Bahria University

INTERNEE PSYCHO DIAGNOSTIC REPORT

Name N.K

Father Name M.A

Age 47 years

Gender Male

Date of Birth 13-4-1975

Assessment date 5-march-2023

Assessment by Muhammad zubair

Informant Client himself

Reason and source of referral

The client was referred to trainee clinical psychologist with complaints of self-talk,

selflaugh, hallucination, delusion, lack of interest, by fountain house Lahore. He came with

his brothers who admitted his in fountain house for his illness. Client had these symptoms

since last 18 years and got persistent with the passage of time due to different factors.

Previous Complaints:
Complaints Duration

‫خود سے بات کرنا‬ 15 Years

‫ میں اپنے روحانی والد سے بات‬15 Years

‫کرتا ہوں۔‬

‫ ۔ میرے روحانی والد پوری دنیا کو‬15 Years

‫کنٹرول کرتے ہیں۔‬

Presenting complaints:
• ‫خاموش رہنا‬ 4 month

• ‫صرف سوچتے رہنا‬ 4 month

• ‫خاندان کی زندگی کی حفاظت کی پریشانی‬ 8 month

• ‫موت کا خوف‬ 4 month

Tentative Diagnosis: F20.9 Schizophrenia Multiple episodes, currently in partial remission

Tests Administered:

• Mental Status Sheet Examination (MSSE)

• Bender Gestalt Test (BGT)

• Test of non-verbal intelligence (TONI)

• Positive and Negative Syndrome Scale (PANSS)

• Rotter Incomplete Sentence Blank (RISB)

• Thematic Apperception Test (TAT)

Clinical interview:

According to the client, he has visited the Fountain House for 15 years. He was a

very naughty child in school. After completing his B.A., he started a Law degree but left it

after 2 years. His parents are deceased. Then he started to communicate with his spiritual

father. Sometimes his spiritual father scares him with loud voices calling his name .Then

his friend Sam comes to calm him down from his fear and he realizes that it is only his

father. The client also reported a fear of death. He believes that humans are the main

creatures and can do whatever they want. He enjoys talking to his spiritual father, who

always communicates with him. The spiritual father knows whatever the client says and

does. The spiritual father even controls the weather, sunrise, and everything else. The client

believes that his father controls the whole world. He refers to the evil spiritual father as a

'dude' and an angel as an 'angel.' The client gets divorced after a year of marriage. As a

hobby, he enjoys playing cricket and singing. The client thinks that he is very famous in

his city.

Psychological Evaluation:
Table 1

Table showing Scores of Bender Gestalt Test (BGT)

Percentile rank Visual Motor Index Descriptive rating % of Population

<2 <70 Significantly Impaired 2.34

2-7 70-79 Mildly to Moderately Impaired 6.87

8-23 80-89 Below Average 16.12

24-76 90-109 Average 49.61

77-92 110-119 High average 16.12

93-98 120-129 Superior 6.87

>98 <70 Very Superior 2.34

Emotional indicator

Small size in drawing is also associated with anxiety, withdrawal, and constriction

timidity.
Table 2

Table showing scores of Test of Non Verbal Intelligence (TONI)

Index Score Percentile Rank Descriptive term

<70 <3 Very Poor

70-79 3-8 Poor

80-89 9-24 Below Average

90-110 25-75 Average

111- 120 76-91 Above Average

121-130 92-98 Superior

>130 >98 Very Superior

Table 3

Table showing scores of Positive and Negative Syndrome Scale (PANSS)

Response Category Raw Score T Score Ranges Categories

Positive 37 76 7 to 49 very much above average

Negative 17 63 7 to 29 slightly below average

General Psychopathology 41 77 -42 to +42 Average

Anergia 8 56 16 to 112 slightly below average

Thought Disturbance 13 64 Average

Activation 20 or Higher 5 63 slightly below average

Paranoid Belligerence 3 79 below average

Depression 27 or higher 10 72 Average

Qualitative Interpretation:

Client shows severe illness on PANSS. Client’s score on PANSS was n range that can

depict a major level of psychotic symptoms. His Raw score included sever and extreme

delusions, suspiciousness, anger, guilt feelings, anxiety.

Table 4

Table showing the scores of Rotter’s incomplete sentence blank test (RISB)
Item Responses score Total

C3 9 6*9 54

C2 3 5*3 15

C1 5 5*4 20

N 18 18*3 54

P1 4 4*2 8

P2 1 1*1 1

P3 0 0*0 0

The score 153 on RISB indicates that the client faced adjustment issues with environment.

"In general, the client shows their own symptoms in their attitude across almost all items.

They write about their hallucinations and delusions in most of the items (items 1, 2, 3, 12,

39). The client shows resistance to other topics such as society, marriage, and study by

giving short responses of one to two words. They show openness only in sharing their

symptoms and are reluctant to discuss their past social interactions. For example, on item

26 about marriage, the client's response is destructive. On the item about secrecy, the client

shows distrust."
Table 5

Table showing evaluation of Thematic Apperception Test (TAT)

CARD NEED PRESS Object Conflicts Anxiety Inner Defense
relation mechanism
Number state

1 Understanding Detachment Dejection Denial

3BM Succorance Dejection Projection

5 Achievement

9BM Passivity Denial

10 Projection

7BM Denial

15 Achievement

Dominance

13MF Sex

17BM Play Elation

13B Play Dominance

Qualitative Interpretation:

Client most card stories had shown the need of achievement,

Dominance, physical or sexual needs . Clients Defense mechanism is denial and projection.
Behavioral Observation

The client was sitting comfortably and his sitting posture was appropriate. He was

cooperative. He was in a good mood, his overall appearance was fine but he wasn’t too

hygienic. He had eye contact, he had emotional withdrawal during session, while telling

about married life. His mood was happy most of the sessions. He has absent insight about

his problem. He was not much social with his fellow members in Fountain house.

Conclusion.

"The client, N.K, a 38-year-old male, was admitted to Fountain House Lahore for

psychological evaluation and treatment. He presented with complaints of sadness, self-talk,

self-laughter, lack of interest, sleep issues, and worthlessness. The client had poor insight

into the problem and showed reluctance to talk about his past social experiences. He

insisted on ending the first session when discussing his divorce period. During

psychological testing, he showed poor insight into his hallucinations and took pride in

talking about his own symptoms. The client also displayed a grandiose attitude by

discussing his hallucination symptoms."

Tentative Diagnosis

295.90 Schizophrenia, First episode, currently in partial remission

Limitations

The client showed emotional withdrawal many times during session. Client shows lack of

interest in confronting their symptoms.

Recommendations

• Client was recommended follow plan for appetite.

• Client was recommended to take his medicines daily on time and don't skip that.

• Client was recommended follow daily activity chart.

_________________ ___________________ ____________________

(Assessor Name) (Supervisor Name) (Head of Department

MS Internee Internship Supervisor Name)

Biopsychosocial Model

Adapted from Barker P.

Biological Psychological Social

Predisposing • Family • Fearful/anxious • socially inactive

history of temperament •
substance use death of mother

Precipitating • Increase in • fear of death

hashish use,
. Skip
medication
Perpetuating •Brother and • Her lack of adaptive
brother in law coping mechanisms
also have resulted in using self-
auditory harm to cope
hallucination
Protective • Medically • Previously • Good interpersonal
healthy responded well to support from his friends of
CBT hospital.
Treatment plan : Systematic steps in treatment planning
Variable Define Technique used
Functional Urgency of ( Medication
impairment achieving goals compliance)
Social support Cognitive CBT for psychosis
behavioral vs. (Thoughts and feeling
relationship _Abc model)
enhancement Making the B-c
Connection

Problem Narrow symptom High Problem

complexity/chronicity focus vs. resolution Complexity
of thematic unre- (•Free association
solved conflicts Dream work.
. • Cathartic discharge.
• Enacting opposite
patterns of how the
client typically
behaves.
• Exploring thematic
patterns in behavior
and relationships
Coping style Behavioral symptom Internalizers
oriented vs. internal • Introversion.
insight oriented • Intellectualization.
interventions • Denial.
• Repression.
• Social withdrawal.

Resistance HIGH / Low High Resistance

Anxiety • Self-monitoring.
Supportive, • Therapist
nondirective, or reflection.
paradoxical vs. • Support and
structured, directive reassurance.
interventions • Prescribing that no
change occur

Subjective distress Increase/decrease • Decrease arousal

arousal • Poor emotional
investment in
treatment.
• Low energy level.
Case Formulation

Presentation complaints (symptomology)

*Self-talk *Fear of death *Delusion * hallucination (auditory ) *Appetite *disturbance in sleep

Assessment
• Mental Status Sheet Examination (MSSE)
• Bender Gestalt Test (BGT)
• Test of non-verbal intelligence (TONI)
• Positive and Negative Syndrome Scale (PANSS)
• Rotter Incomplete Sentence Blank (RISB)
• Thematic Apperception Test (TAT)

Precipitating factor

*Divorce *death of the father of the client *Genetic *Aggression

Predisposing factor

*Schizotypal personality

Perpetuating factor

*Substance use

Protective factor

*Medication compliance

Diagnosis
F20.9 Schizophrenia Multiple episodes, currently in partial remission
Treatment plan

Patient Name & Age Mr. N.k is 45-year-old male

Presenting complaints Self talk *Fear of death *Delusion *
hallucination (auditory ) *Appetite
*disturbance in sleep
Test Administration Mental Status Sheet Examination(MMSE),
Bender Gestalt Test (BGT,)Test of Non-
Verbal intelligence(TONI), Positive and
Negative Syndrome Scale (PANSS),Rotter
Incomplete Sentence Blank(RISB),House Tree
Person(HTP).

Tentative Diagnosis
F20.9 Schizophrenia Multiple episodes, currently
in partial remission
Goals of Therapy

short Term Goals

Rapport Building, Technique ( Active listing )

Engagement of patient in therapy and ensuring

confidentiality so he can open up easily.

• Identify challenging and delusional

beliefs

• Medication compliance

• Take care of Hygiene ( Tooth brush,

clean clothes, take a bath daily)

Long term plans Psychoeducation of client about

etiology of genetic schizophrenia

Socialization
Daily activity ( group therapy, drawing,
plying cricket)
Follow Appetite chart

CBT for delusion

Relapse prevention
Main techniques Appetite chart,
Daily activity chart

CBT for psychosis( Thoughts and

feeling _Abc model)
Making the B-c Connection

Relapse prevention
No. of session planned 10-12 sessions