Lecture Three

We have mentioned that severe, long term mental illness may have both an acute and a residual phase. Schizophrenia is one of those conditions which has residual effects that cause the individual to continue to experience some limitations even though active delusions or hallucinations are no longer present.

Diagnostic Criteria for 295.60 Residual Type

A type of schizophrenia in which the following criteria are met:

Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attentuated form (odd beliefs, unusual perceptual experiences).

Consider the following case Study:

A tall, well-groomed, 30 year old African AMerican man walked into the emergency room of a large urban hospital, registered under the name Harry Backman, and asked to be admitted to Ward Three if the psychiatric division. He claimed that, despite the fact that all of his identification cards bore the name Harry Backman, his real name was Johnson. "And your first name?" asked the resident psychiatrist. "We're not allowed to divulge our first names," he confided. He went on to explain that in fact he was Agent Johnson, an FBI agent on a mission to find Harry Backman, who had last been seen in Pittsburgh several years earlier. He claimed to have followed Harry from city to city, often posing as a patient in a psychiatric hospital where Harry had been treated in order to obtain information about him. Harry had a seizure disorder for which he took phenytoin and primidone, and he , and he had also taken trifluoperazine in the past. Agent Johnson did not take any medications. Communicating with his spuperiors at the FBI via a high frequency radio stashed in his bag. Agent Johnson had come to the hospital in order to be admitted to the very ward on which Harry Backman had been treated as a ten year old boy, in order to seek clues about Harry's whereabouts. The patient had confided his fear that the "real" Harry was, in fact, dead, and that an imposter might be posing as Harry in order to collect his welfare checks.

During the interview, the patient was generally cooperative and engaging. His affect ranged from serious to jocular, and when his story was challenged, he became defensive and hositle. There was no evidence of disorganized speech, cognitive impairment, or hallucinations. Results of a physical examination, including a thorough neuroloigcal examination, and all laboratory tests were normal.

A call to the shelter where Agent Johnson lived confirmed that his name was Harry Backman, that he carried a diagnoses of chronic Schizophrenia and seizure disorder, and that he was maintained on trifluoperazine, phenytoin, and primidone. These medications were subsequently prescribed by the emergency room physician. In addition, a social worker at the shelter said that Harry had been wandering the streets in the past few days, frequently not returning to the shelter at night. She had not wirnessed any seizures, and she did not know anything about Agent Johnson.

On the following day, the patient had a generalized tonic-clonic seizure, lasting approximately two minutes, during which he hit his head on the floor. He was treated in the medical emergency room; all tests, including a computed tomography scan, were normal. After a brief period of postictal confusion, the patient woke up. He responded to the name Harry and acknowledged that he had had a seizure. The confused resident scratched her head and said, "But I thought Harry had a seizure disorder!" " I AM Harry!" said the patient with a smile, "I've found him."

(Spitzer, R., Gibbon, M., Skodol, A., Williams, J. and First, M., 1994, pp.5-6)

This case study illustrates both an acute phase of Harry's illness and some reports from others who had known Harry at other times. It is likely that even in his best times, Harry would speak of himself as two separate entities and would recount his delusions as if they were events which had really happened.

Food for Thought:

How is Harry like some of your clients who experience severe mental or cognitive disabilities?

Have you ever witnessed someone in an acute phase of their illness? What was it like? How did others reacte? How was this individual eventually treated? What happened?

Schizoaffective Disorder

Another type of psychotic disorder carries with it symptoms resembling both a mood disorder and schizophrenia. Although you may not notice a difference in the way these individuals behave when compared with others experiencing a bipolar or depressive disorder or even schizophrenia, the mood component of the condition is responsive to antidepressant medication. Schizophrenia is treated primarily with antipsychotic medications. Appropriate diagnosis of the disorder in this case makes a tremendous difference in the course of treatment.

295.70 Schizoaffective Disorder

An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.

Note: The Major Depressive Episode must include Criterion A1: depressed mood.

During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify type:

Bipolar Type: if the disturbance includes a MAnic or Mixed episode (or a Manic or Mixed Episode and Major Depressive Episodes)

Depressive Type: if the disturbance only includes Major Depressive Episodes.

Personality Disorders

A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. These conditions can coexist with other mental disorders that have a biological origin. Because personality disorders develop over a lengthy period of time and serve to ensure that an individual gets what they want from life and relationships, they are resistant to treatment. Medication has little effect on aspects of personality and psychotherapy is often based upon the willingness of the individual to open themselves to positive change. Individuals with personality disorders have learned ways for dealing with stress, avoiding conflict or challenge, and getting what they want and need in ways that are disturbing to others and seen as dysfunctional. As you read the descriptions below, you may notice that many of the mechanisms chosen by individuals with personality disorders are mechanisms adopted by almost everyone at some point in their lives. However, most individuals are able to change their mechanisms for dealing with issues as is appropriate to the situation. Individuals with personality disorders tend to approach all of life's situations with the same pattern of perceptions, reactions, and behaviors. Many times, people with personality disorders are seen as manipulative, immature in their emotional reactions, unpredictable, explosive, and by-and-large pretty troublesome.

Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that other's motives are interpreted as malevolent.

Schizoid Personality Disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.

Schizotypal Personality Disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricites of behavior.

Antisocial Personality Disorder is a pattern of disregard for, and violation of the rights of others.

Borderline Personality Disorder is a pattern of instability in interpersonal relationships, self image, and affects, and marked impulsivity.

Histrionic Personality Disorder is a pattern of excessive emotionality and attention seeking.

Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Dependent Personality Disorder is a pattern of submissive and clinginig behvior related to an excessive need to be taken care of.

Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control.

You may recognize a number of these traits in your clients. The personality patterns we develop affect the way we perceive, relate to, and think about our environments and ourselves. You may be reminded of clients of yours who seem less interested in actually working than they are in being present in the program and holding onto a pattern of dysfunctional behaviors. The reaction of others to people with a personality disorder often sounds a lot like this:

"Boy, he got me again. I really thought I had convinced that he should take that job. He agreed that he had all the qualifications and was certainly ready to go back to work. He sat right there and said all the right things. He even called to went to the interview and did exactly what we discussed. So the first day of his job went really well and I complimented him on it. It was as if me saying it was the cue for him to self destruct. He started off calling me every day on his break and then two or three times while he was supposed to be working. I thought he was just panicked so I made a point to meet him a few times before he clocked in, just to give him some reassurance. But he kept calling more and more until finally I told him that I couldn't be there every morning. So he walked right in and quit his job. I heard him laughing about it a few days later. He told his buddies that he didn't want a job anyway. He was just trying to keep me hopping!"

Here's another case study for you.

"During the course of a routine physical examination, Nick, a 25-year-old single, African American man, suddenly started crying, and blurted out that he was very depressed and was thinking about a suicide attempt he had made when he felt this way as a teenager. His doctor referred him for a psychiatric evaluation.

Nick is tall, bearded, muscular, and handsome. He is meticulously dressed in a white suit and has a rose in his lapel. He enters the psychiatrist's office, pauses dramatically, and exclaims, "Aren't roses wonderful this time of the year?" When asked why he has come for an evaluation, he replies laughingly that he has done it to appease his family doctor "who seemed worried about him." He has also read a book on psychotherapy, and hopes that "maybe there is someone very special who can understand me. I'd make the most incredible patient." He then takes control of the interview and begins to talk about himself, after first remarking, half jokingly, "I was hoping you would be as attractive as my family doctor."

Nick pulls out of his attache case a series of newspaper clippings, his resume, photographs of himself, including some of him with famous people, and a photostatted dollar bill with his face replacing George Washington. Using these as cues, he begins to tell his story.

He explains that in the last few years he has discovered some now-famous actors, one of whom he describes as a "Physically perfect teenage heart throb". He volunteered to coordinate publicity for the actor, and as part of that posed in a bathing suit scene that resembled a famous scene from the actor's hit movie. Nick, imitating the actor's voice, laughingly, and then seriously, describes how he and the actor had similar pasts. Both were rejected by their parents and peers, but overcame this to become popular. When the actor came to town, Nick rented a limosine and showed up at the gala "as a joke", as though he were the star himself. The actor's agent expressed annoyance at what he had done, causing Nick to fly into a rage, When Nick cooled down, he realized that he was "wasting my time promoting others, and that it was time for me to start promoting myself". "Someday," he said, pointing to the picture of the actor, "he will want to be president of my fan club."

Nick has had little previous acting experience of a professional nature, but he is sure that success is "only a question of time". He pulls out some promotional material he has written for his actors and says, "I should write letters to God-He'd love them!" When the psychiatrist is surprised that some materials are signed by a different name than the one Nick has given the receptionist, Nick pulls out a document explaining the name change. He has dropped his family name and taken as his new second name his own middle name.

When asked about his love life, Nick says he has no lover, and this is because people are just "superficial". He then displays a newspaper clipping in ehich he had letters his and his ex-lover's names in headlines that read : "The relationship is over". More recently he has dated and adored a man with the same first name as his own; but as he became disenchanted, he realized that the man was ugly and was an embarrassment because he dressed so poorly. Nick then explains that he owns over 100 neckties and about 30 suits, and is proud of how much he spends on putting himself together. He has no relationships with other homosexual men now, describing them as "only interested in sex". He considers heterosexual men as "mindless and without aesthetic sense". The only people who have understood him are older men who have suffered as much as he has. "One day, the mindless, happy people who have ignored me will be lining up to see my movies."

Nock's alcoholic father was very critical of him, was rarely around, and had many affairs. His mother was "like a friend". She was chronically depressed about her husband's affairs and turned to her son, often kissing him on the lips, until he was 18, when she started an affair of her own. Nick then felt abandoned and made his suicide gesture. He described a tortured childhood, being picked on by his peers for looking odd, until he began body building.

At the end of the interview, Nick is referred to an experienced clinician associated with the clinic, who charges a minimal fee (10dollars) which he can afford. However, Nick requests a referral to someone who would offer him free treatment, seeing no reason for paying anyone as the therapist "would be getting as much out of it" as he would.

(Spitzer, R, et al, 1994, pg.84-85)

Final Thoughts:

This is a lot of reading and digesting! You will not be expected to know all of these diagnoses by heart of course. My hope is that when you encounter a client record with these diagnoses, you would have some basic understanding of the condition and what behaviors you might expect to encounter. Our Quiz for this lecture will deal with how these various conditions might be expected to effect the vocational readiness of individuals. I will be asking you to make some mental application of this material rather than recite criteria. I hope you enjoyed thinking about these conditions and how they might look in the lives of people you have encountered. I'm looking forward to our discussion on Wednesday.