Summary of case

S.N was 35 years old. He belongs to a lower middle-class family. He had a nuclear
family system. He was working at a private restaurant as a waiter. He worked there for 4
years. He got his education till primary school. Patient had family conflicts especially with
his elder brother and father. He was settled in a village then moved to Sargodha due to a
family conflict that was raised in his village. He was living with his family in Sargodha. His
home atmosphere was very conflicting and full of stress. He wanted to get married to his
girlfriend, but his family was not ready for this, due to this issue he had multiple quarrels
with his family on daily basis. Patient’s symptoms begin to appear in several forms. He was
referred by the psychologist in Fountain House for the purpose of psychological assessment
and the management of psychological problem. After that his condition got worse and
symptoms began to appear such as conflicts paranoia, social interactions, feeling of guilt,
irritability, loss of association, auditory hallucination, Aggression, delusional thinking, and
self- harm. The symptoms arise almost one year, due to family conflicts. The presenting
complaints and their duration of symptoms as well as results of psychological tests applied
showed that patient had been suffering from [295.90 (F20.9)] - Schizophrenia, First Episode
Currently in Partial Remission.
Assessment tools were used Clinical observation, Clinical interview, Case history,
Mental status examination (MSE), DSM-5 Self-Related Level 1 Cross-Cutting Measure-
Adult, brief psychiatric rating scale (BPRS), Mini-Mental status exam (MMSE) and Rotter
incomplete sentence blank (RISB). After proper diagnosis different psychological
interventions were used for patient’s treatment like, Rapport Building, psycho education
family counseling and social skills training relaxation training.
Identifying information
Name S. N
Age 35 years old
Gender Male
Birth order 2nd born
Siblings 2
Occupation Waiter in a private hotel
Education Primary
Religion Islam
Parents Alive and together
Father Working on fields of others
 Mother Homemaker
Psychiatrics history No psychiatric illness

Source and Reason for referral

The patient was admitted in Fountain House Sargodha. Patient was brought by his
brother. He was referred to as a trainee clinical psychologist for the purpose of psychological
assessment.
Presenting complaints
Presenting complaints of the patient were following:
Table 1
Presenting complaints of the patient as reported by him are given below.
Symptoms Durations Presenting complaints
Aggression 2.5 years ‫ا‬%%‫ہ آت‬%%‫ابو غص‬%%‫ی وجہ کے بے ق‬%%‫یر کس‬%%‫بغ‬
‫ہے۔‬
Paranoid delusion 1 year ‫میرا بھائی مجھے مارنا چاہتا ہے۔‬
Paranoid delusions 3 years ‫ر‬%%‫ے کی زمین پ‬%%‫یری حص‬%%‫ائی م‬%%‫یرا بھ‬%%‫م‬
‫قبضہ کرنا چاہتا ہے۔‬
Auditory hallucinations 7 months ‫میرے کانون میں آوازیں آتی ہیں۔‬
Irritability 6 months ‫ھر چیز سے بیزار‬
No social attraction 2.3 years ‫ا نہیں‬%%‫ا اچھ‬%%‫ات کرن‬%%‫ے ب‬%%‫وں س‬%%‫مجھے لوگ‬
‫لگتا اور میں اکیال رہتا ہوں۔‬
Loss of association 11 months ‫آیک بات سے دوسری بات شروع کر دینا۔‬

History of presenting complaints

The patient was born into a lower-middle-class family, experienced a relatively stable
early life in a village setting. Raised in a nuclear family, he received primary education
before entering the workforce at a private restaurant as a waiter. The patient's early years
were spent in a village environment within a joint family. He navigated the routine of primary
education and exhibited no early signs of psychological distress. Family life was relatively
ordinary during this period, offering a stable foundation.
As adolescence approached, the patient sought opportunities beyond the village,
leading to a pivotal move to Sargodha. This transition, driven for a better life, set the stage for
heightened familial conflicts. The once-stable family dynamics unraveled, with strained
relationships forming the backdrop of his teenage years.
 Family life became a source of increasing tension, particularly concerning the
patient's desire to marry his girlfriend. This desire acted as a catalyst for daily quarrels,
notably escalating to a point where the patient resorted to physically abusing his father. The
ensuing strain significantly impacted the patient's mental health, shaping his interpersonal
relationships and perceptions of family.
At the age of 25, he had a romantic relation with his girlfriend. When he kept his
desire in front of his family, but family showed a resistance. This intensified family conflicts.
Despite his attempts to establish a new life in Sargodha, persistent quarrels with his family
members, particularly the elder brother and father, escalated daily. The familial resistance to
his marriage plans contributed significantly to his mental health. Once he physically abuse his
father during one of the confrontations, revealing the profound impact of the ongoing familial
conflicts on his mental well-being.
His occupation as a waiter for four years added an additional layer of stress to his life.
The social dynamics at work, combined with the challenges arising from family conflicts
impacts his psychological distress. He assumed that his brother wanted to kill him. He told
that once his brother tried to give him poison in the food. Due to his mental conditions his
brother admit him in the fountain house Referred by a psychologist to Fountain House for a
psychological assessment, the patient's symptoms began to surface more prominently.
Background information
Family history
His father was 67 years old and worked in the fields of other. He had an aggressive
nature, patient had conflicting relationship with his father. Patient reported that once he
physically abused his father.
His mother was 55 years old. She was a housemaker. He had a good relationship with
his mother. He sometimes verbally abuses his mother in aggression.
His siblings include one sister and one elder brother. His relationship with his siblings
was weak because he was an angry person and often fought with them. He also has problems
in the relationship with his elder brother. He likes to enjoy with friends. He belongs to a
lower middle-class family. He said that his brother wanted to kill him. He doesn’t like his
brother. In the beginning his family environment was calm and good. But when land issues
arise, he faces many quarrels and stressor. He has too many conflicts with his elder brother.
He was reported that the overall home atmosphere is not friendly and good as all family
members are aggressive and his brother seems to be problematic with him. His family was
not cooperative and supportive.
Personal history
He was born into a lower-middle-class family, the patient's birth occurred at home.
The absence of any notable complications during birth suggests a standard and uneventful
birth into the world. The family, though economically modest, would have prioritized the
well-being of the newborn, and routine postnatal care would have been administered to
support his growth and development. A supportive family environment during these
formative years would have contributed to the patient's overall health and well-being, setting
the stage for the early stages of personal and familial development.
Educational history
The patient's educational journey unfolded within the parameters of a lower-middle-
class family, shaping a narrative that reflects challenges. Attending primary school marked
the initial phase of formal education, representing a foundational period of academic learning
and social development. Despite the patient's limited formal education, the completion of
primary schooling suggests an engagement with the basics of literacy and numeracy.
The transition from primary education to the workforce saw the patient embark on a
career as a waiter in a private restaurant. The combination of limited formal education and the
practical experience gained as a waiter highlights the patient's adaptability and
resourcefulness in navigating life's challenges.
History of physical and psychiatric illness
In his symptomatic history, the onset symptoms are at the age of 31 years. Treatment
was applied but it is less affected. So, symptoms again start to appear.
Sexual History
The patient achieved puberty in 7th grade. He reported having slight problems with
adjusting to the physical changes happening. But gradually the issues were resolved. He
reported a history of masturbation which he started in 10th grade and was still doing once or
twice a month. The patient had heterosexual orientation.
Premorbid Personality
The premorbid history of the patient reveals a relatively stable early life within a
lower-middle-class nuclear family, marked by routine milestones such as completing primary
education. Transitioning into adolescence, the patient found employment as a waiter,
showcasing adaptability and practical skills despite limited formal education. Before the
onset of the disorder the patient was an introverted person. He doesn’t have many friends. He
used to be very upset due to the home atmosphere. A significant relocation to Sargodha
triggered heightened family conflicts, particularly surrounding the patient's desire to marry,
leading to strained relationships with the elder brother and father. These challenges, along
with social and romantic aspirations, characterize the premorbid phase, offering crucial
insights into the patient's life before the onset of pronounced mental health symptoms.
Psychological Assessment
The patient was assessed by a trainee clinical psychologist to identify and explore the
present symptoms and the possible maintaining and exacerbating factors that would aid in
identification of the diagnosis. Two modes of assessment were followed i.e. Informal and
Formal Assessment.
Table 2
Informal and Formal Assessment Measures Used.
Informal Assessment Formal Assessment
Clinical Observation Cross Cutting Measure level-1 Adult
Clinical Interview Brief Psychiatric Rating Scale (BPRS)
Mental Status Examination (MSE) Mini Mental status exam (MMSE)
Rotter incomplete sentence blank (RISB)

Informal assessment
Clinical observation
Clinical interview
Mental status exam

Clinical observation
Clinical observations of the patient with schizophrenia and paranoid features include
pronounced aggression and irritability, as by a history of physical abuse towards family
members, particularly the father. The patient exhibits social withdrawal, potentially linked to
paranoid thoughts and delusional thinking, impacting both workplace interactions and
familial relationships. Emotional distress is evident through frequent quarrels and conflicts,
indicative of underlying psychological struggles. Distorted thought processes are apparent in
the patient's belief in an intention to cause harm against him and suspicions regarding his
family's intentions.

Clinical interview
In the clinical interview, the trainee engaged the patient in a compassionate and
structured conversation to gather comprehensive information about his thoughts, feelings,
behaviors, and personal history. Open-ended questions explored the nature and onset of
symptoms, with a focus on understanding the patient's unique perspective.
The patient was exhibiting signs of paranoid schizophrenia, describes a pervasive
belief that his family is conspiring against him, engaging in coded communication, and
posing a threat. He reports auditory hallucinations. The patient expresses anger and mistrust
towards his family, highlighting frequent conflicts, including physical violence. Work
interactions are also marred by distrust. These insights emphasize the distressing impact of
paranoid delusions on personal relationships and daily functioning. The interview
underscores the importance of a nuanced understanding for an accurate diagnosis and the
development of a tailored treatment plan addressing the multifaceted challenges associated
with paranoid schizophrenia. The clinician assessed the patient's current mental state,
including mood, affect, thought processes, and potential cognitive distortions.
Mental Status Examination (MSE)
The Mental State Examination is a comprehensive workup of a patient, based on
interviews, tests, and other sources of information and including details of mental status,
personality characteristics, diagnosis, prognosis, and treatment options.
Table 3
Mental Status Examination of the Patient
Domains Status
Appearance & Behavior The patient's appearance is casual, with
somewhat neglected grooming. During the
interview, there is noticeable restlessness,
fidgeting, and frequent shifts in body
posture, reflecting a high level of irritability.
Speech The patient's speech is fluent but tangential,
often deviating into paranoid themes.
Responses are occasionally lengthy and
convoluted, with tangential associations
evident in discussions about familial
conspiracies.
Mood and affect The patient's mood is predominantly angry,
with frequent expressions of frustration,
especially concerning family dynamics. The
affect is congruent with the angry feelings,
 displaying limited emotional range
throughout the interview.
Thought process The thought process is characterized by
tangentiality and circumstantiality, with
paranoid themes dominating the content.
The patient tends to elaborate extensively on
perceived conspiracies involving family
members.
Thought content The content of the patient's thoughts is
preoccupied with the belief that his family is
conspiring against him. There are reported
auditory hallucinations, whispers
reinforcing the conspiracy, contributing to
the patient's paranoid ideation.
Perception The patient reports hearing whispers that
align with the paranoid belief of a
conspiracy, indicating disturbances in
auditory perception.
Cognition The patient is generally oriented to time,
place, and person. However, insight into the
irrationality of paranoid thoughts is notably
impaired, as evidenced by the patient's
unwavering belief in the family conspiracy.
Insight and judgement Insight is limited, as the patient fails to
recognize the irrationality of paranoid
beliefs. Judgment is impaired, evident in the
patient's history of physical altercations with
family members, reflecting poor decision-
making in response to perceived threats.
Formal assessment
Cross Cutting Measure Level-1 Adult
Brief Psychiatric Rating Scale (PBRS-18)
Mini-Mental Status Examination
Rotter Incomplete Sentence Blank (RISB)

Cross Cutting Measure Level-1 Adult

The adult version of measure consists of 13 domains including depression, mania,
anger, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problem, memory,
repetitive thoughts and behavior, dissociation, personality functioning, and substance use.
Each item inquiries about how much or how often the individual has been bothered by the
specific symptoms during the past 6 months. The DSM-5 level-1 cross cutting symptoms
measure is self or informant-rated assessment of mental health dimensions that are relevant
across psychiatric disorders.
Quantitative Interpretation
Table 4
Cross cutting measure level-1 applied on the patient to check the range of the
domain.
Domain Scoring Range
Depression 2 Mid
Anger 4 Moderate
Mania 1 Mild
Anxiety 2 Mild
Somatic symptoms 1 Mild
Suicidal ideation 0 None
Psychosis 8 Severe
Sleep problem 1 Mild
Memory 1 Mild
Repetitive thoughts and behavior 2 Mild
Dissociation 0 None
Personality disorder 0 None
Substance use 1 Mild

Qualitative Interpretation
The patient obtained the highest score on the domain of psychosis which was 8 as the
maximum score.
Brief Psychiatric Rating Scale (PBRS-18)
The BPRS-18 is a tool used in psychiatry to assess the severity of psychiatric
symptoms. It is a shorter version of the original BPRS, designed for efficient and focused
evaluation. The scale comprises 18 items, each assessing a specific symptom domain.
Quantitative Interpretation
Table 5
BPRS-18 applied to the patient to check the severity of the illness.

Statement Scoring
somatic concern 3
Anxiety 4
Emotional withdrawal 4
Conceptual disorganization 5
Guilt feeling 3
Tension 5
Mannerism and posturing 3
Grandiosity 5
Depressive mood 4
Hostility 4
Suspiciousness 6
Hallucinatory behavior 5
Motor retardation 3
Uncooperativeness 1
Unusual thought content 2
Blunted effect 2
Excitement 1
Disorientation 1

61

Interpretation score
Score Range
18-31 Mild level illness
32-53 Moderate level illness
 54-126 Severe level illness

Qualitative Interpretation
According to the scores obtained by the patient on BPRS, it is evident that he had
been severely ill with schizophrenia.

Mini-Mental Status Examination (MMSE)

The Mini-Mental State Examination (MMSE) is a widely used screening tool
for assessing cognitive function in adults. It consists of a brief series of questions and tasks
that evaluate various cognitive domains, including orientation, memory, attention, language,
and visuospatial skills. The maximum score is 30, with lower scores indicating potential
cognitive deficits.
Table 6
MMSE applied to the patient to check the severity of the illness.
Component Score
Orientation to time 2
Orientation to place 2
Registration 2
Attention and calculation 3
Recall 3
Language naming 1
Language repetition 1
Language comprehension 1
Reading 0
Writing 0
Drawing 0
Total 15

Quantitative interpretation
Score Range
28-30 Cognitive impairment absent
24-27 Mild
18-23 Early dementia
17-10 Moderate cognitive impairment
 0-9 Severe impairment

Qualitative interpretation
S.N score 15 points on MMSE which Indicates a moderate level of cognitive
impairment, often associated with more advanced stages of dementia.

Rotter Incomplete Sentence Blank (RISB)

The Rotter Incomplete Sentence Blank (RISB) is a projective psychological test
developed by Julian B. Rotter. In this assessment, individuals are presented with sentence
stems that are intentionally left incomplete, and they are asked to complete these sentences in
a way that reflects their thoughts and feelings. It is used for checking adjustment and area of
adjustment, personal adjustment, social adjustment, and sexual adjustment.
Quantitative interpretation score
Table 7
Scoring of RISB administered on patient.
Code Response Score Frequency
P3 1 0 0
P2 1 1 1
P1 18 2 36
N 7 3 21
C1 4 4 16
C2 1 5 5
C3 12 6 72
Total - - 151

Qualitative interpretation of RISB

Scoring of RISB
Obtained score Cut of score Category Range
151 135 136-240 Maladjusted

S.N obtained 151 scores on RISB which indicates his maladjusted behavior.
Case formulation
S.N was 35 years old. He belongs to a lower middle-class family. He had a nuclear
family system. He was working at a private restaurant as a waiter. He worked there for 4
years. He got his education till primary school. Patient had family conflicts especially with
his elder brother and father. He was settled in a village then moved to Sargodha due to a
family conflict that was raised in his village.
He was living with his family in Sargodha. His home atmosphere was very conflicting
and full of stress. He wanted to get married to his girlfriend, but his family was not ready for
this, due to this issue he had multiple quarrels with his family on a daily basis. Patient’s
symptoms begin to appear in several forms. He was referred by the psychologist in Fountain
House for the purpose of psychological assessment and the management of psychological
problem.
After that his condition got worse and symptoms began to appear such as conflicts
paranoia, social interactions, feeling of guilt, irritability, loss of association, auditory
hallucination, Aggression, delusional thinking, and self- harm. The symptoms arise almost
one year, due to family conflicts. The presented complaints and their duration of symptoms as
well as results of psychological tests applied showed that patient had been suffering from
schizophrenia, 295.90 (F20.9).

Predisposing factors Family dynamics, and interpersonal conflicts,

contributing to the development of the
disorder.
Precipitating factors Persistent family conflicts, especially related
to the individual's desire to marry his
girlfriend against his family's wishes.
Perpetuating factors Continued family conflicts, lack of social
support, and the individual's difficulty in
 trusting others.
Protective factors Mothers support, willingness to recovery from
illness.

The contribution of personality to the development of schizophrenia is intricate,

involving complex interactions between genetic predispositions and environmental factors.
While certain personality traits, such as heightened neuroticism or social withdrawal, have
been correlated with an increased risk of schizophrenia, they are not direct causes. Genetic
influences on both personality and schizophrenia may intersect, and individuals with specific
traits might be more susceptible to stress, a known environmental factor linked to
schizophrenia. Social isolation and unusual cognitive styles associated with personality traits
may also play roles in the onset or exacerbation of symptoms. However, it is crucial to
emphasize that schizophrenia is a multifaceted disorder influenced by various factors beyond
personality, requiring thorough clinical evaluation and professional intervention for accurate
diagnosis and treatment.

Case formulation

Predisposing factors: Family

dynamics, and interpersonal
Presenting complaints
conflicts.
Loose of associations
Paranoid delusions
Irritable mood Precipitating factors: Especially
related to the individual's desire to
Auditory hallucination marry his girlfriend.
Lack of communication
Self-absorbed
 Perpetuating factors: Continued
family conflicts, lack of social
support, and the individual's difficulty
in trusting others.

Psychological Assessment
• Clinical Observation
Diagnosis: [295.90 (F20.9)] -
• Clinical Interview Schizophrenia, First Episode Currently
• MSE in Partial Remission
• Cross cutting level 1
adult
• Brief Psychiatric
Rating Scale (PBRS)
• MMSE
Management techniques
• RISB
Psychoeducation
Family therapy
Social skill training
Community support services
Individual psychotherapy
Relaxation technique
Aggression management
Diagnosis
[295.90 (F20.9)] - Schizophrenia, First Episode Currently in Partial Remission
Prognosis
The patient had developed insight into his illness and mental problem and was
willing to get control and manage it. He was motivated regarding his treatment. He had some
chances of recovery from it.

Management plan
• Long term goals
• short term goals
Long term goals
• Achieve and maintain long-term stability by effectively managing and preventing the
recurrence of psychotic symptoms.
• Enhance social and occupational functioning to promote independence and a higher
quality of life.
• Ensure consistent and appropriate adherence to prescribed medications to maintain
symptom control.
• Facilitate the individual's integration into the community and reduce social isolation.
• Strengthen family relationships and provide ongoing support for both the individual and
their family.

Short term goals

Following table shows short term goals of patient:
Short term goal Therapeutic intervention
Build a trusting and collaborative • Introduction and establishing
relationship with the patient and offer a rapport.
foundational understanding of the nature • Psychoeducation
and course of schizophrenia.
Equip the patient with practical coping • Coping skills
strategies to manage symptoms and enhance • Stress reduction techniques,
daily functioning. • Problem-solving strategies.
Conduct family psychoeducation sessions to • Family psychoeducation
help family members understand
schizophrenia, reduce stigma, and learn
 effective ways to support the patient.
Focus on activities of daily living, such as • Basic self-care skills
personal hygiene, nutrition, and sleep
hygiene.
Encourage participation in small social • Social engagement
activities, connect with support groups, and
work on improving communication skills.
Monitor medication adherence, adjust • Stabilize medications
dosage if necessary, and address any
immediate side effects.
Help him to stay connected to reality during • Mindfulness exercises
hallucinatory experiences. • Relaxation strategies

Summary of therapeutic intervention

1. Targeted goal
To develop a rapport with patient
Therapeutic intervention
• Introduction and orientation
• Active listening
• Empathy, building trust.
Procedure
In a therapeutic session aimed at building rapport with a patient experiencing
schizophrenia, a person-centered approach was employed, drawing from principles of
therapeutic alliance and effective communication (Rogers, C.R. 1951). The session began
with a warm greeting and orientation to the therapeutic environment to establish a sense of
safety. Active listening techniques were applied, including maintaining eye contact and using
reflective responses to convey understanding (Geldard, K., & Geldard, D. 2009). Empathy
was demonstrated by acknowledging the patient's experiences and validating their emotions.
The therapeutic goals were collaboratively established, ensuring the patient's active
involvement in decision-making. Psychoeducation about the therapy process, medication
management, and coping strategies was provided, incorporating visual aids for clarity
(National Institute for Health and Care Excellence 2014).
Outcome
• Strengthened therapeutic alliance.
• Fostering trust, engagement
• Provide a supportive foundation for further interventions.

2. Targeted goal
Focus on activities of daily living.
Therapy
• Positive reinforcement
• Behavior modification
Procedure
In the therapeutic intervention focusing on activities of daily living (ADLs), the
procedure involved a collaborative exploration of the patient's routines and habits related to
personal hygiene, nutrition, and sleep hygiene. Drawing from cognitive-behavioral principles
(Beck, 1979), the therapist and patient identified specific challenges and established
achievable goals to enhance self-care practices. Psychoeducation was incorporated to
emphasize the connection between ADLs and overall well-being, highlighting the impact on
mental health (Mueser et al., 2006). Behavior modification strategies were employed,
encouraging gradual changes and positive reinforcement. Regular check-ins and adjustments
to the plan, inspired by person-centered principles (Rogers, 1951), ensured ongoing support
and tailored interventions based on the patient's progress and preferences. This holistic
approach aimed to promote self-efficacy, contributing to improved daily functioning and
overall mental health.
Outcome
• Activities of daily living were improved.
• Self-care practices
• Enhanced daily functioning.
• A positive impact on the patient's overall mental health and well-being.
3. Targeted goal
Anger management
Therapy
• Coping strategies
• Incorporating relaxation techniques
 • Assertiveness training
• Problem-solving skills
Procedure
The process began with identifying triggers and distorted thought patterns
contributing to anger. The therapist and patient collaboratively developed coping strategies,
incorporating relaxation techniques, assertiveness training, and problem-solving skills.
Psychoeducation on anger dynamics and its physiological manifestations was provided
(Feindler & Ecton, 1986). Regular monitoring of anger episodes and associated emotions
facilitated ongoing feedback and adjustments to the intervention plan. This evidence-based
approach aimed to enhance the patient's emotional regulation, reduce impulsive anger
responses, and promote constructive ways of managing and expressing anger.
Outcomes
• Improved emotional regulation.
• Reduced impulsive anger responses.
• Enhanced problem-solving skills.
• a heightened awareness of anger triggers.
• An overall improvement in the patient's ability to manage and cope with anger-
inducing situations.