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Psychopathology Case Studies: Psychotic Disorders
Case #1: Magical Art?
Isaac, a 31-year-old single male, joins a therapeutic art group that runs twice weekly at an art school in the small northeastern city where he lives. It is an open group, with a core of long-standing members but fairly frequent additions or dropouts, and Charlene, the art therapist who facilitates the group, is keenly attuned to the subtle shifts in group dynamics that ensue whenever one of these changes takes place. Within a few weeks of Isaac’s appearance, she is noticing that a couple of group members have become much more reticent, unwilling to share their reactions to their own (or others’) artwork. She also observes that two other long-time group members who occupy leadership positions among their peers frequently exchange covert glances and smiles or grimaces whenever Isaac contributes to group discussions. Her own sense of his speech is that he tends to be a bit stilted or overelaborate, and that he sometimes takes too long to get to the point, but that he is mostly logical and goal-directed. He speaks softly but clearly and modulates well, though his facial affect is slightly constricted and he often averts his gaze from the person to whom he is speaking after the first few words. He seems shy or anxious, but not especially odd.

Isaac’s artwork, on the other hand, does have a rather strange ‘feel’ to it. He tends to avoid messy materials like clay, paint, or pastels, preferring drawing and collage-making. His drawings include exquisitely detailed architectural exteriors: depictions of palaces and temples set in rocky, forbidding landscapes. Sometimes words or phrases are written across the sky or on the temple walls: “The Day is soon,” “Moon Commune,” “Submission Rules.” Often angelic or demonic faces peer through the clouds or emerge from mountain peaks or minarets. His collage work, likewise, is painstakingly precise, but usually populated by scantily clad models.

Curious to know more, Charlene conducts a 1:1 interview with Isaac. He is the son of a single mother who attended college but worked as a restaurant hostess. Isaacs’s delivery was complicated; the umbilical cord was wrapped tightly around his neck for several minutes. Perhaps as a result, he suffered from a slight left-sided weakness as a young child, but this resolved. He had little contact with his father, who worked as a tax lawyer but drank excessively and whose practice dwindled. He was often alone as a boy, since his mother had to work in the evening. He coped with this by becoming deeply involved in certain television programs, books, and video games. Those he enjoyed most tended to have fantastic themes, and his inner world came to be populated by fantasy figures. Never very popular in school, still he mostly escaped bullying and performed well academically. He attended a local college for three years, majoring in English, but never graduated, and now works as a barista at an upscale coffee bar across the street from the art school.

Isaac hesitates, gazing intently at Charlene, then reveals (his words coming out in a rush) that he was disturbed, during his teenage years, by images of bloodily tortured women that both repelled him and generated sexual excitement. She feels some trepidation, and although she strives to control her expression, he seems to sense her unease. For a moment she sees a hungry look on his face, then it vanishes, and he looks down with his usual self-deprecating half-grimace. Speaking more softly than ever, he describes how he was able to bring these fantasies under control by training himself in Golden Dawn ritual magic. “It was a long dark night alone in my soul, but it helped me gain mastery of self, so I persevered. And five years ago I succeeded in attaining the knowledge and conversation of the Holy Guardian Angel. He has been with me ever since, guiding me, advising me: when necessary, chastising me. I must do what I must do, and my true will is to create perfect harmony across the crystal spheres of the Sephirot by completing the alchemical wedding. I have been building power and spreading my influence through the patrons of the coffee shop. But it is going slowly, and I am still alone. That’s why I joined your group. My art will win me my bride. Of this I am sure.”

In the weeks that follow, Isaac’s art becomes increasingly baroque in detail and darker in theme. He shares his work exultantly, shooting conspiratorial looks at Charlene. His excitable behavior seems to frighten other group members, two of whom stop attending sessions. One day Charlene decides that she must ask him to leave the group. She visits the coffee bar to ask him to meet with her, only to learn that he was fired a week before. The employee who so informs her is reticent, but implies that Isaac’s behavior toward customers had grown inappropriate.

Case #2 – Public Health
Janette is a 23-year-old graduate of an elite liberal arts college who accepted a fellowship that entailed public health outreach to impoverished regions of Indonesia. (She had been admitted to medical school, but was allowed a year’s deferment in order to pursue this enterprise.) She quickly learns that while the work is often rewarding, it can also be quite disturbing – many of the patients they see suffer from disfiguring, painful disorders that are virtually never seen in the developed world, and resources are scarce. Even when the agency is able to import medical supplies, large portions of these goods are confiscated by corrupt governmental officials. Furthermore, she has very few social outlets; there are only three westerners working for the agency, and even amongst them there are language barriers that make intimate communication difficult. Finally, living conditions are poor: the climate is hot and humid, the food is unfamiliar and sometimes far from fresh, and the building in which they live and work lacks running water.

After spending five months in this environment, Janette (who has been ill several times and lost twenty pounds) begins to suspect that she is being poisoned. She restricts her eating, eliminating suspect foods, but her health continues to deteriorate. Within a few days, she comes to believe that evil magicians are casting spells on her. She tells her associates about this conspiracy, using language that seems all but incomprehensible – insisting, for example, that the sorcerers use computer programming language to enchant her coffee, causing her to suffer from fits of coughing and rewiring her thoughts so she will think tea is coffee and drinking it, thus falling foul of the stringent anti-drug laws of the land and leading to her imprisonment.

Janette’s associates, deeply concerned about her mental status, arrange to have her flown back to the U.S.A., where she is met at the airport by her parents and brought to a psychiatric hospital. At first, she considers this to be an Indonesian prison and insists that those were not her parents, only clever facsimiles prepared by the Javanese magicians, but within ten days of her return, living in the stable hospital environment and receiving neuroleptic medications, she abandons her strange beliefs, her speech normalizes, and she is ready to return home on a greatly reduced dose of medication. In the aftermath, she decides to put off medical school for awhile longer lest the stress trigger another episode, but does begin a master’s degree program in public health, earning top grades and collaborating with her advisor on an interesting study that is eventually published with Janette as co-author.

Case #3 – Celestial Railroad
John is a 19-year-old single male. The son of professional parents and graduate of an affluent suburban public school, he left home for the first time to attend an elite four-year college in a distant state. John had always been a good student, placing in the top 20% of his high school class and winning an award in History for a term paper on the colonial slave trade. Although not especially sociable, he did have two or three close friends and was considered “one of the gang” by the other members of the track team, on which he competed in the 400 meter run.

As a freshman in college, John did not connect well with his classmates. He became a social isolate, even eating his meals in solitude in the dining commons. His personal grooming became erratic, as he frequently wore the same undergarments for 2 – 3 days and rarely washed his hair. Even academically, he did not excel as he had expected – his exam grades were mostly in the “C” range except for “B’s” in history. He took to wandering about the campus at night, glancing furtively at his classmates and sometimes muttering indistinctly to himself. His parents noticed the change in their son when he returned home for Thanksgiving. Mother took pains to tidy him up, and father gave him a talking-to about taking proper care of one’s self. John had little to say to either.

Two weeks after the return from Thanksgiving, as classes neared their end, John’s R.A. was sufficiently disturbed by his behavior that she visited his room to inquire after his frame of mind. He was initially disinclined to open the door and allow her entry, but once they were sitting down together he opened up. He informed her that he had realized, in a flash of insight, that his college was involved in slavery. “Most of the endowment is invested in companies doing business in countries where child labor and prison labor are condoned, you know. And the layout of the campus is representative of the antebellum south, it’s a plantation. Here, I’ll show you.” He pulls out a notebook and a pencil, and begins sketching rapidly. What he draws looks something like a plan of the college, but the buildings are marked with peculiar symbols – crosses, torches, swastikas, ghostly shapes, etc. – that he explains as he continues to add details. “See, the students live in these barracks, they’re caught up, like the African diaspora and an African holocaust, if they run it can only be in circles, they never get out. It’s a hologram, really, a 3D image of the south rising again, and the president is trying to bring it all back, the bad old days when people were kidnapped away from their homes and taken to strange lands where they don’t speak the language, strangers in that strange land they suffer unendurably. I have to help, you see, it used to be the underground railroad, but that’s over, now it’s going to be the celestial railroad. Do you see how it all adds up?” He finishes the sketch with what looks like an equation, a series of numbers and letters separated by the signs of mathematical functions. The R.A. excuses herself politely and rushes off to contact the Dean of Students.

John is hastily admitted to a psychiatric hospital. Two weeks of aggressive treatment succeed in bringing his symptoms under control. He remains fragile, though, and does not return to that college next semester. Instead, he lives at home, attends a nearby community college on a part-time basis, works part-time in his father’s accounting firm, and begins re-establishing contact with some of his high school friends, while continuing to receive supportive treatment from a psychiatrist.

Case #4 – Killer
Darryl is a 54-year-old married man, an attorney employed as a high-level civil servant with the state government’s department of transportation. He has fathered two children, both of whom have completed college and begun independent lives. About two years ago, he began to suspect (and soon to believe quite firmly) that an organized crime syndicate was infiltrating his department and manipulating events so as to expose the department to ridicule, ultimately convincing the legislature to relax controls on quality of construction and compliance with safety guidelines by contractors. His own role is crucial; because of his careful work in writing the regulations and associated enforcement procedures, he has been targeted for elimination – either by being forced out of his job, or by being physically harmed.

Darryl’s suspicions turned to a neighbor’s 28-year-old son, Frank, who dropped out of college and moved back home (working on and off as a lifeguard, tennis coach or bartender). Frank, Darryl decided, had contracted with the criminal syndicate to carry out the “hit” when it became necessary. Darryl confronted Frank in the tavern where he worked. When Frank denied any involvement with criminals, Darryl held off on further action for several weeks, but his suspicions were not fully allayed.

Then, on a weekday afternoon about a week ago, Darryl entered the tavern, angrily insisted that Frank put him in contact with his superiors in the mob, and, when the young man demurred, shot him fatally with an automatic pistol in front of a dozen customers. He then waited and surrendered calmly to the police, explaining the situation. Darryl was arrested but found not competent to stand trial and remanded to a state psychiatric facility for evaluation and treatment. Upon interview, he is calm and rational. He is well-groomed and neatly attired. There are no signs of disorganization in his speech as he explains the conspiracy and his need to take effective action against it. He denies ever experiencing hallucinations. He also denies ever having suffered from prolonged periods of elated or dysphoric mood. All of his friends, co-workers, and family members concur that Darryl has always been a model citizen, though several do note that he has often been perceived as an “intense” person.

Case #5 – Mommy Dear
Sharon is a 42-year-old divorced woman. A high school dropout who married at age 17 and had three children over the next five years, she worked part-time as a grocery store clerk but was primarily supported by her husband, an automobile mechanic seven years her senior. She underwent several periods during which her mood deteriorated, she gained weight and suffered from late insomnia, her ability to focus her thoughts seemed impaired (e.g., she had trouble keeping track of the food and cleaning supplies needed for the household, often burned dinner, and sometimes let the children go off to school without their books or lunches), and she saw herself as a dismal failure in life. The first of these occurred after the birth of her third child, who turned out to be mildly mentally retarded (though she did not know this at the time). Her obstetrician prescribed fluoxetine to good effect, and her primary care provider renewed this prescription for about a year in response to each subsequent episode. At age 29, after recovering from her third episode, Sharon began to hear the voices of her ancestors talking to her as she sat at the kitchen table waiting for the children to return home from school. She was fascinated by their tales of days gone by and proud to have been selected to receive their confidences, and sat for hours at a stretch, drinking coffee, smoking cigarettes, and smiling to herself. She stopped taking proper care of the house, lost her job for inattentiveness and grossly inaccurate cashouts, and began deteriorating in terms of her personal hygiene. When her husband remonstrated with her, she told him that she had been selected as the messenger of a new revival of the faith (which surprised him, as she had never before attended church or shown any interest in scripture). Her ideas continued to spin on in fanciful directions, and her behavior around the house continued to grow more peculiar. For example, she began wrapping garbage in Christmas paper and storing it in various closets as well as under the children’s beds. Eventually her husband contacted their physician, who referred them to a psychiatrist. Sharon was puzzled by the psychiatrist, but eventually agreed to be admitted to a hospital “for a rest.” Treated aggressively with thioridizine, she recovered sufficiently to return home after a month-long stay, but relapsed two months later and had to be readmitted. After this second episode, she was discharged to a supervised housing program. During her first six months there, she underwent yet another episode of intense sadness (along with weight gain, insomnia, etc.), actually becoming convinced that she had killed her children. Even when they tearfully confronted her, she insisted that they were really dead, that these were mere phantoms before her and that the souls of her children must be in heaven while she atoned for their sins in hell. A year later, when Sharon showed no sign of being able to return home, her husband initiated divorce proceedings. He eventually remarried. She stayed in the supervised apartment program except for occasional readmissions to the hospital, either for a resurgence of hearing voices and attributing those voices to her being chosen for a great mission or for a further lapse into painful dysphoria. All told, she has been hospitalized eleven times in thirteen years. She is maintained on five different medications – risperidone, paroxetine, carbamazepine, clonazepam, and trihexyphenidyl – attends a day hospital program, and has occasionally done some volunteer work, but has never been able to resume gainful employment. Her children, who are now fully grown, visit her sometimes. The eldest, a daughter, has begun suffering bouts of severe dysphoria and has made two suicide attempts. The second, a son, is a “loner,” working as a parking lot attendant and spending his spare time watching television.

Case #6 – One-Way Street

Jake is a 38-year-old single male, a high school graduate who has not held competitive employment for more than a few months at a stretch during his adult life. He resides in a studio apartment in a run-down building situated in a dingy neighborhood of a mid-sized city. Most of his time is passed either walking around the downtown area, sitting on park benches (or, during cold weather, in the public library), or watching television at home. When in public, he attracts a certain amount of attention by his somewhat disheveled appearance and odd behavior. He wears rumpled, not very clean clothes, sports a shaggy beard and unkempt, greasy hair, and is often observed to be carrying on one end of an angry argument – even though alone. People tend to go into nearby shops or cross the street to avoid him, especially when he is obviously angry. The only people with whom he interacts are a few pushcart vendors and people who, like him, pass their days on park benches. (He also sees these people at the soup kitchen where he often dines, and sometimes at the mental health clinic – when he goes there, which is seldom.)

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