Lesson 1: Clinical Disorders – Part C

• deterioration in personality
• the negative symptoms of anhedonia (the inability to experience pleasure in normally pleasurable activities)
• lack of motivation
• social withdrawal

Somatic

People with this delusion believe that they have some physical defect or medical problem. This defect or problem may be accompanied by smelling or feeling things that are not really there (e.g., odd odours, insects crawling over or underneath their skin).

Description

Brandon, a 42-year old postal worker, was brought to an emergency room because of his belief that there was a contract out on his life (someone wanted him killed). Approximately four months previously, Brandon had been accused of tampering with a package at work. He denied this accusation, and because his job was in jeopardy, he filed a protest. At his formal hearing he was vindicated (proven innocent), which in his view humiliated his boss and made his boss angry.

About two weeks after his hearing, Brandon began to notice that his colleagues were avoiding him. He noted they would turn away as he was walking toward them and he believed they were talking about him. While he was unable to clearly hear what they were saying, he was sure they were avoiding him because his boss had taken out a contract on his life.

Brandon was functioning fairly well until he began to notice large white cars driving up and down the street on which he lived. He became increasingly alarmed and was certain “contract killers” were in these cars. At this time he refused to leave his apartment without an escort and would panic and run home when he saw the white cars. After one such incident, his wife insisted that he accompany her to the local hospital.

Both Brandon’s wife and brother described Brandon as a basically well-adjusted man who liked spending time with his wife and two children.

Brandon had served (with distinction) in Vietnam and while he did not see much combat, he was pulled from a burning vehicle moments before it blew up. Aside from his belief that there was a contract on his life, Brandon’s speech and behaviour were ordinary. Although he admitted he was anxious, Brandon denied having hallucinations and other psychotic symptoms (apart from his belief in the contract killers) and noted that he was not depressed, and had no change in appetite, sex drive, energy level, or concentration.

Diagnosis

Brandon’s anxiety resulted from his belief that contract killers had been hired to kill him. Because there was no reason to believe his boss had arranged such a contract, it was evident that Brandon was delusional. In reality, because contract killers are sometimes hired, the delusion was non-bizarre. Apart from his delusion, Brandon’s behaviour was not odd - he did not experience any hallucinations nor did he have symptoms of depression, bipolar disorder, or drug abuse (a potential organic cause of delusions). Because of this, a diagnosis of delusional disorder was made. The content of his delusion involved the theme of danger and harm such that the diagnosis was further classified as persecutory.

His DSM diagnosis is Axis I: delusional disorder, persecutory type

Follow-up

Brandon was hospitalized and given an antipsychotic drug, but, unfortunately, he remained delusional for the first week of treatment. He even became convinced that a few of the other patients on his ward (the ones with Italian names) were contract killers sent to kill him. Over the next month, with continued treatment, Brandon’s delusions faded. Upon discharge, Brandon announced “I guess my boss has called off the contract. He couldn’t get away with it now without publicity.”

Brandon had two relapses over the following 18 months, each involving the same content and both occurring after he had stopped taking his medication. Each relapse was quickly and effectively treated with the continuation of his medication.

- Typical onset of schizophrenia occurs before the age of 45: while men and women are equally affected, the disorder often appears earlier in men (late teens or early twenties) and later in women (late twenties to early thirties).

- Approximately 1 percent of the population develops schizophrenia during their lifetime - the speech of schizophrenics can be so disorganized that they may be incomprehensible or frightening to others.

- Available treatments can relieve many symptoms, but most people with schizophrenia continue to suffer some symptoms throughout their lives. It has been estimated that no more than one in five individuals recovers completely.

- The onset of schizophrenia is very rare for people under 10 years of age or over 40 years of age.

- The earlier that schizophrenia is diagnosed and treated, the better the outcome of the person and the greater the likelihood of recovery.

- Schizophrenia occurs in all societies at about the same rate, regardless of class, colour, religion, or culture.

- Schizophrenia ranks among the top 10 causes of disability in developed countries worldwide.

Teen Mental Health

http://teenmentalhealth.org/learn/mental-disorders/schizophrenia/

No relation

~ 1-2%

The Parents

Henry, the father, was prone to irrational behaviour, was suspicious, and often demonstrated inappropriate sexual behaviour, including promiscuity. He also often drank heavily. Henry’s wife, Gertrude, married Henry only after he threatened to kill her if she did not accept his proposal. Gertrude remained oblivious to the problems in the family and was coping with her own sexual dysfunction.

Early in the 1930s, Gertrude gave birth to quadruplet girls. Except for being premature and having low birth weights, the babies were relatively healthy. Hester, the smallest, was fitted with a truss (an abdominal compression device) because of a bilateral hernia, but she was sent home with her sisters after six weeks in the hospital. At this point in time, the media became very interested in the quadruplets. Henry and Gertrude even began to charge admission when the general public wished to visit their home and view the girls.

This enterprise, however, was soon terminated when Henry and Gertrude became worried that the girls might contract diseases or be kidnapped! The girls continued to have an air of “celebrity” about them – and they often sang or danced as a group. Because of the extra attention their celebrity gave them, the girls often clung together for protection and, as a result, became socially isolated.

Henry and Gertrude encouraged this isolation because of their fear of “the outside world.”Henry and Gertrude, almost immediately after the children’s birth, began treating the girls as two sets of twins rather than one set of quadruplets. They considered Nora and Myra to be the superior set of twins while Hester and Iris were the inferior or problematic set. Hester, to the dismay of her parents, began to masturbate at the age of three. It was thought that this behaviour arose from the fact that she experienced irritation from her truss.

Henry, by this point, began to express outwardly his various fears and obsessions to the family. He patrolled their yard with a loaded gun and watched over the girls with extreme attention for fear they would get into sexual trouble and/or be sexually assaulted if he did not keep watch. Henry imposed many restrictions on the girls from birth up to the point of their breakdowns. He insisted on watching them dress and undress and was reported to have sexually molested at least two of his daughters.

Gertrude was also dysfunctional in sexuality. She believed sexual threats were everywhere, but when the girls complained about Henry’s sexual attentions, she dismissed their concerns with the comment that Henry was just testing their virtue. If the girls objected to his advances, then everything was fine.

Hester continued to masturbate as she grew older and had convinced Iris to do the same. This behaviour so upset the parents that they forced the girls to undergo a clitoral excision (clitoral multilation). To the dismay of Henry and Gertrude, the operation did not stop the girls from masturbating. Consequently, Gertrude continued to give Nora and Myra most of her affection and attention.

Young Adulthood

Throughout their school career, the girls were considered to be hard-working and “nice” by their teachers. It was evident, however, that Nora and Myra were academically superior to Hester, with Iris falling between the two groups. During the summer before entering her senior year, Hester began to exhibit odd behaviours. She became temperamental and destructive. She even struck Nora with such force that she rendered Nora unconscious. At time, she did not appear to know what she was doing. Hester had just turned 18. Despite barely being able to manage Hester, Henry and Gertrude decided to keep her home while the other girls completed their senior year.

None of the girls was permitted to have boyfriends and all had various physical difficulties (e.g., gastrointestinal distress, menstrual irregularities, and enuresis or bed wetting). After graduation, Nora, Myra, and Iris obtained employment as office workers.

Their father, however, continued to spy on them lest they become romantically involved with men. Myra, the most independent sister, would defy her father and occasionally go out at night.

At work, none of the three sisters was comfortable with the responsibilities that were given them. Nora, the second sister to develop symptoms of schizophrenia, quit work, stayed home, and took to her bed. She became increasingly more disturbed. She would position herself on her knees and elbows until they bled. She walked and talked in her sleep and groaned a lot - especially at meal time. When Nora was 22 years old, she was admitted to the hospital and diagnosed with schizophrenia.

Iris was the next sister to display odd behaviour. She resigned from her job, developed a “spastic colon,” and had episodes of vomiting and insomnia. She also believed that people were paying too much attention to her and, at this time, it was noted that Henry was extremely attentive to both her and her outside activities. Within months of Nora’s hospital admission, Iris had a breakdown. She screamed, fidgeted, heard voices that were not there, drooled, and was unable to swallow solid food. She, too, was diagnosed with schizophrenia.

At age 24, Myra fell victim to schizophrenia. The onset of the disorder was similar to that of her sisters. She suffered from anxiety, nausea, and insomnia. She, too, would wake up at night screaming. Unlike her sisters, Myra resisted hospitalization. It was only when the entire family relocated to the National Institute of Mental Health (NIMH) that she was hospitalized. The staff of NIMH found Myra to be autistic, disordered in thought, and impaired in reasoning. She was diagnosed with schizophrenia. Of interest if not importance, the deterioration of Nora, Iris, and Myra began after they had been subject to persistent and inappropriate sexual advances by a man. As usual, their parents ignored the complaints of their daughters.

Outcome

By the time the family arrived at NIMH, Nora had been hospitalized three times, Iris five, and Hester none, despite her psychotic behaviour at home. During their three-year stay at NIMH, the sisters were given various forms of treatment. Myra was well enough to be discharged after her stay, but Iris, Hester, and Nora were transferred to a state hospital. Henry died of liver disease during this period.

At the time of Dr. Rosenthal’s 1963 report, it was evident that each sister was affected somewhat differently by schizophrenia. For instance, Hester’s prognosis was bleak. Iris fluctuated between severe disturbance and relative normalcy, Nora was marginally coping outside the hospital. Myra was working, married, and doing well. An update on the situation of the quadruplets, completed approximately 20 years after the initial report, revealed that the situation had not changed much. Myra was still doing well with two children of her own, and the other three sisters, living at home with Gertrude, continued to display similar symptoms to those they had in 1963.

An important point of this report is that, although the four women are genetically identical and suffer from schizophrenia, the actual expression of the illness differs among them. All four sisters had smaller than normal cerebral ventricles (fluid-filled spaces in the brain) compared to individuals without schizophrenia. The sisters also responded differently to antipsychotic medications over the years. This suggests that, while heredity is very important in the expression of schizophrenia, it is not the only factor of importance. Possibly, perinatal factors (i.e., factors affecting the developing fetus in the womb or affecting the newborn during the first few weeks after birth) had variable impact on the siblings.

Environmental and social factors also play important roles in the expression of schizophrenia. For example, Hester, the least favourite daughter of Henry and Gertrude, faced the harshest environmental conditions and had the worst outcome. The environment of Iris, Hester’s “twin,” was similar. Myra, who was more independent and assertive, was the most favoured daughter and had the best outcome.

Nora’s environment was similar to Myra’s, but Nora, unfortunately, was her incestuous father’s “favourite” daughter. It is evident from this study that environmental and social forces are quite powerful determinants of personal destiny. Both our genes and our environment interact to make us who we are!