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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INTRODUCTION

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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Case study: a young male with auditory hallucinations in paranoid schizophrenia

Affiliation.

  • 1 Adelphi University, Garden City, New York, USA. [email protected]
  • PMID: 22613753
  • DOI: 10.1111/j.2047-3095.2011.01197.x

Purpose: The purpose of this case study is to demonstrate use of the nursing process and the standardized nursing languages of NANDA International (NANDA-I), the Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC) to assist a young male with paranoid schizophrenia to deal with auditory hallucinations.

Data sources: Data were obtained from the experience and expertise of the author and published literature.

Data synthesis: This case study demonstrates nurses' clinical decision making in providing care for an adolescent with mental illness.

Conclusion: This case study provides the pertinent nursing diagnosis, patient outcomes, and nursing interventions for a young male with auditory hallucinations in paranoid schizophrenia.

Implications for nursing: The use of NANDA-I, NOC, and NIC can provide the necessary framework for enhancing and improving the management of care with patients who experience auditory hallucinations in paranoid schizophrenia.

© 2011, The Authors. International Journal of Nursing Terminologies and Classifications © 2011, NANDA International.

Publication types

  • Case Reports
  • Hallucinations*
  • Nursing Diagnosis
  • Schizophrenia, Paranoid / diagnosis
  • Schizophrenia, Paranoid / nursing*

Case Reports in Schizophrenia and Psychotic Disorders

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The Use of Narrative Therapy on Paranoid Schizophrenia

  • Research in progress
  • Published: 10 May 2023
  • Volume 68 , pages 273–280, ( 2023 )

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  • Karina Therese G. Fernandez 1 ,
  • Anne Therese Marie B. Martin 1 &
  • Dana Angelica S. Ledesma 1  

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Research suggests that a clinical diagnosis of schizophrenia is strongly linked with experiencing negative stereotypes and an inability to recover. In challenging the scientific-logical practice of diagnostic labeling, which totalizes the person’s experience around the illness, Narrative therapy offers a unique approach to treating schizophrenia by putting the spotlight on the client’s values, strengths, and beliefs. This allows the client to discover an alternative life narrative beyond their diagnosis. This study presents a case of a 40-year-old woman with paranoid schizophrenia. She felt that the people in her workplace were out to harm her so she would never work in her field again. At home, she had also begun to question herself as a mother. Narrative therapy techniques such as externalization, thickening the landscape of action and identity, and re-membering were used to aid the client’s recovery and helped her to shift from a problematic view of her identity. The present case focuses on providing steps to guide practitioners in using Narrative therapy for a case where the client has internalized their diagnosis as their identity.

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example case study of paranoid schizophrenia

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Abbreviations

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Acknowledgements

The authors would like to acknowledge the Ateneo Bulatao Center for its constant encouragement and support to advance academic research alongside clinical practice.

The authors did not receive support from any organization for the submitted work.

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Karina Therese G. Fernandez, Anne Therese Marie B. Martin & Dana Angelica S. Ledesma

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All authors contributed to the study. Material preparation, data collection, and analysis were performed by Karina Therese G. Fernandez. The first draft of the manuscript was written by Karina Therese G. Fernandez, Anne Therese Marie B. Martin, and Dana Angelica S. Ledesma. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Ethics Approval

This study received ethical approval from the University Research Ethics Office of the Ateneo de Manila University. This research study was conducted retrospectively from data obtained for clinical purposes. A copy of the approval letter has been provided in Appendix A.

Consent to Participate and Publication

In the informed consent given by the Ateneo Bulatao Center for Psychological Services to its therapy clients, there is a very detailed checklist of the extent of how their information can be used. One specific item is “session notes for the purposes of research (paper publications and paper presentations). We have attached a copy of an unsigned informed consent form for reference (see Appendix B).

Informed Consent

By signing an informed consent form, we obtained permission from the client to share her story. Furthermore, her identifying information was changed to ensure confidentiality. Though the informed consent form already covers the consent for data in the therapy sessions to be published, as recommended by informal discussions with members of the University Research Ethics Committee of the Ateneo de Manila University, a second request for informed consent to publish was made after therapy.

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Fernandez, K.T.G., Martin, A.T.M.B. & Ledesma, D.A.S. The Use of Narrative Therapy on Paranoid Schizophrenia. Psychol Stud 68 , 273–280 (2023). https://doi.org/10.1007/s12646-022-00709-z

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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.

Olanzapine 5mg tablet pack

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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Ethical Issues in Schizophrenia

  • Nataly S. Beck , M.D. , and
  • Jacob S. Ballon , M.D. , M.P.H.

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The schizophrenia spectrum disorders are defined by abnormalities in one or more of the following domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms ( 1 ). Associated with significant social and occupational dysfunction, schizophrenia is arguably one of the most debilitating diagnoses an individual can have. The lifetime prevalence of schizophrenia is approximately 0.3%–0.7%, although variation across countries has been reported ( 1 ). Approximately 5%–6% of patients with schizophrenia die by suicide, with about 20% attempting suicide at least once and with many more having significant suicidal ideation—often driven by command hallucinations to harm oneself or others ( 1 ). Thus, schizophrenia can be a devastating illness, not only through its effects on the individual patient’s functioning and quality of life but also through its effect on the individual’s core personality and unique characteristics. In addition, because patients with schizophrenia commonly lack insight into their disorder and/or their need for treatment, patients and their families may struggle to obtain appropriate, comprehensive, and ongoing care.

In addition to these challenges to the individual’s functioning across multiple domains, schizophrenia may also impair one’s ability to meet one or more of the key components of informed consent, such as the capacity for decision making and voluntariness. Although loss of capacity is by no means a given for patients with schizophrenia (i.e., the diagnosis should not be equated with lack of capacity [ 2 ]; decision-making capacity must be assessed in a domain- and task-specific manner), schizophrenia may be associated with diminished capacity to make certain kinds of decisions, under certain circumstances, especially if the decision intersects with specific delusional ideas.

From an ethics perspective, the principles of autonomy and truth-telling may sometimes conflict directly with the principles of doing good (beneficence) and avoiding harm (nonmaleficence) when working with patients with schizophrenia. Examples of this include telling half-truths to patients who are paranoid or encouraging and/or actively persuading patients to involve their family members in their care ( 3 ). In addition, psychiatry might be considered the primary specialty in which its practitioners are often called upon to determine whether a patient can make decisions on his or her own. In the case of schizophrenia, these determinations can be challenging and complex.

Therefore, the purpose of this commentary is to outline ethical principles that are commonly encountered in schizophrenia. Foundational medical ethical principles, listed here ( 4 , 5 ), are discussed in relation to the case illustrations.

  A.Respect for persons: regard for an individual’s worth and dignity

  B.Autonomy: self-governance

  C.Beneficence: the responsibility to act in a way that seeks to provide the greatest benefit

  D.Fidelity: faithfulness to the interests of the patient

  E.Nonmaleficence: the commitment to do no harm

  F.Veracity: the duty of truth and honesty

  G.Justice: the act of fair treatment, without prejudice

  H.Privacy: protection of patients’ personal information

  I. Integrity: honorable conduct within the profession

Case Illustration 1

AB is a 28-year-old man who has a diagnosis of unspecified psychosis that began several years after he developed a chronic medical condition. He has decreased mobility and numerous difficulties because of these conditions, including the need for a percutaneous endoscopic gastrostomy (PEG) tube. Because he had such significant comorbid medical and psychiatric illness, he was hospitalized for 8 months on a medical unit to recover while being treated for suicidal ideation, depression, and psychosis by consulting psychiatrists. He also developed catatonia, was mute, and was unable to walk for over a year because of his comorbid medical and psychiatric conditions. After receiving significant medical treatment, AB resumed the ability to ambulate, to the point where he is now able to walk around his home (he lives with his parents) and around the block. Meanwhile, he has also been treated for the psychotic symptoms with olanzapine and lorazepam. His treatment was disrupted for a few weeks because of the COVID-19 pandemic, during which time AB developed increased psychotic symptoms. His paranoia included the belief that there were organizations of people after him, and he called 911 on multiple occasions because of his fears, resulting in multiple visits from the police to his home.

1.1 Which of the following would be a reasonable next step (or steps) for the psychiatrist? (Select all that apply)

  A. Have AB’s parents take a picture of the PEG tube site while AB is asleep and send this to his physicians for examination.

  B. Provide a short-term prescription of lorazepam to be administered to AB and then take him for examination of his PEG tube site by his medical providers.

  C. Obtain an ethics consultation.

  D. Do a capacity evaluation.

Communicating a choice: AB indicates that he does not want any medical care for his gastrostomy tube; his choice remains consistent from day to day and from hour to hour.

Understanding the relevant information: AB is unable to state any information about his medical condition or treatment. He is unable to state the possible risks, benefits, or alternatives to treatment and is unable to state the possible risks or benefits of no treatment.

Appreciation of the situation and its consequences: AB does not believe that there is anything wrong with him. He does not believe that he needs any treatment and is unable to state why his doctors recommend the treatment that they are recommending. His refusal to allow his PEG tube to be examined is related to paranoia from his psychotic disorder.

Reasoning about treatment options: AB is unable to engage in a rational process of manipulating the relevant information of the situation because of his paranoia. He is unable to compare treatment options and consequences and is unable to offer reasons for selection of a particular option.

1.2 Which of the following ethical principles were upheld by performing a capacity evaluation as opposed to the first two choices listed for Question 1.1?

  A.Privacy and integrity

  B.Autonomy and fidelity

  C.Respect for persons and justice

  D.Beneficence and veracity

1.3 Which of the following is least likely to be recommended by the ethics consultant?

  A.If not already done, determine and document that AB lacks the capacity to make a decision regarding wound care (i.e., that he is incapable of providing an informed refusal).

  B.Assess whether benefits of the wound evaluation outweigh the burdens (including the use of sedating medications or physical restraint).

  C.If benefits outweigh the burdens, ask AB’s mother (surrogate decision maker) whether she agrees.

  D.If AB’s mother (surrogate decision maker) agrees, proceed with minimal necessary restraint (assuming efforts to obtain cooperation without constraint do not work) needed to provide indicated treatment.

  E.Recommend that AB’s mother (surrogate decision maker) consider obtaining probate conservatorship to help in the determination of future medical decisions for the benefit of AB.

Case Illustration 2

2.1 Was it ethical for these external motivations to be suggested by the physician? What were the ethical principles involved in making this suggestion?

  A.Yes, the psychiatrist’s suggestion was ethical. The ethical principles involved are autonomy, fidelity, and beneficence.

  B.No, the psychiatrist’s suggestion was not ethical. The ethical principles involved are privacy, respect for persons, and justice.

2.2 Does the patient have the capacity to refuse the long-acting injectable medication? What are the guiding ethical principles that are being balanced in this part of the case?

  A.Yes, the patient has the capacity to refuse the medication. The ethical principles include integrity and justice.

  B.No, the patient does not have capacity to refuse the medication. The ethical principles include autonomy and fidelity.

  C.No, the patient does not have the capacity to refuse the medication. The ethical principles include respect for persons and nonmaleficence.

  D.No, the patient does not have the capacity to refuse the medication. The ethical principles include veracity and privacy.

2.3 What are the ethical principles involved in deciding whether to leave out important information such as what the medication is primarily intended to treat or the patient’s diagnosis?

  A.Integrity and privacy

  B.Respect for persons and fidelity

  C.Veracity and nonmaleficence

  D.Autonomy and fidelity

 1.1.The answers are C and D. Choice A interferes with the principles of fidelity and autonomy. Choice B interferes with the principles of autonomy, nonmaleficence, and veracity. Choices C and D both avoid interfering with these principles.

 1.2.The answers are B and C. Choice B is the correct choice because autonomy (self-governance) and fidelity (faithfulness to the interests of the patient) are the most directly involved principles in this part of the case. AB did not want to have the PEG tube site observed, so his autonomy and fidelity were the principles most upheld by performing the capacity evaluation. Choice C is also correct, in that autonomy and respect for persons are tightly related. One respects autonomy out of respect for persons and dignity. Justice is a correct answer because rather than assuming a patient with schizophrenia lacks capacity, a capacity evaluation was actually performed. Choice A is not the best answer because privacy (protection of the patient’s personal information) and integrity (honorable conduct within the profession) are not immediately pertinent in this example. Although it may be argued that taking the picture of the PEG tube site would have interfered with the patient’s privacy and that performing a capacity evaluation as opposed to the other options would help support the principle of integrity, there exists another answer that is a better fit. Choice D is incorrect because beneficence (the responsibility to act in a way that provides the greatest benefit) and veracity (the duty of truth and honesty) are not the best answer choices provided here.

 1.3.The answer is E. Choice E is the only answer that is somewhat questionable, as the ethics question did not involve a request for input into obtaining probate conservatorship. Although a probate conservatorship might be advisable for AB, that topic was not put forth to the ethics consultants.

 2.1.The answer is A. Although whether the psychiatrist’s suggestion is ethical depends on the specific external motivation, what is known so far about the case makes the psychiatrist’s suggestion acceptable. Choice A is also correct because the principles of autonomy (self-governance), fidelity (faithfulness to the interests of the patient), and beneficence (the responsibility to act in a way that seeks to provide the greatest benefit) are more directly related to the case. Choice B is incorrect not only for stating that the psychiatrist’s suggestion is unethical, but also because the principles of privacy (protection of the patient’s personal information), respect for persons (regard for an individual’s worth and dignity), and justice (the act of fair treatment, without prejudice) are not as directly related in this example.

 2.2.The answer is B. The patient does not have capacity to refuse the medication because her consent to receive the medication wavers often. This is the first of the criteria for capacity, stating a clear and consistent choice. The ethical principles involved are autonomy (self-governance) and fidelity (faithfulness to the interests of the patient).

 2.3.The answer is C. Veracity (the duty of truth and honesty) and nonmaleficence (to do no harm) are the ethical principles being weighed in this part of the example. Should YS ask about her diagnosis or seek an explanation of how the psychiatrist is considering her symptoms or experience, then the psychiatrist should engage in a discussion appropriate to the questions, taking time to carefully explain in lay language the diagnosis and how the diagnosis is made.

The authors report no financial relationships with commercial interests.

The authors acknowledge David Conklin, M.D., and Kerstin Asquith, M.D., for their critiques.

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4 Bernert RA, Roberts LW : Ethical considerations in the assessment and management of suicide risk . Focus 2012 ;10:467–472. Link ,  Google Scholar

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Case study: A patient with severe delusions who self-mutilates

Lesiba t. lebelo.

2 Department of Psychiatry, School of Medicine, University of Pretoria, Pretoria, South Africa

Gerhard P. Grobler

1 Department of Psychiatry, Mamelodi Hospital, Pretoria, South Africa

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.this study.

Background and introduction

Although some overlapping features exist between self-injury and intention to die, there is growing recognition that non-suicidal self-injury (NSSI), including major self-mutilation (MSM), and suicidal behaviour are distinct entities as evidenced by their significance in terms of aetiology, psychiatric impairment, psychological function, method of self-harm and course or outcome between the two phenomena. 1

We present a case of self-harm in a mental healthcare user diagnosed with schizophrenia to highlight the distinction made above.

Case presentation

Mr X is a 38-year-old, unemployed, single male with no children and with an elementary level of education. This was his index presentation with a 4-year history characterised by ongoing persecutory delusions, as well as auditory hallucinations. He was brought to the Emergency Department by ambulance because he was found to be bleeding profusely from his scrotum in the toilet of a petrol filling station. He alleged that he had cut open his scrotum to remove his testicles before his ‘tormentors’ could do so. He stated clearly that he did not want to die because he valued his life. This was therefore not an attempt at suicide.

He was initially admitted to the urology ward and then referred to psychiatry. The multi-disciplinary team diagnosed him with and treated him for schizophrenia. He responded well to haloperidol 2.5 mg orally in the morning and 5 mg orally at night. A long-acting injectable antipsychotic, flupenthixol decanoate 20 mg intramuscular was also prescribed. No adverse effects were reported. Lorazepam was titrated downwards from 1 mg orally twice daily to 1 mg orally at night, and then stopped before he was discharged. Lansoprazole 30 mg daily orally, tramadol 50 mg three times daily orally and paracetamol 1 g orally were also prescribed as needed.

Upon discharge, on day 44 of the admission, the patient was symptom free with no psychotic or anxiety features.

The patient did not manifest any depressive symptoms throughout his hospitalisation, nor on his 4-week follow-up visit subsequent to discharge. He also demonstrated full and complete understanding that the voices, the self-conviction and his belief that people were coming to harm him were all part of his illness called schizophrenia. He also demonstrated full understanding that the belief of being harmed and people conspiring against him were also part of his schizophrenic illness that had been untreated for at least the past 4 years. With no negative emotion, he demonstrated intellectual understanding with unconditional acceptance of his illness. We emphasised to him that he must be consistent with medical check-ups at his local clinic as some other medical conditions can cause his illness to resurface. It was further emphasised to him that for as long as he took his treatment regularly and as prescribed the schizophrenia would be managed and controlled well. He agreed to stay away from all psychoactive substances. This user was amenable to following up with a clinical psychologist, an occupational therapist and a social worker.

He was followed up 1 month later and then referred to his local clinic for continuation of the prescribed treatment, appointments for continuation of psycho-education, counselling and relevant psycho-therapies. This patient responded well and remitted only on antipsychotic agents.

Literature review and discussion

In a study of measurable variables, paranoia and auditory hallucinations, psychotic-like experience (PLE) and stressful life events all contributed to the patient causing self-harm. Compared to those without PLEs, the prevalence of NSSI was higher than those with PLEs. 1

Psychotic-like experiences are highly prevalent in the general population, with figures of 20% or above being reported in some studies. 1 Major self-mutilation (or NSSI) is a rare but potentially catastrophic complication of severe mental illness. Most people who inflict NSSI have a psychotic disorder, usually a schizophrenia spectrum psychosis. It is not known when in the course of psychotic illness, NSSI is most likely to occur. 2 In general, schizophrenia is associated with worse social functional outcomes compared with other psychotic disorders, but the few studies that directly tested this assumption by comparing the longitudinal courses of social functioning in affective and non-affective psychoses have yielded conflicting findings. 3

Cases of genital self-mutilation reported in the literature have been in patients with psychosis, including schizophrenia. 4 Our own literature review found only a few case reports, published in 1974 (a female patient with schizophrenia and erotomania), 1986 (autocastration with biblical delusions) and in 1995. Greilsheimer writes that: ‘Men who intentionally mutilate or remove their own genitals are likely to be psychotic…’. 5

The reason for presenting the case is that there was no similar case recorded in our country, using Google Scholar search engine database of at least the past 5 years, nor elsewhere when we searched using the following keywords: ‘Self-castration, non-suicidal self-injury and psychosis, self-castration due to psychosis’.

In the South African context, the promulgation of the Traditional Health Practitioners Act no. 35 of 2004 has become an important precipitant for the local review of the place of culture and religion/spirituality in secular areas such as health, mental health and spirituality. 6 Our patient did not display delusions with religious or spiritual content. This particular patient was not practising any religion although he claims to believe in God. He emphasised that he was convinced by his delusions and hallucinations that some people known to him were conspiring to cut his scrotum and extract his testicles for some ritualistic practices. Their psychosis can eventually weaken their faith as they may think that they have been successfully bewitched and cursed even if they have been mentally stabilised.

Patients living with schizophrenia and who suffer persistently high levels of psychotic symptoms as well as poorer (psychosocial) functioning and lower self-esteem have higher severity of suicide behaviour. 7 Even in first episode psychosis, one in 10 people engages in self-harm. 8

It is important to take note of this case as it is the first of its kind and adds to existing knowledge in mental health that untreated and long-standing psychosis can result in the patient harming himself irreversibly such that they lose the capacity to reproduce.

Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. The mobility of the scrotum may be one reason, severe injury is rare. Given the importance of preserving fertility, traumatic injuries of the testicles deserve careful attention. Testicular injuries can be divided into three broad categories based on the mechanism of injury: (1) blunt trauma, (2) penetrating trauma and (3) degloving trauma. Such injuries are typically seen in males aged 15–40 years.

Our patient was psychotic with auditory hallucinations, persecutory delusions and bizarre delusions which did not include religious delusions when he harmed himself. He was convinced that his ‘tormentors’ were listening to his thoughts and he consequently planned to cut open his scrotum to remove his testicles before they could do that to him. The main reason our patient injured himself was not to die but to relieve himself of the constant and increasing threats of being robbed of his testicles. It is important in the South African context to treat a psychiatric patient by using the multi-disciplinary team approach which is also holistic in nature and covers all aspects of mental healthcare service provision, including spirituality, as most citizens (92%) of South Africa expressed religious affiliation. 9

Not all patients who harm themselves, even severely, are suicidal. Some just want to rid themselves of tormenting psychosis as in this case.

Acknowledgements

The authors wishes to acknowledge their colleagues who supported this project and their patients from whom they learnt much.

Competing interests

The authors have declared that no competing interest exists.

Authors’ contributions

Both authors contributed equally to this work.

Ethical consideration

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability statement

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Lebelo LT, Grobler GP. Case study: A patient with severe delusions who self-mutilates. S Afr J Psychiat. 2020;26(0), a1403. https://doi.org/10.4102/sajpsychiatry.v26i0.1403

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