Case Presentation

Digna E. Vera
July 21, 2014


1) Demographics: Single, unemployed 50 year old African American female with diagnosis of
schizoaffective disorder. Client currently resides in Richmond, VA. She appears to be
unmotivated to take care of her personal appearance. The client eats and drinks other members
food/drinks and laughs when confronted. She interacts with select members, mainly the men
who give her cigarettes. She enjoys music and has been observed dancing and singing.

2) Reason for Initiating Services: The client requested to attend the center to enhance her
interpersonal skills, increase her personal hygiene and activity level. She requires case
management to monitor medication compliance, and linkage to community resources.

3) Chief complaint(s): Presenting symptoms include; religious preoccupation, thought
blocking, delusional thoughts, and auditory hallucinations (hearing the voice of God telling her
not to move).

4) Developmental History: Her mother passed away in October 2010 and she did not want to
attend the funeral. She has two children who live with their paternal grandparents and visit for
the holidays. She was married; however, her husband was murdered in Richmond in 1993 while
working as an Insurance agent. She has had a long history of mental illness dating back 26
years. Her father continues to visit her on a weekly basis.

5) Family medical history: Unknown

6) Personal medical history: Diabetes, obesity, gastro esophageal reflux disease, and urinary
incontinence.

7) Trauma history: None indicated

8) Psychiatric history: Hospitalized July 2012; several tests conducted to determine why she
frequently appeared to become catatonic. Due to the client disconnecting wires attached to her
head, she was discharged from hospital without any explanation to her catatonic episodes. Over
the years she signed in with the last name John instead of her legal name. Although she did not
talk about Sir Elton John, her affect brightened when his name was mentioned.

9) Mental status at intake: Client oriented to time, person and place. Unkempt appearance,
and poor hygiene. Reported auditory hallucinations, her thought processes and mood within
normal limits. No report of side effects from medication.

10) Current mental status: Her appearance remains disheveled (clothes stained with
food/drink). She is usually quiet and withdrawn. She sits by herself with her head lowered and
often drooling on her clothes. Many days she does not respond to directed questions and remains
seated in the same chair for most of the day.

11) Current medications: Aspirin (1mg)/daily, Benztropine (2mg)/twice daily, Clozapine
(400mg)/daily, Desmopressin (0.1mg)/three times daily, Docusate (100mg)/daily, Cymbalta
(60mg)/daily, Lisinopril (5mg)/daily, Meformin (500mg), Ranitidine (150 mg)/twice daily.

12) Results of any psychological testing: None indicated, however, she requires annual
physical exam to monitor physical health.

13) Complete multiaxial diagnosis: Schizoaffective disorder,

14) Conceptualization: Client may be suffering due to the environment in which she grew up.
Despite having both parents at home, client may have lacked nurturing from a parent or both.
The death of the clients husband may have contributed more to her mental status. There may
also be a history of mental illness in her family, many generations before her.

15) Client strengths: She can perform her duties in the clerical unit without supervision. She
has stable housing and is able to express her needs.

16) Treatment goals: To remain stable in the community with no hospitalizations for at least 12
months, monitor her weight; attend unit meetings and psycho educational groups more
frequently.

17) Quality of therapeutic relationship: Although the client sits with her head lowered, she
recognizes my voice when I approach her and start a conversation. She addresses me as
sweetie, honey, etc. Likes to talk, ask questions, ask for whatever Im eating and usually picks
up her head by the time I initiate conversation.

18) Central themes in treatment: None

19) Your experience of the client: Pleasant demeanor, big smile, and a glow when approached.
She will not initiate conversations but will respond if approached and has lots to say once she
gets going.

20) Questions you have about the case or challenges you wish to discuss: None