Category: A2 – Clinical Psychology

Case Description

Demographics

• 14 year old boy;
• remarkable physical features – elongated face, large ears;
• middle SES;
• residing in urban area;
• attained age-appropriate developmental milestones;
• born from unplanned but wanted pregnancy

Background

• exposed to father’s aggression from childhood;
• boy 10 years old when parents divorced over domestic violence issues;
• started living with maternal grandparents from when he was 11 years old

Early Symptoms

• not specific to schizophrenia
• declining academic performance and handwriting starting at 12 years of age;
• fist fights and other undesirable behaviour at school;
• preference for solitary activities, particularly eating alone at home

Early Treatment

• consultation with private psychiatrist;
• medicine given which reduced aggression and irritability;
• medicine gradually stopped

Intermediate Symptoms

• after 1 year of early treatment, schizophrenia-specific symptoms seen;
• auditory hallucinations, hearing commanding voices;
• paranoia of mother conspiring with those talking in commanding voices to tease him;
• eventual drop out from school;
• talking to self and shouting at imaginary persons till late night;
• declining socialization and self-care

Intermediate Treatment

• consultation with a different psychiatrist;
• diagnosis of schizophrenia now achieved;
• prescription of antipsychotic medicines;
• some improvement in symptoms;
• poor compliance due to side effect of weight gain;
• relapse within 3 months

Hospitalization

• Hospitalization due to frequent aggressive episodes;
• diagnosis of very early onset schizophrenia (VEOS) achieved;
• initial improvement with antipsychotic medicines and subsequent discharge;
• readmission to hospital after return of hallucinations and aggression after two weeks;
• ECT (electro-convulsive therapy) now administered;
• psychoeducation regarding schizophrenia and supportive psychotherapy provided to family;
• activity schedule, occupational therapy and modifications for diet also provided to boy;

Recovery

• resolved issues post hospitalization – violence, hallucinations
• unresolved issues – irritability, socialization, apathy, avolition, weight gain, aversion to start school, bone marrow function

Relevant Issues and Debates

Case Studies

• Justification
  • in-depth exploration of symptoms, treatment and recovery of schizophrenia in the body;
  • longitudinal investigation of the progress of schizophrenia in the boy – right from birth and childhood circumstances to treatment and recovery in the present day

• Strengths
  • Comprehensive understanding of schizophrenia;
    • investigation of aspects like difficulties in school, academic decline, challenges in the family, treatment using outpatient and inpatient treatment, use of medication and ECT, etc.
  • Understanding of Progression of schizophrenia
    • changes in behaviours of boy noted overtime such as declining academic performance, increasing social withdrawal, increasing aggression and violence, etc.

• Weaknesses
  • Limited generalizability of findings;
    • the boy’s case had peculiar features, including his facial appearance, relationship with father, history of domestic violence at home, etc. which integrate to form a unique case that might not apply to child cases of schizophrenia;
  • Subjectivity of Findings
    • diagnosis and treatment of the boy was subject to the clinical judgment of different psychiatrists

Individual and Situational Explanations

• Case supports both explanations–
  • Individual explanation supported by peculiar appearance of boy and temperament;
  • Situational explanation supported by aggressive behaviour of father and divorce during childhood and exposure to various treatments

• Strengths
  • Holistic perspective;
    • inclusion of both individual and situational aspects gives a more comprehensive understanding of the disorder
  • Increased Potential for Treatment;
    • consideration of individual and situational factors enables psychiatrists better opportunity to treat patients as they can target multiple factors for improvement

• Weaknesses
  • Limited exploration of Situational Explanation
    • more situational factors such as the boy’s school environment, relationship with teachers and fellow students, etc. could be investigated further for even better understanding of the disorder
  • Limited exploration of Interaction of Individual and Situational Explanations
    • while both explanations have been investigated – their interaction – or how each compounds with the other in the progression of the disorder is not sufficiently explored, limiting understanding

Use of Children

• Strengths
  • Developmental Perspective of Schizophrenia;
    • gradual development of schizophrenia from general symptoms in childhood to specific progression in adolescence explored
  • Early Identification and Intervention
    • a VEOS case is presented by using a child, showcasing the impact of schizophrenia in near adolescence, its identification and intervention

• Weaknesses
  • Ethical Considerations
    • the boy was too disturbed to provide informed consent to his diagnosis and treatment – and to withdraw even when he experienced severe side effects and many interventions proved ineffective
  • Practical Challenges
    • the boy was too young especially during the early phase to self-report his experiences and he might have been selected in the first place due to availability which is not the case with many children, limiting generalizability

Idiographic versus Nomothetic

• Study largely supports an idiographic approach since it is a single case study

• Strengths
  • Individualized Understanding
    • unique factors to the boy – his family background, symptoms at school, physical appearance, response to medications, improvement of symptoms in response to various treatments, etc. explored to provide a deeper understanding
  • Personalised Treatment
    • boy provided with treatments specific to his symptoms at various stages – first general medication, then antipsychotic medication, then ECT and tailored therapy, etc. resulting in probably the best outcomes

• Weaknesses
  • Restricted Generalizability
    • since specific investigation and treatment was conducted, the understanding and application may not generalize beyond the boy’s case
  • Extensive use of Resources
    • customization of treatment to the boy meant consultation with various psychiatrists, trial of different treatments, etc. over the course of several years – which is not practicable beyond research investigation

Generalizability of Findings

• Strengths
  • Longitudinal Investigation
    • the case shows possibility of recovery from several intense symptoms of schizophrenia over the course of long-term treatments
  • Multidisciplinary Approach
    • use of a variety of methods borrowed from psychiatry, psychology and occupational therapy to treat the boy brings about the role of complex factors in schizophrenia treatment

• Weaknesses
  • Focus on Single Case of Schizophrenia
    • only the case of one boy of a very specific age, nationality, etc. was investigated; restricting generalizability to adults, children of other nationalities, etc.
  • Limited Followup of Treatment Outcomes
    • only a 6-month long follow-up was done to study which symptoms of the disorder still persisted or did not in the boy, limiting understanding to longer term outcomes

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