CASE 8

Paul is a 17-year-old White boy, who presented for treatment of schizophrenia. He

came to our specialized outpatient treatment clinic at the urging of his psychiatrist
and his parents who were concerned about his behavior. Paul reported previous
inpatient treatment at a local psychiatric hospital in the Midwest, at the age of 16.
He reported that his symptoms were increasingly debilitating and negatively
impacting his personal relationship with his parents, particularly his step-father.
He had been diagnosed with undifferentiated schizophrenia (295.90), and his
global assessment of relational functioning was 60.

Paul’s self-reported symptoms were also observed by his parents and are
consistent with a diag-nosis of schizophrenia. He experienced lack of pleasure and
interest throughout each day, and severe difficulty empathizing with other
people’s feelings. He had periods of withdrawal and isolation in his room during
the week, right after school, and the majority of the day during the weekends. He
also reported ongoing suspiciousness and distorted perceptions. Paul’s symptoms
have been consistent and have encompassed his daily life for years. For example,
he was pre-occupied with oversleeping and running late to school, and feeling
severely stressed that he would start hearing voices again that tell him to hurt
himself. He reported that he had struggled with delusions since his sophomore
year of high school.Paul reported difficulty in forming meaningful relationships
with parents and peers.

Due to his medication, he had a low libido and had no interest in a romantic
relationship. He also described feeling powerless over handling his own affairs
and had difficulty trusting that his parents would not commit him to a hospital
again. He had difficulty expressing his feelings and would act out as a bid for
attention.

The client’s family is composed of mother (Sue), 35 years old; stepfather (Jack),
48 years old; and Paul, 18 years old. On the telephone, the mother reported that
Paul is very aggressive, throws things, and yells for no apparent motive.
Historically, Paul grew up as an only child in a family with his mother and
stepfather, in a middle-class, rural community. He excelled in school and
participated in sports and Boy Scouts until he began hearing voices at age 13. He
refused to attend school reporting that he was concerned that his teachers were
“out to get him” and that there was a plot to discredit him around his peers. He
stopped bathing, brushing his teeth, and failed to show any emotional expressions
when around his parents. He became impulsive and took action without thinking
about the consequences. He reports being arrested for hitting a pizza delivery boy
on the head with a frying pan because voices instructed him to steal the delivery
boy’s pizzas and his car. After this incident, Paul was committed by his parents to
a psychiatric hospital for 6 weeks and monitored on the antipsychotic medication
Risperdal 75 mg. After returning home, he experienced diminished ability to
experience pleasure, which resulted in him becoming more defiant and distant.
The ensuing negative impact on his relationship with his parents was
significant.Paul’s mother reported that her son thinks she needs therapy, not he;
that it is his life and he can do what he wants alone, without the help of doctors;
that doctors do not understand or help; that it is not his fault; and that others or
circumstances are to blame. His stepfather related that Paul’s ambition is to be a
rock star and that he is very self-centered and puts a lot of demands on his mother.
As a child, Paul was very demanding in getting his needs met, and Paul’s mother
would sacrifice her own needs for the needs of her son. Mother dedicated the
majority of her time to Paul as a way to keep him close and safe. The stepfather
reported that he resents his wife for babying her son and sees her as “incapable of
letting her son grow up.” Paul’s stepfather disen-gaged by isolating himself at
home physically and emotionally and avoiding interaction with both Paul and his
mother, due to feelings of frustration and powerlessness.

KASUS 8

Paul adalah bocah kulit putih berusia 17 tahun, yang datang untuk perawatan skizofrenia.
Dia datang ke klinik perawatan rawat jalan khusus kami atas desakan psikiater dan orang
tuanya yang peduli dengan perilakunya. Paul melaporkan perawatan rawat inap sebelumnya
di rumah sakit jiwa setempat di Midwest, pada usia 16 tahun. Dia melaporkan bahwa
gejalanya semakin melemahkan dan berdampak negatif pada hubungan pribadinya dengan
orang tuanya, terutama ayah tirinya. Dia telah didiagnosis dengan skizofrenia dibedakan
(295,90), dan penilaian global tentang fungsi relasional adalah 60.

Gejala yang dilaporkan sendiri oleh Paul juga diamati oleh orang tuanya dan konsisten
dengan diagnosis skizofrenia. Dia mengalami kurangnya kesenangan dan minat sepanjang
hari, dan kesulitan parah berempati dengan perasaan orang lain. Dia memiliki periode
penarikan dan isolasi di kamarnya selama seminggu, tepat setelah sekolah, dan sebagian
besar hari selama akhir pekan. Dia juga melaporkan kecurigaan yang sedang berlangsung
dan persepsi yang terdistorsi. Gejala-gejala Paul konsisten dan meliputi kehidupan sehari-
harinya selama bertahun-tahun. Misalnya, dia sudah terlalu sibuk dengan tidur berlebihan
dan terlambat ke sekolah, dan merasa sangat tertekan bahwa dia akan mulai mendengar
suara lagi yang menyuruhnya untuk melukai dirinya sendiri. Dia melaporkan bahwa dia telah
berjuang dengan delusi sejak tahun kedua di sekolah menengah. Paul melaporkan kesulitan
dalam membentuk hubungan yang bermakna dengan orang tua dan teman sebaya.

Karena pengobatannya, ia memiliki libido rendah dan tidak tertarik pada hubungan
romantis. Dia juga menggambarkan perasaan tidak berdaya menangani urusannya sendiri
dan kesulitan mempercayai bahwa orang tuanya tidak akan membawanya ke rumah sakit
lagi. Dia mengalami kesulitan mengungkapkan perasaannya dan akan bertindak sebagai
upaya untuk perhatian.

Keluarga klien terdiri dari ibu (Sue), 35 tahun; ayah tiri (Jack), 48 tahun; dan Paul, 18 tahun.
Di telepon, sang ibu melaporkan bahwa Paul sangat agresif, melempar barang-barang, dan
berteriak tanpa motif yang jelas. Secara historis, Paul tumbuh sebagai anak tunggal dalam
keluarga dengan ibu dan ayah tirinya, di komunitas pedesaan kelas menengah. Dia unggul di
sekolah dan berpartisipasi dalam olahraga dan Pramuka sampai dia mulai mendengar suara-
suara pada usia 13 tahun. Dia menolak untuk menghadiri sekolah melaporkan bahwa dia
khawatir bahwa gurunya "keluar untuk mendapatkan dia" dan bahwa ada rencana untuk
mendiskreditkan dia di sekitar teman-temannya. Dia berhenti mandi, menyikat giginya, dan
gagal menunjukkan ekspresi emosional ketika berada di dekat orang tuanya. Dia menjadi
impulsif dan mengambil tindakan tanpa memikirkan konsekuensinya. Dia melaporkan
ditangkap karena memukul seorang pengantar pizza di kepala dengan penggorengan karena
suara-suara menginstruksikan dia untuk mencuri pizza pengantar pizza dan mobilnya.
Setelah kejadian ini, Paul dilakukan oleh orang tuanya ke rumah sakit jiwa selama 6 minggu
dan dipantau pada obat antipsikotik Risperdal 75 mg. Setelah kembali ke rumah, ia
mengalami penurunan kemampuan untuk mengalami kesenangan, yang membuatnya
menjadi lebih menantang dan jauh. Dampak negatif berikutnya pada hubungannya dengan
orang tuanya adalah signifikan. Ibu Paul melaporkan bahwa putranya berpikir dia
membutuhkan terapi, bukan dia; bahwa ini adalah hidupnya dan dia dapat melakukan apa
yang dia inginkan sendirian, tanpa bantuan dokter; bahwa dokter tidak mengerti atau
membantu; bahwa itu bukan salahnya; dan bahwa orang lain atau keadaan harus
disalahkan. Ayah tirinya menceritakan bahwa ambisi Paul adalah menjadi bintang rock dan
dia sangat egois dan menaruh banyak tuntutan pada ibunya. Sebagai seorang anak, Paul
sangat menuntut dalam memenuhi kebutuhannya, dan ibu Paul akan mengorbankan
kebutuhannya sendiri untuk kebutuhan putranya. Ibu mendedikasikan sebagian besar
waktunya untuk Paul sebagai cara untuk membuatnya tetap dekat dan aman. Ayah tiri
melaporkan bahwa ia membenci istrinya karena mengasuh putranya dan melihatnya
sebagai "tidak mampu membiarkan putranya tumbuh dewasa." Ayah tiri Paul lumpuh
dengan mengisolasi dirinya sendiri di rumah secara fisik dan emosional dan menghindari
interaksi dengan Paul dan ibunya, karena perasaan frustrasi dan ketidakberdayaan.