PSYCHOPATHOLOGY-II

(MPS331N)

CIA II
Causal Formulation in Psychological Disorders
Topic: Schizophrenia

Submitted by:
Yashita Chhabra (22223134)

Submitted to:
Prof. Hema M. A.
Assistant Professor

Submitted on:
06 November 2023

Department of Psychology,
School of Humanities and Social Sciences
CHRIST (Deemed To Be University) Delhi NCR
 1

Case Summary
Mrs. M, a 55-year-old woman from an upper-middle-class background, is currently
admitted to a rehabilitation center, and her clinical presentation is marked by a constellation of
complex and distressing symptoms. She lives with her 18-year-old daughter, having separated
from her husband, and it was her brothers who brought her to the center due to their concern
about her suspicious behavior.

One prominent aspect of Mrs. M's condition is her pronounced paranoid ideation. She
expresses a profound fear of her family, believing they harbor malevolent intentions towards her.
She alleges that her husband attempted to poison her, a belief indicative of persecutory delusions,
a hallmark of various psychotic disorders, including paranoid schizophrenia. These delusions are
causing significant distress, contributing to her withdrawal from social interactions, and
compelling her to keep garbage bags inside her home to avoid venturing outside.

Mrs. M also identifies herself as a homeopathy doctor, operating her clinic from her
residence. However, her brother contradicts her statements, asserting that while she did study,
she never actually practiced. This discrepancy suggests a possible delusion of grandeur or false
beliefs about her professional status.

Furthermore, Mrs. M exhibits distinctive behaviors that hint at a potential comorbid

obsessive-compulsive component. She constantly keeps her head covered with a scarf, even
when wet, and experiences discomfort if asked to change it. Additionally, she collects her fallen
hair, which may reflect an obsession with personal appearance and grooming, although this
behavior could also be part of a broader delusional system.

Her deep concern regarding her daughter's education and career is noteworthy. Her
fixation on hoarding newspaper advertisements related to university admissions and courses,
coupled with her refusal to declutter old advertisements, underscores her preoccupation with her
daughter's academic future. This intense focus, possibly linked to delusions of reference or
overvalued ideas, appears to be a source of considerable distress and emotional agitation.

During her initial assessment at the psychiatric unit, Mrs. M exhibited marked discomfort
due to the presence of a CCTV camera and the psychologist's smartphone. Her fury at being
 2

recorded and misused reflects her paranoid delusions and the belief in pervasive surveillance.
Additionally, her incessant repetition of inquiries about university entrance exam dates for her
daughter and her murmurings during interactions with healthcare providers hint at disorganized
thought processes and possibly auditory hallucinations.

Her emotional presentation is marked by blunted affect, wherein her emotional

expression is limited, and she maintains a constant affect throughout the assessment. This
emotional blunting is characteristic of schizophrenia spectrum disorders and adds another layer
to her complex clinical profile.

Mrs. M's impulse control is notably poor, and she reacts with anger and fear when she
perceives her privacy is compromised. Her confrontational behavior when her delusions are
challenged is consistent with the typical response in paranoid delusional disorder.

In summary, Mrs. M presents a challenging and intricate clinical picture characterized by

paranoid delusions, delusions of reference, emotional blunting, and potential comorbid
obsessive-compulsive traits. Her inability to discern the irrationality of her beliefs, coupled with
impaired judgment, suggests severe impairment in her capacity to function independently. Given
the complexity of her symptoms, a comprehensive evaluation is crucial to confirm her diagnosis
and establish an appropriate treatment plan. Mrs. M's prognosis depends on early intervention,
her response to treatment, family support, and the successful management of her symptoms,
which are deeply ingrained and profoundly distressing.

Diagnosis
Mrs. M’s diagnosis is Code 295.50 (F20.9)/ ICD -11 code is 6A20, severe Schizophrenia
Disorder. Mrs. M meets the criteria for Schizophrenia Disorder with a rule out of paranoid
delusional disorder and obsessive-compulsive disorder with paranoia. It was ruled out because
there were several examples in his case study where she was hoarding things, had obsessive
thoughts of sending her daughter to a university, had delusions about her occupation, and had
paranoia about her family trying to kill both the mother and the daughter. However, it was
eventually analyzed that Mrs. M presented symptoms of schizophrenia with delusions as she
believed that her family wanted to harm her, and her husband tried to poison her. She meets the
 3

criteria for hallucinations because she murmurs while a psychologist is trying to talk to her. She
meets the criteria for disorganized speech because she will reply to something that isn't being
asked of her. Lastly, she meets the criteria for negative symptoms like flat affect, as evidenced by
not changing her facial expression throughout the session with the psychologist, and has socially
withdrawn and avoided interaction with others during the pandemic. She has also shown a lack
of motivation in managing the household, as evidenced by keeping garbage bags inside. Mrs. M
presented less talkative than usual moments and used to isolate herself from others, and if anyone
tried to get into her space, she used to get violent.
Etiology
The etiology of the case of Mrs. M, a 55-year-old female with schizophrenia and other
behavioral disturbances, may involve a combination of factors contributing to her clinical
condition:
1. Biological Factors
Genetic Predisposition: There may be a genetic susceptibility to the development of
psychotic disorders, as specific individuals may have a family history of similar
conditions.
Neurochemical Imbalance: Dysregulation in neurotransmitter systems, particularly
dopamine, may play a role in the formation of paranoid delusions.
2. Psychological Factors
Early Trauma or Stress: Early life experiences or significant life stressors could have
contributed to the development of her paranoid beliefs and thought disorder.
Coping Mechanisms: Mrs. M's preoccupation with surveillance and her appearance may
be related to maladaptive coping strategies for managing her distress.
3. Environmental Factors
Life Events: Specific life events, such as the separation from her husband or the social
isolation experienced during the COVID-19 pandemic, could have triggered or
exacerbated her symptoms.
Social Isolation: Mrs. M's self-imposed isolation and hoarding behavior may have been
reinforced by the pandemic and a lack of social interaction.
4. Cognitive Factors
 4

Cognitive Biases: Cognitive distortions, such as selective attention to perceived threats

and misinterpretation of social cues, may contribute to her paranoid delusions.
Obsessive-Compulsive Traits: Her preoccupation with her appearance, constant use of a
wet scarf, and hair collection may be indicative of obsessive-compulsive tendencies.
5. Interpersonal Factors
Family Dynamics: Interactions within her family, especially any conflicts or strained
relationships, may have influenced her delusional beliefs and contributed to her feelings
of paranoia.
Social Support: Mrs. M's limited social support network and her perceived lack of trust
in family members may exacerbate her symptoms.
6. Cultural Factors
Cultural Beliefs and Practices: Cultural factors, including her cultural background, may
influence the expression and interpretation of her symptoms, such as her practice of
keeping her head covered.

Psychopathology Conceptualization
Cognitive Model of Positive Symptoms of Psychosis
The cognitive model of positive symptoms of psychosis provides insight into how
individuals with psychotic disorders, such as schizophrenia, interpret and respond to their
experiences. It focuses on understanding the cognitive processes that underlie the presence of
positive symptoms, which include delusions (irrational beliefs) and hallucinations (false sensory
perceptions). According to this model, individuals with psychosis may exhibit biases in
information processing, leading them to misinterpret their environment.
One key element of the model is the role of anomalous experiences or distressing events.
These experiences can serve as triggers for the development of delusions or hallucinations. For
instance, a person may misinterpret a coincidental event as having personal significance, leading
to a delusion. The cognitive model also emphasizes the importance of cognitive and emotional
factors in maintaining positive symptoms. Delusions and hallucinations can persist because
individuals with psychosis may engage in reasoning strategies that confirm their beliefs, even in
the face of contradictory evidence.
 5

Additionally, emotional factors, such as anxiety or stress, can exacerbate positive

symptoms. These emotions can increase the salience of anomalous experiences and contribute to
the persistence of delusions and hallucinations. In this model, the presence of positive symptoms
is seen as a result of the interplay between cognitive biases, emotional distress, and anomalous
experiences. Understanding these cognitive processes is essential for developing effective
interventions, such as cognitive-behavioral therapy for psychosis, which aims to challenge and
modify irrational beliefs and reduce distress associated with positive symptoms.

Fig 1. The cognitive model for positive symptoms of psychosis

In the context of cognitive models for positive symptoms of psychosis, the case of Mrs.
M can be analyzed. She exhibits several hallmark features of psychosis. Her belief that her
family, particularly her brothers and husband, intends to harm her and her husband's alleged
poisoning attempt represents delusions of persecution, a typical positive symptom of psychosis.
Mrs. M's social withdrawal, marked by extreme avoidance of social interactions and a reluctance
to leave her home during the COVID-19 pandemic, is consistent with this delusional thinking.
 6

Moreover, her fixation on practicing homeopathy, her hoarding of newspaper

advertisements, and her peculiar habit of collecting fallen hair signify bizarre beliefs and
behaviors often observed in individuals with psychotic disorders. The repetition of specific
phrases, like inquiring about university entrance exam dates, reflects thought disorder. Mrs. M
also demonstrates a perception of surveillance, as she becomes extremely uncomfortable in the
presence of a CCTV camera and a psychologist's smartphone, perceiving them as monitoring
devices. Her constant facial expression without emotional variation suggests affective flattening,
another characteristic of psychotic symptoms.
Animal Models for Schizophrenia
Animal models for schizophrenia are crucial tools for studying and understanding this
complex and debilitating mental disorder. These models typically involve rodents like mice and
rats and aim to simulate critical aspects of schizophrenia, such as its behavioral, neurobiological,
and cognitive abnormalities. Construct validity is an essential consideration when developing
these models, ensuring that they closely represent relevant features of schizophrenia, including
genetic, neurochemical, and environmental factors contributing to the disorder.
Behavioral assays are a primary method for assessing these animal models. Researchers
look for behaviors in animals that mirror symptoms seen in humans with schizophrenia, such as
social interaction deficits, cognitive impairments, sensorimotor gating abnormalities, and
changes in locomotor activity. Pharmacological models involve administering drugs like NMDA
receptor antagonists to induce schizophrenia-like behaviors in animals, while genetic models
manipulate specific genes associated with the disorder. Environmental models examine the
impact of early-life stressors and environmental toxins on brain development and susceptibility
to schizophrenia.
These models allow researchers to investigate the neurobiological mechanisms of
schizophrenia, including brain structures, neurotransmitter systems like dopamine and glutamate,
and neural circuits. Additionally, they provide a platform for testing potential treatments and
therapies for schizophrenia. It's essential to recognize that animal models are not perfect
representations of the human condition, but they are invaluable for advancing our understanding
of schizophrenia and developing new treatment approaches. Researchers must interpret their
findings cautiously and consider their relevance to human patients.
 7

Fig 2. The animal model for schizophrenia

The case of Mrs. M unveils a range of behaviors and symptoms that can be related to
aspects typically explored in animal models for schizophrenia. Mrs. M presents notable changes
in her daily life that bear a striking similarity to symptoms associated with schizophrenia, a
complex and challenging mental disorder. Her behaviors can be linked to various aspects of the
disorder, revealing a multifaceted picture.
First and foremost, her profound paranoia and suspiciousness, directed toward her family
members, particularly her husband, and brothers, where she believes they harbor harmful
intentions, align with the classic paranoid delusions often observed in individuals with
schizophrenia. These paranoid ideations can be studied in animal models by examining
alterations in social interactions and trust, forming a crucial aspect of research into this complex
mental condition. Furthermore, her propensity for social isolation is evident through her
reluctance to engage with others during the COVID-19 pandemic and her extreme measures to
avoid going outside. This withdrawal from social situations closely reflects the social withdrawal
often seen in individuals with schizophrenia. Researchers can emulate this behavior in animal
 8

models by introducing changes in housing conditions or subjecting animals to social stressors,

creating an avenue for investigation.
Moreover, Mrs. M's delusional beliefs, including her conviction that her husband tried to
poison her and her unwavering assertion of her profession as a homeopathy doctor despite her
brother's denial, can be classified as delusional thinking, a hallmark of schizophrenia. These
delusional thought patterns offer valuable insights that can be explored in animal models to
understand better their underlying mechanisms and their role in the disorder. In addition, Mrs.
M's heightened sensory sensitivities are exemplified by her insistence on covering her head with
a scarf, her preference for a wet scarf despite discomfort when asked to replace it, and her habit
of collecting fallen hair. These behaviors provide clues to sensory abnormalities and can be
replicated and studied in animal models through assessments of responses to sensory stimuli,
shedding light on the sensory aspects of schizophrenia. Furthermore, Mrs. M's repetitive
behaviors, such as hoarding newspaper advertisements and her resistance to decluttering old
ones, mirror the repetitive speech and muttering frequently observed in schizophrenia patients.
These repetitive behaviors represent a crucial component in understanding the cognitive aspects
of the disorder and can be integrated into animal models for further study.
Lastly, her tendency to become violent when confronted or contradicted echoes the
emotional dysregulation and aggressive tendencies sometimes exhibited by individuals with
schizophrenia. These emotional responses can be examined in animal models to decipher the
neural and neurochemical underpinnings of such behavior.

Diathesis-Stress Model
The Diathesis-Stress Model can also analyze the case presented above, as it allows us to
shed light on the dynamic relationship between inherent vulnerabilities and the external stressors
that have likely played a role in the development of schizophrenia and possible
obsessive-compulsive traits. According to this model, Schizophrenia is a brain disorder in which
marked alterations in brain activity and biochemistry increase susceptibility to the effects of
stressful events and persistent deficits in cognitive and social performance (Yank, Bentley, &
Hargrove, 1993). It accounts for approximately two-thirds of all psychotic disorders (Kessler et
al., 2007). The term prodrome here refers to the precursors that indicate a potential
pre-psychotic, at-risk mental state that could be prevented, delayed, or modified if identified
 9

early enough (Yung & McGorry, 1996). The Diathesis-Stress Model is a theoretical framework
that proposes that the development of schizophrenia, a complex and multifactorial mental
disorder, results from an interplay between a predispositional vulnerability (diathesis), may
include genetic factors, neurobiological abnormalities, psychological traits, and environmental
factors (stressors) include psychosocial stress, trauma, substance abuse, social isolation, and
other experiences that increase the risk of developing schizophrenia.
The Diathesis-Stress Model proposes that the interaction between an individual's
diathesis and environmental stressors is crucial in the onset and exacerbation of schizophrenia.
When individuals with a predisposition encounter significant stressors, it can lead to the
emergence of symptoms and the development of the disorder. In essence, the model recognizes
that not everyone with a diathesis for schizophrenia will develop the disorder. It is the presence
of environmental stressors that can act as the catalyst, triggering the expression of the diathesis
and leading to the manifestation of psychotic symptoms.

Fig 3. The diathesis-stress support model for schizophrenia

In the case of Mrs. M, the Diathesis-Stress Model can be applied to understand the
factors contributing to the development of her condition. It suggests that Mrs. M may have had a
 10

diathesis or vulnerability to psychotic symptoms, possibly influenced by genetic,

neurobiological, or early-life factors. This diathesis is being exacerbated by the significant
psychosocial stressors she is currently experiencing, including marital separation, social
isolation, and her strong paranoid delusions. Her presentation is characterized by a complex set
of symptoms, including paranoid thought processes, limited emotional expression, and
difficulties in impulse control. The stress factors, particularly her paranoid beliefs and
preoccupation with surveillance, have likely triggered her current condition.

Prognosis
Her prognosis is greatly influenced by how she responds to treatment. Antipsychotic
drugs and psychotherapy are frequently used in the treatment of psychotic disorders. Mrs. M's
prognosis is going to be significantly impacted by her capacity to react favorably to treatment.
While treatment resistance might result in more severe and persistent symptoms, positive
treatment outcomes can lead to symptom alleviation and increased functioning.
Her prognosis is further influenced by her understanding of her condition and her
devotion to treatment. People with psychotic disorders frequently lack insight, which can make it
difficult for them to recognize when they need treatment and to follow through on recommended
plans. Failure to take medication as prescribed might make a condition worse and make recovery
more complex. Another factor is her network of social support, which includes her family's
involvement. In Mrs. M's situation, her family is supportive because her brothers were worried
enough to take her to a rehabilitation facility. She can better control her symptoms and enhance
her quality of life overall with the help of her family and a caring environment.
A better prognosis also depends on early intervention. The earlier adequate mental health
care is provided to a person with a psychotic disease, the higher the odds of halting further
decline and promoting recovery. The fact that Mrs. M was admitted to a treatment facility
suggests that intervention has already started. Lastly, her prognosis and treatment plan may be
influenced by her interactions and engagement, as evidenced by her repeated words and
difficulty with technology. In summary, the prognosis for Mrs. M's condition is tentative and
dependent on several variables. Her future course will be determined mainly by early
intervention, a precise diagnosis, therapeutic response, social support, treatment adherence, and
 11

the specifics of her disease. To give her the support and care she needs to become well and lead a
better life, mental health specialists must collaborate closely with her family.
 12

Reference
Jones, C. A., Watson, D. J., & Fone, K. C. F. (2011). Animal models of schizophrenia. British
Journal of Pharmacology, 164(4), 1162–1194. https://doi.org/10.1111/j.1476-5381.2011.01386.x

Kessler, RC, Amminger, GP, Aguilar-Gaxiola, S, Alonso, J, Lee, S, & Ustun, TB (2007). Age of
onset of mental disorders: A review of recent literature. Current Opinion in Psychiatry, 20(4),
359–364. http://dx.doi.org/10.1097/YCO.0b013e32816ebc8c.

Kuipers, E., Garety, P., Fowler, D., Freeman, D., Dunn, G., & Bebbington, P. (2006). Cognitive,
emotional, and social processes in psychosis: Refining cognitive behavioral therapy for persistent
positive symptoms. Schizophrenia Bulletin, 32(Supplement 1), S24–S31.
https://doi.org/10.1093/schbul/sbl014

Yank, GR, Bentley, KJ, & Hargrove, DS (1993). The vulnerability-stress model of schizophrenia:
Advances in psychosocial treatment. American Journal of Orthopsychiatry, 63(1), 55–69.

Yung, AR, & McGorry, PD (1996). The prodromal phase of first-episode psychosis: Past and
current conceptualizations. Schizophrenia Bulletin, 22(2), 353–370.

Yung, AR, Phillips, L, & McGorry, PD (2004). Treating schizophrenia in the prodromal phase:
back to the future. Taylor & Francis.