PSYCHOTHERAPY REPORT

PURPOSE : Psychotherapeutic management

CRF No. : ……..
SOURCE OF INFORMATION: Patient herself and her mother.
RELIABILITY & ADEQUACY: Information obtained was reliable and
adequate.
NAME OF THE SUPERVISOR : xxxx
NAME OF THE THERAPIST : Nishi Varsha Kerketta
DIAGNOSIS : Residual Schizophrenia
SOCIO- DEMOGRAPHIC DETAILS:
xxxxxxx
CHIEF COMPLAINTS:
❖ Decreased sleep
❖ Irritability Since 2 months
❖ Aggressive behaviour
❖ Stays alone
❖ Socially withdrawn

NATURE OF ILLNESS:
❖ MODE OF ONSET : Insidious
❖ COURSE OF ILLNESS : Continuous
❖ PROGRESS OF ILLNESS : Deteriorating

PRECIPITATING FACTORS: stress due to excessive pressure of getting job

or getting married.
HISTORY OF PRESENT ILLNESS:
Index patient was maintaining well before 2019. She gradually started talking to
self, started complaining that someone is controlling her mind, started seeing
people and hearing commanding voices which instructed her to do suicide. Her
sleep was also decreased. Then since, 1 week of the symptoms she was
immediately taken to the local psychiatrist from where she had been taking
continuous medications. Consequently, her symptoms were resolved but
meanwhile there was a relapse for 1 month when she stopped taking her
medicines because the patient and family members thought that her symptoms
has improved but again she started showing similar symptoms due to which her
mother again immediately started her previous medication. This improved her
symptoms and she was maintaining well but again in December 2021 she started
showing irritability, aggressive behaviour, staying alone and socially withdrawn
followed by decreased sleep, for which she was brought to RINPAS by her
mother and uncle on 04.03.22.
RELEVANT NEGATIVE HISTORY:
▪ No history suggestive of persistent increased energy, elated mood, inflated
self-esteem, thought alienation, psychotic symptoms, significant head
injury, Mental retardation, Epilepsy, persistent fever, persistent decreased
energy, sad mood, low self-esteem, worthlessness, hopelessness, suicidal
ideations or substance use.
TREATMENT HISTORY:
Index patient was first treated by a local psychiatrist for her symptoms in 2019.
FAMILY TREE:

DETAILS ABOUT FAMILY MEMBERS:

• Patient is the 1st born child to her parents with one younger brother.
 • Her father is a businessman.
• Patient’s mother is a housewife.
• Younger brother is 20 years old and is a student pursuing graduation.
PHYSICAL AND PSYCHIATRIC ILLNESS IN THE FAMILY:
Nil
FAMILY RELATIONSHIP:
❖ Patient has cordial relationship with her father.
❖ Patient had strained relationship with her mother.
❖ Patient’s relationship with her younger brother is cordial.
❖ Patient’s relationship with other family members is strained.
PRESENT LIVING CONDITIONS:
The patient stays in a joint family, in a pucca house with all basic amenities.
PERSONAL HISTORY:
Index patient was born out of full-term pregnancy normal at hospital, her
immediate birth cry was present and overall developmental milestones were
achieved. In middle and late childhood, the patient mostly used to be shy, well-
adjusted with teachers and having few friends. She also participated in
extracurricular activities in school. There was no evidence of conduct disorder,
phobias etc. She completed her M.B.A and is currently unemployed.
PREMORBID PERSONALITY:
• Social Relations: Her relation towards her primary family members was
cordial.
• Use of Leisure Time: She spent most of her time listening music
• Predominant mood: Euthymic
• Attitude Towards Self: Positive attitude
• Attitude Towards Work and Responsibilities: was hard working and
responsible.
• Religious beliefs: patient was quite religious.

MENTAL STATUS EXMINATION

The index patient came by herself, greeted the examiner and sat comfortably on
the chair provided. She looked of her stated age with average body build. She was
well kempt and tidy. Touch with the surrounding was present. She showed
frequent cries throughout the first interview. Initially she was uncooperative as
she reported that her mother forcefully brought her to meet doctor but with
constant motivation she gradually became cooperative and communicative.
Rapport was established. Eye to Eye contact was maintained adequately.
Psychomotor activity was increased showing agitation in the patient. Attention
was aroused and sustained for a considerable period of time.
Speech was audible, reaction time was normal, the rate of which was rapid, range
and volume was high, it was pressured at times, and was relevant & coherent.
Mood was subjectively reported as “mera mann cool hai” and was objectively
reported as agitated. The range of the affect was restricted, inappropriate to the
setting of examination and incongruent to the thought content.
Productivity of thoughts was normal, which was relevant, coherent as well as goal
directed. Thought disturbances and perceptual disturbance were not reported at
present. Her orientation to Time, Place and Person was intact. Her immediate,
recent & remote memory was intact. Abstract Reasoning was at conceptual level.
Her Personal, social and test judgement was satisfactory. Insight was at Grade I
level (complete denial of illness) as patient stated “nothing mera koi problem ni
hai”.

ASSESSMENT:
• Clinical interview
• Psychological assessment
• Behavioural analysis

CLINICAL INTERVIEW:
Detailed clinical interview was taken from both the patient and her mother about
the mode of onset of illness, its nature of development across the course of time,
progress of deterioration, precipitating factors and predisposing factors which
might have contributed towards the development of illness. Information about the
pre-morbid personality was tried to be elicited.

PSYCHOLOGICAL ASSESSMENT:
1.Eysenck’s Series of Digit Span Test
This test was administered to assess the attention and concentration of the
patient. She obtained a digit forward score of ‘5’ and digit backward score of ‘3’
indicating that attention was aroused and sustained for a considerable period of
time.
2. Sack’s sentence completion test (SSCT)
This test was administered to elicit the areas of conflicts in patient’s
personality and attitudes in different areas like family area, interpersonal
relationships, self-concept, work etc.
The index patient’s principal areas of conflict where severe disturbance is present
includes attitude towards mother, fear-ratings and attitude towards future.
In the domain of interpersonal relationship, there is severe conflict found in the
interpersonal relationship with mother, as the patient feels that her mother
unnecessary interferes in her life. Patient also showed severe conflict in the area
of attitude towards future.
Moderate conflicts were present in the area of attitude towards goals and attitude
towards own ability. Which suggests, there is guilt and regret over past mistakes,
feelings of inferiority related to her own abilities.
3. Positive and Negative Syndrome Scale (PANSS)
This test was administered to assess the severity of positive, negative and
general psychopathology of schizophrenia in the patient. The patient obtained a
total score of 10 in positive symptoms scale, 14 in negative symptoms and 20 in
general psychopathology of schizophrenia, indicating mild level of severity in
positive, negative and general psychopathological features of schizophrenia in
patient.
4. Draw A Person Test (DAPT)
This test was administered to assess the underlying attitude, concerns, and
personality traits of the index patient. Prominent features seen in the patient as
per interpretation of the figure drawn by the patient are emotional attachment to
a member of the opposite gender as indicated by drawing opposite sex first.
Drawing of larger dominant female figure indicates passivity, inadequacy,
submissiveness and related psychosexual disturbances. It also indicates about
patients’ substance abuse. Left placements of both the drawings shows
uncertainty, apprehensiveness and self-orientation in the patient. Drawing of hand
behind back of both the drawings indicates evasiveness in the patient. Drawing
of spiked fingers shows aggressiveness in the patient.
BEHAVIORAL ANALYSIS:
Initial analysis of problem behaviour:
Behaviour excess:
• Aggressive behaviour
• irritability
Behaviour deficit:
• being isolated
• decreased interaction with people in the surroundings
• decreased sleep and appetite
Behaviour asset:
• cordial relation with people in general
• interest in drawing
• proper maintenance of hygiene
• regular with her routine work
CLARIFICATION OF THE PROBLEM SITUATION:
Index patient is a single girl child to her parents due to which she always got
extra and abundant love and attention from her parents and her family members.
But as she completed her M.B.A she sat free at home having a careless nature
towards doing job. But as time passed, family members were worried about her
getting job and her marriage due to which she also got pressure from her family
members. This made the patient stressed about her situation and she started
remaining alone. Then, in 2019 she started having behavioural problems,
consequently she gradually started talking to self, started complaining that
someone is controlling her mind, started seeing people and hearing commanding
voices which instructed her to do suicide. Her sleep was also decreased. Then
since, 1 week of the symptoms she was immediately taken to the local psychiatrist
from where she had been taking continuous medications. Consequently, her
symptoms were resolved but meanwhile there was a relapse for 1 month when
she stopped taking her medicines because the patient and family members thought
that her symptoms have improved. From then onwards patient her mother used to
be overly concerned about the patient’s illness due to which she always used to
restrict the patient for everything which made patient to have hostility towards
her mother. Consequently, the patient gradually again started showing similar
symptoms due to which her mother again immediately started her previous
medication. This improved her symptoms and she was maintaining well but again
in December 2021 she started showing irritability, aggressive behaviour, staying
alone and socially withdrawn followed by decreased sleep, for which she was
brought to RINPAS by her mother and uncle.
Motivational Analysis:
The patient has although doesn’t have insight about her illness and is partially
motivated for her treatment as due to her mother’s pressure.
Developmental functioning:
• Biological functioning
Her sleep has decreased.
• Behavioural functioning
After the progression of the illness, she remains irritable and easily gets
indulged in arguments with family members specially with her mother as
her mother shows extreme concern about her illness and the patient has
complete denial of illness. Although she has insight that she had illness in
past. She frequently shows aggressive behaviour.
• Social functioning
After the onset of the illness, she loves being isolated and has become
socially withdrawn.
Analysis of self-control:
The index patient lacked of self-control as she couldn’t control her aggressive
behaviour and easily gets irritable at minor things.
Analysis of relevant social relationship:
The patient is close to her father.
Analysis of physical and socio-cultural environment:
The patient currently stays with her parents, in a joint family in the urban area of
Ranchi.
Psycho-diagnostic formulation:
Index patient X, 29 years old, female, Hindu, Hindi speaking, pursued M.B.A,
unmarried, belonging to Middle socio-economic status, hailing from urban area
of Ranchi district of Jharkhand came to RINPAS OPD on 31.7.2021 with her
mother and uncle, with the following chief complaints: decreased sleep,
irritability, aggressive behaviour, stays alone and socially withdrawn the duration
of which is for 2 months. The mode of onset is insidious, course of which is
continuous and its progress is deteriorating. On MSE, Speech was found to be
rapid, the volume of which was high, it was pressured at times. Affect was
observed as agitated, which was restricted, inappropriate to the setting of
examination and incongruent to the thought content. Insight was found at Grade
I level.
Psycho-therapeutic formulation

Predisposing Factors:
• Vulnerability to stress
• Short temperedness

Precipitating factors:
• Excessive pressure of getting job
or getting married.
Residual
Perpetuating factors: Schizophrenia

• Sitting free after completion of

her M.B.A
• Careless attitude towards future
plans
• Mother’s emotional over
involvement towards patient’s
illness

Consequences:
• Irritability
• Aggressive behavior
• Hostility towards her mother
• Negative attitude towards her
medical compliance
• Being isolated
• low social interaction
• decreased sleep

Protective factors:
• Support from her parents
• Maintenance of regular routine
Short term goal:
• Developing insight in the patient and educating patient about the nature of
her illness
• To motivate the patient for therapy
• To improve her sleep pattern
• To reduce her intense emotional state
• Improving her interpersonal communication skill
• To improve her attitude towards her drug compliance

Long-term goals:
• To improve her interpersonal relationship
• To reduce expressed emotion
• Medical adherence
• Relapse prevention

Therapeutic package:
• Psychoeducation
• Supportive psychotherapy
• Interpersonal and social rhythm therapy
• Dialectic Behaviour Therapy
• Family counselling
Therapy sessions:
18 sessions were individually conducted in the rate of 1 session each week. In
which 5 sessions were conducted along with her mother.
Target wise Therapy report:
• Developing insight in the patient and educating patient about the
nature of her illness

To developing insight in the patient and educating patient about the nature
of her illness, psychoeducation was provided to the patient and her family
members including her mother and uncle about the nature, causative
factors, prevalence, availability of treatment options and their efficiency.
They were educated about the causal factors and how the factors interacted
with the patient’s personality and environmental stressors in order to result
 in the formation of her illness. She was reminded that her motivation and
sincere efforts are necessary for reducing her illness. She was also psycho-
educated about the acquiring of coping skills in order to deal with the
interpersonal problems that serve to perpetuate her illness. It was pointed
out to her that she could reap maximum benefits from therapy, if she
regularly practices the skills taught during the sessions in actual real-life
situation outside. She was told about the therapeutic importance of
homework assignment and the role it plays in facilitating the process of
recovery. The fact that psychotherapy is a collaborative process requiring
cooperation and participation of both client and therapist was stressed
upon.

• To motivate the patient for therapy

As the patient lack of motivation towards therapy thus the initial session
aimed at conveying the need and rationale for therapy. Her cooperation for
therapy was ensured. To motivate the patient persuasion, reassurance,
suggestion techniques were used. In the course of the therapeutic process,
verbal reinforcement such as praise was provided to the patient. In later
sessions, better cooperation from the patient’s side was found.

• To improve her sleep pattern

To target this goal, with the help of interpersonal and social rhythm therapy
she was taught the importance of circadian rhythms and routines in our life,
including eating, sleeping, and other daily activities. After identifying her
routine, she was made to understand and taught to keep the routine
consistent and address those problems that arise, which might upset her
routine by focusing on building better and healthier interpersonal
relationships and social skills. She was also taught about the sleep hygiene.

She was taught to follow some sleep habits including: following a nightly
routine that allows time for relaxing activities like meditation, yoga or
stretching, getting up and going to bed around the same time each day,
creating a healthy sleep environment that includes dim lights and ideal
room temperature, shutting off all electronics at least 60 minutes before
 going to bed, limiting caffeine or alcohol intake before bedtime, getting
enough physical activity earlier in the day and avoiding large meals with
high fat content before bed. These habits were asked to follow by the
patient in order to improve her sleep.

• To reduce her intense emotional state

The index patient had frequent aggressive behaviour in any small things
and she used to be irritable anytime. Hence, she was taught the skills to be
calm and to regulate her emotions by using the skill training of core
mindfulness and emotion regulation from Dialectic Behaviour Therapy.
She was taught the mindfulness skills to live in the moment, focusing on
what is happening inside as well as around her in a non-judgemental way
including her breathing, sensations inside her body, noises around her,
inner feelings and thoughts and also her reactions to specific situations. She
was also taught to focus on healthy coping skills in the midst of emotional
or stressful situations. At the same time, she was also taught to be calm and
avoid engaging in impulsive behaviour. The patient was also taught to
regulate her own emotions by identifying and changing her emotions of
aggressiveness to a calm and positive emotions. She was taught to exercise
the opposite action in which she was taught to act or use opposite response
to a particular situation that would make her angry or irritable.

• Improving her interpersonal relationship and communication skill

The index patient has dysfunctional communication pattern due to which

her interpersonal relationship is strained with her family members specially
with her mother. Thus, to improve her interpersonal communication and
relationship she was taught the skills of interpersonal effectiveness from
Dialectic Behaviour Therapy, in which she was taught to become more
assertive in a relationship while still keeping a positive and healthy
relationship. The patient was at the same time, taught to listen and
communicate more effectively. She was also helped to learn how to deal
with challenging people effectively and respect herself and others. For the
purpose of improving relationship and positive communication pattern, the
exercise of GIVE was used which taught her to be gentle, showing interest
with good listening skills, acknowledging other people’s thoughts and
feelings, and also to have easy attitude.
 • To improve her attitude towards her drug compliance

The patient had extreme negative attitude towards her drug compliance as
she used to think that she had already recovered her previous illness so
there is no reason to continue her medicines. Thus, to improve her drug
compliance again psycho-education was given to the patient. She was told
about the need for regular and proper medication. She was told about the
side effects of medication. She was also told about the effects of poor drug
compliance.

• To reduce expressed emotion

It was evident from the interview and therapy sessions that the
interpersonal relationship of patient with her mother was strained. It was
also seen during sessions that there was expressed emotions presented by
her mother in the form emotional over involvement towards patient’s
illness. For this individual counselling was done by patient’s mother and it
was brought into light the consequences of her expressed emotion in
perpetuating the patient’s illness.
Therapy outcomes:
• Increased awareness about the nature of her illness
• Enhanced motivation for therapy
• Improved drug compliance
• Improved interpersonal relationship and communication
• Improvement in sleep
• Improvement in regulating intense emotional state
• Reduction in expressed emotion
Future plan:
• Monitoring progress
• Medical adherence
• Regular follow-up to ensure sustained improvement
 • Helping the patient to improve her social support network
• Relapse prevention

Supervised by: Reported by: