Case StudyAs part of his internship, Trey is working night intake at a psychiatric hospital in a medium-sized college town. It’s been pretty quiet all evening until a little after 1 a.m. when he hears shouting in the outer hallway.Trey looks at Lisa, his fellow student intern, who says, “What’s going on out there?”A moment later the doors burst open, and a young man, who looks about 18 years old, is escorted into the intake desk. He is agitated and has tears on his face, but he is not showing signs of violence or aggression, beyond the brief shouting he did out in the hallway.He plunks himself down in the chair across from the intake desk and buries his face in his hands, rocking slightly and moaning. He has a slight body odor and is perspiring heavily.”He’s all yours,” Lisa whispers.Trey ignores her and moves quickly to the intake desk. Lisa runs off to find the supervising nurse, who has gone on break.”Hey there,” Trey says calmly, bending over to look into the patient’s eyes. “I’m Trey. What’s up?”He is almost surprised when the patient stops rocking, sits up, and lowers his hands. “Hey,” he says quietly. “I’m Matt, and this is hell, dude.””Not quite,” Trey smiles. “I’m here to help. Can you tell me what’s happened?””I’m going all to pieces,” Matt says, “little screws and bolts and debris flying off everywhere.”Trey says nothing; he just waits.”I had kind of a breakdown in my dorm,” Matt says. “I threw my laptop out the window.””Ooh, that’s rough. Bad night, huh?””Bad week, a bad month, bad year, bad bad life. Bad bad bad bad bad bad bad bad BA-A-A-AD.””What happened?””Where you wanna start?”In fits and starts, Matt conveys small clues that hint at his story.Matt has always been a “nerd,” he says, according to his older brothers. As a child he often withdrew from playgroups at school to play on his own. In isolation, he has always managed to perform well academically, but in group work or group assignments, he has tended to resort to outbursts and a refusal to participate. He says he has always been awkward in social situations and has always found it hard to carry on “a good, rewarding conversation.””And I’m freakin’ clumsy. Klutzy. A klutz,” he says, looking everywhere but at Trey. “I’m the opposite of an athlete, the opposite of my brothers.”Although his speech is frequently eccentric, Matt manages to convey a very brief picture of how, because of his withdrawal, negative thoughts, and social awkwardness, people tend to leave him on his own, both at large extended family gatherings or social functions in his family’s community and place of worship.In his senior year of high school, Matt’s grades and SAT scores gained him entrance to a leading Midwest university-despite his disruptive problems.Matt had been looking forward to going away to school, hoping that part of his problems “fitting in” had to do with his family’s “obscenely proper prominence” in the community, and his older brothers’ “super-dude images, which,” he says, “I will never live up to.””At the same time,” he says during intake, “I was also pretty nervous, pretty stressed, pretty freaked out, pretty freaky.”In his first week of college, Matt found orientation week “disorienting,” he jokes with a slight smile. “Orientation disoriented me. It dissed me. I got dissed. There were people everywhere, like climbing-the-walls-and-on-top-of-you everywhere.”Except when Trey first initiated the conversation, Matt, for the most part, has worked to avoid eye contact and continually bounces his left leg nervously. He is gripping the arms of his chair and looks as if he’s about to fly right out of it.”My roommate is a jock,” he says. “Jocular jock. Oh, Jocularity, wouldn’t you know they’d put me with a jocular-not-so-very-jocular-jock. They plan that stuff, you know. Just to keep me from escaping, from making a fresh start. Guy’s a jerk, and now, here I am.” He grins and expands his arms, gesturing the psychiatric ward around him.”And now here I am, just 8 weeks into my first semester away from home, and I’ve just been admitted for totally breaking down, shooting laptop missiles from the second freakin’ floor. They win.”If Matt is truly suspected of having newly diagnosed or recent-onset schizophrenia, should Trey be letting the conversation focus so much on Matt’s childhood? Where might intake or assessment be best focused?Based on this initial phase of Matt’s intake interview alone, what symptoms are already suggested in his behavior that would be significant in terms of potential psychosis or schizophrenia?
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