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jlogan22
I believe the primary diagnosis for this individual is…
I believe the primary diagnosis for this individual is schizophrenia.
What would be a good case formulation for this case report?
DSM Diagnosis:
The patient to be presented is A, a high school senior in his second hospitalization; he had been briefly hospitalized the previous year. A was selected for presentation because his Rorschach was replete with responses that were poorly articulated, amorphous, vague, de-animat-ed, and occasionally contaminatory. His responses also often lacked stability and constancy. He was, for example, unable to remember many of his responses once the card was removed, even though the responses had been given only a few seconds earlier. This lack of stability of representations also characterized his interpersonal behavior on the ward. He quickly became confused when close to others or when he had to participate and interact with more than one or two people. At these times he reported experiences of blurred perception and confused thinking. Clinical reports suggested strong wishes for fusing and merging with important figures, such as his therapist. His difficulties seemed to have begun early. and there were few, if any, reports of meaningful relationships in his life. His current difficulties seemed to have evolved in a slow, gradual, undramatic decompensation over many years.
Case 1 – Patient A:
A, a 19-year-old, male, high school senior, was admitted for a second hospitalization. The first hospitalization was for a brief period and had taken place about one year earlier. A had a pale complexion. rigid gait and posture, awkward movements, and a frequently expressionless gaze. He rarely expressed feelings and often gave the impression of being in a daze and not quite in contact with his surroundings. When embarrassed or tense. he would break into an inappropriate and self-conscious giggle. Occasionally, however, when he was pleased by something, he would smile in a warm, childlike fashion. At times, he stared in an intense, scrutinizing way. but more often sat back in a chair as if sleeping, but possibly daydreaming or hallucinating. He rarely spoke spontaneously or answered questions with more than a sentence. His speech was coherent, and his vocabulary and syntax were appropriate. Although he seemed of above average intelligence. he constantly complained of difficulty in concentrating and remembering.
He had trouble keeping his thoughts organized or pursuing a topic for any length of time. His discussions of the events of his life were mostly a series of disjointed incidents or fantasies, usually expressed in very concrete. visual terms. He described feelings of confusion when he tried to converse for more than a few minutes or when he was in close proximity to several people. During such experiences, he felt overstimulated, his eyes would hurt, and he would either close his eyes or try to fixate on one specific point, such as a spot on the wall. He also hinted that at such times faces tended to blur and the furniture and walls almost acquired a life of their own. In addition to these hallucinatory tendencies, he also had somatic delusions about the physical deteriorative process going on within him.
Initially, he had concerns about being subjected to violence or ridicule in the hospital, and he was prone to anticipate criticism and ridicule. or attack and 10 misinterpret the slightest gesture or alterations in the tone of voice. There was no evidence, however, of systematized delusions: nor did he mention any suicidal ideation. His dominant state seemed to be a kind of affectless depression, with constant expressions of a feeling of hopelessness and helplessness (he was born *dumb, inept, degenerate,” etc.). He often wished to remain in his bed. He did express, however, a wish to communicate. to have friends, and to be the center of attention. But he felt like he was not able to change anything about this. He repeatedly expressed concern about being misunderstood, and about annoying or boring people. In his more lively moments. his behavior had a childlike, teasing quality, and on occasion, he even tried to be humorous, although in a rather weird and self-deprecating fashion.
A was a planned full-term baby. Forceps were used in his delivery. but otherwise, it was uneventful. He was bottle-fed. During his first year. A was sickly, with many colds and severe bouts of croup, that required a great deal of his mother’s attention, holding and rocking him. She said that she was often afraid they “would lose him.” He outgrew this sickliness by the time he was 1 year old when the family moved to a new home. A walked at 13 months and talked somewhat earlier when he was around I year of age. He never used baby talk and quickly began to use sentences. Daytime toilet training was accomplished at about 2 ½ years. but A remained enuretic at night until he was 10 years old. He was affectionate. outgoing child until he was 3 when he was sent to nursery school. He was so unhappy and shy that his teacher and mother decided that he should remain at home the following year. At 5 he started kindergarten, with none of the earlier difficulties. This was also the year in which his brother was born. In spite of subsequent bitter hostility between the boys, his mother reported that initially, A was delighted to have a baby brother. It was only later, when his brother began to walk and to get into A’s toys, that the angry rivalry became apparent to the mother.
A’s report of his childhood was mostly a series of concrete. isolated incidents or fantasies with great vagueness as to their location in time. A’s earliest memory, which he dated around age 3. was of getting lost and being found a few blocks from home. Most of his memories had to do with feeling scared, humiliated, or injured. He remembered being scared to be left alone in the house. hearing straßge noises and having a hallucination of a monster coming out of the furnace. He would sometimes imagine his parents being changed into Frankenstein-type monsters. He had an imaginary companion, a bodyguard who could summon troops to his defense. a fantasy that he still experienced at the time of his second hospitalization. He remembered being injured in a car because of his mother making a sudden stop. He also vividly recalled a boy having his toes cut off by a lawnmower.
He remembered his father as big and powerful, but that his mother did most of the disciplining. frequently shouting at and occasionally spanking him. His most vivid memories of his early school years were of being slapped by a teacher in the first grade for making noise and of being humiliated by being forced to stand in front of the class. He was occasionally hit or beaten by other boys and would complain to his mother. On the rare occasions when he would fight back and get the best of a fight. he felt very ashamed and worried a pattern that persisted in later years.
During A’s early years, the family moved several times. When ^ was 10. the family moved once again. After this move, A’s mother began to work full-time. She employed a maid and felt that A continued to see as much of her as before since he was away at school when she was at work. He apparently did fairly well in the fifth and sixth grades and had several friends, both from school and from his neighborhood. With these friends he *shared interests in playing ball, hiking, weight lifting, petty shoplifting, comic books, and other fairly age-appropriate concerns. He also learned about sex from these friends.
According to his mother, A’s school difficulties began 2 years later, when he was 12 ½ years. An older boy began bullying and tormenting A, and his life was made miserable. Furthermore, this boy involved all the other boys. even those formerly friendly to A, in tormenting him, so that he was then totally friendless and began to protest going to school. The following year, in eighth grade, the bully was no longer in A’s school, and he regained some of his former friends. But his grades did not improve substantially, and he continued to have trouble studying.
He began masturbating when he was about 13 years old. His main fantasy was, and remained, of his watching a girl eating and the girl looking at him. He would draw pictures of his masturbation fantasies. particularly of naked men being watched by women. He remembered mostly feelings of anger and fear toward his father. He felt that his father was practically never at home and, even when home. not available to spend time with him. His father occasionally slapped him and frequently criticized him for his poor manners, childishness, and so on.
Ninth grade was a “disastrous” year for A. His family moved again. he had no friends, and he flunked all his courses. The other boys ignored him in school, he felt extremely isolated, and he hardly tried to do schoolwork. He missed a lot of school, pretending to be sick. and spent a great deal of time in his room, daydreaming or listening to popular music. He also engaged in many sexual and make-believe games with his younger brother. He liked his brother to pretend to be a princess or a baby. and sometimes he took these roles himself. He felt guilty for having instigated these games, which he believed may have contributed to his brother’s psychological problems.
The following year his parents decided to send A to boarding school. with the hope that the enforced living arrangements at the school would help him make friends. It was during his second year at this school that concern was first expressed about A’s emotional problems. School officials urged psychiatric help, and he entered once-a-week therapy for a year. A felt very angry and hurt about being sent away to boarding school. He was reluctant to talk about his two years there, except for the repetitive themes of feeling lonely, isolated, and ridiculed and of doing extremely poorly in his schoolwork. While he was away at school his father was killed in an accident. Beyond the initial shock, A remembered no specific reaction or grief over his father’s death. There was no evidence that his behavior changed in any significant way afterward. He felt vaguely guilty about his father’s death because he remembered so many angry feelings toward him. His mother became increasingly more tense and irritable, and there were many squabbles and arguments at home about such issues as his refusal to go to school and staying in his room. It was at this point that the mother sought consultation, and it was recommended that A be hospitalized.
A’s difficulties seemed to have developed in a slow, gradual, and undramatic decompensation over many years. Before his first hospitalization, he spent the academic year at a boarding school. He found it difficult to study and failed several courses. Socially, he was quite isolated; most of the boys paid attention to him only to tease or ridicule him. He had several homosexual experiences, which he said he enjoyed. However. he was most distressed by several hallucinatory experiences such as hearing a voice call his name or feeling that a hand was touching his head when no one was around. He was given psychological tests at this time. At the end of the school year, he returned to his mother’s home and spent his time in his room listening to records. His mother kept urging him to go out, and violent arguments ensued between them. With his younger brother also showing indications of severe disturbance, the home situation quickly became intolerable, and the mother decided to hospitalize A. At first, A resisted; then, after an incident in which he lost his temper and threw a magazine at his mother, he agreed he needed hospitalization: A was discharged after 2 weeks because “I behaved well and obeyed all the rules. He was sent to a halfway house where he lived for 6 months until his second hospitalization. During this time, he had daily group psychotherapy; but apparently, he did not get very involved and felt very tense, uneasy, and at times bored. He was particularly uneasy when his mother attended the sessions and he was encouraged to confront her with his feelings While at the halfway house, he was enrolled in a school. but he rarely went to classes and soon dropped out. It was then decided that he should have a job. but he worked for only a few days. as a messenger. Most of his interest during this time was centered around his relationship with a seriously disturbed girl. This was his first involvement with a girl. and they engaged in some sexual activity. Apparently. the relationship involved confusion about sexual identity and roles. At times. A saw himself as the girl’s protector; he liked to listen to her and let her cry on his shoulder. At other times. he experienced her as a big powerful, masculine creature or as a mother and himself as a girl or a baby. The relationship ended when the girl was hospitalized. A felt responsible. and he considered his own subsequent hospitalization as partly a punishment for his “degenerate” behavior.
When A entered the hospital for his second hospitalization, he was timid and somewhat confused, but he appeared to be genuinely optimistic about the prospects of his stay in the hospital. During the first few days on the ward, he felt encouraged by the style of the hospital and proceeded to tell various staff members quite a bit of unconnected information about himself. -anecdotes from his past, expressions of loneliness. and brief descriptions of family relationships. In general, he was quite candid about his problems as he saw them. Relationships with other patients were much harder for A. During the first week or so, he made attempts to join group conversations and to make friends. When his somewhat awkward attempts at friendliness met with little success. he became more and more isolated, spending as much of each day as he could on his bed. A stated two reasons for spending so much time on his bed to avoid people and to enjoy his fantasies, for example, of being a strong person and saying “no to a persistent salesman” or alternately thinking of himself as a famous millionaire and an auto mechanic. It was clear that he was also gratified by the attention he received from staff members when they insisted that he get off his bed and do something.
Early in his hospital stay, A became upset about the homosexual undercurrent on the ward, particularly some direct overtures from another patient, who was about his age. Despite A’s discomfort about this incident. this patient was the only person with whom A had any real friendship for more than 2 months. A felt somewhat homosexually attracted to him. but stated probably accurately, that the main reason for seeking his company was that the other patient’s boisterousness made him feel more alive and that he was one of the few patients who showed some interest in him. ^ occasionally called him “Dad.” and, when confused. he called other patients by the names of boys he had known at school. Gradually. A came to feel that he could no longer confide in the other patient, so the friendship dissolved. Later, A became interested in a female patient, enjoyed talking with her, and was very pleased and sexually stimulated when they both drank soda together out of the same bottle. A began to spend increasing amounts of time with this female patient, and he soon decided that he was in love with her. This one-sided romance was very painful for A. and he found it difficult to refrain from pestering her to spend unreasonable amounts of time with him. Traumatic as this experience was. it seemed to help A break out of his pattern of isolation. He spent less time daydreaming on his bed, stayed up later, and was generally livelier in his activities on the A’s timidity and lack of self-assurance affected a number of aspects of his life on the ward. For instance, he had great difficulty sustaining normal conversations. On one occasion, he asked to talk to one of the aides, and after a period of silence, abruptly asked, “What do you think of the possibility of a future merger of China and Russia?” He later explained that he was trying to make small talk. A entered the hospital’s high school to complete his senior year and graduate. When he first entered classes, he was quite explicit about his problems with school. However. shortly after the class began a sex education unit in biology. he stopped participating and gradually became stuporous and monosyllabic. He would do his assignment only if the teacher insistently told him to do it. A’s problems with passivity and his difficulties in concentrating and maintaining focus were so great that without some compulsory, clear, structured activities, school was very difficult for him.
In the first few weeks of therapy. A seemed pleased to be in individual therapy and was relatively active in talking about himself. He talked in rapid succession about a variety of themes, including his problems with “identity.” his guilt about his father’s death and his brother’s condition, his strong dependence on his mother, and his wish to be babied by her. He spoke of his sexual problems and his difficulties with girls. He considered himself “bisexual’* at best and was convinced that he was born with inadequate genitals. He also mentioned that he had been going downhill physically. that he was fat and flabby. and that some vague pains in his leg might indicate that it would have to be amputated. The intensity of his passivity, inertia, and withdrawal became apparent only later.
In therapy. he talked more and more about his feelings of discouragement. He talked about not being able to make any friends among the patients, or missing the halfway house. and of wishing that he was at home with his mother. He constantly apologized and blamed himself for his inability to communicate. It was pointed out to him that initially, he seemed to have expected that the new therapist and the new hospital would result in some sudden magical change in his condition and that he was disappointed. He was also concerned that he was making the therapist somewhat discouraged and wanted to know whether he was a “heavy case.” The therapist agreed that A had been seriously incapacitated for a long time and that he had experienced his life for many years as merely being pushed around from house to house, school to school, and hospital to hospital so that he felt he had no will or initiative of his own. But the therapist stressed that he was not as hopeless or helpless as he presented himself. pointing out that he was withdrawn and passive from a sense of discouragement and fear and from an attempt to gain some satisfaction from his fantasies. The therapist also hinted on several occasions that there might be a good deal of anger behind his attitude. While this made A anxious. he increasingly talked about feelings of resentment toward his mother, particularly at her emphasis on good manners, the importance of school achievement, and so on.
The therapist was quite active during the sessions, making comments in a spontaneous and direct fashion. A was encouraged to experience the therapist as a real person, interested in helping him, but with limited powers either benevolent or malevolent. With his relationship with his mother in mind, A was told that the therapist could not and would not manage his life and would not be drawn into a battle between an irresistible force and an immovable object. A agreed that this statement made him feel both safe and disappointed. He told the therapist at times that he considered himself “Lough.” Yet it was pretty clear that, for him, the highlights of the sessions were the moments during which he found that he and his therapist had something in common–for instance, when they were both smoking or when the therapist expressed knowledge of places where A had been. These occasions probably triggered some fantasies of merging, and he would beam with a blissful, childish smile and tell the therapist that he liked him.
At the other extreme, he expressed some anger toward the therapist, in mild words and by pretending to fall asleep, when the therapist said that he did not share A’s conviction that defective genitals were the cause of all his problems. A also reported several dreams. The more salient of these dreams included looking at himself in the mirror and seeing, instead, the face of another “rugged” patient; seeing himself sitting on a giant tape recorder and flying through the shell of a building, sleeping next to his mother on top of the mast of a ship and being frightened of falling down, and a nightmare about watching a parade by people stacked on top of each other and of feeling trapped and running.
From A’s account, the events of his early years, the personalities of his parents and brother, and the nature of his interactions with them remained obscure. It can be speculated that this lack of information in his account reflected, in part, difficulties in establishing and maintaining stable self and object representations, so that he was unable to describe himself and other people as having clearly differentiated characteristics. The mother’s account of A’s history, up to his adolescence, was also uninformative. A’s selection of memories from his early years stressed his constant fearfulness and expectations of injury, humiliation, and ridicule. He gave the impression that most of his early relationships were strongly sexualized, but at a very early oral level, and he showed a massive confusion of sexual identification and an absence of relatively conflict-free areas of competence and achievement. It seemed as if early in life he had acquired the conviction that any activity on his part could end only in failure or ridicule or in damage to himself or to others. It appeared that at the beginning of adolescence. A’s development practically ceased, and he began a downhill trend. His capacities for schoolwork and social relations lessened, and he withdrew more and more into an autistic fantasy life. His activities seemed to have consisted mostly of getting himself into the role of victim or scapegoat for his peers and of defeating, in a passive-aggressive fashion, his mother’s demands and expectations. A’s very infantile and clinging, but also a fearful and angry, relationship with his mother seemed to be central to his emotional life. He described his mother as intrusive and seductive. but also as confusingly demanding and threatening. It appeared that one of the functions of A’s passivity was angry pulling back from his mother. at the same time drawing her attention to him and maintaining his dependency upon her. It also seems that the competition with his brother had turned into a competition for pathology. A seemed to have experienced his father as alternately threatening or shadowy and weak. His homosexual trends seemed to involve a lack of any differentiated sexual identification, rather than a definite feminine identification. They probably also represented at. tempts to gain. by a sort of osmosis or merging, some sense of masculinity and liveliness through physical closeness to males. It was difficult to assess what role the relatively recent death of his father played in A’s difficulties. but the lack of any overt reaction or change seemed troublesome.
His inability to tolerate any steady interaction or stimulation without becoming disorganized and confused suggesting serious ego defects that had been present from early childhood. His difficulties seemed to have had a slow course. with no clear precipitating events. In his overt behavior, he never acted in a way that was grossly bizarre, or violent. or self-destructive. Yet there seemed to be few areas of intact functioning and no developed skill to give him a sense of competence, and self-esteem. or gratification. Insofar as he had any sense of self. it seemed to be the negative identity of a doomed patient who was born defective an identity that was stubbornly defended and also put in the service of his passive negativism. The possibility of further growth for A seemed to depend on his reaching a level where he could express hostility and rage in a more direct and active fashion. As would be predicted from his unstable object-
representations on the Rorschach and his difficulties thus far on the TAT with extrapolating beyond the immediate stimulus. he refuses to make up a story because “there’s nothing on the paper.” He cannot make up a story without a tangible stimulus. As he states. he needs to draw a visual stimulus before he can begin to speculate or allow himself to consider a situation.
The report in his case history of his need to draw his masturbation fantasies is consistent with the test indications of his inability to establish adequate mental representations. The test data are consistent with the clinical reports, which suggested that he had difficulty keeping his thoughts organized and pursuing a topic for any length of time. His description of his past life was presented as a series of disjointed incidents, which were usually expressed in “very concrete and visual terms.” Participation in a conversation for more than a few minutes at a time or in a social situation in which he was close to people caused disruption and feelings of confusion. He contained these feelings of confusion by fixating on one point or particular perceptual feature. His difficulties with representations and object constancy were clearly evident to the school teacher who commented that he needed clear, structured activities in order to facilitate his maintaining focus and concentration. A also commented in therapy about faces being blurred, which was another expression of the vagueness of his perceptions. The therapist also observed that often for A, furniture, and walls almost acquired a life of their own, The perceptual passivity observed on A’s Rorschach is consistent with his constant expression of feelings of hopelessness and help. lessness and his wish to remain in bed. The vagueness and devitalization of his human responses on the Rorschach and his perceptions of profiles are indications of his severe isolation, loneliness, emptiness, and inability to establish contact. A’s preoccupation with merging and fusing was suggested, for example. in a report made by the nursing staff that in one attempt to talk to an aide, he abruptly asked, “Well, what do you think of the possibility of a future merger of China and Russia?” A tendency toward fusion and merging was evident in the therapist’s observation that A felt most comfortable when he and the therapist were engaging in the same activity, such as smoking a cigarette, or when the therapist indicated that he had had similar experiences to A. A similar tendency was also expressed in a dream in which he looked at himself in the mirror and instead saw the face of another patient.
A’s difficulty with maintaining object constancy. his tendency toward merging and fusing, his extreme passivity and isolation, the vagueness of his experiences, his difficulty with sustaining concentration and focus, and his devitalization of people all suggested serious ego defects. which were probably present from early childhood. While the test data were quite consistent with the other clinical material in suggesting serious impairments, the test protocols were by no means bleak. They showed that A was capable of establishing adequate reality contact at times and that he was able to maintain some degree of investment in people. While in the initial clinical impression, it was thought that therapy would be a long process resulting in only limited improvement, the test data suggested that he could be responsive to therapeutic endeavors. After several years of therapy. he was discharged from the hospital. At last report, he was in outpatient psychotherapy and enrolled in a junior college. and doing reasonably well. He continued, however, to live within a few miles of his mother’s home.
