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Case Study of a Young Patient with Paranoid Schizophrenia

Article · January 2015

DOI: 10.5958/2320-6233.2015.00023.1

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Vipasha Kashyap
Vallabh Government College, Mandi (Himachal Pradesh)
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 International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

DOI: 10.5958/2320-6233.2015.00023.1

14. CASE STUDY OF A YOUNG PATIENT WITH PARANOID SCHIZOPHRENIA

Ms. Vipasha Kashyap

Psychologist ,Dr. Rajendra Prasad Govt. Medical College and Hospital
Kangra Himachal Pradesh
Introduction

Dementia praecox or schizophrenia is a rare disorder, but a well known entity. The word
‘schizophrenia’ comes from the combination of the Greek words skhizein (split) and phren
(1)
(mind). According to the International Classification of Mental and Behavioural Disorders
(ICD-10) schizophrenia falls in the category of F20.(2) It is a disabling group of brain disorders
characterized by symptoms such as: hallucinations, delusions, disorganized communication, poor
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planning, reduced motivation, and blunted affect.(3) Genes and environment, and an altered
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chemistry and structure of the brain, are identified as causes of schizophrenia.(6) There are seven
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subtypes of schizophrenia, classified according to their symptoms.(1) Paranoid schizophrenia (a

sub-type of schizophrenia) is dominated by relatively stable, often paranoid, delusions, usually
accompanied by hallucinations, particularly auditory and perceptual disturbances. Disturbances
of affect, volition, and speech, and catatonic symptoms are not prominent. ICD10 labels it as
F20.0 under the category of schizophrenia, schizotypal and delusional disorders.(2) Research
shows the prevalence of schizophrenia varying within four to seven per 1,000 persons. (4,5) This
research article consists of a case report of paranoid schizophrenia.
Consent of the participant or the care givers was not taken for the publication of this case report.
Data which can reveal the identity of the client has not been provided here.

Case study

History: A 25 years old male, the eldest among his three siblings, belonging to a middle
socio-economic class was diagnosed with paranoid schizophrenia (ICD10 classification). His
parents and a close relative reported the patient as having been reserve and shy since childhood,
rarely initiating a conversation or any activity and hesitant to talk to others. Behavioral changes
were noticed by members of the family as he entered adolescence, but were taken in a lighter

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 International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

vain and ignored. His irritable nature and an anti- social behaviour worsened over the years, and
finally, had a violent bust out on a minor financial issue of the family with a neighbour.

There was no history of any complicated trauma, alcohol and drug dependence, physical or
psychiatric illness of the mother during pregnancy

His formal schooling commenced at the age of four, and completed secondary education at the
age of nineteen. School phobias or any kind of learning difficulty was not reported. The patient
quit his studies in accordance with his parents’ advice. He preferred indoor/solo games, like cars
and video games, rarely indulged in group activities and did not have a very healthy relationship
with the younger siblings. His activities were mostly sedentary. He at times regretted not being
sent to a more established and well reputed school than the one he had attended.
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The mental status examination revealed that, his eye contact was not continuous and he moved
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his eyes suspiciously and furtively. He tried a little hard to change the body postures and
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lethargic movements of the limbs (particularly) were also noticed. Quantity of speech was
reduced, and the patient became hesitant on expression of some of his views and beliefs. During
conversation, there were blank intervals and tangentiality in his train of thoughts, with changes in
pitch. Generalizations based on in-appropriate or limited information were also present. He was
not able to understand and use the concepts easily. His attention and concentration were intact to
an extent. Reaction time was normal and no compulsive acts or habits were present. Orientation
to time, place and person were intact. The patient’s insight into the illness was ‘grade one’, as he
completely attributed it to others around him.

Clinical features: The patient presented with the complaints of restlessness and irritability at the
time of admission, and an incident of a violent attack on his mother just before the arrival in the
health care centre. The dominant symptoms at the time of admission and during his stay in the
health care centre were: suspicious behaviour, delusions of reference and persecution (such as:
sound of blasts, a relative inflicting him with some mantras), auditory (sounds of people talking
about him) and olfactory (poisoning of the air) hallucinations were also present, but were rare.
On investigation it was learned that, in the prodromal state the patient presents non specific
symptoms like: loss of interest, irritability, oversensitivity, lack of appetite and insomnia. The
parents reflected on his non-compliant behaviour regarding the medication and reported that,

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 International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

which makes administration of medication a difficult for the parents (who then resort to tricks,
like: these drugs are for your psycho-sexual disorder, as the patient once had a hallucination that
his penis nerve is being cut). In addition to the presence of the atypical clinical features, a history
of head injury was reported when the patient was 10 years old, when a metal rod pierced his fore
brain. Deterioration of psycho-social functioning was observed and reported by the parents.

Treatment history: Investigations included the general physical examination and the routine
investigations, along with the formulation of case history in the health care centres he visited or
where he was admitted since diagnosis. There were no positive findings on CT scan and EEG
records. The client first saw a psychiatrist in April 2006, after his first violent episode. The client
was prescribed regular medication after this to alleviate the symptoms of the disorder. Some of
the prescribed drugs (from 2006 to 2014) were: Olanzapine, Divalproex sodium, Espazine plus
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trifluoperazine, Trihexyphenidyl, Aripiprezole and Trihexyphenidyl hydrochloride. He was

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given drug therapy along with instructional therapy. Parents and a caregiver were psycho-
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educated about the disorder of the client, as psycho-education has broad potential for many
forms of mental health problems.

Intervention: Psycho-education, instructional therapy, along with cognitive behavioural

technique.

Psycho-education is a more holistic and competence-based approach of health and emphasizes

(17,18)
on coping, and empowerment. Initially, the client and caregivers were made aware about
this particular disorder, considering that the more knowledgeable the client and the caregivers
are, the more positive health related outcomes are for all. On investigation, it was found that,
they were not having precise knowledge about what this disorder is all about. The
parents/caregivers were also informed about certain reinforcement for positive change
techniques, medication management and adherence, and crisis planning, provision of relevant
up-to-date information in a timely and flexible manner, attention to family conflict,
communication, loss, problem solving, and attention to social as well as clinical needs for the
person with illness, along with expanded social support for the family, through multiple family
psycho-education and family support groups. After an empathic relation was established with the
client, CBT (cognitive behaviour therapy) was applied in one of the sessions with the client. He

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 International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

was not aware about his problem, felt irritated whenever was interrupted by someone, otherwise
compliant and revealed a lot of information about himself (contrary to the information provided
by the formal/informal caregivers). He was discharged after 23 days from the health care centre,
and the client/caregivers did not continue with the regime of the sessions planned in the
beginning. A healthy therapeutic alliance could not be formed with the client and the caregivers.
Socio-economic status (Kuppuswamy’s Upper-middle, Grade II)19 of the family, and their
inability to give time, and focus on the problems of the client was a major hindrance in this case.
Progress and outcome: The course of the disorder in the patient was ‘episodic with stable
deficit’. The drug therapy was helpful for the patient, but his non-complaint behaviour was a
major hindrance in the maintenance of his normal functioning at home and in the society.
Instructional therapy was effective when the patient complied and was on medication.
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Discussion
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Schizophrenia and other psychoses are very frequent disorders, and are among the most severe
and impairing medical diseases.(7) The average age of onset for many psychotic disorders is at the
most critical period of educational, occupational and social development, their consequences
often lead to lifelong disability. These patients also have increased physical morbidity and
(8,9,10
mortality in comparison to healthy population. ) In this case too, the progression of the
disease was gradual and reached its peak in the critical period of life, while the client was in his
adolescence and facing stress due to academics. People with persisting psychotic disorders need
adequate and uninterrupted treatment in a stable, safe and stimulating environment. (11) The client
lives in a supportive and a healthy environment. There is absence of any particular severe stress
of childhood sexual or physical abuse in the patient, except for the fore brain injury and
complaints of not sending the patient to a more established school.
A differential diagnosis of delusional or paranoid disorder, paranoid personality disorder and
depression was considered.
For the management of the symptoms short-term instructional therapy and psycho-education to
the client and the formal/informal caregivers were applied. Parents were instructed to manipulate
the environment at home and make the surroundings comfortable for the patient. Research also
suggests that the living environment of people with schizophrenia influences their social

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 International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

relationships.(12) A study demonstrates that, if people with schizophrenia have supportive social
relationships they have a better quality of life, fewer symptoms, and fewer admissions to
hospital.(13) In this case, the stress on the parents and their family, their socio-economic status,
and lack of knowledge about the disorder, is a major factor in the progression of the disease.
Recommendations
. Insight oriented psychotherapy may prove to be helpful, because insight into the illness is
important in the treatment of the disease.
. Formation of a therapeutic alliance is also necessary between the patient and the therapist,
because it is one of the predictors of successful therapy.(14) It needs to be established specially in
the cases, who are non-complaint and lack insight into their problem.
. Cognitive behaviour therapy (CBT) can also be utilized, so that the patient agrees that he/she
has symptoms of mental illness. The main goal of CBT should be to reduce the severity of or
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distress due to the symptoms.(15)

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. Inference chaining can also be useful for looking at the key personalized meaning underlying
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particular delusions.(15,16)
. The focus of health services is still on the medical solutions to schizophrenia, along with this
we need to focus on the psycho-social aspect of the life of affected individuals.

References
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U.S.A.: Wadsworth Group.
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review of the incidence of schizophrenia: The distribution of rates and the influence of sex,
urbanicity, migrant status and methodology. BMC Med 2: 13.
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