Psychopathology Case Studies: Psychotic Disorders Case #1: Magical Art? Isaac, a 31-year-old single male, joins a therapeutic art group that runs twice weekly at an art school in the small northeastern city where he lives. It is an open group, with a core of long-standing members but fairly frequent additions or dropouts, and Charlene, the art therapist who facilitates the group, is keenly attuned to the subtle shifts in group dynamics that ensue whenever one of these changes takes place. Within a few weeks of Isaac’s appearance, she is noticing that a couple of group members have become much more reticent, unwilling to share their reactions to their own (or others’) artwork. She also observes that two other long-time group members who occupy leadership positions among their peers frequently exchange covert glances and smiles or grimaces whenever Isaac contributes to group discussions. Her own sense of his speech is that he tends to be a bit stilted or overelaborate, and that he sometimes takes too long to get to the point, but that he is mostly logical and goal-directed. He speaks softly but clearly and modulates well, though his facial affect is slightly constricted and he often averts his gaze from the person to whom he is speaking after the first few words. He seems shy or anxious, but not especially odd. Isaac’s artwork, on the other hand, does have a rather strange ‘feel’ to it. He tends to avoid messy materials like clay, paint, or pastels, preferring drawing and collage-making. His drawings include exquisitely detailed architectural exteriors: depictions of palaces and temples set in rocky, forbidding landscapes. Sometimes words or phrases are written across the sky or on the temple walls: “The Day is soon,” “Moon Commune,” “Submission Rules.” Often angelic or demonic faces peer through the clouds or emerge from mountain peaks or minarets. His collage work, likewise, is painstakingly precise, but usually populated by scantily clad models. Curious to know more, Charlene conducts a 1:1 interview with Isaac. He is the son of a single mother who attended college but worked as a restaurant hostess. Isaacs’s delivery was complicated; the umbilical cord was wrapped tightly around his neck for several minutes. Perhaps as a result, he suffered from a slight left-sided weakness as a young child, but this resolved. He had little contact with his father, who worked as a tax lawyer but drank excessively and whose practice dwindled. He was often alone as a boy, since his mother had to work in the evening. He coped with this by becoming deeply involved in certain television programs, books, and video games. Those he enjoyed most tended to have fantastic themes, and his inner world came to be populated by fantasy figures. Never very popular in school, still he mostly escaped bullying and performed well academically. He attended a local college for three years, majoring in English, but never graduated, and now works as a barista at an upscale coffe ...

1. Psychopathology Case Studies: Psychotic Disorders
Case #1: Magical Art?
Isaac, a 31-year-old single male, joins a therapeutic art group
that runs twice weekly at an art school in the small northeastern
city where he lives. It is an open group, with a core of long-
standing members but fairly frequent additions or dropouts, and
Charlene, the art therapist who facilitates the group, is keenly
attuned to the subtle shifts in group dynamics that ensue
whenever one of these changes takes place. Within a few weeks
of Isaac’s appearance, she is noticing that a couple of group
members have become much more reticent, unwilling to share
their reactions to their own (or others’) artwork. She also
observes that two other long-time group members who occupy
leadership positions among their peers frequently exchange
covert glances and smiles or grimaces whenever Isaac
contributes to group discussions. Her own sense of his speech is
that he tends to be a bit stilted or overelaborate, and that he
sometimes takes too long to get to the point, but that he is
mostly logical and goal-directed. He speaks softly but clearly
and modulates well, though his facial affect is slightly
constricted and he often averts his gaze from the person to
whom he is speaking after the first few words. He seems shy or
anxious, but not especially odd.
Isaac’s artwork, on the other hand, does have a rather strange
‘feel’ to it. He tends to avoid messy materials like clay, paint,
or pastels, preferring drawing and collage-making. His drawings
include exquisitely detailed architectural exteriors: depictions
of palaces and temples set in rocky, forbidding landscapes.
Sometimes words or phrases are written across the sky or on the
temple walls: “The Day is soon,” “Moon Commune,”
“Submission Rules.” Often angelic or demonic faces peer
through the clouds or emerge from mountain peaks or minarets.
His collage work, likewise, is painstakingly precise, but usually

2. populated by scantily clad models.
Curious to know more, Charlene conducts a 1:1 interview with
Isaac. He is the son of a single mother who attended college but
worked as a restaurant hostess. Isaacs’s delivery was
complicated; the umbilical cord was wrapped tightly around his
neck for several minutes. Perhaps as a result, he suffered from a
slight left-sided weakness as a young child, but this resolved.
He had little contact with his father, who worked as a tax
lawyer but drank excessively and whose practice dwindled. He
was often alone as a boy, since his mother had to work in the
evening. He coped with this by becoming deeply involved in
certain television programs, books, and video games. Those he
enjoyed most tended to have fantastic themes, and his inner
world came to be populated by fantasy figures. Never very
popular in school, still he mostly escaped bullying and
performed well academically. He attended a local college for
three years, majoring in English, but never graduated, and now
works as a barista at an upscale coffee bar across the street from
the art school.
Isaac hesitates, gazing intently at Charlene, then reveals (his
words coming out in a rush) that he was disturbed, during his
teenage years, by images of bloodily tortured women that both
repelled him and generated sexual excitement. She feels some
trepidation, and although she strives to control her expression,
he seems to sense her unease. For a moment she sees a hungry
look on his face, then it vanishes, and he looks down with his
usual self-deprecating half-grimace. Speaking more softly than
ever, he describes how he was able to bring these fantasies
under control by training himself in Golden Dawn ritual magic.
“It was a long dark night alone in my soul, but it helped me gain
mastery of self, so I persevered. And five years ago I succeeded
in attaining the knowledge and conversation of the Holy
Guardian Angel. He has been with me ever since, guiding me,
advising me: when necessary, chastising me. I must do what I

3. must do, and my true will is to create perfect harmony across
the crystal spheres of the Sephirot by completing the alchemical
wedding. I have been building power and spreading my
influence through the patrons of the coffee shop. But it is going
slowly, and I am still alone. That’s why I joined your group. My
art will win me my bride. Of this I am sure.”
In the weeks that follow, Isaac’s art becomes increasingly
baroque in detail and darker in theme. He shares his work
exultantly, shooting conspiratorial looks at Charlene. His
excitable behavior seems to frighten other group members, two
of whom stop attending sessions. One day Charlene decides that
she must ask him to leave the group. She visits the coffee bar to
ask him to meet with her, only to learn that he was fired a week
before. The employee who so informs her is reticent, but
implies that Isaac’s behavior toward customers had grown
inappropriate. Case #2 – Public Health
Janette is a 23-year-old graduate of an elite liberal arts college
who accepted a fellowship that entailed public health outreach
to impoverished regions of Indonesia. (She had been admitted
to medical school, but was allowed a year’s deferment in order
to pursue this enterprise.) She quickly learns that while the
work is often rewarding, it can also be quite disturbing – many
of the patients they see suffer from disfiguring, painful
disorders that are virtually never seen in the developed world,
and resources are scarce. Even when the agency is able to
import medical supplies, large portions of these goods are
confiscated by corrupt governmental officials. Furthermore, she
has very few social outlets; there are only three westerners
working for the agency, and even amongst them there are
language barriers that make intimate communication difficult.
Finally, living conditions are poor: the climate is hot and
humid, the food is unfamiliar and sometimes far from fresh, and
the building in which they live and work lacks running water.
After spending five months in this environment, Janette (who

4. has been ill several times and lost twenty pounds) begins to
suspect that she is being poisoned. She restricts her eating,
eliminating suspect foods, but her health continues to
deteriorate. Within a few days, she comes to believe that evil
magicians are casting spells on her. She tells her associates
about this conspiracy, using language that seems all but
incomprehensible – insisting, for example, that the sorcerers use
computer programming language to enchant her coffee, causing
her to suffer from fits of coughing and rewiring her thoughts so
she will think tea is coffee and drinking it, thus falling foul of
the stringent anti-drug laws of the land and leading to her
imprisonment.
Janette’s associates, deeply concerned about her mental status,
arrange to have her flown back to the U.S.A., where she is met
at the airport by her parents and brought to a psychiatric
hospital. At first, she considers this to be an Indonesian prison
and insists that those were not her parents, only clever
facsimiles prepared by the Javanese magicians, but within ten
days of her return, living in the stable hospital environment and
receiving neuroleptic medications, she abandons her strange
beliefs, her speech normalizes, and she is ready to return home
on a greatly reduced dose of medication. In the aftermath, she
decides to put off medical school for awhile longer lest the
stress trigger another episode, but does begin a master’s degree
program in public health, earning top grades and collaborating
with her advisor on an interesting study that is eventually
published with Janette as co-author.
Case #3 – Celestial Railroad
John is a 19-year-old single male. The son of professional
parents and graduate of an affluent suburban public school, he
left home for the first time to attend an elite four-year college
in a distant state. John had always been a good student, placing
in the top 20% of his high school class and winning an award in
History for a term paper on the colonial slave trade. Although
not especially sociable, he did have two or three close friends

5. and was considered “one of the gang” by the other members of
the track team, on which he competed in the 400 meter run.
As a freshman in college, John did not connect well with his
classmates. He became a social isolate, even eating his meals in
solitude in the dining commons. His personal grooming became
erratic, as he frequently wore the same undergarments for 2 – 3
days and rarely washed his hair. Even academically, he did not
excel as he had expected – his exam grades were mostly in the
“C” range except for “B’s” in history. He took to wandering
about the campus at night, glancing furtively at his classmates
and sometimes muttering indistinctly to himself. His parents
noticed the change in their son when he returned home for
Thanksgiving. Mother took pains to tidy him up, and father gave
him a talking-to about taking proper care of one’s self. John had
little to say to either.
Two weeks after the return from Thanksgiving, as classes
neared their end, John’s R.A. was sufficiently disturbed by his
behavior that she visited his room to inquire after his frame of
mind. He was initially disinclined to open the door and allow
her entry, but once they were sitting down together he opened
up. He informed her that he had realized, in a flash of insight,
that his college was involved in slavery. “Most of the
endowment is invested in companies doing business in countries
where child labor and prison labor are condoned, you know.
And the layout of the campus is representative of the
antebellum south, it’s a plantation. Here, I’ll show you.” He
pulls out a notebook and a pencil, and begins sketching rapidly.
What he draws looks something like a plan of the college, but
the buildings are marked with peculiar symbols – crosses,
torches, swastikas, ghostly shapes, etc. – that he explains as he
continues to add details. “See, the students live in these
barracks, they’re caught up, like the African diaspora and an
African holocaust, if they run it can only be in circles, they
never get out. It’s a hologram, really, a 3D image of the south

6. rising again, and the president is trying to bring it all back, the
bad old days when people were kidnapped away from their
homes and taken to strange lands where they don’t speak the
language, strangers in that strange land they suffer unendurably.
I have to help, you see, it used to be the underground railroad,
but that’s over, now it’s going to be the celestial railroad. Do
you see how it all adds up?” He finishes the sketch with what
looks like an equation, a series of numbers and letters separated
by the signs of mathematical functions. The R.A. excuses
herself politely and rushes off to contact the Dean of Students.
John is hastily admitted to a psychiatric hospital. Two weeks of
aggressive treatment succeed in bringing his symptoms under
control. He remains fragile, though, and does not return to that
college next semester. Instead, he lives at home, attends a
nearby community college on a part-time basis, works part-time
in his father’s accounting firm, and begins re-establishing
contact with some of his high school friends, while continuing
to receive supportive treatment from a psychiatrist.
Case #4 - Killer
Darryl is a 54-year-old married man, an attorney employed as a
high-level civil servant with the state government’s department
of transportation. He has fathered two children, both of whom
have completed college and begun independent lives. About two
years ago, he began to suspect (and soon to believe quite
firmly) that an organized crime syndicate was infiltrating his
department and manipulating events so as to expose the
department to ridicule, ultimately convincing the legislature to
relax controls on quality of construction and compliance with
safety guidelines by contractors. His own role is crucial;
because of his careful work in writing the regulations and
associated enforcement procedures, he has been targeted for
elimination – either by being forced out of his job, or by being
physically harmed.
Darryl’s suspicions turned to a neighbor’s 28-year-old son,

7. Frank, who dropped out of college and moved back home
(working on and off as a lifeguard, tennis coach or bartender).
Frank, Darryl decided, had contracted with the criminal
syndicate to carry out the “hit” when it became necessary.
Darryl confronted Frank in the tavern where he worked. When
Frank denied any involvement with criminals, Darryl held off
on further action for several weeks, but his suspicions were not
fully allayed.
Then, on a weekday afternoon about a week ago, Darryl entered
the tavern, angrily insisted that Frank put him in contact with
his superiors in the mob, and, when the young man demurred,
shot him fatally with an automatic pistol in front of a dozen
customers. He then waited and surrendered calmly to the police,
explaining the situation. Darryl was arrested but found not
competent to stand trial and remanded to a state psychiatric
facility for evaluation and treatment. Upon interview, he is calm
and rational. He is well-groomed and neatly attired. There are
no signs of disorganization in his speech as he explains the
conspiracy and his need to take effective action against it. He
denies ever experiencing hallucinations. He also denies ever
having suffered from prolonged periods of elated or dysphoric
mood. All of his friends, co-workers, and family members
concur that Darryl has always been a model citizen, though
several do note that he has often been perceived as an “intense”
person.
Case #5 – Mommy Dear
Sharon is a 42-year-old divorced woman. A high school
dropout who married at age 17 and had three children over the
next five years, she worked part-time as a grocery store clerk
but was primarily supported by her husband, an automobile
mechanic seven years her senior. She underwent several
periods during which her mood deteriorated, she gained weight
and suffered from late insomnia, her ability to focus her

8. thoughts seemed impaired (e.g., she had trouble keeping track
of the food and cleaning supplies needed for the household,
often burned dinner, and sometimes let the children go off to
school without their books or lunches), and she saw herself as a
dismal failure in life. The first of these occurred after the birth
of her third child, who turned out to be mildly mentally retarded
(though she did not know this at the time). Her obstetrician
prescribed fluoxetine to good effect, and her primary care
provider renewed this prescription for about a year in response
to each subsequent episode. At age 29, after recovering from
her third episode, Sharon began to hear the voices of her
ancestors talking to her as she sat at the kitchen table waiting
for the children to return home from school. She was fascinated
by their tales of days gone by and proud to have been selected
to receive their confidences, and sat for hours at a stretch,
drinking coffee, smoking cigarettes, and smiling to herself. She
stopped taking proper care of the house, lost her job for
inattentiveness and grossly inaccurate cashouts, and began
deteriorating in terms of her personal hygiene. When her
husband remonstrated with her, she told him that she had been
selected as the messenger of a new revival of the faith (which
surprised him, as she had never before attended church or
shown any interest in scripture). Her ideas continued to spin on
in fanciful directions, and her behavior around the house
continued to grow more peculiar. For example, she began
wrapping garbage in Christmas paper and storing it in various
closets as well as under the children’s beds. Eventually her
husband contacted their physician, who referred them to a
psychiatrist. Sharon was puzzled by the psychiatrist, but
eventually agreed to be admitted to a hospital “for a rest.”
Treated aggressively with thioridizine, she recovered
sufficiently to return home after a month-long stay, but relapsed
two months later and had to be readmitted. After this second
episode, she was discharged to a supervised housing program.
During her first six months there, she underwent yet another
episode of intense sadness (along with weight gain, insomnia,

9. etc.), actually becoming convinced that she had killed her
children. Even when they tearfully confronted her, she insisted
that they were really dead, that these were mere phantoms
before her and that the souls of her children must be in heaven
while she atoned for their sins in hell. A year later, when
Sharon showed no sign of being able to return home, her
husband initiated divorce proceedings. He eventually
remarried. She stayed in the supervised apartment program
except for occasional readmissions to the hospital, either for a
resurgence of hearing voices and attributing those voices to her
being chosen for a great mission or for a further lapse into
painful dysphoria. All told, she has been hospitalized eleven
times in thirteen years. She is maintained on five different
medications – risperidone, paroxetine, carbamazepine,
clonazepam, and trihexyphenidyl – attends a day hospital
program, and has occasionally done some volunteer work, but
has never been able to resume gainful employment. Her
children, who are now fully grown, visit her sometimes. The
eldest, a daughter, has begun suffering bouts of severe
dysphoria and has made two suicide attempts. The second, a
son, is a “loner,” working as a parking lot attendant and
spending his spare time watching television.
Case #6 – One-Way Street
Jake is a 38-year-old single male, a high school graduate who
has not held competitive employment for more than a few
months at a stretch during his adult life. He resides in a studio
apartment in a run-down building situated in a dingy
neighborhood of a mid-sized city. Most of his time is passed
either walking around the downtown area, sitting on park
benches (or, during cold weather, in the public library), or
watching television at home. When in public, he attracts a
certain amount of attention by his somewhat disheveled
appearance and odd behavior. He wears rumpled, not very clean
clothes, sports a shaggy beard and unkempt, greasy hair, and is

10. often observed to be carrying on one end of an angry argument
– even though alone. People tend to go into nearby shops or
cross the street to avoid him, especially when he is obviously
angry. The only people with whom he interacts are a few
pushcart vendors and people who, like him, pass their days on
park benches. (He also sees these people at the soup kitchen
where he often dines, and sometimes at the mental health clinic
– when he goes there, which is seldom.)
One day, Jake actually does assault someone, though not
seriously – he simply strikes a passing man with his fist, yelling
something incoherent at him, then passes on. The police have no
trouble identifying Jake from the man’s description and pick
him up. Noting Jake’s erratic behavior and appearance, the desk
sergeant calls for a psychiatric evaluation. A team of three
clinicians visits Jake in his jail cell. They report that he: (1)
seems to misunderstand or badly misinterpret much of what they
say, usually in such a way that he views them as hostile, (2)
seems to be responding to other voices at times, (3) claims that
the man he assaulted had said something derogatory about his
(Jake’s) mother, and (4) often seems to wander off the subject,
shift into seemingly unrelated topics, reason badly, or just stop
talking in mid-sentence. They also note that he admits to having
discontinued his usual medications about a month ago. Based on
their report, the judge who arraigns Jake the next day deems
him not competent to stand trial and orders him remanded to a
state psychiatric hospital.
The staff at the state hospital knows Jake rather well, as he has
been admitted there on six other occasions. His longest stay
(five months in duration) was when he was 19 years old. That
hospitalization was precipitated by his having assaulted his
father, whom the young man claimed was abusing his (Jake’s)
mother and preventing Jake from achieving the great things he

11. was destined to do. It was noted that Jake had always been a bit
of a social outcast among his peers, a poor student (he received
special education services, though their precise nature is
unknown), and a boy of slovenly habits. He responded
reasonably well to a combination of medication, group therapy,
and rehabilitative services, though he was considered still to be
symptomatic when discharged. Jake’s pattern ever since has
been to improve considerably while in the hospital, then relapse
gradually after being discharged. He has lived on modest social
security benefits for the last 15 years and received case
management services when not hospitalized, though he tends
not to keep his appointments.
The members of Jake’s treatment team anticipate that they will
be able to restore him to competency within 2 – 3 months, and
that his sentence (assuming he is found guilty of breach of
peace) will be no longer than his stay in the hospital.
Meanwhile, they hope to do what they can to get him spruced
up, improve his frame of mind, and possibly motivate him to try
to improve his life in the community.
Diagnostic Workup
Case:
Date:
Diagnosis (es): Please add DSM-5 Codes as well

12. Other Conditions That May Be a Focus of Clinical Attention:
Rationale
1. Document the patient’s symptoms that meet criteria for any
diagnosis assigned.
2. Discuss any alternative diagnoses that were considered, and
how the differential was made.