Mr. Jones the Schizophrenic: a Case Study

Rebecca Cronin December 11, 2000 Clinical Psychiatry Dr. R. Boland

Mr. Jones the Schizophrenic: A Case Study

Mr. Jones, a 46-year-old white male, comes to the Providence Center for long-term management of schizophrenia. A voluble and friendly man, Mr. Jones exemplifies many of complicated issues in the course and treatment of this disorder. In many ways, his course is typical of schizophrenia, but he also shows the marked variation in quality of life and symptomatic manifestations that can be associated with the disease. In addition, his case also raises important issues of both comorbid substance abuse and the unfortunate long-term effects of antipsychotic medication that can occur over the lifelong course of schizophrenia.

To begin, let us first discuss the criteria for the diagnosis of schizophrenia. Schizophrenia is defined in the DSM-VI as “a disorder that lasts for at least 6 months and includes at least 1 month of active- phase symptoms (i.e. two [or more] of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms.)”1 In addition, the patient must exhibit global criteria of marked social or occupational dysfunction, and exhibit a constellation of symptoms not better accounted for by either a drug induced psychosis or a general medical condition. Schizophrenia must also be differentiated from both Schizoaffective Disorder and Mood Disorder with Psychotic Features, which is complicated by the fact that many schizophrenics also exhibit a some signs of a mood disorder, usually a depression. Schizophrenia can also be broken down into different subtypes and described by the longitudinal course of the disease as seen at least 1 year after the initial episode.

Schizophrenia has been documented in cultures around the world, and has a prevalence of about 0.5-1.5% of the general adult population. The first “break” occurs in young adulthood, typically in the early – mid twenties for men and in the late twenties for women. The first psychotic episode can be either acute onset or insidious onset. Most individuals experience an insidious onset with a prodromal phase, which is usually noted by family members or friends as the patient becomes progressively withdrawn, uninterested in work or school, inattentive to personal hygiene and grooming, anger, and begins to exhibit peculiar behaviours. Eventually, the prodromal phase resolves into an active phase, with evidence of Criterion A symptoms. These symptoms must persist for 1 month, or be considered as likely to have continued for 1 month in the absence of treatment for those patients who access and respond to treatment early in an active episode. Also, some sign of dysfunction must be present for at least 6 months following the active phase. After the first year, the course can be characterized according to persistence of symptoms and characteristics of interepisodic periods.

Mr. Jones described a typical onset of schizophrenia, a “break” at age 25 when he experienced intense visual and auditory hallucinations. Before the acute episode, Mr. Jones recounted a history of intense alcohol abuse and a decrease in interest in his occupation. He said that he had previously been a very successful semi-professional golfer, but that he started to hang around with musicians and to abuse alcohol and other drugs, and left home to “see the country” in the company of the J. Giles Band. His “break” occurred after an intense alcohol binge, but his visual hallucinations persisted for weeks with alcohol abstinence, longer than can be explained by Delirium Tremens. Mr. Jones is unusual in that his hallucinations are primarily visual, not auditory as for the majority of schizophrenics. After his initial break, he tried to get his life back together, but eventually felt that he need to drink to “keep himself going.” With alcohol abuse, his hallucinations increased and he experienced more auditory hallucinations. This trajectory continued on a downward spiral for about a year. He then joined AA and sought treatment for his persistent hallucinations. He reports that he still has visual hallucinations, even with medication compliance, but also states that he is aware of the fact that they are hallucinations and “not really there.”

1Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. Mr. Jones also described in detail many of his delusions. His delusions are of the persecutory, referential, and grandiose type. He believes that most people are really angels, and that he has a special mission from the angels that must be protected from the CIA. He stated that he receives messages from “the ESP people,” who are really angels, encoded to him in music on the radio. The ESP people also sometimes put certain thoughts in his head (thought insertion) or steal his thoughts and incorporate them into popular music (thought withdrawal). He showed a surprising amount of insight during this discussion, repeatedly stating that he knew these things weren’t true, but he still thought them.

Mr. Jones did not recount or exhibit any negative symptoms. He displayed some degree of disorganized speech, and on the mini-mental status exam had some trouble drawing a clock, but his concentration, attention, calculation ability, and memory were all intact. During the interview he displayed some signs of tangentiality and circumstentiality, as well as some slight perseveration. However, for the most part his thoughts were organized, his speech was voluble, and his affect was animated and appropriate. This leads me to believe that Mr. Jones’ schizophrenia is of the paranoid subtype. This classification is supported by a relatively high level of social functioning. Mr. Jones is divorced but currently in a relationship with a woman in Florida, where he has been living for the past 8 months involved in a business deal. Also, Mr. Jones did not display prominent disorganized, catatonic, or negative symptoms, further helping us to define his disorder as Paranoid. Paranoid schizophrenics are more likely to be able to sustain social and occupational function, have a greater capacity for independent living, and have a better overall prognosis. With regards to course, Mr. Jones is best described as Continuous without prominent negative symptoms, in that his hallucinations and delusions persist even with medication and have persisted for the majority of time since his first active phase.

As mentioned above, Mr. Jones’ case points out some of the difficulties of long-term treatment of schizophrenia. In particular, schizophrenics have high incidence of concurrent substance abuse, such as Mr. Jones’ alcoholism and heavy smoking (80%-90% of schizophrenics are smokers )2. While Mr. Jones does not currently drink, he describes in the past having gone off his medication during alcohol binges. Substance abuse must be treated along with schizophrenia to ensure compliance and avoid exacerbation of psychosis. Also, Mr. Jones exhibits a medication-induced movement disorder. During the interview he was unable to stop moving and also demonstrated twitching and spasm, indicating probable tardive dyskinesia, a frequent side effect of anti-psychotic medication. Mr. Jones is aware of his constant movement and but says he tries not to be embarrassed by it. This is just one example of the noxious side effects of anti-psychotic medication that contribute to non-compliance.

Despite the difficulties Mr. Jones has faced during the course of his illness, he says that he remains optimistic. He does not feel badly about being a schizophrenic. In this he is again an exception. Unfortunately for patients, and their families, schizophrenia is usually a devastating disease that severely limits social and occupational functioning. Schizophrenia remains, for most patients, a difficult and heartrending disorder.

2 DSM-IV-TR, p. 304.