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Schizophrenia & Delusional Disorders

Case Study of Sally

Of the many psychiatric disorders, schizophrenia and paranoia are two that are perhaps most commonly known to the general public. Whether this is due to the rate of incidence or to the ease of characterizing the disorders in print, dramatizations, or media, is difficult to say. These two disorders are categorically similar and are taxonomically considered to be psychoses. There are three main classes of psychoses: Mood or Affective Disorders, Schizophrenic Disorders, and Paranoid or Delusional Disorders. The DSM-IV_TR definitions of Schizophrenia and Paranoia are long and complicated, though somewhat redeemed by the intriguing histories of the discovery and definition of the disorders -- and by the associated lore.

Schizophrenia. The term schizophrenia means split mind and it was first applied to the disorder by Bleuler in 1911, who thought the brains of schizophrenics developed an inability to integrate emotions, thoughts, and contact with reality (Acocella, 1999). Bleuler diagnosed the Polish / Russian ballet dancer Vaslav Nijinsky with the disorder at age 29 when, after three years of suffering from symptoms, Nijinsky had a complete breakdown and was sent to Switzerland to be treated by Bleuler (Acocella, 1999). The most fascinating aspect of Nijinsky's deterioration was that he wrote a diary over a period of six weeks in 1919 as he was descending into psychosis -- it is perhaps the only sustained account of its kind by an artist that is not a retrospective, and it has been published (Acocella, 1999).

For someone to receive a diagnosis of schizophrenia, The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) stipulates that a person must manifest two of the major symptoms of the disorder: "(1) delusions, (2) hallucinations, (3) grossly disorganized or catatonic behavior, (4) disorganized speech, or (5) negative symptoms" (American Psychiatric Association, 2000). Negative symptoms include flat affect, inability to speak, and profound lack of interest in goals, desire, or motivation. That said, if the "delusions are bizarre" or the "hallucinations involve voices commenting consistently or voices conversing with each other," then a diagnosis of schizophrenia can be given on the basis of only one of those two symptoms. To rule out single episodes that could easily be attributed to other causes, the constellation of symptoms must be present for at least a month, and there must be continuity of behavioral manifestation for at least six months. Symptoms that are precursors to (prodromal) or follow (residual) an active phase are common in the disorder. The types of behavioral and cognitive manifestations of the disorder that might be evidenced include, "somatic delusions, delusions of being controlled, thought broadcasting, and grandiose delusions" (Meyer, et al., 2009). Five subtypes of schizophrenia have been identified: "Paranoid, Disorganized, Catatonic, Undifferentiated, and Residual." (American Psychiatric Association, 2000).

The Case of Sally

Sally's early family life was a bit precarious (Meyer, et al., 2009 ) Her mother smoked and was seriously ill with a virus while carrying Sally (Meyer, et al., 2009 ) Sally's maternal grandfather was eccentric and somewhat of a loner (Meyer, et al., 2009 ) Sally exhibited a degree of hyperactivity, but talked and walked late (Meyer, et al., 2009 ) Her parents were combative and conducted a "long-term conflict-habituated marriage" (Meyer, 2009, p. 89). Her father was largely absent, and overly critical when present (Meyer, et al., 2009 ) Her mother maintained a "symbiotic relationship" with her daughter (Meyer, et al., 2009 ) Despite being quite bright, Sally's study efforts seemed always a bit disconnected so she did not receive good grades in school (Meyer, et al., 2009 ) Sally was not good at making and keeping friends, and this was exacerbated by her mother's possessiveness -- potential friends were subtly driven away (Meyer, et al., 2009 ) More and more of Sally's time was spent in the company of her mother or alone -- Sally developed increasingly odd mannerisms and interests as a result (Meyer, et al., 2009 ) Sally's schizophrenia reached an acute active stage when she went away to college (Meyer, et al., 2009 )

Behavioral components. Sally began having conversations with herself in her dorm room, causing the roommate assigned to her to move out (Meyer, et al., 2009 ) Sally withdrew into a catatonic state -- she sat unresponsive in a chair and just stared at the floor (Meyer, et al., 2009 ) If someone moved her arms or legs, they would stay as arranged (Meyer, et al., 2009 ) Her condition was labeled "waxy flexibility (Meyer, et al., 2009 )" After this serious acute attack, and a period of hospitalization, Sally recovered enough to go back to school (Meyer, et al., 2009 )

Sally's attendance in college classes became erratic and she became more reclusive (Meyer, et al., 2009 ) Sally evidenced a second acute phase and was re-hospitalized at the insistence of her father (Meyer, et al., 2009 ) Sally was able to obtain and keep a low-paying, low-demand job for a time (Meyer, et al., 2009 ) When not working, Sally stayed alone in her room or did jobs around the house (Meyer, et al., 2009 )

Apparently, in response to her mother's needy behavior, Sally did not come directly home from work but began to wander the streets and neighborhoods (Meyer, et al., 2009 ) Sally's behaviors become more deviant, until one day she was picked up by the police -- Sally had been wading in the shallow part of a pond in a park in town (Meyer, et al., 2009 ) She was heard muttering to herself (Meyer, et al., 2009 ) Sally was hospitalized and then transferred and admitted to a hospital for mentally ill patients (Meyer, et al., 2009 )

Biological components. Genetically at risk for odd or eccentric behavior (Meyer, et al., 2009 )

Cognitive components. The second acute episode caused Sally to exhibit a hebephrenic pattern in which she rocked or was unresponsive or burst out giggling (Meyer, et al., 2009 )

Emotional components. Parenting manifested attributes of a strained and combative marriage with varying degrees of competition for Sally's attention and compliance (Meyer, et al., 2009 ) The mother, in particular appeared to substitute hyper-focused attention on her daughter for expected and normal harmonious interactions with her husband (Meyer, et al., 2009 )

After her acute episode at college, Sally's mother brought her home (Meyer, et al., 2009 ) Sally's condition worsened (Meyer, et al., 2009 ) The cycle of Sally getting better, Sally being taken home by her mother, and Sally's mother "taking care of her" repeated (Meyer, et al., 2009 ) Sally's mother did not help Sally stay on her outpatient therapeutic regimen (Meyer, et al., 2009 )

Shortly after moving back home and working at a part-time job, Sally's father died from a heart attack (Meyer, et al., 2009 ) Following the death of her husband, Sally's mother exhibited more neediness and dependence on her daughter (Meyer, et al., 2009 )


Published in 1959, an article by argued that schizophrenic patients -- presumably young people -- act as mediators of a sort between emotionally disparate parents, albeit unsuccessfully (Bowen, et al., 1959). The authors suggest -- though their sample is admittedly small -- that the most frequent relationship pattern in the family is "an intense two-some between the mother and patient which excludes the father and from which he permits himself to be excluded' (Bowen, et al., 1959). The parents in this reciprocal relationship are "separated from each other by an emotional barrier which, in some ways, has characteristics of an 'emotional divorce'" (Bowen, et al., 1959). The tack taken in this article is characteristic of the times when parents were "blamed" for all types of problems with their children. A well-known example is Bruno Bettelheim's accusation of the refrigerator mother being the cause of her…[continue]

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