John Nash was a mathematician who developed paranoid schizophrenia. He was admitted to a psychiatric hospital after exhibiting erratic behavior due to believing he was part of a secret government mission. At the hospital, he realized the mission and some people he knew were hallucinations. He was prescribed medication but stopped taking it due to side effects, which caused a relapse in his psychosis. The case study provides details on Nash's history and current symptoms and mental status exam.

1. Case Study 1
Running Head: CASE STUDY
Case Study: Movie “A Beautiful Mind”
Jeffery W. Belford
Queens College
Case Study: Movie “A Beautiful Mind”

2. Case Study 2
Brief Description of Movie
A Beautiful Mind is a movie based on the real life story of the famed mathematician John
Nash and his lifelong struggles with his mental illness. Nash enrolled as a graduate student at
Princeton in 1948. He was a recipient of the prestigious Carnegie Prize for mathematics. He
became obsessed to find his own unique and original mathematical theory. In the mean time, his
roommate, Charles, became his best friend. After successfully developing his own theory, known
as game theory, he became a professor at the Massachusetts Institute of Technology (MIT). Here
he met his wife Alicia (in his class), and they got married shortly thereafter.
One day he runs into his former roommate Charles and his young niece Marcee. While he
was working for the Pentagon deciphering complex encryption, he encounters a mysterious
secret agent by the name of William Parcher. Parcher gives him a new assignment to look for
patterns in magazines and newspapers possibly from the Soviets. He was ordered to write a
report of his findings and place them in a specified mailbox. As this secret assignment is going
on, he becomes increasingly paranoid and begins to behave erratically.
After observing this erratic behavior, his wife, Alicia contacts (informs) a doctor at a
psychiatric hospital. Nash was admitted. While in the hospital, he continues to believe that the
Soviets were trying to extract information from him, and that the workers at the psychiatric
facility were Soviet kidnappers. However, after he is confronted with his own documents which
were sitting in the mailbox and never opened, he finally realized that he has been hallucinating.
He came to realize that the secret agent William Parcher, and Nash's friend Charles and his niece
Marcee were all part of his hallucinations. After numerous shock therapies, Nash is released with
antipsychotic medication.

3. Case Study 3
However, the side effects of the antipsychotic medication affect his sexual relationship
with his wife and, his intellectual capacity. This leads him to stop taking his medication causing
a relapse of his psychosis, which almost cost the life of his infant son. He withdraws from
society until the 1970s. Subsequently, he tries to return to reality by going back to teaching at
Princeton. He eventually earns the privilege of teaching again with the help of his former
colleague. Over the years, he has learned how to distinguish his hallucination/delusion from
reality, check to ensure that any new acquaintances are in fact real people, and not hallucinations.
He is honored by his fellow professors for his achievements in mathematics, and goes on to win
the Nobel Memorial Prize in Economics for his revolutionary work on game theory.
Date of Intake: September 5, 1960 when John Nash was first relapsed after non adherent to
his antipsychotic medication.
Biographical Data
Initials: J.N. Date of Birth: 6/13/1928 Gender: Male
Marital status: Married Ethnicity: Caucasian Occupation: Unemployed
Source & reliability - self; reliable
C/C: "I stopped taking my medication for a while. Now I’m having hallucinations and am
paranoid again."
Identification, Chief Complaint and Reasonfor Referral:
Mr. J.N. was referred by his psychiatrist where he was previously diagnosed for paranoid
type schizophrenia. His psychiatrist did not feel an admission was warranted and referred him to
the mental health outpatient clinic. Mr. J.N complains of recurring auditory and visual

4. Case Study 4
hallucinations with paranoia. He states that “I just can’t distinguish what’s real and what are
hallucinations.” He expressed feelings of hopelessness and guilt towards his family especially his
wife. He identified having difficulties with his memory/intellectual capacity and low sexual
libido as main reason why he stopped taking medication.
History of Present Illness:
Mr. J.N is a 32-year-old former college professor. He has been having recurrent auditory
and visual hallucinations with paranoia after stopping his psychotropic medication due to side
effects. He was referred to the mental health outpatient clinic by his psychiatrist. His psychiatrist
did not feel an admission was warranted since Mr. J.N. was not suicidal or homicidal.
He claims that he has been having hallucinations since he went to college. He did not
realize his delusion/hallucinations until last year when his wife called psychiatrist and admitted
him for his erratic behavior.
Mr.J.N. is recurrently seeing and hearing three figures; Charles who was thought to be his
roommate in college, Charles' young niece Marcee, and William Parcher who is a secret
government agent. He claims that he has been perceived them as real people until his first
admission last year. He continues to see and hear them even when he is on psychotropic
medication but is able to distinguish it from reality and not to react to it.
Mr. J.N. stopped taking his medication when it interferes with his memory/intellectual
capacity and sexual libido. He is a highly motivated scholar who places utmost importance on his
scholarly work and intends to go back to his work as college professor. He is also worried that
his marriage is falling apart due to his inability to perform sexual intercourse with his wife. He is

5. Case Study 5
currently not working and is dependent on savings and income of his wife. He perceives that his
marriage at this point is in jeopardy.
Past Psychiatric History
He reports that he has been having auditory and visual hallucinations since he was in
college. He was diagnosed with paranoid type schizophrenia last year. He stopped taking his
medication when it interferes with his memory/intellectual capacity and sexual libido.
History of Substance Abuse
He identifies himself as social drinker. He used to drink regularly when he was in college
but has not had alcohol recently. He denies any use of illicit drugs.
Past Social and Developmental History
Education
He attended Carnegie Institute of Technology and graduated in 1948 with bachelors and
master’s degrees in mathematics. Then he enrolled as a graduate student at Princeton in same
year with scholarship. He reported his academic performance was excellent although he did not
attend most of his class. After successfully developing his own mathematical theory, known as
game theory, he became a professor at the Massachusetts Institute of Technology (MIT). He had
been teaching as a faculty until last year when he was admitted to psychiatric inpatient unit for
the first time.
Family History

6. Case Study 6
Mr. J.N. grew up in Bluefield, West Virginia. His father was an electrical engineer for the
electric power company. His mother had been a schoolteacher before she married then became a
housewife. Both parents were very supportive for their son's education, providing him with
encyclopedias and even allowing him to take advanced mathematics courses at a local college
while still in high school. He reports no known family history of medical or mental illness.
He met his wife as his student at MIT. They got married in 1957, and had good
relationship until his first inpatient admission last year. He reports that he has not been able to
perform sexual intercourse with his wife due to the side effects of his psychotropic medication.
He is currently not working and is dependent on savings and income of his wife. He perceives
that his marriage at this point is in jeopardy and wants to restore his relationship with his wife.
Occupational History
Mr. J.N. was a professor, teaching mathematics at the MIT. He also worked contract for
the Pentagon deciphering the complex encryption. He had been teaching as a faculty until last
year when he was admitted to psychiatric inpatient unit for the first time. He is currently not
working and is dependent on savings and income of his wife.
Social History
Mr. J.N. identifies himself as isolative, avoids any social contact as much as possible. He
stays home most of the day, doing errands including taking care of his infant son. He cut off the
contact with his colleagues since his diagnosis for paranoid type schizophrenia. He reports that
he feels ashamed, and perceives himself as a failure often. He also reports feeling guilt toward
his wife since he can no longer function as a good husband.

7. Case Study 7
Client’s Strengths
Mr. J.N. kept his appointment and is actively seeking help at this time. He has insight into
his problems. He wants to restore his relationship with his wife and is willing to take medication
in order for him to get better. He hopes the new medication will work without debilitating side
effects on his cognition and sexual libido.
Medical History
No known medical illness
Review of Systems
Vital Signs: BP: 110/80, Pulse: 80, Respirations: 18, Temperature: 98.6, Pain: 0
General: Weight: 196 lbs., Height: 71 inches, Body Mass Index (BMI): 27.4, no recent weight
gains/losses
Skin: No rashes/lesions/ itchy. Mid-dry skin whole body. No hair, nails, or skin changes.
HEENT:
Head: no neurologic illness/ headache/ head injury.
Eyes: reports 20/20 vision
Ears: hearing good. no tinnitus/ vertigo/ infections/ drainages.
Nose: no cold/fever.
Throat/ mouth: no bleeding/ sore/ hoarseness. last dental visit 2 months ago

8. Case Study 8
Neck: no lumps, goiter, pain, or swollen glands
Breasts: no pain or discharge
Respiratory: no cough/ wheezing/occasional sputum.
Cardiovascular: V/S WNL, no murmurs/chest pain/palpitations/edema. No dyspnea, orthopnea,
chest pain, palpitations. Last EKG, 1959; unremarkable
Gastrointestinal: good appetite. no pain/ nausea/ vomiting. Regular bowel movements, stool
color and size normal, no bleeding, sometimes excessive belching and passing of gas, no pain
jaundice or liver problems
Urinary: no dysuria/ hematuria/ painful urination.
Genital: no pain/sore/ lesions, has not been sexually active due to the side effects of
antipsychotic medication
Peripheral Vascular: none
Musculoskeletal: no muscle or joint pain/ swelling
Neurologic: no neurologic problems/ seizures/ motor, sensory loss
Hematologic: no anemia/ bleeding
Endocrine: no known thyroid problems-TFT is within normal limit, tolerates temperature
changes.
Medications: He has not taken his psychotropic medication for a while, which is unknown at
this time.

9. Case Study 9
Primary Care Provider: He has been seeing a psychiatrist from his inpatient admission last
year, who made the initial referral.
Allergies: He denies known allergies.
Mental Status Examination
Appearance and Behavior: Mr. J.N. dressed appropriately. He appears to be the stated age. He
is quiet but focusing on interview. He is cooperative and reasonable.
Mood and Affect: Mood appears to be depressed. His affect is constricted.
Speech and Thought Process: His speech is normal with appropriate rate and volume. He had
no loose associations, tangential thought, thought blocking or other signs of thought disorder.
Thought Content and Perception: He is recurrently seeing and hearing three figures; Charles
who was thought to be his roommate in college, Charles' young niece Marcee, and William
Parcher who is a secret government agent. He claims that he has been perceived them as real
people until his first admission last year. He continues to see and hear them even when he is on
psychotropic medication but is able to distinguish it from reality and not to react to it. But since
he stopped taking his medication, it became more difficult to distinguish it from reality and
greatly interferes with his life.
Cognitive and Intellectual Functioning: He stopped taking his medication when it interferes
with his memory/intellectual capacity. It was unacceptable for him since he intended to go back
to his work as a college professor. He reports no cognitive/intellectual problem since he stopped
taking psychotropic medication. His memory is intact, and he was able to recall dates with

10. Case Study 10
regards to his work history. There was no evidence of gross cognitive dysfunction during the
interview. He has insight into his problems and is goal directed to manage his mental illness.
Mini-mental Status Exam: He scored a 30, no cognitive impairment.
Hamilton Depression Scale: He scored 12 which would indicate mild depression.
Negative Syndrome Scale (PANSS): He scored 65 both high on positive and negative
symptoms.
DSM-IV Diagnosis:
Axis I: 295.3 - Schizophrenia, Paranoid Type
Axis II: None
Axis III: None
Axis IV: 1- Marital problem, client has been unable to have sexual relationship with his
wife for a while due to the side effects of psychotropic medication
2- Financial stressors related to unemployment
Axis V: GAF 43
Narrative Summary and Formulation
Mr. J.N. is a 32yr old white, married male former college professor. He was referred by
his psychiatrist where he was previously diagnosed for paranoid type schizophrenia. He kept his
appointment today and appears motivated for treatment. He is currently married to his wife for 3
years and has an infant son. He has no family history of significant medical or mental illness. He

11. Case Study 11
has been having recurrent auditory and visual hallucinations with paranoia after stopping his
psychotropic medication due to side effects. He expressed feelings of hopelessness and guilt
towards his family especially his wife.
He claims that he has been having hallucinations since he went to college. He did not
realize his delusion/hallucinations until last year when his wife called psychiatrist and admitted
him for his erratic behavior. Mr.J.N. is recurrently seeing and hearing three figures; Charles who
was thought to be his roommate in college, Charles' young niece Marcee, and William Parcher
who is a secret government agent. He claims that he has been perceived them as real people
until his first admission last year. He continues to see and hear them even when he is on
psychotropic medication but is able to distinguish it from reality and not to react to it. But since
he stopped taking his medication, it became more difficult to distinguish it from reality and
greatly interferes with his life.
Mr. J.N. stopped taking his medication when it interferes with his memory/intellectual
capacity and sexual libido. He is a highly motivated scholar who places utmost importance on his
scholarly work and intends to go back to his work as college professor. He is also worried that
his marriage is falling apart due to his inability to perform sexual intercourse with his wife. He is
currently not working and is dependent on savings and income of his wife. He perceives that his
marriage at this point is in jeopardy.
Mr. J.N. identifies himself as isolative, avoids any social contact as much as possible. He
stays home most of the day, doing errands including taking care of his infant son. He cut off the
contact with his colleagues since his diagnosis for paranoid type schizophrenia. He reports that

12. Case Study 12
he feels ashamed, and perceives himself as a failure often. He also reports feeling guilt toward
his wife since he can no longer function as a good husband.
Mr. J.N. kept his appointment and is actively seeking help at this time. He has insight into
his problems and is goal directed to manage his mental illness. He wants to restore his
relationship with his wife and is willing to take medication in order for him to get better. He
hopes the new medication will work without debilitating side effects on his cognition and sexual
libido.
Treatment Plan
Medication
Risperdal 1mg bid p.o. as starting dose for two days. Then increase dose to 2mg bid p.o.
Risperdal relieve the psychotic symptoms including hallucinations and manic episode.
Cognitive Behavioral Therapy for psychosis (CBTp)
Cognitive behavioral therapy for schizophrenia (CBTp) is an evidence based practice
based on the work by Aaron T. Beck, MD. Initially, CBTp research focused on adjunctive
treatment for patients with medication resistant positive symptoms; however, more recent studies
have expanded to include areas such as the treatment of negative symptoms, comorbid disorders
and the use of a group modality. Several randomized clinical trials and meta-analyses have
established CBTp as an effective treatment for the symptoms associated with schizophrenia
(Draper et al, 2010). Client will be seen weekly for therapy.

13. Case Study 13
Family Therapy
The patient will initially benefit from couple counseling. The goal will be to restore
client’s relationship with his wife. Also psychoeducation for his wife will be offered. Research
findings support family psychoeducation as evidence-based treatment for serious mental illnesses
and benefits for families. Because major psychiatric disorders frequently are long term with
episodic crises, caregivers have ongoing needs for support (Lefley, 2010).
Administer Positive and Negative Syndrome Scale (PANSS) after 4 weeks
The Positive and Negative Syndrome Scale (PANSS) is a medical scale used for
measuring symptom reduction of schizophrenia patients. It is also widely used in the study of
psychosis. The name refers to the syndrome of positive symptoms, meaning those symptoms of
disease that manifest as the presence of traits, and the syndrome of negative symptoms, meaning
those symptoms that manifest as the absence of traits and a series of general symptoms for
patients with different psychosis. The scale has seven positive-symptom items, seven negative-
symptom items and 16 general psychopathology symptom items. Each item is scored on the
same seven-point severity scale (PANSS, 2012).
Intervention
Risperdal 1mg bid p.o. as starting dose for two days. Then increase dose to 2mg bid p.o.
Risperdal relieve the psychotic symptoms including hallucinations and manic episode. Compare
to conventional agent, atypical antipsychotics are known for less risk for EPS/TD, more effective
against negative symptoms, and potential effects on cognitive function thus improve outcomes
and prognosis (Risperidone, 2012).

14. Case Study 14
Outcome
He began to see the effects of the medication in a couple of weeks. He reports less
auditory hallucinations, and visual hallucinations are almost gone. After 4 weeks, symptoms
continue to improve without any adverse effect on his cognition and libido. He did not report any
side effects from Risperdal.
Intervention
Antipsychotic medications are frequently helpful in reducing psychotic symptoms and
relapse; however, many clients continue to experience persistent distress and disabilities. Almost
50% have persistent psychotic symptoms even when adhering to pharmacological treatment
(Dickerson, 2000). Many people with schizophrenia have residual symptoms and disabilities that
persist throughout their lives.
There is accumulating evidence from controlled clinical trials that CBT is effective in
reducing psychotic symptoms, increasing adherence to medication, improving response of
chronic residual symptoms and as an adjunct to inpatient treatment (Beck & Rector, 2001).
Mr. J.N was seen initially twice a week for 60 minutes for the first two weeks of
treatment. He was later seen weekly for 60 minutes. The CBTp consists of 14 sessions in 12
weeks. The emphasis of the sessions was to help him understand his mental illness, how it affects
his life/relationship and to assist him in making changes. He was engaging and eager to make
changes.

15. Case Study 15
The beginning sessions focused on gathering information to formulate an interpersonal
inventory, and identify goals based on client’s problem list. The client and I agree that the
priority is to distinguish his delusion from reality because it will have most beneficial effect on
other problems when it is resolved. As the session continues, we try to analyze his hallucinations,
such as its contents, frequency, and how it affects his mood. Also we try to evaluate how he
interprets these stimuli, which caused paranoia in the past. Client is constantly challenged for the
evidence for his delusion, and encouraged to use reasoning process. Most sessions consist of
discussing the negative effect of his current way of thinking then going over alternative views
that can positively impact on his functional level and relationship. We discuss how his cognition
plays a role in his symptom management then continue to work on creating new balanced
thoughts.
Outcome
As the sessions progress, he begins to focus on changing the way he thinks. With the help
of antipsychotic medication, his hallucinations are much less to the level that he can ignore them
most of the day. He was able to distinguish his delusion from reality. He starts to explore his own
ways to validate the reality from hallucination, such as checking to ensure that any new
acquaintances are in fact real people. The CBTp enabled him to reason his delusion, and distract
him from hallucinations. He is much more positive regarding current condition and has hopes for
his future.
Intervention
Initially couple therapy is offered. The client agrees early in treatment to have his wife
come in. His wife participates for two sessions, discussing how they feel about their relationship.

16. Case Study 16
His wife acknowledges and agrees with him regarding how his mental illness affects their
relationship.
She is also offered family psychoeducation (FPE). Family psychoeducation (FPE) is one
of six evidence-based practices endorsed by the Center for Mental Health Services for
individuals suffering from chronic mental illnesses. Multiple family group psychoeducation
(MFG) has been shown to be an effective component of FPE in reducing symptom relapses and
rehospitalizations for individuals with schizophrenia. It allows family members to increase their
understanding of the biology of the disorder, learn ways to be supportive, reduce stress in the
environment and in their own lives, and develop a broader social network (Jewell et al, 2009).
Outcome
The client reports good relationship with his wife since attending couple therapy. Both
share mutual agreement/respect for each other and accept the effects of his mental illness. He
was able to have sexual relationship since he does not experience any side effects from his new
antipsychotic medication. His wife reports that FPE was very helpful in order for her to better
understand her husband’s illness. She also reports beneficial relationship with other families in
group, sharing story and information.
Summary of Treatment
Mr. J.N. benefited from medication and CBTp. He is responding well to atypical
antipsychotic without any side effects. In CBTp, he is encouraged to identify his own delusional
or paranoid beliefs and to explore how these beliefs negatively impact his life. He was engaged
in experiments to test these beliefs.

17. Case Study 17
Treatment focuses on thought patterns that cause distress and also on developing more
realistic interpretations of events. Delusions are treated by developing an understanding of the
kind of evidence that a person uses to support their beliefs and encouraging him to recognize
evidence that may have been overlooked.
He was retested with PANSS, and scored 34 showing improvement on both positive and
negative symptoms. Mr. J.N. benefited from treatment and continues to be seen in therapy.

18. Case Study 18
References
Beck, A., & Rector, N. (2001). Cognitive therapy of schizophrenia: A new therapy for the new
millenium. American Journal of Psychotherapy, 54, 291-300.
Dickerson, F. (2000). Cognitive behavioral psychotherapy for schizophrenia: A review of recent
empirical studies. Schizophrenia Research, 43, 71-90.
Draper, M. L., Velligan, D. I., & Tai, S. (2010). Cognitive behavioral therapy for schizophrenia:
A review of recent literature and meta-analyses. Minerva Psichiatrica, 51(2), 85-94.
Jewell, T. C., Downing, D., & McFarlane, W. R. (2009). Partnering with families: Multiple
family group psychoeducation for schizophrenia. Journal of Clinical Psychology, 65(8),
868-878. doi: 10.1002/jclp.v65:810.1002/jclp.20610
Lefley, H. P. (2010). Treating difficult cases in a psychoeducational family support group for
serious mental illness. Journal of Family Psychotherapy, 21(4), 253-268. doi:
10.1080/08975353.2010.529014
Lincoln, T. M., Ziegler, M., Mehl, S., Kesting, M., Lüllmann, E., Westermann, S., & Rief, W.
(2012). Moving from efficacy to effectiveness in cognitive behavioral therapy for psychosis:
A randomized clinical practice trial. Journal of Consulting and Clinical Psychology, 80(4),
674-686. doi: 10.1037/a0028665
Positive and Negative Syndrome Scale (PANSS). (2012).
http://www.panss.org/home/index.php?option=com_content&task=blogsection&id=5&Item
id=9

19. Case Study 19
Risperidone. (2012). PubMed Health.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000944/
Small, N., Harrison, J., & Newell, R. (2010). Carer burden in schizophrenia: Considerations for
nursing practice. Mental Health Practice, 14(4), 22-25.
Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for
schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia
Bulletin, 34(3), 523-537. doi: 10.1093/schbul/sbm114