schizophrenia case study class 12

Psychology Project Class 12 CBSE – Schizophrenia

Table of Contents

The word schizophrenia – which translates roughly as “splitting of the mind” and comes from the Greek roots Schein [ to split] and phren [mind] was coined by Eugene Bleuler in 1908 and was intended to describe the separation of functions between personality, thinking, memory and perception. American and British interpretation of Bleuler leads to the claims that he described its main symptoms as A’s:

Flattened affects, autism, ambivalence, and impaired association of ideas.

Bleuler realized that the illness was not a demotion , as some of the patients improved rather than deteriorated and thus proposed the term schizophrenia instead.

Treatment was revolutionized in the mid-1950s with the development and introduction of chlorpromazine.

In the early 1970s, the diagnostics criteria for schizophrenia were the subject of a number of controversies while eventually led to the operational criteria used today. It became clear after the 1971 US_UK diagnostic study that schizophrenia was diagnosed to a far greater extent in America than in Europe. These were some of the whole DSM manuals, recently in the publications of the DSM-III in 1930.

The term schizophrenia is commonly misunderstood to mean that affected persons have a “split personality.” Although some people diagnosed with schizophrenia may hear voice and may experience the choice as distinct personalities, schizophrenia does not involve a person changing among a distinct, multiple personalities, schizophrenia does not involve the confusion arises due to literal interpretation of Bleuler’s term “schizophrenia [Bleuler originally associates schizophrenia  with dissociation and included split personality in his category of schizophrenia]. Dissociative identify disorder [having a split personality] was also often misdiagnosed as schizophrenia based on the loose criteria in the DSM-II. The first known misuse of the term to mean “split personality” was in an artist by the poet T.S Eliot in 1933. Other scholars have traced earlier roots. Rather the term means a “splitting of mental function reflecting the presence of the illness.”

• Disorder – Schizophrenia
• Specialty – Psychiatry
• Symptoms – False reliefs, Confused thinking, Voices
• Usual Unset – Early adulthood
• Duration – Chronic
• Causes – Environment and genetic factors
• Risk Factor – A problem during pregnancy, raised in a city
• Diagnosis Method – Counseling, job training
• Treatment Medication – Antipsychotics
• Prognosis – 18 years shorter life expectancy

SIGNS AND SYMPTOMS

Individuals with schizophrenia may experience hallucination [ most reported are hearing voices] delusion and disorganized thinking and speech. That may range from loss of train of thought to sentence only connected in meaning, to speech that is not understandable known as word salad social withdrawals, sloppiness and hygiene, and loss of motivation and judgment are all common in schizophrenia.

Distortions of self-experience such as feeling as if one’s thoughts or feeling s are not really one’s own to reliving thoughts are being inserted into one’s mind sometimes termed passively phenomenon is also common. There is often an emotional difficulty, for example, lack emotionally responsive, particularly to stressful or negative stimuli and that such withdrawal, irritability, dysphoria and clumsiness before the onset of the diseases children who go on to develop schizophrenia may also demonstrate decreased intelligence, decreased motor development, isolated play preferences, social anxiety, and poor school performances.

A combination of genetic and environmental factors play a race in the development of schizophrenia. People’s inter-family history of schizophrenia who have a technique has a 20-40% chance of being diagnosed one year later.

GENETIC FACTORS

An estimate of heritability varies because of the difficulty in separating genetic and environmental influences, averages of 0.80 have been given. The greatest single risk factor for developing schizophrenia has a first-degree relative with the disease more than 40%, negative stimuli, and such sensitivity may cause vulnerability to symptoms or be the disorder. Some evidence suggests that the context of delusional beliefs and psychotic experience can reflect emotional causes of the disorder and that now a person interprets such experience can influence symptomatology. Further evidence for the role of psychological mechanisms comes from the effects of psychotherapies on symptoms of schizophrenia.

POSITIVE SYMPTOMS

Positive symptoms are those that most individuals do not normally experience, but are present with schizophrenia. They can include delusion, disordered thought, and speech and tactile, auditory, visual, olfactory, and gustatory typically regard as Manifestation of psychosis. Hallucinations are also typically related to the content of the delusional theme.

NEGATIVE SYMPTOMS

These are deficits of normal emotional responses or to other thought processes and less responsive to medications. They commonly include flat expressions or little emotions, poverty , lack of form relationships, lack of motivation. Negative symptoms appear to contribute more to people’s quality of life, functional, and the other than symptoms do. People with greater negative symptoms often have a history of poor adjustment before the onset of illness, and response to medications is often limited.

COGNITIVE DYSFUNCTION

The deficit in cognitive activities is widely recognized as a core feature of schizophrenia. The extent of the cognitive deficit an individual’s experiences are the predictions of how functional an individual will be in maintaining treatment. The presence and degree of cognitive dysfunction in an individual with schizophrenia has been reported to be an indicator of functionality than the presentation of positive or negative symptoms. The deficits impacting the cognitive function are found in a large number of areas: working memory, long-term memory, semiotic processing, episodic memory, attention, learning.

Late adolescence and early adulthood are peak periods for the onset of schizophrenia, critical years in a young adult social, and sanction development. In 20% of men and 23% of women diagnosed with schizophrenia, the condition manifested itself before the age of 19-20 minimize the developmental disruption associated with schizophrenia, much work has recently been done to identify and treat the pre-onset phase of the illness, which has been detected up to 30 months before the onset of symptoms. Those who go on to develop schizophrenia may experience transient or self-thinking psychotic symptoms of social.

SUBSTANCE USE

• Almost half of those with schizophrenia use drugs or alcohol excessively. Puephetonime , cocaine, and to lesser extent alcohol, can result in a transmit stimulant psychosis or alcohol-related psychosis that present very similarly to schizophrenia although it is not generally believed to cause of the illness, people with schizophrenia use nicotine at a much higher rate than the general population
• Alcohol use can occasionally cause the development of the chlorine, induced psychotic disorder via a kindling mechanism. Alcohol use is not associated with an earlier onset of psychosis.
• Cannabis can be a contributory factor in schizophrenia, potentially causing the disease in those who are already at risk.

The first time psychiatrist treatment for this is antipsychotic medication, which can reduce the positive symptoms of psychosis in about 7 to 14 days. Antipsychotics, however, fail to improve negative symptoms and cognitive dysfunction significantly. Those on antipsychotics, continued use decrease the risk of release. However, the use of antipsychotics can use to dopamine hypersensitivity, increasing the wish of symptoms if antipsychotics are stopped.

The choice of which to use is based on benefits, risks, and costs. It is debatable whether, as a class, typical or typical antipsychotics are amisulpride, olanzapine, risperidone, and clozapine may be more effective are associated with greater side effects. Typically antipsychotics have equal drop-out, and symptoms replace races to when used at low to moderate dosages.

There is a good response in 40-50%, a postal response in 30-40% acid treatment resistance failure of symptoms to responds satisfactorily after in weeks schizophrenia occurs along with obsessive-compulsive disorder[OCD] considerably more often than could be explained by chance, although it can be difficult to distinguish obsession that occurs in OCD from the delusion of schizophrenia .

Prevention of it is difficult as there are no reliable for the later development of the disorder. There is tentative evidence for the effectiveness of early inventions to prevent schizophrenia. While there is some evidence that early intervention of those with a psychotic episode may improve short-term outcomes, there is a little benefit from these measures after five years. Accounting to prevent schizophrenia in the prodrome phase is to uncertain benefit and, therefore, as of 2009, is not recommended. Cognitive-behavioral therapy may reduce the risk of psychosis in those at high risk.

TYPES OF SCHIZOPHRENIA

• Paranoid : delusions or authority hallucinations are present, thought disorder, disorganized behavior, or affecting flattering are an illusion and persecutory and organized, put some addition to these, either themes such as religiosity or somatic may be present.
• I have disorganized : named hebephrenic schizophrenia in the ICD where thought disorder and flat affects are present together.
• Catatonic : the subject may be almost immobile or exhibit agitated purposes. Symptoms can include and waxy flexibility .
• Undifferentiated : psychotic symptoms are present, but the criteria for paranoid, disorganized, or catatonic types have not been met.
• Residual : where the positive symptoms are present at a low intensity only.

DIFFERENTIATED DIAGNOSIS

Psychotic symptoms may be present in several other mental disorders, including borderline personality disorder, drug intoxication, and drug-induced psychosis. Delusion is also present in delusional disorder, and social withdrawal in social anxiety disorder and social avoidant personality disorder has symptoms that are similar out less severe than those of schizophrenia, and being unloved or abused increases the risk of psychosis. Living in an urban environment during childhood or as an adult has consistently even found to increase the risk of schizophrenia by a factor even after taking into account drug user, and size and social group, other factors that play an important role include social isolation schizophrenia and imagination related to social adversity. Racial discrimination, family dysfunction, unemployment, and poor housing conditions.

It has been hypothesized that in some people, the development of schizophrenia is related to dysfunction such as the sun with non-celiac gluten sensitivity or abnormalities in the intestinal flora. A subgroup of a person with schizophrenia presents an immune response to gluten different from that found in people with celiac, with elevated of certain serum.

A number of attempts have been made to explain the link between altered brain function and schizophrenia. One of the most common is the domains hypothesis, which attributes psychosis to the mind’s faulty interpretation of the misfiring of aspanimgic neurons.

PSYCHOLOGICAL

Many psychological mechanisms have been implicated in the development and maintenance of schizophrenia. Cognitive basis has been identified in those with the diagnosis or those at risk, epically when under stress or in a confusing situation. Some cognitive features may reflect global neurocognitive deficits such as money loss, while others may be related to particular issues and experiences.

DEVELOPMENT FACTORS

Factors such as hypoxia and infection, or stress and malnutrition schizophrenia in the mother during fetal development, may result in a slight increase in the risk of schizophrenia are more likely to have been in winter or spring/ at least in the northern hemisphere, which may be a result of increased of viral exposure in the uterus. The increased risk is almost five to eight percent. Other inflection during pregnancy is around one time with that may increase the risk included toxoplasma Gondi and Finlandia.

RESEARCH DIRECTIONS

Research has found a tentative benefit in using to treat schizophrenia. Nidotherapy is changing the environment to improve their ability to function is also being studied; however, there is not enough evidence to make a conclusion about its effectiveness.

Negative symptoms have proven a challenge to treat, as they are generally not made better by medication of various agents have been exposed for possible benefits in this area, there have been trials on drugs with anti-inflammatory activities used on the premises that inflammation a role in the pathway might play schizophrenia.

The primary treatment of schizophrenias antipsychotic medications, often in combination with psychological and social supports. Hospitalization may occur for either voluntarily or [if mental legislation allows it ] involuntarily. Long-term hospitalization is uncommon since dunstisthonatization beginning in the 1950s, although it still occurs. Community support service, including drop-in centers, visits by members of a community mental health team, supported employment and supports group, is common. Some evidence indicates that regular exercise has a positive effect on the physical and mental health of those with schizophrenia.

Schizophrenia has great human and economic costs. It represents a decreased life expectancy by 10-20 years. This is primarily because of its association with obesity, poor diet, sedentary lifestyles, and smoking, with an increased rate of suicide playing a lesser role, antipsychotic medications may also increase the risk. These differences in life expectancy increased between the 1970s and 1990s.

Schizophrenia I a cause of disability with active psychosis ranked as the third most disability after guardipragia and dementia and of paraplegia and blindness.

Approximately three-fourths of people with schizophrenia have ongoing disability with relapse, and [6.7 million people globally are deemed to have moderate or severe disability from the condition. Some people do recover completely, and others function well in society. Most people with schizophrenia independently with community supports. About 85% are unemployed. People with the first episode of psychosis a good long-term outcome occurs in 42%, an immediate outcome 35%, and a poor outcome in 27%. Outcomes for schizophrenia appear better in the developed world.

SOCIETY AND CULTURE VIOLENCE

People with the same mental illness, including schizophrenia, are at a significantly greater risk of being victims of both violent and non-violent crimes. Schizophrenia has been associated with a higher rate of violent acts but not appear to be related to associate substance abuse. Rate of homicides liked to psychosis are similar to those linked to substance misuse, and parallel the overall rate in a violence independent of drug misuse is controversial, but certain aspect if individual historic or mental states may be factor absent 11% of people in prison suicide have been schizophrenia had while   2% have mood disorder. Ameer’s study found about 8-10% of people in which schizophrenia has had committed a violent act in the past year compared to 2% of the general population.

ACKNOWLEDGMENT:

I am very thankful to everyone who supported me, for I have completed my project effectively and moreover on time. I am overwhelmed in all humbleness and gratefulness to acknowledge my depth to all those who have helped me to put these ideas well. I am equally thankful to my psychology teacher Mrs.Ritu. She gave me moral support and guided me in difficult matters regarding the topic with the help of valuable suggestions and encouragement. I would like to thank my parents, who, despite their busy schedule, gave me different ideas in making this project unique.

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

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Very early-onset psychosis/schizophrenia: Case studies of spectrum of presentation and management issues

Jitender aneja.

1 Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Kartik Singhai

Karandeep paul.

Schizophrenia occurs very uncommonly in children younger than 13 years. The disease is preceded by premorbid difficulties, familial vulnerability, and a prodromal phase. The occurrence of positive psychotic symptoms such as delusions and hallucinations depends on the level of cognitive development of child. Furthermore, at times it is very difficult to differentiate the psychopathology and sustain a diagnosis of schizophrenia in view of similarities with disorders such as autism, mood disorders, and obsessive compulsive disorders. Here, we present three case studies with varying presentation of childhood-onset psychosis/schizophrenia and associated management issues.

Introduction

Schizophrenia is a chronic severe mental illness with heterogeneous clinical profile and debilitating course. Research shows that clinical features, severity of illness, prognosis, and treatment of schizophrenia vary depending on the age of onset of illness.[ 1 , 2 ] Hence, age-specific research in schizophrenia has been emphasized. Although consistency has been noted in differentiating early-onset psychosis (onset <18 years of age) and adult-onset psychosis (onset >18 years), considerable variation is observed with regard to the age of childhood-onset schizophrenia or very early-onset psychosis/schizophrenia (VEOP/VEOS).[ 2 , 3 ] Most commonly, psychosis occurring at <13 years of age has been considered to be of very early onset and that between 13 and 17 years to be of adolescent onset.[ 4 ] Furthermore, VEOS has been considered to be rare and shown to have differing clinical features (including positive and negative symptoms, cognitive decline, and neuroimaging findings), course, and outcome when compared with that of early-onset or adult-onset schizophrenia.[ 3 ] Progress in acknowledgement of psychotic disorders in children in the recent times has led primary care physicians and paediatricians to increasingly serve as the principal identifiers of psychiatrically ill youth. In recent years, there has been substantial research in early intervention efforts (e.g., with psychotherapy or antipsychotic medicines) focused on the early stages of schizophrenia and on young people with prodromal symptoms.[ 5 ] Here, we report a series of cases with very early onset of psychosis/schizophrenia who had varying clinical features and associated management issues.

Case Reports

A 14-year-old boy, educated up to class 6, belonging to a family of middle socioeconomic status and residing in an urban area was brought with complaints of academic decline since 3 years and hearing voices for the past 2 years. The child was born out of a nonconsanguineous marriage, an unplanned, uneventful, but wanted pregnancy. The child attained developmental milestones as per age. From his early childhood, he was exposed to aggressive behavior of his father, who often attempted to discipline him and in this pursuit at times was abusive and aggressive toward him. Marital problems and domestic violence since marriage lead to divorce of parents when the child attained age of 10 years.

The following year, the child and the mother moved to maternal grandparents’ home and his school was also changed. Within a year of this, a decline in his academic performance with handwriting deterioration, and irritable and sad behaviour was noted. Complaints from school were often received by the mother where the child was found engaged in fist fights and undesirable behavior. He also preferred solitary activities and resented to eat with the rest of the family. In addition, a decline in performance of daily routine activities was seen. No history suggestive of depressive cognitions at that time was forthcoming. A private psychiatrist was consulted who treated him with sodium valproate up to 400 mg/day for nearly 2 months which led to a decline in his irritability and aggression. But the diagnosis was deferred and the medications were gradually tapered and stopped. Over the next 1 year, he also started hearing voices that fulfilled dimensions of commanding type of auditory hallucinations. He suspected that family members including his mother collude with the unknown persons, whose voices he heard and believed it was done to tease him. He eventually dropped out of school and was often found awake till late night, seen muttering to self, shouting at persons who were not around with further deterioration in his socialization and self-care. Another psychiatrist was consulted and he was now diagnosed with schizophrenia and treated inpatient for 2 weeks with risperidone 3 mg, olanzapine 2.5 mg, and oxcarbazepine 300 mg/day with some improvement in his symptoms. Significant weight gain with the medication lead to poor compliance which further led to relapse within 3 months of discharge. Frequent aggressive episodes over the next 1 year resulted in multiple hospital admissions. He was brought to us with acute exacerbation of symptoms and was receiving divalproex sodium 1500 mg/day, aripiprazole 30 mg/day, trifluperazine 15 mg/day, olanzapine 20 mg/day, and lorazepam injection as and when required. He was admitted for diagnostic clarification and rationalization of his medications. He had remarkable physical features of elongated face with large ears. Non-cooperation for mental state examination, and aggressive and violent behavior were noted. He was observed to be muttering and laughing to self. His mood was irritable, speech was laconic, and he lacked insight into his illness. We entertained a diagnosis of very early-onset schizophrenia and explored for the possibilities of organic psychosis, autoimmune encephalitis, and Fragile X syndrome. The physical investigations done are shown in Table 1 . Further special investigations in the form of rubella antibodies (serum IgG = 64.12 U/mL, IgM = 2.44 U/mL) and polymerase chain reaction for Fragile X syndrome (repeat size = 24) were normal. His intelligence quotient measured a year ago was 90, but he did not cooperate for the same during present admission. Initially, we reduced the medication and only kept him on aripiprazole 30 mg/day and added lurasidone 40 mg twice a day and discharged him with residual negative symptoms only. However, his hallucinations and aggression reappeared within 2 weeks of discharge and was readmitted. This time eight sessions of bilateral modified electroconvulsive therapy were administered and he was put on aripiprazole 30 mg/day, chlorpromazine 600 mg/day, sodium divalproex 1000 mg/day, and trihexyphenidyl 4 mg/day. The family was psychoeducated about the illness, and mother's expressed emotions and overinvolvement was addressed by supportive psychotherapy. Moreover, an activity schedule for the child was made, and occupational therapy was instituted. Dietary modifications in view of weight gain were also suggested. In the past 6 months, no episodes of violence came to our notice, though irritability on not meeting his demands is persistent. However, poor socialization, lack of motivation, apathy, weight gain subsequent to psychotropic medications, and aversion to start school are still unresolved. Influence of his multiple medications on bone marrow function is an impending issue of concern.

Details of investigations done in the three children

An 11-year-old boy, educated up to class 3, belonging to a rural family of lower socioeconomic status was brought with complaints of academic decline since 2 years, repetition of acts, irritability since a year, and adoption of abnormal postures since 6 months. He was born out of a nonconsanguineous marriage, uneventful birth, and pregnancy. He was third in birth order and achieved developmental milestones at an appropriate age. Since 2 years, he would not attend to his studies, had poor attention, and difficult memorization. He attributed it to lack of friends at school and asked for school change. There was no history of low mood, depressive cognitions, conduct problems, or bullying and he performed his daily routine like his premorbid self at that time. Since a year, he was observed to repeat certain acts such as pacing in the room from one end to another, continuously for up to 1–2 h, with intermittent stops and often insisted his mother to follow the suit, stand nearby him, or else he would clang on her. He prohibited other family members except his mother near him and would accept his meals only from her. He repeatedly sought assurance of his mother if he had spoken everything right. He also washed his hands repeatedly, up to 10–20 times at one time, and was unable to elaborate reason for the same. His mood during that period was largely irritable with no sadness or fearfulness. He mostly wore the same set of clothes, would be forced to take bath or get nails/hair trimmed, and efforts to these were often met with aggression from the patient. Eventually, he stopped going to school and his family sought faith healing. Within the next 5–6 months, his illness worsened. Fixed gaze, reduced eye blinking, smiling out of context, diminished speech, and refusal to eat food were the reasons for which he was brought to us. His physical examination was unremarkable and his mental state examination using the Kirby's method showed an untidy and ill-kempt child, with infrequent spontaneous acts, and occasional resentment for examination. He had an expressionless face, with occasional smiling to self, negativism, and mutism. No rigidity in any of the limb was observed. He was diagnosed with catatonic schizophrenia and probable obsessive compulsive disorder (vs mannerisms). We performed a battery of physical investigation to rule out organic psychosis [ Table 1 ]. He responded to injection lorazepam with which catatonia melted away. He was also prescribed olanzapine up to 15 mg/day, fluoxetine 20 mg/day, and dietary modification and lactulose for constipation. The family left against medical advice with 50%–60% clinical improvement [rating on Bush Francis Catatonia Rating scale (BFCRS) reduced from 10 to 4]. He relapsed within a month of discharge, initially with predominance of the probable obsessive compulsive symptoms. Fluoxetine was further increased to up to 60 mg/day. But within the next 2 months, the catatonic symptoms reappeared and he was readmitted. He had received olanzapine up to 25 mg/day, which was replaced with risperidone. In view of nonresponse to intravenous lorazepam, we administered him five sessions of modified bilateral Electro-convulsive therapy (ECT) (rating on BFCRS reduced from 8 to 0). The family was psychoeducated about the child's illness and the need for continuous treatment was emphasized. He was discharged with up to 80%–90% improvement. At follow-ups, he started participating at farm work of the family, took care of self, with some repetition of acts such as washing of hands, and denied any associated anxiety symptoms. However, efforts to re-enroll in school had been futile as the child did not agree for it. He has been maintaining at the same level since 6 months of discharge.

A 7-year-old girl, student of second class, belonging to a high socioeconomic status family living in an urban locality was brought with complaints of academic decline, irritability, and abnormal behavior for the past 9 months. The child was born out of a nonconsanguineous marriage, is first in order, and was a wanted child. Maternal health during pregnancy was normal, but the period of labor was prolonged beyond 18 h, so a lower segment caesarean section was performed. There was no history of birth-related complications and the child's birth weight was 2.80 kg. The child attained developmental milestones as per age. The child had a temperament characterized by high activity levels, below average threshold of distractibility, average ability to sustain attention and persist, easy to warm up, adaptation to new situations, and regular bowel and bladder habits. She was enrolled in school at the age of 4 years and progressed well till 9 months back when a decline in her academic interest was observed by her class teacher. Deterioration of her handwriting skills and avoidance of group activities in school were observed. Similarly, at home persistent irritable behavior was seen and her play activities with her siblings reduced. However, her biofunctions were normal during this period.

One month prior to visiting us, she started insisting on wearing the same dress. She wore the same colored or at times the same dress which she would not take off even at bed or bath time. In addition, a change in her mood from largely irritable to cheerful was noted. Her activity levels were increased and it would be difficult to make her sit quietly in class. Her speech output was more than her usual self and she talked incessantly. Her sleep duration also decreased and she started getting up 3–4 h earlier than her usual routine. In view of these symptoms, her family made first contact with us. Her physical examination was normal and mental state examination revealed her to be cheerful, overactive, and difficult to interrupt. She sang and danced during the interview. We diagnosed her with acute mania on the basis of clinical evaluation and assessment on MINI Kid 6.0.[ 6 ] The details of her physical examination are depicted in Table 1 . She was initially treated with olanzapine 5 mg/day which was later on increased to 10 mg/day. However, no response was observed with it in the next 2 weeks, so it was cross tapered with sodium valproate which was built up to 400 mg/day. She improved by nearly 50%, but her mood still remained cheerful/irritable. She did not resume her school and was brought irregularly for the follow-up. Within the next 2 months, she also started muttering to herself and made certain abnormal gestures. She often feared staying alone, or while going to bed insisted the lights to be kept on and ask someone to accompany her in the toilet unlike her previous self. When asked, she reported seeing a lady in white clothes, with no other details. She stopped asking for food on her own and remained lost in her fantasy world. However, her interest in dressing and appreciating herself in mirror persisted. Her mood during this period was mostly labile and often changed from cheerful to sad or irritable. As per the family, the medications were continued as advised. So in view of the emerging picture, the diagnosis was revised to schizo-affective disorder, and in addition to hike in dose of sodium valproate to 500 mg/day, risperidone 2 mg/day was also added. However, even after 8 weeks of treatment with this combination with hike of risperidone to 4 mg/day, there was no relief. The child is still symptomatic, does not go to school, and has significant dysfunction. Psychosocial intervention in the form of psychoeducation, activity scheduling for the child, and occupational therapy has been instituted in addition to the existing treatment regimen, but results are yet to be seen.

The older concept of neurodegenerative etiology of schizophrenia has been superseded by evolving neurodevelopmental nature of this disease. The latter has been attributed to initiation of the underlying pathophysiological processes long before the onset of clinical disease and interaction of the various genetic and environmental factors. The more accommodating theorist propose schizophrenia to be of neurodevelopmental in origin which in turn speeds the process of neurodegeneration.

On clinical front, VEOS is associated with a more insidious onset, prominent negative symptoms, auditory hallucinations, poorly formed delusions which is in part due to less developed cognitive abilities.[ 7 ] The presence of history of speech and language delay as well as motor development deficits have been observed in major studies on childhood-onset schizophrenia, be it the Maudsley early-onset schizophrenia project or the NIMH study.[ 8 , 9 ] Premorbid deficits in social adjustments and presence of autistic symptoms have also been shown. Moreover, the early onset of psychosis is associated with poor prognosis, worse overall functioning, and multiple hospitalizations.[ 7 ] The duration of untreated psychosis in childhood-onset psychosis has been shown to be smaller in hospital-based studies[ 10 ] and larger in community settings.[ 11 ] In addition, the presence of comorbidities and an organic etiology or history of maternal illness during pregnancy is a common finding in VEOS.[ 10 ] In addition, obsessive compulsive symptoms are frequently observed in first-episode drug-naive schizophrenia patients and have a poorer outcome, more severe impairment of social behavior, and lower functioning.[ 12 ] However, in many instances it is very difficult to differentiate the obsessive compulsive symptoms from the motor symptoms of schizophrenia such as stereotypy and mannerisms and varying degree of insight.[ 13 ]

In the present case series, all the children had an insidious onset of illness, with initial symptom of academic decline, and poorly formed psychotic symptoms/psychotic-like experiences. All the children reported here had dropped out of school, showed a shift in their interests, withdrew from social circle, appeared to be distant, had impaired self-care, and often lacked concern for others along with a range of mood disturbances. All these symptoms fit into the classical description of prodromal symptoms of schizophrenia.[ 14 ] In contrast to available evidence, no history of motor, speech, or language delay was noted in any of the child. Furthermore, no history suggestive of autistic features or problems in social adjustments prior to onset of illness was forthcoming.

However, the diagnosis of schizophrenia could be clearly made in the first case, while the second child had predominant catatonic and probably obsessive compulsive symptoms. It is difficult to ascertain the diagnosis of schizophrenia on the basis of presence of only catatonic symptoms and no delusions and hallucinations or negative symptoms as required by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or International Classification of Diseases, Tenth Revision. However, it is very difficult to sustain any other diagnosis for the second child. In the third child, the illness has been evolving and the clinical picture changed from predominant mood symptoms to psychotic-like experiences at later stage. Therefore, at present a diagnosis of schizo-affective disorder is entertained. We could not find any possible organic etiology in any of the three cases with the best of our efforts.

With provision of pharmacological and psychosocial treatment in accordance to the available treatment guidelines,[ 15 ] remission was not achieved in two of the three children. Currently, the available evidence also suggests that the prognosis of childhood-onset schizophrenia is mainly poor as it disrupts the social and cognitive development and thus nearly two-third of children do not achieve remission.[ 16 ] On a positive note, we have been able to retain all the children in treatment.

Other issues faced by the families of three children and the treating team are briefly discussed below. In countries like India, where significant expenses are born by patients/family, associated stigma, limited social services, and the anti-psychotic related adverse effects raise the burden of care exponentially. In 2/3 index patients, the family bore the costs of special investigations, which was not possible in the second child and led to financial difficulties for the single mother of the first child. Adding on, the availability of rehabilitation services for children with major mental illnesses is scarce in various parts of our country. Furthermore, we successfully used ECT for management of acute disturbance in two of the three patients prior to the notification of Mental Health Care Act, 2017 that prohibits its use in minors. The case series also put forward a strong case for strengthening and sensitizing primary care physicians and pediatricians in identifying and treating cases of VEOP, since they are more likely to be the first points of contact with patients of the discussed age group. In view of the duration of untreated psychosis being a very eloquent prognostic factor for VEOP and the symptomatology of the same showing significant heterogeneity, armoring primary care physicians and pediatricians with the right skills to identify, treat, or refer patients with VEOP, especially in the prodromal period, might profoundly contribute in decreasing the morbidity and improving prognosis. Citing this lacuna which could be filled and used to our advantage, Stevens et al .[ 17 ] elaborated and discussed various questions which practitioners might find useful.

Childhood-onset schizophrenia is a rare occurrence. The current case series highlights differing clinical presentation of VEOS/VEOP in children and adolescents. Certain other issues pertinent to the management of VEOS/VEOP are also touched upon in this article. With the early recognition of childhood mental health illnesses, we need to build and strengthen ample child and adolescent mental health services in India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgement

The authors thank Dr. Sonam Arora, MD, DNB (Pathology), for providing assistance in laboratory investigations and article writing.

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CBSE Class 12 Psychology Important Case Study Based Questions 2023: Read and Solve for Tomorrow's Exam

Psychology important case study questions for cbse class 12: practice important psychology case study-based questions for cbse class 12. these questions are important for the upcoming cbse class 12 psychology board exam 2023..

  CBSE Class 12 Psychology Exam 2023: Hello students! kudos to the efforts you put into tackling your 2023 board examinations. We understand that the last few weeks were tremendously tiring, both mentally and physically. Don’t worry, take a deep breath and relax as this is the final phase of your CBSE examination 2023. The class 12 Psychology exam is the last in the lane. Its paper code is 037. The exam is planned for 05th April 2023, that is, tomorrow. The exam will be for 3 hours scheduled between 10.30 AM to 01.30 PM. We believe you have already solved the sample question and previous year papers for Class 12 Psychology and must be aware of the exam pattern. If not, please refer to the links below.

• CBSE Class 12 Psychology Previous Year Question Papers: Download pdf
• CBSE Board Class 12 Psychology Sample Paper 2022-23 in PDF

CBSE Class 12 Psychology, Important Case Study-Based Questions:

Case 1: .

Read the following case study and answer the questions that follow: 

Sundar, a college-going 20-year-old male, has moved from his home town to live in a big city. He has continuous fear of insecurity and feels that enemy soldiers are following him. He gets very tense when he spots anyone in a uniform and feels that they are coming to catch him. This intense anxiety is interfering with his work and relationship, and his friends are extremely concerned as it does not make any sense to them. Sundar occasionally laughs abruptly and inappropriately and sometimes stops speaking mid-sentence, scanning off in the distance as though he sees or hears something. He expresses concern about the television and radio in the room potentially being monitored by the enemies. His beliefs are fixed and if they are challenged, his tone becomes hostile. 

Q1. Based on the symptoms being exhibited, identify the disorder. Explain the other symptoms that can be seen in this disorder.

Q2. Define delusion and inappropriate affect. Support it with the symptoms given in the above case study.

Read the case and answer the questions that follow. 

Alfred  Binet, in 1905,  was requested by the French government to devise a method by which students who experienced difficulty in school could be identified.  Binet and his colleague,  Theodore  Simon,  began developing questions that focused on areas not explicitly taught in schools those days, such as memory, and attention skills related to problem-solving.  Using these questions, Binet determined which were the ones that served as the best predictors of school success. 

Binet quickly realised that some children were able to answer more advanced questions than older children were generally able to answer and vice versa.  Based on this observation, Binet suggested the concept of mental age or a measure of intelligence based on the average abilities of children of a  certain age group.  This first intelligence test is referred to as the Binet-Simon  Scale. He insisted that intelligence is influenced by many factors, it changes over time,  and it can only be compared in children with similar backgrounds. 

Q1 . Identify the approach on which the Binet-Simon Intelligence Scale is based. Discuss its features.

Q2 . ‘Binet quickly realised that some children were able to answer more advanced questions than older children were generally able to answer and vice versa’. Why do individuals differ in intelligence? Using examples, give reasons for your answer.

Read the following case study and answer the questions that follow :

All the Indian settlers were contemptuously and without distinction dubbed “coolies” and forbidden to walk on footpaths or be out at night without permits. 

Mahatma Gandhi quickly discovered colour discrimination in South Africa and confronted the realisation that being Indian subjected him to it as well. At a particular train station, railway employees ordered him out of the carriage despite his possessing a first-class ticket. Then on the stagecoach for the next leg of his journey, the coachman, who was white, boxed his ears. A Johannesburg hotel also barred him from lodging there. Indians were commonly forbidden to own land in Natal, while ownership was more permissible for native-born people. 

In 1894, the Natal Bar Association tried to reject Gandhi on the basis of race. He was nearly lynched in 1897 upon returning from India while disembarking from a ship moored at Durban after he, his family, and 600 other Indians had been forcibly quarantined, allegedly due to medical fears that they carried plague germs. 

Q1. What is the difference between prejudice and discrimination ? On the

basis of the incidents in the above case study, identify a situation for each

which are examples of prejudice and discrimination.

Q2. What do you think could have been a source of these prejudices ? Explain

any two sources. 

Read the given case carefully and answer the questions that follow: 

Harish belonged to a family of four children, him being the eldest. Unlike any first born, he was not given the attention he should have had. His father worked as an accountant, while his mother stayed at home to look after the kids. He dropped out of school and could barely manage to get work for a little salary.

His relationship with his family played an important role in building his disposition. He felt a certain feeling of insecurity with his siblings, especially his brother Tarun, who was able to finish college because of parental support.

Due to the hopelessness Harish felt, he started engaging in drinking alcohol with his high school friends. Parental negligence caused emotional turmoil. He also had insomnia which he used as a reason for drinking every night.

Over time, Harish had to drink more to feel the effects of the alcohol. He got grouchy or shaky and had other symptoms when he was not able to drink or when he tried to quit.

In such a case, the school would be the ideal setting for early identification and intervention. In addition, his connection to school would be one of the most significant protective factors for substance abuse. His school implemented a variety of early intervention strategies which did not help him as he was irregular and soon left school. Some protective factors in school would be the ability to genuinely experience positive emotions through good communication.

(i)It has been found that certain family systems are likely to produce abnormal functioning in individual members.

In the light of the above statement, the factors underlying Harish's condition can be related to model.

(A) Humanistic

(B) Behavioural

(C) Socio-cultural 

(D) Psychodynamic

(ii) Over time, Harish needed to drink more before he could feel the effects of the alcohol. This means that he built a alcohol. towards the

(A) Withdrawal

(B) Tolerance

(C) Stress inoculation

(D) All of the above

(iii)He got grouchy or shaky and had other symptoms when he was not able to drink or when he tried to quit. This refers to

(A) Low willpower symptoms.

(B) Addiction symptoms

(C) Withdrawal symptoms

(D) Tolerance symptoms

(iv) Which of the following is not true about substance related and addictive disorders?

(A) Alcoholism unites millions of families through social interactions and get-togethers.

(B) Intoxicated drivers are responsible for many road accidents. 

(C) It also has serious effects on the children of persons with this disorder.

(D) Excessive drinking can seriously damage physical health.

Read the given case carefully and answer the questions that follow:

Monty was only 16 years when he dealt with mixed emotions for every couple of months. He shares that sometimes he felt like he was on top of the world and that nobody could stop him. He would be extremely confident. Once these feelings subsided, he would become depressed and lock himself in the room. He would neither open the door for anyone nor come out.

He shares, "My grades were dropping as I started to breathe rapidly and worry about almost everything under the sun. I felt nervous, restless and tense, with an increased heart rate. My family tried to help but I wasn't ready to accept." His father took him to the doctor, who diagnosed him. Teenage is a tough phase as teenagers face various emotional and psychological issues. How can one differentiate that from a disorder? Watch out when one is hopeless and feels helpless. Or, when one is not able to control the powerful emotions. It has to be confirmed by a medical practitioner.

During his sessions, Monty tries to clear many myths. He gives his perspective of what he experienced and the treatment challenges. "When I was going through it, I wish I had met someone with similar experiences so that I could have talked to her/him and understood why I was behaving the way I was. By talking openly, I hope to help someone to cope with it and believe that it is going to be fine one day."

Now, for the last five years Monty has been off medication and he is leading a regular life. Society is opening up to address mental health issues in a positive way, but it always helps to listen to someone who has been through it.

(i)Monty's symptoms are likely to be those of

(A) ADHD and anxiety disorder

(B) Bipolar disorder and generalised anxiety disorder 

(C) Generalised anxiety disorder and oppositional defiant disorder

(D) Schizophrenia

(ii) During his sessions, Monty tried to clear many myths. Which one of the following is a myth?

(A) Normality is the same as conformity to social norms.

(B) Adaptive behaviour is not simply maintenance and survival but also includes growth and fulfilment.

(C) People are hesitant to consult a doctor or a psychologist because they are ashamed of their problems.

(D) Genetic and biochemical factors are involved in causing mental disorders.

(iii) With an understanding of Monty's condition, which of the following is a likely symptom he may also be experiencing?

(A) Frequent washing of hands

(B) Assuming alternate personalities

(C) Persistent body related symptoms, which may or may not be related to any serious medical condition

(D) Prolonged, vague, unexplained and intense fears that are not attached to any particular object

(iv) Teenage is a tough phase as teenagers face various emotional and psychological issues. The disorder manifested in the early stage of development is classified as,

(A) Feeding and eating disorder

(B) Trauma and stressor related disorder

(C) Neurodevelopmental disorder

(D) Somatic symptom disorder

• CBSE Class 12 Psychology Syllabus 2022-23 .
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• On what day CBSE Class 12 Psychology 2023 exam is? + As per the official schedule, the CBSE class 12 psychology exam will be conducted on 05th April 2023. It would a Wednesday.
• Is it important to solve case study questions for CBSE Class 12 Psychology exam? + Yes, as per the updates made by the CBSE Board in the past few years, the psychology paper now carries case study questions. It is of 4 marks with multiple subparts. Thus, students are advised to practice case-based questions to score fully in this section.
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Very Early-Onset Schizophrenia in a Six-Year-Old Boy

• Samantha Slomiak , B.S. ,
• Dena R. Matalon , M.D. ,
• Lisa Roth , M.D., M.S.

Search for more papers by this author

Very early-onset schizophrenia is characterized by hallucinations, delusions, and cognitive impairment in children less than 13 years old. The prevalence of very early-onset schizophrenia is unknown but is estimated to be 1:30,000 children. Very early-onset schizophrenia is the pediatric counterpart to early-onset schizophrenia, which affects adolescents 13–18 years old, and adult-onset schizophrenia, which affects individuals over 18 years old ( 1 ). Although the DSM does not differentiate between very early-onset schizophrenia, early-onset schizophrenia, and adult-onset schizophrenia, the age at onset of schizophrenia can have distinct clinical ramifications. Very early-onset schizophrenia tends to present insidiously, with a premorbid period characterized by developmental delay and diminished school performance. Oftentimes, children with very early-onset schizophrenia are misdiagnosed with pervasive developmental disorder before they develop florid psychosis ( 2 ). As very early-onset schizophrenia progresses, it shares more clinical features with early-onset schizophrenia and adult-onset schizophrenia, including hallucinations, delusions, and paranoia. However, it tends to be more severe and disabling than adult-onset schizophrenia, resulting in lower educational performance and poorer social relationships ( 1 ). It is also characterized by a higher rate of cytogenetic abnormalities than adult-onset schizophrenia ( 3 ), suggesting that affected individuals carry an even stronger genetic predisposition to schizophrenia. We describe the case of a 6-year-old boy with new-onset schizophrenia, who showed unusual behavior suggestive of psychotic symptoms as early as infancy.

“Kyle” is a 6-year-old boy with a history of mild developmental delay who presented with one month of disorganized behavior, hallucinations, and developmental regression. At 3 months old, he began tracking objects his parents were unable to see. At 7 months old, he began visually fixating on unseen objects and would “open his eyes widely, become very excited, flap his arms, and tense his legs,” according to his mother. He did not begin walking until 20 months old and was referred to early intervention for gross motor delay. At age 3, he began talking to someone his parents could not see, leading them to believe he had an imaginary friend. While learning to read at age 5, he would say, “Stop mom! The words are talking back!” This possibly suggests an experience of auditory hallucinations. In kindergarten, he was held back due to poor attention but remained socially interactive without grossly abnormal behavior. Then, one month prior to admission, he developed frank hallucinations and severe social withdrawal. He frequently whispered to himself nonsensically and was so internally preoccupied that he often was unable to follow commands. The patient's family history was notable for 1) schizophrenia in a maternal cousin, two paternal cousins, and his paternal great grandmother; 2) bipolar disorder in two paternal cousins; and 3) autism in a paternal cousin and a paternal great aunt. His pediatrician performed a preliminary workup, including routine laboratory examination and a CT of the head, which were normal. The pediatrician referred the patient for admission to our hospital.

On initial evaluation, the child appeared thin and younger than his stated age. His mother stated that he had been eating only intermittently, resulting in significant weight loss and failure to thrive (body mass index=14.5, weight <10th percentile; height <3rd percentile). His behavior was notable for stereotyped pursing of his lips, repetitive blinking, and poor eye contact. The child was mumbling to himself, and upon questioning, his speech was impoverished and disorganized. His affect was flat and intermittently guarded. He endorsed visual hallucinations of “people in [his] eyes” who were “following [him] everywhere,” named “Shavonni, James, and Jack,” who appeared “black with yellow teeth and green eyes.” The child's mother endorsed that he had a history of paranoid delusions that people were chasing him or taking away his food. He expressed passive suicidal ideation, saying, “God said it's time for me to come to heaven,” as well as homicidal ideation toward an unclear target, saying “I'm gonna cut you up; I'm gonna kill you.” He did not exhibit self-injurious or violent behavior.

The patient received a comprehensive medical workup, including MRI of the brain, lumbar puncture (with oligoclonal bands, myelin basic protein, paraneoplastic, and N-methyl-D-aspartate receptor antibody testing), EEG, rheumatologic screening (with antinuclear antibody, C-reactive protein, erythrocyte sedimentation rate, ceruloplasmin, celiac, and thyroid testing), metabolic screening (with lactate, pyruvate, acylcarnitine, urine organic acid, and plasma amino acid testing), urine drug screen, and heavy metal panel, which were normal. The consulting psychiatrist deferred initiation of antipsychotic medications given the patient's age and instead started clonazepam for agitation control. Given the patient's unusually young age at presentation, possible lifelong symptoms, and a strong family history of mental illness, he was referred for genetic testing. Chromosome single nucleotide polymorphism microarray analysis showed a 22q11.2 deletion (low copy repeat-A/low copy repeat-D).

22q11.2 deletion syndrome is the most common chromosomal microdeletion syndrome. The 22q11.2 region contains large areas of low copy repeats, which are subject to meiotic error, resulting in recombination and subsequently deletions, most commonly between low copy repeat-A and low copy repeat-D. The syndrome encompasses a wide spectrum of manifestations, including congenital heart defects; chronic infections; palatal, parathyroid, and gastrointestinal abnormalities; and behavioral differences. Oftentimes, children with 22q11.2 deletion syndrome have speech delay, with their first words at 24 months ( 4 ). Perhaps most concerning, 75% of individuals with 22q11.2 deletion syndrome are affected by psychiatric illness, most commonly autism, attention deficit hyperactivity disorder, anxiety, and psychosis. Specifically, patients with 22q11.2 deletion syndrome are at a 25-fold increased risk for developing a psychotic disorder compared with the general population, and nearly 25% of these patients develop schizophrenia ( 5 ).

Twin, family, and adoption studies have shown that hereditary factors have a strong influence on the development of schizophrenia ( 6 ). However, only several genomic regions have been linked to schizophrenia, and there have been no individual causative genes identified. The 22q11.2 microdeletions are the only confirmed copy number variation known to cause schizophrenia ( 7 ). The genetics of schizophrenia appear to be highly complex, with numerous genes of minor effect interacting with each other to produce the phenotype. Attention has most recently turned to the role of epigenetics in the development of disease ( 6 ). It has been hypothesized that the genes responsible for the development of schizophrenia might be abnormal transcriptional units that code for RNA regulators of protein coding gene expression, rather than abnormalities in the coding genome itself ( 8 ).

The above case not only underscores the heritability of schizophrenia, but also is noteworthy for the clinical signs that preceded the patient's first break psychotic episode. Delayed milestones in all domains, including motor, speech, social, and cognitive development, characterize the premorbid period of schizophrenia. This effect is more pronounced in those with very early-onset schizophrenia than in those with early-onset or adult-onset schizophrenia ( 9 ). Stereotyped behaviors, such as flapping and echolalia, are also frequently present and can lead to a misdiagnosis of pervasive developmental disorder ( 2 ). Additionally, the premorbid period of very early-onset schizophrenia is often punctuated by declining academic function, with accelerating deterioration when the acute psychotic phase approaches. In the above case, the patient presented with nearly all of these predictive clinical signs, including developmental delay, stereotypy, and a decline in academic performance necessitating withdrawal from kindergarten.

Many clinicians are hesitant to make a diagnosis of very-early onset schizophrenia, with an average of 2 years from onset of symptoms to diagnosis. One challenge to diagnosis lies in the decision to attribute hallucinations to a pathological process given that non-pathological hallucinations occur in 8% of children. Contextual information is essential in making these distinctions, with special attention to the preservation of social relationships, higher premorbid functioning, and environment-specific symptoms ( 2 , 9 ). Once a diagnosis is made, considerable controversy exists surrounding the use of antipsychotics in children due to limited data on safety and efficacy. Antipsychotics are generally recommended for severe cases, with evidence to suggest that early initiation improves outcomes, especially control of positive symptoms. The present case highlights that subtle clinical signs, including developmental delay, stereotypy, academic decline, and possible hallucinations, can herald the development of very early-onset schizophrenia.

Key Points/Clinical Pearls

Very early-onset schizophrenia is defined as the onset of schizophrenia in children less than 13 years of age; DSM criteria for diagnosis are the same as adult-onset schizophrenia.

Very early-onset schizophrenia has a premorbid period characterized by global delay in domains of motor, speech, social, and cognitive development; it is often misdiagnosed as pervasive developmental disorder due to the presence of stereotypy.

The genetics of schizophrenia are largely unknown; the 22q11.2 microdeletion is the only copy number variation associated with schizophrenia.

The authors thank Dr. Avram Mack for his mentorship of Dr. Roth and assistance with conceptualization of this article. The authors also thank Dr. Elaine Zackai for her mentorship of Dr. Matalon and her endlessly inspiring clinical acumen that led to the patient's diagnosis, as well as Donna McDonald-McGinn, M.S., CBC, for her groundbreaking work on the neuropsychological manifestations of 22q11 deletion syndrome.

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2. Abidi S : Psychosis in children and youth: focus on early-onset schizophrenia . Pediatr Rev 2013 ; 34(7):296–305 Crossref ,  Google Scholar

3. Addington AM, Rapoport JL : The genetics of childhood-onset schizophrenia: When madness strikes the prepubescent . Curr Psychiatry Rep 2009 ; 11(2):156–161 Crossref ,  Google Scholar

4. McDonald-McGinn DM, Sullivan KE, Marino B, et al. : 22q11.2 deletion syndrome . Nat Rev Dis Primers 2015 ; 1:15071 Crossref ,  Google Scholar

5. Tang SX, Yi JJ, Moore TM, et al. : Subthreshold psychotic symptoms in 22q11.2 deletion syndrome . J Am Acad Child Adolesc Psychiatry 2014 ; 53(9):945–947 Google Scholar

6. Kato C, Petronis A, Okazaki Y, et al. : Molecular genetic studies of schizophrenia: challenges and insights . Neurosci Res 2002 ; 43(4):295–304 Crossref ,  Google Scholar

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• Psychology /

Psychological Disorders Class 12 Notes

• Updated on  
• Jan 25, 2024

Often referred to as mental disorders or psychiatric disorders, Psychological disorders are one of the largest areas of enquiry in Psychology. All major disorders are categorized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). This volume helps in the treatment, analysis and detection of disorders in patients. Psychological disorders are covered in class 12th to help students prepare for a career in Psychology . In this blog, we present to you our detailed and insightful notes on Psychological Disorders Class 12:

This Blog Includes:

Concept of abnormality and psychological disorders, approaches to study abnormality and psychological disorders, factors underlying abnormal behaviour, major psychological disorders, anxiety disorders, separation anxiety disorders, somatic symptom and related disorder, dissociative disorders, bipolar and related disorders, schizophrenia disorders, neurodevelopmental disorders , feeding and eating disorders, substance related and addictive disorder, important questions for psychological disorders class 12, psychological disorders class 12 ncert pdf.

Also Read: 100 Psychological Facts You Must Know

Before we begin our notes on Psychological Disorders Class 12, let’s understand the concept of abnormality and psychological disorders. Meaning of Abnormality can be aptly described with the help of 4Ds :

• Deviance : Psychological disorders are characterized by Deviance, Unusual, Bizarre, Strange
• Dysfunction : Interferes with the normal functioning of an individual.
• Distress : It implies behaviour that is unpleasant and distressing to oneself and to others.
• Danger  It means behaviour that is harmful and dangerous to the person concerned and others.

Psychological Disorders Class 12 also covers the different approaches to the study of abnormality and mental disorders:

• First Approach views abnormal behaviour as deviation from social norms and those who are not able to fit in the society are viewed as deviants
• The second Approach is the maladaptive approach according to which behaviour that does not help the other person in leading a fulfilling life should be viewed as abnormal.

There are various factors underlying Abnormal Behaviour according to Psychological Disorders Class 12:

Biological Model

A wide range of biological factors like hormonal imbalances, faulty genes, and other factors may have repercussions on the normal functioning and development of individuals. As per various researches and studies, Abnormal activity by various neurotransmitters may lead to abnormal behaviour and Psychological disorders like schizophrenia may happen because of the high activity of dopamine and depression may be due to the low activity of serotonin.

Genetic Model

A lot of Psychological Disorders like Schizophrenia, Depression, Anxiety Happen because of hereditary factors and genetic mapping of individuals. These may be regressive in nature but can be triggered in an individual life to external stimuli.

Psychological Model

According to Psychological Disorders Class 12, there are several Psychological factors due to which the development of Psychological Disorders may happen and some of those factors are Maladaptive Family Structure, Faulty Parent-Child relationship, severe stress, maternal deprivation etc. Various other psychological models which provide a substantial explanation of Psychological disorders are explained as follows:

• Psychodynamic Model focus on the fact that human behaviour whether normal or Abnormal is a result of Psychological forces (Id, Ego, Superego) in the unconscious mind and the relative strength of Id, Ego and Superego determines a person’s personality.
• Behavioural Model states that human behaviour whether normal or Abnormal can be learnt and unlearnt. Abnormal behaviour is a result of learning Maladaptive ways of Behaving. There are three most eminent theories of the behavioural model are classical conditioning, operant conditioning and social learning.
• Cognitive Model states that Abnormal Behaviour is a consequence of faulty thinking and negative and irrational beliefs about one self and others and drawing broad negative conclusions on the basis of insignificant event results in abnormal behaviour.
• Humanistic-Existential Model -This model views human beings in a positive light and believes that human beings are inherently positive, cooperative and can self-actualize. Those who lack meaning in their lives tend to leave empty, depressed and dysfunctional lives.
• Socio-cultural model : Various socio-cultural factors like employment conditions, war, prejudice, discrimination, culture(collectivistic or individualistic) explain human behaviour whether normal or Abnormal in the best possible manner.
• Diathesis Stress Model : As per this model Psychological Disorders develop when a Diathesis (biological predisposition to the disorder) is set off by a stressful situation.

Also Read: Must Watch Movies on Psychological Disorders

According to Psychological Disorders Class 12, some major psychological disorders are covered by DSM5 are:

Anxiety is defined as a vague and unpleasant feeling of fear and apprehension and some of its symptoms are rapid heart rate, fainting, dizziness, sweating etc. The main types of anxiety disorders are described as follows:

Generalised Anxiety Disorders

• Consists of vague, intense and inexplicable that is not attributed to any particular object or cause. 
• Its symptoms are frequent worry, apprehension, hypervigilance that involves continuous scanning of dangers in the environment and motor tension. A person finds it pretty difficult to stay at ease and relax.

Panic Disorder

• Comprising frequent anxiety attacks in which the person experiences intense terror and here, anxious thoughts are experienced due to a specific cause or stimuli.
• Symptoms include shortness of breath, choking, nausea, fear of going crazy or death, chest pain etc.

Phobias  

According to Psychological Disorders Class 12, Phobias are defined as irrational fears related to a particular object, person or situation. Three types of Phobias are

• Specific Phobias highly irrational fears such as fear of a specific type of animal or being enclosed into enclosed spaces
• Social Phobias is defined as a feeling of intense fear and embarrassment when dealing with others in public
• Agoraphobia is the fear of entering unfamiliar situations and people with agoraphobia have problems in leaving their home as well and thus due to which they are not able to carry out their normal activities as well.

It is defined as an intense fear of being separated from attachment figures to such an extent that it hinders their development as well. Children with Separation Anxiety Disorder show the following symptoms are reluctant to go to school alone, shadow every move of their parents and throw tantrums when they are away from their parents even for a little while.

Obsessive-Compulsive and Related Disorders

• People who suffer from OCD are preoccupied with a certain idea or a thought and they are unable to prevent themselves from carrying out a particular activity that hinders their normal day to day functioning.
• Obsessive Behaviour means the inability to stop thinking about a particular Behaviour or a thought.
• Compulsive Behaviour is the need to perform certain behaviours over and over again.

Also Read: Social Influence and Group Processes Class 12 Notes

Trauma and Stress- Related Disorder

• People who have been victims of bomb blasts, terrorist attacks often experience Post Traumatic Stress Disorder (PTSD).
• Recurrent Dreams
• Frequent flashbacks
• Emotional distress

These are defined as conditions in which the client feels some of the physical symptoms and Psychological difficulties without any biological and medical cause. Main types of somatic symptom and related disorders are explained as follows-

Somatic Symptom Disorder

• Persistent body Related symptoms are seen in this disorder which does not have a definite medical cause.
• People with this disorder are preoccupied with their Symptoms, worry about their health and thus, make frequent visits to doctors.

Illness Anxiety Disorder

As the name suggests, people with illness Anxiety Disorder are preoccupied about the thought of developing a serious illness.

Conversion Disorder

Clients with conversion Disorder report loss of a body part or bodily function like deafness, blindness, difficulty in walking etc.

Dissociation is defined as a feeling of estrangement, unreality or depersonalisation etc. Some of the major Dissociative Disorders mentioned in the psychological disorders class 12 chapter are-

Dissociative Amnesia

• Its main characteristic feature is extensive but selective memory loss where people fail to remember either a particular incident, phase of life or cannot remember anything about their past. It is associated with high stress.

Dissociative Identity Disorder

• Its main root lies in Traumatic childhood experiences and it is also known as multiple personality disorder. A person assumes alternate or different personalities which may or may not be aware of each other.

Depersonalisation

• This involves a dream-like state in which there is a sense of being separated from self and reality.
• A person’s sense of reality is temporarily lost.

Dissociative Fugue

• New identity formation happens because of an unexpected travel away from the workplace and home.
• People with Dissociative Fugue experience inability to recall the previous identity.

Depression is defined as one of the most widely recognized mental disorders and it usually indicates a range of negative emotions and behavioural changes. Depression is usually experienced either after a fallout in a relationship or our failure to attain a significant goal.

Major Depressive Disorder

It is characterised by loss of interest and enthusiasm in most of the activities in our life and along with that other symptoms include irregular sleep patterns, change in body weight, irritability, withdrawal from social relationships, etc. Factors predisposing to Depression are mentioned below-

• Age : Women are likely to get depressed in young adulthood and men are likely to get depressed during middle age either due to midlife crisis.
• Genetics : It is a crucial factor that determines an individual’s proneness to depression.
• Other factors : Significant bad phase in life or lack of desired social support can cause depression as well.

People who suffer from mania are highly euphoric, talkative and easily distractible and episodes of mania are accompanied alternatively by depression. In bipolar mood disorder, both mania and depression happen alternatively and in between, there are periods of normal mood as well.

Suicide  

Suicide is a major concern as the suicide rate has increased and some of the symptoms of suicide are mentioned below

• Difficulty in maintaining concentration.
• A drastic change in personality.
• Change in eating and sleep pattern
• Cut off from family and friends 
• Drug and alcohol abuse.

Factors leading to suicide are given below-

• The last attempt of suicide is the strongest factor.
• Significant problems in the family, peer group, work-life, and inability to deal with them may lead to suicide.
• Culture also is an important factor determining suicide.

Some measures suggested by WHO to reduce Suicide

• Care for people who attempted suicide and providing them much needed support
• Limiting access to suicide.
• Early identification, treatment and prevention of people who are at risk

It is the descriptive term for a group of psychotic disorders in which functioning in personal, social and work life deteriorates and the causes behind that can be motor abnormalities, unusual emotional states and strange perceptions. Psychological disorders class 12 states the symptoms of Schizophrenia is classified into three categories:

Positive Symptoms

They are defined as bizarre additions to a person’s behaviour and they are mentioned below and are basically excess of thought, emotion and behaviour.

It is defined as a false belief that is firmly held on inadequate grounds and they are of various types –

• Delusion Of Persecution -People believe that they are being plotted against, spied upon and threatened.
• Delusion Of Reference -People attach special and personal meaning to actions and events of others
• Delusion Of Grandeur -People believes themselves to be highly empowered.
• Delusion Of Control- People believes that their thoughts, emotions, feelings are in the hands of others.

Hallucination

Perceptions that occur in absence of stimuli are defined as hallucination and various types of Hallucination are described as follows-

• Auditory Hallucination : Patients hear sounds or voices that speak sounds, phrases, words etc.
• Tactile Hallucination -People experience tingling and burning sensation.
• Olfactory Hallucination -People experience the smell of poison or smoke.

Negative Symptoms  

They are pathological deficits and include poverty of speech, blunted and flat affect and social withdrawal.

• Alogia -People show a reduction in speech content
• Blunted Effect – People show less anger, sadness, joy etc.
• Flat effect -People at times exhibit no emotion at all.
• Avolition – Inability to start or complete a course of action.

Psychomotor Symptoms

They move less spontaneously and make odd gestures.

• Catatonic Stupor -People remain motionless and silent for long stretches of time.
• Catatonic Rigidity -People maintain rigid postures for hours.
• Catatonic Posturing -People maintain awkward and bizarre positions for long stretches of time.

Formal Thought Disorders 

In the chapter, Psychological disorders class 12, there are formal thought disorders wherein people are not able to think rationally, communicate properly, quickly switch from one topic to another and at times invent their own phrases too.

According to Psychological Disorders Class 12, there are neurodevelopmental disorders manifest during early childhood and impact academic and personal development. They are characterised as excesses or deficits in a particular behaviour. Several neurodevelopmental disorders are discussed as follows-

Attention-Deficit /Hyperactivity Disorder

Main features of ADHD are-

• Inattention is defined as the ability to sustain attention in academics or play. Children who are inattentive quickly lose interest in boring activities, are disorganized and find it difficult to follow instructions.
• Impulsivity is defined as the inability to control their immediate reaction to the stimulus in the environment and they are habitual of instant gratification and they find it difficult to delay their gratification.
• Hyperactivity Children who are hyperactive have difficulty sitting still through class and are in constant motion. Boys are four times more likely to get diagnosed with ADHD as compared to girls.

Autism Spectrum Disorder

This disorder is characterised by difficulty in social communication, interaction and restricted categories of interests. Children with autism are unresponsive to others in social situations, face problems in communication and are intellectually deficient as well.

Specific Learning Disorder

The individual experiences problems in processing information accurately and efficiently and in reading, writing. In the early years of childhood, academic performance is usually below average but with efforts and inputs, it can be improved.

Disruptive, Impulse-Control and Conduct Disorders

Various disorders under this category according to the chapter on Psychological Disorders Class 12-

• People exhibit an age-inappropriate amount of stubbornness and are defiant.
• People behave in a hostile manner.
• Verbal Aggression includes actions like name-calling, swearing etc.
• Physical Aggression includes hitting, fighting with others.
• Proactive Aggression includes bullying and dominating others without being provoked.
• Hostile Aggression is aimed at inflicting injury to others.

According to Psychological Disorders Class 12 chapter, there are various eating disorders:

Anorexia Nervosa

People with Anorexia Nervosa see themselves as overweight and thus due to their self-image, they exercise extensively and refuse to eat. They can starve themselves to death as well at times.

Bulimia Nervosa

People with Bulimia Nervosa may over-eat and then purge their body by vomiting or using laxatives and thus, feel relieved.

Binge Eating

Binge Eating is characterized by frequent episodes of out-of-control eating. The erratic eating patterns can be harmful to the health and well-being of the individual.

Disorders which are related to maladaptive Behaviours resulting from regular and consistent use of substance involved are included under substance-related and Addictive disorders and some of the frequently used substances are explained below-

• People who abuse alcohol and rely on it to handle severe situations and this addiction interfere with their ability to function well in their social, personal, and work lives.
• Due to excessive consumption of alcohol, the body of alcoholics develops a tolerance for alcohol which means that they have to consume it to feel normal.
• Withdrawal of alcohol results in a huge range of Psychological problems like anxiety, depression and other health problems as well.

Heroin  

• It impacts our social and occupational functioning.
• People develop a tolerance for it and experience withdrawal when they stop consuming Heroin
• It paralyzes breath and may lead to death as well.
• May cause problems in short term memory and attention.
• People develop a tolerance for it and experience withdrawal when they stop consuming Cocaine
• People who are Cocaine addicts may function poorly in their work-life and social life.
• It has serious repercussions on Psychological and physical well-being.

Also Read: Class 12 Psychology Sample Papers

Important question and answers for Psychological Disorders Class 12-

Q. Identify the symptoms associated with depression and mania. Ans . Symptoms of Mania are highly euphoric, talkative and easily distractible and symptoms of depression are loss of interest in all the activities which they like, change in eating and sleeping patterns, cut off from family and friends etc.

Q. Describe the characteristics of hyperactive children. Ans. Children who are hyperactive have difficulty sitting still through class and are in constant motion.

Q. Distinguish between obsessions and compulsions . Ans. Obsessive Behaviour means the inability to stop thinking about a particular Behaviour or a thought. Compulsive Behaviour is the need to perform certain behaviours over and over again.

Must Read: Entrance Exams for Psychology after 12th

A lot of Psychological Disorders like Schizophrenia, Depression, Anxiety Happen because of hereditary factors and genetic mapping of individuals.

Anxiety is defined as a vague and unpleasant feeling of fear and apprehension and some of its symptoms are rapid heart rate, fainting, dizziness, sweating etc.

Perceptions that occur in absence of stimuli are defined as hallucination.

This was all about Psychological Disorders class 12 notes. Worried about how to revise at the last moment for exams? Don’t worry! We, at Leverage Edu , are here for you to provide all the required notes to help you revise faster and ace your examinations. Follow us on Facebook , Youtube , Instagram and LinkedIn . 

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ORIGINAL RESEARCH article

Intersubjectivity in schizophrenia: life story analysis of three cases.

• 1 Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Santiago, Chile
• 2 Escuela de Psicología, Facultad de Ciencias Sociales, Pontificia Universidad Católica de Chile, Santiago, Chile

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

Introduction

Pathological experiences are usually described as phenomena that are divorced from the life context in which they are manifested. Nevertheless, in the field of phenomenological psychopathology, symptoms have traditionally been considered from a more comprehensive perspective: they are embedded in the person’s life thus their contents and meanings can only be understood within the context of that life. In themselves “unhistorical,” symptoms become connected meaningfully only within the comprehensive picture of the patient’s life as a whole ( Jaspers, 1997 ).

An even stronger argument could be made to the effect that “no mental illness can be diagnosed, described, or explained without taking account of the patients’ subjectivity and their interpersonal relationships” ( Fuchs, 2012 , p. 342). It is clear that psychopathological manifestations cannot simply be reduced to the workings of the nervous system ( Fuchs, 2011 ). For that reason, the recommendation here would be not to establish linear or “cause/effect” relationships, but to approach mental illnesses with the notion of a “circular” mode of causality, regarding their emergence from subjective, neural, social, and environmental influences continuously interacting with each other ( Fuchs, 2012 ).

Contemporary psychopathological phenomenology regards schizophrenia as a paradigmatic disturbance of embodiment and intersubjectivity ( Dörr, 1970 , 1997 , 2005 , 2011 ; Blankenburg, 2001 , 2012 ; Fuchs, 2001 , 2005 , 2010a ; Sass and Parnas, 2003 ; Stanghellini, 2004 , 2009 , 2011 ). From this approach, it seems appropriate to use methods that attempt to characterize not only the patients’ symptomatic disturbances but also the interpersonal processes involved, broadening the scope of exploration to areas not taken into account in the criteriological manuals of diagnostic systems Diagnostic Statistical Manual of Mental Disorders (DSM) and International Classification of Deseases (ICD) ( Fuchs, 2010b ).

This paper presents the life story analysis of three cases that form part of the corresponding author’s doctoral dissertation entitled “Study of disorders of the pre-reflexive self and of the narratives of first admitted patients with schizophrenia” (unpublished), covering a total of 15 patients with schizophrenia during their first psychiatric hospitalization.

Here, “life-world” refers to the person’s subjectively experienced world, which emerges in the process of conceiving one’s self and the others through a history of social interactions ( Husserl, 1970 ; Schutz and Luckmann, 1973 ; Varela, 1990 ; Varela et al., 1991 ; Maturana and Varela, 1996 ).

Materials and Methods

Study design.

The study was developed within the qualitative paradigm, it being an explorative–descriptive type of study. This type of studies proceeds with inductive logic: in other words, both hypotheses and analysis categories are developed as the study progresses, and emerge from the data itself (Danhke, 1989 quoted in Hernández et al., 2003 ).

The so-called “critical case sampling” criteria was used, where the interest in an in-depth approach to the phenomena means working with few cases, with representativeness not being of key importance for these purposes. Thus, the significance and understanding emerged by qualitative inquiry have more to do with the richness of the cases chosen and also with the observational and analytical abilities of the researcher, rather than with size of the sample ( Patton, 1990 ; Schwartz and Jacobs, 1996 ; Creswell, 1998 ).

Participants

The broad research covered a total of 15 patients with schizophrenia during their first psychiatric hospitalization. All of them were males, aged between 18 and 25. Additional inclusion criteria were the following: (1) accessibility to the sample, (2) homogenous sample ( Halbreich and Kahn, 2003 ), and (3) earlier first onset and higher risk of developing schizophrenia in men ( Aleman et al., 2003 ).

The three cases were selected due to the variety of subtypes to illustrate the interpersonal processes involved in schizophrenia, taking the intersubjective dimension of the patients’ life stories into consideration. Cases 1, 2, and 3, as they appear in the paper, correspond to patients with diagnoses of disorganized-type, paranoid-type, and catatonic-type schizophrenia, respectively.

Instruments

In-depth interviews.

In-depth interviews were used to gather qualitative data from the first encounter with the patients and from their life stories. These interviews had open questions aimed at allowing for a natural manifestation of the patients’ accounts. For the first encounter, the recommendations on interviews for the phenomenological diagnosis of schizophrenia were taken into account ( Dörr, 2002 ), and clinical biographical focus criteria were used to perform the life story interviews ( Sharim, 2005 ).

Positive and Negative Syndrome Scale

The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987 ) is a rating scale used for measuring symptom severity of patients with schizophrenia. The name refers to the two types of symptoms: positive, which refers to an excess or distortion of normal functions (e.g., hallucinations and delusions), and negative, which represents a diminution or loss of normal functions.

The Examination of Anomalous Self-Experience

The Examination of Anomalous Self-Experience (EASE; Parnas et al., 2005 ) is a semi-structured interview for the phenomenological examination of disorders of the pre-reflexive self, postulated as early markers or basic phenotype of the schizophrenic spectrum ( Raballo et al., 2011 ). The EASE explores a variety of anomalous self-experiences, which typically precede the onset of positive symptoms and which also often underlie negative and disorganized symptoms ( Parnas and Handest, 2003 ).

Data gathering was performed by means of semi-structured interviews, which are characterized by the use of eminently “open” research questions. Less structured methods allow for the emergence of ideographic descriptions, personal beliefs and meanings, focusing on “how” the psychological processes occur ( Barbour, 2000 ).

Five encounters with the patients were carried out. These encounters were coordinated throughout the three following phases:

Phase I: A first encounter to record the patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episode (30–45 min interview carried out 1–2 weeks after hospitalization), following the confirmation of the diagnosis of schizophrenia in accordance with expert judgment and the standard diagnostic criteria of DSM-IV-R ( American Psychiatric Association, 2003 ) and ICD-10 ( OrganizaciónMundial de la Salud, 2003 ).

Phase II: Two subsequent encounters to carry out the EASE ( Parnas et al., 2005 ; 30–45 min per interview carried out 1 month after hospitalization), when patients did not score with “positive” symptomatology on the PANSS ( Kay et al., 1987 ).

Note: The results of Phase II of the broad research have not been included in this paper. The results from the EASE exploration will be published in a complementary paper focused on basic self-disorders entitled “The lived body in schizophrenia” (in preparation).

Phase III: Finally, two further encounters were held to perform the life story interviews (30–45 min per interview carried out 1–2 months after hospitalization). The first encounter started with the open instruction “tell me about your self,” “tell me about your life,” while the second one was focused mainly on the patients’ significant social interactions and personal meanings, also including their first image in life, their early dreams (hopes), their self-definition, and their expectations about the future.

All the interviews were recorded on video and fully transcribed for subsequent analysis. Extracts of the patients’ accounts were kept literally in quotes.

First Encounter (Phase I)

The patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episodes were summarized in corresponding descriptions containing the essential structure of the transcripts, which were obtained with the “Descriptive Phenomenological Method in Psychology” ( Giorgi, 2009 ), by following five steps: (1) the researcher reads the entire transcript in order to gain an overall sense, (2) the same transcript is then read more slowly, and underlined every time a transition in meaning is perceived, providing a series of units constituting meaning, (3) the researcher then eliminates redundancies and clarifies the meaning of the units, connecting them together to obtain a sense of the whole, (4) the arising units are expressed essentially in the language of the subject, revealing the essence of the situation for him, and finally, (5) there is the summarizing and integrating of the achieved understanding in a description with the essential structure of the transcript.

Life Story Interviews (Phase III)

The criteria of the clinical biographical focus were considered in the life story analysis, which are part of the so-called “clinical human sciences” paradigm ( Legrand, 1993 ; Sharim, 2005 , 2011 ). This approach stresses the life story method, in which the clinical dimension is constantly present, working primordially on singularity: case-by-case, story-by-story.

At the same time, the examination of singularity and heterogeneity of individual situations allows the progressive appearance of common processes that structure behavior and organize these situations ( Sharim, 2005 , 2011 ; Cornejo et al., 2008 ). This method highlights the role of the subject in recounting his life story, giving the possibility to analyze the reciprocal relationship between the subject’s determination by his history and his potential to create his own existence ( De Gaulejac, 1999 ; De Gaulejac et al., 2005 ).

The in-depth analysis of the life stories was developed under a course guided by the co-author of this paper. The course was called “Hermeneutic analysis of biographical material for the study of patients with schizophrenia” and took place during one academic semester at the Catholic University of Chile. The analysis focused on the personal meanings ( Fuchs and De Jaegher, 2009 ) by following the patients’ history of significant social interactions.

Therefore, the transcripts were analyzed by peer researchers (corresponding author and co-author of this paper) both clinical psychologists with a specialty in psychotherapy. To avoid bias each researcher previously made a separate analysis and then met for the co-analysis, ensuring with this procedure the validity of the qualitative research ( Maxwell, 1996 ; Morrow, 2005 ; Fischer, 2009 ).

Firstly, an individual (case-by-case) in-depth analysis of each narration using a hermeneutic approach was carried out. In this analysis each life story was re-constructed, carrying out a thematic and chronological ordering, which enabled the identification of “biographical milestones,” as well as the analytical axes in each life story. Second, a cross-sectional analysis was carried out contemplating the stories all together, revealing the differences, similarities, and shared structural dimensions.

Ethical Issues

The broad research, covering 15 patients with schizophrenia during their first psychiatric hospitalization, was regarded as entailing no physical, psychological, or social risks for the subjects involved, based on the Declaration of Helsinki principles, the Council for International Organizations of Medical Sciences (CIOMS) 1992 International Ethical Guidelines for Biomedical Research Involving Human Subjects, and the 1996 International Conference on Harmonisation (ICH) Good Clinical Practice guidelines, by the following Ethics Committees: (1) Research into Human Beings Ethics Committee of the University of Chile’s Medical Faculty, dated January 19, 2011. (2) Ethics Committee Research of the Psychiatric Hospital, dated August 2, 2012. (3) Ethics Committee Research of the North Metropolitan Health Service (Santiago, Chile), dated August 16, 2012.

The Ethics Committees also approved the patients’ and their tutors’ (legal representatives) consent documents. In this regard, the following ethical aspects were taken into account: (1) consent was informed and obtained from the patients’ tutors by the attending doctor at Phase I of the study, considering that as a patient affected by an acute episode of schizophrenia, his competence or capacity is diminished and he must be authorized to participate. (2) Consent was obtained directly from the patients at Phase II of the study. (3) Pseudonyms were employed to protect the identity of the patients and ensure confidentiality (internal codes were used for each patient to replace their original names).

Note: Careful attention was paid in this paper to the protection of the patients’ anonymity. Identifying information such as dates, locations, hospital numbers, etc., was avoided.

Individual Analysis (Case by Case)

Santiago (Santi) is an 18-year-old patient, diagnosed with disorganized-type schizophrenia. He has completed 8 years of basic school education. His father died of cancer 1 month before his hospitalization: until then, he lived with him and his two brothers. He is the middle brother. The patient’s mother left home when he was 12 years old.

First encounter . A first interview was carried out after 2 weeks of hospitalization. In this encounter, the patient indicates that although he considers himself to be a “normal” person, begins to recognize a “ repetitive failure .” It is primarily the mediating process of thinking that has become the main impediment in this case.

The patient indicates that he hears voices, which are as if his own thoughts were repeated inside his head, like an echo, “ as if I was reading them aloud but with my mouth closed .” Most of the voices repeat meaningless things that he does not understand. He also hears voices on the radio, repeating what he is thinking: these are voices of unknown people who seem to be talking to him. Additionally, it sometimes seems to him that some television personalities repeatedly say things to him, all sorts of non-sense. He does not know how or why they do.

There are periods in which the “repetitive failure” intensifies, to the extent that it prevents him leaving home, and that only by going to bed to sleep is he able to take a break from these thoughts. This has made it difficult for him to progress with his studies or concentrate. He feels that this situation is annoying for him and is harmful because he cannot live a normal life.

At first, the patient figured it was sort of a game, playing with the voices and thoughts, but he could not control it, he could not stop it, he kept on playing. This was sometimes unbearable for him, and has even made him want to hang himself.

Biographical milestones . The life story interviews were carried out after 2 months of hospitalization. The patient was receiving the usual pharmacological treatment and had recently completed 12 electroconvulsive therapy sessions.

“My mum left me when I was 12”

Santi begins his account by indicating that he has had a hard life. He refers to his parents’ divorce, and particularly to when his mother left him alone with his brothers when he was 12. His mother moved away from the city and got married again. “ It was very hard, when she wasn’t there and we lacked a mother’s love .”

In addition to being angry with his mother when she left home, Santi also points out that he did not get on with her as a child. He remembers that she used to get very annoyed with him when he and his father sometimes made fun of her.

The mother returned after 2 years for her children. Santi’s brothers agreed to go with her, but he preferred to remain with his father. At the age of 14, he was living alone with his father. However, the brothers returned 2 years later, when he was 16, due to the serious situation with the mother’s new husband, who beat them.

Santi states that he got on well with his brothers; they had an affectionate relationship, one of friends, between them. They helped each other out and shared the housework between them.

“I died in high school”

Santi acknowledges that a significant change took place in his life at school. As a young child, he was a very good pupil and wanted to study medicine, but at the age of 12 he lost interest in his studies, skipped school, and began taking drugs. He had to repeat the last school year twice due to absenteeism. He liked the typical tools of the medical trade and wanted to have a stethoscope. “ Now that I have them here (at the psychiatric hospital), I ask myself, why can’t I, if everyone else can? ”

He stopped taking drugs at the beginning of this year and returned to his studies. He wanted to study accountancy to earn money. He had recently started the first year of high school when he was hospitalized.

“My dad passed away recently”

Santi states that his first memory is one of being with his family, when he was 7. It is a memory of the time when they were still living with their mother. He recalls it was his father who took them to a pretty square at the center of the city. “ Nice memories, everything was nice with my dad. ”

The father worked in the public sector and had taken early retirement, the reason for which is unknown. He did not remarry or have a relationship with another woman. Santi has a very positive image of him. He describes him as hard worker, a good father and who liked to go out and play ball with him and his brothers.

Santi displays an empathetic attitude toward his father, even a certain loyalty, which is made clear when he recounts the time when his mother left home, and later when his brothers left. In fact, he decided to stay alone with his father, despite the pain caused by the separation from his mother and brothers. “ My dad went through an extremely painful time, to put it one way, he didn’t show it but, inside, he was feeling bad .”

The father passed away 3 months ago, from cancer, at the age of 65. He became ill a month before dying, and had immediately told his sons of his disease, so they were aware of how much longer the doctor had given him. The father was hospitalized at the time of his death.

Santi recognizes that he was very attached to his father, he states that “ even too much .” He realizes that he still has not gotten over the death of his father, “ because of my illness, I still have not gotten over it. I haven’t realized what it all really means .”

“ I see the future as nothing ”

Since the last 4 years, Santi has been becoming more and more distanced from the world, to the point where he is extremely isolated. He has no friends, does not study or work, takes no part in social activities and has not embarked on any romantic relationship.

During the week, he helped with some household chores, such as making lunch. Nor did he do anything special during the weekend, except go out to the square with his brother. He spent a lot of time in his room playing on his PlayStation. “ I see the future as nothing, the way I’m going. Not doing anything, not studying, because where will I get like this? It’s looking bad, isn’t it? I’m worried .”

Life story analysis . The patient took part in the interviews without any problems. He appeared interested in obtaining more information on his state of health and motivated to seek help to secure a speedy discharge. He interrupted the interviews on a number of occasions to ask what his illness was, if it was very serious and when his attending doctor would discharge him. Generally, he appeared constantly concerned about his state and anxious to put an end to his confinement.

His life story contains a series of events that could be regarded as stressful. It is certainly possible to establish a connection between the death of his father (i.e., the patient’s state of grief) and the emergence of the first acute episode, and also to identify his mother’s leaving home as the crucial biographical milestone in the development of the prodromal stage of schizophrenia. Somehow, the sense of abandonment in the world has come to dominate the patient’s life.

The scale of the emotional impact of the recent loss of a father is obvious: nevertheless, the patient at no time displays any signs of sadness and does not cry. Instead of a spontaneous emotional expression, he rationally discerns the seriousness of the situation and like a “witness” he testifies the tremendous impact this must have on his life.

He manifested an initial perplexity, conveyed with a degree of humor, in light of the apparent oddness and incomprehensibility of the account of his anomalous experiences (“the repetitive failure”). Nevertheless, although he recounts sad events in his life, any actual sadness can only be assumed. To put it one way, it is possible to “intuit” the patient’s suffering, through the loneliness, abandonment and lack of support in his life, rather than by means of an explicitly emotional manifestation on his part.

The patient notices the paradoxical situation involved (of being hospitalized) when he states that he regards himself as a “normal” person, except for his “repetitive failure.” Far from merely being a game, as he previously regarded it, it is now given the name of schizophrenia, a diagnosis that defines him as a seriously ill patient and justifies his compulsory commitment to a hospital. This has led him to realize that what is happening to him is not socially acceptable, and is thus regarded as more serious in his own judgment.

Angel is a 22-year-old patient, diagnosed with paranoid-type schizophrenia. He has 11 years of basic school education and lives with his parents and the eldest of his three sisters. He is the youngest of the siblings and the only brother. His family are evangelical Christians.

First encounter . A first encounter was carried out a week into his hospitalization. The patient has not been able to find a convincing explanation for the fear he feels, which he recognizes as his major impediment. He thinks he could be delivered over to the Tribulation – the Tribulation is a biblical time of pain.

About 3 months ago he began to feel persecuted by people. His house was the only place he felt safe, but for a few weeks now he has even begun to feel unsafe at home. The idea that somebody can hurt him comes from the fear he feels and he thinks that the worst thing would be that somebody kills him somehow, like stabbing him, for example. This fear is a distressing feeling, of wishing to escape, when he suddenly feels that something bad is going to happen to him.

He is quite concerned about his problem, and thinks a lot about it, and how to solve it. He wants to find a way to overcome the fear. He would like to find a “ clear and precise ” answer to what he should do, how he should live and how to face up to his fear. He wishes that the bible could tell him what to do in the Tribulation, “ if I was in that time, that it told me in light of this fear to do this or that, to face up to it, don’t be afraid, I’ll be with you .”

Biographical milestones . The life story interviews were carried out 1 month into the patient’s hospitalization. He was receiving usual pharmacological treatment and his suitability for electroconvulsive therapy was being assessed.

“ When I was a kid I went to school ”

Angel woke up one night and found himself alone at home: it was very dark and he started crying. This is the earliest image that he recalls from his childhood. He also remembers that he would sometimes run up the stairs because he thought that someone, “ perhaps the bogeyman ,” was after him.

He remarks that his grades were not great but things went well for him at school. During his childhood, he felt good because he went out to play and climb trees. He also liked to fix televisions and take apart toy cars. He stresses the fact that he was more outgoing and playful as a child.

His family was always good to him, and he notes that he had a happy childhood. He was closest to his mother, as she stayed at home and was very attentive and loving toward him. His mother was of good character, and only punished him on a couple of occasions, “ because once I hit my sister with a hammer, when I was playing, and my mum punished me, she gave me a slap on the behind .”

“My sisters were very critical of me”

Angel has three older sisters. He has had a difficult relationship with them, and particularly with the eldest. He points out that his sisters criticized him a great deal and made fun of him. Therefore, even as a child, he took great care to say the right thing, so as not to make a fool of himself and feel embarrassed.

He was not only concerned to ensure that he said the right thing, but also with his personal appearance. He was very sensitive about the comments his sisters made about him. He states that he was very shy as a child, and when he was embarrassed by something he would run away and did not want to come back.

“Then I went to high school”

At high school, Angel was unable to make friends. He notes that he changed, became less playful, less “chatty” and more reclusive. He did not play ball so much or join in with classmates as often.

He also comments that he found it difficult to appear in front of his classmates, and skipped school when he had to give a talk to the class on a subject. This got worse when he started to suffer from acne, which made him feel that people were looking at him too much and a little persecuted.

It was because of the acne that Angel began to skip school, until he stopped going completely and became totally isolated. “ By this point, the acne wasn’t as bad, but it was the fact I missed school, I skipped class a lot, I was embarrassed that I skipped school so much, and that’s why I stopped studying .”

“ Then I went out to work. That’s when it all went wrong ”

Angel does not think that his acne is any better, but somehow he learned to come to terms with this concern. He has spent a lot of time at home, in his room playing on his PlayStation. This is what he has mostly done over the last 4 years, as he admits. “ I didn’t see anyone except for my family, not friends, because it’s a bit solitary on the PlayStation, you get closed in on yourself when you’re on it .”

After 4 years, Angel went out to work. He notes that it is when everything went wrong. He had spent a lot of time at home, without going out. He notes that he was perhaps unprepared to go out and experience life like that all of a sudden. It was then that he began to feel that people were after him.

“ Now, as a person ”

In adolescence, Angel wanted to be an air force pilot but he could not apply because he did not finish his studies and was under the required height – “ it came as quite a blow, but I was still interested in mechanics .”

Angel does not have a clear vision of what the future holds, principally because he has not overcome the fear of being harmed and the thought that “somebody” will kill him, which is his most serious affliction. Nevertheless, he indicates that, if he can overcome his fear, he would like to work and study mechanics and electronics, which have been interests of his since childhood.

Life story analysis . The patient was very willing to take part in the interviews, although he generally appeared tired and dispirited. He seemed not to have much to say, or not to be ready to recount his story. He is of a religious disposition and a frequent reader of the Bible where, above all, he hoped to find an explanation for the problem affecting him: his fear.

His account is mainly based around the fear of being harmed, which is the subject of his delusion. He even appears, in a way, excited when talking about the problem of his fear and about the different explanations he uses to understand what is happening to him. Aside from this core problem afflicting him, his account barely touched on other aspects of his life, and he appeared to become dispirited, tired, and uninterested when moving away from the subject of his delusion.

He seems concerned that he is unable to find certainty in things, above all with regard to explaining his fear. He feels prey to a fear that is completely restrictive, and is unable to find a satisfactory explanation that would allow him to understand what is happening to him or to give a completely convincing response to overcome the situation. He is aware of the extent of the fear and the significant limitations it causes in his life, and of the lack of any clear orientation as to how to overcome it.

The patient conveys a feeling of “ontological” uncertainty or insecurity. From an early age in his life, the world (and others) acquired a sense of unreliability or threat. Shame and fear of ridicule are the predominant emotional aspects of his experience in childhood. Somehow, later on in adolescence these emotions led to the fear of persecution. Persecution progressively became a fear of being hurt until it reached the extreme point of a fear that he would be killed, which manifested itself in the first acute episode.

Salvador (Salva) is a 25-year-old patient, diagnosed with catatonic-type schizophrenia. He has completed 12 years of compulsory school education and lives with his father and older brother. His parents divorced 2 years ago.

First encounter . The first interview was carried out when the patient had been hospitalized for close to 2 weeks. He explains that 2 years ago started with an episode of mental illness: “ I was getting cramps in the back of my brain .” It was because of the confusion these cramps caused in his brain that he went to the psychiatrist. Then, he was diagnosed with depression and treated with medication for a year but the problem persisted.

He feels mental pressures, and indicates it is as if they squeeze his brain. His thoughts are jumbled up, all messed up with ideas. Reality gets distorted for him as well, as if he were in a constant dream. In addition, he has felt someone possessing his body and explains it as “demonic possession.” He thinks that spirits get in when someone is depressed. It is something he cannot control, something unpredictable, imminent.

The patient is worried about the state of his mental health. It worries him to “live like this,” and he feels a deep-seated desperation. He does not want to do anything and feels depressed, downcast, dispirited, and powerless. Before he was hospitalized, he wanted to committed suicide by jumping off a hill due to the desperation.

Biographical milestones . When the life story interviews were carried out, the patient had been hospitalized for a month and a half. He was receiving the usual pharmacological treatment.

“ My interest in religion began at the age of 8 ”

Salva completed his primary education at a Christian school. He liked the religious part of school because religion was taught in a fun way. When he was a child, he used to go to church with his family. “ I liked the teachings about love, love for one another, love for one’s neighbor .”

He points out that he was a very good student and got very good grades. He wanted to be a vet when he was a child, because he liked animals. He describes himself as a gentle, playful, brotherly, sweet boy.

“ They moved me to a worldly high school ”

The change of school had a negative impact on Salva. His performance suffered, and he went from being an outstanding student to being just an average one. He notes that students at the new school were treated more coldly.

He had wanted to be a vet since childhood but he could not go to university, as he did not pass the entrance exams. He therefore chose to study architectural drawing at a college, but did not manage to complete his first year there.

“ My mum was sweet to me when she was Evangelical ”

Salva had a good relationship with his mother as a child. He points out that his mother was very loving toward him whilst she was Evangelical. Later, however, for reasons unknown to him, she distanced herself from church. Their relationship deteriorated when he was a teenager.

He got on badly with his mother because, he explains, of their very different characters. His mother ill-treated him and frequently insulted him. This made him feel powerless. “ She was really aggressive, and punished and hit me for anything. She used to insult me in all kinds of ways, she called me mentally ill .”

His mother also fought with his father and brother. She drank, and when she did so she became more violent.

“ I went through a lot in 2010 ”

Salva states that he had his first episode of “mental illness” 2 years ago, and has not been able to work or study since then. “ I did nothing at home, just playing games on the computer; I’d play on it, football games and PlayStation. I spent a load of time doing that .”

It was in this same year that his mother left home and his father fell ill with diabetes. His brother had had a heart attack at the end of the previous year.

His mother left home to live with a new partner, saying she wanted her independence. At first he missed her, but was also angry. He did not want to see her or be with her after she left.

Salva continued to live with his father and brother. He feels very attached to them, and is concerned about their health. He feels he has a really great father, because he has had to play a double role. He gets on well with his brother too, who he regards as a second father.

“ It’s great at church, they treat me really well ”

Salva’s current friends are evangelicals and he joins them at church. He likes going to the church because there he got to know beautiful people and had a much closer relationship with God. “ I like being in communion with God, praying, singing, that’s how I look for protection .”

He has had four episodes of “demonic possessions,” all of which happened at church. It was at church where he was told that his bodily experiences were “possessions” and that they are somehow “normal.” However, the treatment he was given there was unsuccessful. They carried out “deliverances,” which are a way of getting the devil out the body with prayer.

At the moment, Salva does not know why these episodes have happened to him, or whether they are due to an illness, and has not even talked much about the matter with his attending doctor.

“ In the future, I want to study massage therapy ”

Over the course of the last 7 years, Salva worked on and off in a number of fields. He took jobs as a shelf stacker in a supermarket, a cleaner at a cinema and a shop assistant. His last job was 2 years ago selling fragrances in a street market.

He has remained socially isolated over the last 2 years, only keeping in touch with his evangelical friends at church sporadically. “ I’ve found it difficult to relate to people in recent years. I haven’t worked much or had much of a social life. I’ve been isolated .”

In the future he would like to have children, a wife and work giving massages, although he realizes that he remains scared about his mental state, that he feels vulnerable.

Life story analysis . The patient took part in the interviews willingly, although he did appear very tired and sleepy (he was constantly yawning). The disordered thoughts persist, as do his low spirits, mental pressures and the uncertainty in the face of possible new “possessions.” He talks about himself and his life quite candidly and seems naïve, as if recounted by a small child. He speaks calmly, slowly, with little verve. It is a story with few elements told at a basic level of articulation.

He is very religious, a habitual reader of the Bible and a regular churchgoer. Now, although the episodes were “demonic possessions,” fear does not appear to be the predominant or explicit emotion: it is rather the loss of control of his bodily experiences and the unpredictable nature of these episodes that make the patient desperate. In other words, his desperation is due to his inability to once again feel normal or healthy.

He left school 7 years ago and has not developed a specific plan to carry out his life. Although he wishes to have a “normal” life, his life project faces a vacuum. However, the lack of a plan does not seem to concern him at all. Instead, what most worries the patient at present is the state of his mental health, that is, the anomalous bodily experiences he is not able to control.

It is possible to make a connection between the emergence of the first acute episode and a series of stressful events that occurred in the patient’s life at that time: his mother left home, his father fell ill with diabetes and his brother had heart problems, all in the same year. Although, the negative impact of the change in high school and the deterioration of the relationship with his mother in his adolescence are the crucial biographical milestones identified in the development prodromal stage of schizophrenia.

Besides, what the patient explains as “spirits getting into” does not seem to correspond to a typically clinical depression (as it was diagnosed initially), but rather to a severe “passivity” of his own existence, which finds concrete form in his disembodied experiences.

Cross-Sectional Analysis

The cross-sectional analysis shows that a severe disorder of intersubjectivity starts developing in early adolescence. Beginning at an early stage, the patients progressively distance themselves from the social world. This distancing becomes a structural element, a key part in the prodromal stage of schizophrenia.

It is not an active deliberate distancing, but rather an overall difficulty that hampers the living of a normal life. It implies a progressive “passiveness” of the patients’ own existence, which manifests itself not only in the disturbances of self-experience and body alienations of the acute phases, but also in the patients’ radical withdrawal from the social world.

For several years, the patients have not worked or studied, have had no social life, and have stayed shut in at home watching television or playing on their PlayStation for hours at a time. Here, it is important to notice that the acute episode occurred at a time when they were planning to return to their studies or the world of work after a number of years of extreme isolation.

It is possible to make a connection between the prodromal stages of schizophrenia and several stressful events that occurred in the patients’ lives. It is also possible to follow a continuity in the experience of vulnerability regarding the main personal meaning configured early in life: the feeling of abandonment, the fear of ridicule and the feeling of powerlessness, corresponding to Cases 1, 2, and 3, respectively.

Nevertheless, the patients’ withdrawal from the social world is what eventually leads to the manifestation of their psychosis. Somehow, in their attempts to returning to intersubjectivity, all of a sudden the patients confront themselves with their own “vulnerability” of being in the world.

Although they have some ideas about what to do in the future, the patients are insufficiently prepared, and lack a specific plan to implement them properly. Their life project faces a vacuum. This is what makes their condition so severe: there is an interruption in the patients’ normal unfolding of life.

The patients do have a concept of what a “normal life” should be (basically, to study, to have a job, to marry, and to have a family), but they do not seem to possess the factual grounding needed to deal with the world, as if they were lacking the implicit “know how” to carry out the normal life they wish to live.

It should be noted that the patients’ life stories feature a series of healthy elements or personal qualities that reflect a certain nobility of character: sensitivity, authenticity, naivety, empathy, and innocence. There does not appear to be any secondary gain associated with the symptoms.

Key Findings

In acute phases of schizophrenia, patients’ accounts concentrate on (or are limited to) the disturbances of self-experience or body alienations. In other words, patients’ accounts lie outside the time-space dimension of the social context and exclude personal history. Body alienation appears to be the way in which the de-subjectivized accounts find concrete form (or are materialized).

The assessment of the life stories complements the symptomatic descriptions embedding them in the patients’ life-worlds, thus incorporating a social horizon. In this way, the dimension of intersubjectivity is illustrated in the patients’ history of significant social interactions, discovering the interpersonal elements to integrate in psychotherapeutic and prevention models.

The articulation of the patients’ life stories allow to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence. Thus, the spatiotemporal dimension of the personal history allows the understandability of the interpersonal processes involved in schizophrenia from a broader perspective.

From the individual analysis of the life stories, it is possible to identify the patients’ biographical milestones, the personal meanings involved in their significant social interactions, and also continuity in their experience of vulnerability of being in the world, which are useful elements to consider for psychotherapeutic treatment.

The cross-sectional analysis of the life stories shows that a severe disorder of intersubjectivity starts in early adolescence, which should be a useful element to consider for the early detection and on the prevention. Beginning at an early stage, the patients progressively distance themselves from the social world, ending in a radical withdrawal. This distancing becomes a structural element, a key part of the prodromal stage of schizophrenia, as it was found in every case of the broader sample covering 15 patients with schizophrenia.

Social interactions are interrupted prior to the emergence of acute symptoms, possibly due to the threatening or anxiety provoking encounters with others. Nevertheless, the underlying anguish was not measured in this study. Instead, the study shows the personal vulnerability that leads to a psychotic break (or to the culmination of the intersubjective interruption).

Clinical Implications

Psychotherapeutic interventions for patients with schizophrenia have been widely neglected in general. Current treatments are primarily with medication, including elctroconvulsive treatments in acute phases, thus following a medical-biological model that has not been questioned sufficiently. In this context, the intersubjective dimension seems extremely relevant for both the development of psychological treatments and the understanding of the interpersonal processes involved in schizophrenia (as an interruption in intersubjectivity).

From the very start of hospitalization, psychotherapeutic support would appear of fundamental importance. The patients should be accompanied on their return to intersubjectivity, whereas efforts should be made to provide proper emotional support for the realization of the overall problem affecting them. Prior to interventions focused on tasks (for example, successfully performing a social role, such as studying or working), the patients need to experience being in the world with another person, in a synchronous accompaniment of affective reciprocity.

In other words, the intersubjective dimension should be integrated in psychotherapeutic models focusing on the patients’ social interactions. These models should be oriented to developing a collaborative encounter between the patient and the therapist, as well as enhancing metacognitive capacities, as it has been shown to be helpful especially for the recovery of patients with schizophrenia in several case studies ( Dimaggio et al., 2008 ; Harder and Folke, 2012 ; Lysaker et al., 2013 ).

The process of recovering understandability would be a key aspect in overcoming the patients’ alienation. Therefore, special consideration should be given to psychotherapeutic approaches that focus upon encouraging patients’ self-understanding and the establishment of a common communicative base between patient and psychotherapist ( Holma and Aaltonen, 1997 , 2004a , b ; Seikkula and Olson, 2003 ; Seikkula et al., 2006 ). The idea is that the patient’s experience can be explicitly shared on the basis of a common meaning by a dialog process that takes into account the other’s point of view (or second person-perspective; Stanghellini and Lysaker, 2007 ).

Patients’ narrativity should improve along different levels of articulation, by the recognition of beliefs, the incorporation of emotions and the reconstruction of different meaningful life events. However, during acute phases delusional beliefs constitute the patients’ only available form of cognitive and interpersonal organization, so instead of confronting them, the focus should be placed on the difficulty in pragmatically comprehending others and on the experience of vulnerability ( Lysaker et al., 2011a , b , c ; Salvatore et al., 2012a , b ; Henriksen and Parnas, 2013 ; Škodlar et al., 2013 ).

Besides, acute psychosis in schizophrenia manifests itself with a collapse of the temporal dimension of the narrative plot, which leads to a de-contextualization of self-experience ( Holma and Aaltonen, 1997 , 2004a ; France and Uhlin, 2006 ). From the so called “literacy hypothesis” ( Havelock, 1980 , 1991 ), which belongs to studies that follow the transition from orality to literacy in the development of the thematic consciousness, it could be noted that in the acute phase the patients lose the modality of ordering their experience in consensual logical sequences, displaying a narrativity with epic or poetic characteristics ( Guidano, 1999 ).

The re-establishment of the consensual ordering given by the locational/situational aspects of the life story (by articulating the self-experience in thematic/chronological sequences; Havelock, 1980 , 1991 ; Bruner and Weisser, 1991 ; Narasimhan, 1991 ; Guidano, 1999 ; Irarrázaval, 2003 ; Bruner, 2004 ; Holma and Aaltonen, 2004a ) allows to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence.

In this sense, the articulation of the patients’ life stories, expressed as narrative creations of their own subjectivity (and meanings), allows for the spatiotemporal dimension “re-ordering,” as well as for the understanding of the interpersonal processes involved in schizophrenia from a broader perspective. This psychological understanding reveals the intersubjective dimension that connects the emergence of the acute episode with the patients’ biographies, taking into account the personal meaning at play in each case.

In the case of Santi, there appears to be a need for emotional support aimed at accompanying him in becoming aware of the magnitude of the loss caused by the recent death of his father and, subsequently, to help him to develop strategies to deal with his feeling of abandonment in the world.

With Angel, his fear of ridicule is a structural emotional trait that dominates his life and is becoming a fundamental part of his worldview. Here, it is most important to deal with his sense of embarrassment and help him to accept himself. The aim is to provide a new, positive meaning to the sense of himself, overcoming his fear of ridicule in his encounters with others, or in other words, recovering the legitimacy of the sense of himself.

Salva requires an intervention in terms of developing a more basic sense of self-embodiment, which would be aimed at reflecting the feelings of “the other,” to re-establish primordial reciprocity. Additionally, space needs to be created in which the patient can recover a feeling of protection in the world, overcoming the feeling of powerlessness.

From this viewpoint, taking into consideration the story the patient tells of himself improves the articulation of self-narrative, which should gradually be extended toward diverse areas of his life whose elaboration appears important for him to make his way back to daily life. It would be important to articulate the present considering the experience that takes place in the actual interpersonal context, and from here to articulate the future as a horizon of possibilities.

Therefore, reconstructing the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia, but also on the psychotherapeutic intervention best suited to each individual case. Moreover, when intervention in acute phases of schizophrenia focuses mainly on reducing “positive” symptomatology, without assessing the psychological and social elements that are part of the overall situation affecting the patient, relapse seems highly likely.

Limitations of the Study

Regarding the limitations of the study, mainstream scientific research in mental health has been dominated by quantitative methodologies and statistical analyses of big samples (representativeness), while the value of in-depth psychological analyses has been underestimated.

There is a predominant excessive confidence in the accuracy of numbers, as if they could not be easily manipulated in data analyses. This tendency has been supported by the illusion that numbers represent exactly (as a mathematical formula) the experience of the subject, rather than the patients’ own stories.

While qualitative methodology has been the tradition for research in humanities and social sciences, psychotherapy research has been developed using the methodologies of the medical sciences, which are mostly quantitative, being the randomized controlled trials being the favored design.

Nevertheless, research in psychotherapy should be guided by questions that are relevant to clinical practice. It should not be forgotten that methodologies are only means to carry out scientific research, but should not be the ultimate aim in themselves. Thus in this field of research it seems necessary to incorporate the questions psychotherapists need to answer to improve the practice of psychotherapy (to help patients), and then to choose the most appropriate methodologies.

However, one of the main advantages of qualitative studies is the open, mindful and detailed assessment of the subjective experience, enabling the emergence of the patients’ worldview and their personal meanings, which cannot be obtained by means of superficial assessments. Therefore, psychotherapists should also have a voice on the debate of which methodology is best suited to improving the practice of psychotherapy.

Future Directions

Certainly, it would be important to systematize the results of this study in a model of psychotherapeutic treatment for persons with schizophrenia, which should include the intersubjective dimension, starting from the hermeneutic analysis of the patients’ life-worlds toward a meaning-based psychotherapeutic practice. This model would eventually require evidence of effectiveness.

Moreover, it would be interesting to explore gender differences in the processes involved in schizophrenia, investigating prodromal and acute stages, as well as life stories of women with schizophrenia. In addition, improvement is needed regarding the differential diagnosis between acute phases of schizophrenia and acute phases of other severe mental disorders, such as major depression and bipolar disorder.

Finally, the future challenge in the field of phenomenological psychopathology would be to develop a comprehensive/unified philosophical framework for an embodied science of intersubjectivity. And, consistently, to continue developing coherent methodologies for empirical research, since this is the closest we can get to the patients’ life-worlds.

Author Contributions

Co-author Dariela Sharim made substantial contributions to the analysis and interpretation of data to include in the paper; she revised the paper critically for important intellectual content; she made a final approval of the actual version of the paper to be published; she agreed upon the accuracy and coherence of the development of the sections for the paper.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thank Thomas Fuchs from Heidelberg University, the Reviewers and the Editor for their helpful comments to improve the manuscript. Leonor Irarrázaval would like to thank Comisión Nacional de Investigación Científica y Tecnológica (CONICYT) for the grant “Beca Doctorado Nacional” (Doctorado en Psicoterapia UCH/PUC) and German Academic Exchange Service DAAD for the grant “Short duration research scholarships for doctoral students and young researchers.”

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Keywords : schizophrenia, phenomenology, hermeneutic, intersubjectivity, life stories, clinical psychology

Citation: Irarrázaval L and Sharim D (2014) Intersubjectivity in schizophrenia: life story analysis of three cases. Front. Psychol . 5 :100. doi: 10.3389/fpsyg.2014.00100

Received: 03 December 2013; Accepted: 24 January 2014; Published online: 12 February 2014.

Reviewed by:

Copyright © 2014 Irarrázaval and Sharim. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Leonor Irarrázaval, Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Av. Manuel Rodríguez Sur 253, Oficina 206, Santiago CP 8370057, Santiago de Chile, Chile e-mail: [email protected]

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Understanding Schizophrenia: A Case Study

Schizophrenia is characterized mainly, by the gross distortion of reality, withdrawal from social interaction, disorganization and fragmentation of perception, thoughts and emotions. Insight is an important concept in clinical psychiatry, a lack of insight is particularly common in schizophrenia patient. Previous studies reported that between 50-80% of patients with schizophrenia do not believe, they have a disorder. By the help of psychological assessment, we can come to know an individual's problems especially in cases, where patient is hesitant or has less insight into illness. Assessment is also important for the psychological management of the illness. Knowing the strengths and weaknesses of that particular individual with psychological analysis tools can help to make better plan for the treatment. The present study was designed to assess the cognitive functioning, to elicit severity of psychopathology, understanding diagnostic indicators, personality traits that make the individual vulnerable to the disorder and interpersonal relationship in order to plan effective management. Schizophrenia is a chronic disorder, characterized mainly by the gross distortion of reality, withdrawal from social interaction, and disorganization and fragmentation of perception, thought and emotion. Approximately, 1% world population suffering with the problem of Schizophrenia. Both male and female are almost equally affected with slight male predominance. Schizophrenia is socioeconomic burden with suicidal rate of 10% and expense of 0.02-1.65% of GDP spent on treatment. Other co-morbid factors associated with Schizophrenia are diabetes, Obesity, HIV infection many metabolic disorders etc. Clinically, schizophrenia is a syndrome of variables symptoms, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over the time, but the effect of the illness is always severe and is usually long-lasting. Patients with schizophrenia usually get relapse after treatment. The most common cause for the relapse is non-adherent with the medication. The relapse rate of schizophrenia increases later time on from 53.7% at 2 years to

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Clinical pearl i – pharmacokinetics, clinical pearl ii – clozapine and agranulocytosis, clinical pearl iii – hyperprolactinemia and associated complications, case based clinical pearls: a schizophrenic case study.

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O. Greg Deardorff , Stephanie A. Burton; Case Based Clinical Pearls: A schizophrenic case study. Mental Health Clinician 1 February 2012; 1 (8): 191–195. doi: https://doi.org/10.9740/mhc.n95632

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Clinical pearls based on the treatment of a patient with schizophrenia who had stabbed a taxi cab driver are discussed in this case study. Areas explored include the pharmacokinetics of fluphenazine decanoate, strategies to manage clozapine-associated agranulocytosis, and approaches to addressing hyperprolactinemia.

Forensic psychiatry is a subspecialty in the field of psychiatry in which medicine and law collide. Practiced in many facilities such as hospitals, correctional institutions, private offices and courts, forensic psychiatry requires the cooperation of health care and legal professionals with the common goal of helping patients become competent of their legal charges and returning to a productive life in the community. In contrast to general psychiatric patients, the clients in this field have been referred through court systems instead of general practitioners and are evaluated not only for their symptoms but also their level of responsibility for their actions.

These patients can be some of the most challenging to treat because of factors such as non-compliance, an extensive history of failed medication trials, and the severity of their mental illness. Some of the most severe mentally ill patients reside in forensic psychiatric hospitals and have spent much of their lives institutionalized. Treatment refractory schizophrenia, defined as persistent psychotic symptoms after failing two adequate trials of antipsychotics, is a common occurrence in forensic psychiatric hospitals and often requires extensive manipulation of medication regimens to obtain a desired therapeutic response. Like other patients, these patients may present with barriers to using the most effective treatment such as agranulocytosis, inability to obtain and maintain therapeutic drug levels due to fast metabolism, or bothersome adverse effects such as hyperprolactinemia. In treatment resistant patients, it may still be necessary to use these medications even when barriers are present due to a lack of alternative therapeutic options not previously exhausted. In addition to complex regimens, treatment plans for these patients often require trials of multiple medication combinations or unique exploitation of interactions and biological phenomena.

We report a forensic case study that exemplifies multiple clinical pearls that may be useful in patients with treatment refractory schizophrenia. A 31-year-old African American female presented to the emergency room escorted by law enforcement after stabbing a cab driver with a pencil. The patient stated she was raped by the cab driver and while in the emergency room stated that “dirty cops brought me here.” She was admitted to the inpatient psychiatric unit to determine competency to stand trial for the assault of the cab driver. She had been in many previous correctional institutions with a known history of schizophrenia and additional diagnoses of amenorrhea, hyperprolactinemia, and obesity.

The patient's history was significant for auditory hallucinations and paranoid delusions beginning by age fourteen with a diagnosis of major depression with psychotic features. By age eighteen, she was diagnosed with schizophrenia, paranoid type. She had multiple previous hospitalizations and a history of poor compliance as an outpatient. There was no known history of tobacco, alcohol, or illicit drug use. Her family history was significant for schizophrenia, diabetes mellitus, and drug use. The patient reported abusive behavior by her grandmother, who was her primary caretaker as a child.

During hospitalization, the patient continued to report sexual assaults, accusing both patients and staff of rape, and declined to participate in groups. She denied any visual or auditory hallucinations but continued to exhibit paranoid delusions. The patient was later found to be permanently incompetent to stand trial and was committed to the state's department of mental health for long term treatment of her psychiatric illness.

The patient was previously treated with fluphenazine decanoate intermittently for two years with difficulty obtaining the desired therapeutic response. After approximately two months of therapy, the patient presumably at steady state (~14 day half-life) still failed to demonstrate any clinical response. There is no conclusive evidence that fluphenazine levels correlate with clinical outcomes, however the psychiatrist had worked with this patient in the past and felt the lack of response in this situation justified a fluphenazine level. 1 The fluphenazine level was shown to be 2.2ng/ml (therapeutic range 0.5–3 ng/ml) while taking fluphenazine decanoate 50mg intramuscularly (IM) every two weeks. Increasing the target drug level to the upper edge of the normal range was warranted in this patient due to the persistent positive symptoms and a desire to continue using a long-acting injectable agent, which can ensure the delivery of medication in uncooperative and noncompliant patients. Fluphenazine is a high potency first generation antipsychotic that can improve positive symptoms of schizophrenia; however it is not effective in treating the negative symptoms. It was decided that the addition of a CYP2D6 inhibitor such as fluoxetine would not only provide increased levels of fluphenazine, but would also improve the patient's negative symptoms such as flat affect, anhedonia, social isolation and amotivation. 2 Thus, fluoxetine was given as 20 mg orally (PO) daily resulting in an increase of the fluphenazine level by 0.9 ng/ml (40%) after twenty two days of therapy to 3.1 ng/ml. One month later the fluphenazine decanoate dose was increased to 125 mg IM every two weeks (max 100mg/dose), with continued fluoxetine treatment, resulting in a supratherapeutic level of 3.6 ng/ml. Positive and negative symptoms only showed minor improvement. A 6-week study by Goff, et al. demonstrated an increase of up to 65% in fluphenazine serum concentrations in patients administered concomitant fluoxetine 20 mg/day. 2 In this case, the addition of fluoxetine safely and effectively elevated fluphenazine blood levels. Addition of an inhibitor may be beneficial in patients who are CYP2D6 ultra-rapid metabolizers, as was suspected in this patient.

Many complications, including prolonged jail time, can arise from forensic clients being non-compliant with their medications, which is the reason long acting injectables are often warranted. Our patient had a history of non-compliance and continued to experience positive symptoms despite treatment with fluphenazine. Therefore, the decision was made to try another long-acting antipsychotic injection. After reviewing the patient's chart, it was noted that a previous trial of oral haloperidol 30mg/day showed moderate improvement. Thus, after tolerability and efficacy was determined with oral haloperidol the patient was converted to haloperidol decanoate 300 mg (10–15 x oral daily dose of haloperidol) administered every three weeks beginning two weeks after discontinuation of fluphenazine decanoate 125 mg IM every two weeks. Fluphenazine levels approximately six weeks after its discontinuation (and two weeks after the discontinuation of fluoxetine 20 mg PO daily) were still supratherapeutic. Given that this patient had a fluphenazine level of 3.6 ng/ml near the time of haloperidol decanoate administration, it would be questionable whether another high potency antipsychotic would be of any additional benefit in comparison to the increased risk of extrapyramidal side effects (EPS). Data provided in one study showed fluphenazine decanoate as being detectable for up to 48 weeks after discontinuation. 3 Because fluphenazine decanoate can be detected for such an extended period of time, it leaves the patient at a continued risk for extrapyramidal side effects, especially if another antipsychotic is added shortly thereafter. In the forensic population, many patients have treatment refractory schizophrenia and the use of antipsychotics will need to be life-long. It is often common for these patients to be on multiple concurrent agents, increasing the risk for developing long-term extrapyramidal side effects. Therefore, it is important to minimize the risk of these symptoms whenever possible.

Despite supratherapeutic levels of fluphenazine, the psychiatrist felt it would be beneficial to continue haloperidol decanoate 300 mg every three weeks with increased monitoring for signs and symptoms of EPS.

During the current admission the patient continued to exhibit paranoid behavior and lack of insight, expressed anger, and disliked attending or participating in groups. Her medication history included haloperidol, fluphenazine, quetiapine, aripiprazole, asenapine, olanzapine, paliperidone, and sixteen days of clozapine therapy before leukopenia warranted discontinuation. Due to her extensive history of failed antipsychotics and the known superior effectiveness of clozapine, this patient was an ideal candidate for clozapine therapy. Additionally, because of the poor quality of life a declaration of incompetency would lead to, using the most effective possible agent is an important priority in forensic patients. Clozapine is the most effective antipsychotic based on the U.S. Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the UK Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS). 4 , 5 In regards to the significant blood draws and monitoring that is continuously required, clozapine can be a challenging medication to use in treatment refractory patients.

One strategy we are currently working on in our hospital to help increase the number of patients on clozapine is using a point of care (POC) lab device which will allow a complete blood count (CBC) plus 5-part differential to be completed by finger stick, instead of weekly blood draws that our nurses, physicians and, especially, patients dislike. The cost of the POC lab device is approximately $20,000, although upon completion of a cost analysis it was found that five CBCs per day would pay for the cost of the machine after one year. Many times, these patients can become irritated and violent when having their blood drawn, especially, if on a consistent basis. Repetitive blood draws was noted by our physicians to be the largest obstacle in using clozapine in our treatment refractory patients.

Our primary challenge in using clozapine for this patient was finding a way to maintain the absolute neutrophil count (ANC) within acceptable limits (≥1500mm 3 ), which is not uncommon for many patients. The Clozaril Patient Monitoring Services revealed 0.4% of patients had pre-treatment white blood cell counts (WBC) too low to allow initiation of clozapine. Of these patients, 75% were of African or African-Caribbean descent, likely due to the increased leukocyte marginalization that has been shown to be more prominent in these populations. 6 Of all neutrophils in the body, 90% reside in the bone marrow and the remainder circulates freely in the blood or deposit next to vessel walls (margination). The addition of lithium has been shown to increase neutrophil counts by 2000/mm 3 through demarginalization of leukocytes. 7 This increase is not dose –related but may require a minimum lithium level of 0.4 mmol/L. 8 , 9 Lithium therapy used to increase neutrophil counts may be especially effective in patients of African or African-Caribbean descent due to demarginalization of leukocytes. In this patient case, lithium 300 mg by mouth three times daily was initiated for fifteen days to increase the absolute neutrophil count from 1200/mm 3 to ≥ 1500/mm 3 for continuation of clozapine while the white blood cells continued to stay within appropriate limits of ≥3000/mm 3 . It was soon realized that lithium was being cheeked, so liquid form was given, but discontinued after the patient continued to spit the medication out. Unfortunately, clozapine was discontinued thereafter as a result of noncompliance with the lithium causing failure to maintain appropriate white blood cell counts.

Another possible strategy for obtaining appropriate WBC and ANC levels that would enable clozapine continuation is to obtain blood samples later in the day. A study recently published compared the same set of patients having early morning blood draws to blood draws taken later in the day (mean sampling time - pre/post was 5 hours 24 minutes). 10 They showed a difference in the pre/post time change in WBC values being marginally significant (mean increase=667/mm 3 , p=.07), with a significant difference (mean increase=1,130/mm 3 , p=.003) between the pre/post time change in ANC values. ANC values were impacted to a greater extent by the time change than WBC values in this sample. Changing the time at which blood draws are taken during the day may allow for clozapine continuation by limiting the risk of pseudoneutropenia, however it remains the clinician's responsibility to discern between benign or malignant neutropenia. 10 It is recommended, for patients with WBC values trending down or below the predefined criteria, to have labs redrawn several hours after the morning lab before clozapine therapy is discontinued. 10 In this case study, obtaining the sample later in the day may have allowed our patient to continue clozapine therapy.

The patient in this case had additional diagnoses of amenorrhea and hyperprolactinemia. The diagnosis of amenorrhea prompted clinicians to obtain labs showing a prolactin level of 168.8 ng/ml (normal ranges: 3–20ng/ml for men; 4–25ng/ml for non-pregnant women; 30–400ng/ml for pregnant women). Lab monitoring of prolactin levels is not necessary if the patient is not exhibiting symptoms such as disturbances in the menstrual cycle, galactorrhea, gynecomastia, retrograde ejaculation, impotence, oligospermia, short luteal phase syndrome, diminished libido or hirsutism. Monitoring guidelines published in 2004 by APA recommend screening for symptoms of hyperprolactinemia at each visit for the first year and then yearly thereafter. Mt. Sinai Conference Physical Health Monitoring Guidelines for Antipsychotics published in 2004 recommended monitoring at every visit for the first twelve weeks and then yearly.

Occasionally, practitioners are confronted with the dilemma of whether treatment of hyperprolactinemia is warranted in asymptomatic patients. In answering that question, a few things should be considered, such as the patient's risk for osteoporosis and/or cardiovascular disorders. If there are no physical issues of concern, then psychological issues should be addressed. Estrogen deficiency, which may occur with increased prolactin, mediates mood, cognition and psychopathology. 11 Results of several studies conducted in women with hyperprolactinemia have demonstrated increased depression, anxiety, decreased libido and increased hostility. Men shared similar problems but did not exhibit an increase in hostility. 12 The authors hypothesized that women demonstrated increased hostility as a protective mechanism for their offspring.

Antipsychotic medications have differing potencies in regards to hyperprolactinemia, which may help guide product selection. The most potent inducer is risperidone, followed by haloperidol, olanzapine, and ziprasidone. 13 Clozapine and quetiapine are truly sparing, and aripiprazole has even been shown to reduce prolactin levels. 14 Aripiprazole may be a viable treatment option in some patients with hyperprolactinemia. In one study, females with risperidone induced hyperprolactinemia taking therapeutic doses of risperidone 2 to 15 mg/day showed significantly lower prolactin levels from weeks 8 to 16 compared to baseline when administered aripiprazole (3, 6, 9, or 12 mg daily). 15 The mean percent reductions in prolactin concentration at 3, 6, 9, and 12 mg daily were approximately 35%, 54%, 57%, and 63%; however, there was little variability in prolactin levels above 6 mg daily of aripiprazole. Therefore, unless giving liquid form, aripiprazole 5mg daily should be an optimal dose in lowering prolactin levels. In this case, the patient exhibited the clinical symptom of amenorrhea, which correlated with an elevated prolactin level. The addition of aripiprazole 10 mg by mouth once daily decreased this patient's prolactin level by 51 ng/mL (30.3%) after twelve days of treatment.

If an elevated prolactin level is incidentally found, the patient should be monitored for symptoms and labs may be repeated. In patients exhibiting symptoms of hyperprolactinemia with a serum level <200 ng/mL, the antipsychotic dose should be reduced or the agent changed to a more prolactin-sparing drug. 13 If switching the agent is not reasonable, the addition of a dopamine agonist such as bromocriptine or cabergoline may be beneficial, as well as the antiviral agent amantadine. 16 In patients with levels >200 ng/mL, or with persistently elevated levels despite changing to a more prolactin-sparing agent, an MRI of the sella turcica should be obtained to rule out a pituitary adenoma or parasellar tumor. 13 Practitioners should be aware that prolactin levels may remain elevated for significant periods of time following discontinuation of a long acting causative agent due to continued D 2 receptor antagonism. 1 One study found elevated prolactin levels in patients who discontinued fluphenazine decanoate as much as six months after the last injection. 1 , 3  

In summary, we have discussed a few clinical pearls to be considered when working with treatment refractory patients with schizophrenia and outlined some unique aspects of treatment in forensic clients. First, we reviewed potential complications and concerns with using fluphenazine decanoate. In addition, we discussed that ultra-rapid CYP2D6 metabolizers may need an increase in dose when appropriate and/or an addition of an inhibitor. Secondly, patients with agranulocytosis that may benefit from clozapine may find improvement in WBC and ANC values with the administration of lithium and/or changing the time of day in which labs are drawn.

Lastly, hyperprolactinemia may result in not only physical symptoms but psychological symptoms as well. Also, health care providers should not only be cognizant regarding how and when to monitor for hyperprolactinemia, but also the various treatment options available, such as changing to less offensive agents, dopamine agonists, or adding low dose aripiprazole. This patient case exemplified multiple strategies that can be considered when managing treatment refractory patients in which alternative options for therapy are not readily available.

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Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

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[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

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