September 10, 2012

Shutter Island: Movie Review

Overview

In the movie “Shutter Island”, main character, Andrew Laeddis struggles with recognizing reality because he suffers from paranoid schizophrenia. The movie is set in 1954 at Ash Cliff, a treatment facility on Shutter Island for the “criminally insane”. Laeddis believes himself to be a U.S. Marshall who has come to the island with his partner, Chuck, to investigate the disappearance of one of the patients. As Laeddis continues the investigation, he reveals that he is actually investigating the island because he suspects that there is a conspiracy occurring in which all of the staff is involved. He suspects that clinicians are conducting inhumane experiments on patients and sending them back into the world as “ghosts” with their memories erased due to brain surgery. Laeddis often links this to the Nazi experiments on human subjects and is especially angered by this because of his experiences fighting for the United States in World War II. Throughout the film, Andrew Laeddis refers to himself as Edward ‘Teddy’ Daniels and believes that Laeddis is a man who killed his wife, Dolores, in a fire. At the end of the film, the psychiatrist reveals that he is actually Laeddis and that there is no missing patient, Rachel Solando, but only that Andrew created this fantasy so that he would not have to remember that his wife was “manic-depressive” and murdered his children, after which he murdered her.
Laeddis suffers from paranoid schizophrenia. According to the DSM IV-TR (2000), schizophrenia is a psychotic disorder characterized by at least two of the following five symptoms: hallucinations, delusions, disorganized speech, disorganized behavior, and negative symptoms (anhedonia, avolition, alogia, and flat affect). Symptoms also must impair social or occupational functioning, last longer than six months, must not be due to substance use or a general medical condition, and there must not have been any mood episodes (manic, depressive, or mixed). Laeddis qualifies for a specific type of Schizophrenia, referred to as the paranoid type. People suffering from paranoid type are highly suspicious and engage primarily in their delusions and hallucinations and do not have prominent symptoms of disorganized speech and behavior. Schizophrenia is prevalent in roughly 1% of the population and can be one of the most costly disorders due to need of repeated hospitalizations because of suicidal or homicidal behavior. Schizophrenia is also one of the most deteriorative disorders, and once there has been one episode, clients most often do not return to baseline and decompensate more and more as the disorder progresses.

Diagnostic Summary

Schizophrenia symptoms present differently in all clients. In “Shutter Island”, the symptoms that Laeddis experienced were more on the positive spectrum (delusions and hallucinations), and he did not present with as many negative symptoms. In clients with schizophrenia, it is much more common for clients experiencing more positive symptoms to have better life outcomes and return to baseline. However, in the film, Laeddis had been at the facility for two years and had been delusional for almost the entire time. The end of the movie remains ambiguous as to whether or not he was finally aware of reality. Also, in the film, Laeddis experienced many visual hallucinations, referred to as “walking nightmares”. In the general population, this is much more uncommon. Most people diagnosed with schizophrenia only experience auditory hallucinations. Laeddis also qualifies for a specifier, the paranoid type because he is highly suspicious of everyone around him. At first, he is kind to staff and then decides they are trying to hurt him. He believes that his partner has turned on him, and he is suspicious about everything that is happening on the island. Please see the chart below for other symptoms that Laeddis experienced.

DSM IV-TR Criteria for Schizophrenia How Symptoms Met Criteria in “Shutter Island”

Hallucinations: Laeddis experiences visual hallucinations of his wife, daughter, and a psychiatrist in a cave.

Delusions: Laeddis believes that he is still a U.S. Marshall investigating a case on the island. He believes that his Psychiatrist is his partner and that when speaking to clients, he is investigating them. He also believes that he murdered many people in WWII, which the psychiatrist denies at the end of the film.

Disorganized Speech: Laeddis found a note (left by himself) that read, “The rule of 4. Who is the 67th patient?” Other than this, Laeddis does not engage in other characteristic disorganized speech, such as neologisms, tangential speech, or loose associations.

Disorganized Behavior: Laeddis’ psychiatrist states that he is often agitated and easily provoked. Laeddis engages in violent acts when agitated, such as blowing up a car, attacking a guard and a patient, and injecting a Psychiatrist with a sedative.

Negative Symptoms: (anhedonia, alogia, avolition, flat affect) Laeddis does not demonstrate any negative symptoms. His affect is labile as he is calm and contemplative one moment and aggressive the next. Client still engages in pleasurable activities (investigating crimes), and he does not have any speech impairments.

Impaired Functioning: Laeddis is unable to live in the real world, as his experiences are so far from reality. Laeddis is suspicious of everyone around him and is violent when he becomes paranoid.

Paranoid Type: Laeddis shows complete preoccupation with his delusion of being a U.S. Marshall investigating the island. He is frequently suspicious of those around him and is violent when he feels threatened. While there is some disorganized behavior and speech present, it is not prominent.

For the most part, the disorder was accurately portrayed. Laeddis qualified for the symptoms of schizophrenia, paranoid type, which is how he was portrayed in the film. He did not have an over-abundance of symptoms, as occurs in some films. The only discrepancy would be that clients with less negative symptoms generally have better outcomes, but Laeddis had not gotten better after two years of treatment. However, the movie was set during a time period in which psychotropic medications were just beginning to be utilized, so although psychiatrists had attempted to use chlorpromazine, it may be that the treatment methods of the time were unable to aid clients at the same rate as they can today.

Etiology

Not much is known about Laeddis’ biology. There is no mention of any underlying general medical conditions. Laeddis did consume large amounts of alcohol and is portrayed as an alcoholic when his wife and children were still alive. Laeddis does not seem to have any physical disabilities or impairments. There is no mention of his parent’s health or mental health. Laeddis is in good physical shape and “highly intelligent”. However, Laeddis was taking an antipsychotic, chlorpromazine, for quite a while and recently stopped which caused him withdrawal symptoms (migraines and tremors). The symptoms of withdrawal caused him to believe that he was being given medications that would allow staff to take advantage of him and use him for experiments. Due to current research on schizophrenia, Laeddis probably suffers from enlarged ventricles and decreased levels of dopamine and serotonin.

Laeddis suffers from many psychological conditions. Other than his diagnosis as a paranoid schizophrenic, Laeddis also suffers from symptoms of Post Traumatic Stress Disorder (PTSD) which co-occurs with his schizophrenia and relates to his psychological themes of guilt and suspicion. While in WWII, Laeddis saw many dead bodies and felt a great amount of stress. He has frequent flashbacks and nightmares about the dead bodies and also the dead bodies of his wife and children. Laeddis engages in great efforts to avoid thinking about his memories from the war and his deceased children by engaging in delusions and avoiding talking about what happened. He is also hyper-vigilant and exceedingly agitated. One of the major contributors to his delusions is Laeddis’ guilt for not helping his wife obtain psychiatric treatment. Dolores had “manic-depressive” disorder and set their house on fire. Because Laeddis knew she needed help before she murdered the children, he takes responsibility for his children’s deaths as well as hers. The guilt he feels is so over-whelming that he does not know how to cope with it, other than by making himself feel like a hero on an important investigation.

Socially, Laeddis did not have much support before he was committed. Laeddis did not have anyone to talk to about Dolores and her mental health or about his horror from experiences at war. Laeddis was quite isolated and remains isolated within his mind on Shutter Island. Not much is said about his relationship with his parents other than that he was “raised by wolves” indicating a negative childhood experience. Although Laeddis felt isolated, he carried a high rank in society, was an esteemed Marshall, and had a comfortable lifestyle (he lived in a large and beautiful home on a lake). His feelings of isolation and the importance of maintaining his image as an important figure of society caused him to ignore his problems instead of face them. Now he is still attempting to use this method by living a fantasy in which he is a hero.

Social Work Prospective

Overall, the writers and directors of “Shutter Island” provided an accurate and believable portrayal of Paranoid Schizophrenia. Although the film is acute, Laeddis does not demonstrate symptoms that are more common among clients with schizophrenia. For example, there are usually more disorganized and also negative symptoms. Another potential problem with the accuracy of the diagnosis is that the movie will likely increase the stigma that “people with mental illness are dangerous” because it is set in a prison for the criminally insane. The general public has a negative perception of those who have mental illness because they believe they are impulsive, dangerous, and commit crimes for no reason, and this movie definitely portrays mental illness in a similar light. When choosing a film for the project, it seems that many dramas present mental illness in a negative light, whereas comedies often are more positive and de-stigmatizing.

As for the PODS, racial, and sexual issues of discrimination and oppression are not explored, as the characters are generally white and heterosexual. While the psychiatrists are all men, there are both male and female nurses, but issues of gender are not discussed. The main discussion of oppression in the film is that of the patients receiving treatment. Laeddis does not believe that the staff is humane, but is in fact conducting experiments on patients. He is somewhat correct but not in the way he believes. The staff is attempting a new type of treatment, client-centered therapy, which is more moral and humane. Throughout the film the psychiatrists highlight the dark past of mental health treatment and their hopes for the future of the field. In that regard, social justice seems to prevail in the hope that clients will be treated like people, and it may be the one aspect of the film that attempts to remove stigma from mental illness.

While “Shutter Island” is an excellent movie and accurately portrays paranoid schizophrenia, it may not be the best film for the general public to watch to learn about mental illness. It is quite educational relating to symptoms of the disorder, the mindset of a client, and the history of treatment, but it is not uplifting and certainly casts a negative light on clients. It is a good movie for social work students to watch as it relates to many topics in class, deals with diagnosis and treatment, and is a great movie, but I would not recommend it to the general public as a way to learn about mental illness.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.

Scoresese, M. (2010). Shutter island. Paramount Pictures.

Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock's Synopsis of Psychiatry (10th ed.). Philadelphia: Wolters Kluwer.

Posted by desolada at 08:49 PM | Comments (1)

Example Biopsychosocial Assessment

January 16, 2012 3-4 PM
Present for this assessment are the client, Chloe (pseudonym); and evaluator Alissa Bleecker, MSW intern

Identifying Information and Referral Source
Chloe is a 28 year old African American female presenting for evaluation of possible depression and anxiety. She is referred by her primary care physician, Dr. Albanese.

Presenting Problem
Chloe reports that since her boyfriend, Eric, has come back into her life, she has been “feeling anxious, overeating and sleeping 10-12 hours at a time”. Chloe is “looking for guidance and direction” in regard to her relationship with Eric, who is also the father of her daughter, Drew. Eric had been absent from her life in the last 10 months and has recently returned stating that he wanted to marry Chloe. Chloe reports often feeling “anxious” about decisions concerning Eric, and that her “over-eating and over-sleeping” are recurring symptoms from times in which he has broken-up with her in the past and also when he has re-entered her life. Chloe also stated that she has withdrawn from her friends because “they don’t support [her] relationship with Eric”.

Psychiatric History
Chloe was seen briefly at an outpatient facility once because of a professor’s referral “during undergrad. But I wasn’t trying to address issues, and she thought it was just silly college girl problems. She didn’t take me serious”. She has never been hospitalized or prescribed psychiatric medication.

Medical History
Chloe’s had two abortions, one in 2011 and another during her undergraduate work. Other than this, Chloe’s history is negative for hospitalizations, surgery, or major illness. Due to working third shift, Chloe sleeps during the day and reports sleeping 10-12 hours each day. Chloe is “constantly eating throughout the day, even when she is not hungry”. She reports eating more when thinking about Eric.

Family of Origin History
Chloe states that she has a pretty good relationship with her family. Her mother is “a huge support, even though [she] can’t tell her everything because she can be judgmental” due to her religious beliefs. Chloe’s relationship with her mother was strained when she had her daughter out of wedlock, and said that this was difficult for her mother to accept. Chloe also has a good relationship with her stepfather, although he “works all the time and is not there very often”. However, when he is home, they get along.

Chloe has two siblings, a younger brother and sister. Chloe’s sister is 21 and it’s “a typical sister relationship. She looked up to me growing up”. However, now that her sister is an adult, she “is out of control”. Her sister and mother often argue and do not get along very well. Chloe reports that her relationship with her brother is also good, but “he’s too spoiled”, and he has an “unrealistic relationship with her daughter”. Chloe thinks he has too high of expectations for her daughter, Drew.

Chloe’s daughter, Drew, is three years old, and she “loves her to death”. Although Drew “gets on [her] nerves sometimes”, Chloe thinks they are well bonded.

Current Relationship/Family Issues
Chloe reports that her relationship with Eric has been rocky with multiple break-ups and a history of domestic violence. Chloe and Eric first met when Chloe was 15 and working at a bagel shop. Eric is 12 years older than Chloe and has always been a flirt. When they became friends, he had a girlfriend, and as soon as they broke-up, Chloe and Eric began dating. Chloe believes dating him so soon after his break-up was a mistake because “he had unresolved issues”.

Chloe says that the first time that there was conflict in their relationship was when she became pregnant with Drew. After learning of her pregnancy, Eric left her for a year, and Chloe moved in with her parents. After his return, things were better until Eric’s mom passed away. After her death, “he wouldn’t communicate”. They were in danger of losing their home, so Chloe put her and Drew’s things in storage. Then Chloe did not see Eric for 10 months until he recently returned stating that he wanted to marry her.

Chloe states that she and Eric have “normal sexual health”, and she had only been with one man until the most recent break-up. After the break-up, she slept with another man but “didn’t enjoy it”.

Social History
Spirituality- Chloe is a Christian and states that her beliefs are important to her. Her beliefs cause her to feel “guilt over the abortions, premarital sex, and having a child out of wedlock”.

Peers-Chloe reports having a couple of really good friends whom she “sees from time to time”. She can “rely on them to vent” but has recently “pulled back from them” because they do not approve of her relationship with Eric.

Culture-Chloe identifies as African American. Chloe reports no concerns or stressors related to cultural or ethnic factors.
Strengths- Chloe reports that her strengths include that she “gives everyone the benefit of the doubt”. She also is “intelligent, a hard worker, and a good mother”.

Educational/Occupational History
Chloe completed her bachelor’s degree in Philosophy and would like to obtain a master’s degree in health administration. She currently works for the State Government “as a paper pusher”, as she is in charge of the mailings. Chloe has been employed here for eight years, and is not very enthusiastic about her job. Chloe reports that she does not get along with her supervisor and “calls off a bit when dealing with Eric”.

Legal History
Chloe denies any history of involvement with the legal or criminal justice system.

Critical Issues
Chloe and Eric have a history of domestic violence. When Eric becomes angry he often is destructive and has destroyed her glasses and laptop. Chloe reported one incident of domestic violence to the police, in which Eric was arrested and took anger management courses. Although there has not been an incident since then, Chloe is worried that “he might do it again”.

Chloe denies homicidal ideation, plan or intent, as well as current or past abuse or trauma. She denies current suicidal plan or intent. Chloe is able to contract for safety at this time.

Substance Use/Abuse History
Chloe denies any substance use for herself, Eric, and her immediate family.

Mental Status Exam
At the assessment, Chloe’s appearance and grooming were appropriate and casual. Physical abnormalities were not observed. Psychomotor activity was within normal limits. Tics/stereotypes were absent. Behavior and responsiveness to examiner was subdued but cooperative. Consciousness and orientation were alert. Affect was limited and mood was “anxious”. Thought processes seemed normal, as did thought content and perception. Cognitive functions, while not formally measured, seemed appropriate. Chloe displayed excellent insight and psychological mindedness.

Cultural Formulation
Chloe identifies as an African American female. She does not note any concerns related to her cultural identity. When asked about why she believes she is experiencing her presenting symptoms, Chloe attributes her current difficulty to Eric, saying “he tells me the type of life he wants to lead, but he doesn’t act it. He seems changed now though because he’s talking about marriage. I used to be the only one talking about getting married. I just don’t want to make another mistake”.
Chloe has treated her feelings of anxiety by eating and sleeping. She states that sleeping helps because she when she is asleep, she does not have to think about Eric. She recognizes that her anxiety is negatively impacting her life because “any time not devoted to [her] daughter is negative.”

Chloe has chosen to participate in therapy with the hope that a therapist can “help [her] make a decision.” She says she “needs a sounding board for a new perspective.”

Formulation/Diagnostic Summary
Chloe is a 28 year old African American female presenting with symptoms of depression and anxiety. The following symptoms and findings are prominent and clinically significant: over-sleeping, over-eating, isolative behavior, and feelings of anxiety. The symptoms are relatively acute. Protective factors include supportive family and friends, as well as Chloe’s insight and motivation for treatment. Significant Biopsychosocial stressors include absences from work and her relationship with her supervisor. Other stressors include her relationship with her partner and a history of domestic violence. Differential diagnosis should include depression as well as anxiety.

Diagnosis
Axis l: 300 Anxiety Disorder NOS Axis ll: deferred Axis lll: deferred Axis lV: mild-moderate stressors: work difficulty, relationship conflicts Axis V: 60

Recommendations
1. Weekly individual psychotherapy to reduce depressive symptoms and improve social and occupational areas.
2. Psychiatric evaluation to address potential use of antidepressant medication.
3. Biweekly couples Therapy session
4. Meeting with PCP to rule out any medical etiology for symptoms.

Posted by desolada at 08:44 PM | Comments (0)

“The Eden Express”: An Inside Look at Schizophrenia

When reviewing novels to read for the memoir project, I hoped to find a first person account of a serious and persistent mental illness. Working at Assertive Community Treatment (ACT) for my field placement, I am engaged with this client population daily. However, understanding the diagnostics of a disorder is quite different from understanding the actual client’s experience and thought processes. By reading a memoir that features a first person narrative of mental illness, I hoped to become more aware and empathetic to the experiences of my clients. After perusing the list, I chose to read “The Eden Express” by Mark Vonnegut.

“The Eden Express” chronicles Vonnegut’s post-collegial journey (moving to British Columbia, creating a commune, and trying to be a “good hippie”) during the late 1960s and early 1970s. Throughout this journey, Vonnegut becomes symptomatic and is hospitalized twice and diagnosed with schizophrenia. In the afterward, Vonnegut describes the changes in DSM criteria and states that if diagnosed today, he would be diagnosed with “manic depressive” disorder. However, the symptoms that Vonnegut describes appear to be more closely related to schizophreniform disorder due to his extreme yet short-lived psychosis. For example, Vonnegut’s psychotic episode lasts less than six months and much more positive symptoms are described than negative symptoms. After his recovery, friends and family believe that he has returned to baseline; this indicates that he has not decompensated nor retains negative symptoms.

Other prominent symptoms of schizophrenia spectrum disorders that Vonnegut experiences include visual hallucinations of a face, auditory command hallucinations, ideas of reference, paranoia about being poisoned, and grandiose delusions of being the messiah and of having killed his father and girlfriend (Virginia). Cognitively, he experiences difficulty inhibiting sensory stimuli, and difficulty with attention. Vonnegut also engages in clang associations, neglects hygiene and groom, has lack of sleep and lack of appetite, is catatonic at times, and is suicidal in regard to delusions of his death saving the world. While Vonnegut does exhibit some symptoms of depression, it is in response to the anxiety and grief that his delusions cause.

Vonnegut’s behaviors while psychotic are similar to the types of behavior that I see at ACT. Many of my clients do not maintain hygiene and groom and are often naked (just as Vonnegut runs through the neighborhood in the nude). Vonnegut made an insightful observation while hospitalized, stating that: “most of how you’re treated…is determined by how you are dressed. If you have on a suit and tie, there’s no such thing as a locked door. With nothing but a sheet, there’s no such thing as an open one” (195). When I visit a client, I conduct a mini mental status exam and hygiene and groom is the first aspect that I notice. Other similarities include difficulty paying attention to the conversation, staying on a specific topic, and processing multiple questions at once. Although, I have yet to experience a client who clangs, I do see clients who have grandiose delusions about living in a palace, being a king, a messiah, or a rock star. Many of my clients also endorse auditory hallucinations, most of which are persecutory like Vonnegut.

Being able to observe so many similarities between the behaviors of Vonnegut and my clients makes me wonder what their internal experiences are like. Some clients seem quite stable, but when asked more about their history, will speak at length about their views of the world, most of which are extremely disorganized, tangential, delusional, and paranoid. I really appreciated this memoir because I can see how difficult it might be to focus on a conversation with a care provider while there are so much internal stimuli and at the same time, there is a sensory overload. It was also interesting to read that Vonnegut felt as though everything in his mind was coming together to give him the knowledge of the world, and that it all made sense. It is easy to see how difficult it can be to do reality testing and challenge these strong ideas which are blossoming in the mind, while it is difficult to process what the clinician is saying.

When Vonnegut was finally hospitalized, his initial treatment was shocking because he was not informed about his treatment at all. He was given Thorazine three times a day but was not told what it was or why it was necessary. His illness was not described to him or even officially diagnosed. Also, he was released with no aftercare plans, medications, or even a prescription. It seems quite obvious that he would quickly relapse, and he was hospitalized again weeks later. This time, he was court ordered to receive treatment due to aggression and hostility. The same doctor (Dr. Dale) was his attending clinician, but was much better the second time around. He described schizophrenia as biochemical and described the effects of the Thorazine. After being stabilized in the hospital, Vonnegut had another episode, and after being isolated, a patient came to him and told him that he was freeing him from his power. Vonnegut states that this was the most helpful treatment that he ever received because he felt relaxed and released from his grandiose delusions of controlling the world. He was also given electroshock therapy and Thorazine.

I find it interesting that Vonnegut attributes his sustained recovery to his counseling sessions with Dr. Dale and the incident with the patient. Because of nature of the illness, a medication regiment is extremely important in maintaining mental health, but clients often choose not to see this because it strips them of power over themselves. I have often heard clients voice concern over lack of control of their body and mind and the need for medication to sustain this control, but Vonnegut either does not recognize this or he is an exception to what many clients experience.

Throughout the memoir, Vonnegut reflects on his cultural identity, stating “I am a white middle-class American heterosexual male… I am a down-under hippie revolutionary, alienated from the reins of power and persecuted by cops” (182-183). Although Vonnegut would be considered in the majority in all cultural categories, he often struggles with this because of his “hippie” status and desire to be one with others and one with the oppressed populations. After his first psychotic break, he even admits to being prideful because he feels that he has attained a heightened self-awareness by being a minority and oppressed in the realm of mental health.

As a member of the middle class, Vonnegut had used money from his parents to attend college, where he studied liberal arts and became quite political. He then purchased land and organized a commune to run the land and live and work together on the farm. When Vonnegut needs to be hospitalized, he does not have the burden of finances for the stay, the aftercare, or the medications because his parents are able to support him financially. Being a white male, he was also able to receive adequate care and was not discriminated against for his cultural identity. Throughout his psychotic episode, Vonnegut explores and agonizes about his “repressed sexuality” but he does not make this known to his friends or clinicians, so he is not stigmatized for straying from the norm (by having group sex or sex with an animal). Because of living in a commune, the client has surrounded himself with open and accepting friends who are able to support him through his illness.

As a part of greater society, Vonnegut would likely have had a very different experience and be stigmatized, but since he was living on his self-made commune with other hippies, he had a very different experience. Vonnegut’s culture is deeply tied to the hippie movement in the United States. He describes the hippie movement and the commune as all being one and aiding each other. Because of this, he believed that his friends would take care of him. He says, “There are lots of pressures in the hip community that make that sort of decision even harder to come to than normally. Doctors don’t know anything, mental hospitals are repressive, fascist, etc. Hippies are supposed to be able to take care of their own” (164). The cultural norms of the historical time period and the type of environment in which they lived made a strong support network but made treatment difficult. Vonnegut’s friends believed that his psychological distress was not negative but that he was enlightened. At many times, Vonnegut’s symptoms were even further exasperated by marijuana use on the commune. It is because of the hippie community’s societal norms that Vonnegut was untreated for such a great length of time; his friends did not believe in mental hospitals until he was too ill to function.

Seeing Vonnegut in a full blown psychotic episode made his friends question their beliefs regarding mental illness. While they originally believed that “ ‘schizophrenia is a sane response to an insane world’. ‘Mental illness is myth’. [and] The Sanskrit word for crazy means touched by the gods” (164). They later reflected that, “this whole thing is really giving me a whole new outlook on mental illness” (156). The hippie community that Vonnegut was a part of believed that it was ideal to try to achieve a higher level of awareness. Many experimented with drugs to try to become more self-aware, and many of Vonnegut’s early symptoms demonstrated some of these unusual and philosophical ideas. The early symptoms were then positively reinforced by both self and friends because it was desirable to learn to think differently and see the world in a new way. Thus, the time period, life experiences, and social network made a huge impact on Vonnegut’s course of illness and treatment.

One of the most positive aspects of commune living was that Vonnegut had many social supports. Vonnegut’s main social supports were his girlfriend (Virginia), dog (Zeke), and core commune companions (Simon, Mary, Joe, Sarah, Kathy, and Jack). Also, although Vonnegut did not see his family often, they were supportive in visiting him at the hospital, assisting with aftercare, and wrote him letters while he was living at the commune. Because of the many social supports, Vonnegut was able to receive great monitoring by his friends. There were times when he refused to eat, and they would sneak protein and vitamins in his beverages to help sustain him. They also took turns watching him 24/7 when he became suicidal before his hospitalization. After he was hospitalized, they all assisted with aftercare in reminding him to take medications and helping him get to and from his biweekly psychiatrist appointments. While these same supports had not been helpful in recognizing a need for more serious care, they did provide quality care to Vonnegut throughout the course of his illness.

Throughout the memoir, Vonnegut described a feeling of disconnectedness when it came to his girlfriend and their sexual relationship. While Vonnegut does explore some same-sex feelings while psychotic, he later denies them and believes that Virginia has difficulty with intimacy. Maintaining intimate relationships can be quite difficult for clients with schizophrenia because of repeated episodes, retained negative symptoms, and a general decompensation of the mind. However, although Vonnegut and Virginia do eventually go in separate directions, Vonnegut writes in the afterward that he is happily married with two children. As Vonnegut is most likely wrongly diagnosed and actually has schizophreniform disorder, it would be easier to have an intimate relationship, especially once he is stable.
Although Vonnegut’s friends faced many challenges in caring for him, especially when he was suicidal, they were able to work together and provide 24/7 support. They were also able to support one another and relieve each other of care taking responsibilities due to their living arrangement. This is not the case for many care givers. Many clients with schizophrenia live isolated lives because their care givers become exhausted and frustrated and eventually leave their loved one. This is harmful for both parties, and it is the reason that family group therapy was created, to support the care giver and client.

The memoir is also a historical piece in that it reflects the culture of mental illness during the late 1960s and early 1970s. The DSM II would have been the clinician’s main tool (Castillo 1997). The DSM II was similar to the DSM I except that it took a more biomedical approach, where the DSM I integrated biopsychosocial. This change was due to the new advances in medications, primarily the discovery of lithium and neuroleptic medications. The DSM II also was more disease-centered and the paradigm shifted even more towards this approach in the 1970s. The view of schizophrenia as a brain disease and a chemical imbalance is certainly seen in the memoir as Dr. Dale describes the illness as “biochemical” and treats Vonnegut primarily with Thorazine. It is, however, quite progressive that Dr. Dale also utilized therapy sessions, which is more client-centered, and was not as utilized during this cultural period.

Overall, Vonnegut allows readers to enter the mind of a client with schizophrenia and to understand psychiatry in its early stages. Vonnegut’s experiences are also unique as his social network is rather unusual and demonstrates that there are both positive and negative aspects to any culture.

References
Castillo, R. J. (1997).Why culture? Culture & Mental Illness, 1-22.

Vonnegut, M. (1975). The Eden Express: A Memoir of Insanity.

Posted by desolada at 08:32 PM | Comments (0)

Nina: A Case Study of Schizophrenia

Nina: A Case Study of Schizophrenia

The following is a case study of a client being treated for schizophrenia by an Assertive Community Treatment team in Michigan. This client will be given the pseudonym, Nina, for purposes of privacy and confidentiality.

Schizophrenia

According to the DSM IV-TR (2000), schizophrenia is a psychotic disorder characterized by at least two of the following five symptoms: hallucinations, delusions, disorganized speech, disorganized behavior, and negative symptoms (anhedonia, avolition, alogia, and flat affect). Symptoms also must impair social or occupational functioning, last longer than six months, must not be due to substance use or a general medical condition, and there must not have been any mood episodes (manic, depressive, or mixed). Schizophrenia is prevalent in roughly 1% of the population and can be one of the most costly disorders due to need of repeated hospitalizations because of suicidal or homicidal behavior. Schizophrenia is also one of the most deteriorative disorders, and once there has been one episode, clients most often do not return to baseline and decompensate more and more as the disorder progresses.

Nina, who is a 45 year old African American female, exhibits many of DSM IV-TR criteria for Schizophrenia. Nina experiences tactile hallucinations, as she believes that snakes are in her stomach and she can feel them crawl up her throat, and “they eat the medicine”. The feeling of snakes inside her is greatly distressing to her and causes her to vomit most evenings. Nina also has persistent delusions that she has “spirit babies” that live both inside of her and in Highland Park. Nina often desires to return to Highland Park to find her “spirit babies” and “the spirit man who [she] fornicated with”. Nina reports having up to 20 children but says she does not know their names. She reports that some of them “be crackin” and try to convince her to consume drugs for them to eat. Nina currently takes Vicodin and Klonopin for arthritis in her knees, but says she rarely feels relief because the spirits will steal these substances.

Nina also has delusional beliefs that she has psychic abilities and knows when a crime is about to take place. Nina reports that she often calls the police to warn them of future crimes. However, she says they do not listen to her, and when she watches the news and sees that the crime occurred, she feels guilty. When speaking with Nina about her psychosis, she is often tangential and loosely associated with time. For example, Nina will begin talking about her appointment with the psychiatrist last week, and a sentence later say that she was talking to him about being pushed into the street by the spirits. When asked when the event occurred, she reported that it occurred in 2004, but the meeting with the psychiatrist occurred in 2012. Nina will also perseverate on certain topics such as “fornicating with the spirit man”, having an alien baby at age 5, and how “Jesus breathed life back into [her] when [she] died of lung cancer”. Nina does not however, display disorganized behavior and she always appears with good hygiene and groom. She also does not currently appear to have any negative symptoms. Nina presents with a good mood and appropriate affect.

Multi-Axial Assessment for Nina

I. Schizophrenia
II. deferred
III. Arthritis in both knees; Type II Diabetes
IV. Unable to work; Problems with Social Network
V. 45

Treatment

Nina is currently an Assertive Community Treatment (ACT) client, and this treatment modality is the best fit for Nina and for clients like Nina who have experienced multiple hospitalizations for psychosis. Assertive Community Treatment is an evidence-based practice which provides a much different and progressive type of service than an inpatient facility; it offers community-based, at home care for clients with severe and persistent mental illness (ACTA 2012). Through ACT, a multidisciplinary team of social workers, a nurse, psychiatrist, peer-support, and mental health practitioner provide mental health care to clients both in the office and in the community. In the morning, ACT teams travel to the homes of 7-12 clients each day to provide at home care. During this visit, social worker observes clients take AM medications and observes the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance; the whole visit lasts approximately 10-15 minutes. In the afternoon, staff involves clients in different support groups such as co-occurring groups, shopping, art, nutrition, and walking groups. Staff also use afternoons to see clients in the office and assist clients with miscellaneous appointments and needs.

Programs like ACT are beneficial to clients who have many needs, who have difficulty with medication adherence, or who have chronic symptoms and who wish to continue to live independently (ACTA 2012). A program like ACT can benefit Nina because she has chronic symptoms; every day she feels the snakes inside of her stomach or talks about the spirits weighing her down. While Nina does report that she has a mental illness called schizophrenia, her definition of her illness is far different than most. Nina believes she was cursed and that is her illness. She does not think that she hallucinates or has delusions but that the spirits are real. Nina’s little insight into her illness would make it difficult for her to live independently without ongoing mental status assessments and medication management. Nina has stated that she would probably take more medication if she did not have ACT because “the spirits eat the pills” so she would take more to compensate. Nina states that she appreciates ACT “observing” her and assessing her mental health.

Research also supports the benefits of ACT programs in regard to decreased rates of hospitalization, higher rates of medication adherence, and improved quality of life. Zygmunt et al. reviewed literature about the necessity of medication adherence for clients with schizophrenia, stating that 50% of those diagnosed with schizophrenia will stop taking medications within a year after first discharge (2002). Once clients have stopped taking medications, they will experience increased risk of relapse (3.7% greater than compliant clients), and symptoms can negatively impact quality of life. Researchers then studied psychosocial techniques and therapies for improving medication compliance. Zygmunt el al. did find that programs such as ACT were more effective, as was motivational interviewing, because each focused on behavioral training. Findings suggest that clients will be more compliant when given concrete instructions and problem-solving strategies. Behavioral training was effective because clients were provided direct feedback for compliance.

Other alternative behavioral treatments include Cognitive Behavioral Therapy. First and foremost researchers maintain that medication compliance is critical for ACT clients, but that CBT and training can improve client’s functioning and reduce symptoms because it provides skills training and helps clients improve coping skills for dealing with their mental illness. Pinninti et al. (2010) believes that “the improvement in functioning included interventions, such as helping clients make appropriate life decisions, improving social and leisure skills, and dealing with barriers to employment”. However, behavioral training can be difficult for clients who have little insight into their illness. For Nina, attempting CBT on its own is quite a challenge, and one that I have actually attempted. When I first started doing wellness visits at Nina’s, she was always cooperative, calm, euthymic, and conversational. She had spoken to me about interpersonal problems with a friend, and I asked if she would like to try CBT. Nina was eager to try, but I quickly learned that she was not as stable nor had as much insight as I had thought. During the first session she perseverated about the spirits and snakes the entire session. Following sessions were similar. Thus CBT may not be the best option for all clients, but if clients are stable on the medications, it can be more helpful, and it can also complement ACT programs.
Cultural Considerations

As an African American female raised in Highland Park (Detroit), Nina has a specific set of cultural values which affects the way she views her illness and recovery (Castillo 1997). In Nina’s specific culture, witchcraft is a real and accepted norm, and she believes that at the age of 18, a neighbor cast a spell on her. Nina believes this was the moment when she first experienced a spirit of a dead woman entering her body. Ever since then, she believes that spirits have entered her and stayed with her because she was cursed to be a vessel for the spirits. When discussing Nina’s illness with clinical jargon, such as calling the spirits “hallucinations”, Nina becomes angry and says she is misunderstood and that no one believes her.

Thus, in discussing Nina’s illness, it is much more helpful to her and client-centered to refer to her manifestations in her own terminology, “spirits”, and to explore the implications of these manifestations along with ways to cope with them. At first, this was difficult for me to approach due to my diagnostic ethnocentrism revolving around traditional western cultural schemas. However, after reminding myself to take a client-centered approach and use Nina’s own language and reflective listening, I became better able to build rapport and connect with Nina. For example, instead of discussing what the spirits are, Nina and I discuss how the spirits effect her life. Nina feels much guilt because she believes she has many children who she cannot spend time with, so instead of continuously conducting and failing with reality testing, we discuss how this guilt affects Nina, how she can cope, and how she can move forward.


References

ACTA (2012). ACT model. Assertive Community Treatment Association. http://www.actassociation.org/. Retrieved March 1, 2012.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.
Castillo, R. J. (1997). Cultural assessment. Culture & Mental Illness, 55-75.

Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health., 46, 4, 337-41.

Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock's Synopsis of Psychiatry (10th ed.). Philadelphia: Wolters Kluwer.

Zygmunt, A., Olfon, M., Boyer C., & Mechanic, D.(2002) Interventions to improve medication adherence in schizophrenia. Am J Psychiatry, 159, 10. 1653-64.

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