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1. SCHIZOPHRENIA WORKSHEET Read the case studies and make a list of the symptoms presented and whether the diagnostic criteria is positive or negative. As an extension…
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  • 1. SCHIZOPHRENIA WORKSHEET Read the case studies and make a list of the symptoms presented and whether the diagnostic criteria is positive or negative. As an extension can you identify the sub types? NAME OF CASE SYMPTOMS PRESENTED POSITIVE OR Paranoid, catatonic or STUDY NEGATIVE disorganised? RICHARD LAURA ANNE MARIA ESTHER TODD ALAN ANDY JOEL
  • 2. SCHIZOPHRENIA WORKSHEET Categories of Schizophrenia in DSM-IV There are three types of schizophrenic disorders included in DSM-IV – disorganised, catatonic and paranoid –initially proposed by Kraepelin many years ago. The present descriptions of Kraepelin’s original types demonstrate the great diversity of behaviour that relates to the diagnosis of schizophrenia. Disorganised schizophrenia Kraepelin’s hebephrenic form of schizophrenia is called disorganised schizophrenia in DSM-IV. Speech is disorganised and difficult for a listener to follow. The patient may speak incoherently, stringing together similar sounding words and even inventing new words, often accompanied by silliness or laughter. He or she may have flat affect or experience constant shifts of emotion, breaking into inexplicable fits of laughter and crying. The patient’s behaviour is generally disorganised and not goal directed; for example, he or she may tie a ribbon around their big toe or move incessantly, pointing at objects for no apparent reason. The patient sometimes deteriorates to the point of incontinence, voiding anywhere and at any time, and completely neglects his or her appearance, never bathing, brushing teeth or combing hair. Catatonic Schizophrenia The most obvious symptoms of catatonic schizophrenia are the catatonic symptoms described earlier. Patients typically alternate between catatonic immobility and wild excitement, but one of these symptoms may predominate. These patients resist instructions and suggestions and often echo (repeat back) the speech of others. The onset of catatonic reactions may be more sudden than the onset of other forms of schizophrenia, although the person is likely to have previously shown some apathy and withdrawal from reality. The limbs of the person with catatonic immobility may become stiff and swollen; in spite of apparent obliviousness, he or she may later relate all that occurred during the stupor. In the excited state, the catatonic person may shout and talk continuously and incoherently, all the while pacing with great agitation. Catatonic schizophrenia is seldom seen today, perhaps because drug therapy works effectively on these bizarre motor processes. Alternatively, Boyle (1991) has argued that the apparent high prevalence of catatonia during the early part of the century reflected misdiagnosis. Specifically, she details similarities between encephalitis lethargica (sleeping sickness) and catatonic schizophrenia and suggests that many cases of the former were misdiagnosed as the latter. This was portrayed in the film “Awakenings”, which was based on the writings of Oliver Saks. Paranoid Schizophrenia The diagnosis paranoid schizophrenia is assigned to a substantial number of recently admitted patients to mental hospitals. The key to this diagnosis is the presence of prominent delusions. Delusions of persecution are most common, but patients may experience grandiose delusions, in which they have an exaggerated sense of their own importance, power, knowledge or identity. Some patients are plagued by delusional jealousy, the unsubstantial belief that their sexual partner is unfaithful. The other delusions described earlier, such as being persecuted or spied on, may also be evident.
  • 3. SCHIZOPHRENIA WORKSHEET Vivid auditory hallucinations may accompany the delusions. Patients with paranoid schizophrenia often develop ideas of reference; they incorporate unimportant events with a delusional framework and read personal significance into the trivial activities of others. For instance, they think that overheard segments of conversations are about them, that the frequent appearance of a person on a street where they customarily walk means that they are being watched, and that what they watch on television or read in magazines, somehow refers to them. Individuals with paranoid schizophrenia are agitated, argumentative, angry, and sometimes violent. But they remain emotionally responsive, although they may be somewhat stilted, formal and intense with others. They are also more alert and verbal than patients with other types of schizophrenia. Their language, although filled with references to delusions, is not disorganised. Evaluation of Subtypes Although these subtypes form the basis of current diagnostic systems, their usefulness is often questioned. Because diagnosing types of schizophrenia is extremely difficult, diagnostic reliability is dramatically reduced. Furthermore, these sub-types have little predictive validity; that is, the diagnosis of one over another form of schizophrenia provides little information that is helpful in either treating or in predicting the course of the problems. There is also considerable overlap among the types. For example, patients with all forms of Schizophrenia may have delusions. Kraepelin’s system of sub-typing has not proved to be a useful way of dealing with the variability in schizophrenic behaviour. Supplemental types included in DSM-IV are also flawed. The diagnosis of undifferentiated schizophrenia applies to patients who meet the diagnostic criteria for schizophrenia but not for any of the three sub-types. The diagnosis of residual schizophrenia is used when the patient no longer meets the full criteria for schizophrenia but still shows some signs of the illness. In spite of the problems with current sub-typing systems, there is continuing interest in differentiating different forms of schizophrenia. A system that is currently attracting much attention distinguishes between positive and negative symptoms (as opposed to types of patients) continues to be used increasingly in research on the aetiology of schizophrenia. Positive schizophrenia (type I). Characterised by the presence of abnormal behavioural symptoms such as hallucinations, increased dopamine receptors. Negative schizophrenia (type II). Characterised by the absence of what would normally be there – poverty of speech, flattening affect and social withdrawal associated with structural abnormalities of the brain. Andreasen and Olsen (1982) evaluated fifty-two patients with schizophrenia and found that sixteen could be regarded as having predominantly negative symptoms, eighteen as having predominantly positive symptoms, and eighteen as having mixed symptoms. Although these data suggest that it is possible to talk about types of schizophrenia, subsequent research has indicate that most patients with schizophrenia show mixed symptoms (e.g. Andreasen, Flaum et al., 1990) and that very few patients fit into the pure positive or pure negative types.
  • 4. SCHIZOPHRENIA WORKSHEET RICHARD, 23 YEARS OLD Richard remembered the period after his discharge from the army as one of the worst in his life. About two years after his return to civilian life, Richard left his job because he became overwhelmed by lack of confidence in himself, and he refused to look for another job. He stayed home most of the day. His mother would nag him that he was lazy and wouldn’t do anything. He became slower and slower in dressing and undressing and taking care of himself. When he went out of the house he felt compelled to ‘give’ interpretations of everything he looked at. He did not know what to do outside the house, where to go, when to turn. If he saw an arrow he would follow the arrow interpreting it as a sign sent by God that he should go in that direction. He was afraid to go out because it involved making decisions or choices that he felt unable to make. He stayed home most of the time. He gradually became worse, was completely motionless, and had to be hospitalised. ESTHER, 31 YEARS OLD Esther is an unmarried woman who lives with her elderly mother. A belief that the outside world is filled with radio waves that will insert evil thoughts into her head keeps Esther from leaving the house. The windows in her bedroom are ‘protected’ with aluminium foil that ‘deflects the radio waves’. She often hears voices that comment of these radio signals. ALAN 44 YRS "Suppose for just a minute that I am right about what is going on," Alan suggested one day. "You know how the CIA operates. They gather a tiny bit here and a tiny bit there-- most of it from easily available public sources--and they put it together like a giant anagram till, suddenly, it spells something meaningful." He went on further, stating, "If what I know is going on is true, then it makes sense that everyone denies the truth of what I am saying. Sure, it looks like there is some other good explanation for everything that happens. That's the way they would arrange it if they are smart and they are…I'm on to them and they don't know it yet. Everything looks innocent, sure. But that's the way they operate. You can't tell me that all the things that have happened are nothing but accidents. I know better.
  • 5. SCHIZOPHRENIA WORKSHEET ANN, 26 YEARS OLD Ann graduated from high school and from a school for commercial art. At the age of 18 she started going out with Henry. They became engaged shortly thereafter and went out together frequently until their marriage. Both found married life boring. There was little conversation between them. Ann’s disappointment in Henry increased. They had nothing in common; she was artistically inclined, whereas he had an ordinary, conventional outlook toward life. It was at this time that she started to go dancing and then met Charles. Her interest in him increased but she knew that she was married and that a divorce was not compatible with the precepts of the Catholic church. Her conflict grew and put her in a state of great agitation. One evening she came home from dancing and told her mother that she was going to give up her husband Henry, marry Charles, go to brazil with him, and have twenty babies. She was talking very fast and saying many things, several of which were incomprehensible. At the same time she told her mother she was seeing the Virgin Mary in visions. She then went to her mother-in-law and told her to take her son back because he was too immature. The following day Ann went to work and tried to get the entire office to go on their knees and recite the rosary. A few days later her mother took her to a priest whom she ‘told off’ and finally spat at. A psychiatrist was consulted and he recommended hospitalisation. MARIA, 19 YEARS OLD Maria is a college student who has been psychiatrically hospitalised for more than a month. For days before her admission, and for the weeks she has been in the hospital, Maria has been mute. Rigidly posturing her body and staring at the ceiling, she spends most of the day in a trance-like state that seems impenetrable. Her family and college friends are mystified. In trying to sort out why and when she began showing such odd behaviour, the only incident that could be recalled was Maria’s ranting and raving, just prior to going into the catatonic state, that one of her lecturer’s was a ‘demon’. TODD, 16 YRS OLD. His family had been noticing odd behaviours for some time. After starting Tai Chi lessons some months ago, he would assume karate like positions for lengthy periods, seemingly oblivious to anything going on around him. When taken to a hospital, he would assume such postures, and the psychiatrist could move his limbs and Todd would be "frozen" in that position for minutes at a time. He spoke rarely, and even when he answered his doctor's questions, little information would be conveyed.
  • 6. SCHIZOPHRENIA WORKSHEET ANDY, 24YRS. Andy was being treated at a medical facility for a self-inflicted mutilation of his penis, which he explained as the result of trying to get his girlfriend pregnant from long distance. He spoke about the special symbolism of words and numbers, and stopped to laugh inappropriately at times. He also stated that he was suffering because dwarfs had stuck him with green needles. Once in the mental hospital he was loud, threatening, and preoccupied with the sexual connotations of objects on the ward. He would indulge in open and prolonged masturbation. His speech was chatty, spontaneous, loud, and laced with delusional material JOEL 18 YRS Joel got into trouble from an early age; he did poorly in school and ran around with other marginal and delinquent boys. After dropping out of high school, he held unskilled jobs for periods of time but never got along well with co-workers or bosses. In his late teens he was arrested for attempted rape. His attorney found out that Joel had been mad at the woman, whom he had picked up in the bar, because he thought she could control his erections with her cigarette lighter. There was no particular evidence that Joel had hallucinations, but he held several delusional beliefs; none of them, however, were systematic or paranoid. LAURA, 40 YEARS OLD Laura’s desire was to become independent and leave home as soon as possible. She became a professional dancer at 20 and was booked for vaudeville theatres in many European countries. It was during one of her tours in Germany that Laura met her husband. They went to live in a small town in France after a year they decided to emigrate to the US. They had no children, and Laura showed interest in pets. She had a dog who became sick and partially paralysed, and vets felt there was no hope of recovery. Her husband asked her whether the dog should be destroyed. From that time on Laura became restless, agitated and depressed. Laura started to complain about the neighbours. A woman who lived below was knocking on the wall to irritate her. She woke up in the middle of the night under the impression that she was hearing noises from the apartment downstairs. She would become upset and angry at the neighbours. Later she became more disturbed. She started to feel that the neighbours were now recording everything she said; maybe they had hidden wires in the apartment. She started to feel ‘funny’ sensations. There were many strange things happening, which she did not know how to explain; people were looking at her in a funny way in the street; in the butcher shop, the butcher had purposely served her last, although she was in the middle of the line. During the next few days she felt that people were planning to harm either her or her husband. In the evening when she looked at television, it became obvious to her that the programs referred to her life. Often the people on the programs were just repeating what she had thought. They were stealing her ideas.
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