, rather than a cause. The case study states that the client was categorised as “educationally subnormal” at a young age despite the fact that he reads and writes well. The effects of this label being placed at a young age may have developed a self fulfilling prophecy in which he believed and acted in agreement with his “subnormal” label; hence turning to alcohol, crime and homelessness, and eventually withdrawing from reality.
With both the dopamine and sociogenic hypotheses in mind, the overarching approach of Schizophrenia seems to take a diathesis-stress perspective. This argues that some individuals possess a predisposition to developing the disorder which is then triggered following a series of stressful life events (Nuechterlein et al 1994 and Fowles 1992). The Holmes and Rahe Stress Scale (Holmes and Rahe 1967) (see appendix ix) lists 43 stressful life events which can have an influence on the development of illnesses. The scale presents five stresses experienced by the client; jail term, death of a family member (father); personal injury or illness (as he spent time in a psychiatric ward), change in residence (has lived at home, in care, homeless, in prison) and change in financial state (because he is now unemployed). Although this scale includes a large list of life stressors, it does not take into account the lack of parental bond, the abuse he experienced as a child and the sheer stress that the client’s delusions are causing, i.e. he lives in “continual fear”. Although the diathesis-stress perspective seems plausible in describing the current client’s case, this theory suggests that Schizophrenia can only be developed after relevant life stresses. Contrary to this, Despert (1937) reported nine Schizophrenic children under the age of 7 years who did not experience relevant levels of stress; and further to this, the University of North Carolina (1999) claims that Childhood Schizophrenia is mainly due to complications with early brain development, rather than stressful life events. The presenting client has displayed signs of social withdrawal since school age, suggesting that his schizophrenic tendencies may have been developing from a younger age; thus possibly the product of dysfunctional brain development. With this in mind, it is still clear that he experienced many stressful events in his childhood and the diathesis-stress model appears the most plausible theory in describing his case.
The case study reports that the client spent six months in a psychiatric institution at the age of 20. However, information is unknown regarding why he was admitted, his diagnosis, the treatment he received (drugs or therapy) and why he was released. Therefore, this information must be sought in order to compile a full medical history of the client. The clinician also needs information regarding possible substance abuse throughout the client’s life, as well as a full report of any history of mental illness in his family.
In conclusion, it appears that the presenting client has developed symptoms of Schizophrenia due to a number of stressful life events during his childhood, adolescence and early adulthood which can be best explained in terms of the Diathesis-Stress model. After analysing his behaviour he can be tentatively diagnosed as ‘Paranoid Schizophrenic’, code 295.30, providing that the above factors are investigated further.
SECTION B: TREATMENT
It is now imperative that a care plan is devised for the client diagnosed as ‘Paranoid Schizophrenic’ (code 295.30) due to the fact that there is a high prevalence of suicide amongst Schizophrenics due to the psychotic symptoms and depression (Royal College of Psychiatrists 2010; Bowle et al 2006). Forms of schizophrenia have other wider implications on a range of other life factors, such as; social support networks and employability (Manning and White 1995; Rinaldi and Hill 2000), therefore it is important that the presenting client receives a beneficial treatment plan as soon as possible.
Antipsychotic drugs are regarded as the best form of treatment for individuals suffering with psychotic episodes (delusions or hallucinations) (National Institute for Health and Clinical Excellence 2011). In addition to this, ‘Clozapine’ has been found to be the most effective antipsychotic drug on the market (McEvoy et al 2006). As an example, a three-month assessment found a larger decrease in positive and negative Schizophrenic symptoms amongst patients treated with Clozapine, compared to patients treated with Quetiapine or Risperidone (McEvoy et al 2006). This suggests that Clozapine may be beneficial for the treatment of the presenting client, as it significantly reduces symptoms; of which the client suffers disturbing, bizarre delusions of persecution. However, Clozapine has been reported as intolerable in some cases, as it produces a range of physical side effects. Arsenjo et al (2010) report that Clozapine patients may develop agranulocytosis – a reduction of white blood cell production – as a result of taking the drug. For this reason, patients receiving the drug are required to have blood tests every 1-2 weeks as a precaution. Despite the fact that this form of treatment can cause serious physical problems (Arsenjo et al 2010); the current zeitgeist in Western society remains to view mental illness in terms of medical science. The use of antipsychotic drug treatments is a convenient treatment accepted as the ‘norm’ by many practitioners, because it is cheap, easy to produce, administer, and measure (Gallagher 2007).
In terms of the client presented in the current case study, providing antipsychotic medication could prove problematic, due to his paranoid nature. He is extremely suspicious of “professionals who attempt to care for him”; therefore he could not be trusted to take the recommended dosage every day. As an alternative, ‘depot’ antipsychotics, in particular Resperidone, seem to be a relevant treatment for the client. This consists of the client undergoing injections of the antipsychotic drug into the muscle every fortnight (NHS Tower Hamlets 2008). Resperidone is recommended as it is the only atypical antipsychotic available as a ‘depot’, reducing the chance of muscle stiffness which is often found amongst typical depots (NHS Tower Hamlets 2008).
In review of the above mentioned antipsychotic treatment methods, the current client should be given a care plan consisting of ‘depot’ Resperidone antipsychotics, because in this way, the professional health team can monitor that he is receiving the correct dosage, rather than it being the client’s responsibility; who is highly paranoid and cannot be trusted to take the medication on his own accord. This form of treatment aims to stabilise the dopamine levels in the brain, in line with the dopamine-hypothesis of Schizophrenia (Davey 2008) and should reduce the severity of his delusions. If the client fails to meet an appointment for his medication, his GP or Practise Nurse will be responsible to contact the client’s Community Psychiatric Nurse, who could arrange a home visit, to administer the drug in his own home.
In addition to antipsychotic drugs, psychotherapy has been found effective at treating the social side of Schizophrenia; “most people who went to a self-help group were very satisfied with the experience and said they got better” (Seligman 1995). Psychotherapy can include counselling, group therapy, or Cognitive Behavioural Therapy (CBT) and aim to increase the interpersonal, social, employability and grievance issues of patients. CBT consists of one-to-one therapy meetings with a professional, and it is advised that at least 16 sessions are required for a significant improvement (National Institution for Health and Clinical Excellence 2011). Bradshaw (1998) reported that a three-year course of CBT of a Schizophrenic woman found major improvements in psychosocial functioning, attainment of treatment goals and reductions in symptomology and hospitalisation. Further to this, Seligman (1995) further reported that “psychotherapy alone worked as well as psychotherapy combined with medication”; implying that psychotherapy may be even more effective than drugs; although this has not been agreed by other literature (Dickerson 2000). Cases like the above (Bradshaw 1998) indicate that psychotherapy can have a positive effect on Schizophrenic individuals. It would be beneficial for the client to take part in a long-term course of CBT alongside his medication of Resperidone ‘depot’ because it will increase his interpersonal social skills and aid him with dealing with everyday issues. The factors that the client should address during his therapy time are; social skills, relationships/friendships, education/employment, and grief. It would also be beneficial for the client to talk about the stressful events that occurred in his childhood, which may provide an understanding of why his psychosis developed, in line with the diathesis-stress perspective (Nuechterlein et al 1994); although an initial meeting will give the client to choice of what he wishes to discuss.
The client has been unemployed for the majority of his life, and similarly, 96% of individuals diagnosed with Schizophrenia in the UK were unemployed in 1999 (Perkins and Rinaldi 2002). However, Rowland and Perkins (1980) have stressed the importance of work for Schizophrenic individuals. They argue that work ensures a good quality of life as it; increases social contacts, offers social support, provides status and identity, and offers structure of time along with a sense of achievement, to which Shepherd (1984) agrees. The main barrier tends to be with employers reluctance to hire persons with a psychiatric record (Manning and White 1995; Rinaldi and Hill 2000), however the ‘Supported Employment Programme’ aims to fight against this stigma. This programme offers work experience to individuals receiving care from mental health services, in order to equip them with necessary work skills to gain future employment (NHS Foundation Trust 2011). It is highly recommended that the client joins this programme, but he must first take part in therapy regarding social skills, etc.
Furthermore, internet forums have been found a useful approach with dealing with the alienation and isolation experienced by Schizophrenics (Haker, Lauber and Rossler 2005). This is interesting because another zeitgeist of modern Western culture is the internet. This form of self-help will be beneficial to the client, because it will enable him to talk to people in similar situations to him without requiring face-to-face contact. This will help because the case study claims he is suspicious of “professional” help, therefore advice provided by individuals similar to him may be more accepted. As he is unemployed, he may not have internet access in his home, however Coventry Library offers free internet access to its members (Coventry City Council 2011). Therefore, it is recommended that the client joins membership of Coventry Library, where he can spend up to 1 hour a day on the internet free of charge, during which time he should visit some online Schizophrenia Support Forums. This may increase his self-esteem due to the feeling of ‘belonging’ to the forum, and will also provide structure for his days.
In conclusion, the best treatment programme for the current client will be to; provide injections of Resperidone ‘depot’ once a fortnight at the client’s GP surgery, provide 1-hour Cognitive Behavioural Therapy sessions with a therapist once a fortnight, and the client would be highly advised to spend at least 1 hour a week on the Schizophrenia support websites. A care plan will be devised, and the treatment can begin straight away. The care plan will be reviewed in 3 months’ time, at which point, any necessary changes can be made.
CONCLUSION
After reviewing the case study of Sean Murphy, it appears that he can receive a diagnosis of ‘Paranoid Schizophrenia’ providing various factors are investigated further; possible drug/substance abuse, details of previous psychiatric admission, history of medication and family mental health background. The most beneficial treatment plan for Sean would combine ‘depot’ Resperidone medication to reduce the severity of his delusions, alongside Cognitive Behavioural Therapy to address his social skills.
