My third week of seeing clients and I’m still alive. *fist pump* I will admit that I am quite enjoying the actual work with the clients, but dealing with parents can be tough. Real tough. Some parents/caretakers are resistant, even the ones that called in the referral. I won’t begin to try and understand what they are feeling, but I do my best to ensure them I’m not there to remove their kids, judge them, etc. Once I get in the door, I think they realize that, but getting into the home is the hard part…
We had a mandatory meeting at work on Friday. It was Cultural Heritage day so we got learn about each other’s backgrounds. They also invited some people from the UM Eye Institute to talk about working with deaf children. They taught us the science behind hearing problems, the kind of devices to assist with hearing, auditory verbal therapy, etc. I especially find cochlear implants to be quite incredible. We also talked about Deaf culture, and the very different opinions found within this population. It was quite interesting!
Now, on to the interesting topic. One of my cases is a 16 year old girl who was diagnosed with Undersocialized Conduct Disorder, Aggressive Type. The biopyschosocial also talked about some reported psychosis. When I met with the teen for the first time, she was quite fascinating and a bit scary in her perception/attitude. She does not like school and does her schoolwork only when she feels like it. She likes to fight with people and has no interest in friends. She socially isolates, sits in her bedroom alone and talks to herself. She reported hearing command hallucinations, "random" voices that make her laugh and sometimes tell her to do "dangerous things", like fight and do drugs. She denied any drug use or any thoughts/commands of self-harm. She also mentioned going to her boyfriend’s house and just sitting in the front room alone. I noticed she had psychomotor agitation as she constantly used her hands during the session. She made little eye contact with me and giggled to self occasionally. Her affect was pretty blunt but her mood was normal.
She lacks compassion for her younger siblings, as evidenced by her statement "I hate them" as she broke their crayons. She reported that she loves her mother, and when asked if she ever tells her mother: “I don’t tell anyone I love them.” She doesn’t follow rules, and I’m serious when I say this, she could give a bleep about anyone or anything. I encouraged her to be honest and gave her feedback on her interaction with her mother and siblings. She constantly reminded me that she does what she wants to, not what anyone tells her. I praised her substance-free choices and validated her report of hallucinations. I did not challenge them. I tested her insight and her judgment, and I think both are pretty poor. One great thing is that she is willing to comply with treatment/medication. I gave her mother the contact information for a pysch eval, and if she hasn’t called when I go back Tuesday, we’ll call together. She needs one, stat!
I’m praying she isn’t developing Schizophrenia. I, of course, am not licensed or an expert, by any means, but doesn’t it sound like it? She’s having both positive (hallucinations/psychomotor agitation) and negative (blunted/flat affect, lack of interest, social isolation) symptoms. I read through the biopyschosocial and mother reported depression with psychosis and drug use on her end, but no mental illness that she’s aware of on dad’s end. I know there’s a strong genetic component. I think you have a 10% chance of developing it of one parent has it, and a 50% if both parents have it. But, what if mom’s diagnosis was wrong and she’s actually Schizoaffective? That would put her in the spectrum. Mom also used crack/marijuana for many years, so the child could have some prenatal factors, like stress, malnutrition, infection. And she was born in the Spring. Research shows that viral exposure in utero can up your chances of developing Schizophrenia. And then there is the environment piece. Living in an urban environment, social isolation, poor housing, family dysfunction and childhood exposure to trauma are all risk factors.
What do you think?
-SWS
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It does sound like a challenging case, both diagnostically and just to sit with! Conduct Disorder (and Oppositional Defiant Disorder) can be a precursor of schizophrenia, but, I would ask more questions. First, people sometimes reference "voices" when they're not really experiencing AH. They have to be perceived as OUTSIDE her head to be AH. Also, how do you feel sitting with her (and her mother, for that matter)? If you can feel her engaging mutually with you, it's a mood or personality d/o rather than psychosis. If she creeps you out, it's more likely antisocial pd. If it feels like you're on different planes of experience, it's psychosis..... Natalie (practicewisdom.blogspot.com)
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