Case Study

Vignette. Mrs. W.

Rose W. is a 69-year-old retired, African American woman who lives independently in her own apartment. Her 48-year-old son lives in the same apartment building as she does, but on a different floor; he sees her several times a week. Mrs. (not Ms.) W. married her son’s father when she was 19 and divorced him 5 years later. She has not been married or had a significant romantic relationship since then. She retired from work cleaning houses and cooking about 5 years ago, and she receives Social Security and Medicare. Mrs. W. has hypertension, arthritis, and Type II diabetes, all of which are being controlled by medications. She had been receiving care in a neighborhood clinic for a number of years, until the clinic closed. She came to the attention of the social worker when she was seen for an initial appointment by a primary care resident (PCR) in the ambulatory care clinic of a large metropolitan teaching hospital. Her PCR referred her because he was concerned about what he thou ght were psychotic symptoms. Interviews with Mrs. W. and her son revealed the following information:

• Mrs. W. hears people whispering or, rarely, talking, particularly if she is not busy or is not listening to the radio or TV. As near as we can ascertain, she has had these experiences since she was a young woman. When asked about the possibility that these experiences might be a misinterpretation of sounds coming from her radiator, the radio or another appliance, or from other apartments, her son said that he had been with her sometimes when this occurred and that there seemed to be no external trigger, and that as far as he knew she had always been like that.


• Ms. W. also said that she felt that “the two homosexuals next door” were watching her, and she stated at one point in the interview that she thought that perhaps the PCR and social worker “might be together.” When asked about this, she didn’t want to say more but seemed suspicious when we were both in the room with her at the same time. Her son also said that she had had these kinds of ideas for as long as he knew and that her family had always thought that she was odd that way. That is, she would, for no apparent reason, become suspicious of other people around her. He said that he and the family members used to try to “talk some sense into her,” but no one had ever had any luck with this approach. He said that people had learned that the best thing to do was to just ignore these kinds of things, and these ideas would usually go away, except for her ideas about her neighbors who were always very kind to her. He said that she often was suspicious of people that she had just met and believed either that they were lovers or that they were watching her. “Normally, once she gets used to you, she’s fine, but not at first.”


• Her son said that neither the auditory hallucinations nor the delusions/over-valued ideas had ever interfered with her ability to work, go to church, or function in other ways. He said that, as far as he knew, she had never been referred to a mental health professional nor received treatment for these problems. He also said that there had been no changes in either of these conditions in the past months.


• Mrs. W. says that she spends most of her days watching TV, listening to the radio, reading the Bible, or doing errands. She goes to church every Sunday and to prayer meeting Wednesday nights. She participates in church social activities a couple times a month, has a couple friends that she sees about once every week or two, and has extended family that she sees at about the same frequency, though she sees her son at least once a week.


• Mrs. W. did not want to discuss her family history, but her son said that he thought that an uncle (Mrs. W’s brother) had been in a local psychiatric hospital for drug abuse and “nerves.” It sounded like he may have had PTSD subsequent to service in the Korean conflict. Another family member had a nervous breakdown, but no one ever talked about the details.

Activity #1. Class Discussion

• Do the students believe that these are psychotic symptoms, normal and expected occurrences in someone living alone, or is she just odd? What additional information would they want to gather, if any, to decide what sort of experiences she is having?


• Given the above information what might they recommend to the PCR? Why? What additional information, if any would they want to gather before making a recommendation to the PCR?


• In the unlikely event that the class has difficulty with coming up with possibilities, some of the options might include:


1. Suggest that the PCR refer Mrs. W. to a psychiatrist for evaluation and possible treatment of the psychosis. Continue to follow and treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Referral option)
2. Suggest that the PCR prescribe an appropriate antipsychotic (or other) medication to Mrs. W. Medication monitoring as appropriate with frequent follow-up visits while she is being stabilized on the medication, then tapering the visits to a less frequent schedule. Continue to observe and treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Medication option)
3. Suggest that the PCR not take any action on the psychotic symptoms at the present time. Instead continue to observe and treat her medical condition as appropriate, but with more frequent (monthly) visits to the primary care clinic in order to build a relationship with her and to monitor her psychotic symptoms and functioning. (Watchful monitoring option)
4. Suggest that the PCR pay no attention to the psychotic symptoms unless they become severe or she needs hospitalization. Continue to follow and treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Do nothing now option)
5. Suggest that the PCR ask her son to keep close tabs on his mother, systematically monitoring her symptoms on a frequent (every day or two) basis. Continue to observe her and to treat her medical condition as appropriate with visits to the primary care clinic every 3 months as in the past. (Family observation option.)

Activity #2. Role Play

Ask the students to divide into groups consisting of the following: Mrs. W., her son, the PCR, and the social worker. Ask each group to pick an option from above and role play the social worker conversations with the PCR, Mrs. W., and her son. If they ask whether the conversations should be conducted with each individually or with groups (e.g., Mrs. W. and her son together), suggest that is up to the group, but they should be able to explain the rationale behind their decision.

Activity #3. Class Discussion

Have the class read and discuss the social worker’s reasoning for the action that he took in this case (see below). List the advantages and risks of this approach. Are there other options that would be better?

The social worker in this case chose Option #3-Watchful monitoring. His reasoning was that it is very likely that Mrs. W. would not accept or follow through with a referral to a psychiatrist. Nor would she be likely to accept or take antipsychotic medications, particularly if she clearly understood what the medications were for. He thought that those two were likely given her suspiciousness of new people and given both her and the family’s reluctance to discuss mental health issues in family members. Furthermore, he was concerned that there was a very good chance that such a referral or prescription might result in her dropping out of treatment at the primary care clinic and might impede her developing a (relatively) trusting relationship with her new PCR. He felt that it was important for her to develop a relationship with the PCR and with other staff at the primary care clinic. Since she had been living with and functioning independently despite having these symptoms for her entire adult life, the social worker recommended that the PCR keep an eye on her at present, hold off more aggressive treatment of the symptoms, and monitor the symptoms periodically in case her situation changed or the symptoms worsened. Then at that time, they could revisit a referral or treatment that would be based on a better, and hopefully, more trusting relationship. He also recommended that Mrs. W.’s son continue seeing her at about the same frequency as he had been but to notify the PCR or the social worker if he noticed any changes in Mrs. W.’s behavior, her suspiciousness and hallucinations, or her living situation. He suggested that, as they got to know Mrs. W. and her son better, they should consider providing some psychoeducation on psychotic symptoms to him or to Mrs. W. and him together.

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