Article Type: Research Article Article Citation: Simona Trifu,
Beligeanu Mihaela, Iacob Beatrice-Ștefana, and Larimian
Ștefania-Parisa. (2021). PARANOID SCHIZOPHRENIA -BETWEEN HYPERSEXUALITY
AND SADOMASOCHISM. International Journal of Research -GRANTHAALAYAH, 9(3), 195-203.
https://doi.org/10.29121/granthaalayah.v9.i3.2021.3791 Received Date: 14 March 2021 Accepted Date: 31 March 2021 Keywords: Paranoid Schizophrenia Discernment Personality
Disorders Defense
Mechanisms Coping Strategies
Syndromes Guardianship Sexuality Sadism Motivation/Background: In this paper we aimed at
clinically analyzing a patient diagnosed with paranoid schizophrenia, who also
displays features specific to multiple personality disorders, in the context of
a presentation whose key topic is sexuality. Given the global prevalence and
the severity of schizophrenia, it is increasingly important to appropriately
adapt and identify the patients' clinical and non-clinical personality profile.
This paper also aims at making the profile of a patient diagnosed with axis I
disorder ever since the age of 19, who also has got traits specific to certain
personality disorders. At the same time, the work provides an interpretation of
the behaviour from the psycho-dynamic point of view. Method: The following instruments were
used for performing the analysis: a clinical interview, heteroanamnesis,
psychological tests, clinical course monitoring, psychodynamic interpretations,
defence mechanisms identification, psychiatric observation
and treatment. Results: Based on the materials
aforementioned, it has been established a possible diagnosis which
includes multiple disorders: Antisocial Personality Disorder, Histrionic
Personality Disorder, Schizotypal Personality Disorder, Obsessive Compulsive
Personality Disorder, Cotard Syndrome, Kandinsky-Clérambault Syndrome. and
there were identified defense mechanisms and coping strategies, under the
influence of sexuality and sadomasochistic impulses. Conclusions: It is highlighted the clinical picture of a patient with paranoid schizophrenia, who presents symptoms for differential diagnoses, with disorganized discourse focused on sexuality, with delusional ideation, psychotic manifestation, but also with high suggestibility, especially on the paternal line.
1. INTRODUCTION1.1. IDENTIFICATION DATAThe patient, aged 40, single, medically
retired, is living only with his father, who is also his legal guardian. The
patient graduated from a prestigious high school and claims having got the
highest mark (10) at the high school leaving examination. He was a university
student of the Energetics School, but he repeated the
first year 3 times. At the social-cultural and economic level, we may infer
that the patient has been having a high living standard ever since the
communist period, as his father owns a villa downtown Bucharest. His mother
died in 2012, of lung cancer. The patient originates from a family who belonged
to the upper-class during communism. He is known to be a patient diagnosed with
schizophrenia and the disease onset is at about the age of 19, when he was
admitted at the Predeal mental hospital. He states undergoing the fifteenth
round of hospitalization at the Psychiatry Department. He thinks having
undergone the military service, ‘but he does not remember when he took the
oath’. As far as his professional life is concerned, he was supported by his
parents and worked with his father, for 6 years. 1.2. REASONS FOR HOSPITALIZATIONThe patient came to the hospital saying at
the emergency room (ER) that he had set fire to his house the day before. He
came to the hospital out of his own will, not accompanied by the police. He is
known for other hospitalizations at the Psychiatry Department, as well. Until
the age of 40 he has totaled 15 hospitalizations here. His clinical signs upon admission include the
following symptoms: logorrhea, flight of ideas, fast speaking, the absence of
logical associations, hard to follow speeches, psychomotor agitation, wide
gestures, spatial-temporal disorientation, the lack of any logical support for
what he is stating, tangentiality, circumstantiality, emotional flattening: he
does not feel guilty for having caused the fire. Three days prior to the incident, the patient
came to us in order to get hospitalized on a voluntary
basis, however the medical practitioners that examined him at the time deemed
that he did not require hospitalization. 1.3. DISEASE HISTORYOnset: The
patient's first hospitalization was at the Predeal mental hospital, at the age
of 19. He had an early onset of the disease, right after he graduated from high
school. Even though he claims having got the 10 mark at the high school leaving
examination and that he was a brilliant child, with vast knowledge in multiple
fields, he repeated the first university year 3 times and specifies having had
difficulties from the romantic relationships point of view. Until the age of 40
he has had 15 hospitalizations, his diagnosis being paranoid schizophrenia. Ever since childhood he has been displaying
'particular sexuality' and in high school he was attracted to porn magazines
and anal sex. He is a pervert, with sadomasochistic elements. In a previous non-voluntary hospitalization,
the patient displayed a bizarre behaviour, which was psychotically modified: he
used the shower to get anal satisfaction, but this was more an act of
self-aggressiveness, as he caused heavy hemorrhage to himself. His father, in his capacity of legal
guardian, was the one who decided whether his son should be on treatment or
not, even though the physicians prescribed it each time. In the aftermath of
this hospitalization, the patient came every two or three weeks, in order to get a shot of Flupentixol Depot,
for two years. After this period of time, even though
his symptoms improved considerably, he gave up the treatment, as his father
claimed that his son's 'tushy is aching'. The patient came to the ER three days before
setting fire to the house where he was living, but he was not hospitalized at
that time. For the current hospitalization, the patient came voluntarily to the
ER the following day after setting fire to the house where he was living with
his father. The patient displayed emotional flattening: he did not feel any
guilt for the fire that he had caused, saying that he had set fire to the house
because 'he did not stand the mess, as he likes spotless houses'. He also
specified that the fire 'was not premeditated, but spontaneous' and that it
took him two hours and a half to think about it. The investigation revealed the
fact that the patient did not have any discernment when he set the house on
fire. The patient is spatially-temporally
disoriented and is not able to recount moments from his life history, saying
that he thinks having undergone the military service, 'but I don't remember if
I took the oath'; 'I was either an officer or CIA kind of executive'. 2. MATERIALS AND METHODSThere
have been the following tools used in the analysis of the patient: a clinical
interview, heteroanamnesis, psychological tests, monitoring of the clinical
evolution, psycho dynamic interpretations, identifying the defense mechanisms, observation and psychiatric treatment. 3. RESULTS AND DISCUSSIONS3.1. PSYCHOLOGICAL EXAMINATIONRemarks: The patient
wears the proper attire for the hospital (pajama and robe). He uses ample
gestures while talking. During the interview he is answering questions and he
is being cooperative, although in some situations logical associations are
lacking. The speech is rich, the patient has some knowledge in the psychology domain and he is bringing some personal opinions in regards
to specific subjects. Perception: The patient
displays qualitative disorders of the perception, meaning hallucinations. The
patient declares that he 'never ever' hears voices, but from what he says it
ensures that in fact he does: 'I was hearing a voice pushing me to kill' -
auditory hallucination. We can also notice preoccupations in the sexuality
area, but it is hard to distinguish how much is pleasure and how much sadism.
The realm of perception also includes : auditory hallucinations - 'the voice
was telling me to kill a beautiful child', 'it was the angels who came and told
me to set the house on fire' ; visual hallucinations - 'I saw the angels come
into the house' ; pseudo hallucinations - they are not projected outside, but
take place in the patient's mind, as they are not distinguished as voices
clearly perceived as coming from the exterior of the patient's psychological
apparatus : 'I was never hearing the voices with my ear'. Thought: The patient
has disorganization in thinking, which will be presented in the following
lines. Although, based on his speech, what he says is not logically supported,
the patient is striving, so he is not unwilling. Thus, both quantitative and
qualitative disorders can be identified. Regarding the quantitative disorders,
we remind: the acceleration of the ideational rhythm by running away from
ideas: he answers tangentially to the questions, he also has a prosexic
disorder, he talks a lot, he loses the connections between the associations
that he makes. Regarding the qualitative disorders, there are to be mentioned:
obsessive ideas: `I wanted to commit an abominable crime - the most beautiful
girl or the most beautiful boy - to end it to pieces and then to torment myself
like a snake`. He claims that the idea does not belong to him, that it is
foreign to him and that it comes from outside of him; delusional ideas of
grandeur: he claims to have had a connection with great personalities (he
mentioned well-known people such as famous actors or local celebrities), to
have worked for the SRI / CIA, that he is indestructible; delusional ideas of
power: the father is heterophile; delusional ideas of filiation: claims to be
American; delusional erotomaniac ideas: discourse focused on sexuality;
religious delusions: defines schizophrenia as `sexual desire with God`;
delusional ideas of transformation and possession: he claims to have an extra
chromosome that makes him indestructible and allows him not to age; delusional
ideas of persecution can emerge from his metaphor related to `the doll and the
puppeteer`, but also from his relationship with co-workers; delusional ideas of
negation: he claims to be indestructible and immortal, in direct connection
with Cotard syndrome; interpretation ideas: the patient looks at the world in
an egocentric manner, considers that everything that happens is a reference to
him: the episode when he was with his friend in the park and he felt like the
world stopped for him; he believes he has the buttons that can destroy
everything (and that he can push at any time), the flamethrowers; delusional
ideas of influence: `I heard some voices telling me to commit such an
abominable crime, beyond reason`, he claims to have an extra chromosome that
explains both the reason why he doesn't look old and why he is immoral. Speech: From the
oral speech, it can be determined the delirious subtext of grandeur and
symbolism `Either I was an officer, either a director for the Romanian
Intelligence Service; `We live in a world full of Puppets and Puppeteers`. Even
if the speech is disorganized, the patient has a specialty language, and his
vocabulary is complex, rich, offering a lot of significant details which he has
taken from the books he read and the movies he watched (He thinks that they put
electrons in his head). He is logorrheic, active, his speech is fast. Attention: Presents a
slightly incapacity of focus, stability and selection
of attention, he offers tangential and circumstantial answers (when he is asked
if his mother was the one who got cancer, his first answer is `yes`, then `no`;
evasive answer when he is asked for the first time why he thinks he is 70 years
old). The auditory hallucinations represent a key symptom of the paranoid
schizophrenia, the patients being distracted by them. Memory: The patient
shows a selective hypermnesia (he does not remember enrolling into the army,
but he is convinced he did, and after his affirmation he starts talking about a
different subject, he is recounting his high school leaving examination; when
he is asked if he has ever liked boys, he is states that they are just as
innocent in front of God). Moreover, the patient presents multiple
confabulatory statements: he cannot remember whether or not
he enrolled in the army, but he is convinced he is an American soldier.
However, he believes that his parents are not his real parents however, thus
causing an emotional reversal. Awareness of the disease: He
admits the harmful effects of insomnia to his mental and physical state. He
knows that the schizophrenics have auditory hallucinations in their ears, but
he thinks he is special, saying `I do not hear voices in my ears like the
schizophrenics`, when he is actually facing auditory
pseudo hallucinations. 3.2. POSITIVE DIAGNOSISSchizophrenia is a family of diagnostics
usually represented by positive symptoms (delirious ideas, hallucinations,
perception disorders, bizarre behaviors) and negative symptoms (lack of normal
behavior, like social distancing; lack of speech [alogia]; flattened affect;
lack of motivation and initiative and/or anhedonia) (World Health Organization,
2004). The presence of schizophrenia is supported by the following negative
symptoms: emotional flattening (he does not feel culpability after setting the
house on fire; does not grief his mother’s death, he is reliving the feel of
fear that he will be next), lack of social skills, (the difficulty of involving
in romantic relationships or friendships), but also by the positive symptoms):
perception disorders (pseudo hallucinations and auditory hallucinations). A
subtype of schizophrenia, with a late debut, characterized by delirious ideas
of persecution or auditive hallucinations. Delirious ideas are typically of
persecution, of grandeur or both; hallucinations are usually tied to the
content of delirious fear. The cognitive function and mood are affected on a
much lower level than in other forms of schizophrenia. (American Psychiatric
Association, 2013). Paranoid schizophrenia is justified by the following
symptoms: mental automatism (example, the fire), xenopathy: When he receives
orders, not in the persuasive manner, but in an unconscious plan and he is
being told what to do from outside (`I was hearing some voices telling me to
commit such an abomination of a crime, beyond ration`), delusion, just how it
has been mentioned before and the pseudo hallucinations: `I never heard voices
in my ear` . 3.3. DIFFERENTIAL DIAGNOSIS3.3.1. KANDINSKY-CLERAMBAULT SYNDROME It is the psychic automatism syndrome and the
core of paranoid schizophrenia. The psychic automatism syndrome is focused on
the spontaneous, involuntary, 'mechanical' production of the psychic life
(impressions, ideas, memories) imposed to the consciousness of the subject who
loses his/her intimacy (psychic transparence) and feels guided from the outside
(xenopathic phenomena) (Trifu, 2016). It is a syndrome appeared from the
patient’s conviction that his thoughts are no longer his own. It comprises delusional
ideas of influence, pseudo hallucinations and xenopathy. The patient's symptoms
are the psychic hallucinations ('I was never hearing the voices with my ear')
and xenopathy (what makes the patient think those 'abominable things is a kind
of SuperEgo of mine'. The patient also says that 'the world is constructed of
puppets and puppeteers' and his history can metaphorically imply the fact that
he is the puppet and his father is the puppeteer,
because the latter one has got a very large influence upon his son. 3.3.2. COTARD SYNDROME It is a psychotic condition characterized by
intense delusions of negation, enormity and immortality (`I have been made
indestructible by my father and mother`), the patient saying `I was not able to
feel my lung anymore`, meaning that a part of the body has disintegrated
or it stopped existing. (VandenBos, 2020). 3.3.3. STRUCTURE OF PERSONALITY If there is proof of premorbid personality
traits, then both the personality disorder and
schizophrenia can exist simultaneously. 3.3.4. ANTISOCIAL PERSONALITY DISORDER An example of an antisocial act of which the
patient presented was to burn down his own house. The act `was not directed, it
was spontaneous`. The manifestation of the patient includes the careless
ignorance regarding his own safety and others’ (initially he wanted to burn
down the house while his father was also inside), accompanied by the lack of
guilt, remorse and empathy; emotional flattening.
Besides, he’s recalling without remorse how he set the
house on fire `to burn the house down, just like that`, `from the door hasta la
vista, lighter on`. Moreover, the patient has aggressive phantasms: the desire
to kill a small boy or girl. The fact that the patient talked about explosions
and flamethrowers denotes his increased degree of danger;
pyromaniac impulses. Another aspect of which the patient is confronting is the
dual character (`I have always been a double man, like a spy, a man with two
faces, a face in the society and another face at home`). 3.3.5. HISTRIONIC PERSONALITY DISORDER After consulting the DSM V criteria, we found
that the patient has a number of characteristics
associated with Histrionic personality disorder. Each one of them will be
presented, along with the appropriate example: the patient feels uncomfortable
in situations where he is not in the center of attention and he has a constant
need to tell stories and experiences that are out of the ordinary. Another
specific aspect of this disorder is the inappropriate interaction of the
individual with other people and also the inadequate
behavior, which is sexual or provocative. Often, the patient has
a tendency to turn his discourse into a sexualized one, often making
references to these topics, even if the person he is talking to is comfortable
with this or not. Moreover, he has a style of verbal expression that aims to
impress the audience, but which is superficial and lacks details. The patient
often quotes movies or books and compares his own life with fantastic events.
Also, the way he expresses his emotions is exaggerated, theatrical and dramatic.
The patient's stories are accompanied by interjections, onomatopoeias and other
elements that have the role of providing impact at the level of his speech. The individual is suggestible. Thus, the
patient's father has an increased influence on him, which can result from
situations such as: hiring the son in the same job as the father, the metaphor
`doll and puppeteer`, the father-doctor discussion, focused on the direct
influence on the patient. He misjudges relationships with those around him and
considers them to be much closer than they really are. For example, the patient
considers that he has a much closer relationship with the tenant who lives on
the ground floor of his house than he actually had. People diagnosed with histrionic personality
disorder often tend to make uncontrolled gestures in order to
receive attention. Thus, setting his own house on fire can be considered by the
patient a tool to get everyone's attention. The patient tries to stand out as a
moral person that has set his motives straight, claiming that if he were rich,
he would donate a large part of his fortune to hospitals (Trifu, 2016). Moreover, the patient's description of
himself is exaggerated, full of grandeur: he expresses his ability to live
forever compared to ordinary mortals and emphatically emphasizes that he hears
voices in his head, not in his ears, contrary to what the medical staff might
assume. He can often play the role of the victim to
be the center of attention: `I never considered myself smart enough`, `I suffered
like a dog that I had no girlfriend`, `When you see that you live in a mess and
you will not have a sports car ... ` as he feels a constant need to be in the
spotlight. 3.3.6. OBSESSIVE COMPULSIVE PERSONALITY DISORDER Obsessive-compulsive disorder is
characterized by obsessions. According to DSM-V, obsessions are `Recurrent and
persistent thoughts, urges, or images that are experienced, at some time during
the disturbance, as intrusive and unwanted, and that in most individuals cause
marked anxiety or distress`. He states the following wishes: `I wanted to
commit an abominable crime, to kill the most beautiful girl or the most
beautiful boy and then to torment myself like a snake`, `I heard some voices
telling me to commit such an abominable crime, beyond reason`. He mentions that
these thoughts do not belong to him, that he does not recognize them as his
own. The patient is aware that these ideas are not his own, that those ideas
are associated with his aggression and that they physically make his life
better. There is to be mentioned that at the time of the interview, the patient
was already under the effect of his treatment, which played an important role
in terms of awareness of obsessions. It is probable that, before medication, he
wasn't aware of the effect of those intrusive thoughts
and considered them as his own. 3.4. SYMBOLIC INTERPRETATIONSExploring the content and themes of
hallucinations and delusional ideas is often a way to link them to the
patient's past and provides valuable information about his underlying emotions.
Given that delusions and hallucinations are culturally defined, it will be
necessary, as in any complex assessment, to take into account
the cultural context and to assess the content of delusions and hallucinations
both in relation to the patient's belief system and in relationship with
religious and cultural influences and context. 3.4.1. FREUDIAN DEFENSE MECHANISM Displacement: Although he
claims to have lung cancer, his mother is the one who was diagnosed with this
disease. Out of the patient's desire to identify the reason that determined his
mother’s cancer, he has a theory, developed by using acausal synchronicities,
through an allusive mechanism - he did an x-ray when he was admitted to
psychiatry for a check-up, and in 6 months, his mother was diagnosed with
cancer. In his psychotic disorganization of thought, he associated washing
clothes in the hospital with the cancer's onset, so he assumed the disease was
his own. This approach can also be attributed to the unconscious guilt he faces
as a result of an unhealthy relationship with his
mother. Projection: he describes
his colleagues as being: `sadistic`, with `nervous problems` and no
decision-making power, but, in fact, this can actually refer
to his own attributes. Cleavage: between the
person who would like to be and the person who is (SuperEgo versus Ego). Rationalization: he
complains about the appearance of his former girlfriend, whom he calls
`grandmother`. This can be a mechanism that allows him to get over a failed
relationship and to make him feel better and happier as a single man. Regression: he is
fixated in his anal stage; the regression may result from his fixation for
cleaning. Denial: mentions
that he is indestructible, immortal and denies his condition. 3.4.2. COPING MECHANISMS Throughout the speech, the patient described
several coping methods, both functional and dysfunctional (David, 2006). One of his coping mechanisms is to run: `I'm running until I'm exhausted`. Moreover, even after
setting his house on fire, the patient wandered around Bucharest for a while
before turning himself in at the emergency room. This may indicate his
intention to detach himself from his own problems, emphasizing his avoidant
behavior. On the other hand, several dysfunctional, destructive or self-destructive coping mechanisms are
presented. He repeatedly mentions aggressive gestures or behaviors, some of
which are coping mechanisms: `If your wife died and you had a nuclear button
that you could use, wouldn't you wipe off the whole earth? ` Moreover, he also
shows self-aggressive tendencies. A representative moment for this aspect is
the shower incident, when he introduced the shower head in his anus, behavior
loaded with masochistic, aggressive and self-punitive
tendencies. In fact, the patient repeatedly mentioned his desire to `torment
like a dog`. He often associates this desire with biblical characters or
religious examples. Therefore, this coping mechanism is reminiscent of the
religious model of punishment for the forgiveness of the sin. 3.4.3. PYROMANIA Although the reason for hospitalization is
setting his house on fire, the patient does not have criteria for diagnosis
under the spectrum of pyromania, according to DSM-V. Instead, the decision to
set his house on fire rather refers to a dysfunctional coping mechanism of the
patient who, overwhelmed by the negative feelings in his own house, in a
cathartic gesture, decides to set it on fire. Moreover, the place where the
fire starts is the bed itself, the source of all the patient's mental
suffering. Along with the flames, there is a spiritual cleansing of `misery`,
both physical and mental, which obsesses the patient and occupies the whole
spectrum of thought, which produces a disorganization of associations and
attacks his contact with reality. 3.4.4. SADOMASOCHISM Sadism is a personality trait. This is part,
along with Psychopathy, Machiavellianism and Narcissism, of the extended
version of the Dark Trade (Međedović&Petrović, 2015).
Therefore, sadism is a personality trait with negative valence, often observed
in the patient's speech. He takes pleasure in hurting others, repeatedly
mentioning his desire to commit `an abominable crime`. Moreover, he repeatedly
emphasizes that the subjects of his aggression would be `the most beautiful
girl or the most beautiful boy`. This delusional idea is recurrent in the
patient's discourse and, although in the past it was considered that sadistic
fantasies are rare in schizophrenic patients, there is a higher prevalence
(Smith, 1999). Masochistic behavior refers to a number of models of self-destructiveness or self-harm,
without suicidal intent (McWilliams, 2011). For example, the patient inserts
the shower head in the anus. His goal is not self-satisfaction, but
self-aggression. Moreover, during the interview, the patient repeatedly
emphasizes phrases related to torment and suffering: `I suffered like a dog`,
`to torment me like a snake`. It is unclear what is the source of the patient's
masochistic desires, but it seems that his aggressive tendencies were only
directed towards himself, even if in the imaginary spectrum the aggression is
directed towards others. One hypothesis would be that the patient wants to go
through suffering, even self-caused, to deal with his problems, in the form of
a dysfunctional coping mechanism. Another option would be that he obtains a
state of well-being by being in torturous situations. In fact, the masochism
could be a veiled expression of strategically oriented aggression to avoid hetero-aggression. Identifying the reason for the patient's
masochistic desires and behaviors is necessary to perform a therapeutic
intervention in order to reduce the negative
consequences of the patient's aggression. 3.4.5. THE EGO CONFLICTED BY SUPEREGO One of the most important parts of the
patient's discourse is the conflict between SuperEgo and Ego, Freudian
structures developed in early childhood, under the influence of parental
figures (Gabbard, 2014). There is an internal conflict, between low
self-confidence and the superiority he displays, along with his defiant
attitude, which refer to omnipotence. Throughout the speech, the patient
mentions multiple delusional ideas of grandeur that may refer to surreal
expectations of reality. He mentions the desire to have a sports car, a big and
clean house and makes multiple references to the desire for a perfect life.
There is a conflict between the rigid SuperEgo and the mediocre Ego, which the
patient cannot manage. Thus, he creates his own fantastic reality, through his
delusional idea of grandiose and filiation: he claims to be
American, associates with great personalities of the time, mentions that he
works for the secret services, etc. This conflict between SuperEgo and Ego also
resides in the multiple mentions to his father, whom he feels he cannot compare
to. He is stuck in the position of a schizophrenic son who has barely graduated
from college and has not worked for more than 6 years. He is a prisoner of his
constant mental deterioration and is under the continuous paternal influence,
who guides even his medical path. Throughout his life, the father, being a
nomenclaturist, tried to offer his son the same professional path. Due to the
onset of the disease, however, the patient was unable to meet the father's
standards, which created a strong conflict between the two. Moreover, the
SuperEgo seems to offer even an internalized image of the paternal figure
which, being unattainable for the son, contributes to his anguish and mental
suffering. 3.4.6. THE WORLD IS CONSTRUCTED OF PUPPETS AND PUPPETEERS This symbolic sentence can metaphorically
imply the fact that the patient is the puppet, namely the object of the
manipulation, and the puppeteer is outside, he is a force that controls him. We
can metaphorically think that the puppeteer may even be his father. The father
is the patient's companion and he has had a
significant impact upon his subsequent development. It was him who had him
hired in the same place where he was working, too, and it is still him who
interrupted the patient's treatment. The absence of the mother is felt in the
patient's life, so the father is his only attachment figure. He cannot reach
his father's standards and he has got a psychotically modified behaviour,
thinking that 'he has got American blood' and that 'he is indestructible'. The
father had knowledge of his suggestibility and it is possible that he may
voluntarily or involuntarily suggested to him to set fire to the house in order to receive an amount of money from the insurance
company. This is not for sure, but the certain thing is that the father has got
a great deal of influence upon the patient. 3.5. WHAT IS PARTICULAR?His act of setting the house on fire is
considered an element of a quasi-psychotic episode because he does not support
the idea that he was urged from the outside to put the act together (the
exclusion of xenopathy and the delusion of influence), although he is stating
that he burned the house down because it was dirty. It was concluded that the
patient was lacking judgement when he put the act together. The fact that he
presented himself before and after the fire to the hospital voluntarily proves
that he was conscious, but he performed the act indiscriminately, being so
suggestive, it is possible that he misinterpreted allusively a conversation
between him and his father, which had some form of influence over him. The
speech thematic of the patient is oriented towards the sadomasochistic
sexuality aspect: anal sex tendencies (the shower incident, the erotic
pleasures from his teens with his first sexual partner). Moreover, he is
associating schizophrenia with the sexual desire with God, the Father. 4. CONCLUSIONS & RECOMMENDATIONS4.1. EVOLUTION, PROGNOSIS, RECOMMENDATIONS, DISCUSSIONSGiven that there is no clear chronology of
the patient's symptoms, it cannot be specified exactly whether the schizotypal
personality disorder (Predescu, 1989) is a premorbid diagnosis, prior to the
onset of schizophrenia. Therefore, the following criteria specific to this
disorder will be mentioned, in case the patient matches it: poor social and
interpersonal relationships - `I suffered for so many years watching movies
alone`, acute discomfort and reduced ability to develop close relationships -
`when I was a child I suffered like a dog that I could have a girlfriend`,
cognitive distortions- lived the feeling of `deja-vu`, had a premonition that
he will be the next member of the family who will suffer from cancer,
explaining his conviction: `I know this is how it’s going to be, but I cannot
explain why` and with perceptual distortions such as hallucinations and
pseudo-hallucinations. Regarding the prognosis, there is a fine line
that differentiates a positive evolution of the disease from a negative one. On
the one hand, we can talk about a negative evolution, based on the tense family
climate, poor coping mechanisms, repeated discontinuation
or refusal of treatment, but also the patient's suggestibility in front of his
own father. On the other hand, there may be a positive evolution supported by
disease awareness and IQ, which seems to be high. 4.2. TREATMENTIn the aftermath of the patient's latest
hospitalization, a shot of Flupentixol Depot was given to him every two-three
weeks. He followed the treatment for two years and his symptoms improved
considerably. After this time frame, the patient gave up the treatment, because of the fact that his father refused to take him to
the hospital for the administration. Flupentixol belongs to a group of
medicines called neuroleptics. It acts upon the nervous ways, in specific areas
of the brain, and it helps correcting the lack of balance of certain chemical
substances at the level of the brain, which cause the symptoms of the disease.
By supporting the patient's father to have a better relationship with his son,
the latter one can adapt himself better to social life and the symptoms
improvement process can be accelerated and better upheld thanks to the direct
contribution of the people close to him (Schaffer &Rodolfa, 2019). 4.3. CONCLUSIONSWhereas in the recovery of patients with
schizophrenia, the relationship with the family is of crucial importance, the
support of the father in the relationship with his son is highly
recommended. Thereby a mediation between
them could take place and transform a tensioned and destructive relationship
into a beneficial and healthy one. Moreover, this relationship will support the
recovery path of the patient (Lidz&Lidz 1949). Given the responsiveness to
the treatment, the only factor that can positively influence the patient’s
prognosis is the familial relationship, especially in the context of which the
patient represented a high degree of suggestibility, which results from his
behavior in relation with the paternal influence. SOURCES OF FUNDINGThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. CONFLICT OF INTERESTThe author have declared that no competing interests exist. ACKNOWLEDGMENTNone. REFERENCES [1] American
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