A complex case of Schizophrenia and Factitious disorder one year later

Dr. Elizabeth Coleman and members of the forensic team presented a compelling case study of a patient called Miss X and her continued journey to recovery one year later, in the latest Grand Rounds session.

Miss X diagnosed with Schizophrenia was a challenge to the team, and who presented as treatment resistant and prone to frequent acts of violence. To protect her from herself or from causing harm to others, Miss X had been in and out of seclusion for the past two years and relied heavily on chemical restraints.  When she was taken out of seclusion, she would wear a five point harness in a modified wheelchair which restricted her movement.  Miss X also had a five person team to move her from the seclusion room to the modified wheel chair and a person with her at all times.

Now one year later, Miss X is no longer in seclusion and has no need for the restraints.  She continues to work with the team on her recovery journey.

It was a diagnosis of Factitious disorder that opened up the possibility of a different treatment plan for Miss X.  Factitious disorder presents when there is falsification of signs or symptoms associated with identified deception, where the person presents himself to be ill and exaggerates symptoms and where there is noted deceptive behaviour in the absence of no obvious external rewards.  Miss X presented with these symptoms.

So what worked?  The team did not believe that additional medications was the solution.  In fact, Miss X often refused medication.  Upon deliberation, the team felt that the alternative approach was to give Miss X some control.  This was a multidisciplinary approach, with nursing staff realizing that they had to acknowledge their fear when the recommendation was made to remove the restraints.

“It is easy to get wrapped up in behaviours and we were determined to not do that and focus instead on why we are here.  We aimed at looking at the human side of the person and realized we were working with her and not against her illness,” shares the team.

They created a mini team who would work directly with Miss X.  The team quickly realized that the voices that Miss X would say she heard and that would tell her to do violent things were a coping strategy for her and a way to reassert some control.  It was therefore key for the team to work with Miss X to help her regain some control.

The lesson from Eleanor Longden, herself a voice hearer, was a good starting point for the team.  “We can learn to cope not only with the voices but also with the underlying social and emotional problems that the voices represent.  We can deconstruct the voices as symptoms and reconstruct them as meaningful experiences.”

The team continues to work with Miss X and her family, who has made tremendous gains in her recovery this past year. “While Miss X needed the team to come together with different skills, views and ideas, the team needed time to acknowledge gains and reassess.  We need to challenge the definition of recovery to mean not the extinction of all symptoms but a functional happier person, who can develop relationships and do the things that she enjoys,” says Dr. Coleman.