8.13: Schizophrenia

Name: Nina Sayers
Source: Black Swan (movie, 2010)

Background Information

Nina Sayers is a Caucasian female who is presumed to be in her early to middle twenties, although her actual age is unknown. She currently works as a ballerina in a New York City ballet company whose name is undisclosed. Although there are not any known distinct physical illnesses, abnormalities, disorders, or disadvantages currently within Sayers, there are observable health concerns. The patient is visibly underweight and has serious cuts, bruises and other wounds on her feet, although both of these concerns can be attributed to her career as a dancer. However, there are also various lesions and abrasions throughout the surface of Sayers’ body which cannot be attributed to anything in her current daily environment. It is speculated that these lesions could be self-inflicted. Sayers currently lives by choice with her mother. Her mother, although not diagnosed, has observable generalized anxiety disorder symptoms, as well as some neurotic personality traits. It is also observed that the mother displays a very rich sense of control over Sayers’ life, such as her scheduling, room design, personal decisions, etc. Sayers appears to not have very many, if any, close friends or relatives outside of her mother. It is undisclosed whether or not Sayers has had any contact with her biological father. It is assumed that he does not actively participate in her life. Until recently, there was not any reported drug or alcohol history. However, as of late she has reported experimenting with ecstasy, a derivative of MDMA, as well as engaging in small amounts of social drinking. Her current goal is to become the principle dancer of her current ballet company. Most of her daily activities are related to improving her performance as a dancer.

Description of the Problem

Sayers currently displays a whole host of symptoms that could be indication of several disorders. The lesions and abrasions as aforementioned fit the description of self-mutilation; however, Sayers denies ever abusing herself, and frequently reports not knowing how the lesions and abrasions appeared on her body in the first place. Sayers often suffers from both visual and audio hallucinations. These hallucinations include items such as seeing feathers physically protrude from her skin, seeing and hearing paintings laughing at her, having conversations and encounters with people that never took place, and peeling off pieces of her own skin that are obviously still in tact, among many other hallucinations. She is also currently under some delusions as well. She believes that another one of her co-dancers is trying to take her starring role in the next upcoming production from her when there is not any evidence to support such a claim. She also believes that this co-dancer is sleeping with the program director, when there is no evidence to support this claim either. In general, Sayers is very convinced that various people are intentionally trying to take this acclaimed dancing role from her, or as she refers to it, her chance to be “perfect.”

Diagnosis

The diagnosis for Sayers that seems to fit appropriately is Schizophrenia, Paranoid Type (295.30).

1. To be diagnosed with schizophrenia, two or more of the following characteristics must be present:

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e., affective flattening, alogia, or avolition
Sayers definitely has both the first and second characteristics of delusions and hallucinations, as described in the section of “Description of the Problem.”

1. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.

The delusions and hallucinations have made both Sayers’ work and personal life dysfunctional. She has been late for rehearsals and has caused a great amount of interpersonal disturbance amongst her coworkers.

1. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal or residual symptoms.

The hallucinations of skin peeling and the delusion of denial of having part of her own lesions and abrasions have been present with Sayers for the majority of her life. During the last one to two month period is when her visual and auditory hallucinations have become more frequent. It is also during the last one to two month period that the persecutory delusion of having her role taken from her has become prominent. It is unknown if she has suffered from other persecutory delusions previously.

1. Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

During observation, Sayers has not met any criteria that would indicate any of the mood disorders. Her persistent amount of dance practice may signify a possible manic episode, but since she has always spent a great deal of time practicing, it appears as if it is too consistent to be considered an episode, therefore disqualifying her from any mood disorders.

1. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

As previously stated, there is not any known, distinct physical illnesses, abnormalities, disorders, or disadvantages currently within Sayers that would explain her schizophrenic symptoms. She did not have any drug history until recently, but her symptoms were present long before her intake of any substance.

1. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month.

There is no history of either of the above listed disorders present in Sayers.
To fit the Diagnostic Criteria for 295.30 Paranoid Type,the following criteria are met:

1. Preoccupation with one or more delusions or frequent auditory hallucinations.

Sayers is completely preoccupied by her persistent tactile, visual, and auditory hallucinations. She is also completely preoccupied with her delusion of someone trying to take her role from her.

1. None of the following are prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Sayers displays none of the above listed behaviors.

Accuracy of Portrayal

The average person watching this movie would see a reasonably accurate portrayal of the onset of Paranoid Schizophrenia, especially since Nina Sayers is in the perfect age range for onset, but not necessarily the daily experience after onset. Of course, the movie overdramatized a lot of the symptoms that the average schizophrenic would experience, but not to the point that the symptoms were so exaggerated that to make the case that she was schizophrenic was invalid if one were to make an assessment. In fact, this movie actually somewhat helps the portrayal of schizophrenia in the media, as many movies and television shows give examples of the symptoms of Dissociative Disorder as evidence of schizophrenia, which are totally inaccurate and confuse the audience as to what schizophrenia actually is. Although symptoms would not occur as rapidly as they do in Nina Sayers in most common cases of schizophrenia, it is plausible. Therefore, Black Swan is a decent portrayal of a person’s descent into paranoid schizophrenia.

Treatment

To treat Sayers, after a full medical examination, it would be best to immediately start her on a mid-level dosage of an anti-psychotic, such as Vesprin. Most people with schizophrenia respond very well to current medication in comparison to people with other Axis I disorders. After pharmaceutical treatment begins and an appropriate dosage has been stabilized, it would be best to start Sayers and her mother into family therapy, as to educate and help both of them find ways to cope with this disorder, and to help Sayers’ mother be more tolerant and understanding of Sayers’ symptoms. Social Skill training would also be beneficial to Sayers, because as previously stated, she has no close friends or any type of social support outside of her mother. Social Skill training would also help Sayers interact more efficiently with the other people who work at the dance company, lessening interpersonal disturbances caused by her disorder.