SCHIZOPHRENIA SPECTRUM DISORDER

Introduction

Schizophrenia is a brain disorder that affects how people think, feel, expresses
emotions, perceives and relates to others. It is a mental disorder that usually appears in
late adolescence or early adulthood. The hallmark symptom of schizophrenia is
psychosis, such as experiencing auditory hallucinations (voices) and delusions (fixed
false beliefs). Schizophrenia and the other psychotic disorders are some of the most
impairing forms of psychopathology, frequently associated with a profound negative
effect on the individual’s educational, occupational and social function. The spectrum
of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional
disorder, schizotypal personality disorder, schizophreniform disorder, brief psychotic
disorder, as well as psychosis associated with substance use or medical conditions.

Schizophrenia occurs in people from all cultures and from all walks of life. The
disorder is characterised by an array of diverse symptoms, including extreme oddities
in perception, thinking, action, sense of self and manner of relating to thers. The
hallmark of schizophrenia is a significant loss of contact with reality referred to as
psychosis.

It was a Swiss psychiatrist named Eugen Bleuler (1857-1939) who gave us this
diagnostic term in 1911. Bleuler used Schizophrenia (from Greek roots of Schizo
pronounced “schizo” and meaning “to split or crack”, and phren, meaning “mind”,
because he believed that this condition was characterised primarily by disorganisation
of thought process, a lack of coherence between thought and emotion and an inward
orientation away (split off) from reality. In Schizophrenia, he described that there was
a split within the intellect, between the intellect and emotion, and between the intellect
and external reality.

Schizophrenia is the prototypical psychotic disorder. Not only it is the most

common psychosis, but schizophrenia tends to involve abnormalities in all five of the
emphasized symptom domains: Hallucinations, delusions, disorganized thinking
(speech), grossly disorganized or abnormal motor behaviour (including catatonia), and
negative symptoms.
 Like the DSM-V neurodevelopmental disorders, schizophrenia is viewed as a
neuropsychiatric disorder with complex genetics and a clinical course that tends to
begin during a predictable stage of development. Whereas the neurodevelopmental
disorders tend to begin during childhood, symptoms of schizophrenia tend to reliably
develop late adolescence and early adulthood.

Definition

World Health Organisation (WHO) defines schizophrenia is characterised by

significant impairments in the way reality is perceived and changes in behaviour related
to persistent delusions, persistent hallucinations, experiences of influence, control or
passivity, disorganised thinking which is often observed as jumbled or irrelevant
speech, highly disorganised behaviour, and negative symptoms such as very limited
speech, restricted experience and expression of emotions, inability to experience
interest or pleasure, social withdrawal, extreme agitation or slowing of movements,
maintenance of unusual postures.

American Psychiatric Association (APA) defines Schizophrenia is a chronic brain

disorder that affects less than one percent of the population. When the Schizophrenia
is active, the symptoms include delusions, hallucinations, disorganised speech, trouble
with thinking and lack of motivation. With treatment, most symptoms of schizophrenia
will greatly improve and the likelihood of a recurrence can be diminished.

Prevalence of Schizophrenia

Schizophrenia affects approximately 24 million people or 1 in 300 people (0.32%)

worldwide. This rate is 1 in 222 people (0.45%). It is not as common as many other
mental disorders. It is estimated that less than 1% of people are affected by
schizophrenia. The prevalence of Schizophrenia differs across the world, within
countries, and at the local and neighbourhood level. Prevalence studies of
schizophrenia in India report rates of between 1.5 per 1000 and 2.5 per 1000.
Schizophrenia affect more males than females. The ratio is 55.61% were males and
44.39% were females affected by schizophrenia.

Causes of Schizophrenia
 A combination of genetics, brain chemistry and environment contributes to
devekopment of Schizophrenia.

Biological causes of Schizophrenia

Genetics – There is a strong genetic component to schizophrenia. Schizophrenia can

run in families, which means a greater likelihood to have schizophrenia may be passed
from parents to their children.

Pregnancy related causes of schizophrenia - Maternal infections and Flu during

pregnancy are associated with increased risk of schizophrenia.

Pregnant women’s exposure to pet animals and its infections - When pregnant
women is exposed to cat can cause infections with Toxoplasma Gondii.

Prenatal / birth complications – There is a link between pre-natal/birth complications

and development of schizophrenia in the offspring.

RH Incompatability - Maternal and fetal Rh incompatability which arises when a

mother with Rh negative blood type produces antibodies against the Rh proteins in her
Rh-positive fetus’s blood, a specific complication that give rise to schizophrenia due to
increasing risk of hypoxia (oxygen shortage) to the developing fetal brain.

Neurotransmitters - Problems with certain naturally occurring brain chemicals,

including neurotransmitters called Dopamine and Glutamate may contribute to
Schizophrenia.

Changes in the brain structure - Differences in the brain structure and central
nervous system is linked with schizophrenia.

Psychological causes of Schizophrenia

Maternal Stress – High stress levels experienced by the mother during pregnancy can
increase the chances that the child will have schizophrenia later in life. High stress
levels during pregnancy is linked to lower child IQ.

Child abuse - Child abuse is a significant cause to develop schizophrenia later. It

included all forms of neglect, emotional, physical and sexual abuse.
Environmental causes of Schizophrenia - It includes everything other than genetic
factors. Environment includes the house, family and neighbourhood. Environment
includes everything from the social, nutritional, hormonal and chemical environment
in the womb of the mother during pregnancy upto social dynamics and a stress a person
experiences, to street drug use, education, virus exposure, vitamin deficiency and abuse.

Factors/Risk factors of Schizophrenia

There are certain factors seem to increase the risk of developing or triggering
schizophrenia including

Genetics - Different combinations of genes makes more vulnerable to schizophrenia.

Inheritance plays a major risk factor.

Brain development - Even subtle differences in the brain structure can increase the
risk.

Neurotransmitters - Neurotransmitters are chemicals that carry messages between

brain cells. Schizophrenia is caused by changes in neurotransmitters like Dopamine
and Seratonin.

Family history of Schizophrenia - Those who have immediate relatives with a history
of schizophrenia or other psychiatric diseases like schizoaffective disorder, bipolar
disorder, depression have significantly increased risk of developing schizophrenia over
that of the general population.

Pregnancy and birth complications – Factors such as malnutrition or exposure to

viruses and toxins may impact the fetal brain development and leads to development of
schizophrenia.

Psychoactive or psychotropic drugs - Taking mind-altering drugs like psychoactive

or psychotropic drugs during teen years and young adulthood

Stress and Trauma - Psychological stresses like trauma in the aftermath of war,
natural disaster, concentration camp imprisonment. Thus stress plays a significant role
in developing schizophrenia.

Life changing events – Events like losses in relationships, job, school, accidents may
play a risk factor to develop schizophrenia.
Substance and drug abuse - Drugs like cannabis, cocaine, LSD or amphetamines may
trigger schizophrenic symptoms.

Categories or types of schizophrenia

(i) Paranoid Schizophrenia - This is the most common type of Schizophrenia.

It may develop later in life than other forms. Symptoms include
hallucinations and delusions, but speech and emotions may not be affected.
In paranoid schizophrenia the clinical picture is dominated by absurd and
illogical beliefs that are often highly elaborated and organised into a
coherent, though delusional framework.
(ii) Disorganised schizophrenia – It is also known as Hebephrenic
schizophrenia, it typically develops between 15 to 25 years old. Symptoms
include disorganised behaviours and thoughts, alongside short-lasting
delusions and hallucinations. They show little or no emotions in their facial
expressions, voice, tone or mannerisms. It is characterised by disorganised
speech, disorganized behaviour and flat or inappropriate affect.
(iii) Catatonic chizophrenia - This is the rarest schizophrenia diagnosis,
characterised by unusual, limited and sudden movements. Patient may often
switch between being very active or very still. Client cannot talk much but
may mimic other’s speech and movement. Catatonic schizophrenia
involves pronounced motor signs that reflect great excitement or stupor.
(iv) Residual schizophrenia - With history of psychosis, patient may
experience negative symptoms such as slow movement, poor memory, lack
of concentration and poor hygiene.
(v) Simple Schizophrenia - It is rarely diagnosed. Negative symptoms such
as slow movement, poor memory, lack of concentration and poor hygiene
are most prominent early and worsen, while positive symptoms such as
hallucinations and delusions, disorganised thinking are rarely experienced.

Symptoms of Schizophrenia

Schizophrenia involves a range of problems with thinking (cognition), behaviour

or emotions. Signs and symptoms may vary, but usually involve delusions,
hallucinations and disorganised speech and disorganised behaviour . The
symptoms are Positive and negative symptoms

Positive symptoms of schizophrenia

Delusions - Delusions are false beliefs that are not based on reality. They are fixed
false beliefs held despite clear or reasonable evidence that they are not true. They
may think that they are being harmed or harassed, certain gestures or comments are
directed at them, they feel that they have exceptional ability or fame, feels that
another person is in love with them, or a major catastrophe is about to occur.
Delusions occur in most people with schizophrenia.

Hallucinations - They are the experience of hearing, seeing, smelling, tasting or

feeling things that are not there. They are vivid and clear with an impression similar
to normal perceptions. Auditory hallucinations, “hearing voices”, are the most
common in schizophrenia and related disorders.

Disorganised thinking and speech - This refers to thoughts and speech that are
jumbled or do not make sense. The person may switch from one topic to another
or respond with an unrelated topic in conversation. Disorganised thinking is
inferred from disorganised speech. Effective communication can be impaired and
answers to questions partially or unrelated. Speech may include putting together
meaningless words that cannot be understood, sometimes known as word salad.

Disorganised or abnormal motor behaviour - They are movements that can

range from childlike silliness to unpredictable agitation or can manifest as repeated
movements without purpose. When the behaviour is severe, it can cause problems
in the performance of activities of daily life. It includes catatonia, when a person
appears as if in a daze with little movement or response to the surrounding
environment.

Negative symptoms of Schizophrenia

 Negative symptoms refers to reduced or lack of ability to function normally. It
refers to what is abnormally lacking or absent in the person with a psychotic
disorder. Negative symptoms are lack of emotions like doesnot make eye contact,
neglect of personal hygiene, does not exhibit or exchange facial expressions or
speaks in a monotone. Person lost interest in every day activities, social withdrawal
and lack of ability to experience pleasure.

Functional consequences

Schizophrenia is associated with social and occupational dysfunction.

Completing education and maintaining exployment are negatively impacted by
symptoms of the illness, and most individuals diagnosed with schizophrenia are
employed at a lower level than their parents. Many have few or limited social
relationships outside of their immediate family.

Diagnosis of Schizophrenia

Diagnosis of schizophrenia involves ruling out other metnal healh disorders and
determining that symptoms are not due to substance abuse, medication or a medical
condition. Determination of a diagnosis of schizophrenia inclues

Physical examination – This helps to rule out other problems that could be causing
symptoms and to check for any related complications.

Tests and Screenings - Tests to rule out other conditions with similara symptoms,
and screening for alcohol and drugs. Tests like MRI and CT scan to rule out brain
pathology.

Psychiatric evaluation - A psychiatrist or any mental health professional like

clinical psychologist or counsellor checks mental status by observing appearance
and demeanor and asking about thoughts, moods, delusions, hallucinations,
substance use, and potential for violence and suicide. This also includes discussion
of family and personal history.

DSM-5 criteria for schizophrenia – According to DSM-5 criteria schizophrenia

can be usually diagnosed if the client experiences 1 or more of the following
symptoms most of the time for a month like delusions, hallucinations, hearing
voices, incoherent speech, abnormal motor behaviour, negative symptoms such as
flattening of emotions, loss of interest in life.

Prognosis of Schizophrenia

While a schizophrenia diagnosis can come with an increased risk of mortality

due to co-morbid conditions and the risk of suicide, proper treatment can help an
individual a productive and happy life. Like many chronic diseases dprognosis
depends on a lot of personal factors, including how early a diagnosis was made,
how much an individual is able and willing to follow a treatment plan, and the
support system they have. 50% of the people with schizophrenia recover or
improve to the point they can work and live on their own. 25% are better but need
help from a strong support network to get by 15% are not better

Treatment for Schizophrenia

There is no cure for schizophrenia. It requires life long treatment. Aim is to

focus on managing or reducing the severity of symptoms. It is important to get a
treatment from a psychiatrist for mental health professional who has experience in
treating people with schizophrenia. Treatment with medications and psychosocial
therapy can help manage the condition. Hospitalisation may be needed in some
cases.

Medication – Medications are corner stone of schizophrenia treatment.

Antipsychotic medications are commonly prescribed to control the symptoms by
affecting the brain neurotransmitter dopamine.

Psychological Interventions

Family Therapy – Anderson developed family therapy in 1980 to counter problem

of high expressed emotion in families. Aims of family therapy is to educate
relatives about schizophrenia. To stabilize the social authority of the doctor and the
family. To improve how the family communicated and handled the situation. To
teach patients and carers more effective stress management techniques.
Communication skills training was given to teach family to listen, to express
emotions and to discuss things.
Cognitive Behavior Therapy (CBT) – The central idea of CBT is that
schizophrenic’s problems are based on incorrect beliefs and expectations. CBT
aims to identify and alter irrational thinking about general beliefs, self-image,
beliefs about what others think, expectations of how others will act, methods of
coping with problems

Coping Strategy Enhancement (CSE) - It is another form of CBT. Tarrier (1987)

used interview techniques and found that people with schizophrenia can often
identify triggers to the onset of their psychotic symptoms, and then develop their
own methods of coping with the distress caused. CSE aims to teach individuals to
develop and apply effective coping strategies which will reduce the frequency,
intensity and duration of psychotic symptoms and alleviate the accompanying stress
which includes education and rapport training and symptom targeting.

Psychosocial intervention - This includes individual therapy to help the individual

cope with stress and illness. Social training can improve social and communication
skills.

Vocational Rehabilitation - It provides the individual with the skills need to return
to work. It makes maintaining a regular job easier.

Family support and education - Support from family and friends can help reduce
stress and create feeling of inclusion for schizophrenic individuals. Educational
programs for family members and friends about schizophrenia and its symptoms
and interventions is the best psychotherapy nowadays.
 A CASE OF SCHIZOPHRENIA

DEMOGRAPHIC DETAILS

NAME: SC

AGE: 45 years

GENDER: Female

MARITAL STATUS: Single

MOTHER TONGUE: Tamil

EDUCATION: 12th grade. Dropped out of school

OCCUPATION: Unemployed

SOCIO-ECONOMIC STATUS: Low socio-economic background

RELIGION: Hindu

PLACE: Chennai

FAMILY TYPE: Joint family

NUMBER OF FAMILY 9
MEMBERS:
SOURCE OF REFERRAL: Psychiatrist from Nagerkoil Government
Hospital
REASON FOR REFERRAL: Client developed severe delusions and
hallucinations and doing things which may
endanger her life.
INFORMANT: Maternal aunt, younger brother

The information obtained from the client and the informant is reliable and consistent
but inadequate.

The case history and mental status examination presented is based on the information
provided by the supervisor.
CASE HISTORY

Presenting complaints by the patient

Client SC feels lonely

Client can hear voices telling her to do things

Client says that God is talking to her

She feel so sad that she could not study.

Client is very much disturbed by the loss of her mother.

Complaints presented by the informants

Client is suffering seizures regularly

Client has anger outbursts

Client SC remains aloof.

SC talks alone and laughs at herself.

Client tries to run away from home many times.

She is having issues with her memory.

She remembers certain childhood instances only with references, but she is not aware
of anything in the recent past 10 years.

History of present illness

It was 1995 and the client SC was 17 years, when she had her first seizure attack.
Her first attack was a very severe seizure where she experienced uncontrollable
twitching and jerking movement of all limbs, eye balls moving towards one side, she
bit her tongue during seizures, had froth in her mouth and loss of control in the bladder.
The seizure lasted for five minutes. After the seizure SC fell unconscious for almost
20 minutes.
 After retaining consciousness, SC experienced a period of confusion and had a
sudden urge to run away from her house claiming that someone was calling her. She
also tried to remove her clothes. It was also reported that the client started talking to
herself and laughing when no one was around her after the first seizure.

The client was also reported to have started experiencing delusions where she
repeatedly told her family members that God is talking to her and she is immortal. SC
was taken to Royapettah Government Hospital in the same year and was given
medications on the advice of consulting doctors and the psychiatrist. Despite
medications, ever since the attack, SC has been getting seizures on a frequent basis.
This led to her not attend her 12th classes most of the time. The informants reported
that there were no known causes for the seizures to occur. No pattern was observed as
SC’s seizures appeared on an irregular and unpredictable basis.

In the year 2002, when the client was around 23 years, the client ran away from her
Kanyakumari home once. Informant reported that her brothers and her relatives had to
llok out for her and bring her back home. The informant also reported that this has
happened quite a few times. To avoid her running away when unsupervised, SC was
locked in her house whenever she had to left alone. The informants reported that Sc’s
seizures have become severe over the years, especially after 2010 when her mother
passed away.

In the year 2011, the client attempted to take her seizure medications all at once
when she was alone at home, leading to drug overdose. Her twin came home after a
few minutes later, and SC informed her brother about the overdose and fainted almost
immediately. She was taken to hospital and treated. Her medications were also reduced
post this incident. After regaining consciousness, SC was asked on why she tried to
take all the medicines altogether for which she replied by saying that some voice from
the inside insisted her to do it.

According to the informants, the client gets two distinct types of seizures. In one
type, SC ws seen to have violent, uncontrollable jerking movements, and in the other
type, jerking movements were absent but used to stare at the wall and fell down and
become unconscious at times. Almost everytime, SC did not have a control over her
bladder, thus urinating herself during seizures. The client did not explicitly express any
fear that her seizures may recur or that she could predict or foresee that was about to
get one. Her most recent seizure was a mild one on 9th May 2022, the previous night
before their visit to IMH.

Onset of her illness is insidious in nature.

Course of illness is episodic type.

Precipitating factors

Adequate information was not available for precipitating factors.

Associated disturbances

Client SC reported that she experiences periods of confusion often ever since she
started getting seizures. The informants were also reported that the client had difficulty
in remembering recent events over the last 10 years, but the client appears to recollect
childhood incidences.

Client also has sleep disturbances and was also reported that her sleep cycle is
fluctuating. Due to repeated falls during seizures, her front teeth has fallen off. This
has resulted in lack of clarity of speech.

Negative history

The client SC has no history of delirium or dementia. Though the client have had
several falls during her seizures, but has no history of severe head injury but she
experiences headaches once in a while.

Treatmental history

(i) Past medical history

Client SC first developed her seizures in 1995 when she was doing her
12th grade, she had very severe type of seizures and fell unconscious after
seizure attack and there was no control of bladder during the episodes. She
has developed seizures every now and then, so client SC was first taken to
Royapettah Government Hospital, Chennai in 1995 for treatment of her
seizure problems. Inspite of medications there was no improvement.
 (ii) Past psychiatric history
In the year 2010, the client was taken to another place called
“Matharebootham” and treated there as an in-patient for 15 days to control
her issues with anger, shouting/yelling at others, talking to others and poor
appetite. In the first few weeks of the tear 2022, she was taken to Nagerkoil
Government Hospital for re-starting her psychiatric treatment. The
consultant psychiatrist there referred the client SC to visit the Institute of
Mental Health, Kilpauk, Chennai for further treatment.

Family history

Client SC is the first of three children in her family. She is 45 years old as of 2022.
She has a dizygotic twin brother, 45 year old named MS, currently working in a Life
Insurance Company in Nagerkoil. He was reported to have appropriate developmental
milestones and is married for the past 18 years and also has two children, a 16 year old
boy and a 14 year old girl.

Client also has another younger brother named BSS, currently working in a private
automobile company in Chennai. He is married to CD for the last 14 years and has two
children, a 13 year old boy and a nine year old girl. The client is said to have a closer
relationship with her youngest brother, BSS.

Client’s father YS was 64 when he passed away due to dual kidney failure in 2010.
He was also diagnosed with diabetes earlier.

Client’s mother MB was 55 when she passed away due to a head injury after she
slipped and fell in the bathroom in the year 2010. She had a leg injury earlier that year.

Client’s maternal aunt MY has been taking care of the client since 2010 and both
live together in Kanyakumari. They are currently residing at BSS’s place at Chennai
for the past 4 months due to the client’s treatment in IMH.

The client’s maternal uncle PA, had attempted suicide once by consuming Oleandeer
seeds (Arali Vidhai) in the year 1975 due to undisclosed reasons. He was admitted to
the hospital immediately and was recovered. PA’s wife was recognised with emotional
disturbances for a long time. It was reported that she used to have heavy but irregular
periods and was always sad.
Genogram

PERSONAL HISTORY

Birth and early development

 Client SC was born through normal delivery as a full-term baby. Client’s informant
reported that her developmental milestones were slightly delayed. More information
could not be obtained about her early development.

Behaviour during childhood

SC’s sleep patterns were normal during her childhood. She went to school but never
made friends or talk and mingle with them. More information could not be obtained
from the client or from the informants. No major physical illnesses in childhood were
reported.

School

Client SC herself reported that she was weak in academics. She started her
schooling in Amala Convent, Kanyakumari at 4.5 years of her age. She informed that
she cleared her 10th board exams by indulging in malpractice and realised that it was
wrong on her part to do so, and that she could not retain any information that she
studied.

During her 12th standard, her first seizure attack happened and since then, she was
irregular to school. She eventually dropped out without attempting her 12th board
exams.

Sexual history

Sexual history could not be elicited.

Menstrual history

Client SC’s age of menarche is at 13 years. The informant reported that client had
an appropriate reaction towards menarche. It was also reported that client’s periods
had been irregular. No signs of emotional disturbances in relation to periods were
reported.

Use and abuse of substances

No history of use and abuse of substances were elicited.

PREMORBID PERSONALITY
Social Relations

Client SC is having a very close relationship only with her youngest brother BSS.
Client had no friends in her school also.

Intellectual activities

No relevant information was provided by the client and also by her informants.

Mood

Client SC is despondent, worried, self-depreciative.

Character

1. Attitude towards work and responsibility

Client SC is bored, discouraged, impulsive, haphazard, rigid, cannot make
any decision.
2. Interpersonal Relationships
Client is not having good interpersonal relationships with all her family
members. She is having a very close relationship with her youngest brother
BSS only. Client did not have friends in school also.
3. Energy and initiative
Client is having irregular fluctuations in energy and output. Often client is
impulsive to go out of her home.
4. Fantasy Life
No relevant fantasy life, no content of day dreaming was elicited.
5. Habits
Client SC is not having any eating fads. No history of alcohol consumption
or substance use.
Once client SC has consumed all her seizure medications all at once and
became unconscious, she was hospitalised for the same. When asked client
replied that some voice from her head asked her to consume all seizure
medicines at one.
Client often runs out of her home.
Her sleeping and excretory functions are normal.
6. Interests and Hobbies
 No relevant information regarding her interests and hobbies were elicited.

MENTAL STATUS EXAMINATION

General appearance and Behaviour

Client SC looks age appropriate, untidy and unkempt in appearance. Client SC was
relaxed during the first half of the session and then began to grow increasingly restless
as the session progressed. She was able to maintain eye contact only at times.

It was also observed that the client fell asleep once , while the informants were
reporting about the case history. Rapport was established almost instantly and she was
very co-operative with the intern. The client seemed willing to talk but lacked clarity
and hence she had to repeat herself twice or thrice in order to be understood.

Psychomotor activity

Psychomotor activity of the client ws observed to be with in normal limits.

Speech

Initiation of speech

Client SC’s speech was spontaneous.

Prosody

It is normal paced speech.

Tone of speech

It is low tone, inaudible at times. Her speech lacked clarity since most of her front
teeth fell off due to repeated falls during seizures. The client had to repeat herself twice
or thrice because of this.

Reaction time

Her reaction time was normal.

Relevence

Client’s speech was relevant and coherent.

Thought

Form of thought

There was no indication of formal thought disorder.

Thought stream and process

There was absence of flight of ideas, no pressure of speech was reported. Her
thought stream and process is normal.

Thought content

Client SC experienced multiple delusions. These delusions appears to be fixed.

Thought withdrawal – client is having delusional beliefs and she feels that her
thoughts and memory have been taken and given off to two or three people. She is
having delusions of grandeor as she is immortal and she is also having religious
delusions as if God is talking to her.

Client is also having preoccupation of thoughts as client reported that she is having
feelings of worthlessness due to her inability to complete her education. She also
reported feelings of worry that her mother is not there and with her any more.

Mood and Affect

Subjective report of mood Client says that she is not fine, she is worried, how can
she be happy like this.

Objective report of mood Client is dysthymic. Client expressed a high range of

affective response. Mood and affect were congruent with her thought process.

Perception

Auditory hallucinations were present. Client’s hallucinations were reported to be

verbal, intermittent. SC reported that she hears multiple, familiar and human-like
voices heard which are in second person. She reported that these voices are distressing
and unpleasant, since they always command her on what to do and what not to do.

Client’s distressing auditory hallucinations as reported by the client

• “Don’t take bath”

• “Don’t eat food”
• “Pull your teeth out”
• Run away from the house”
• “Don’t listen to your aunt”.

CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS

Orientation

Orientation to place:- Client SC was oriented to place. She was able to respond that
she is in Chennai, and currently in Government Hospital to treat her seizures. So client
SC is oriented to place.

Orientation to time:- Client SC was oriented to time only to a certain extent. When
questioned SC responded the date and month correctly, but not the year. She also
incorrectly reported that it was afternoon, when it was actually morning.

Orientation to person:- Client SC was oriented to the person only to a certain extent.
When asked about her relatives, she correctly mentioned that it was her maternal aunt,
but incorrectly referred to her younger brother as elder brother, and client reported that
the voice in her mind told her to do it that way.

So client SC is oriented to place, but she is oriented to time and person only to a
certain extent.

Attention and concentration

Digit span test:- The digit span test was conducted, and client was able to recall upto
4 digit in the forward order and 3 digits in the backward order.
Serial subtraction test:- Client was able to perform serial subtraction test. She once
mentioned that she needed a chalk and slate to calculate the serial subtractions properly.
Yet, she only gave the right responses within a very short span of time.

Days or Months Test:- Client was able to tell the days of the week in backward order
in both Tamil and English languages.

So it can be concluded that her attention was able to be aroused and sustained and
concentration of the client is functional.

Memory

(i) Immediate Memory:- Client’s immediate memory was measured using

digit-span test. Her immediate memory appeared to be intact.
(ii) Recent Memory:- Client’s recent memory was assessed by address test.
Client could not recall the after few minutes. Her recent memory is
impaired.
(iii) Remote Memory:- Client’s remote memory was tested by asking her to
recall her date of birth, the year of her parents passed away, the year she
completed her education and number of family members. Client was unable
to answer these questions. Her remote memory is also impaired.
From the above three tests, we can infer that client’s immediate memory is
intact, and her recent and remote memories are impaired.

Intelligence

With respect to general information client SC was unable to correctly recall the name
of our country’s Prime Minister and the names of 5 cities in India. So we can infer that
client is having very poor fund of knowledge.

Comprehension

Client’s comprehension aspect is intact as she responded correctly to all the

questions like what she will do when she feels cold, she replied that she will wear
sweater or cover herself with a woollen blanket, when asked what she will do if it rains
when she goes out, she replied that she will take an umbrella and go.

Arithmetic
 SC was able to answer all the questions pertaining to arithmetic correctly. It was
assessed by asking questions like how much is 4 rupees and 5 rupees, client replied as
9 rupees, and when asked i borrowed 6 ruppes from my friend and returned 2 rupees,
how much do still i owe her, client replied as 4 rupees. Client’s arithmetic is intact.

Thus client’s fund of knowledge is inadequate to a small extent.

Abstraction

Similarities test:- When the client was asked between the similarities of Orange and
Banana, client rightly answered as both are fruits.

Differences test:- When the client was asked between differences among stone and
potato, she replied that potato is a vegetable and stone is used to build buildings. Her
response is correct.

Proverb test:- Client could not respond to proverbs.

From the above 3 tests we can conclude that her abstraction was not slightly functional
because client could not give the meaning of the proverb.

Judgment

Personal judgment:- Client’s personal judgment is intact as client expressed her

personal future wish to study more.

Social Judgment:- Client’s social judgment is poor.

Test Judgment:-

Fire problem:- When the client was asked, If the house in which she is living, catches
fire, what is the first thing she will do, client replied that she will try to put off fire.

Letter problem:- When the client was asked, when the client is walking on the
roadside she sees a stamped and sealed envelope with an address on it which someone
has dropped, what she will do, client replied that she will post the letter in the near by
post box.

We can infer that client’s personal and test judgment is intact and her social
judgment is impaired.
Insight

Client’s insight level was observed to be at” 4”, as she is aware that she is sick but
told that it is due to unknown reasons.

INVESTIGATIONS DONE

The following investigations were done as a part of the in-take interview:

Binet Kamat Test of Intelligence (BKT) – To assess the client’s intelligence level.

• The client scored 40, indicating moderate intellectual functioning.

• It was observed that the client managed to complete simple arithmetic problems
with out any difficulty. She seemed to struggle only with complex arithmetic
problems.

Vineland Social Maturity Scale (VSMS) – To assess the client’s differential social
capacities. The client obtained a score of 49 ( 3 years and 10 months), indicating a
severe impairment in social functioning.

SUMMARY

Ms. SC is a 45 year old single Hindu female from a low socio economic background
came to Institute of Mental Health in Chennai with her maternal aunt and her younger
brother. Client is having longer acquaintance with them for nearly 45 years with her
aunt and 40 years with her younger brother. Client complains that she feels lonely, she
can hear voices telling her to do things, she feels that God is talking to her, she feel sad
that she could not study and she has lost her mother. The complaints presented by the
informants about the client are, client has seizures frequently, she has anger outbursts,
she remains aloof, talks alone and laughs at herself, she tries to runaway from home,
she has issues with memory. She remembers certain childhood instances only with
references but is not aware of any thing in the

past 10 years.

In 1995 when client was 17 years old, she is in 12th standard, she had violent and
severe seizure attacks and fell unconscious. After regaining conscious SC experienced
a period of confusion and had sudden urge to runaway from home as if someone was
calling her. She tried to remove her clothes too. Client had repeated seizure attacks
inspite of medical treatment and quit her 12th standard. Client repeatedly ran out of
home, so she was forced to lock inside the house. Client is having auditory
hallucinations and delusions of grandior. Once when she was locked inside the house,
she consumed all the medications all at once and became unconscious and was
hospitalised, client told that she did so according to the inner voice heard. Client has
sleep disturbances. From 1995 she was given treatment for seizures and from 2010 she
was given psychiatric treatment.

Client’s maternal uncle attempted suicide and was recovered. His wife is also
having emotional disturbances. SC’s developmental milestones were slightly delayed.
SC never made friends or talk or mingle with them in the school. SC was weak in
academics. Client fell asleep when informants were reporting history. Client
experienced multiple delusions of grandior and auditory hallucinations. Client feels
hopeless and worthless and very much worried about the death of her mother.

Client’s subjective mood is worry, she is not fine and happy, her objective mood is
dysthymic and expressed high range of affective response. Client’s orientation to time
and person is only to a certain extent. Client’s recent and remote memories were
impaired. Client’s fund of knowledge is inadequate to a small extent. Her abstraction
was slightly dysfunctional. Her insight level was at 4, as she is aware that she is sick,
but she does not know the reasons. Binet-Kamat Test (BKT) of intelligence shows
client has moderate intellectual functioning. Vineland Social Maturity Scale (VSMS)
indicates that client SC has severe impairment in social functioning.

CASE FORMULATION

DIAGNOSTIC FRAMEWORK

Provisional Diagnosis is Schizophrenia spectrum Disorder with auditory

hallucinations and delusions of Grandior with seizures.

Client SC is meeting the DSM-5 diagnostic criteria. SC has presented auditory

hallucinations, delusions of grandior, religious delusions, disturbances in perception,
moderate level of intelligence and severe impairment in social functioning.

Schizophrenia DSM-5 Diagnostic Criteria.

 Client SC is having chronic and severe mental disorder that affects how she thinks,
feels and behaves. Client is lost in touch with reality. Her symptoms are very much
disabling her.

Schizophrenia

A. Two or more of the following, each present for a significant portion of time
during a one month period or less if successfully treated. Atleast one of these
must be present.
Points in favour of diagnosis of Schizophrenia
• Client SC is having delusions of grandier
• Client is having auditory hallucinations
• She is having disorganised behaviour
• She is having disorganised thought (speech)
• Client is having negative symptoms as
(i) Avolition – Client is having very diminished emotional
expression.
(ii) Alogia – She is having very limited speech.
(iii) Anhedonia – Client did not feel happy.
B. For a significant portion of the time since the onset of the disturbance, level of
functioning in one or major areas such as work, interpersonal relations or self-
care, is markedly below the level achieved prior to the onset, failure to achieve
expected level of interpersonal, academic or occupational functioning.
Points in favour
• Client SC did not make friends in school.
• She is very close only to her younger brother in her family.
• She discontinued her 12th standard.
• She is weak in academics.
• She is untidy and unkempt in appearance.
• VSMS scale shows severe impairment in social functioning.
C. Continuous signs of disturbance persist for atleast 6 months. This 6-month
period must include atleast 1 month of symptoms that meet criterion A (i.e)
active phase symptoms.
Points in favour
 Client is having symptoms of delusions, hallucinations, disorganised behaviour,
disorganised thought expressed by speech and negative symptoms like
Anhedonia, Alogia and Avolition persists for years since her 17th year of age.
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic
features have been ruled out.
Points in favour
• Client is not having major depressive or manic episodes that occurred
concurrently with active-phase of symptoms.
• Client did not develop any mood episodes during active phase of
symptoms.
E. The disturbance is not attributable to the physiological effects of a substance
(e.g. a drug of abuse, a medication) or another medical condition.
Points in favour
• Client is not using tobacco, alcohol and substances like psychoactive
drugs.
F. There is no history of ASD – Autism Spectrum Disorder or a communication
disorder.

Specifier

Client is having multiple episodes, currently in full remission.

Severity

Very severe. Client SC has all positive and negative symptoms of Schizophrenia.

DIFFERENTIAL DIAGNOSIS

1. Schizo-affective disorders
2. Bi-polar disorders with psychotic features
3. Schizotypal or Paranoid personality disorder
4. Drug and medication induced psychosis
5. Psychosis secondary to organic causes

1. Schizo affective disorders

 Schizo affective disorder is a mental health disorder that is marked by a
combination of schizophrenia symptoms such as hallucinations or delusions and
mood disorder symptoms such as depression or mania.
Points in favour
• Client is having delusions of grandior, religious delusions
• She is having auditory hallucinations
• Client is not having mood disorder symptoms as depression or mania.

2. Bipolar disorder with psychotic features

Bipolar disorder with psychotic features are often misdiagnosed as
Schizophrenia.
Points in favour
• The positive symptoms of Schizophrenia resemble symptoms in manic
episodes especially with psychotic features includes delusions of
grndior, auditory hallucinations, disorganised speech, paranoia.
• The negative symptoms of Schizophrenia closely resemble the
symptoms of depressive episode like apathy, extreme emotional
withdrawal, lack of affect, low energy, social isolation.
• Both bipolar disorder and schizophrenia share common medication.
• The two disorders share abnormalities in some of the same
neurotransmitter systems.
(i) Both depressive symptoms of bipolar and negative symptoms of
Schizophrenia are mediated by neurotransmitter Seratonin
(ii) Both positive symptoms of Schizophrenia and symptoms of
mania are mediated by excess of neurotransmitter Dopamine.

3. Schizotypal or paranoid personality disorder

Schizotypal personality disorder
Schizotypal personality disorder is characterised by pervasive pattern of
discomfort in close relationships with others, along with presence of odd
 thoughts and behaviours. The oddness in schizotypal personality disorder is not
as extreme as that observed in schizhophrenia.
Points in favour
• Client is not having friends
• Client is close only to her younger brother in her family
• Client is exhibiting delusions of grandiour and auditory hallucinations.
• Client is having disorganised motor behaviour.

Paranoid personality disorder

In paranoid personality disorder the person is distrustful and

suspicious of others. No actual delusions or other symptoms of schizophrenia
are present.

Points in favour

• Client is trusting her maternal aunt and her younger brother who
accompanied client to IMH.
• Client is not suspicious of others.
• Client is having delusions of grandior, religious delusions.
• Client is having auditory hallucinations.

4. Drug and medication induced psychosis

Medication or substance induced psychotic disorder is characterised by
hallucinations and delusions due to the direct effects of a substance or
withdrawal from a substance in the absence of delirium.
The anabolic steroids, anti-cholinergic medications can lead to delirium
especially if abused. Substance abuse like alcohol, cocaine, opiates, psycho
stimulants, hallucinogens often leads to disturbed perceptions, thought, mood
and behaviour.

Points in favour
• Client SC developed psychotic symptoms like delusions, hallucinations,
disorganised thought and behaviour after she started taking medicines
for her seizures since 2009.
 • Once client SC consumed all her seizure medications at once and
became unconscious and she was hospitalised for the same.

5. Psychosis secondary to organic causes or Organic Psychosis

Organic or secondary psychosis can be seen in diverse conditions as
metabolic disorders like hypoglycaemia, hypoxaemia or electrolyte
disturbances, endocrine disorders like Addison’s disease, Cushing’s syndrome,
hypo or hyperpara- thyroidism, infectious diseases, heavy metal toxicity, neuro
degenerative disease, stroke and auto-immune disorders like Systemic Lupus
Erythematosis (SLE).
Points in favour
• Client is often having severe form of seizures
• Client with schizophrenia exhibited her seizures first when she was 17
years old, when she was in her 12th grade.
• Client is not responding to any medication for seizure and 6 years later
she has developed schizophrenia.
• After seizures client was unconscious many times and fell down, which
would have caused some organic damage in her brain.

THEORETICAL FRAME WORK

1. Neuro-biological theory
According to neuro-biological theory, schizophrenia is the result of neuro
transmitter dysregulations like
• There is excessive secretion of Dopamine
• Reduced glutamate in the Cerebro Spinal Fluid (CSF)
• Reduced levels of Seratonin.

Client SC developed schizophrenia symptoms like delusion, hallucination,

disorganisation in thought, speech and motor action after taking medicines
for her severe seizures for many years. This would have caused imbalance
in neurotransmitter releases. So proper medications in the form of
pharmacotherapy initially help the client to be free from her symptoms.

2. Psychodynamic theories
 Sigmund Freud formulated 2 models which explains schizophrenia
(i) Conflict Dense Model
In conflict dense model, during intense conflict there is use of
primitive defences which leads to regression to pre-oedipal phase of
development which leads to schizophrenic pathology.
(ii) Deficiency Deficit Model
Conflict with severe withdrawal of libidinal energies from
outside, so it leads to break down from the external reality which
leads to schizophrenic symptoms.

3. Erik Erikson’s psycho-social development theory

According to Erik Erikson’s psycho social development, client SC is in stage
6 of Intimacy Vs Isolation. Client is still stagnant in this stage where her need
for intimacy is not met, she was isolated in a room because she used to run away
from home often. Normally in this stage all forms of close relationship or form
of long term partnership develops and continues to grow. So social skills
training will help the client to pass out this stage smoothly, with out any
stagnation. Inter personal skills training will also be useful to the client.
4. Ecological systems theory
Bronfenbrenner’s ecological systems theory views child development as a
complex system of relationships affected by multiple levels of the surrounding
environment from immediate settings of family to school tosociety broad
cultural values, laws and systems. Micro system is the most influential level of
the ecological systems theory. This is the most immediate environmental
setting for the development of the child such as family and school. Client SC
has developed problems in this micro system of family so she and her family
will be benefitted by family therapy to improve social and communication
skills.

5. Social Learning theory and Schizophrenia

Social learning theory is a theory of social behaviour which states that the
behaviour of human beings is influenced significantly by the way other
members in society label them. Social groups create the concept of psychiatric
 deviance by constructing rules for groups to follow. Thus client SC has the
symptoms of schizophrenia which is seen as deviation from norms.
6. Cognitive theories
Cognitive theories of Schizophrenia speculates that individual’s view of the
self is influenced by a combination of genetic vulnerability, early childhood
experience and environmental stressors in the life. And that these factors
determine how internal and external experiences ar interpreted. Cognitive
theories also explains that schizophrenia is due to the complex interaction of
predisposing neurobiological, environmental, cognitive and behavioural factors
with the diverse symptomatology. The impaired integrative function of the
brain, the domain specific cognitive deficits, increases the vulnerability to
aversive life experiences, which leads to dysfunctional beliefs and behaviours.
Client SC has problem in information processing and dysfunctions in her
perception. Client is having planning an nexecutive deficit also.
7. Interpersonal theories
The essence of the schizophrenic dynamism is a confusion in the
interpersonal relations by the appearance in awareness of referential processes
ordinarily excluded from awareness. The etiology can be traced to a
pathological symbiotic relationship with the mothering one in which there is an
overwhelming degree of anxiety transmitted to the infanct. This theory helps
us to go for interventions like non-threatening and non-demanding approaches
by identifying and strengthening client’s assets and increasing her self-esteem.
So interventions can be directed toward the client’s re-socialisation and reality
testing. From the therapist side acceptance and unconditional positive regard
with empathy will make successful psychotherapeutic inventions as the client
SC has very poor interpersonal relationship with her family members, she did
not have friends in her school, there is social isolation. So by developing inter
personal and communication skills client SC can manage her symptoms easily.

RESEARCH

1. The effect of Cognitive Behavioral Treatment on the positive symptoms of

Schizophrenia Spectrum Disorders: A meta-analysis
Gregoire Zimmermann, Jerome Favrod , October 2005
 Despite the effectiveness of anti-psychotic pharmacotherapy, residual
hallucinations and delusions do not completely resolve in some medicated
patients of Schizophrenia. Additional Cognitive Behaviour Therapy (CBT)
seems to improve the management of positive symptoms. Fourteen studies
including 1484 patients published between 1990 and 2004 were identified and
meta-analysis of their results were performed. Compared to other adjunctive
measures, CBT showed significant reduction in positive symptoms. CBT is a
promising adjunctive treatment for positive symptoms in Schizophrenia
Spectrum Disorders.

2. Recent advances in social skills training for Schizophrenia

Alex Kopelowicz, Robert Paul Liberman, Roberto Zarate, 02 Aug 2006
Social skills training consists of learning activities using behavioural
techniques, which enable the persons with Schizophrenia and other disabling
disorders to acquire interpersonal disease management and independent living
skills for improved functioning their communities. A large and growing body
of research supports the efficacy and effectiveness of social skills training for
Schizophrenia.
When the type and frequency of the training is linked to the phase of the
disorder, patients can learn and retain a wide variety of social and independent
living skills. Generalization of the skills for use in everyday life occurs when
patients are provided with opportunities, encouragement, and reinforcement for
practicing the skills in relevant situations.
Recent advances in skills training include special adaptations and
applications for improved generalisation of training into the community, short-
term stays in Psychiatric inpatient units, dually diagnosed substance abusing
mentally ill, minority groups, amplifying supported employment, treatment
refractory schizophrenia, older adults, overcoming cognitive deficits, and
negative symptoms as well as the inclusion of social skills training as part of
multidimensional treatment and rehabilitation programmes.

3. Family therapy/ Family interventions for Schizophrenia

Lisa B Dixon, Anthony F. Lehman 01 January 1995
 This evidence based research article shows the efficacy and effectiveness of
psycho educational family interventions in the treatment of persons with
Schizophrenia. There is substantial evidence that psycho educational family
interventions reduce the rate of patient relapse. These interventions improve
patient functioning and family well-being. Interventions with multifamily
groups that include the patient may be of superior benefit for subgroups of
patients.

4. Coping Strategy Enhancement (CSE): A method of training residual

schizophrenia symptoms
Nicholas Tarrier, Susan Harwood, Amanda Baker 16 June 2009
Coping Strategy Enhancement (CSE) is a method of teaching coping skills
to patients with Schizophrenia who experiences unremitting psychotic
symptoms. This method is based on a through behaviour analysis of each
symptom and assessment of any coping strategy the subject may already
employ. The subject is then systematically trained in the use of appropriate
coping strategies in response to the occurrence of their psychotic symptoms.
Two case studies were described in which CSE was used. Both patients showed
considerable improvements over treatment, with 6 month follow-up.

5. Cognitive approaches to schizophrenia: theory and therapy

Aaron T. Beck et al. Annu Rev Clin Psychol, 2005

A theoretical analysis of schizophrenia based on a cognitive model integrates

the complex interaction of predisposing neurobiological, environmental,
cognitive, and behavioral factors with the diverse symptomatology. The
impaired integrative function of the brain, as well as the domain-specific
cognitive deficits, increases the vulnerability to aversive life experiences, which
lead to dysfunctional beliefs and behaviors. Symptoms of disorganization result
not only from specific neuro-cognitive deficits but also from the relative paucity
of resources available for maintaining a set, adhering to rules of communication,
and inhibiting intrusion of inappropriate ideas. Delusions are analyzed in terms
of the interplay between active cognitive biases, such as external attributions,
and resource-sparing strategies such as jumping to conclusions. Similarly, the
content of hallucinations and the delusions regarding their origin and
characteristics may be understood in terms of biased information processing.
The interaction of neuro-cognitive deficits, personality, and life events leads to
the negative symptoms characterized by negative social and performance
beliefs, low expectancies for pleasure and success, and a resource-sparing
strategy to conserve limited psychological resources. The comprehensive
conceptualization creates the context for targeted psychological treatments.

Integrating the research findings

Client SC is having residual hallucinations and delusions despite her

pharmacotherapies for her seizures and psychotic symptoms, Cognitive
Behaviour Therapy (CBT) seems to be useful to improve the management of
her positive symptoms like delusions, hallucinations and disorganised thought,
speech and behaviour.

For client SC social skills training is a kind of learning activities using

behavioural techniques which enable the client to acquire inter personal skills
and independent living skills and it helps to improve her social skills very much.

Evidence based family therapy research suggests family therapy will be very
much helpful for psychoeducational interventions during her treatment. It also
helps to reduce relapse of the symptoms. It helps to improve client’s
functioning and well being of her family.

Coping Strategy Enhancement (CSE) skills helps to teach coping skills to

client SC who is having Schizophrenia with psychotic symptoms. Thorough
behaviour analysis of each symptom and assessment of her coping strategy
helps to reduce her symptoms. It is very helpful to plan further
psychotherapeutic interventions for her to prevent relapse also.

Cognitive psychotherapeutic interventions for client SC helps to integrate

the complex interaction of predisposing neuro biological, cognitive,
environmental and behavioural factors which helps to understand impaired
brain function with domain specific cognitive deficits, client’s vulnerability to
aversive life situations which leads to dysfunctional beliefs and behaviours
which were exhibited as both positive and negative symptoms of schizophrenia.
Thus this research is very useful to plan cognitive interventions for the client.

RECOMMENDED INTERVENTIONS

Schizophrenia requires lifelong treatment, even when symptoms have

subsided. Treatment with medications and psychosocial therapy can help to
manage the condition. In some cases hospitalisation may be needed. A
psychiatrist well experienced in treating schizophrenia guides treatment. The
treatment team for client SC includes Psychiatrist, clinical psychologist,
psychologist, counsellor, social worker and psychiatric nurse.

Psychotherapeutic interventions

1. Cognitive Behaviour Therapy (CBT)

Cognitive Behaviour Therapy (CBT) helps the client to identify her
thinking patterns that leads her to unwanted feelings and behaviour. CBT
helps client to learn to change this thinking with more realistic and useful
thoughts. Central idea of CBT is client’s problems are based on incorrect
beliefs and expectations. CBT aims to identify and alter irrational thinking
of the client includes her general beliefs, self image, beliefs about what
others will think, expectations of how others will act, methods of coping
skills with problems. Client SC may require a series of CBT sessions over
the course of number of months. CBT sessions usually lasts for an hour.

2. Cognitive Enhancement Therapy (CET)

Cognitive Enhancement Therapy is an evidence based practice designed
to help schizophrenia and related cognitive disorders, improves brain and
cognitive development, social cognition and increase vocational
capabilities. Cognition is the major source of disability in Schizophrenia.
So CET targets client’s cognitive deficits as medicines are not effective in
improving cognition.
CET focuses on client’s social cognition
 Impairments in brain function such as attention, memory, problem
solving can seriously affect social function.
CET may be given for 48 weekly sessions to the client
• Neurocognitive exercises
• Home work
• 30 – 60 minute individual coaching to work on home work
assignments and to clarify doubts.

CET helps client SC to improve

Interpersonal effectiveness, attention, memory, motivation, affect,

vocational effectiveness, awareness of social context, active thinking,
awareness of illness/disability, cognitive flexibility, mental stamina,
spontaneity, foresightfulness and perspective taking.

3. Coping Strategy Enhancement (CSE)

Coping strategy enhancement (CSE) is an detailed interview technique
used in clients with schizophrenia can identify triggers to the onset of their
psychotic symptoms, and then develop their own methods of coping
strategies with the disorders caused, like client can turn up TV to drown the
voices she is hearing by
(i) Education and Rapport building:- Therapist and client work
together to improve the effectiveness of client’s own coping
strategies and develop new ones.
(ii) Symptom targeting:- A specific problem is selected for which a
particular coping strategy can be devised. Strategies are practiced
with in a session and the client is helped through any problems in
applying it. Client is given them homework tasks to practice, and
keep a record of how it is worked.

Psychosocial interventions

Once symptoms recedes, in addition to continuing medication psychological and

social (psychosocial) interventions are important. They include
 (i) Individual Psychotherapy
Therapist or Psychiatrist during a session can teach the client how to deal
with their thoughts and behaviours. Client will learn more about her illness
and its effects as well as how to tell the difference between what is real and
what is not real. It helps them to manage everyday life.
Individual psychotherapy help the client to normalise thought patterns.
It helps her to learn to cope with stress and identify early warning signs of
relapse can help her to manage her stress.
(ii) Social skills Training
Social skills training focuses on client to improve communication and
social interactions and improving the ability to participate in daily activities.
(iii) Rehabilitation
Schizophrenia usually develops during the years, the client was building
her career. Rehabilitation includes job-counselling, problem solving
support and education in money management.
(iv) Family Therapy
Family therapy provides support and education to families dealing with
schizophrenia patients.
a. Family therapy aims to educate client’s relatives about schizophrenia.
b. Family therapy helps to improve to communicate and handle the
situation.
c. Family therapy helps to teach client and family members more effective
stress management techniques.
d. Family therapy helps to stabilize social authority of the client, family
and the doctor.

Family Education

Family member’s knowledge about schizophrenia can help the client a lot. Research
shows that schizophrenics who have a strong support system do better than those
without encouragement of family and friends. So educating the client’s family about
schizophrenia will help the client co cope up her symptoms and helps to improve her
social and communication skills.

Self-help groups
 Client can be encouraged to participate in community care and outreach programs
to continue working on her social skills. The National Alliance on Mental Illness
(NAMI) is an outreach organization that offers free peer to peer program and gives 10
sessions for adults with mental illness. Client can learn more about her condition from
people who have experienced themselves or been through it with a loved one.

Assertive Community Treatment

Assertive Community Treatment offers highly personalized services to help people

with schizophrenia to meet life’s daily challenges like taking medicines. Assertive and
Community Treatment professionals can help client to handle problems proactively and
work to prevent crisis.

Social Recovery Therapy

Social recovery therapy focus on helping the client to set and achieve goals building
a sense of optimism and positive beliefs about themselves and others.

Vocational Rehabilitation and Supported Employment

Vocational rehabilitation and supported employment focuses on helping the client

with schizophrenia to prepare for, find and keep jobs.

Pharmacotherapy

First medicines are the cornerstone for the client SC. So client SC can be referred
to the psychiatrist and she may be given anti-psychotic medicines by the psychiatrist
for her psychotic symptoms. Sometimes antipsychotic medicines can cause side
effects, so client may be reluctant to take the medications. So psychotherapy helps the
client to cooperate with treatment and may be helpful to reduce the dosage of
antipsychotic medicines in the near future when there is reduction of both positive and
negative symptoms of Schizophrenia.

Learning outcomes

By doing the case study of the client SC with provisional diagnosis of Schizophrenia
Spectrum Disorder with delusions of grandior, auditory hallucinations with seizures I
have got the opportunity to learn in detail about the Schizophrenia, its incidence and
prevalence, , its causes, risk and predisposing and precipitating factors, symptoms and
diagnosis through detailed history taking followed by Mental Status Examination,
clinical assessment of cognitive functions, I have learnt how to diagnose with the help
of DSM-5 and also how to make differential diagnosis which helps to rule out other
similar disorders, knowledge about the prognosis and outcome of the disorder.

By doing case formulation, I have learnt how to apply theoretical formulations based
on the symptoms this Schizophrenia spectrum disorder. By studying relevant research
findings based on this case, I have learnt to integrate theoretical formulations and
research findings which was very useful to plan for interventions with different
approaches.

This case study gave me an immense opportunity to explore the intervention

techniques like Cognitive Behaviour Therapy (CBT), Cognitive Enhancement Therapy
(CET) which mainly focus on client’s social cognition and its improvement, Coping
Strategy Enhancement (CSE) which helps in client’s education and rapport building to
improve client’s own coping strategies during adverse situations and problems. I have
also learnt about psychosocial interventions like individual psychotherapy, social skills
training, family therapy, rehabilitation, Family education in the form of psycho
education for the client’s family, self-help groups, Assertive Community Treatment,
Social Recovery therapy, vocational rehabilitation and supported employment. This
case study helped me to learn about the counsellor’s role of unconditional positive
regard based on Carl Roger’s and also when to go for pharmacological interventions
with the help of the psychiatrist. In this case study i have learnt the importance of
referring to the psychiatrist for pharmacotherapy when the client’s symptoms were very
severe and also learnt how integrated and eclectic approach is very useful for this client
with Schizophrenia who has both positive and negative symptoms.