Adult Case Report

Identifying Information:
Client’s Name I.R
Age 37
Gender Female
Marital Status Married
Date of Birth 31-12-1986
Birth Order 3rd
No. of siblings 04
No. of children’s 03
Assessment date
Examinee Ammara Maryam

Reason and Source of Referral:

The client was referred to the trainee clinical psychologist by the Psychiatrist a
t the outpatient department of Punjab Institute of Mental Health (PIMH) to assess the client’s
current level of adjustment and to
Clinical Interview:
Clinical interview is conducted with the aim of collecting detailed information to

inform assessment and diagnosis (Allen & Becker, 2019). It was directly conducted with the

client to gain in-depth insight into their level of adjustment, current and past concerns as well

as, family history, past significant events, personality traits as well as the history and course

of development of their issues and more. All of these areas were explored with the client

using open ended communication and rapport building skills. The elicited information was

then used as an aid in reaching the diagnosis and devising an individualistic management

plan. Client’s problem start 6 months ago when her brother leaves the home and cut down her

contact with his sister because client’s parents asked his brother to not visit his sister house

on daily basis. After that client remain tense and had headache, restlessness, auditory

hallucinations, tactile hallucination, anger and some times start self talk. Because client was

very attached to her younger brother. She said that she miss her a lot, and she experience

headache and a sensation of something moving in her mind. She couldn’t tolerate any noise,

and it was difficult for her to bear it. She also often got angery on her children and husband.

Client also reported that a few day after her brother left, there was a death in our neighbors.

Aftar that I became afraid of dying and constantly worried that I will also die leaving my

children behind. These thoughts made me cry and I started talking to my self.

While taking about her symptoms client reported that after this incident she often feel

as someone is calling her or she could hear the voice of her younger brother. When she

respond to these voices, her children tell her that it was just your imagination and that there

were no voices. While taking about medication no significant ailments were reported.

However, the birth of all her children was via C-section delivery. In addition to that, she has

been receiving pharmacological treatment for her symptoms for 3 months, and was
prescribed mood stabilizers, antipsychotics and anti-depressants with varying combinations,

doses and time periods over the 3 months.

Client’s birth was through normal delivery. No complications reported during

pregnancy. All developmental milestones were appropriately achieved. Client birth was

normal. She achieved her developmental milestones at her appropriate age. Her birth order

was 2nd. She had 3 brothers. Her younger brother had gender identification issue. Client’s

father was a land lord while her mother was a house wife. She was really lovingly attached to

her father and had an excellent relationship with him full of love and support. She also had a

healthy relationship with her mother, who was loving and caring towards her. However, she

passed away due to a heart attack when I.R was at a young age about 18 years old. As

reported by the client, she strongly felt the absence of her mother during her marital years

especially during the postpartum period and believes that longing for her mother was one of

the biggest stressors for her during that time. The client has three brothers who are all very

protective of her, and she shares a loving bond with them. They were always there for her

during the difficult times and are still looking out for her. She was very attached to her

younger brother. Client got married in 2013. Her husband was a taxi driver. She had 1 son

and 2 daughters. It was reported that the initial 5 years of the marriage were happy and she

was really satisfied with her in laws, her partner and her new home as there was no

interference by anyone and she was living independently with her husband. However when

her husband came back from saudia permanentely and start taxi driving their finicial situation

kept deteriorating. Due to financial issues they often start arguments in front of their children.

There is a family history of Schizophrenia, I.R’s father’s younger brother was

diagnosed with schizophrenia at a young age and has been receiving treatment for it since. He

is currently married and leading a healthy life alongside managing his symptoms via

consistent medication. While taking about her school and friendship she reported that she got
education till metric. She had an appropriate relationship with her peers and teachers but

never make friends in her life. She was an average student. She was very close to her younger

brother and consider him as her sister and best friend. She shares every thing with her

younger brother.

Her orientation of time, place and person was intact. She was very spoiled by her

family . They used to fulfil all her demands and gave her preference in anything. If someone

doesn’t listen to her , it would make her very angry. She was not very social but she always

enjoyed being the center of attention. After getting married her husband treat her very well

and fulfilled all her wishes. However things changed when her husband started driving a taxi.

Since then, their financial situation hadn’t been as good as before and she couldn’t fuilfil her

own and her children’s desires. This had led to argument with her husband, and she feels very

angry because of it.

Test Administered:

 Bender Gestalt Test (BGT)

 Test of Non-verbal Intelligence (TONI)

 Beck Depression Inventory (BDI)

 House Tree Person (HTP)

Behavioral Observation:

Client was 56 year old female sitting in a comfortable position. Her hygiene was maintained.

She was wearing seasonal appropriate cloth. When she entered the room she was looking

upwards while her shoulders were down. Her eye contact was made but not maintained. Her

pitch was medium . Her tone was a little bit aggressive. She was giving clarifications that I
‘m in all aspects of my life. Her speech was relevant. She was looking very sad. During the

sessions she talked a lot about her childerns . His tone and pich was low. She performed the

BGT with full attention and concentration. She used eraser a lot of time whle drawing the

figures. Perfectionism can be seen from her figures. She was thought a lot while performing

TONI. She give too much time on HTP. While drawing HTP she was continuously checking

time on phone because her duty time was started.

Psychological Evaluation:

Subjective Rating of symptoms sadness, anger, loss of appetite, loss of interest,

worthlessness, restlessness, loss of concentration

Table 1.

Symptoms Rating
Headache 8
Restlessness 6
Auditory Hallucination 6
Tactile Hallucination 7
Anger 7
Self-talk 4

Table2.

Client’s score on Bender Gestalt Test

Total raw score Visual-motor index Percentile rank Descriptive rating

31 106 66 Below Average

BGT is used to check the cognitive functioning and visual motor integration of the client.

Client’s scored 31 which indicates that her psycho neurological functioning is average on

BGT. Client had fatigue during session but she was still cooperative during the assessment.
She used 2 pages for drawing all figures. She draw most of the underlying figures correctly.

She found it difficult to join the parts of last figure together. She used eraser in most of the

figures because she found it difficult to draw the exact shape of figure. He completes the test

in 17 minutes.

Emotional Indicators of BGT:

Over worked, reinforced lines can be seen in design 5,14,15,16. She erased and

redraw the design which is associated with impulsiveness and aggressiveness.

Table 3.

Client’s score on Test of Non-Verbal Intelligence

Chronological Raw Score Index Score Percentile Rank Descriptive Term

Age

37 Below Average
TONI-4 offers an assessment of intelligence, aptitude, abstract reasoning, and

problem solving. Client score indicate that her level of intelligence, aptitude, abstract

reasoning, and problem solving abilities are average. Client complete the test in 20 minutes.

She was facing concentration problem during the assessment. His response time was normal.

There is not showing any problem in his cognitive abilities.

Table no.3

Subscales Raw Score T Score Descriptive Range

Positive 19 49 Average

Negative 17 42 Slightly below Average

Composite 2 51 Average

General Pathology 41 51 Average

Anergia 7 41 Slightly Below Average

 Thought disturbance 12 49 Average

Activation 6 48 Average

Paranoid 8 52 Average

Depression 7 44 Slightly Below Average

Client’s t-score on positive scale is 49 which indicates average level of positive

symptoms. On negative scale she scored 42 which indicates moderate to low level of negative

symptoms. On composite scale 2 score indicates a slight predominance of positive

symptoms over negative symptoms. 51 t-score score on general pathology indicates moderate

to high overall pathology. While 41 score on anergia shows mild level of lack of energy or

motivation. Moderate level of thought disturbance can be seen by 49 score on it. 648 t-

scorescore on activation, 52 score on paranoid and 44 score on depression indicates mild

level of these symptoms. She had moderate to severe level of poor impulse control and

moderate level of active social avoidance can also be seen in the client.

House Tree Person:

Client draw a small house on the right side of the page with close door which shows

that she is not very social. Small door and windows of the house shows suspiciousness.

Strong lines of the house shows her need for protection. Single line of house shows

constriction.

Client draw fantasy like tree which indicates Unrealistic thoughts and distorted perception of

the world. Client draw a bizarre tree which shows psychosis. Small branches shows limited

skills. Client draw the tree without roots which shows sense of insecurity. Long trunk of the

tree shows regression.

Her large head shows regression and grandiosity. His mid feet and hand shows

schizoid. Her emphasized hands shows external aggression. Her spread fingers shows open
aggression. Her expansion of arm shows her desire to be prominent. Her long and week arms

shows dependency and nurturance. Large same sex figure shows aggression. Eye dots shows

rigidity. Heavy line of mouth shows sadism and oral aggression. Large ears shows auditory

hallucination. Her missing neck shows her immaturity and lack of impulsive control.

Tentative Diagnosis:

Prognosis:

Conclusion:
 Management Plan
Client’s Name I.R

Age 37

Presenting Complaints Headache, Hallucinations, Anger

Test Administered  Bender Gestalt Test (BGT)

 Test of Non-Verbal Intelligence

(TONI)

 Positive and Negative Syndrome

Scale (PANSS)

 House Tree Person Test (HTP)

Goals of Therapy Therapeutic Techniques

Short Term Goals

Building a therapeutic alliance with the clie Rapport building techniques: empathetic un
nt derstanding, active listening, restating parap
hrasing, summarizing, reflecting content and
feeling
Educating client about schizoaffective disor Psychoeducation
der; its nature and importance of relapse pre
vention; causes, symptoms, treatments
Teach relaxation skills to deal with post-sess Deep Breathing technique
ion overwhelm
Building medication adherence Psychoeducation
Cost and Benefit analysis
To build healthier sleeping habits Sleep Hygiene tips
Progressive muscle relaxation
Anger thermometer for anger management

To provide a positive outlook about the pres Gratitude journaling

ent circumstances; boost wellbeing
Long Term Goals

Main therapies

No. of session planned

Initial Phase

Middle Phase

Final Phase
Case Formulation:

Predisposing factor
Uncle had diagnosed
with schizophrenia in
young age

Precipitating facto
rs Presenting Complaints
Perpetuating factor
Younger brother Sleeplessness, restlessne
left the homes ss, anger, auditory Death in neighbors
hallucination, tactile
hallucination,self talk

Protective factors
Medication,
Therapy, Family
support
Case Conceptualization:
Case Conceptualization of Schizophrenia by (Garety et al.,2001)

Biopsychosocial Emotions
Stressful Event
Vulnerability Tension
Brother left home
and cut down contact Headache
Family history of with her
schizophrenia Restlessness
Death in neighbours
Financial issues sadness

Cognitive Dysfunction Appraisal of experience a

s external
Auditory Hallucination
Auditory experience as
Tactile Hallucination
externa despite her
Self-Talk children's assurance that it
was her imaginations

Appraisal influenced b
y Positive Symptoms
her attachment to her br
Auditory Hallucination
other
Tactile Hallucination
her dependence on him
for emotional support Self-talk

Maintaining Factors
Lack of insight
Genetic vulnerability
Financial difficulty