Case Study 1

Running Head: CASE STUDY

Case Study: Movie “A Beautiful Mind”

Jeffery W. Belford

Queens College

Case Study: Movie “A Beautiful Mind”

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Brief Description of Movie

A Beautiful Mind is a movie based on the real life story of the famed mathematician John

Nash and his lifelong struggles with his mental illness. Nash enrolled as a graduate student at

Princeton in 1948. He was a recipient of the prestigious Carnegie Prize for mathematics. He

became obsessed to find his own unique and original mathematical theory. In the mean time, his

roommate, Charles, became his best friend. After successfully developing his own theory, known

as game theory, he became a professor at the Massachusetts Institute of Technology (MIT). Here

he met his wife Alicia (in his class), and they got married shortly thereafter.

One day he runs into his former roommate Charles and his young niece Marcee. While he

was working for the Pentagon deciphering complex encryption, he encounters a mysterious

secret agent by the name of William Parcher. Parcher gives him a new assignment to look for

patterns in magazines and newspapers possibly from the Soviets. He was ordered to write a

report of his findings and place them in a specified mailbox. As this secret assignment is going

on, he becomes increasingly paranoid and begins to behave erratically.

After observing this erratic behavior, his wife, Alicia contacts (informs) a doctor at a

psychiatric hospital. Nash was admitted. While in the hospital, he continues to believe that the

Soviets were trying to extract information from him, and that the workers at the psychiatric

facility were Soviet kidnappers. However, after he is confronted with his own documents which

were sitting in the mailbox and never opened, he finally realized that he has been hallucinating.

He came to realize that the secret agent William Parcher, and Nash's friend Charles and his niece

Marcee were all part of his hallucinations. After numerous shock therapies, Nash is released with

antipsychotic medication.
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However, the side effects of the antipsychotic medication affect his sexual relationship

with his wife and, his intellectual capacity. This leads him to stop taking his medication causing

a relapse of his psychosis, which almost cost the life of his infant son. He withdraws from

society until the 1970s. Subsequently, he tries to return to reality by going back to teaching at

Princeton. He eventually earns the privilege of teaching again with the help of his former

colleague. Over the years, he has learned how to distinguish his hallucination/delusion from

reality, check to ensure that any new acquaintances are in fact real people, and not hallucinations.

He is honored by his fellow professors for his achievements in mathematics, and goes on to win

the Nobel Memorial Prize in Economics for his revolutionary work on game theory.

Date of Intake: September 5, 1960 when John Nash was first relapsed after non adherent to

his antipsychotic medication.

Biographical Data

Initials: J.N. Date of Birth: 6/13/1928 Gender: Male

Marital status: Married Ethnicity: Caucasian Occupation: Unemployed

Source & reliability - self; reliable

C/C: "I stopped taking my medication for a while. Now I’m having hallucinations and am

paranoid again."

Identification, Chief Complaint and Reason for Referral:

Mr. J.N. was referred by his psychiatrist where he was previously diagnosed for paranoid

type schizophrenia. His psychiatrist did not feel an admission was warranted and referred him to

the mental health outpatient clinic. Mr. J.N complains of recurring auditory and visual
 Case Study 4

hallucinations with paranoia. He states that “I just can’t distinguish what’s real and what are

hallucinations.” He expressed feelings of hopelessness and guilt towards his family especially his

wife. He identified having difficulties with his memory/intellectual capacity and low sexual

libido as main reason why he stopped taking medication.

History of Present Illness:

Mr. J.N is a 32-year-old former college professor. He has been having recurrent auditory

and visual hallucinations with paranoia after stopping his psychotropic medication due to side

effects. He was referred to the mental health outpatient clinic by his psychiatrist. His psychiatrist

did not feel an admission was warranted since Mr. J.N. was not suicidal or homicidal.

He claims that he has been having hallucinations since he went to college. He did not

realize his delusion/hallucinations until last year when his wife called psychiatrist and admitted

him for his erratic behavior.

Mr.J.N. is recurrently seeing and hearing three figures; Charles who was thought to be his

roommate in college, Charles' young niece Marcee, and William Parcher who is a secret

government agent. He claims that he has been perceived them as real people until his first

admission last year. He continues to see and hear them even when he is on psychotropic

medication but is able to distinguish it from reality and not to react to it.

Mr. J.N. stopped taking his medication when it interferes with his memory/intellectual

capacity and sexual libido. He is a highly motivated scholar who places utmost importance on his

scholarly work and intends to go back to his work as college professor. He is also worried that

his marriage is falling apart due to his inability to perform sexual intercourse with his wife. He is
 Case Study 5

currently not working and is dependent on savings and income of his wife. He perceives that his

marriage at this point is in jeopardy.

Past Psychiatric History

He reports that he has been having auditory and visual hallucinations since he was in

college. He was diagnosed with paranoid type schizophrenia last year. He stopped taking his

medication when it interferes with his memory/intellectual capacity and sexual libido.

History of Substance Abuse

He identifies himself as social drinker. He used to drink regularly when he was in college

but has not had alcohol recently. He denies any use of illicit drugs.

Past Social and Developmental History

Education

He attended Carnegie Institute of Technology and graduated in 1948 with bachelors and

master’s degrees in mathematics. Then he enrolled as a graduate student at Princeton in same

year with scholarship. He reported his academic performance was excellent although he did not

attend most of his class. After successfully developing his own mathematical theory, known as

game theory, he became a professor at the Massachusetts Institute of Technology (MIT). He had

been teaching as a faculty until last year when he was admitted to psychiatric inpatient unit for

the first time.

Family History
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Mr. J.N. grew up in Bluefield, West Virginia. His father was an electrical engineer for the

electric power company. His mother had been a schoolteacher before she married then became a

housewife. Both parents were very supportive for their son's education, providing him with

encyclopedias and even allowing him to take advanced mathematics courses at a local college

while still in high school. He reports no known family history of medical or mental illness.

He met his wife as his student at MIT. They got married in 1957, and had good

relationship until his first inpatient admission last year. He reports that he has not been able to

perform sexual intercourse with his wife due to the side effects of his psychotropic medication.

He is currently not working and is dependent on savings and income of his wife. He perceives

that his marriage at this point is in jeopardy and wants to restore his relationship with his wife.

Occupational History

Mr. J.N. was a professor, teaching mathematics at the MIT. He also worked contract for

the Pentagon deciphering the complex encryption. He had been teaching as a faculty until last

year when he was admitted to psychiatric inpatient unit for the first time. He is currently not

working and is dependent on savings and income of his wife.

Social History

Mr. J.N. identifies himself as isolative, avoids any social contact as much as possible. He

stays home most of the day, doing errands including taking care of his infant son. He cut off the

contact with his colleagues since his diagnosis for paranoid type schizophrenia. He reports that

he feels ashamed, and perceives himself as a failure often. He also reports feeling guilt toward

his wife since he can no longer function as a good husband.

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Client’s Strengths

Mr. J.N. kept his appointment and is actively seeking help at this time. He has insight into

his problems. He wants to restore his relationship with his wife and is willing to take medication

in order for him to get better. He hopes the new medication will work without debilitating side

effects on his cognition and sexual libido.

Medical History

No known medical illness

Review of Systems

Vital Signs: BP: 110/80, Pulse: 80, Respirations: 18, Temperature: 98.6, Pain: 0

General: Weight: 196 lbs., Height: 71 inches, Body Mass Index (BMI): 27.4, no recent weight

gains/losses

Skin: No rashes/lesions/ itchy. Mid-dry skin whole body. No hair, nails, or skin changes.

HEENT:

Head: no neurologic illness/ headache/ head injury.

Eyes: reports 20/20 vision

Ears: hearing good. no tinnitus/ vertigo/ infections/ drainages.

Nose: no cold/fever.

Throat/ mouth: no bleeding/ sore/ hoarseness. last dental visit 2 months ago
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Neck: no lumps, goiter, pain, or swollen glands

Breasts: no pain or discharge

Respiratory: no cough/ wheezing/occasional sputum.

Cardiovascular: V/S WNL, no murmurs/chest pain/palpitations/edema. No dyspnea, orthopnea,

chest pain, palpitations. Last EKG, 1959; unremarkable

Gastrointestinal: good appetite. no pain/ nausea/ vomiting. Regular bowel movements, stool

color and size normal, no bleeding, sometimes excessive belching and passing of gas, no pain

jaundice or liver problems

Urinary: no dysuria/ hematuria/ painful urination.

Genital: no pain/sore/ lesions, has not been sexually active due to the side effects of

antipsychotic medication

Peripheral Vascular: none

Musculoskeletal: no muscle or joint pain/ swelling

Neurologic: no neurologic problems/ seizures/ motor, sensory loss

Hematologic: no anemia/ bleeding

Endocrine : no known thyroid problems-TFT is within normal limit, tolerates temperature

changes.

Medications: He has not taken his psychotropic medication for a while, which is unknown at

this time.
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Primary Care Provider: He has been seeing a psychiatrist from his inpatient admission last

year, who made the initial referral.

Allergies: He denies known allergies.

Mental Status Examination

Appearance and Behavior: Mr. J.N. dressed appropriately. He appears to be the stated age. He

is quiet but focusing on interview. He is cooperative and reasonable.

Mood and Affect: Mood appears to be depressed. His affect is constricted.

Speech and Thought Process: His speech is normal with appropriate rate and volume. He had

no loose associations, tangential thought, thought blocking or other signs of thought disorder.

Thought Content and Perception: He is recurrently seeing and hearing three figures; Charles

who was thought to be his roommate in college, Charles' young niece Marcee, and William

Parcher who is a secret government agent. He claims that he has been perceived them as real

people until his first admission last year. He continues to see and hear them even when he is on

psychotropic medication but is able to distinguish it from reality and not to react to it. But since

he stopped taking his medication, it became more difficult to distinguish it from reality and

greatly interferes with his life.

Cognitive and Intellectual Functioning: He stopped taking his medication when it interferes

with his memory/intellectual capacity. It was unacceptable for him since he intended to go back

to his work as a college professor. He reports no cognitive/intellectual problem since he stopped

taking psychotropic medication. His memory is intact, and he was able to recall dates with
 Case Study 10

regards to his work history. There was no evidence of gross cognitive dysfunction during the

interview. He has insight into his problems and is goal directed to manage his mental illness.

Mini-mental Status Exam: He scored a 30, no cognitive impairment.

Hamilton Depression Scale: He scored 12 which would indicate mild depression.

Negative Syndrome Scale (PANSS): He scored 65 both high on positive and negative

symptoms.

DSM-IV Diagnosis:

Axis I: 295.3 - Schizophrenia, Paranoid Type

Axis II: None

Axis III: None

Axis IV: 1- Marital problem, client has been unable to have sexual relationship with his

wife for a while due to the side effects of psychotropic medication

2- Financial stressors related to unemployment

Axis V: GAF 43

Narrative Summary and Formulation

Mr. J.N. is a 32yr old white, married male former college professor. He was referred by

his psychiatrist where he was previously diagnosed for paranoid type schizophrenia. He kept his

appointment today and appears motivated for treatment. He is currently married to his wife for 3

years and has an infant son. He has no family history of significant medical or mental illness. He
 Case Study 11

has been having recurrent auditory and visual hallucinations with paranoia after stopping his

psychotropic medication due to side effects. He expressed feelings of hopelessness and guilt

towards his family especially his wife.

He claims that he has been having hallucinations since he went to college. He did not

realize his delusion/hallucinations until last year when his wife called psychiatrist and admitted

him for his erratic behavior. Mr.J.N. is recurrently seeing and hearing three figures; Charles who

was thought to be his roommate in college, Charles' young niece Marcee, and William Parcher

who is a secret government agent. He claims that he has been perceived them as real people

until his first admission last year. He continues to see and hear them even when he is on

psychotropic medication but is able to distinguish it from reality and not to react to it. But since

he stopped taking his medication, it became more difficult to distinguish it from reality and

greatly interferes with his life.

Mr. J.N. stopped taking his medication when it interferes with his memory/intellectual

capacity and sexual libido. He is a highly motivated scholar who places utmost importance on his

scholarly work and intends to go back to his work as college professor. He is also worried that

his marriage is falling apart due to his inability to perform sexual intercourse with his wife. He is

currently not working and is dependent on savings and income of his wife. He perceives that his

marriage at this point is in jeopardy.

Mr. J.N. identifies himself as isolative, avoids any social contact as much as possible. He

stays home most of the day, doing errands including taking care of his infant son. He cut off the

contact with his colleagues since his diagnosis for paranoid type schizophrenia. He reports that
 Case Study 12

he feels ashamed, and perceives himself as a failure often. He also reports feeling guilt toward

his wife since he can no longer function as a good husband.

Mr. J.N. kept his appointment and is actively seeking help at this time. He has insight into

his problems and is goal directed to manage his mental illness. He wants to restore his

relationship with his wife and is willing to take medication in order for him to get better. He

hopes the new medication will work without debilitating side effects on his cognition and sexual

libido.

Treatment Plan

Medication

Risperdal 1mg bid p.o. as starting dose for two days. Then increase dose to 2mg bid p.o.

Risperdal relieve the psychotic symptoms including hallucinations and manic episode.

Cognitive Behavioral Therapy for psychosis (CBTp)

Cognitive behavioral therapy for schizophrenia (CBTp) is an evidence based practice

based on the work by Aaron T. Beck, MD. Initially, CBTp research focused on adjunctive

treatment for patients with medication resistant positive symptoms; however, more recent studies

have expanded to include areas such as the treatment of negative symptoms, comorbid disorders

and the use of a group modality. Several randomized clinical trials and meta-analyses have

established CBTp as an effective treatment for the symptoms associated with schizophrenia

(Draper et al, 2010). Client will be seen weekly for therapy.

 Case Study 13

Family Therapy

The patient will initially benefit from couple counseling. The goal will be to restore

client’s relationship with his wife. Also psychoeducation for his wife will be offered. Research

findings support family psychoeducation as evidence-based treatment for serious mental illnesses

and benefits for families. Because major psychiatric disorders frequently are long term with

episodic crises, caregivers have ongoing needs for support (Lefley, 2010).

Administer Positive and Negative Syndrome Scale (PANSS) after 4 weeks

The Positive and Negative Syndrome Scale (PANSS) is a medical scale used for

measuring symptom reduction of schizophrenia patients. It is also widely used in the study of

psychosis. The name refers to the syndrome of positive symptoms, meaning those symptoms of

disease that manifest as the presence of traits, and the syndrome of negative symptoms, meaning

those symptoms that manifest as the absence of traits and a series of general symptoms for

patients with different psychosis. The scale has seven positive-symptom items, seven negative-

symptom items and 16 general psychopathology symptom items. Each item is scored on the

same seven-point severity scale (PANSS, 2012).

Intervention

Risperdal 1mg bid p.o. as starting dose for two days. Then increase dose to 2mg bid p.o.

Risperdal relieve the psychotic symptoms including hallucinations and manic episode. Compare

to conventional agent, atypical antipsychotics are known for less risk for EPS/TD, more effective

against negative symptoms, and potential effects on cognitive function thus improve outcomes

and prognosis (Risperidone, 2012).

 Case Study 14

Outcome

He began to see the effects of the medication in a couple of weeks. He reports less

auditory hallucinations, and visual hallucinations are almost gone. After 4 weeks, symptoms

continue to improve without any adverse effect on his cognition and libido. He did not report any

side effects from Risperdal.

Intervention

Antipsychotic medications are frequently helpful in reducing psychotic symptoms and

relapse; however, many clients continue to experience persistent distress and disabilities. Almost

50% have persistent psychotic symptoms even when adhering to pharmacological treatment

(Dickerson, 2000). Many people with schizophrenia have residual symptoms and disabilities that

persist throughout their lives.

There is accumulating evidence from controlled clinical trials that CBT is effective in

reducing psychotic symptoms, increasing adherence to medication, improving response of

chronic residual symptoms and as an adjunct to inpatient treatment (Beck & Rector, 2001).

Mr. J.N was seen initially twice a week for 60 minutes for the first two weeks of

treatment. He was later seen weekly for 60 minutes. The CBTp consists of 14 sessions in 12

weeks. The emphasis of the sessions was to help him understand his mental illness, how it affects

his life/relationship and to assist him in making changes. He was engaging and eager to make

changes.
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The beginning sessions focused on gathering information to formulate an interpersonal

inventory, and identify goals based on client’s problem list. The client and I agree that the

priority is to distinguish his delusion from reality because it will have most beneficial effect on

other problems when it is resolved. As the session continues, we try to analyze his hallucinations,

such as its contents, frequency, and how it affects his mood. Also we try to evaluate how he

interprets these stimuli, which caused paranoia in the past. Client is constantly challenged for the

evidence for his delusion, and encouraged to use reasoning process. Most sessions consist of

discussing the negative effect of his current way of thinking then going over alternative views

that can positively impact on his functional level and relationship. We discuss how his cognition

plays a role in his symptom management then continue to work on creating new balanced

thoughts.

Outcome

As the sessions progress, he begins to focus on changing the way he thinks. With the help

of antipsychotic medication, his hallucinations are much less to the level that he can ignore them

most of the day. He was able to distinguish his delusion from reality. He starts to explore his own

ways to validate the reality from hallucination, such as checking to ensure that any new

acquaintances are in fact real people. The CBTp enabled him to reason his delusion, and distract

him from hallucinations. He is much more positive regarding current condition and has hopes for

his future.

Intervention

Initially couple therapy is offered. The client agrees early in treatment to have his wife

come in. His wife participates for two sessions, discussing how they feel about their relationship.
 Case Study 16

His wife acknowledges and agrees with him regarding how his mental illness affects their

relationship.

She is also offered family psychoeducation (FPE). Family psychoeducation (FPE) is one

of six evidence-based practices endorsed by the Center for Mental Health Services for

individuals suffering from chronic mental illnesses. Multiple family group psychoeducation

(MFG) has been shown to be an effective component of FPE in reducing symptom relapses and

rehospitalizations for individuals with schizophrenia. It allows family members to increase their

understanding of the biology of the disorder, learn ways to be supportive, reduce stress in the

environment and in their own lives, and develop a broader social network (Jewell et al, 2009).

Outcome

The client reports good relationship with his wife since attending couple therapy. Both

share mutual agreement/respect for each other and accept the effects of his mental illness. He

was able to have sexual relationship since he does not experience any side effects from his new

antipsychotic medication. His wife reports that FPE was very helpful in order for her to better

understand her husband’s illness. She also reports beneficial relationship with other families in

group, sharing story and information.

Summary of Treatment

Mr. J.N. benefited from medication and CBTp. He is responding well to atypical

antipsychotic without any side effects. In CBTp, he is encouraged to identify his own delusional

or paranoid beliefs and to explore how these beliefs negatively impact his life. He was engaged

in experiments to test these beliefs.

 Case Study 17

Treatment focuses on thought patterns that cause distress and also on developing more

realistic interpretations of events. Delusions are treated by developing an understanding of the

kind of evidence that a person uses to support their beliefs and encouraging him to recognize

evidence that may have been overlooked.

He was retested with PANSS, and scored 34 showing improvement on both positive and

negative symptoms. Mr. J.N. benefited from treatment and continues to be seen in therapy.
 Case Study 18

References

Beck, A., & Rector, N. (2001). Cognitive therapy of schizophrenia: A new therapy for the new

millenium. American Journal of Psychotherapy, 54, 291-300.

Dickerson, F. (2000). Cognitive behavioral psychotherapy for schizophrenia: A review of recent

empirical studies. Schizophrenia Research, 43, 71-90.

Draper, M. L., Velligan, D. I., & Tai, S. (2010). Cognitive behavioral therapy for schizophrenia:

A review of recent literature and meta-analyses. Minerva Psichiatrica, 51(2), 85-94.

Jewell, T. C., Downing, D., & McFarlane, W. R. (2009). Partnering with families: Multiple

family group psychoeducation for schizophrenia. Journal of Clinical Psychology, 65(8),

868-878. doi: 10.1002/jclp.v65:810.1002/jclp.20610

Lefley, H. P. (2010). Treating difficult cases in a psychoeducational family support group for

serious mental illness. Journal of Family Psychotherapy, 21(4), 253-268. doi:

10.1080/08975353.2010.529014

Lincoln, T. M., Ziegler, M., Mehl, S., Kesting, M., Lüllmann, E., Westermann, S., & Rief, W.

(2012). Moving from efficacy to effectiveness in cognitive behavioral therapy for psychosis:

A randomized clinical practice trial. Journal of Consulting and Clinical Psychology, 80(4),

674-686. doi: 10.1037/a0028665

Positive and Negative Syndrome Scale (PANSS). (2012).

http://www.panss.org/home/index.php?option=com_content&task=blogsection&id=5&Item

id=9
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Risperidone. (2012). PubMed Health.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000944/

Small, N., Harrison, J., & Newell, R. (2010). Carer burden in schizophrenia: Considerations for

nursing practice. Mental Health Practice, 14(4), 22-25.

Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for

schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia

Bulletin, 34(3), 523-537. doi: 10.1093/schbul/sbm114