Case Report II

Submitted by:

Noormah Saghir

Sap Id: 1600

Section B

Submitted to:

Ms. Sobia Ikram

Date of submission: Monday, May 16, 2022

 Case Report 2

Schizophreniform disorder
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Table of content

Case Report # 2----------------------------------------------------------------------------------------8

Case Summary 4

Identifying Data 5

Reason and source of referral 6

Presenting complaints 6

Initial observation of the client 7

History of Present illness 7

Background Information 8

Personal history 8

Birth and Early Childhood 8

Educational History 8

Sexual History 8

Family History 8

Drug History 8

Forensic History 8

Past medical and Psychiatric History 9

Premorbid personalities 9

Assessment 9

Informal Assessment 9

Clinical interview 9

Behavioral Observation 10
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Formal Assessment 10

Quantitative Analysis 11

Qualitative Analysis 11

Case Formulation 14

Biopsychosocial and Spiritual Model 15

Diagnosis 16

Prognosis 16

Propose management Plan 16

Appendices 17

Refrences……………………………………………………………………………………18
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Case Summary
Abc is a 28 years old woman. Client was brought to the Benzair Hospital Rawalpindi, Pakistan for
psychological assessment and management of the problem of client. The client was presented with the
complaints of hallucinations, disorganized speech, poor appetite and decreased need for sleep. Assessment
was done on both the informal and formal levels. For informal assessment, clinical interview was conducted
and mental status examination was used, and for the purpose of formal assessment mini mental status
examination was used, function ability assessment was conducted, depression anxiety and stress scale
(DASS) was used. For the purpose of management cognitive behavioral therapy, social skill training and
physical fines exercises was used.
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Identifying Data

Name Abc

Age 28 Years Old

Gender Female

No. of siblings 4 (2 brothers and 2 sisters)

Birth Order Second among 4 siblings

Occupation Direct selling in cosmetic products

Education Intermediate

Marital Status Single

Address Chakwal

Religion Islam

Socio-economic status Lower middle class

Informant Brother
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Reasons and Source of Referral:

The client was referred to clinical psychologist by her brother for psychological assessment and
management.

Presenting complain (according to informant)

Frequency, intensity and duration table

Complaints Frequency Intensity Duration

‫ وہ مجھے‬.‫مجھے هللا کی آواز آتی ہے‬ Always 9/10 3 months

‫مختلف کام کرنے کو بولتے ہیں‬

‫میں ایک فرشتہ ہوں‬ Sometimes 8/10 2 months

‫ صرف دو‬.‫رات کو نیند نہیں آتی ہے‬

Always 9/10 2 months
‫سے چار گھنٹے سوتی ہوں‬

‫بھوک نہیں لگتی ہے‬ Always 9/10 1 month

‫اکیلے میں سکون ملتا ہے‬ Sometimes 8/10 2 months

‫هللا نے مجھ سے کہا ہے کہ میں اس‬

Sometimes 7/10 2 months
‫ملک کی زمیداری میرے اوپر ہے‬

‫میرا بھائی میرے خالف ہے‬ Sometimes 7/10 1 month

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Initial Observation of the client

The client was a short height woman with average weight. Her personal hygiene was not so good. She
was wearing neat clothes. She was maintaining adequate eye contact. Her sitting posture was much relaxed.
The client seems quiet motivated to seek treatment.

History of present illness

Clients belongs to a middle class family. According to client to fulfill his family needs she started a
job at cosmetics company. Sometimes she had to do a night shift. Everything was fine. The atmosphere of
the workplace was not good. That’s the time when client psychological problem started. Her boss is trying to
do flirt with her. But she did not tell anybody because she was afraid that everybody blames her. Besides
this she also thought that her family life also disturbs if she told her family about her boss. She was not
happy and remained sad every time. But she was relaxed at least she got enough money to pay her family
bills. After sometime she realized that her boss was trying to make physical contact with her. She was
sexually harassed by her boss. She told her mother about this left the job. Her family life got disturb. Also
due to job lost their financial situation was also very bad. They fought daily. She got stressed so much. One
of her friend told her about her about the nicotine pouches available at market. She used to take Velo every
time for pleasure purposes. Clients sister reported that the client was remained so depressed so she advised
her to took the anti-depressant. She took anti-depressant without any prescription to get relief. According to
client’s mother 3 months ago she suddenly started praying and also perform tahajjud every day. At first
client’s family became happy but the problem is started when client started saying that I’m an angel and
God talks to me daily at night 3:00 am. At first client’s family thought that she was doing it because of
depression. Her brother thought that she was doing it on purpose to gain attention. But her mother was
really worried and she took her to the clinic near their house. They gave her some medicines. But her
condition became even worst. She also had poor appetite and sleeping problems. She became very weak.
Clients brother reported that she said I’m the future prime minister of the country. And sometimes she also
said that I’m going to meet the God he called me. The problem increased day by day. Her aunt took her to a
Babaji. They did everything they could do but there was no difference. Her condition was so worst that one
day she tried to kill her brother because according to her that was the right thing to do and someone from
Jannah had told her to do this. At that time her brother became terrified by knowing that fact that she is
dangerous for her family as well as for herself. After consulting with friend client’s brother took her to the
hospital in Chakwal. Then she was referred to Benazir Hospital for psychological assessment.
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Background Information

Personal history

Birth and Early childhood

Client was born through normal delivery. Client reported that her early childhood was not good. Her
mother was mentally ill. Her brother used to do all her works and he played a role of mother for her. When
she was 15 years old her mother started to getting better.

Educational history
Client reported that she was an average student. She used to go to government school and college.
Her education was till Bachelors level. She a had a plan to do Masters. She had good relationship with her
friends and teachers.

Sexual history
Client reported that she had a boyfriend but they never got involved in physical relationship. Client
used to do a job in cosmetic company. She had to do a night shift. Her boss wanted to make a physical
relationship with her and flirt with her. Client was sexually harassed by her boss. She got stressed after
this unfortunate event.

Family history
Client belongs to a lower middle class family. She lives in a nuclear family system. According to
client she was very close to her brother. The atmosphere of the family was not so good. Her mother is
mentally ill. Client’s mother had schizophrenia. She uses to beat her children by saying that they are evil.
At that time her brother was the one who played the role of caring mother for her sister(client). Client
reported that she has one sister and two brother. She had good communication pattern with her siblings.

Drug history
The client tried different kind of drugs with friends. But the client had not severe level of
addiction for any kind of drug. Client reported that for adventure purpose she and her friends tried
cigarette, vape, sheesha, cannabis but that is only for one time. Besides this after the incident of
harassment client uses velo nicotine pouches for mental relief. But she is not addicted to it.

Forensic history
No court or police case was reported.
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Past medical & psychiatric illness

Client had not reported any serious past medical history. Besides this she had some anxiety issues.
But that was not of severe level. According to client when she was sexually harassed by her boss she got
depression. That was client assumption that she had depression. She never consults to any psychologist
that she had depression. She used anti depression without any doctor’s prescription.

Pre-morbid personality

Client had loving and charming personality. She was able to socialize with her neighbors and
business partners. She was able to do household activity such as washing clothes, kitchen preparation. She
was able to engage in leisure activity such as internet suffering. She was very good in art and craft. She had
also won a medal in debate competition.

Assessment

In order to assess client’s problem two types of assessment was carried out that is:

1. Informal Assessment

Informal assessment comprised of:

a. Clinical Interview

b. Mental Status Examination

2. Formal Assessment

The formal assessment comprised of:

a) Mini Mental Status Examination

b) Function Ability Assessment

d) Depression Anxiety and Stress Scale (DASS)

Clinical Interview

Clinical interview was conducted with the client to get detailed information about his family,
personal and the history of psychiatric problem. The client had proper insight about her problem, and she
was motivated to seek treatment. During the complete interview session, the client was attentive.

Mental state examination

MSE is done with patient at first presentation to the clinical psychologist to assess about her verbal
& nonverbal symptoms of illness. It provides basis for psychiatric diagnosis and clinical assessment. The
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client was wearing pant shirt. She was short heighted woman of average weight. Her appearance was
consistent with her reported age. Her personal hygiene was not so good. Her behavior was inappropriate.
She raised

voice several times when during interview when questions were asked. She got irritated. She was upset.
She answered questions fluently but sometimes she talked irrelevant. During interview she said that God
was again calling her. Client’s attention and concentration was proper as he performed correctly in digit
span, spelling backward, and calculations. Her memory, intellect and vocabulary were good. She was able
to recall the event from in past easily. Her information and vocabulary was proper as he correctly stated the
name of president of Pakistan, prime minister and the capital city. Her was good in abstractions too as he
clearly stated the difference between two objects, and commonly used proverbs.

2. Formal Assessment

a. Mini Mental Status Examination (MMSE)

Mini-Mental State Examination (MMSE) is a set of 30 questions that doctors and other healthcare
professionals commonly use to check for cognitive impairment (problems with thinking, communication,
understanding and memory).
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Table 2 Results of Mini Mental Status Examination

Domain Comment Score

Year, date, day, month = Client able to state season 5/5

Orientation
Place = client recognize and know where she is 5/5

Client can names 3 different object (shoe, banana,

Registration 3/3
chair) in the first trial

Attention and Client need to calculate 100 – 3 for 5 times

2/5
Calculation Client able to answer 94 only

Recall Client able to recall 3 objects correctly. 3/3

Able to name object (pencil & watch). 2/2

Able to repeat sentence 1/1

Able to follow instructions 3/3

Language Able to read 1/1

Able to make a sentence 1/1

Able to copy picture exactly 1/1

Total score Interpretation: mild to moderate cognitive impairment 27/30

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b. Function Ability Assessment

Table 3 Results of Function Ability Assessment

A. Living skill Score Comments

Dressing 1 Independent in dressing
Eating 1 Behavior is socially appropriate
Grooming 1 Independent in all areas
Domestic Skills 1 Independent in all areas
Time management 1 Able to manage time with priorities ( leisure, work, rest )
Money management 1 Independent in all areas

A. Task Organization Score Comments

Attention Span 1 Attend the task for more than 30 minutes

Problem Solving 1 Solve problems independently

Decision Making 1 Make decisions independently

Frustration Tolerance 1 Deal with simple and complex tasks independently

Memory Functioning 1 Able to manage time with priorities ( leisure, work, rest )

Verbal Instructions 1 Follows all verbal instructions independently

Learning Ability 1 Learns simple and complex tasks without difficulty

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A. Personal/Interpersonal
Score Comments
Abilities
Difficulties in two areas- initiation, voice tone
Communication Skills 3
God eye contact, listening and body language
Social skills
2 Intermittent difficulties in 1 area – poor social interaction

Passivity 1 Independent assertive functioning

Aggressions 2 Communicates aggression in some situation

Self-control 1 Regulates behavior appropriately to all situations

Difficulties in 2 areas – self-confidence and role
Self-concept 1
expectation
Reality Orientations 1 Independent in identifying
Can deal with minor stress, occasionally not able to deal
Managing Stress 2
with major stresses
Initiative 1 Functioning allow independence

A. Motor Task Score Comments

Balance allows independent functioning

Balance 1
( sitting, walking, standing )

Coordination 1 Intermittent –VM, PM, GM.

c. Depression Anxiety and Stress Scale

Table 4 Results of Depression Anxiety and Stress Scale

Depression Anxiety Stress

Total Scoring 6 5 17

Interpretation 0-9 0-7 15-18

Normal Normal Mild

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Case Formulation

The client was 32 years old female was referred with the complaints of hallucinations, disorganized
speech, poor appetite and decreased need for sleep. She was very close to her brother. The history of client
suggests that her childhood was not good as her mother is schizophrenic patient. Her brother played a role
of mother for her sister (client). She belongs to a lower middle class family. These factors proved to be the
predisposing factors of client’s problem. According to Henriksen (2017), If your brother or sister or one
parent has the illness, your chance of having schizophrenia is around 10 percent. According to Jennifer
Casarella (2020), You're more likely to get schizophrenia if someone in your family has it. If it's a parent,
brother, or sister, your chances go up by 10%. If both your parents have it, you have a 40% chance of
getting it. The background information of client showed that the client has the insight of everything
happened to her.
Client was sexually harassed by her boss in workplace. According to client to fulfill his family needs she
started a job at cosmetics company. Sometimes she had to do a night shift. Everything was fine. The
atmosphere of the workplace was not good. That’s the time when client psychological problem started. Her
boss is trying to do flirt with her. But she did not tell anybody because she was afraid that everybody blames
her. Besides this she also thought that her family life also disturbs if she told her family about her boss. She
was not happy and remained sad every time. But she was relaxed at least she got enough money to pay her
family bills. After sometime she realized that her boss was trying to make physical contact with her. She was
sexually harassed by her boss. These factors proved to be the precipitating factors of client’s problem. Sexual
abuse is a strong predictor of schizophrenia in later life, a leading psychiatrist has told the International
Congress of the Royal College of Psychiatrists 2011. According to Andre Tomlin (2011) Eight in every 100
people have experienced molestation while one per cent of men and three per cent of women report having
had non-consensual sexual intercourse. It is possible to calculate that if sexual abuse ceased, there might be as
much as a 17 per cent reduction in people suffering from schizophrenia.
The atmosphere of the home was very distant and not communicative. Also due to the illness the clients
mother was not in the condition of taking care of her family. The client had bad relationship with her mother.
Her mother thought that the client doing all this to gain attention. Also she used to take anti-depressant without
the prescription. She also took nicotine pouches (Velo) for pleasure purposes. These factors proved to be the
perpetuating factors of client’s problem. Nicotine usage increases the risk of psychosis. Research has found
links between psychosis and nicotine particularly in regard to schizophrenia (Railton, 2018)
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Bio Psycho Social and Spiritual Model

Biological Factors Psychological Factors

• There is family history of Emotional Dysregulation
schizophrenia. Client mother
is schizophrenic patient.

Diagnosis
F20.81 Schizophreniform disorder

Social Factors Spiritual Factors

Sexually harassed by her boss Client believes that God talks to her
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Diagnosis

F20.81 Schizophreniform disorder

Prognosis

Points in favor of prognosis

• Patient has good moral support from her family

• Patient is compliance and motivated to treatment

• Positive observable changes were also seen in client’s mood.

Points against the favorable prognosis

• Patient lack of communication skills

Propose management plan

1. Cognitive behavioral therapy used to reduce psychotic symptoms and provide awareness.
Psychoeducation refers to the process of educating patients about their conditions and useful truths
about life in general.
2. Social skill training used to facilitate communication skills and to enhance self-motivation. Social
skill training, when carried out with high intensity and sufficient duration, has been shown to improve
the capacities for personal effectiveness among persons with schizophrenia.
3. Psychical fitness activity also contributed to reduce the symptoms of schizophrenia
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Appendices
Depression Anxiety and Stress Scale
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References

1. Henriksen, M. G., Nordgaard, J., & Jansson, L. B. (2017). Genetics of Schizophrenia: Overview of
Methods, Findings and Limitations. Frontiers in human neuroscience, 11, 322.
[Link]

2. Casarella, J. (2020, June 29). Your Guide to Schizophrenia. Retrieved from WebMD:
[Link]

3. Tomlin, A. (2011, July 1). Mental Health. Retrieved from The Mental Elf:
[Link]
cause-of-schizophrenia/#:~:text=The%20worse%20the%20abuse%2C%20the,abuse%20is%20common
%20in%20childhood

4. Railton, D. (2018, March 2018). Smoking every day can increase psychosis risk, study finds. Retrieved
from MEDIACLNEWSTODAY: [Link]