CASE STUDY for Schizophrenia and Other Psychotic Disorders Janet Three months into Janet’s freshman year, her parents were summoned by the dean of the small out-of-town college she was attending to come and pick up their daughter. The dean said Janet was behaving strangely. She had begun to wander around the campus at night, barefoot and dressed only in a short nightgown. According to her roommate, Janet had “not been herself” for the past six weeks. She had stayed in her room continuously, hoarded food, wrote incessantly, and refused to attend classes except for one taught by Dr. M., an older married man with whom Janet had become intensely preoccupied. She acted a if she were in her own world. She was unapproachable and was irritated by her roommate’s attempts to converse. During the past few weeks, Janet had talked to herself frequently. It sounded to her roommate like one-half of a dialogue about what Janet and Dr. M. should do, and whether he was angry with her. Janet’s parents found their daughter in an extremely agitated state. She was dressed in a bizarre way, wearing all kinds of mismatched clothing that was inappropriate for the weather as well as for the setting. She was unkempt and obviously had not bathed. At first she was unresponsive and barely acknowledged her parents’ presence. When she did speak she became overexcited. She explained repeatedly that she had to stay at college because Dr. M. was passionately in love with her. She said he was unable to come to her because his wife kept him imprisoned at home at night. She reported that “voices” commanded her to unite with Dr. M at any cost in order to save the world from destruction. Janet also was convinced that Dr. M.’s wife was reading her thoughts and now intended to harm her. When Janet’s parents told her they were taking her home, she became violent. She attacked them and wrecked her dorm room. Her words indicated that she was experiencing her parents’ efforts as an attack by some dangerous beings, and she argued vehemently but incoherently with these persecutors. The police were called and Janet was taken to the emergency room of the local hospital. The threatening and acutely alarming nature of her hallucinations led staff psychiatrists to conclude that Janet was a danger to herself and others. Immediate hospitalization was advised. Upon admission, Janet was so out of control she had to be put in restraints until the medication she was given began to take effect. Janet was especially fearful that the hospital staff was collaborating with Dr. M.’s wife. She thought they were incarnations of evil forces intent on keeping Janet and Dr. M. apart so that they could not save the world. Janet became more subdued as her medication took effect, but she continued to be uncommunicative around the ward. Although the acute phase of condition passed, the general prognosis for full recovery was guarded because of indications that this episode was only one part of a long and insidious process of deterioration. Clinical Discussion Several features of the acute onset of Janet’s disordered condition are typical of schizophrenia, including her rapid deterioration and its occurrence during her first major separation from home. Her parents reported that she always had been a shy and socially awkward and sensitive girl. For a time around age seven, she had refused to go to school. The whole family had undertaken a brief therapy designed to enable Janet to return to school. This seemed to clear up her behavior enough for her to attend school, but she she was not happy. During early adolescence, Janet began to have frequent arguments with her mother. On several occasions, these arguments culminated in a self-destructive act. On one occasion Janet scratched her wrists with a razor blade in front of her mother, following which the school psychologist referred her to therapy. Janet refused to go, although her more provocative and worrisome behavior decreased after this episode. Janet continued to behave eccentrically, like needing to engage in complex rituals in order to go to sleep, or not wanting to be seen eating, but these behaviors were accommodated by her family and others. The depth of Janet’s anxiety and the rigidity and fragility of her coping mechanisms, therefore, were masked while she remained at home. These quickly broke down, however, when she left the safety and supportive atmosphere of her accustomed surroundings and family. Within her unfamiliar new environment, Janet found it impossible to feel safe. Her “substitute reality” enabled her to feel more secure. In her fantasies, she attained the special status of being desired by an important person, Dr. M. Also, dwelling exclusively on this one relationship helped limit her focus so that she felt less overwhelmed by all the new surroundings. She explained her anxiety about the imagined danger she was in as due to threats to her ties with Dr. M. She saw these threats as coming both from his wife and from the hospital staff. The pervasive sense of terror that accompanied her internal disintegration required a broader explanation, however, which became her conviction of impending world destruction. Her preoccupation with Dr. M. was a desperate attempt to save herself from this psychological catastrophe. The theme of salvation in her delusional system (Janet and Dr. M. were to unite to save the world) illustrates her hope of being rescued. Her parents, the dean, her roommate, and the hospital staff all were part of a threatening system that stood between Janet and the safer alternative reality she had constructed. The elaborateness of Janet’s alternative reality makes it a systematized delusion. In this complex story Janet uses a paranoid type of delusion to try to make sense of her anxiety and thereby to control it. Accompanying the delusional system is Janet’s overall decline in hygiene, daily functioning, appearance, and ability to manage her impulses in response to being challenged. The broad sweep of these disruptions indicates that the delusional system was failing to contain her overall breakdown. The appearance of mistaken sensory perceptions (in this case hearing voices) indicates the presence of auditory hallucinations, which often are part of a schizophrenic process. While delusions reinterpret the meanings of things, hallucinations change the actual intake of reality through the perceptions. Janet’s hallucinations instruct her about increasingly terrifying inner experiences (called command hallucinations). These, in turn, give rise to a concern that she might endanger herself or others because she ins unable to use judgment and reality testing, and because she is fearful and reacts explosively to anything she views as a threat. This explains why she was hospitalized, even though she wasn’t voicing a direct threat at the moment. The outcome for Janet is unsure. While some of her more florid symptoms may be controlled by medication, indications of weakness in her adaptation are long-standing and began years before the onset of the acute schizophrenic phase. Her ability to resolve this crisis effectively is in doubt, less because of the presence of delusions and hallucinations than because of her long history of weakness in psychosocial functioning. Case Questions 1. What is the precipitating stressor event that probably triggered the onset of Janet’s schizophrenic episode? What other factors may have contributed? 2. Identify Janet’s primary delusion. How can we understand this as a way that Janet is trying to “make sense” of her collapsing world? How do her hallucinations fit together with her delusion? 3. Janet’s hospitalization both makes her available for treatment and protects her and others. Explain the nature of danger to Janet and others that exists in her current acute condition.