Name:
Date:
Agent Johnson
A tall, well-groomed 30-year-old man walked into the emergency room of a large urban hospital, registered under
the name Harry Backman, and asked to be admitted to Ward Three of the psychiatric division. He claimed that,
despite the fact that all of his identification cards bore the name Harry Backman, his real name was Johnson. “And
your first name?” asked the resident psychiatrist. “We’re not allowed to divulge our first names,” he confided. He
went on to explain that in fact he was Agent Johnson, an FBI agent on a mission to find Harry Backman, who had last
been seen in Pittsburgh several years earlier. He claimed to have followed Harry from city to city, often posing as a
patient in the psychiatric hospitals where Harry had been treated in order to obtain information about him. Harry
had a seizure disorder for which he took phenytoin and primidone, and he had also taken trifluoperazine in the past.
Agent Johnson did not take any medications. Communicating with his superiors at the FBI via a high-frequency radio
stashed in his bag, Agent Johnson had come to this hospital in order to be admitted to the very ward on which Harry
Backman had been treated as a 10-year-old boy, in order to seek clues about Harry’s whereabouts. The patient
confided his fear that the “real” Harry was, in fact, dead, and that an imposter might be posing as Harry in order to
collect his welfare checks.
During the interview, the patient was generally cooperative and engaging. His affect ranged from serious to jocular,
and when his story was challenged, he became defensive and hostile. There was no evidence of disorganized speech,
cognitive impairment, or hallucinations. Results of a physical examination, including a thorough neurological
examination, and all laboratory tests were normal.
A call to the shelter where Agent Johnson lived confirmed that his name was Harry Backman, that he carried a
diagnosis of a seizure disorder, and that he was maintained on trifluoperazine, phenytoin, and primidone. These
medications were subsequently prescribed by the emergency room physician. In addition, a social worker at the
shelter said that Harry had been wondering the streets in the past few days, frequently not returning to the shelter at
night. She had not witnessed any seizures, and she did not know anything about Agent Johnson.
On the following day, the patient had a generalized tonic-clonic seizure, lasting approximately 2 minutes, during
which he hit his head on the floor. He was treated in the medical emergency room; all tests, including a computed
tomography scan, were normal. After a brief period of postictal confusion, the patient woke up. He responded to the
name Harry and acknowledged that he had a seizure. The confused resident scratched her head and said, “But I
thought Harry had the seizure disorder!” “I AM Harry!” said the patient with a smile. “I’ve found him!”
Page 1 of 8
Name:
Date:
DSM-IV-TR Casebook Diagnosis of "Agent Johnson"
The only obvious sign of psychopathology in this case is Harry's belief that he is another person, FBI Agent Johnson.
This is clearly a delusion of false identity. Although grandiose delusions of false identity occasionally occur in manic
episodes of Bipolar I Disorder, delusions of false identity almost invariably are symptoms of Schizophrenia.
If we try to make a diagnosis on the basis of the very limited information that we have about Harry, the first task is to
decide whether his delusion is bizarre. Bizarre delusions involve phenomena that do not occur in real life, such as
thought broadcasting or being controlled by an outside force. It is hard to apply the concept of bizarre delusions to
Harry's belief that he is Agent Johnson. On the one hand, there are FBI agents who track down other people, and
people do deliberately change their identities. On the other hand, people cannot literally stop being themselves and
become someone else.
We suspect that Harry's reference to communicating with his superiors via a high-frequency radio indicates that he
probably has auditory hallucinations. The combination of delusions (whether bizarre or not) and hallucinations, plus a
chronic illness with social and occupational dysfunction, in the absence of a mood disorder or a substance or general
medical condition that could account for the disturbance, substantiates a diagnosis of Schizophrenia (see DSM-IV-TR).
We would note the epilepsy only on Axis III, as we doubt that it is etiologically responsible for the disturbance.
Page 2 of 8
Name:
Date:
Low Life Level
Louise Larkin is a pale, stooped woman of 39 years, whose childlike face is surrounded by scraggly blond braids tied
with pink ribbons. She was referred for a psychiatric evaluation for possible hospitalization by her family doctor, who
was concerned about her low level of functioning. Her only complaint to him was, “I have a decline in self-care and a
low life level.” Her mother reports that there has indeed been a decline, but that it has been over many years. In the
last few months Louise has remained in her room, mute and still.
Twelve years ago Louise was a supervisor in the occupational therapy department of a large hospital, living in her
own apartment, and engaged to a young man. He broke the engagement, and she became increasingly disorganized,
wandering aimlessly in the street, wearing mismatched clothing. She was fired from her job, and eventually the
police were called to hospitalize her. They broke into her apartment, which was in shambles, filled with papers, food,
and broken objects. No information is available from this hospitalization, which lasted 3 months, and from which she
was discharged to her mother’s house with a prescription for an unknown medication that she never had filled.
After her discharge, her family hoped that Louise would gather herself together and embark again on real like, but
over the years, she became more withdrawn and less functional. Most of her time was spent watching TV and
cooking. Her cooking consisted of mixing bizarre combinations of ingredients, such as broccoli and cake mix, cooking
them, and then eating them alone because no one else in the family would eat her meals. She collected cookbooks
and recipes, cluttering her room with stacks of them. Often when her mother entered her room, she would quickly
grab a magazine and pretend to be reading, when in fact she had apparently just been sitting and staring into space.
She stopped bathing and brushing her teeth. She ate less and less, although she denied loss of appetite, and over a
period of several years lost 20 pounds. She would sleep at odd hours. Eventually she became enuretic, wetting her
bed frequently and filling the room with the pungent odor of urine.
On admission to the psychiatric hospital, Louise sat with her hands tightly clasped in her lap and avoided looking at
the doctor who interviewed her. She answered questions readily and did not appear suspicious or guarded, but her
affect was shallow. She denied depressed mood, delusions, or hallucinations. However, her answers became
increasingly idiosyncratic and irrelevant as the interview progressed. In response to a question about her strange
cooking habits, she replied that she did not wish to discuss recent events in Russia. When discussing her decline in
functioning, she said, “There’s more of a take-off mechanism when you’re younger.” Asked about ideas of reference,
she said, “I doubt it’s true, but if one knows the writers involved, it could be an element that would be directed in a
comical way.” Her answers were interspersed with the mantra, “I’m safe. I’m safe.”
Page 3 of 8
Name:
Date:
DSM-IV-TR Casebook Diagnosis of "Low Life Level"
Several features of this case suggest the diagnosis of Schizophrenia. There are Louise's extreme decline in functioning
over a period of several years and her many oddities of behavior and speech. In addition, there is no evidence of a
mood disorder or of a general medical condition or substance that could account for this disturbance. What makes
the diagnosis more problematic is the apparent absence of delusions or hallucinations, which are usually present
during the active phase of Schizophrenia.
DSM-III and DSM-III-R did permit the diagnosis of Schizophrenia, even in the absence of delusions and hallucinations,
if there were two of the following three symptoms: incoherence or marked loosening of association, catatonic
behavior, or flat or grossly inappropriate affect. It would have been difficult to diagnose this as a case of
Schizophrenia without stretching these criteria. Louise's speech is at times incoherent, but her affect, although
described as shallow, is not flat or grossly inappropriate, and she has no catatonic symptoms. The criterion describing
the characteristic symptoms of Schizophrenia in DSM-IV (and DSM-IV-TR) includes additional negative symptoms:
alogia (poverty of amount or content of speech) and avolition (pervasive inability to persist in goal-directed
activities). Because her speech is at times incoherent and she is unable to work or cope with more than minimal selfcare (avolition), the DSM-IV-TR diagnosis would be Schizophrenia (see DSM-IV-TR).
Page 4 of 8
Name:
Date:
Emilio
Emilio is a 40-year-old man who looks 10 years younger. He is brought to the hospital, his twelfth hospitalization, by
his mother because she is afraid of him. He is dressed in a ragged overcoat, bedroom slippers, and a baseball cap and
wears several medals around his neck. His affect ranges from anger at his mother (“She feeds me crap…what comes
out of other people’s rectums.”) to a giggling, obsequious seductiveness toward the interviewer. His speech and
manner have a childlike quality, and he walks with a mincing step and exaggerated hip movements. His mother
reports that he stopped taking his medication about a month ago and has since begun to hear voices and to look and
act more bizarrely. When asked what he has been doing, he says, “Eating wires and lightning fires.” His spontaneous
speech is often incoherent and marked by frequent rhyming and clang associations (speech in which sounds, rather
than meaningful relationships, govern word choice).
Emilio’s first hospitalization occurred after he dropped out of school at age 16, and since that time he has never been
able to attend school or hold a job. He has been treated with neuroleptics during his hospitalizations but doesn’t
continue to take medications when he leaves, so he quickly becomes disorganized again. He lives with his elderly
mother, but sometimes disappears for several months at a time and is eventually picked up by the police as he
wanders in the streets. There is no known history of drug or alcohol abuse.
Page 5 of 8
Name:
Date:
DSM-IV-TR Casebook Diagnosis of "Low Life Level"
The combination of a chronic illness with marked incoherence, inappropriate affect, auditory hallucinations, and
grossly disorganized behavior leaves little doubt that the diagnosis is chronic Schizophrenia. The course would be
noted as Continuous because Emilio apparently never has prolonged remissions of his psychosis. The prominence of
his disorganized speech and behavior, his grossly inappropriate affect, and the absence of prominent catatonic
symptoms indicate the Disorganized Type.
Page 6 of 8
Name:
Date:
Oberrealschul Student
The patient I will show you today has almost to be carried into the room, as he walks in a straddling fashion
on the outside of his feet. On coming in, he throws off his slippers, sings a hymn loudly, and then cries twice (in
English), “My father, my real father!” He is 18-years-old, and a pupil of the Oberrealschul (high school), tall, and
rather strongly built, but with a pale complexion, on which there is very often a transient flush. The patient sits with
his eyes shut, and pays no attention to his surroundings. He does not look up even when he is spoken to, but he
answers, beginning in a low voice, and gradually screaming louder and louder. When asked where he is, he says, “You
want to know that too; I tell you who is being measured and is measured and shall be measured. I know all that, and
could tell you, but I do not want to.” When asked his name, he screams, “What is your name? What does he shut? He
shuts his eyes. What does he hear? He does not understand; he understands not. How? Who? Where? When? What
does he mean? When I tell him to look, he does not look properly. You there, just look! What is it? What is the
matter? Attend; he attends not. I say, what is it, then? Why do you give me no answer? Are you getting impudent
again? How can you be so impudent? I’m coming! I’ll show you! You don’t turn whore for me. You mustn’t be smart
either; you’re an impudent, lousy, shameless, miserable, lousy fellow I’ve never met with. Is he beginning again? You
understand nothing at all – nothing at all; nothing at all does he understand. If you follow me now, he won’t follow,
will not follow. Are you getting still more impudent? Are you getting impudent still more? How they attend, they do
attend,” and so on. At the end he scolds in quite inarticulate sounds.
The patient understands perfectly, and has introduced many phrases he has heard before into his speech,
without once looking up. He speaks in an affected way, now babbling like a child, now lisping and stammering, sings
suddenly in the middle of what he is saying, and grimaces. He carries out orders in an extraordinary fashion, gives his
hand with the fist clenched, goes to the blackboard when he is asked, but, instead of writing his name, suddenly
knocks down a lamp, and throws the chalk among the audience. He makes all kinds of senseless movements, pushes
the table away, crosses his arms, and turns round on his axis, chair and all, or sits balancing, with his legs crossed and
his hands on his head. Catalepsy can also be made out. When he is to go away, he will not get up, he has to be
pushed, and calls out loudly, “Good morning, gentlemen; it has not pleased me.”
…The patient himself was always quiet and very industrious, but of moderate mental endowment. Seven
months ago, during the holidays, he suddenly began to learn in a quite senseless way, and then became confused,
thought he was laughed at for being dirty, and washed himself all day long, was afraid his effects would be taken,
broke the windows, seemed to hear voices, attacked his mother without any cause, became wet and dirty in his
habits, and would not speak a word. In the hospital he was almost dumb, was cataleptic, gave his hand stiffly and
jerkily, and almost entirely refused to eat. His expression was generally indifferent, though sometimes cheerful, and
visits from his relations made no impression at all on him.
The patient understood quite well what was taking place around him, but as a rule he did not obey orders;
indeed, he sometimes did the exact opposite of what was wanted. Thus, he shut his eyes when his pupils were
mentioned, covered his face with his handkerchief if you wished to see it, and drew his hand back when he ought to
have stretched it out. He was often dirty, and also smeared feces about, and rolled them into little balls – a sign
diagnostic of great emotional dullness. After refusing food for a long time, he suddenly asked for Swiss cheese and
then for chocolate, and devoured them both greedily. From this we can plainly see the senseless and impulsive
nature of his refusal of food. Once he laid his outstretched leg on the next bed, and remained in that position when
the bed was moved away. In the seventh month of the illness the patient began to be excited, after having sung
occasionally during the period of dumbness. In the middle of the night he threw away his bedding, rocked
rhythmically up and down on the bedspread, and screamed incessantly, “Now, I want you to know where my brother
is.” Since then he has been in a continual state of excitement, is destructive and abusive, and talks in a confused way.
He briefly informed his relations, from whom he takes the eatables they bring when they come to see him, without
talking to them much, that he was going to travel by Gibraltar to the Cameroons and by Constantinople to Bucharest.
Page 7 of 8
Name:
Date:
DSM-IV-TR Casebook Diagnosis of "Oberrealschul Student"
In the absence of any known general medical condition that could account for the disturbance, the combination of
disorganized speech and catatonic behavior (stupor and excitement) clearly indicates the diagnosis of Schizophrenia
(see DSM-IV-TR). The diagnosis is further confirmed by the history of onset of symptoms 7 months previously, with a
clear deterioration in functioning. Although the hyperactivity, confused speech, and irritability might suggest a Manic
Episode, there is no description of a period with a persistent elevated, expansive, or irritable mood. Although the
patient often is irritable and even violent, his mood seems to fluctuate unpredictably. In contrast, when irritability is
seen in mania, it usually is a response to frustration of grandiosity or hyperactivity.
Although delusions and hallucinations have been present, the most prominent and persistent features are the
disorganization of speech and behavior. The patient's frequent incoherence and grossly disorganized behavior are
characteristic of the Disorganized Type of Schizophrenia. However, there are also numerous prominent examples of
classic catatonic behavior: he exhibits negativism (e.g., refuses to do what is asked of him or does the opposite),
catatonic excitement (e.g., excessive motor activity that is purposeless and not influenced by external stimuli), and
posturing (e.g., kept his leg in an awkward position). In DSM-IV-TR, the Disorganized Type is not diagnosed if the
clinical picture is dominated by catatonic symptoms, which represent more specific forms of disorganized behavior.
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