Here are the instructions for this assignment: (1) Watch Dr. Elyn Saks' TED talk about her personal experience with schizophrenia here. (2) Read the attached vignette about a patient named Janet. (3)
Case vignette for Schizophrenia and Other Psychotic Disorders Janet Three months into Janet's freshman year, her parents were summoned by the dean of the small o ut-of-town college she was attending to come and pick up their daughter. The dean said Janet was behaving strangely. Sh e had begun to wa n der around the campus at night, barefoo t an d dressed only in a short nightgown. According to her roommate, Jane t had "not been herself" for th e past six weeks. She had stayed in her room continuously, hoarded food, wrote in cessantly, an d refused to attend classes ex cept for one taught by Dr. M., an older marr ied man with whom Jan et had become intensely preoccupied. She ac ted a if she were in her own world. She was u nap proachable and was irritated by her roommate's attem p ts to co nverse. During the past few weeks, Janet had talked to herself frequentl y. It sounded to her roommate like one-half of a d ialo gue ab out what Janet a n d Dr. M. should do, and whether he was angry with her.Janet's parents found their daughter in an extremel y agitated state. She wa s dressed in a bizarre way, wearing all kinds of mismatch ed clothing that was inappropriate for the weather as well as f or the setting. She was unkempt and obviously ha d not bathed. At first she was unresponsive an d barely acknowledged her parents' presence. When she did sp eak she became overexcited. She explained repeatedly that she had to stay at college because Dr. M. was passionately in lo ve with her. She said he was unable to come to her because his wife kept him im prisoned at home at night. She reported that "voi ces" commanded her to unite with Dr. M at any cost in order to save the world from destruction. Janet also wa s convinced that Dr. M.'s wife was reading her th oughts and now intended to harm her.
When Janet's parents told her they were taking her home, she became violent. She attacked them and wrecked her dorm room . Her words indicated that she was exper iencing her paren ts' effo rts as an attack by some dangerous beings, and she argued vehemently but in coherently with these p ersecutors. The police were cal led and Janet was taken to th e emergency room of the local h osp ital. The th reatenin g and acutely alarming nature of her hallucin ations led st aff psychiatrists to conclude that Janet was a dan ger to hers elf and others. Immedi ate hospitalization was ad vised. Upon admission, Janet was so out of cont ro l she had to be put in restraints until the med ication she was given began to take effect. Janet was especially fearful that th e hospital staff was collaborating with Dr. M.'s wife. She thought they were incarnations of evil forces intent on keeping Janet an d Dr. M. apart so that they co uld not save the world. Janet became mo re subdued as her medication took effect, bu t she continued to be uncommunicative around th e ward. Although the acute phase of conditio n passed, the general prognosis for full recovery was guarded because of ind ications that this ep isode was only o ne p art of a lon g an d in sidious process of deterioration.
C linical Dis cussion Sev eral features of the acute onset of Janet' s disordered condition are typical of schizophrenia, in clu ding her rapid deteriorati o n and its occurren ce during her first major separation from hom e. Her parents reported that she alwa y s had been a shy and socially awkward and sensitive girl. For a time around age seven, she had refused to go to school. The whole family had undertaken a brief therapy designed to enable Janet to return to school. This seemed to clear up her behavior enough for her to attend school, but she she wa s not happy. During early adolescence, Janet began to have frequent arguments with her mo ther. On several occasions, these arguments culminated in a self-destructive act. On one occasion Janet scratched her wrists with a razor blade in front of her mother, following which th e school psychologist referred her to therapy. Janet refused to go, although her more provocative and worrisome behavior decreased after this episode. Janet continued to beha ve eccentrically, like needing to engage in complex rituals in order to go to sleep, or not wanting to be seen eating, but these behaviors were accommodated by her family and others. The depth of Janet's anxiety and the rigidity and fragility of her coping mechanisms, therefore, were masked while she remained at home. These quickly broke down, however, when she left the safety and supportiv e atmosphere of her accustomed surroundings and family.
Within her unfamiliar new environment, Janet f ound it impossible to feel safe. Her "substitute reality" enabled her to feel more secure. In her fantasies, she attained the special status of being desired by an important person, Dr. M. Also, dwelling exclusively on this one relationship helped limit her focus so that she felt le ss overwhelmed by all the new surroundings. She explained her anxiety about the imag ined danger she was in as due to threats to her ties with Dr.
M. She saw these threats as coming both from his wife and from the hospital staff. The pervasive sense of terror that accompanied he r internal disintegration required a broader explanation, however, which became her convi ction of impending world destruction. Her preoccupation with Dr. M. was a desperate attempt to save herself from this psychological catastrophe. The theme of salvation in her delusional system (Janet and Dr. M. were to unite to save the world) illustrates her hope of being re scued. Her parents, the dean, her roommate, and the hospital staff all were part of a threatening system that stood between Janet and the safer alternative reality she had constructed.
The elaborateness of Janet's alternative reality makes it a systematized delusion. In this complex story Janet uses a paranoid type of delusion to try to make sense of her anxiety and thereby to control it. Accompanying the delusional system is Janet's overall decline in hygiene, daily functioning, appearance, and ability to manage her impulses in response to being challenged. The broad sweep of these disruptions indicates th at the delusional system was failing to contain her overall breakdown. The appearance of mistaken sensory perceptions (in this case hearing voices) indicates the presence of au ditory hallucinations, which often are part of a schizophrenic process. While delusions reinterpret the meani ngs of things, hallucinations change the actual intake of reality through the per ceptions. Janet's hallucinations instruct her about increasingly terrifying inner experiences (called command ha llucinations). These, in turn, give rise to a concern that she might endanger herself or othe rs because she ins unable to use judgment and reality testing, and because she is fearful and reacts explosively to anything she views as a threat. This explains why she was hospitalized, ev en though she wasn't voicing a direct threat at the moment.
The outcome for Janet is unsure. While some of her more florid symptoms may be controlled by medication, indications of weakness in her adapta tion are long-standing and began years before the onset of the acute schizophrenic phase. Her ability to resolve this crisis effectively is in doubt, less because of the presence of delusions and hallucin ations than because of her long h istory of weakness in psychosocial functioning.
