June 20, 2014

Example Format of Paranoid Schizophrenia Case Study

The following is an example case study of patient affected by schizophrenia. This will help Psychology and psychiatry students to prepare cases. This is just for reference only so look at the format.

SOCIODEMOGRAPHIC DATA


Name                         : S.K
Age                            :  29
Sex                             : Male
Occupation               : Customer care executive
Religion                    : Christian
Education                 : Plus Two Passed
Marital status           : Unmarried
Place of residence     : Rural

Informants

The information is collected from patient, psychologist, social worker and nurses. The information is reliable and adequate.

Presenting complaints and their duration

Decreased sleep                                                   (2 years and more)
Lack of words used when talking to someone       (13 months)
Decreased social relationships                               (7 months)
Feeling of loneliness                                              (6 months)
Suicidal thoughts                                (4 months)

History of present illness


Onset                                 : Gradual

Precipitating factors        : Psycho social problems like job stress, family issues and hereditary causes
.
Associated disturbances   : Lack of sleep, decreased social life, interpersonal relationships, high job stress, normal appetite and weight. The patient experienced high levels of hyper activity in each episodes of the disorder.

Course of the illness          : Continuous illness but without periodic epizodes.

Past history


In 1997, the patient experienced the first episode of disorder. After this incident many drastic changes happened in him. His sleep is decreased, increased anger towards others, feeling and belief that nobody interested him. In 2006, the patient experienced second episode. In 2011, the patient experienced the final episode.

Family history        

(here family genogram comes)    

- DEAD MALE, FEMALE
                 
- AFFECTED MALE, FEMALE

- UNAFFECTED MALE, FEMALE

- INDEX PATIENT


PERSONAL HISTORY


Birth and early development

                    Mother’s physical health during pregnancy time is normal. Nature of birth was normal. Birth cry was present. He was born from non-consanguineous union. Birth weight and skin colour was normal. No delay of milestone was found.

Behaviour during childhood

Experienced sleep disturbances and temper tantrums in childhood. Relationships with peers were less.

Physical illness during childhood

            There is no clear evidence of physical illness during childhood.

Educational history

          The patient has high scholastic performance. Attitude towards peers was poor.

Occupation

     Started career in computer hardware related job as a technician in 2004. He resigned his job in 2009. Then became a customer care executive in May, 2011 but resigned the job in August, 2011 due to high stress, Work satisfaction is low. Future ambition is to do farming.

Sexual history

      Masturbatory practices were present. No significant anxiety related to sexual fantasies/ practises. No homosexual fantasies.


Marital history

None

Use and abuse of alcohol drugs

       Used to smoke in 2002, when he was in plus two but stopped it. The patient sometimes used drugs to improve memory and toughness. He never consumed alcohol.

PREMORBID PERSONALITY

Attitude to others in social, family and sexual relationships. The relationship with father is not good. But he is very attached to his mother and sister.

Attitude toward self

         He was unable to address a social situation. He is over concerned, selfish and dissatisfied with work.

Moral and religious attitude

       He is very interested in religious activities especially in morality.

Mood

      The mood swings are present from being lively to gloomy.

Leisure activity

       Reading text books related business and accountancy, Carom - board and badminton.

Fantasy life

      There are no fantasy experiences in his early life

Reaction pattern to stress

      He is unable to tolerate frustrations and situations arousing anger and anxiety.

MENTAL STATUS EXAMINATION

General appearance and behaviour

       The patient has good hygiene and cleanliness. He was cooperative, attentive and talkative. The rapport establishment was easy.

Psychomotor activity

       Normal

Talk: The reaction time was normal. Amount of speech was high in an aggressive pace.

Thought

       Stream: There is some flight of ideas and thought blocking.
       Form: Intact.
       Possession: Nil
      Content: Delusion of reference.

Mood

      Subjective explanation of emotion was anxious.

Perception

     The patient feels restless.

COGNITIVE FUNCTIONS

1. Attention and concentration: Intact
2. Orientation: Good orientation about his name, identity, place, time of the day and the date.
3. Memory:  His immediate memory and long term memory is intact but recent memory is low.
4. General information:  He has a high level of general awareness.
5. Intelligence:  He has high level of intelligence as shown by his verbal capacity.
6. Judgement: Intact
7. Insight: The patient is aware of his illness and also not interested in treatment.
8. Social Judgement: Show appropriate behaviour.
9. Test Judgement: Intact.

SUMMARY


  The patient S.K, 31 years old male, unmarried, plus two passed and worked as customer care executive from middle socio-economic status with significant past history of schizophrenia of Grandfather, brother of grandfather and Father. He is characterized by decreased sleep, poor peer relationships, premorbidly submissive and have suicidal thoughts.

The patient presented with gradual onset, continuous illness of two years and more duration precipitated by hereditary causes and family issues characterized by lack of sleep and high levels of activity. Mental status examination revealed delusion of reference, irritable mood, and recent memory loss with intact judgement with presence of insight.

Provisional diagnosis:       Paranoid schizophrenia

Treatment and Management

      1. Cognitive behavioural therapy
      2. Psychotherapy
      3. Social skills training applied in order to enhance the relationships between social and family members.
      4. Pharmacotherapy
      5. Vocational therapy.