schizophrenia case study questions

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

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

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[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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• v.62(4); Fall 2010

Language: English | French

Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy

Purpose: The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.

Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.

Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time.

Intervention: The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal.

Implications: This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.

RÉSUMÉ

Objectif : L'objectif de cette étude de cas consiste à démontrer l'importance de réaliser des entrevues en profondeur avec les patients. Le cas étudié concerne un homme dirigé vers la physiothérapie en raison d'une dysfonction musculosquelettique. Au cours de l'entrevue avec ce patient, un problème psychiatrique a été décelé; par la suite, de la schizophrénie a été diagnostiquée. Le deuxième objectif de cette étude de cas est d'éduquer et de sensibiliser les physiothérapeutes aux signes et aux symptômes aisément reconnaissables de la schizophrénie.

Description du client : Le patient est un jeune homme de 19 ans qui souffre de douleurs chroniques à l'épaule, au coude et au poignet et qui avait été dirigé en physiothérapie. Au cours de l'entrevue, le patient a déclaré qu'il recevait des signaux provenant d'un appareil électronique implanté dans son corps.

Mesures et résultats : L'évaluation préliminaire du physiothérapeute a permis d'identifier un problème qui nécessitait que le patient soit redirigé vers un médecin. Une gestion plus poussée de la dysfonction musculosquelettique de ce patient a été jugée inappropriée à cette étape.

Intervention : Le patient a été dirigé vers une investigation médicale plus approfondie, puisqu'il manifestait des signes de possibles problèmes psychiatriques. Le patient a par la suite été diagnostiqué comme schizophrène et on lui a prescrit du Risperdal.

Implication : Cette étude de cas vient réaffirmer l'importance, pour le physiothérapeute, de procéder à des entrevues approfondies avec les patients pour s'assurer qu'il n'y a pas d'autres problèmes que les seules dysfonctions musculosquelettiques. Les patients qui souhaitent obtenir une évaluation et un traitement musculosquelettique peuvent souffrir aussi d'un problème psychiatrique primaire ou secondaire non diagnostiqué qui exige d'être reconnu par le physiothérapeute et qui nécessitera vraisemblablement une attention médicale ultérieure.

INTRODUCTION

A recent US study demonstrated that less than one-third of diagnoses provided to physical therapists by primary-care physicians are specific. 1 The same study illustrated that physical therapists must assume a greater diagnostic role and must routinely provide medical screening and differential diagnosis of pathology during the examination. 1 Similarly, studies conducted in Australia and Canada have concluded that the majority of referrals for physical therapy are not provided with a specific diagnosis. 2 , 3 Medical screening is important, since physical therapists are increasingly functioning as the primary contact for patients with neuromusculoskeletal dysfunctions, 4 , 5 which means a greater likelihood of encountering patients with non-musculoskeletal disorders, including psychiatric disorders.

As demonstrated by the World Health Organization's International Classification of Functioning, Disability and Health, it is imperative to take an individual's psychological state into account, since disorders in this area can lead to disability. 6 Many psychiatric conditions are commonly encountered in physical therapy practice; for example, depression, anxiety, and fear-avoidance have all been associated with low back, neck, and widespread musculoskeletal pain. 7 – 9 These psychiatric disorders have been identified both as risk factors for musculoskeletal dysfunction and as an important secondary psychosocial aspect of disablement. 7 – 10 It is therefore important for physical therapists to consider the primary and secondary roles of psychopathology in disability.

Although various models of primary-care physical therapy have demonstrated physical therapists' expertise in the realm of neuromusculoskeletal dysfunctions, there is a need for increased competencies in academic, clinical, and affective domains. 5 Few et al. propose a hypothesis-oriented algorithm for symptom-based diagnosis through which physical therapists can arrive at a diagnostic impression. 11 This algorithm takes into account the various causes of pathology, including psychogenic disorders. 11 Although additional research is necessary to validate Few et al.'s algorithm, it provides one model that considers underlying pathologies in determining the appropriateness of physical therapy intervention. 11 The present case report further illustrates the importance of considering the patient's affective and psychological state in order to more effectively screen for and identify psychiatric disorders that require medical referral.

The purpose of this case report is to demonstrate the importance of a thorough patient interview. We present the case of a man, referred for physical therapy for a musculoskeletal dysfunction, who was determined during the patient interview to have an undiagnosed psychiatric disorder, later identified as schizophrenia. In addition, this report is intended to educate physical therapists about the recognizable signs and symptoms of schizophrenia.

CASE DESCRIPTION

The patient was a 19-year-old male university student. His recreational activities included skateboarding, snowboarding, break dancing, and weight training. The patient first sought medical attention from a sport medicine physician in January 2006, when he reported right lateral wrist pain since falling and hitting the ulnar aspect of his wrist while skateboarding in October 2005. Plain film radiographs taken after the injury were negative, and the patient did not receive any treatment. The physician found no wrist swelling, minimal tenderness over the ulnar aspect of the right wrist, full functional strength, and minimally restricted range of motion (ROM). The patient was given ROM exercises and was diagnosed with a right wrist contusion.

Over the next 22 months, the patient returned to the same sport medicine clinic 10 times, reporting pain in his wrist, shoulder, elbow, knee, ankle, and neck. He stated that the elbow, wrist, and shoulder injuries were due to falls while skateboarding and snowboarding or to overuse during weight training; some injuries had no apparent cause. Over the course of his medical care, the patient followed up with three different physicians at the same clinic. He was diagnosed by these physicians, in order of occurrence, with (1) right wrist contusion and sprain; (2) right wrist impingement and left wrist strain; (3) right shoulder supraspinatus tendinopathy; (4) right peroneal overuse injury and strain; (5) disuse adhesions of the right peroneals and right hip adhesions; (6) right ankle neuropathic pain secondary to nerve injury and sprain and right-knee patellofemoral pain syndrome (PFPS); (7) neuropathic pain of the right peroneal nerve; (8) trauma-induced left-knee PFPS; (9) ongoing post-traumatic left-knee PFPS; and (10) right levator scapula strain, chronic right infraspinatus strain, right elbow ulnar ridge contusion, and right wrist chronic distal ulnar impingement secondary to malaligned triangular fibrocartilage complex (TFCC).

After his tenth visit to a physician, the patient was referred for physical therapy for chronic right levator scapula strain and right supraspinatus strain. During the interview, the patient stated that he had right shoulder pain because of a snowboarding injury sustained 1 year earlier and because of a fall onto the lateral right shoulder 2 years ago. Aggravating activities to the shoulder included pull-ups, rowing, and free weights. No position or movement alleviated his pain, and the pain did not fluctuate over the course of the day. His sleep was disturbed only when lying on the right shoulder. The patient was in generally good health, but he said that his right wrist and left knee occasionally felt cold for no apparent reason. He denied experiencing any loss of sensation, decreased blood flow, or numbness or tingling in the knee and wrist. The patient said he believed that his knee and wrist became cold as a result of electromagnetic impulses sent to the joint via an electrical implant in his body and that this device was the cause of his ongoing shoulder pain.

According to the patient, this device had been implanted into his body 2 years earlier by a government organization (the Central Intelligence Agency, the US government, or the US Army) to control his actions. Electromagnetic impulses generated by the implant had caused his falls and injuries; they also caused his joints to become cold or painful when he was doing something “they” did not want him to do, such as break dancing, snowboarding, skateboarding, or exercising. The patient also believed that many other people unknowingly had implants; he claimed that friends, neighbours, professors, and strangers were “working with them” and that they “emotionally abuse[d]” him by giving signs such as kicking a leg back to let him know he was being watched. Furthermore, he indicated that he often received commands telling him to harm his friends or family and that these orders came either from the electrical implant or from the people he claimed were emotionally abusing him. He therefore distanced himself from some friends because he did not want to follow through with these commands. I asked the patient if he felt he would harm himself or others because of his psychotic-like symptoms. He denied any desire to inflict harm on himself or others. Had he posed a threat to himself or others, he would have been “formed” (i.e., committed to a psychiatric facility by the appropriate medical professional).

The patient's past medical and family history were unremarkable. He did not use any prescription or over-the-counter medications, but he felt his thoughts about electrical implants were decreased by the use of marijuana, which he used socially. He was a non-smoker and a social consumer of alcohol. He had a normal gait and appeared comfortable in an unsupported seated position. He denied any weight changes, bowel or bladder problems, night pain, or difficulty breathing.

PHYSICAL EXAMINATION

The patient reported a maximum verbal numeric pain rating scale (NPRS) score of 8/10 and a minimum score of 0/10, with pain usually present in the shoulder. In a double-blind, placebo-controlled, multi-centre chronic pain study, when the baseline NPRS raw score fluctuated by 0 points, the sensitivity and specificity were 95.32% and 31.80% respectively; 12 , 13 when there was a 4-point raw score change, the sensitivity and specificity were 35.92% and 96.92% respectively. 12 The patient stated that when he experienced shoulder pain, it was located on the anterior, posterior, and lateral aspects of his shoulder and radiated down to his elbow and wrist. He reported 0/10 shoulder pain while seated.

Standing posture was assessed in the frontal and sagittal planes. 14 The patient had a mild forward head posture and internally rotated glenohumeral joints in the sagittal plane. The frontal-plane analysis revealed a slight elevation of the right shoulder and level iliac crests. Such visual assessment of cervical and lumbar lordosis has an intrarater reliability of k =0.50 but an interrater reliability of k =0.16. 15

In the frontal plane, the right scapula was abducted four finger-widths from the mid-thoracic spine, and the left scapula was abducted three finger-widths. The scapulas were superiorly rotated bilaterally. Surface palpation of the acromial angle, inferior angle, and spine of the scapula differed less than 0.98 cm, 0.46 cm, and 0.67 cm, respectively, from the actual bony location, with a 95% confidence interval. 16 There was visible hypertrophy of the pectoralis major muscle bilaterally. Active and passive ROM were tested for the shoulders as recommended by Magee. 14 The patient had full bilateral active ROM, with minimal pain at end-range flexion and abduction that was not increased with overpressure in accordance with Magee. 14 He had full passive ROM with no pain reported.

Manual muscle testing based on Hislop and Montgomery revealed 4/5 strength of external rotation at 0° and 45° of abduction, with pain reported along the anterolateral shoulder. 17 Testing also showed 3/5 strength and no pain with resisted abduction with the arm at the side at approximately 30° of abduction. 18 Manual muscle testing is a useful clinical assessment tool, although a recent literature review suggested that further testing is required for scientific validation. 18 Palpation of the shoulder, as described by Hoppenfeld, revealed slight tenderness over the greater tubercle, as well as along the length of the levator scapula muscle. 19

Special tests were negative for the sulcus sign, Speed's test, the drop arm test, and the empty can test, as described by Magee. 14 Research shows that Speed's test has a sensitivity and specificity of 32% and 61% for biceps and labral pathology respectively; 20 the drop arm test has a sensitivity of 27% and a specificity of 88% as a specific test for rotator cuff tears, and the empty can test has a sensitivity of 44% and a specificity of 90% in diagnosing complete or partial rotator cuff tears. 20 , 21 The Neer and Hawkins-Kennedy impingement tests were both negative. 14 According to a meta-analysis by Hegedus et al., the Neer test is 79% sensitive and 53% specific, while the Hawkins-Kennedy test is 79% sensitive and 59% specific, for impingement. 21

I (NS) diagnosed the patient with mild supraspinatus tendinosis, with no evidence of tearing of the rotator cuff muscles, based on the following findings drawn from the patient interview: shoulder pain aggravated by pull-ups, rowing, and free weights; increased pain when lying on the affected shoulder. Additional significant findings from the physical examination included full shoulder active ROM with minimal pain at end-range flexion and abduction; pain along the anterior lateral shoulder with resisted testing of external rotation at 0° and 45° of abduction; negative drop arm and empty can tests; and tenderness over the greater tubercle of the humerus. The musculoskeletal dysfunction did not explain the level of pain reported by the patient (maximum NPRS 8/10), nor was the physical examination able to reproduce the exact location of the reported shoulder pain or the elbow, wrist, and knee pain described by the patient.

I was concerned about a serious pathology or a psychological disorder, given that this 19-year-old had made 10 medical appointments over 22 months for 6 different regions of the body; in my experience of examining and treating patients between the ages of 18 and 25, the frequency of the appointments and the variation in afflicted body parts are not typical of a young patient. The patient's description of his shoulder pain, in terms of location and severity, was not reproducible by physical examination. Throughout our interview, the patient did not maintain good eye contact, spoke in a monotone voice, and had an overall flat affect. Even when he described his beliefs about implants and government control, his voice and demeanour remained expressionless. The patient described persecutory delusions, command hallucinations, and social isolation from friends and family, all of which are signs of psychosis according to the Diagnostic and Statistical Manual of Mental Health . 22

Based on the findings from the patient interview and the physical examination, the patient did have symptoms consistent with a known musculoskeletal dysfunction; however, the undiagnosed and uncontrolled psychiatric symptoms made it more appropriate to refer him back to the physician for evaluation and treatment of his psychosis than to provide physical therapy intervention for his shoulder dysfunction. Furthermore, because research shows that the rate of suicide among patients with schizophrenia can range from 2% or 4% to as high as 15% 23 , 24 and that the rate of suicide is highest among patients close to the date of diagnosis, early recognition is crucial. 23

INTERVENTION

Based on the findings from the patient interview and the signs and symptoms of psychiatric disorders, I explained to the patient that there was a need for further medical investigation. Although the patient did not agree with this initial assessment, he did consent to a follow-up with the referring physician.

I spoke to the referring physician in person and explained to him my findings from the patient interview, specifically the patient's belief that he had electrical implants in his body. I also pointed out the patient's affect and the limited physical findings during the physical examination. I provided the physician with some direct quotes from the patient to demonstrate the level of psychosis he was presenting with. I stated my conclusion that the patient was suffering from some form of psychosis that precluded physical therapy treatment for his shoulder at that time. The referring physician was quite concerned about the patient and called him during our meeting to arrange a follow-up medical appointment.

The physician examined the patient, made similar observations, concurred with my assessment, and concluded that the patient was experiencing some form of psychosis. The plan of care involved referral to a psychiatrist, follow-up with the physician, and explaining to the patient that physical therapy would not be appropriate at this time because of the presence of a serious psychiatric disorder. The patient did not believe that he had a psychiatric disorder, but he was willing to follow up with a psychiatrist. The physician noted that the patient was not a threat to himself or others and that he did not report having homicidal or suicidal thoughts.

The patient followed up with the psychiatrist 11 days after his appointment with the physician. He was diagnosed with schizophrenia and started on a daily dose of risperidone (Risperdal). The patient was also instructed to follow up with the psychiatrist every second week to ensure compliance with the medication and to discuss progress. Further details of the psychiatric assessment and treatment were not available for this case report. Outcomes are also unavailable for this case report, since follow-up by the physical therapist was not possible.

Case Summary

This case report describes a 19-year-old man referred to physical therapy with shoulder, wrist, and knee pain who was later diagnosed with a psychiatric disorder. After completing a thorough patient interview and physical examination, I concluded that the patient was suffering from an undiagnosed psychiatric disorder that required medical referral. The interview revealed that the patient had delusions about electrical devices' being implanted in his body and was experiencing various forms of hallucination. The patient was promptly referred for medical consult and was diagnosed with schizophrenia by a psychiatrist.

Patient Symptoms and Schizophrenia

Schizophrenia is a psychiatric disorder affecting between 0.5% and 1.5% of adults worldwide, with a slightly greater prevalence in men. 22 The age of onset may be from 5 to 60 years; however, more than 50% of first episodes occur between the ages of 15 and 24. 22 , 25 , 26 An earlier onset is more common among men, while later onset is more common among women. 25 Schizophrenia shows a higher incidence in individuals born in urban areas than in those born in rural areas. 22 , 25 Because the patient in the present case fell into several of these categories (male, born in an urban area, experienced onset of symptoms around age 17) and presented with clear symptoms of a psychiatric disorder (delusions, hallucinations), schizophrenia seemed the most likely diagnosis.

The signs and symptoms of schizophrenia are classified as either positive or negative. 22 Positive symptoms are an excess of normal function and include delusions, hallucinations, and disorganized speech; 22 , 27 negative symptoms are a deficiency of normal function and include limited goal-directed behaviour (avolition), limited fluency and productivity of speech and thought, and a flat affect. 22 , 27 The diagnosis of schizophrenia requires the presence of at least two of these positive or negative symptoms lasting at least 6 months. 22 , 27 In this case, the patient presented with delusions (e.g., electrical implants trying to control his and others' actions), including persecutory delusions (e.g., “they are emotionally abusing me”), hallucinations (e.g., hearing voices, seeing signs), and a flat affect. Since the patient was enrolled in university at the time of diagnosis, his cognitive function is assumed to be well preserved. The patient reported no change in symptoms for 2 years.

Schizophrenia is subdivided into five types: paranoid, disorganized, catatonic, undifferentiated, and residual (see Table ​ Table1 1 ). 22 , 28 Based on these observations and on the literature, the patient's symptoms were suggestive of paranoid schizophrenia, 22 which is the most prevalent form of schizophrenia in most parts of the world. 22

Schizophrenia Subtypes 6

The aetiology of schizophrenia remains unknown. 29 , 30 There is a strong genetic predisposition. 29 , 30 Patients who experience the onset of schizophrenia before age 22 are 10 times more likely to have a history of a complicated caesarean birth than patients with a later onset of schizophrenia, which suggests a possible neurodevelopmental factor in early-onset schizophrenia. 31 Mild childhood head injuries may play a role in the expression of schizophrenia in families with a strong genetic predisposition to this disorder. 32 Psychological stress has also been implicated in the onset of schizophrenia, since it often precipitates the first psychotic episode or increases the likelihood of a relapse. 33 , 34 In this case, the patient described a family “break-up” which may have precipitated the onset of psychosis. Details about his childhood head injuries and the circumstances of his birth were not obtained. After being diagnosed with schizophrenia, the patient revealed to the referring physician that his father had experienced something similar when he was younger, which may point to a genetic predisposition.

There are no conclusive diagnostic tests for schizophrenia. 22 However, imaging studies have suggested neurophysiologic changes as an associated finding. Volumetric magnetic resonance imaging (MRI) studies of patients with schizophrenia have demonstrated an overall reduction in grey matter; an increase in white matter; decreased size of the amygdala, hippocampus, and parahippocampus; an overall reduction in brain volume; and larger lateral ventricles relative to a control group. 35 – 37

Psychiatric Disorders as They Relate to Musculoskeletal Dysfunction

As primary-care practitioners, physical therapists may encounter patients with possible psychiatric disorders such as schizophrenia. However, the physical therapy literature on psychiatric disorders as they relate to musculoskeletal disorders focuses mainly on low back pain (LBP). 7 , 8 In an examination of a large number of physical and psychological factors, one prospective case-control study points to the importance of psychological variables as a risk factor for chronic LBP and widespread musculoskeletal pain. 8 Previous research has also concurred with this study in implicating psychological variables as risk factors for LBP and neck pain. 9 , 10 These articles provide a link between psychological disorders and patients seeking physical therapy for musculoskeletal dysfunctions.

In this case report, the physical examination was suggestive of a mild supraspinatus tendinosis, but this did not explain the severity of pain reported by the patient or the referral of pain to the elbow, wrist, and knee. One of the limitations of the physical examination was that there was not sufficient time to perform physical examination of the elbow, wrist, and knee. The patient's undiagnosed and uncontrolled psychiatric symptoms took priority over the musculoskeletal dysfunction and required immediate medical referral without physical therapy intervention. Because of the inconsistencies between interview and physical examination, as well as the patient's perception that an electrical implant was causing his musculoskeletal pain, there is a possibility that at least some of his musculoskeletal symptoms may have been manifestations of his psychiatric disorder.

Effective Patient Interviews

The medical literature indicates that 50% of all mental illness is recognized during the interview process as part of medical assessment by the primary-care physician. 38 As physical therapists embrace their role as providers of primary care, 4 , 5 they must rely on their skills in patient interviewing and physical examination to rule out medical pathology. Improved assessment skills by the physical therapist may help to identify primary or secondary medical pathologies that have not previously been diagnosed. Within the peer-reviewed literature, a number of case studies demonstrate identification of non-musculoskeletal or visceral pathology that can manifest as musculoskeletal disorders; 39 – 41 these case studies are examples of how physical therapists can perform an initial assessment, identify a medical pathology that precludes treatment, and make an appropriate referral. During a patient interview, physical therapists must be well aware of the psychological and psychosocial aspects of the examination to identify relevant aspects of the patient's demeanour (e.g., appropriate self-care) and emotional state (e.g., inappropriate affect). The patient interview should consist of non-leading, open-ended questions about how pain in multiple areas is related and how it is caused. Furthermore, physical therapists should avoid rationalizing the patient's symptoms during the interview process. At a minimum, patients should be permitted to speak about and describe their symptoms in a way that is meaningful to them.

Schizophrenia and Primary Care

Schizophrenia is most often initially recognized by the primary-care physician. 42 Psychiatrists, psychologists, and even the lay community have also been noted in the literature as making the initial identification. 43 – 45 Although conspicuously absent from the literature on the initial identification of schizophrenia, physical therapists are in a position to be important first-contact care providers who can make the initial identification of schizophrenia, and other psychiatric disorders, through effective patient interviews. Although labelling patients as having a psychiatric disorder is outside physical therapists' scope of practice, the diagnostic process is not exclusive to any one profession. In this case, the process of diagnosis, which involves assessing the patient, grouping findings, interpreting the data, and identifying the patient's problems, led me to conclude that the primary dysfunction was psychiatric in nature. 46 This process, which Few et al. call “diagnostic reasoning,” is well within physical therapists' scope of practice and is something we constantly engage in during our daily clinical practice. 11 Diagnostic reasoning involves taking into account all of the possible pathological structures and determining the most likely cause of the patient's symptoms. In practice, expert clinicians do not follow standardized protocols; 46 rather, they pay attention to cues provided by the patient, recognize patterns, and test hypotheses to arrive at a probable cause for the patient's symptoms. 11

IMPLICATIONS AND FUTURE DIRECTIONs

The medical literature has identified gaps in the knowledge of primary-care physicians, specifically a lack of awareness of the symptoms and epidemiology of schizophrenia. 28 To facilitate early recognition, referral, and diagnosis of schizophrenia, the medical literature has suggested increased collaboration among family physicians and mental-health professionals, as well as ongoing mental-health training for family physicians. 47 , 48 Physical therapists should also heed these suggestions. A study in the physical therapy literature recommends mental-health training for recognizing the symptoms of depression in a population with LBP; 7 the same study, conducted in Australia, concluded that physical therapists' ability to recognize depressive symptoms in an outpatient setting was poor. 7

An initial step to address these gaps could be a position paper that draws on the medical literature to inform physical therapists about the presence, prevalence, signs, and symptoms of common psychiatric disorders. As well, future research needs to focus on the incidence of musculoskeletal signs and symptoms in patients with common psychiatric disorders.

KEY MESSAGES

What is already known on this topic.

To the authors' knowledge, there are no known studies in the literature describing a case of a patient referred to physical therapy for musculoskeletal dysfunction who was later diagnosed with schizophrenia.

What This Study Adds

This case report contributes to the existing literature on physical therapists functioning as competent providers of primary care who have the knowledge and skills needed to rule out non-musculoskeletal pathology. It also educates physical therapists about the signs and symptoms of schizophrenia.

Shah N, Nakamura Y. Case report: schizophrenia discovered during the patient interview in a man with shoulder pain referred for physical therapy. Physiother Can. 2010;62:308–315

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• June 01, 2024 | VOL. 181, NO. 6 CURRENT ISSUE pp.461-564
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Our Most Troubling Madness: Case Studies in Schizophrenia Across Cultures

• Etheldreda Nakimuli-Mpungu , M.Med.(Psych), Ph.D.

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For the past four decades, most researchers have observed that persons living with schizophrenia in developing countries have better outcomes than their Western counterparts ( 1 , 2 ). This paradox has been attributed to sociocultural differences between the two regions, but the nature of these sociocultural factors has been elusive. For those who are intrigued by this paradox, the volume Our Most Troubling Madness: Case Studies in Schizophrenia Across Cultures , edited by T.M. Luhrmann and Jocelyn Marrow, with contributions from several young anthropologists, is a must read.

This book, in one of the editor’s own words, “examines the way this terrible illness is shaped by its social context: how life is lived with this illness in different settings, and what it is about those settings that alters the course of the illness, its outcome, and even the structure of its symptoms” (p. 2). The book is organized into three sections. The first section starts with a thought-provoking foreword and an introduction to the rest of the book. The second section consists of 12 case studies, which are presented in a detailed and articulate manner, spanning four continents. Each case study illustrates in detail a particular sociocultural context that affects the healing process for schizophrenia. Readers can select which case studies to read based on their interest.

In summary, the case studies confirm the above-mentioned paradox. In developed countries, individuals are quickly labeled as schizophrenic and identify themselves in their day-to-day lives as, “I am schizophrenic.” This diagnosis, which is regarded as a death sentence by Western societies, is a prerequisite for obtaining health care and social services. Therefore, for affected individuals, the diagnosis becomes a part of their identity, which makes them feel less human for the rest of their lives. Worse still, the nature of the health care system does not allow family members to be actively involved in the care of those living with schizophrenia.

In contrast, the several case studies described from developing countries illustrate that although psychiatrists may indicate in patient records that one meets criteria for schizophrenia, psychiatrists may not reveal this diagnosis to the patient and family members and do not share facts about prognosis. As a result, affected individuals and their family members remain hopeful that they will improve, and family members are motivated to actively participate in the care of affected individuals. Moreover, in the developing world, society requires affected individuals only to be able to fulfill their gender and social roles in their households to be regarded as productive members of society, as opposed to the developed world where one is expected to hold a salaried job to be considered a productive member of society.

In the third and last section of the book, the editors conclude that the different social challenges experienced across different settings all have one thing in common, “the experience of social defeat” (p. 197), which they hypothesize to have effects on the body and brain that increase the risk of psychosis. The editors note that opportunities for social defeat are more abundant in developed than in developing countries, and they provide practical suggestions to improve outcomes of schizophrenia in the Western world.

Although this book falls short on details about the early social environment (e.g., perinatal, childhood, and adolescence) for the majority of cases described, it provides a great starting point where one can find the lived “social experience of schizophrenia” (p. 3). Furthermore, the book illustrates how the case studies from developing countries lend support to some of the novel approaches being used to manage schizophrenia in the United States ( 3 , 4 ). For this reason, I believe this book is suitable not only for the general public but also for scientists, clinicians, and policy makers, especially those in the field of global mental health.

The author reports no financial relationships with commercial interests.

1 Holla B, Thirthalli J : Course and outcome of schizophrenia in Asian countries: review of research in the past three decades . Asian J Psychiatr 2015 ; 14:3–12 Crossref , Medline ,  Google Scholar

2 Kulhara P, Shah R, Grover S : Is the course and outcome of schizophrenia better in the ‘developing’ world? Asian J Psychiatr 2009 ; 2:55–62 Crossref , Medline ,  Google Scholar

3 Aubry T, Tsemberis S, Adair CE, et al. : One-year outcomes of a randomized controlled trial of Housing First with ACT in five Canadian cities . Psychiatr Serv 2015 ; 66:463–469 Link ,  Google Scholar

4 Alanen YO : Towards a more humanistic psychiatry: development of need‐adapted treatment of schizophrenia group psychoses . Psychosis 2009 ; 1:156–166 Crossref ,  Google Scholar

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Case Reports in Schizophrenia and Psychotic Disorders

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Case Study Illustrates How Schizophrenia Can Often Be Overdiagnosed

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Study author Russell Margolis, director of the Johns Hopkins Schizophrenia Center, answers questions on misdiagnosis of the condition and reiterates the importance of thorough examination.

It’s not uncommon for an adolescent or young adult who reports hearing voices or seeing things to be diagnosed with schizophrenia, but using these reports alone can contribute to the disease being overdiagnosed, says  Russell Margolis , clinical director of the Johns Hopkins Schizophrenia Center. 

Many clinicians consider hallucinations as the sine qua non, or essential condition, of schizophrenia, he says. But even a true hallucination might be part of any number of disorders — or even within the range of normal. To diagnose a patient properly, he says, “There’s no substitute for taking time with patients and others who know them well. Trying to [diagnose] this in a compressed, shortcut kind of way leads to error.”

A case study he shared recently in the  Journal of Psychiatric Practice  illustrates the problem. Margolis, along with colleagues Krista Baker, schizophrenia supervisor at Johns Hopkins Bayview Medical Center, visiting resident Bianca Camerini, and Brazilian psychiatrist Ary Gadelha, described a 16-year-old girl who was referred to the Early Psychosis Intervention Clinic at Johns Hopkins Bayview for a second opinion concerning the diagnosis and treatment of suspected schizophrenia.

The patient made friends easily but had some academic difficulties. Returning to school in eighth grade after a period of home schooling, she was bullied, sexually groped and received texted death threats. She then began to complain of visions of a boy who harassed her, as well as three tall demons. The visions waxed and waned in relation to stress at school. The Johns Hopkins consultants determined that this girl did not have schizophrenia (or any other psychotic disorder), but that she had anxiety. They recommended psychotherapy and viewing herself as a healthy, competent person, instead of a sick one. A year later, the girl reported doing well: She was off medications and no longer complained of these visions.

Margolis answers  Hopkins Brain Wise ’s questions.

Q: How are anxiety disorders mistaken for schizophrenia?

A:  Patients often say they have hallucinations, but that doesn’t always mean they’re experiencing a true hallucination. What they may mean is that they have very vivid, distressing thoughts — in part because hallucinations have become a common way of talking about distress, and partly because they may have no other vocabulary with which to describe their experience. 

Then, even if it  is  a true hallucination, there are features of the way psychiatry has come to be practiced that cause difficulties. Electronic medical records are often designed with questionnaires that have yes or no answers. Sometimes, whether the patient has hallucinations is murky, or  possible —  not yes or no. Also, one can’t make a diagnosis based just on a hallucination; the diagnosis of disorders like schizophrenia is based on a constellation of symptoms. 

Q: How often are patients in this age range misdiagnosed?

A:  There’s no true way to know the numbers. Among a very select group of people in our consultation clinic where questions have been raised, about half who were referred to us and said to have schizophrenia or a related disorder did not. That is not generalizable.

Q:   Why does that happen?

A:  There is a lack of attention to the context of symptoms and other details, and there’s also a tendency to take patients literally. If a patient complains about x, there’s sometimes a pressure to directly address x. In fact, that’s not appropriate medicine. It is very important to pay attention to a patient’s stated concerns, but to place these concerns in the bigger picture. Clinicians can go too far in accepting at face value something that needs more exploration. 

Q: What lessons do you hope to impart by publishing this case?

A:  I want it to be understood that the diagnosis of schizophrenia has to be made with care. Clinicians need to take the necessary time and obtain the necessary information so that they’re not led astray. Eventually, we would like to have more objective measures for defining our disorders so that we do not need to rely totally on a clinical evaluation. 

Learn more about Russell Margolis’ research regarding the challenges of diagnosing schizophrenia .

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Case Study: Schizophrenia and Work: Martin’s Story

Martin had been out of work for several years following a prolonged psychotic episode which began when he was studying at university. He desperately wanted to get into work but found that employers treated his prolonged absence “on the sick” with suspicion. He thought that if he could do a period of work experience that would show prospective employers that he was capable of working again but he was afraid that if he did it might affect his benefits.

So Martin made an appointment to see the Disability Employment Advisor at the Jobcentre to discuss his plans. She was understanding and helpful and explained that a work placement would not affect his benefits as long as it was done as part of the Jobcentre’s own scheme. She also told him that the scheme would pay his travel-to work expenses while he was on the placement.

Job-searching

Next Martin researched local employers using the internet and the local press, looking for companies that might have vacancies in the sort of clerical and administrative work he thought he could do. Then he called the companies by ‘phone and speaking to the person on the switchboard checked that he had the correct postal address for them and asked the name of the person in charge of recruiting. It is vital to be able to write to a named person rather than just the Human Resources Manager.

Martin had already spent a lot of time on his CV so now he compiled a covering letter to go with it. It took him about a month to work up his CV and covering letter using books that he got from the local library. He also managed to get advice from a local back-to-work scheme recommended by the Disability Employment Advisor at the Jobcentre. Martin knew that it was essential that his letter and CV had the maximum impact.

Martin sent his CV and letter off to six employers and then waited about a week before calling them up on the ‘phone. He asked to speak to the person he had written to but if the person on the switchboard asked the reason for his call he simply said that he was calling to follow up a letter he had written.

After approaching about 20 employers in this way he finally found one who said there could be an opening for work experience in a couple of months time. So over the next three months Martin kept in touch with the company by ‘phone once a month just to let them know that he was still keen on coming to work for them.

The interview

Finally the company asked him in for an interview. Before going to the interview Martin prepared really well in advance by researching the company well and trying to anticipate the sorts of questions he would be asked. He also went to the local library and took out some books on interview techniques and managed to get on a one day course on interview skills that the Jobcentre had told him about. This included a mock interview which he found particularly useful.

The day of the interview arrived and Martin was very nervous but he was up early and washed and dressed. To be sure of being on time he left an hour early and checked out the location of the office. Then he went to Starbucks for a coffee while he waited. This gave him an opportunity to flick through his notes and prepare on some of the answers he had been working on. He made sure that he was punctual and well groomed and did his best to present himself well at the interview.

Despite being really well prepared walking through the front door of the office was one of the hardest things that he had done for years. But the receptionist was polite and could not have been more helpful. She made him feel welcome and even offered him a coffee (which he declined).

The Human Resources Manager who interviewed Martin was very professional but quickly put him at his ease. He asked questions about his education at school, his hobbies and pastimes and his qualifications and then came the bit that Martin had been dreading when the HR Manager asked him why he had dropped out of college. Martin explained that he had had a breakdown caused by too much stress while he was at college. He went on to explain that although it was a bad breakdown it was behind him now and that with the help of his family and friends and his doctor he had been able to make a really strong recovery. He also explained that in some ways the experience had made him a stronger person and that he had matured as a result of it.

As the end of the interview approached Martin was sure that he had flunked it but the interviewer told him that he had been successful and asked him to start on Monday. Martin was delighted to be offered a period of three months unpaid work experience during which he would work for two days a week at their local office doing clerical and administrative work.

Martin was walking on air when he left the office. All his hard work had been worth it.

The next day Martin called the Disability Employment Advisor at the local Jobcentre to tell them about the offer and see how his benefits would be affected. She confirmed that his benefits wouldn’t be affected as long as he only worked for 16 hours a week.

The placement

For the next three months Martin worked hard at his placement. He made sure that he got all the basics right: being punctual and well groomed every day. At work he was helpful and got on well with the other workers. Although he was very shy at first he soon learned the importance of making small talk with his colleagues and building good working relationships.

As the end of his placement approached Martin wondered if he would be offered a permanent position. He asked the HR Manager about this but sadly he was told that there were no permanent vacancies at that time so when the end of his placement came Martin had mixed feelings. On the one hand he was disappointed that the work experience had not turned into a permanent job but on the other hand he had had three months experience in the workplace and had something to put on his CV to demonstrate to other employers that he could work. And most importantly he had that all important reference from a well respected local employer.

But that isn’t quite the end of the story. Martin continued searching for a job without success for another six months but continued to keep in touch with the HR Manager he had worked for during his work experience. One day he saw in the local press that they were advertising for a clerical assistant so he called them and explained that he was still jobsearching and would be available for this position. The HR Manager was very pleased to hear from him and said that he would call him back. The next day Martin got a call asking him to go in for an interview straight away and was offered the job.

Martin called the Jobcentre Plus helpline and found out what benefits he would be entitled to while he was working and was pleased to find out that he would be better off in work.

Martin has now been employed in his new job for two years and is delighted to be living an independent lifestyle free of the benefits culture he was in before. It has had its difficulties though. For instance Martin found that his illness had left him emotionally very sensitive and that he found it difficult to cope if his work was criticised. But he knew that this was something he had to learn to live with and gradually he managed to learn new social skills that helped him to cope better and at the same time helped him in other areas of his life.

Martin has enjoyed the structure that the new job has brought to his life. He enjoys the work and the social contact that the job entails. He has made new friends and above all his self-esteem has grown vastly. Now when people ask him what he does for a living he no longer has to say that he is unemployed.

Some Key Points from Martin’s Story:

• Research the local job market really well
• Before writing to a firm call to check the postal address.
• Find out the name of the person in charge of recruitment. Writing to a named person makes sure your letter gets read.
• You can’t spend enough time preparing your CV and cover letter. Get as much help as you can from books, the library etc.
• When making follow up calls avoid Mondays and Fridays as these are busy days for people in business. Similarly don’t call too early in the morning or after 3.30 pm and don’t call around lunchtime.
• When making follow up calls be prepared for few false starts but use these to develop your technique. Treat the first half a dozen calls as practice calls.
• Don’t pester firms with too frequent follow up calls. Once every three weeks is about right.
• Be prepared for disappointment and don’t feel let down by it.
• Before going for an interview research the firm really well. Google and Google News and the local press are useful sources.
• It is perfectly normal to be nervous at an interview. Try to minimise the nerves by making sure you have planned and prepared well and getting a good night’s sleep beforehand.
• At the interview you may be asked about your illness. Be honest but there is no need to disclose your diagnosis at this stage unless you are asked directly: a broad brush explanation such as “a breakdown” is sufficient.

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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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