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A Beautiful Mind:Case Study of John Nash

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jenny gavin

on 19 November 2013

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Transcript of A Beautiful Mind:Case Study of John Nash

A Beautiful Mind:Case Study of John Nash
Presentation of the Character of John Nash
Patient Identification
Symptoms
Development History
Personal History
Mental Status Examination
DSM IV Diagnosis
DSM V Diagnosis
Differential Diagnoses
Clinical Formulation
Patient Identification:

Name: John Nash

Gender: Male

Profession:
1948 PhD Student at Princeton University, and co-winner of the Carnegie Scholarship.

Upon completion worked at Wheeler labs

1979 Returns to teach at Princeton

Marital Status: Married with child



Definitions:

Delusion; "delusions are fixed beliefs that are not amenable to change in light of conflicting evidence"

Hallucination; "Perception like experiences that occur without an external stimulus"



Symptoms and observed problematic behaviours:

Hallucinations
1. Charles
2. Parcher
3. Marcee

Delusions:

Paranoid, Grandiose, Persecutory.

Loss of Function:

Interpersonal Relations
Work

Development History:

The first hallucination occurs when he starts at Princeton.

There was no further development for 5 years at which point a second hallucination (Parcher) developed, along with a delusion that he is vital to the Cold War battle with Russia. This occurs at the same time he feels unrecognised and under appreciated in his career

The third hallucination (Marcee) develops during a personal stressful time when he is trying to ask Alicia to marry him, and the hallucination of Marcee can offer him the emotional certainty he desires.

The delusion develops further as more life stressors impact upon him, particularly the discovery that he's about to become a father changes the delusion into a persecutory delusion from it's previous grandiose state.

It is at this time he starts to experience loss of function within his work and interpersonal relationships.

These delusions and hallucinations remain during hospitalisation, until with a combination of insulin treatment and medication they are controlled.

He had a recurrence one year after being released from hospital after he stops taking the medication, and it is at this point that he argues that he can rationalise the delusions and hallucinations away. Showing a level of insight not previously achieved. Again, loss of function was noted.

With ongoing newer medications and his ability to rationalise away the delusions and hallucinations, the symptoms do not develop further
Diagnostic Criteria of the DSM IV

Axis I
- 295.30 Paranoid Schizophrenia
Axis II
- None
Axis III
- None
Axis IV
-
Has just started Princeton.
Stress of trying to find a ‘truly original idea’ in order to ‘matter’.
Stress of maybe not receiving his desired placement at Wheeler.
Stress of wife being pregnant.
Axis V
- GAF Score between 21-30

Axis I - All psychological diagnostic categories.
Paranoid Schizophrenia.

• Prominent delusions and hallucinations: delusions are mainly grandiose, paranoid and persecutory.

• Prominence of positive symptoms of the ‘psychotic dimension’, i.e. delusions and hallucinations.

• Disorganised speech, flat affect, catatonic and disorganised behaviour are not prominent. Cognitive functioning remains largely unaffected.

Criteria (A) Characteristic Symptoms

A1 Delusions- Met!
A2 Hallucinations- Met!
A3 Disorganized Speech- Not Met
A4 Grossly Disorganized or Catatonic Behaviour- Not Met
A5 Negative Symptoms- Not Met


Criteria B Social /Occupational Dsyfunction- Met

Low interpersonal relations – Function as a father: Is unable to care for his son and almost kills him.
Although he marries it is questionable if this marriage would have lasted if not for her unconditional love.
Education- He was unable to function adaquately at work as he was preoccupied with collecting and analysing newspaper articles.

Criteria (C) 1 month of active symptoms
within a 6 month period-Met


Criteria (D)
Schizoaffective and Mood Disorder Ruled out!

Criteria (E)
Disturbance is not due to the direct physiological affects of a substance or a general medical condition.

Criteria (F)
No history of Autism or a Pervasive Developmental Disorder.
Axis II- Personality Disorder or Mental Retardation - None.

Axis III- General Medical Conditions- None

Axis IV - Psychological and Environmental Factors:
Stress of starting at Princeton.
Trying a find a 'truly original idea' in order to 'matter'.
Stress of perhaps not getting his desired placement at Wheeler.
Stress of his wife being pregnant.


Axis V - Global Assessment of Functioning Scale(GAF):

On Admission: GAF scores generally fall between 21-30; Presence of hallucinations or delusions which influence behaviour.

Recurrence: GAF score between 11-20 during his relapse after he stopped taking his medication and nearly kills his son; There is some danger of harm to self or others.

Current: GAF score between 61-70; Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some interpersonal relationships.

Differential Diagnosis:

Delusional Disorder.

A. The presence of one or more non-bizarre delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has not been met.

C. Apart from the impact of the delusions , functioning is not markedly impaired , and behaviour is not markedly odd.

D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional period.

E. The disturbance is not attributable to the physiological effects of a substance or any other medical condition and is not better explained by another mental disorder.



Differences between the DSM IV and the DSM 5






Schizophrenia - DSM 5

A.Two or more of the following, each present for a significant portion of time during a month period
Delusions
Hallucinations
Disorganised Speech
Grossly disorganised behaviour
Negative symptoms

B. For a significant portion of time since onset, level of function in one or more major areas is markedly below the level achieved prior to onset (i.e.. Work, interpersonal relations, self care).

C. Continuous signs of the disturbance persist for at least 6 months. And this time must include at least 1 month of symptoms that satisfy Criteria A.

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out.

E. The disturbance is not attributable to the physiological effects of a substance or any other medical condition.

F. If there is a history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions and hallucinations are also present for at least 1 month.
Differential Diagnoses:
Delusional Disorder.

A. The presence of one or more delusions with a duration of 1 month or longer.

B. Criteria A for schizophrenia has not been met.

C. Apart from the impact of the delusions , functioning is not markedly impaired , and behaviour is not markedly odd.

D. If manic or major depressive episodes have occurred , these have been brief relative to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance or any other medical condition and is not better explained by another mental disorder
Schizoaffective Disorder:

A. An uninterrupted period of illness during which there is a major mood episode, concurrent the Criterion A of schizophrenia.

B. Delusions and hallucinations for 2 or more weeks in the absence of major mood episode during the lifetime of the illness.

C. Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance or another medical condition.

Schizotypal Personality Disorder:

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort, and a reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour which include,
as indicated by 5 of the following
:
Ideas of reference.
Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms.
Unusual perceptual experiences
, including bodily illusions.
Odd thinking and speech.
Suspiciousness and paranoid ideation.
Inappropriate or constricted affect.
Behaviour or appearance is odd
,
eccentric , or peculiar.
Lack of close friends or confidants, other than first degree family members.
Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.

B.
Does not occur exclusively during the course of schizophrenia
, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.


Clinical Formulation
Patient name:
John Nash, 66, married, employed at Princeton University

Model:
This formulation should be conceived of within a biopsychosocial model, with a genetic predisposition, interacting with environmental stressors, resulting in the development of symptoms, and in the long term the development of schizophrenia.
Symptoms:
Has three main hallucinations, each of which offer to fulfil an emotive need experienced.
Hallucinations
Charles – offers friendship and companionship
Marcee – offers unconditional love and support
Parcher – offers an outlet for acknowledgement of his genius and brilliance

Delusion
The patients main delusion is based around geo-political espionage, and the concept of being a spy for the pentagon, which operates through the hallucination of Parcher. This delusion is both grandiose and paranoid in nature, as it allows him to be vital to cracking Russian codes but also makes him suspect the Russians are after him.


Clinical Formulation Cont.

Stressors:
The onset of each hallucination and the delusions are precipitated by a major personal stressor, such as moving to Princeton, preparing to ask his wife (Alicia) to marry him, discovering he’s going to become a father. Stress also exacerbates his hallucinations and makes them more prominent within his mind, presumably as they offer emotional support during stressful moments i.e. returning to Princeton.

Treatment difficulties:
In 1955 he received 50 treatments of insulin and was released from the institution with on going medical treatment. The medication led to a higher loss of function both socially and cognitively, to the point whereby he couldn’t care for his child, be intimate with his wife or do his mathematical work. He stopped taking his medication after a while, leading to a recurrence of the schizophrenia, but led to John discovering he could rationalise away his hallucinations and delusions, and he continues to control them through rationalisation and ignoring recognised hallucinations.


Any Questions??

Do you agree with the diagnosis of schizophrenia, or do other disorders fit better?

Would you place the clinical formulation within the framework of a different clinical model?

If you can rationalize away a delusion does it remain a delusion? Therefore can you still diagnose schizophrenia on the criteria?

DSM IV
1. Presence of at least two symptoms on Criterion A.

However if delusions are bizarre there is only a need for 1 symptom

2. Subtypes of Schizophrenia

Paranoid
Catatonic
Disorganised
Residual
Undifferentiated



DSM 5
1. Presence of at least two symptoms on Criteria A

Reference to bizarre delusions is removed

2. Subtypes have been removed



Personal History

Graduated from Princeton with a PhD in Maths based on his equilibrium dissertation on economics.
Employed at the Wheeler Defence Labs.
Is twice called to the Pentagon to analyse Russian codes which leads to the development of delusions.
Nash gets married and has a baby.
Hospitalized with schizophrenia.
Manages to deal with his delusions and hallucinations through rationalisation.
During 1978 John develops friendly relations with Princeton students and starts teaching.
Wins the Nobel prize in 1994.

Mental Status Examination

Insight
No initial insight into hallucinations or delusions, even with ongoing treatment. Only gains some level of insight with the realisation that Marcee never grows old and from here can rationalise and perceive which thoughts are delusional and identify hallucinations.


Activity Levels
Activity levels remain largely unchanged throughout the development of the disorder, with only medication resulting in avolition.

Bizarre Behaviour
Nash occasionally exhibits bizarre behaviour but this behaviour is always related to interaction with his delusions and hallucinations.


Mental Status Examination
Appearance

Ethnicity
American
Notable movement
Not specific movements (Normal)
Adherence to social conventions
Certain kind of distance with everyone
Grooming
Good
Build (body type)
Average
Psychomotor activity
Normal




Interpersonal behaviour
Courageous
Isolated
Distant
Withdrawn
Speech
Fast
Clear
Coherent
Sometime monotonous
Eye contact
Good

Mental Examination Cont.

Mood

Anxious
Sad
Irritated
worry
determined

Orientation

Oriented to person
Diminished sense of time
Too much time at work
Going to class late or not at all
His dates with Alicia

Intellectual Function

Well above average
Clarity of mind
Advanced level of knowledge in maths
Good use of vocabulary
Concentration on his own task of finding patterns
Cognitive functioning
Excellent visuo-spatial, abstraction, memory, executive functioning (linked to his maths ability)
No negative symptoms


Mental Examination Cont.

Thought Processes

Coherent within his occupational context
Made sense to the listener
Pattern seeking behaviour
For example:
extract an algorithm to define the birds movement
Cluster of pigeons fighting over bread crumbs
Watching a mugging
Watching a football team
Goal directedness
Gets to the point in a direct manner
Associations
No thought blocking or flight of ideas but there is:
Looseness of associations between reality and imagination
False perceptions
Visual, auditory and sensory hallucinations
Non-bizarre delusions (persistent false beliefs)
e.g. the military forces him to decode articles, magazines and newspapers
Generally not dangerousness
Could cause harm to self and others
Full transcript