Case Study - Schizophrenia

I. Personal Information

The client is a 28-year-old Caucasian male and goes by the name of Mr. L. He works at a local supermarket and lives with his mother. He does not have any vices and has no history of illegal drug use.

During his childhood, he had several problems at school. He had behavioural problems in elementary and was socially withdrawn in high school. He repeated eighth grade and eventually dropped out at 11th grade. He was quiet and uninterested, and had only a few friends.

His family history does not include schizophrenia. However, his brother suffers from cerebral palsy, intellectual disability, and seizure disorder. His aunt was also hospitalized after she had a nervous breakdown following her divorce.

II. Case Overview

Mr. L was born at term with no complications, but doctors found heart murmur during his adolescent period.

He was first admitted in a psychiatric hospital in 1998 and was diagnosed with schizophrenia. He had delusions of persecution and constantly feared for his life. He felt that someone wants to torture him and that his friends were criminals. He also cut his wrist and had auditory hallucinations. Moreover, he had trouble concentrating, had decreased energy, and was constantly irritable.

H was initially treated with olanzapine and venlafaxine, but had negative side effects including weight gain. So, his medications were switched aripiprazole and sertraline, which helped control his symptoms. After which, he no longer had further inpatient admissions.

III. Reason for Referral

He was referred for a psychiatric evaluation due to his decreased energy, constant irritability, and difficulty with concentration. He also has delusions of persecution and auditory hallucinations. He felt that someone was going to torture him and that his friends were criminals. He also presented as a danger to himself because he had suicidal tendencies and cut his wrist.

IV. Etiology

Etiology not specified.

V. Significant Observations

 He has a family history of mental illnesses including intellectual disability and nervous breakdown, but not schizophrenia.

 He had behavioural problems in elementary and was socially withdrawn in high school. He also dropped out in 11th grade.

 He had delusions of persecution, auditory hallucinations, trouble concentrating, decreased energy, and irritability.

 He had suicidal attempts wherein he cut his wrist.

 During his interview, he seemed distracted and his speech showed latency; he usually did not respond to questions.

 He was unemployed because of his distraction and poor concentration.

VI. Preliminary Diagnosis

Based from the facts provided in the case, this diagnostician-in-training was able to come up with a preliminary diagnosis which is Schizophrenia 295.90 (F20.9) as justified below:

VII. Symptoms

DSM 5 Criteria Given Facts

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1) Delusions

2) Hallucinations

3) Disorganized speech

4) Grossly disorganized or catatonic behaviour

5) Negative symptoms Mr. L had delusions of persecutory, wherein he feared that someone wanted to torture him. He also had auditory hallucinations. His speech showed latency, and often did not respond to questions. He also usually asked the interviewer