Case Study 1
Schizophrenia - Case of Madeline
Madeline came into the outpatient acute psychiatric unit in the early morning. She arrived
at 6am although she knows that there is no clinic before 9 am. Madeline rarely made
appointments with her outpatient psychiatrist, but sometimes she would request to see her
clinic nurse, also she never kept her appointments. She just popped in spontaneously and
sat in the hall until the nurse could squeeze her into the remnants of her schedule. She
looked homeless, but she was not homeless. She lived in a low-income apartment outside
the city. Madeline rode the bus for about an hour each way, but she said that she enjoyed it
because it was about the only time she got out of her apartment.
Madeline had been living in her apartment for many years. She was a white woman with
shoulder length, brown, tough hair. She was about 50 years old, but she looked 65. Her
hygiene was very poor, and her teeth were visibly rotten. She had many fresh superficial
cuts on her wrists and arms, and few old scares, but she never wanted to talk about it. She
was very thin, and her eyes bulged from her head. She was very slow in speech and in
expressing herself. Madeline abused alcohol, and it is possible that she was usually
intoxicated when she made an appearance at the clinic. She usually sat in the hall in an
oversized, black coat with a few crumpled plastic grocery bags at her feet in the floor. She
used these little bags as a purse, and there were random items inside, usually a bottle of
some kind of liquor wrapped in more bags.
The first time I talked with Madeline, it was less of a conversation and more of an
opportunity to get acquainted with her and to know about her illness. She usually refuses
psychiatric medications, although she used to take them few years ago, because she was
certain they were "poison". Madeline is off all her medication at the moment; however, she
did like to drink alcohol, which professionals see as self-medication for the suffering of
untreated symptoms.
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Madeline talked to me for an hour at the first meeting with her about how she was
"married to a man from the FBI" and how they had "children together". Although she told
me their names, she said she had no contact with the kids or anybody else in her family. She
did not act very upset over the matter, and she seemed emotionally detached from it. I
could neither find her children through public searches nor could I find a record of the "FBI
agent" to whom she claimed to be married. Just because I could not verify the information
does not mean that it was not true; but, likely, her "marriage" to the "agent” was a story she
likes to talk about. Of course, it could have been true. She also claimed that she had been an
actress for many years and traveled "all over the world" but did not really provide any
concrete details. As an actress, she claimed that her manager has “sold her out cheap” after
she refused to have an affair with him”. Madeline told the story as if she was speaking of
someone else’s story and not her own. Madeline’s x-FBI husband still sometimes talks to
her, but in a secret way. She insists that he “knows how to get in touch with her without
raising any doubt” especially with her upstairs neighbor “Jacky the witch” who really hates
her and planning to poison her. In fact Madeline mentioned this neighbor few times in the
past as a dark witch who enjoys watching people suffer.
Madeline denied hearing any strange voices, although that does not mean she did not hear
them. When asked about it, she grew upset and defensive, but she has been seen talking to
someone who was not there, or, at other times, were listening intensively to some sort of
conversation. She was very guarded about a lot of things, so instead of talking about what
she was feeling or sharing insight about her symptoms, she went on and on about the "FBI
agent" and how he "stole all my money!" and now planning to bug her apartment with all
kinds of “little tiny devices”. Madeline was very guarded emotionally and stayed
preoccupied with these fixed ideas. The alcohol factor also complicated her mood and my
ability to get a good read of how she was doing otherwise. Talk therapy with a person who
is psychotic is not very effective and tends to be circular and pointless. Mainly, I just
listened to her and encouraged her to talk about her medication because no amount of
dialogue was going to make her any less psychotic. When I ask Madeline about something
she does not like talking about she either changes the topic of conversation or start crying,
but with no tears. Most of her issues she considers as a result of severe traumatic childhood
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and bad abuse by both her parents. In fact records show that Madeline has lived most of
her life in orphanages and sheltered accommodations.
Madeline has poor self-care and hygiene, alcohol abuse, as well as a flat affect, or little
emotional expression, particularly in her face. The exception to this flat affect is when she
came into the clinic upset about her "check" or "special requests" in which case she was
very argumentative, screamed, and criticized everyone around. She would grit her teeth,
wave her arms, get in your face, but she would never do anything to hurt anybody. "You
come here, you little turkey!" she would scream. It was usually difficult to tell if she was
just angry or if she was intoxicated. Sometimes, her intoxication was more obvious than
others. Madeline also referred to me as a "little rabbit" on friendlier occasions. It seemed to
me that her mood had nothing to do with my performance as a nurse and everything to do
with her illness, not having much money, and alcohol intoxication. Those were the factors
that determined whether she was angry and screaming or quieter and even friendly.
Madeline would sometimes keep very quiet and do not want to talk to anyone. She would
leave requests for "special draws" with long, rambling requests, something like, "Need
$450 for three new tops, mine are torn, a new travel clothes I want to go on holiday, a teddy
bear for my nephew, and a box of chocolate". Madeline had no nephew with whom she was
in contact, and she had no money to go on holiday. When people are living on little money
per month and they have payees required by the Social Security Administration,
accountants at public mental health clinics are not going to accommodate emergency
requests for new clothes, bikinis, teddy bears, and chocolate, or else they are not doing
their jobs very well. Outside of the monthly budget, there was little deviation in money
withdrawn, because there was so little. It basically had to be an emergency. Madeline, like
others, would make requests every time they came in, and then they would be upset when
the requests were denied. People take pride in managing money, or not managing money,
whatever the case may be. So, to have someone else managing their finance seems to take
that power from them leaving many of them feeling insulted and defensive.
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Although Madeline did have a flat affect, she did express her anger and outrage over her
disability check and how it was taken away from her. The clinic paid her rent directly, as
well as her bills, and the rest was divided into weekly "draws" that she picked up. Because
of the alcohol consumption and her lowered inhibitions, she did lower her guard and let
loose in the lobby sometimes. On one occasion she started screaming at me in the little
interview room and a few people came in to check on us. Despite her outbursts, Madeline
seemed to like me, actually, as much as she could. This cannot be said for many patients
and their nurses. Despite her illness and despite coming in sometimes to scream at me, she
liked me. She would sit in a small interview room and tell me over and over again about the
"FBI agent" and her "sons" and how they "abandoned me". Her speech was slow and the
pronunciation of her words was very drawn-out and lazy-sounding. It may have been part
of her personality, it may have been alcohol, and it is possible I never actually saw her
without her being intoxicated to some extent in order to be able to distinguish the
difference.
Madeline did seem sad sometimes, but mainly she was just quiet. She rolled her own
cigarettes because it was cheaper. There was a sad, out-of-this-world look to her, which is
not a very clinical description as much as it is a simple impression of her that I remember.
She did not look healthy, but she also did not seem interested in addressing anything in
regards to her psychiatric condition, alcohol abuse, or medical issues. She refused to go to
the doctor, said they wanted to "control" her, and she never did to my knowledge at least in
the past couple of years. She lived an hour away from hospital, and it was not as if I could
walk a few blocks to knock on her door and escort her as I did with other clients.
Madeline sometimes liked to sit next-door at the Day Center that complemented our mental
clinic. She would eat lunch and sit around for a few minutes. Still, she was not very social. If
I went over there and sat with her, then she would talk to me; but, social skills were never
one of her best qualities. Everything about Madeline seemed in some way indicative of her
desire to avoid people. Her appearance further deterred people from getting too close.
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The Day Center next-door provided a setting where people with similar problems could get
together in a safe environment, have lunch, visit, or attend daily group sessions of various
kinds. Madeline never went to groups, nor would she even see the psychiatrist on the clinic
side, except for one occasion in which she left his office screaming that he could "go to hell!"
Her diagnosis had been made about 30 years ago.
It was surprising to me that Madeline and I hit it off as well as we did, and still we had our
moments. I realized that she did not mean anything personally even when she was
screaming at me. On one occasion, my boss came out to see "what is going on" and
Madeline turned on him. She escalated and I realized it was not me, it was her illness and
alcohol abuse. She was not angry with me, she was just angry; and, it did not matter if it
was me or my boss at whom she screamed. She was simply asked to leave on that occasion
like every other disruptive client, because that is not a healthy environment for anyone,
especially an office full of psychiatric patients who are already kind of on-edge. Eventually,
Madeline would storm out and with frustration walk in her big long coat carrying her
plastic bags towards the main bus terminal downtown. After working with Madeline for
about a year, she was absent for a few weeks, which was unusual. The last time I saw her,
she had turned up at the clinic and told me she was worried because the whites of her eyes
had been yellow a few days prior, which is a sign of jaundice, and it can be an indicator of a
failing liver. The whites of her eyes did not look yellow that day, and she was delusional;
however, we did make her a doctor's appointment in her suburb outside the city. She did
not go to that appointment, which was not unusual at all.
After a few weeks without hearing from her, I made a call to her apartment complex. The
manager said she had not picked up her mail, which was not a good sign. She had not
looked well the last time I saw her, but she never looked well. Without ever going to the
doctor, there had been no opportunity for preventative medication, hospitalization, or even
emergency intervention. All there had been for her was self-medication with alcohol,
untreated symptoms, and a mostly isolated existence in a low-income apartment outside
the city. So, my boss drove me to do a "home visit" at Madeline's apartment. After knocking
on her door and receiving no response, we were forced to call the police to come and open
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her door. The police officer went in first and came back out indicating that there was a bad
smell. He asked if I could go in to identify Madeline because there was "a woman in the
bedroom". When I went inside, her apartment did not look so bad, although the smell was
very bad. Madeline's body was lying face down on her floor. There were fluids around
where the body was lying and it was visibly some three empty bottles of medication, some
type of pain killers. After a while, a week, ten days, whatever, it is a little difficult to identify
a familiar person. People do not look quite the same after they die and the body begins to
undergo the process of decay; but, that could not have been anyone but Madeline. Madeline
had enough of her life and wanted an early check out.
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