Schizophrenia: A Case Study of the Movie

A BEAUTIFUL MIND

Learning Objectives

This guide is designed to be used as a companion to the Universal Studios film, A BEAUTIFUL MIND, which can be rented or purchased in DVD or VHS format from a vendor of the user s choice. It will explain, demonstrate and guide participants in the application of knowledge about symptoms, diagnosis, social, vocational and educational impairment treatment, psychiatric rehabilitation and disability management for a person who has schizophrenia. It will explain DSM-IV-TR multiaxial diagnostic criteria, positive and negative symptoms, mental status, 1st and 2nd generation antipsychotic medications, family intervention, consumer perspectives and the opportunity to apply the material through its Interactive Review and Interactive Review Response Guide. The movie portrays a textbook example of the disorder and is valuable for learning about the illness. It should be emphasized that the Hollywood effect may tend to over/under exaggerate the symptoms and behaviors experienced by many individuals with this disorder.

Table of Contents

Scene/Section Content Description Introduction Mathematics Introduction to main characters, Reasons for delays in diagnosis and treatment, Unique ability to see patterns, Introduction to schizophrenia including age of onset, positive and negative symptoms, hallucinations and delusions

A Challenge

Social and academic impairment, Theprodrome period The Need to Focus

Manifestation of hallucinations, impoverished fluency and productivity of thought and speech, inability to focus, diminished impulse control, prodromol symptoms Governing Dynamics

Absence of symptoms, Flat affect The Pentagon

Reemergence of positive symptoms including ideas of reference and cognitive impairment in executive functioning Teacher and Student

Impaired connecting symptoms Code Breaker

Emotional stress and pain, Intensification of positive symptoms including delusions of grandeur, visual and tactile hallucinations Alicia

Full blown manifestation of positive and negative symptoms The Prodigal Roommate

More interpersonal stress, More intensified positive symptoms, Over elaborate speech

The Wedding

Residual phase of illness, Mental status examination Trouble

Full blown psychosis, Delusions of persecution Dr. Rosen

Psychiatric intervention Mental Illness

DSM-IV-TR multiaxial diagnostic criteria for schizophrenia and paranoid schizophrenia, Devastation of illness to the individual and the family Treatment

Electroconvulsive therapy (ECT), First psychotic episode-a critical period, Low stress environment, Multimodal treatment, Multi-element programs,1st and 2nd generation antipsychotic medication and side effects, Medication noncompliance and long-acting injectable antipsychotic medication, CATIE studies comparing 1st and 2nd generation agents, Current research targeting the Glutamate theory, Alerts for neuroleptic malignant syndrome and agranulocytosis, Psychiatric rehabilitation and family intervention including psychoeducation, behavioral problem-solving, family support, crisis management

Delusions

Treatment of positive symptoms vs. impaired life functioning, Medication compliance vs. noncompliance, Reasons for inconsistencies with treatment, Interventions for continuity of care, Symptom driven impulsive (dangerous) behavior, Command hallucinations, Risk for suicide / homicide, Cognitive remediation and scaffolding, Disability management

Princeton

Psychiatric rehabilitation, Rehabilitation readiness determination, Skill development, smoking prevalence, cessation and health risk to people with schizophrenia, Physical illness and schizophrenia Goodbye, Old Friends

Cognitive remediation and errorless learning A Nobel Prize

More disability management techniques, Recovery from schizophrenia is not unique Interactive Review and Response Guide

References

First Three Scenes/Sections

With the movie, A Beautiful Mind, Ron Howard and Universal Studios provide an opportunity to learn about the illness, schizophrenia, a disease of the brain that impairs an individual s perceptions, concentration, and social interaction and, thus, can be quite disabling. It is characterized by a person s perception of reality which can be very different from the way most other people perceive the same reality. This guide will assist the reader, while viewing the movie, in learning about this illness and its effect on people who have it, their families and their friends. To make the best use of this guide:

1.

VIEW THE FILM IN ITS ENTIRETY, then

2. READ THE GUIDE, SECTION BY SECTION, AS YOU REVIEW THE CORRESPONDING SCENE FROM THE FILM.

The power of this movie is that it is written and filmed from the perspective of a person with schizophrenia as well as from the perspective of others. Thus, it presents not only what is observed about John externally through society s reality; it also demonstrates what drives John internally through his unique reality. It demonstrates how an action or behavior of a person with schizophrenia can appear to be bizarre to an observer while appearing so appropriate to the person experiencing it.

Mathematicians

The film opens in September, 1947, as the Chairperson of Princeton University s mathematics department, Professor Helinger, welcomes the incoming class of mathematicians. Although the significant players are not formally introduced, non-verbal behavior introduces the two who stand out from the group. One demonstrates a feeling of superiority by leaning on the edge of the table with his back to many of the students who are seated on chairs around the table. The other demonstrates a feeling of uneasiness by placing himself behind the entire group, somewhat like an outsider, his hands fidgeting and his eyes mostly fixed the floor. Both students demonstrate a keen awareness of each other.

As John Nash, the person who positioned himself behind the group, and some of the other major players are introduced, it is learned that John is one of the two recipients of a prestigious prize, the Carnegie Scholarship. John is described as a mysterious genius by his major competitor, Martin Hansen, the other recipient of the Carnegie Scholarship. Martin s information infers that John s behaviors have, in fact, been noted to be strange, peculiar and perhaps, mystifying. Martin s does not infer that these behaviors are due to a mental illness.

Martin s inferences are a reminder of the long delays that occur in the diagnosis and treatment of people with schizophrenia, due to various reasons like, patients and family members may not recognize subtle symptoms while abnormal thoughts and behaviors may be attributed to substance abuse, stress or other factors. Stigma, lack of health insurance, or other barriers to accessing medical care may also play a role Whatever the reasons, the duration of untreated psychosis is thought not only to predict initial treatment response in patients with schizophrenia, but may also affect long-term outcomes. More specifically, it has been found that the less time psychosis goes untreated, the more likely it is that antipsychotics would produce a response, including relief from positive symptoms like hallucinations

and negative symptoms like social withdrawal, which will be discussed in more detail later in this e-book (Health Letter-J, 2008. P1).

Because treatment occurs so late in the disease process when the presence of positive symptoms becomes obvious, researchers worldwide have been testing drugs, omega-3 supplements, and psychotherapy with mixed results - taking on the challenges of early detection or even prevention of schizophrenia, perhaps in the prodromal phase. This phase involves an intensification of social difficulties and muted or fleeting psychotic symptoms, such as strange thoughts, odd perceptions, or hearing or seeing something that is not there. The hope is that early intervention efforts might alter the disease course in a way that would improve outcomes and prevent disability. However, preventing schizophrenia is still more dream than reality (Harvard Mental Health Letter - B, 2009, pp. 4-5).

Observational note for later discussion: John demonstrates a unique ability to see patterns with a pattern rising off the glass and synchronizing with patterns on Neilson s tie. Perhaps this may be related to the characteristic of schizophrenia in which there is an assault on one s senses and, therefore, when one sees something, it may look very bright, distorted in color or shape.

In time the scale does tip toward mental illness. John Nash has reached the age coupled with the conditions that surround a schizophrenic break. He has the stress of a new, unfamiliar and competitive environment. His social isolation becomes painfully apparent, i.e., his major competitor humiliates him by his inference that John can be mistaken for a waiter rather than a student of mathematics. John retreats to his room from that situation only to experience further isolation as he looks from his window at students on the outside interacting with one another. At this moment of high stress, a positive symptom of schizophrenia emerges, a hallucination.

According to the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR) (American Psychiatric Association, 2000, p.299), the symptoms that characterize schizophrenia fall into two groups:

Positive - an access or distortion of normal functions, such as, thinking and ideas (delusions), perception and sensations (hallucinations and illusions) and language and communication (disorganized or bizarre speech).

Negative - a deficit or loss in normal functioning, such as,the range and degree of emotions (flat affect), the fluency and productivity of thought and speech (alogia) and the initiation of goal-directed behavior (avolition).

A hallucination is a false sensory perception in the absence of a real external stimulus. It may be induced by emotional and other factors such as drugs, alcohol, and stress. It may occur in any of the senses, thus a person may experience seeing, hearing, touching, smelling and/or tasting something that does not exist (Kaplan and Sadock, 1991, p.202).

So, at a time of high stress from competition and social isolation, John experiences the friendship of Charles via auditory and visual hallucinations. This friendship/hallucination appears to help John survive as it eases John s painful isolation and allows John some social moments and some social drinking, away from mathematics. John uses this opportunity to state to himself, through the image of Charles, that, I don t like people much and they don t like me. Through the image of Charles, John, is able to say to himself that he will not find the higher truth in something as boring as mathematics. In addition, a delusion of grandeur is emerging, i.e., he believes he is superior to the professors and the theorists to be studied in text books as he refers to them as lesser mortals.

A delusion is a false belief, based on incorrect inference about external reality, not consistent with an individual s intelligence and cultural background that cannot be corrected or reasoned.

Delusions of grandeur are exaggerated ideas of one s importance or identity (Kaplan and Sadock, 1991, p. 219).

A Challenge

John is seen on the campus grounds, without Charles, interacting with his peers. Time has passed and John has not attended classes. It also appears that his bizarre thinking has increased as a peer refers to John as psycho, and there is a bizarreness in John s appearance as John is wearing sneakers, white socks and ill fitting pants as he sits next to his peers who all have leather shoes and stylish clothing. The stress of the competition is reinforced as Martin defeats John in a mathematical board game while also reminding John that two colleagues, Bender and Sol, have published a paper and Martin, himself, has

two papers under review. The defeat causes John to rush away from his peers with a very obvious physical clumsiness.

The appearance of physical clumsiness may occur along with other changes like problems with attention and social withdrawal during, what was mentioned earlier as, the prodromal phase of the illness. This period occurs for some time prior to full-blown psychosis. Thus, John, like many other people with schizophrenia, appears to be ill for some time before his psychotic symptoms appear. Psychotic symptoms usually occur later in the disease process (Harvard Mental Health Letter - H, 2008, p. 1).

The Need to Focus

The newly reinforced stress leads John to hold up for two days in the library searching for an original idea and he begins to formulate his original idea. However, once again a high level of stress from competition and isolation trigger John s hallucination of Charles, the playful friend. The hallucination of Charles allows John to take himself from the library to a social environment to eat, drink beer, play pool and be with his peers.

In this bar scene, in addition to John s positive symptom experience of the hallucination of Charles, his negative symptoms of schizophrenia are apparent. There is a deficit in John s fluency and productivity of thought and speech. Specifically, his peers tease him and send him to approach a woman at the bar. However, given his seriously impaired social interactions which he has communicated earlier in his own voice and in the voice of Charles, John approaches this as a mathematical problem, reminding his friends that his odds of success dramatically improve with each attempt. He approaches the woman but is unable to say a word. She breaks the ice and then John says, I don t exactly know what I m required to say in order for you to have intercourse with me.... She, of course, slaps him and leaves. His friends have a good laugh but John is able to comfort himself via his hallucinatory friend, Charles.

John, although brilliant, does not attend classes and has not published any papers. It appears from an earlier conversation that John believes all he has is his mind. However, in this scene John is confronted with possible failure and loss of what he believes is his only asset, his mind. Professor Helinger tells John that he may not get a placement as he did not, focus. John s inability to focus may be an alteration of cognition that is due to his schizophrenia.

Cognition refers to intelligence, memory, academic skills and the ability to use these skills. It is the ability to acquire knowledge, to plan, to make use of one s perceptions and to reason out problems or difficulties. (Fischler and Booth, 1999, p. 2).

Cognitive impairment is recognized as an integral characteristic of schizophrenia with deficits appearing in tasks that require attention, verbal fluency, memory and executive functioning. These impairments are much more influential on social and vocational functioning and quality of life than are psychotic symptoms of the illness. (Tasman, Kay and Lieberman, 2003, p.242).

Following the high stress of this rejection by his professor and the confrontation of pending failure and loss, John s symptoms of schizophrenia, negative, positive and cognitive, are invoked.

John s ability to focus is impaired and he struggles, thinking if he faces the wall rather than the window, he ll be better able to concentrate. At this point John s stress reaches a summit and John bellows about, complaining of the expectation of, their requirements...to follow their rules, read their books and go to their classes..., activities that he has probably been unable to partake in because of cognitively impaired concentration and executive functioning.

A note about rejection, failure and loss: These factors increase one s risk for suicide. Other factors of concern for John that increase suicidal risk include, being unmarried, not working, feeling hopeless, experiencing psychic anxiety, loss of his mental health, and a low level of social involvement/support (Kaplan and Sadock, 1991, p.555).

John s hallucination of Charles, a positive symptom, appears, as well. An explosive episode occurs as John is caught in an internal struggle between his mathematical brilliance and his cognitive impairments. He acts out his struggle in a fight with himself. (The fight is seen from John s perspective, so it does not appear to be odd. For John, Charles is real. However, in reality Charles does not exist and John is fighting with himself). In his desperation, his thoughts include suicide, go on, bust your head, kill yourself , and his behavior includes diminished impulse control, i.e., throwing the desk out the window. However, he is able to attribute those thoughts and actions to Charles, rather than himself. Following each of these actions, the voice of Charles also reinforces John s belief in himself through words of support, friendship and recognition of John s brilliance. Thus, John prevails.

From the time of John s arrival at Princeton University until this point prodromal symptoms of his illness, as mentioned earlier, symptoms prior to the full syndrome before the full onset of the illness- have appeared which include deterioration in functioning and an increase in positive and negative symptoms.

Kaplan and Sadock (1991, p.333) identify prodromal or residual symptoms as social isolation or withdrawal, impairment in role functioning as wage-earner, student, or homemaker, peculiar behavior (eg., collecting garbage, talking to self in public, hoarding food), impairment in personal hygiene and grooming, blunted or inappropriate affect, digressive, vague, overelaborate, or circumstantial speech, or poverty of speech, or poverty of content of speech, odd beliefs or magical thinking, influencing behavior and inconsistent with cultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, sixth sense, others can feel my feelings, overvalued ideas, ideas of reference*), unusual perceptual experiences (e.g., recurrent illusions, sensing the presence of a force or person not actually present) and lack of initiative, interests or energy.

*to be defined later in the text