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CASE REPORT

Submitted By

Vaniya Junaid Khan

SAP ID.: 40617

B.S Psychology

Sem VII-B

Submitted to

Ms. Urooj Taara

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Table of content

Case No Content Page no

1 Case 2: Schizophrenia

About the Disorder 3

Reason and source of referral 5

Presenting complaints 5

Assessment 9

Mental State Examination 9

Formal Assessment 11

Tentative diagnosis 16

Case Conceptualization 16

Theoretical Orientation 17

Progression of Session 18

Termination 20

References 22
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CASE REPORT

About the Disorder:

Schizophrenia is a severe mental disorder in which individuals experience distorted

thinking, perceptions, emotions, language, sense of self, and behavior. People with

schizophrenia may encounter symptoms such as hallucinations (hearing or seeing things that

are not present), delusions (false beliefs), disorganized thinking, and extreme difficulty in

concentrating or completing everyday tasks. The most common features of schizophrenia

include auditory hallucinations and paranoid delusions, while other symptoms may include

lack of motivation, emotional flatness, and social withdrawal. Individuals with schizophrenia

often struggle to distinguish between reality and their distorted experiences, which can lead to

significant disruptions in their daily lives. As a result, individuals may experience impaired

social and occupational functioning, reduced quality of life, and increased vulnerability to

other medical and psychiatric conditions.

DSM 5-TR Criteria:

A. Two (or more) of the following, each present for a significant portion of time during a

1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.

2. Hallucinations.

3. Disorganized speech (e.g., frequent derailment or incoherence).

4. Grossly disorganized or catatonic behavior.

5. Negative symptoms (i.e., diminished emotional expression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning

in one or more major areas, such as work, interpersonal relations, or self-care, is markedly

below the level achieved prior to the onset (or when the onset is in childhood or adolescence,
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there is failure to achieve expected level of interpersonal, academic, or occupational

functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period

must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion

A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.

During these prodromal or residual periods, the signs of the disturbance may be manifested

by only negative symptoms or by two or more symptoms listed in Criterion A present in an

attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have

been ruled out because either 1) no major depressive or manic episodes have occurred

concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during

active-phase symptoms, they have been present for a minority of the total duration of the

active and residual periods of the illness.

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.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood

onset, the additional diagnosis of schizophrenia is made only if prominent delusions or

hallucinations, in addition to the other required symptoms of schizophrenia, are also present

for at least 1 month (or less if successfully treated).

Agency:

The case was taken from Cantonment General Hospital Rawalpindi.

Demographics:
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Name Ms.A

Gender Female

Age 35

Education Till Grade 6

Parents’ status Both alive and married.

Birth order 5th

No. of siblings 7

Occupation Unemployed

Marital status Single

Residence Rawalpindi

Accompanied by Mother and brother

Reason and Source of Referral:

The client was brought in for evaluation at the initiative of her brother, who

independently sought professional help after becoming increasingly concerned about her

inappropriate behavior for her age, like distorted perceptions and thinking styles.

Presenting Complaints:

Mother's Verbatim:

‫ایک سال پہلے گھر سے نکل کر بھائ کے گھر خود ہی چلی گئ تھی۔ بچوں والی حرکتیں کرتی ہے۔ عجیب‬

‫عجیب باتیں کرتی ہے۔ فون بھی صحیح سے استعمال نہیں کر سکتی۔ اس کے چھوٹے بھائی کو بھی یہی مسلہ ہے۔‬
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‫ایک دم ہنستی ایک دم روتی ہے۔ کوئ بات ٹھیک سے نہیں سمجھتی۔ بار بار ماضی کو یاد کرتی ہے۔ اس کی اپنی‬

‫بڑی بہن سے بنتی تھی لیکن آج کل لڑائی کی ہوئی ہے۔‬

Target Symptoms:

According to her mother's report, the client left her family home independently and

went to live with her brother without informing anyone, displaying signs of impulsivity and

poor judgment. She engages in age-inappropriate behaviors and makes bizarre or incoherent

statements, reflecting disorganized thinking.

The client reportedly struggles to use a mobile phone appropriately, indicating

cognitive or functional decline. Her mother also mentioned that her younger brother exhibits

similar symptoms, suggesting a possible familial or genetic component to the condition.

Affective instability was described, with the client laughing and crying suddenly

without clear triggers, suggesting mood lability. She struggles to comprehend conversations

or situations, and often repeats or dwells on past memories, which may reflect cognitive

regression or rumination. Additionally, there has been a recent deterioration in her

relationship with her older sister, with whom she was previously close, indicating

interpersonal difficulties and possible social withdrawal or conflict sensitivity.

History of Present Illness:

According to the details provided by the client's family member, the client has been

displaying these problematic behaviors from an early age. According to the mother, the client

began to experience these behavior changes between the ages of 14-15. However, the client's

brother reports the onset of symptoms to be around the age of 25-26. The disconnect in the

verbatims of the family members needs to be discovered better so as to reach a correct

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conclusion. The client shows disorganized patterns of thinking and perceptions, marked with

tangential thinking and producing meaningless conversations. From the verbatim of the

client, there are pointers that indicate the presence of auditory and visual hallucinations, as

well as delusions.

Past Psychiatric History:

The client has not received any previous psychiatric treatment as reported by the

family. The focus was majorly on receiving spiritual treatment.

Past Medical History:

The client has been taking certain medications as of lately. However, the nature of the

medication and their effectiveness is yet to be confirmed.

Family History:

The client originates from a family of nine members, comprising married parents and

six siblings, with the client being the fifth-born. The parents remained married throughout

their lives; however, the father is now deceased. It was reported that the client’s younger

sister passed away due to cancer. Furthermore, the client’s younger brother is noted to exhibit

psychotic symptoms.

Based on the client's verbal reports, her relationship with her parents appeared to be

significantly strained. She disclosed a history of physical abuse perpetrated by both parents
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and one of her sisters, with particular emphasis on the father's abusive behavior. Conversely,

the client expressed a comparatively stronger emotional attachment to her older sister.

Past Personal History:

The client was born following a full-term pregnancy, delivered at home without any

reported complications. According to the mother’s account, the client was described as weak

and underweight during infancy and experienced frequent episodes of fever. Although the

client's vaccinations were administered on schedule, breastfeeding was reportedly

discontinued earlier than recommended.

The client’s developmental milestones were delayed, with speech development

beginning around two years of age. Other developmental milestones were similarly delayed,

prompting family concern by the time the client was approximately three years old. In

contrast, the eruption of teeth occurred within the normal timeframe.

The client’s early educational history is relatively unremarkable; she attended regular

schooling up to Grade 6. According to the mother’s report, problematic symptoms began to

emerge after this point. However, the client's brother provided a differing account, suggesting

that the onset of symptoms occurred much later, around the age of 25–26, allegedly triggered

by derogatory remarks made by a marriage broker during an arranged marriage proposal

process.

Premorbid Personality:

Prior to the onset of her illness, the patient was described as emotionally sensitive,

socially withdrawn, and reliant on close family bonds. She showed signs of attachment
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insecurity, especially in relation to her parents. Her demeanor was cooperative and respectful,

with a noticeable desire for emotional closeness with her family. Overall, her behavior and

interpersonal style reflected a vulnerable personality structure, which may have made it

harder for her to manage significant life stressors.

Informal Assessment:

Mental State Examination:

Appearance. The client is a 35-year-old woman who appeared adequately groomed,

with clothing appropriate for the season. However, her attire was typically unpressed and

lacked neatness, which may reflect diminished self-care or reduced functional capacity.

Posture and Motor Activity. Her posture was upright and appropriate, yet she

displayed signs of motor restlessness throughout the session. She frequently shifted in her

seat, engaged in repetitive movements, and continuously fiddled with her clothing and

accessories, behaviors suggestive of internal agitation or anxiety.

Facial Expressions. Her facial expressions were incongruent with her emotional

content. For instance, she exhibited an elevated or cheerful expression while discussing

traumatic or distressing life events, indicating emotional dysregulation and poor affective

congruence.

Eye Contact. Eye contact was excessive and intense. She often fixated her gaze on

the clinician in a manner that felt intrusive or disproportionate, possibly reflecting paranoia,

hypervigilance, or poor social boundaries.

Speech. The client's speech was characterized by a rapid and pressured delivery, with

an ecstatic and overly animated tone. Despite her expressiveness, her voice was unusually
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low in volume, as though she were attempting to prevent others from overhearing. This

combination conveyed both heightened arousal and possible suspiciousness.

Psychomotor Behavior. She exhibited psychomotor agitation, evidenced by constant

fidgeting and purposeless movements. There was no sign of catatonia, but her motor

behaviors lacked goal-directedness and appeared driven by internal stimuli.

Mood and Affect. Her mood was labile, with abrupt shifts between excitement and

sadness. Affect was inappropriate at times, cheerful while discussing negative content, further

indicating emotional instability and possible affective blunting.

Thought Content. The client exhibited prominent psychotic symptoms. She

verbalized grandiose delusions, such as having met the Prime Minister, and described

auditory and visual hallucinations, particularly involving her deceased father. Her statements

indicated marked distortions in reality perception.

Thought Process. Thought processes were disorganized and tangential. She

frequently derailed from questions and shifted topics without clear transitions, making it

difficult to follow her line of thinking. This pattern suggests formal thought disorder,

commonly seen in schizophrenia.

Memory. There were notable impairments in both short-term and long-term memory.

The client often conflated past experiences with present events and identified herself as

eighteen years old, suggesting cognitive regression and distorted temporal orientation.

Attention and Concentration. Her attention span was significantly impaired, with

difficulty maintaining focus on questions or conversational themes. She was easily distracted

and required frequent redirection.

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Insight. Insight into her illness was markedly poor. The client denied experiencing

any mental health issues and appeared unaware of the abnormality of her symptoms or

behaviors.

Judgment. Judgment appeared impaired. Her belief in unrealistic scenarios and

failure to recognize the need for treatment suggest a compromised ability to make sound

decisions or accurately assess situations.

Orientation. The client was oriented to place and season, but not to time. Her

temporal confusion and misperception of her own age further highlight disorientation and

cognitive disruption.

Formal Assessment Tests Used:

1.​ House Tree Person (HTP)

2.​ Beck Anxiety Self-Rating Scale (BASRS)

3.​ Rotter’s Incomplete Sentence Blank Test (RISB)

4.​ Positive and Negative Syndrome Scale (PANSS)

5.​ Brief Psychiatric Rating Scale (BPRS)

Personality Assessment:

House-Tree-Person (HTP):

House. Significant pointers to be considered from different elements of the drawing

are as follows: The drawing is centrally placed, which may suggest a sense of rigidity in the
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client’s personality or thinking patterns. Shading is evident in specific areas of the drawing, a

feature often associated with underlying anxiety. The lines throughout the drawing appear to

be relatively pressured, which can further indicate feelings of anxiety or a perceived need for

protection. Notably, extra attention has been given to the roof, suggesting a heightened focus

on fantasy and imagination. Additionally, the drawing includes several irrelevant or excessive

details, such as a clock on the exterior, the client’s name on the front, a sun on the roof, and

birds in the sky. Such over-elaboration is often interpreted as a sign of insecurity. The absence

of pathways or doors in the image may point to a lack of socialization or difficulty in forming

connections with others. There is only one small window, which could reflect shyness or

introversion. Finally, the presence of anthropomorphic features, like human-like faces on the

roof and front wall, may be indicative of a disintegration of self or internal psychological

conflict.

Interpretation. From this drawing, we can identify signs of psychological distress

such as anxiety, social withdrawal, insecurity. The presence of fantastical and irrelevant

detailings, as well as addition of certain anthropomorphic features can be an indicator of a

disorganized thinking pattern or a fragmented sense of self. The majority of these features

align well with the client's diagnosis.

Tree. Significant pointers to be considered from different elements of the drawing are

as follows: The tree depicted in the drawing has a fantasy-like appearance rather than a

realistic one, which may reflect unrealistic thoughts or a distorted perception of reality. The

inclusion of excessive detail throughout the tree suggests a heightened level of anxiety. The

overall composition of the tree is somewhat bizarre, potentially indicating the presence of

psychotic features. The foliage appears untidy, which can be associated with disorganized or
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potentially dangerous thinking. Additionally, the absence of branches may point to

self-withdrawal or a reluctance to form interpersonal connections. The crown of the tree is

scribbled and flat, with the scribbling reflecting emotional instability and the flatness

implying pressure from the surrounding environment. The lack of visible roots may signify

deep-seated insecurities or a lack of grounding. The trunk is unusually long, which can be

another indicator of psychosis. A noticeable vertical emphasis is present in the drawing, often

interpreted as a sign of poor contact with reality. The bark is marked with heavy lines, again

highlighting signs of anxiety. The leaves are drawn larger than normal, which could be

interpreted as a compensatory mechanism following trauma. Furthermore, the pointed nature

of the leaves may suggest underlying aggression.

Interpretation. Major pointers to conclude from this drawing are features such as

aggressive features, distorted perception of reality, anxiety and emotional instability, all of

which are major signs of schizophrenia.

Person. Significant pointers to be considered from different elements of the drawing

are as follows: The central placement of the drawing may indicate a sense of rigidity in the

client’s personality or behavior. The omission of the mouth is particularly significant; it could

suggest an internal conflict related to that part of the body. Given that the client is female, this

omission may also reflect experiences of scolding or verbal control by a maternal figure. A

button is drawn in the center of the clothing, which can symbolize a dependency on maternal

figures. The figure's fingers are fewer than five, a detail often interpreted as a sign of

helplessness and emotional dependency. The arms are extended outward from the body,

which may point to externalized aggression, while their exaggerated length and weak form

further underline themes of dependency. In contrast, the unusually long legs could be
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indicative of a desire for autonomy and independence. The overall use of straight, sharp

edges in the drawing may reflect poor emotional or social adjustment. Notably, the figure

drawn is of the opposite sex, which may suggest a strong emotional dependence on the parent

of the opposite gender. The eyes are prominently detailed and emphasized, a feature often

linked to externalized aggression. An added emphasis on the eyelashes might also imply

underlying sexual concerns. Finally, the nose is drawn in a hook-like shape, which can be

interpreted as a sign of difficulty in communication or expression.

Interpretation. In the drawing of a person, the important conclusions we can draw are

features indicating the presence of conflicts related to autonomy, dependency and

communication. Additionally, cross-gender depiction may suggest dependency on the

opposite-sex parent and the sharp lines suggesting poor adjustment and psychotic features,

which can all align with traits congruent with schizophrenia, such as impaired self-image,

interpersonal dysfunction, and externalised tension.

Symptom-Specific Assessment:

Beck Anxiety Self-Rating Scale (BASRS):

The client has earned a score of 28 on Beck Anxiety Self-Rating Scale which indicates the

presence of moderate levels of anxiety.

Rotter's Incomplete Sentence Blank Test (RISB):

Scores. The client has earned a score of 125 on the RISB protective test for

maladjustments, which indicates that the client has moderate levels of maladjustments.
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Interpretation. Based on the client’s responses, the following conclusions can be

made:

Familial Attitudes. Judging from the responses, item no. 2, 11, 12, 13, 15, 26, 30 and

39 show deep-rooted fear of the client's older brother, who is repeatedly mentioned as

controlling and abusive, eliciting feelings of restriction, distress and unsafety in the client.

Moreover, in item no. 11, we can see a contradiction where the client calls her mother “good”

but also admits that she enforces physical abuse on the client. From these responses, we can

conclude the presence of domestic violence and its negative impacts on the client's

well-being.

Social Attitudes. Responses to item no. 7, 10, 19, 25 and 40 can be referred to

discover the client's social attitudes. The majority of these responses are positive, suggesting

that the client may view others with an eye of kindness, especially people outside the family.

Self-Concept/Self-Esteem. If we refer to item no. 32, 34 and 37, the client refers to

herself as “good” or “very good” which reflects a good and positive self-regard. The only

contradiction can be seen in item no. 34 in which the client shows desire to look better, which

can be an indicator of insecurity or some levels of self-esteem related issues.

General Daily Life Attitudes. Item no. 1, 4, 6, 22, 36 and 28 show some positive

interests, desires and habits like enjoying cricket, studying, praying at bedtime etc. However,

her description of home in item no. 4 can indicate certain levels of blandness and monotony,

or even lack of joy.

Positive and Negative Syndrome Scale (PANSS):

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The client secured a total score of 125, with a score of 37 in positive symptoms, 35 in

negative symptoms and 53 in General Psychopathy. Overall indicating an extreme severity

level, marked with significant impairments in emotional and cognitive functioning.

Brief Psychiatric Rating Scale (BPRS):

The client secured a total score of 60, indicating a severe level of dysfunction.

Tentative Diagnosis:

According to DSM 5-TR criteria, the client appears to have fulfilled the criteria for

Schizophrenia, including hallucinations, delusion, disorganized thoughts etc. which are

supported by the assessments.

Case Conceptualization:

Ms. A, a 35-year-old unmarried woman from Rawalpindi with limited education and

no employment history, was brought in by her brother due to inappropriate behavior,

disorganized thinking, hallucinations, and delusional beliefs. Her symptoms, which appear to

have emerged gradually since adolescence or early adulthood, include mood instability,

impaired reality testing, and significant cognitive and social dysfunction. She has a family

history of psychosis (younger brother), delayed developmental milestones, and reports of

early childhood abuse by both parents and a sister, contributing to emotional vulnerability,

attachment insecurity, and maladaptive coping. Psychological assessments (PANSS, BPRS,

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HTP, RISB) reveal severe psychotic symptoms, anxiety, disorganized thought content, and

dependency issues. Her condition reflects a combination of biological predisposition,

psychological trauma, and social neglect, consistent with a diagnosis of Schizophrenia.

Theoretical Orientation:

Diathesis-Stress Model (Zubin & Spring, 1977)

The Diathesis-Stress Model posits that psychological disorders such as schizophrenia result

from a genetic vulnerability (diathesis) triggered by environmental stressors. This model is

widely applied in understanding the multifactorial origins of schizophrenia.

In Afshaan’s case, there is a clear biological predisposition—her younger brother also

exhibits psychotic symptoms, indicating a potential genetic vulnerability. Environmental

stressors such as reported early childhood abuse by both parents, exposure to inconsistent

caregiving, and strained familial relationships act as major psychological stressors. Her

emotional sensitivity, social withdrawal, and attachment insecurity before the onset of

psychosis suggest the presence of latent vulnerability that was exacerbated by traumatic life

events and chronic familial stress. These risk factors, in combination, support the

applicability of the Diathesis-Stress Model in explaining her psychotic breakdown and its

chronic nature.

Cognitive Model of Psychosis (Beck & Rector, 2003):

The cognitive model of schizophrenia focuses on how dysfunctional beliefs and cognitive

biases contribute to the formation and maintenance of psychotic symptoms such as delusions

and hallucinations.
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Afshaan’s tangential thought processes, grandiose delusions (e.g., believing she met the

Prime Minister), and hallucinatory experiences reflect distorted cognitive appraisal. Her

statements during the clinical interview, such as recalling past trauma with inconsistent affect

(e.g., smiling while recounting abuse), indicate cognitive-emotional dissonance. This aligns

with the model’s assumption that core beliefs (e.g., beliefs of worthlessness, vulnerability)

contribute to misattribution of experiences, leading to faulty interpretation of reality. Her

delusions of reference and auditory hallucinations can be viewed as cognitive errors

exacerbated by long-standing trauma and impaired reality testing.

Psychodynamic Perspective (Freudian Approach):

From a psychodynamic standpoint, schizophrenia is viewed as a regression to a pre-ego state

due to overwhelming anxiety, often tied to unresolved childhood conflicts and trauma.

Afshaan’s psychological profile indicates unresolved intrapsychic conflicts likely rooted in

her early abusive experiences. The omission of the mouth in the HTP drawing and the intense

focus on fantastical elements in both the Tree and House drawings suggest unconscious

repression and symbolic expression of unresolved trauma and internal chaos. Her regression

to an 18-year-old mental age and her preference for living in past memories support the idea

of ego collapse, consistent with psychodynamic interpretations of psychosis as a defense

mechanism against unbearable emotional realities.

Progression of Sessions:

Session 1:
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The initial session focused on establishing rapport with the client and her brother, who had

brought her in for evaluation. An informal clinical interview was conducted to gather

preliminary information and observe the client’s spontaneous communication style and

behavioral presentation. Verbatim accounts were taken from both the client and her brother to

begin forming a clinical picture.

Session 2:

In the second session, the client’s mother was invited to participate in order to gather a

broader familial perspective. A Mental State Examination (MSE) was conducted to assess the

client’s current cognitive, emotional, and perceptual functioning. Observations included her

mood, speech, thought processes, delusional content, and orientation.

Session 3:

This session marked the commencement of formal psychological assessment. The client was

administered the House-Tree-Person (HTP) projective test, Beck Anxiety Inventory (BAI),

and Rotter’s Incomplete Sentences Blank (RISB). These tools were utilized to explore the

client’s emotional functioning, cognitive distortions, anxiety levels, and personality

dynamics.

Session 4:

The formal assessment process continued with the administration of the Positive and

Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS) to

measure the severity and type of psychotic symptoms. After completion of the assessments, a

follow-up session was recommended to begin therapeutic planning. However, the client did

not return for subsequent sessions, and no further contact was made by the family.
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Prognosis:

The prognosis for Afshaan remains clinically poor, primarily due to a combination of

biological, psychological, and socio-environmental factors that impede long-term recovery

and therapeutic engagement. Her condition presents with severe psychotic features, including

persistent hallucinations, delusions, disorganized thought processes, and impaired insight.

These are compounded by significant cognitive regression, as evidenced by her confusion

between past and present, and belief that she is eighteen years old.

In addition to the clinical severity of her symptoms, systemic challenges pose

considerable barriers to effective treatment. These include a fragmented family dynamic, with

reported histories of physical abuse, emotional neglect, and strained interpersonal bonds. The

lack of consistency and openness in caregiver reporting—along with notable contradictions in

the accounts of her mother and brother—further complicate clinical understanding and the

possibility of collaborative care.

Her late presentation to psychiatric services, absence of prior formal mental health

interventions, and reliance on spiritual or informal treatments have also allowed the disorder

to progress untreated for years. Moreover, the presence of another psychotic family member

suggests a possible genetic vulnerability, further reinforcing the chronic and potentially

refractory nature of the illness.

Given these multifactorial risks, her prognosis remains guarded, with a high

likelihood of symptom persistence, poor functional recovery, and recurrent relapses in the

absence of a structured, multidisciplinary intervention and a stable, supportive environment.

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Termination:

Termination in this case was unplanned and client-initiated. After the completion of

the formal assessment phase, the client and her family discontinued sessions without

explanation or prior notice. Despite professional recommendations for continued follow-up,

psychiatric consultation, and therapeutic planning, no subsequent contact was made.

The premature cessation of engagement meant that the treatment phase could not be

initiated, and therefore, no therapeutic relationship was formally consolidated. This abrupt

withdrawal suggests possible treatment resistance, family ambivalence, or lack of

psychoeducation regarding the seriousness and chronicity of schizophrenia.

Given the client's impaired insight, it is possible that she lacked the capacity to

advocate for her own care, while the family’s inconsistent involvement and possible denial of

illness contributed to this disengagement. The termination underscores the need for enhanced

caregiver education, community mental health outreach, and systematic follow-up protocols

in cases of severe psychiatric illness, particularly when client autonomy is compromised.

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References

Sussman, O. (2023). WebPage. Simply Psychology.

[Link]

Kuipers, E. (2006). Cognitive, emotional, and social processes in psychosis: Refining

cognitive behavioral therapy for persistent positive symptoms. Schizophrenia Bulletin,

32(Supplement 1), S24–S31. [Link]

DPSa, M. L. R. M. (2023, February 16). Schizophrenia from the psychodynamic perspective.

Psychiatric Times.

[Link]

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