The client’s name for this case presentation is Clara Hunters. She is a thirty-three-year-old woman. She is white and has been married for five years. According to the client, she has come to see me because she has been “seeing things which are not there.” Additionally, she reports that “the images in my head make it hard to do the things I am supposed to.”
Presenting Problem
When I asked Clara why she felt she needed to see a specialist, she said that she has not felt like herself for a while. “About six months ago, I started to feel that something was trying to kill me. Once I was driving and suddenly, there was a woman smack in the middle of the road! Out of nowhere. I had to swerve to avoid hitting her and almost rolled into the bushes. Oh, my God… I shiver just thinking about it.” Clara reports that the feeling that someone is determined to kill her has been persistent. “I don’t like leaving the house anymore. I mean, how can I when I don’t feel safe outside?” Specifically, Clara says that the objects and persons sent to kill her are sent by God. The client cannot explain the rationale behind this belief, yet she is certain that she is right about it. “For some reason, I feel God is trying to kill me. I don’t know why when I try my best to be a good person. I stopped going to church because I do not want to make Him angrier.”
Aside from the unrelenting feeling of looming death, the client says that her personal and social life have severely been affected. One reason for this is that she sometimes sees and hears things that are apparently imperceptible to others. She says she once saw a figure lurking in the dark of their bedroom window. Her husband, Tim, did not see this figure where Clara says she spotted it. According to the client, “I know what I saw. I am pretty sure there was a man standing by the window. Tim was asleep at the time, but I had not slept a wink that night, so I was alert. I know what I saw…” Due to this experience and many others, Clara feels she and her husband had grown apart. She says that he treats her differently than before. “He also claims that have become robot-like and expressionless. He says he does not recognize me anymore as the woman he married.” In addition, Clara reports that she has been avoiding her friends and rarely went out anymore.
Clara reports that aside from her personal relationships, she felt that her experiences had negatively affected her work. She reports that she was regularly late to work because she did not feel like going at all. “I have no motivation to work. I used to be one of those people who goes the extra mile at work. Just last year, I pioneered a project that brought my company millions of dollars. Now I cannot find the motivation to go into work.” She also says that she sometimes finds it difficult verbalizing answers to questions. “You could ask me a simple accounting question, and I would stare at you as if I am not a CPA. And yet I can’t bring myself to care about losing my job.” In general, Clara feels her personal, social, and work life have been adversely affected by her experiences, which is why she felt the need to see me.
History: Family
Clara has been married to her husband, Tim, for five years with whom she has a two-year-old child. The client describes her home environment as a healthy place where communication thrives. However, the client revealed that she was unfaithful to her husband two years into their marriage. She says her marriage was not affected by the incident because Tim did not find out about it. However, she says her recent mental health experiences had negatively affected the quality of her relationship with both her husband and son.
Client’s Physical Health
Clara appeared to be in perfect physical health. She is not undergoing any treatment or taking any medications.
Occupational History
The client is a certified public accountant working at a medium-sized accounting and consultancy firm. She describes her work environment as extremely stressful because the work is demanding. She has recorded a decreased performance in occupational functioning. Prior to this, she has no history of work problems.
Substance Use History
Clara reports that she used to take alcohol in her twenties. She would consume a bottle of wine a week at home. Her alcohol intake would increase during parties and other social gatherings. Aside from alcohol, she has no other drug use history. The client reports that she permanently stopped taking alcohol when she got pregnant with her son.
Spiritual Information
Clara is a religious person and professes the Catholic faith. She used to attend church until about three months ago when the symptoms became difficult to manage. She says she wants to feel better so she can reconcile with God and the church, which shows spirituality is an essential part of her healing process.
Cultural/ Social Justice Factors
The client does not have any cultural or social justice factors that could be the source of signs and symptoms. On the contrary, she believes being a white woman affords her certain freedom and protection.
Barriers to Treatment/Success
The client has a neurotic personality type, which may make it difficult to treat her symptoms. However, she came in to see me out of her own volition. Readiness to seek help positively influences the success of treatment.
Mental Status Exam: Presenting Appearance
The client is female. Her chronological age is thirty-three years old, while her apparent age is about forty years. She is white, her apparent height is 5′6″, and she looks average in weight. Clara has no physical deformities, but upon physical examination, there are apparent self-harm injuries on her arms.
Basic Grooming and Hygiene
Clara was a bit shabbily dressed for a doctor’s interview, and her hair was unkempt. Additionally, she was in a long-sleeved blouse despite the hot weather, possibly to hide the self-harm injuries.
Gait and Motor Coordination
Poor coordination, signified by clumsiness.
Interpersonal Characteristics and Approach to Evaluation
She was open to evaluation but hesitated when answering some of my questions regarding people sent to kill her.
Speech
The client spoke at a normal rate speech and volume.
Eye Contact
The client was hesitant to make eye contact, and her eyes constantly darted as she spoke.
Expressive Language
She had a few problems expressing herself. For instance, she would sit mute when asked some questions, until I repeated them. She had a good command of English, which is her primary language.
Receptive Language
The client appeared to have trouble comprehending questions which translated to difficulty answering them.
Orientation and Alertness
The client knows their name and where she is. She could also tell the time and answer simple questions that indicates sufficient orientation.
Coherence
She switched between unrelated topics often, and I had trouble following some of the things she said.
Concentration/ Attention
Clara had problems with concentration which manifested in her lack of attention to my questions. I had to repeat some questions for her to answer. She could list days of the week and months of the year in reverse order.
Thought Processes
The client constantly feels detached from herself as if some aspects of herself are not real, which is a sign of depersonalization. She would refer to herself as “the other me who sees things.”
Hallucinations and Delusions
Presence of both hallucinations and delusions was inferred from her answers, but none occurred during the examination.
Judgment/ Insight
The client has good judgment and a good sense of right or wrong. For instance, she demonstrated remorse for her affair because it was wrong.
Intellectual Ability
Clara is of above average intellectual ability demonstrated by her capacity to answer general questions.
Mood
Her mood on most days can generally be described as anxious.
Affect
Restricted affect characterized by a reduction in the intensity of expression.
Facial and Emotional Expressions
The client switched between being expressionless and suspicious.
Suicidal and Homicidal Ideation
Suicidal ideation without a clear plan or intent.
Risk of Violence
Low risk of violence.
Treatment Recommendations
The most important issue to address in Clara’s case is delusions. Delusions can lead to deterioration in her condition and increase safety concerns. This symptom is best treated through pharmacological intervention. I would recommend antipsychotic drugs to help manage delusions. The goal of treatment is to improve cognitive functioning and relieve the client of suffering. Antipsychotic drugs reduce positive symptoms, such as delusions and hallucinations. Specifically, second-generation (atypical) antipsychotics are the most effective drugs for this purpose (Stępnicki et al., 2018). Examples include clozapine, aripiprazole, risperidone, and olanzapine. Atypical antipsychotics drugs are usually preferred over typical antipsychotics because they have fewer extrapyramidal side effects. Clara will possibly respond well to the drugs because she has not experienced delusions for a long time, indicating that the disorder is still in its early stages. To prevent relapse, it could be necessary for Clara to take medication for a lifetime. However, the dosage can be adjusted as a psychiatrist sees fit. It is critical to ensure the client takes medication exactly as directed to avoid deterioration or relapse.
The second treatment option is cognitive-behavioral therapy (CBT). CBT can be used to help the client recognize delusions and manage them. It is important to note that CBT does not eliminate delusions. Instead, it teaches a client how to cope with delusional thinking. CBT would also be helpful in managing negative symptoms such as social withdrawal caused by delusions (Ganguly et al., 2018). For instance, a therapist would help Clara recognize that nobody is trying to kill her and that she does not need to avoid social interaction. Additionally, non-pharmacological treatment such as CBT helps to ensure the client adheres to their medication as prescribed. In general, pharmacological intervention and therapy work best when used in combination.
Answer Key
- F20.9 Schizophrenia.
Key Issues
- Delusions.
- Hallucinations.
- Disorganized speech.
- Mutism.
- Diminished emotional expression.
- Avolition.
- Asocilaity.
- Depersonalization.
Signs of symptoms presented in the case presentation
- The client is convinced someone trying to kill her despite lack of evidence to suggest so (persecutory delusions).
- She also has religious delusions related to God trying to kill her.
- She experiences hallucinations such as the man standing at her bedroom window at night.
- Client switches from one topic to another unrelated topic.
- She gives unrelated answers to questions asked.
- She is occasionally incoherent.
- She sometimes demonstrates a lack of verbal response.
- The client’s husband says she has become “robot-like and expressionless”.
- The client’s interest in her work has reduced and has recorded a decreased performance in occupational functioning.
- She has decreased motivation to perform self-initiated projects at work.
- Clara has abandoned her social life, including meeting with her friends as well as going to church.
- Client is suspicious of others, indicated by her hesitation in answering my questions about the delusions she was experiencing.
- She also had difficulty comprehending some questions.
- Restricted affect characterized by reduction in the intensity of expression.
Any signs of symptoms that were presented but not part of the diagnosis
- The client’s mood can generally be described as anxious.
References
Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic management of schizophrenia symptoms using pharmacological and non-pharmacological treatment. Frontiers in public health, 6, 166.
Stępnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current concepts and treatments of schizophrenia. Molecules, 23(8), 2087.