Case no1:

Schizophrenia
Case Summary

Mr. U.R was a Male with an age of 30 years old. He belonged to middle class family. His birth

order was last. He was referred to trainee Clinical Psychologist for the purpose of psychological

assessment with complaints of persecutory delusions, auditory hallucinations, social withdrawal,

feeling of being alone, sleep disturbance, low mood, inability to express positive emotions,

aggression, self-talk and self-laugh. Formal and Informal assessment was carried out. Formal

assessment was carried out Using PANSS. Informal assessment was carried out using Clinical

Interview, Mental Status Examination and Subjective Rating of Symptoms. After complete

history taking, and assessment, client was tentatively diagnosed with Schizophrenia.
Identifying Data

Name U.R

Age 30 Years

Gender Male

Education Civil Engineering

Occupation employed

No. of siblings 2 sisters

Birth order last

Marital status Married

Religion Islam

Informant The client himself

Reason for Referral

The client came to Fountain house with the complaints of persecutory delusions, auditory

hallucinations, social withdrawal, feeling of being alone, sleep disturbance, low mood, inability

to express positive emotions, aggression, self-talk and self-laugh He was referred to trainee

clinical psychologist for psychological assessment of his complaints.

Presenting complaints

As reported by the client,

History of Present Illness

Client’s father died in a road accident when he was in his first year of university in 2006.

He was very close to his father. He remained in a shock for 2 days after his father’s death. He

was not close to his mother. The client’s problem started 3 years back in 2015 when he got

married. He and his wife started fighting after 1 month of marriage. The reason of the fight was

to get a separate home. He tried to convince his wife, but she didn’t understand at all. After 2

months he moved back to his job at Strategic Plans Division Force SPD. He had a lot of work

pressure. His work was increased twice this time because of marriage holidays. He visited his

family on weekends. Every time he visited, he had to face new problems and issues from his

wife. His wife delivered a baby in 2016. Client reported that his responsibilities increased way

too much and demands of his wife increased too. He stopped visiting the family on weekends

and started working extra hours to met the needs. He visited his family after 3 months. His wife

spent most of her time in her parents’ home. Client reported that he didn’t want to go out and

didn’t feel like talking to anyone. He spent most of the time alone at home.

In the end of year 2016, client was admitted to CMH for depression. He resigned from

his job. He discharged from hospital after 3 months and stayed home. He started facing issues in

his sleep. He avoid his family members. His wife complained that he didn’t talk to my family

members properly. He ignored them whenever they visit. He was aggressive towards his family.

Whenever his sisters came to visit him, he didn’t come out of his room or when he got out he

remained silent. He didn’t even talk to his mother. Client reported that, his relatives threatened

him because of his judgmental behavior towards everyone. So whenever any relative came to his

home, he didn’t come out. His father visited him. His wife left the home in 2018 because of his

attitude and not fulfilling the demands of her. His mother and sisters ask him to come out of his
room and sit with family members but he used to refuse them. Client reported that he did not feel

like going out. He continued facing issues in his sleep, showing aggressive tendencies towards

significant others. He started self-talk and self-laugh and problem got worse when he started

hearing voices of his father. Client reported that his father talked to him.

After 6 months of clients poor condition his sister brought him to fountain house. The

client was assessed by psychiatrist and then referred to psychologist for the further assessment.

Background Information

Developmental History

Developmental milestones were attained age appropriately. There were no delays.

Prenatal and postnatal period was appropriate. There were not any complications during the

pregnancy.

Educational History

Client started going to school at the age of 4 years. He was happy on going to school.

Client was an excellent and talented student. He was an above average student. He liked his

school and continued to study in the same school till 5th class. He shifted to the new school

because of his fathers posting. He had many friends in school. He achieved high grades in

matriculation and intermediate on which his parents became very happy. He completed his FSC

degree from a government college where he had good friends. He got scholarship from his father

reference and got an admission in the university where he completed his civil engineering degree

program.

Occupational History
 Client first started working when he was 25 years old. He worked in an industry located

in Kashmir. He was hardworking and liked his job. His family members were satisfied with his

job. After one year he left the job and at the age of 26 years in started working in SPD. He was

happy and believed that he was doing well in his career. Currently he was unemployed.

Social history

Client had a very large circle of friends in his school and college life. He used to go out

with his friends thrice a week. He used to have a very great time with his friends. But he had

only 2 friends throughout his university life. He didn’t like to hang out. He spent most of the

time of the university in library. In his job, he had good relationship with his colleagues.

Sexual History

The client achieved puberty at the age of 12 years. He had all the sexual information from

one of the friends from his College.

Psychiatric Illness in Family

No history of psychiatric illness was reported in the family. His blood relatives were not

suffering from severe medical problems as well.

Family History

Client’s father died in December 2006 at the age of 50 years. The client revealed that his

father was loving, sympathetic and devoted in his work and supported him in every step of life.

He had a very close bonding with him. He used to spend his time with his father a lot. He worked

in army mess and used to earn average amount of money. He was rigid in religious practices.
 Client’s mother was 45 years old. She was a teacher in a government school. She lived in

khariyan where the school was located. She was doing her job from a very long time. Client

reported that, his mother used to snubbed him a lot. She was very authoritative. She was strict.

She did not give much attention to client. Client didn’t have a good relationship with his mother.

Client was last born among 3 siblings. His elder sister was married. She lived far away

from his residence. He had a healthy and congenial relationship with his sister. Client had a

loving and motherly relationship with his second sister. They both spent a lot of time together.

After his father’s death he got more close to him and would take care of him. After his sister got

married, he spent his time alone.

The client lived in a nuclear family system. Client reported the atmosphere of his home as

healthy and congenial. He reported that his family members are very nice to him and take care of

him. They sit together every day and share their stories of the day with each other. Client also

reported that, whenever his mother came to visit them, he got distressed.

Pre-morbid Personality

Prior to onset of his illness the client was living a healthy life. He shared stable and

cordial relationship with his relatives. He had healthy relationship with his siblings and loved

spending time with them and sharing his daily routine stories with them. He was hardworking

and dedicated towards his profession. He liked working as an engineer and was optimist towards

his future. He was an extrovert and liked socializing. He liked music a lot.

Psychological Assessment

Assessment was carried out at two levels. Formal assessment and informal assessment
Informal assessment

 Clinical Interview

 Mental Status Examination.

 Subjective Rating of Symptoms

Formal Assessment

 Positive and negative syndrome scale (PANSS)

Clinical Interview

Clinical interview was used as an informal assessment. To obtain comprehensive

information about client’s history, problematic behavior and presenting complaints. The data

obtained from the interview was then documented systematically for case presentation.

Mental Status Examination

Client appeared to be a middle age man with average height, wearing shalwar kameez.

His clothes were clean. He did not maintain adequate eye contact. His affect and mood were

congruent which were reported as low. He took long pauses while responding. He also had thought

blockage. He showed signs of tangentiality. He didn’t show any kind of disorganized behavior. He

had flat effect. He reported that his mood was sad. His thought process and content was intact.

Delusions were reported. He did not show any kind of derealization or depersonalization. He was

able to calculate serial numbers. Obsessions and compulsions were not reported. The client did

not show any problem in the orientation of people place and time. His abstract reasoning was normal.

Partial distortions in memory were shown. He took time in remembering things,. The client had

partial insight.
Subjective Rating of Symptoms

Subjective Ratings were taken to measure the intensity of client’s symptoms

Table 1

Showing Raw Scores and Range

Symptom Rating by Client

Social withdrawal 8
Feeling of being alone 8
Sleep disturbance 8
Low mood 8
Inability to express positive emotions 9

Aggression 9

Formal Assessment

Positive and negative syndrome scale (PANSS)

PANSS was used to assess the intensity of the symptoms of schizophrenia in client.

Quantitative Analysis

Table 2

Table showing Positive scale, Negative scale, General psychopathology scale and Composite

scale.

Positive scale Negative scale General psychopathology Bipolar index

(7-49) (7-49) (16-112) (Composite Scale)
25 30 40 -5

Qualitative Anaylsis
 Clients scores are above average. The high score on negative scale indicates that the

client displays negative symptoms more than the positive ones. The composite scale of -5 shows

the predominance of negative symptoms as compared to positive symptoms

Diagnosis

295.90 (F20.9) Schizophrenia

Differential Diagnosis

According to DSM 5 (APA, 2013)

Shizophreniform Disorder

This disorder is of shorter duration than schizophrenia as specified in Criterion C, which

requires 6 months of symptoms. In schizophreniform disorder, the disturbance is present less

than 6 months.

The client was having the reported symptoms for past 2 years without any remission. As

the criterion of schizophreniform is less than 6 months so, this disorder was ruled out.

Brief Psychotic Disorder

This disorder is of shorter duration than schizophrenia as specified in Criterion C, which

requires 6 months of symptoms. In psychotic disorder, symptoms are present at least 1 day but

less than 1 month.

The client was having reported symptoms for past 3 years without any remission. As the

criterion of brief psychotic disorder is less than one month so, this disorder was ruled out.
Case Formulation

According to DSM-5, Schizophrenia is characterized by having two or more of the

symptoms , each present for a significant portion of time during a 1 month period. The symptoms

are Delusions, hallucinations, disorganized speech, grossly disorganized and negative symptoms.

Continuous signs of the disturbance persist for at least 6 months with at least 1 month of

symptoms.

According to psychoanalytic theory, Schizophrenia is a regression to the oral stage when

the ego has not emerged from the id. As there is no distinct ego, by regressing to the primary

narcissistic stage, schizophrenics lose contact with the world. There is heightening of id impulses

specially of sexual nature during adolescence. Freud (1924, 1915,1914) believed that

schizophrenia develops from two psychological processes: regression to a pre-ego stage and

efforts to reestablish ego control. He proposed that when their world has been extremely harsh or

withholding—for example, when their parents have been cold or unnurturing or when they have

experienced severe traumas—some people regress to the earliest point in their development, to

the pre-ego state of primary narcissism, in which they recognize and meet only their own needs.

This sets the stage for schizophrenia. Their near-total regression leads to self-centered symptoms

such as neologisms, loose associations, and delusions of grandeur. Once people regress to such

an infantile state, Freud continued, they then try to reestablish ego control and contact with

reality. Their efforts give rise to yet other psychotic symptoms. Auditory hallucinations, for

example, may be a person’s attempt to substitute for a lost sense of reality.

In this case, when client encountered with a trauma in the form of his father death, client

regressed back to her pre ego stage that is id, in which he unconsciously wanted to get her needs
fulfilled by all means. Due, to this she developed schizophrenia, but only reported auditory

hallucinations and persecutory delusions. So, the death of father act as a predisposing factor.

Environmental factors have also been suggested as risks for Schizophrenia. These

predominately involve any trauma which is often mentioned as a proximal risk factor for the

illness (Velligan, Mahurin & Diamond, 1997). The trauma of his father death was closely linked

with client’s condition.

According to freud, ego’s alienation from reality could cause psychosis. Freud predicted

that paranoid delusions are motivated by unconscious homosexual impulses (Lester, 1975). In

the formal assessment, client scored above average in paranoia. Moreover freud stated that

Schizophrenia was a form of attachment disorder and also stated that schizophrenia develops

when a child did not successfully develop an attachment with the parent of the opposite sex

(Cohen, 2007). Client reported that he had a bad relationship with his mother. He had no

attachment with his mother. In the present case, mothers complaining attitude towards client and

social withdrawal act as maintaining factor.

According to attachment theory, it was found that dismissing and disorganized forms of

attachment were over-represented in psychosis. In dismissing attachment they prefer to keep

others at a distance, valuing achievements over close relationships. This is understood as an

adaptation to early experiences of consistent rejection from caregivers of open expression of

distress. Disorganized attachment has been linked to adverse experiences in childhood, such as

frightening or frightened caregiver behavior or other types of disrupted caregiver behaviors. As

client reported that, he was continuously snubbed and rejected by his mother. That’s why he
distant himself from others in his adulthood. After complete history taking and assessment client

was tentatively diagnosed with Schizophrenia.

Limitation and Suggestion

Limitations are as following:

 Time period for building rapport with the client was very short.

 No informant was available throughout the assessment. Information from family

members could not be collected which could be helpful in identifying more.

 The environment of the room was distracting for the patient during interview.

 Administration of tests was difficult due to continuous interruption by other clients in

ward and paramedical staff.

The suggestions are as following:

 Time period for case study should be extended.

 Assessment should be carried out in a room that is free of distractions.

 More sessions should be conducted to get detailed information about the client’s

problem.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders (5th ed.). USA: American Psychiatric Association.

Kay, S. R., Olper, L. A., & Lindermayer, J. (1988). Reliability and Validity of Positive and

Negative Syndrome scale for Schizophrenia. Psychiatry Research, 23(1), 99-110. Doi: 10-

1016/0165-1781(88)90038-8

Martin, D.C. (1990). The Mental Status Examination. Clinical methods: the history, physical

laboratory examinations, 3rd ed.

Smith, L., Nathan, P., Juniper, U., et al. (2003). Cognitive behavioral therapy for psychotic

symptoms: A therapist’s manual. Perth, Australia: Centre for Clinical Interventions

Figure. 1 Summary of Case Formulation

Presenting Complaints Assessment

 Persecutory delusion
 Auditory hallucinations  MSE
Client  social withdrawal  Clinical Interview
Client  feeling of being alone,  PANSS
 sleep disturbance
 low mood
 Case#2

Precipitating Factors

 Marital conflict
 Work stress at
job

Diagnosis

 Schizophrenia