Case 2 (Schizophrenia)

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Case 2 (Schizophrenia)

Name: Mr. Q. R
Age: 30 years
Gender: Male
No. of siblings: Two
Marital Status: Single
Occupation: Nill
Mother Occupation Housewife
Birth Order Second
Earning Members in Family One
Socioeconomic Status Lower Class
Family System Joint
Father alive/Dead Dead
Mother alive/dead Alive
Head of Family Mother

Presenting Problems
Symptoms
 Auditory Hallucinations
 Delusions
 Significant impairment in major areas i.e., social relations, work, interpersonal
relations.

Reason for Referral


The mother reported concerns about severe anger and assaulting family members at
the Centre of Profound Education (Neuro-psychiatric Clinic).
Psychological/Psychiatric History:
i. Personal: There is no psychological/psychiatric history.
ii. Medical history:
a. Personal: Uncontrolled diabetes.
b. Family: Mother is also diabetic.
iii. Personal history: Excessive sexual needs were found.
iv. Lifetime history of stressful events: There is no lifetime history found.

Behavioral Observations
Mr. Q.R. was normal in appearance with a smile on his face but aggression was
visible in his eyes it seemed like he was trying to hide his aggression behind that smile. He
was open in conversation he talked about his social life. During the conversation, his speech
rate was normal with low volume. He remembered his past events like his engagement and
marriage but those were delusions. He hesitated a little bit on private questions during history
taking due to which he got overwhelmed at the end of the session.
Psychological Evaluation
From the history provided, assessment, and PANSS., he displayed very significant
impairment with his, social interactions, and other major areas i.e., work, interpersonal
relations, etc. He also displayed positive symptoms like auditory hallucinations and delusions
for more than six months. He met the criteria A and B for diagnosis of schizophrenia. He
scored above the cut-off point for diagnosis of schizophrenia.
Tentative Diagnosis
According to DSM-5 TR, (F20.9) Schizophrenia

Proposed Treatment Plan


 Antipsychotic: These medications block the patient’s brain and use certain chemicals
for cell-to-cell communication.
 Other medications: The health practitioner will also prescribe medications to help
reduce the side effects of antipsychotic medications such as tremors.

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