CASE SCENARIO (NCM 117 LAB)

PARANIOD SCHIZOPHRENIA (ROSEMARIE’S GROUP)

A 23-year-old electrical goods salesman attends his general practitioner (GP) surgery with his
mother. He is very articulate but reluctant to talk, insisting that only the police can really help
him. He explains that over the past 6 months his boss and his colleagues have conspired
against him. Initially this was to dismiss him from his job but over the past few weeks they have
conspired to kill him. He feels that they have been monitoring his activities and have even gone
to the extent of bugging his flat and tapping his mobile phone. He is absolutely convinced of this
and shows you some marks on the phone as evidence of it having been tampered with. He
insists, politely, that he will not allow a physical examination as this may present an opportunity
to implant a microchip. In fact, he is very worried that an old dental filling may be a transmitting
device. He is preoccupied with these thoughts and is unable to distract himself. At work he feels
constantly bombarded by his colleagues’ nasty comments about him. He can hear them clearly
even across the showroom. On one occasion he clearly heard derogatory voices from his
manager’s office on the other side of the building. He also knows that colleagues talk about him
because of the way the price labels are arranged. His work has been affected. His boss has
given him a performance warning and he sees this as further evidence of his boss’s antipathy
towards him. He feels that ‘direct action’ is now needed but he refuses to discuss this. He has
contacted the police who have spoken to his colleagues. His mother indicates that the police
say his colleagues admitted talking about him because his behavior has been strange, but
according to the police the charges of conspiracy are baseless and they have asked him to seek
psychiatric help. His mother feels that his concerns are ‘over the top’ but does not feel that her
son is ‘psychotic’. She feels that he is under a lot of stress following a break-up with his
girlfriend 6 months ago and pressure at work. His mother requests medication for him. He flatly
refuses, but says that he will consider it if you ‘endorse’ his letter to the local Member of
Parliament and the Prime Minister about the refusal of the local police to help him.

PARANOID SCHIZOPHRENIA (HAZEL’S GROUP)

A 26-year-old man is referred to the crisis intervention home treatment team by his community
psychiatric nurse. He is interviewed at home in the presence of his wife and 3-year-old child. He
has turned the house upside down as he is convinced that there is a microphone taping his
family conversations. He has been hugging his child, crying inconsolably. He can hear some
‘young lads down the road’ talking about killing him and his family. He feels that TV programs
are discussing him and his family. He has taped newspapers on the windows and has set up trip
wires at the front and back doors. He has not slept for 3 days and has been talking to himself.
He was diagnosed with schizophrenia at the age of 20 and was under the care of the Early
Intervention Team for 3 years. He was treated with risperidone and seemed to have responded
well. However, he stopped taking his medication and had a relapse 2 years ago. He was
assigned a community psychiatric nurse as his care coordinator. Risperidone was re-
commenced but he continued to remain paranoid and suspicious. There was concern about the
possibility of him missing medication, and he was switched to risperidone long-acting depot.
This was continued for over 12 months but without a significant response. Risperidone was
replaced with olanzapine, but this also did not produce a significant response and was
associated with weight gain of 3 stones. Olanzapine was discontinued 3 months ago, and he
was prescribed aripiprazole. His wife insists that he has been compliant, but over the last 6
weeks his mental state has deteriorated.

Mental state examination He appears very frightened and agitated. His eyes are darting, and he
is cowering on the sofa clutching his daughter, who is calm but looks frightened. He seems to
be responding to unseen stimuli and occasionally mutters to himself. He says that voices
describe what he is doing in a commentary. His mood is labile, and he breaks down repeatedly.
His speech is coherent and relevant. There is no formal thought disorder, but he has delusions
of persecution and reference. He does acknowledge that he has mental illness but feels
frustrated that his suspicions are not being taken seriously.

UNDIFFERENTIATED SCHIZOPHRENIA (JIA’S GROUP)

A 24-year-old biology graduate is referred to the outpatient department by his GP. He attends
with his mother, who has been becoming increasingly concerned about him for some time. He
tells you that he is feeling fine in himself. Objectively, you notice that he has reduced
spontaneous movements, his tone of voice is monotonous and soft in volume. There is some
suggestion that he is defensive or suspicious as he often asks you the reason for your questions
and refuses to answer some personal questions. His mood is flat, showing little reactivity during
the course of the interview, but he denies feeling depressed. He denies any psychotic
symptoms and you are unable to detect any thought disorder. His mother tells you that she
began to worry 2 years ago after he finished his University degree course. He had previously
been a high achiever, both academically and socially, with many friends and a hectic social life.
However, since returning from University with a disappointing 3rd class degree, he had made no
efforts to gain any job and seemed to have lost contact with all of his friends. He was spending
all of his time alone, often remaining upstairs in his bedroom for hours on end and interacting
less and less with his family. More recently, he had begun to express some odd ideas,
suggesting that someone was watching him and that other people knew where he was and what
he was doing. His personal hygiene has begun to deteriorate, and he now refuses to allow his
mother to clean his bedroom, which is becoming increasingly cluttered and dirty.

UNDIFFERENTIATED SCHIZOPHRENIA (AJ’S GROUP)

A young man a few months short of his 18th birthday is presented to his general practitioner
(GP) in a state of agitation. Although his parents are worried about him, he does not really think
there is a problem. He is hearing voices and these cause him some anxiety. The voices
sometimes give a running commentary of what is happening. He denies any substance misuse.
He attended Child and Adolescent Mental Health Services (CAMHS) about 12 months ago
when he had lost interest in his previous activities and had become increasingly withdrawn
although no low mood was reported. He was lost to follow-up when his family sent him to live
with some relatives in the hope that a new environment might improve the situation. He has
recently returned home but the situation is worsening rather than improving.

PARANOID SCHIZOPHRENIA (LESLIE’S GROUP)

A 26-year-old man presents to the emergency department in handcuffs, escorted by two

policemen for an evaluation “for causing a ruckus outside the grocery store and threatening
store customers.” The patient refuses to engage in much of the interview. He yells, “Let me go
or they are going to get me! They have been after me for years! You can’t     let them get me!”
He denies depressed mood, suicidal ideation (SI), homicidal ideation (HI), auditory or visual
hallucinations, and prior psychiatric or medical problems. He denies taking prescription
medications or illicit drugs. In response to marijuana use, he retorts, “it’s legal now.” He
prematurely ends the interview, refusing to answer any further questions because “they can
hear us.” The patient refuses to provide any contacts from which to gather collateral information.
On mental status examination, the patient appears disheveled and dirty. He acts suspicious and
guarded, avoiding eye contact. His speech is difficult to follow, and he often turns his head away
and mumbles to himself. The patient’s affect appears blunted. He looks around abruptly several
times and appears to be responding to internal stimuli.