Schizoaffective- Bipolar TypeSchizoaffective Disorder is a disorder in which a mood episode and

the active- phase symptoms of Schizophrenia occur together and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms (American Psychiatric Association, 2000).Diagnostic criteria for 295.70 Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia. Note: The Major Depressive Episode must include Criterion A 1: depressed mood.

B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

Specify typeBipolarType: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes) Depressive Type: if the disturbance only includes Major Depressive Episodes(APA, 2000).Differential Diagnosis

General medical conditions and substance use can present with a combination of psychotic and mood symptoms. Psychotic Disorder Due to a General Medical Condition, a delirium, or a dementia is diagnosed when there is evidence from the history, physical examination, or laboratory tests indicating that the symptoms are the direct physiological consequence of a specific general medical condition. Substance-Induced

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Psychotic Disorder and Substance-Induced Delirium are distinguished from Schizoaffective Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the symptoms(APA, 2000).

Distinguishing Schizoaffective Disorder from Schizophrenia and from Mood Dis-order With Psychotic Features is often difficult. In Schizoaffective Disorder, there must be a mood episode that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial portion of the total duration of the disturbance, and delusions or hallucinations must be present for at least 2 weeks in the absence of prominent mood symptoms. In contrast, mood symptoms in Schizophrenia either have a duration that is brief relative to the total duration of the disturbance, occur only during the prodromal or residual phases, or do not meet full criteria for a mood episode. If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Disorder With Psychotic Features. In Schizoaffective Disorder, symptoms should not be counted toward a mood episode if they are clearly the result of symptoms of Schizophrenia (e.g., difficulty sleeping because of disturbing auditory hallucinations, weight loss because food is considered poisoned, difficulty concentrating because of psychotic disorganization). Loss of interest or pleasure is common in nonaffective Psychotic Disorders; therefore, to meet Criterion A for Schizoaffective Disorder, the Major Depressive Episode must include pervasive depressed mood. Because the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, the appropriate diagnosis for an individual episode of illness may change from Schizoaffective Disorder to Schizophrenia (e.g., a diagnosis of Schizoaffective Disorder for a severe and prominent Major Depressive Episode lasting 3 months during the first 6 months of a chronic psychotic illness would be changed to Schizophrenia if active psychotic or prominent residual symptoms persist over several years without a reClurence of another mood episode). The diagnosis may also change for different episodes of illness separated by a period of recovery. For example, an

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individual may have an episode of psychotic symptoms that meet Criterion A for Schizophrenia during a Major Depressive Episode, recover fully from this epi- sode, and then later develop 6 weeks of delusions and hallucinations without prom- inent mood symptoms. The diagnosis in this instance would not be Schizoaffective(APA, 2000).

Case IdentificationRefferal

Client is visiting this hospital for the past 4 or 5 years, his relatives brought him for the first time to Hospital. Client said that first time he came he was tensed and used to be lethargic and felt sleepy, that’s why his relatives brought him.His siter’s husband’s father suggested that client should see a psychiatrist.Duration of Session

Sessions were conducted from 7/12/2013 to 14/12/2013.Identifying DataBio DataName : XYZAge : 32 years oldSex : MaleFather name : ABC

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Living or Dead : AliveEducation : 7th classOccupation : Job lessMonthly Income : _____No. of siblings : Five sisters and three brothersIndependent/ Dependent : IndependentBirth order : 5thMarital Status : WidowerReligion by birth : IslamAddress : RawalpindiInformant : Patient himselfReferrals : Client’s relative

Presenting Complaints اب کچھ نہيں ہو تا صرف جلن ہوتی ہے، جب ہم نے پانی پیا اور وہ خون کے ساتھ ملا تو سينےميںجلن شروع ہو گئ ۔پہلے ميدہ

کھلا تھا ليکن جب پانی پيا تو سن ہونا شروع ہوگيا دو چار بعد ميدہ خراب ہو گيا جب خون کے ساتھ ملا تو سينے کی بے چينی

شروع ہوگئ ۔ جيسے شرابياتيزاب بھی خون سے ملے گی تو سن ہو گا۔خون کے ساتھ کوئچيز ملے گی تو سن ہو گا نابدن۔اب اور

کچھ نہيں صرف سينے کی بے چينی ہے۔

وں کبھی ت سخت بھوک لگتی پر پھر بھی ايک روٹی کھاتا ہکبھی کببھی ب ہے ہ ، وتی يں، ميد ميں سخت جلن ہےکبھی کھانا نا بھی کھاؤں تو کوئ مسال ن ہ ے ہ

تا ت بڑ بڑ ڈاکٹر کو چيک کروايا سب پيرو فقيرو کو بھی، کوئ ک ہےب ہ ہے ے ے ہ يں باقی ڈاکٹر ايس يں پتا ڈاکٹر سب جانت ےتاويز حقيقت بات کسی کو ن ہ ے ۔ ہ ہے

يں ۔ی ہ ہ

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نی ٹينشن ہے۔ميد ميں پرابلم اس کی وج س ذ ہ ے ہ ہے ے يں ک ميں کام و جاتی مير کو اس کا پتا ن وتا تو ٹينشن شروع يں ہکام ن ہے ہ ے ہے ہ ہ ہ يں جب تين ی نظ__ر آن لگ__ت و جاؤں گا دن رات اي__ک ہپر جاؤں گا تو ٹھيک ے ے ہ ۔ ہ ی يں آر ۔چار دن کام پر گزر جائيں تو اس بات کی مجھ سمجھ ن ہ ہ ے ب ےاگر وں وں ڈاکٹر کی گولی بھی کھات__ا وتی تو گولی کھا کر ليٹ جاتا ہ999سکونی ۔ ہ ہے ہ وں و جات__ا وں يا خاموش ہ999اور جو کوٹلی س دوائ لی تھی و بھی سو جاتا ہ ہ ۔ ہ ے وں ت__و ليٹ__ن کيل ادھ__ر و جا تو ٹھيک تھک جاتا ن کام کرنا شروع ۓجب ذ ے ہ ہے۔ ۓ ہ ہ يں ليٹ جاؤں وں ک ک تا ۔ادھر گھمتا ر ہ ے ہ ہ

و ا پھر مجھ ٹينشن شروع يں ک و آدمی ي بات کر ر ن ميں باتيں آتی ہ99999ذ ے ہے ہ ے ہ ہ ہ ہ م__ار ماس__ٹر ص__احب کی يں جس ط__رح ۔جاتی ب__اتيں اچھ آدمی کی آتی ے ہ ہ ے ہے۔ يں کرتا ۔بر آدمی ک ساتھ بيٹھن کا دل ن ہ ے ے ےيں يں سنت دل کرتا ک ،جب گھر وال بات ن وں جب غص آتا ہتوڑ پھوڑ کرتا ہے ے ہ ے ہے ہ ہ ر ۔چال جاؤں گھر س با ہ ے

وں ۔ميں روتا بھی ہ

Symptoms Changes in appetite and energy Disorganized speech that is not logical False beliefs (delusions), thinking that someone is talking about

him/her and then start taking tension. Lack of concern with hygiene or grooming Mood that is depressed/elevated or irritable Problems sleeping Problems with concentration Sadness or hopelessness Social isolation Irrelevant talk Occupational dysfunctioning Avolition Aggressiveness Depression Incoherent speech Cicumstantialty

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Persecutory dellusions Mood-congruent hallucinationsBehavioral observation

Client seemed to be little restless. He was sitting on a chair. He was attentive throughout the session and answered abruptly to all the questions asked. He was casually dressed his shirts top 2 buttons were not closed, and had un-pleasant odor. Client maintained a good eye contact more than half of the time. Client was cooperative in sense that whatever questions were asked he replied but on the same side he showed resistance because he didn’t explain the incident properly. He showed a great level of voluntary movement in a sense that he kept on knocking his fist rapidly on the desk whenever he gave a response and kept on shaking his right leg and a piece of paper was stucked in his i.d card through out the session he smacked the card on the desk after 10 to 12 min to get it out. And after every 6to 7 minutes he used to drag the metal chair forward whenever he was explaining an event.

Raport was build without much difficulty but the client used to answer every question after explaining a whole story related to it or by giving an example about how he feels. Though most of the time he didn’t gave the answer required he explained the whole story in which answer was no where to be found. Moreover, the client after explaining an event used to ask that whether we understood what he said or not so for conformation he always used to say “understand”(samjhgaye).On client’s right hand’s wrist there was a brown mark and bit of a swelling on it.Personal history

The client was a man 32 years old. Year client was born was 1970, He doesn’t remember the date or month.Birthdate on I.d card that client had when he went to Karachi 3 years back is 1/1/1977.

According to client beacause of a mistake his name has been written different. Client mentioned an incident that why his name is written wrong. He said that his father was illetrate and his master always used to compete with his father. He said that there was a man whose name was ABC and his father was a Subaydaar and when client’s father

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was busy in his work the Subaydar secretly changed client’s name and also made it ABC which is actually subaydar’s son name too.

Client lives in Kashmir, in Rawalpindi he is living with his sister who lives in People colony. They have a residence in Kashmir where client’s parents live, client has 5 sisters out of which one died and 3 brothers. 2 sisters are married and are living in Rawalpindi. Client’s brother’s wife had triplets which according to client can never happen that a woman delivers 3 children.

When client was in 7th class he didn’t get the stipund that army gives to those whose fathers are in army, because the principal said that the name doesn’t match, Client’s name is ABC on one paper and XYZ on the school admission forms.Client said that his name is different in the papers and on the i.d card.

Client left the school after 7th class and went to Karachi at the age of 14, just like every other teenager who wants to live the life upto it’s full.Client’s education is seventh pass he always stood 1st in the class, he didn’t continue his studies further and on asking why he said that whatever is God’s will, God has definietly planned something else for him. Client also said that in 6th class one doesn’t know the ABCD of English.

Client’s parents are alive, he is more attached to her mother. Father was nice but a bit strict he didn’t allow him to remain outside home for a longer time. If some argument occurs client and his family just sort it out. Overall client’s relation with his family were good but if someone doesn’t agree or argues with the client then he gets aggressive and breaks things or feel like leaving the house.

Client got married in 2001, it lasted for one year after which his wife died. Client stated that his wife actually died in a child’s case, she fell ill and the family took her to Doctor in Kotli. By the next morning she was all fine so her brother who lives in saudia brought her sister home. Client said that her brother was illetrate and senseless even though he lives in Saudia. Wife was 6 months pregnant, when they brought her home her brother brought a bed but she said that she was able to walk, they haven’t gone too far that client’s wife fell on the road. Family brought her

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home and called a doctor. Client mentioned that people where he lives were wild animals that his wife was in pain and some were saying that we should take her to the hospital and some were saying no she’ll be fine there is no need, and in this state of confusion client’s wife died. So client has no children. Client at that time was in Karachi he mentioned that he was ill, earlier he was fine but after going to Karachi he fell sick.Client is unwaged for the past 10 years, he used to work earlier no matter how much tensed he was.

Client mentioned that he works on a tandur but they have their own hotels. Client said that when he starts working after 2 to 3 days pass different declamations start coming in his mind and he is not able to understand why this happens.

Client mentioned that his father lives in Balochistan and works in a factory. He said that samething happened with his father that he also started taking tension but now he’s all fine and now samething happens with the client. He said that they visited many hospitals, shrines, and blessed people and spent a lot of money but his father recovered by his ownself. His father was alsoa blessed person he can tell others what will be right for them just by seeing hands. Client said that when he was 14 his father was just like him jobless and tensed and his father felt that on his arrival people used to leave that place, client said that his father used to share this with him but he ignored and used to think that his father is lying.On super highway there is a hotel and client’s father is the head or incharge.

Client said that earlier is uncle was like that, then client’s father contributed money and opened a hotel where they both used to work. Then client’s uncle started to cheat and used to take money without client’s father’s consent. Both quarreled but his uncle said that he’s just and client’s father is putting blame, client’s father said that he’ll leave the hotel he can’t work with such a person. Then client’s father left the house and went to Akkeeq Shah Darbar in Karachi and client’s family didn’t receive any news from client’s father. Back home client’s family sold all

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their animals so that they can buy goods and food for home and for 4 years the situation was same at that time client was studying.

After that client went to Balochistan, where according to him people (waderay) concluded that he is the nephew of the man who owns Superhighway hotel. Client used to sit in their gatherings and people used to discuss that client had a fair complexion he talks fine but but has gone wrong with his face. Accordinig to client those people used to protect him from bad company and fight. Client went to a person who knew client’s father as well that person identified the problem with the client.Client also gained an insight into his problem that this all started because he drank that water in which an acid or powder was mixed and such incidents happened with him.

Client said that he is extremely tensed about his work and irritation in chest starts, and because of this irritation he is mentally tensed. Client said that now he doesn’t have any work so he feels more tensed, and he said that he has no idea that wether he will get better after going to work or not. He states that when he goes to work day and night appears to be same. Client said that when he feels restless he takes a medicine and lye down to sleep. Client take both medicines prescribed by Doctor as well as the medicines prescribed by Doctor in Kotli. Client stated that he lies down and take a sleep or either remain quiet so that his mind starts working again. When client feels tired he wander here and there to find place for sleep. Client said that Declamation comes in his mind that people who are sitting are talking such things and then client start taking tension. Declamation are related to good people like client’s master or teacher. Client feels irritation in chest.

Client mentioned that while he was in Karachi he never smoked a single cigarette or ate Paan.Smoking cigarette gives him a headache he only takes Niswaar.

He mentioned an incident which occurred between the client and his uncle. He mentioned that his uncle is a magician who learned the spell bindings from Bengal. He said that as you know magic is learned after consuming debris and rubbish but some people are even willing to eat a

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dog because they want to do the loss of another person at any cost and such people have been cursed by God. A person walking on wrong or evil path can never follow the path of righteousness.

His uncle had a piece of land which he sold to the client, uncle’s wife is not of a good character. When client returned from Karachi such things happened to him like his uncle started hating him because of this illness and says that he is possessed, mentally retarded and if the client is going somewhere and comes in his uncle’s way then his uncle doesn’t cross him because he believes that client is possessed.

Client said that he went to Karachi where some people were already present before his arrival and all were like him he doesn’t know that wether that man was a magician or what but he looked at him that who is this young boy with a fair complexion, and he used to feed every single man sitting there. Client thought that why these all people are sitting quietly, and that man feeds people, it’s maybe because the people who agree to drink or feed whatever that man gives. Client said that some mentally retarded individuals like him used to sit quietly over there and he also used to feed them (roti) and he never had a fight with any person, peole used to conversate with each other and laughed.

There was a man who had 2 daughters, no one offered him job, he used to do weird talks and kept on running here and there.The man hired him for work, that person made the client drink water, client didn’t knew that whether it is acid or some powder. After drinking water client had a quarrel with that man client had a teapot in his hand he smashed it on his head and he left the place crying. Client said that he used to think that why that man fights with his friends who sit there but same thing happened to him after drinking that water, this incident occured early in the morning. After this incident client started to remain tensed, everybody who used to sit there started to remain aggressive, after 2 3 days client started feeling irritation in his chest.

Client had good school friends one of his friends went to saudia. Client is still in contact with his friends. According to client he can judge what others are talking about if people are talking about him he’ll come to

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know and if they are talking about someone else he will still come to know no matter how far they are sitting.

Client said that although people believe that I take tension because of my wife’s death but he actually knows the truth that it all started in Karachi, when person is ill he take tension of minor things, when a person recovers then he takes less tension. When client was ill he cried a lot and that’s why people started him.

When client feels restless he takes medicine and takes a nap or sits quietly, when his mind starts working its all fine. Client keeps on lying down or finds a place to sleep.Client stated that if a person is nice I want to sit with him but if he’s not good then it’s better to be alone instead of having such a bad company. Client said that Declamation comes in his mind that people who are sitting are talking such things and then client start taking tension. Declamation are related to good people like client’s master or teacher.

On asking whether he hears voices or sees strange things client mentioned 2 incidents to prove that there is nothing wrong with him and such things never happened to him first incident he mentioned was that he went to his friends house at midnight because his refrigerator wasn’t functioning, on his way back he saw another person and started chatting with him that person told him that a woman was staring at you and then she disappeared.

He said that when an illetrate person come to know about something he starts acting like that. He stated that a person becomes suspicious if he hears a sound, and when a persons heart is pure he can sense that who is looking towards him, and same is with the client that if a person is staring at him he’ll feel in his heart and the person staring will feel as if someone whispered in the client’s ear that the person is staring at you according to the client.

Another incident he stated was that clients master called him from Balochistan, and client was attending a funeral, so while he was on his way he felt the urge to look ahead and when he looked his master was standing there, Client said that people think that someone whispers in my

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ear but that’s not the truth it’s actually client’s heart that believes that by looking things will come true, client belives that his heart gets purified.

History of Present IllnessClient was quite social, his relations with family were good. Client

didn’t continue his studies, he left the school when he was in 7 th class. Client went to Karachi at the age of 14. According to clineta person made him drink something which on mixing with blood caused irritation in chest. Client felt restless and a lot sleepier, declamations come in his mind. 1- Premorbid personality

Client was a 32 years old male figure who belonged to middle socioeconomic status. He suffered no birth complications. Client’s childhood was good. He was close to his parents especially mother, father used to be a little strict. He was attatched to his family, and he was a middle born. He had some benefits of being a middle born he was quite pampered.

Client used to share long talks with family and laughs with his relatives, but arguments made him aggressive. He was social had many friends he used to play games with his friends in boyhood. His father was protective towards his family so he used to restrict him from going here and there.

At the age 14 he went to Karachi, because at this age children hardly listen to their parents, and he started working in a hotel. According to the client someone gave him a glass of water mixed with either powder of some kind or an acid that on mixing with blood caused irritation in the chest. And that has been occurring ever since.2- Onset of Illness

Client said that he studied upto 7th class and then he didn’t continue his studies.on asking that why he didn’t continue he said that whatever is God’s will God has planned something else for me. Then he went to Karachi at the age of 14 like every other teenager who wants to spend time with his friends and there this whole thing started.

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Client said that he went to Karachi where some people were already present before his arrival and all were like him he doesn’t know that wether that man was a magician or what but he looked at him that who is this young boy with a fair complexion, and he used to feed every single man sitting there. Client thought that why these all people are sitting quietly, and that man feeds people, it’s maybe because the people who agree to drink or feed whatever that man gives.Client said that some mentally retarded individuals like him used to sit quietly over there and he also used to feed them(roti) and he never had a fight with any person,peole used to conversate with each other and laughed.

There was a man who had 2 daughters, no one offered him job, he used to do weird talks and kept on running here and there.The man hired him for work, that person made the client drink water, client didn’t knew that whether it is acid or some powder. After drinking water client had a quarrel with that man client had a teapot in his hand he smashed it on his head and he left the place crying. Client said that he used to think that why that man fights with his friends who sit there but same thing happened to him after drinking that water, this incident occured early in the morning. After this incident client started to remain tensed, everybody who used to sit there started to remain aggressive, after 2 3 days client started feeling irritation in his chest. According to client earlier the stomach was expanded but when the water came in contact with blood then stomach shrank and the numbness spread in the entire body after 2 3 days stomach got upset and chest irritation started just like when someone drinks wine when it will come in contact with blood then it will cause numbness samething is with acid (tezaab). I feel nothing else except for irritation in chest.

Client mentioned that like when he just entered the room 3 some people left the room immediately on his arrival, he said same thing used to happen with his father and now it happens with him. He said that his uncle started hating him because of this illness and says that he is possessed, mentally retarded and if the client is going somewhere and comes in his uncle’s way then his uncle doesn’t cross him because he

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believes that client is possessed. Client said that now he doesn’t have any work so he feels more tensed, and he said that he has no idea that wether he will get better after going to work or not. He states that when he goes to work day and night appears to be same.

Client said that when he feels restless he takes a medicine and lye down to sleep. Client take both medicines prescribed by Doctor as well as the medicines prescribed by Doctor in Kotli. Client stated that he lies down and take a sleep or either remain quiet so that his mind starts working again. When client feels tiredhe wander here and there to find place for sleep. Client said that Declamation comes in his mind that people who are sitting are talking such things and then client start taking tension. Declamation are related to good people like client’s master or teacher. Client feels irritation in chest.

According to client if a person is good then client sits and conversate with him but if the person doesn’t seem good then he doesn’t like to sit with him, client mentions that it’s better to be alone instead of sitting with such a person. Someimes client feels excessively hungry but still he doesn’t eat much because he feels irritation in chest, client states that it doesn’t matter even if he doesn’t eat.

Client smashes things in house when he feel aggressive, client feels like leaving the house when house members doesn’t listen to him or agree with him.

3- Medical HistoryClient fell sick in childood during the age of 3 according to him, then by

the age of 5 he recovered, after that he never had a fever or fell sick, then he studied upto 7th class and went to Karachi at the age of 14.

Client was never admitted in a hospital. In Kotli he used to visit Doctor in Hospital who used to prescribe him medicines.The Doctor prescribed Kempro but it didn’t give any relief,Kempro is used for gastrointestinal and other issues, but since the patient didn’t get relief it means that disease or problem is just inside client’s head because if it would have

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been real then it would have got better after taking Kempro.When he came to Hospital his condition was same, no ECT done on the client.

Earlier he visited a Hospital and EEG was done but results were normal, but the Doctor prescribed client some medicines and took 5000 fee but after taking medicines tension level was elvated. Client takes medicines regularly, but he mentioned that we can conclude that it’s because of that power or acid that he drank.Client has not suffered from any serious illness.Client has been prescribed Prothadien as a relaxant, according to client after taking medicine he finds place to sleep because he feels sleepy and restless.

Informal AssessmentClient’s condition was a bit dirty and he had un-pleasant odor, which

shows that may be client wasn’t careful about his personal hygiene.He showed great voluntary movements such as shaking his leg smacking the i.d card that depicts that may be he was feeling anxious. Client answered every question in a form of a story or incident that shows that maybe circumstantiality factor is involved.

Client’s wrist was swollen a bit it’s may be because he injects drugs though he said he doesn’t take drugs except niswaar. He complained that when he enters people leave that place on his arrival just like he entered in hospital’s room number 3, people sitting left the room he feels so because may be client is socially isolated.

Formal AssessmentIn formal assessment, properly developed test and techniques are used

which are lawfully designed to assess personality traits. We usually referto these types of tests are standardized measures (Edu, 2006). Formal assessment determines the level of achievement or various other characteristics under analysis. In this case, following are used in assessing the client’s formally.

1. Mental Status Examination (MSE)2. Rotter’s Incomplete Sentence Blank (RISB)3. House Tree Person Test (HTP)

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4. Bender Gestalt Test (BGT)1. Mental Status Examination

Clinicians use the term mental status (or present status ) to refer to what the client thinks about and how the client thinks, talks, and acts. Later, when we discuss particular psychological disorders, we will frequently refer to symptoms reflecting disturbances in mental status. A clinician uses the mental status examination to assess a client’s behavior and functioning, with particular attention to the symptoms associated with psychological disturbance (Mental Status Examination as cited in Trzepacz& Baker, 1993).

The term examination implies that this is a formal instrument, but in reality it is an informal evaluation in which the clinician assesses a client. There are, however, a few specialized mental status examinations that focus on the diagnosis of specific disorders. The Mini-Mental State Examination is one example of a structuredmental status instrument shown to have success in the psychological assessment of individuals with Alzheimer’s disease and other brain syndromes that are diffi cult to identify through other assessment methods (Mental Status Examination as cited inFolstein&Folstein, 2000).Appearacne, attitudes and activity

AppearancesThe client was wearing shalwarkameez in somehow disheveled way.Level of consciousnessThe client was fully aware of surroundings.Apparent age Client looked like a man in his early 30’s.Position/ posture record Client was sitting on chair but was a bit restless as he changed his posture many times during session.Attire/Grooming The client seemed to be dirty Abnormal physical traitsClient had an unpleasant odor. Eye contact He maintaineda good eye contact more than half of the time.

Attitudes

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Degree and type of cooperativeness Client seemed to be cooperative throughout the sessions in a way that he answered every question abruptly. ResistanceHe was still hiding certain issues of his life.

ActivityVoluntary movements He showed great voluntary movments, he knocked his fist rapidly on the desk whenever he gave a response and kept on shaking his right leg and a piece of paper was stucked in his i.d card through out the session he smacked the card on the desk after 10 to 12 min to get it out. And after every 6to 7 minutes he used to drag the metal chair forward whenever he was explaining an event.Involuntary movementsNo involuntary movements observed in the client.Automatic movements No automatic movements observed in the client.

Mood and AffectMoodClient remained in a darkly elevated mood.Affect

Heightened emotions when explaining incidents.Reacted in sudden irritability if someone entered or left the room.Client showed restricted affect.Client’s affects were incongruent to the situations.Client had unreactive affects.

Speech and languageFluency normal fluencyComprehension a bit normal comprehensionRepetition Client repeatedly said “samjhgaye”Naming Client was easily telling the names of thingsWritingClient was able enough to writeReadingClient was able to read correctly.Prosody Client’s tone throughout the session was loud and flow of speech was high.

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Quality of SpeechHigh pitch, disorganized and incoherent, extensive explanations for each question asked.

Thought Process, Thought Content, and PerceptionThought processIdeas were not logically flowing from each other. Decreased connectedness as seen in terms of circumstantiality and loosening of association.

DelusionsDelusion of persecution.Overvalued ideas noneObsessions noneRuminationClient often thought about the incident in his life.Suicidal Ideation noneOther violent ideas nonePhobiasnone

Perceptual AbnormalitynoneHallucinationsMood-congruent hallucinations

Other Perceptual Abnormalities noneCognitionsOrientation Client was fully oriented of time and place.

Attention and concentration Client was fully attentive and concentrated on every question.

RegistrationHis recall ability was fine.Short Term Memory His Short term memory was fine.Long Term Memory Hislong term memory was fine.Visuoconstuctional ability Client was able to copy the geometrical shapes but with errors and erasing.Executive FunctionsHis executive ability was to some extent normal.

Insight and JudgmentIt was poor and he didn’t knew that he has mental illness. He used defense mechanism of denial.

2. Rotter’s Incomplete Sentence Blank Test (RISB)The Rotter Incomplete Sentence Blank popularly known as RISB was

developed by Rotter and Rafferty (1973). Forty stems are in it. These completions are then scored by comparing them against typical items in empirically derived manuals for men and women and by assigning to each

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response a scale value from 0 to 6. The sentence completion method of studying personality is a semi structured projective technique in which the subject is asked to finish a sentence for which the first word or words are supplied. It is assumed that the subject reflects his own wishes, desires, fears and attitudes in the sentences he makes. Currently RISB was administered on client and he scored 164, which is above the cut off score and shows client maladjusted behavior in society (Rotter’s Incomplete Sentence Blank as cited in Murray, 1939).

Client’s relation with his family seemed to be good. Client seems to be more close to his mother. Client wanted to go back home which depicts that he felt good at home and wanted to spend time with his family members. Client’s attitude towards marriage was also positive, he missed his wife a lot. Acoording to client the best moment of his life was when he got married.

ایک ماں جنت ہے۔

سب سے خوشگوار وقت شادی۔

گھر پر جانا ہے۔

Client had social maladjustment. He had occupational and social issues as well it seems that he has been rejected by his relatives or deceived by support group. Client felt that major cause of his failure was the people who deceived him, there seems to be an utter need for a better social circle in client’s life.Client hated bad community and socially inappropriate discussions.Client said that people are both bad and good. Client was unwaged and he was worried that he was not capable of doing a job.Client seemed to have strong religious beliefs.

مجھے ضرورت ہے اچھے لوگوں کی۔

مجھے ناکامی ہوئلوگوں کی وجہ سے جیسے تیزاب پوڈر پانی میں ڈال کر کسی کو چوری سے پلانا۔

میں نہیں کرسکتاکوئ نوکری نہیں۔

مجھے نفرت ہے برے لوگوں سے یا بری بات سے بلکہ نفرت نہیں دکھ محسوس کرتا ہوں۔

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Client wanted to know about his illness which depicts that he has no insight about his illness. He believed that it was some gastrointestinal issue. Client mentioned that he cried a lot which may be because he missed someone who was close to him, he also felt depressed, hopeless and restless may be because he was unable to do any job properly. Client stated that when he was feeling his best he felt happy otherwise he stayed quiet most of the time. Client regeret that he was unable to find peace this may be because of the incident that happened and also because he lost his wife.

مجھے محسوس ہوتا ہے کہ سینے اور معدے کی خرابی۔

کبھی کبار گھبراہٹ بے چینی بے سکونی اور مایوسی محسوس کرتا ہوں۔۔

۔میں روتا بھی ہوں

مجھے پچھتاوا ہے کہ چین کا۔

3. The House-Tree-Person test (HTP)The House-Tree-Person test (HTP) is a projective test designed to

measure aspects of a person’s personality. HTP was designed by John Buck and was originally based on the good enough scale of intellectual functioning. The HTP was developed in 1948, and updated in 1969. Buck included both qualitative and quantitative measurements of intellectual ability in the HTP. A 350-page manual was written by Buck to instruct the test-giver on proper grading of the HTP, which is more subjective than quantitative. The test can also be used to assess brain damage and general mental functioning. The test is a diagnostic tool for clinical psychologists, educators, and employers. The subject receives a short, unclear instruction (the stimulus) to draw a house, a tree, and the figure of a person. Once the subject is done, he is asked to describe the pictures that he has done. The assumption is that when the subject is drawing he is projecting his inner world onto the page. The administrator of the test uses tools and skills that have been established for the purpose of investigating the subject's inner world through the drawings(House Tree Person as cited inGroth-Marnat, Gary, 1997).

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Generally this test is administered as part of a series of personality and intelligence tests, like the Rorschach, TAT (or CAT for children), Bender, and Wechsler tests. The examiner integrates the results of these tests, creating a basis for evaluating the subject's personality from a cognitive, emotional, intra- and interpersonal perspective (House Tree Person as cited inGroth-Marnat, Gary, 1997).Client drew the tree first which depicts that client is concerned with growth, development or issues of life death.TreeClient drew an abstract tree i.e. realistic, not distinct their problems and tend to avoid direct confrontation.Client drew a small trunk that indicates limited ego strength.Client drew thin trunk that suggests maladjustment.Client drew branches with limbs moving downward that depicts low level of energy.Dead branches depicts client’s difficulty in getting attention from his environment, hopelessness.Roots drawn that show mild impairment in orientation.PersonSame sex figure depicts histrionic and manic tendency, restlessness.Figure depicted in motion depicts fantasy activity.Figure is older age with depicts identification with parents of same sex.Alterations were made that show anxiety, conflict area.Client drew an odd shaped head that depicts psychotic aspect.Client omitted eyes that determine that there is a conflict.Client omitted mouth that shows guilt.Neck omission show lack of impulses control and immaturity.Arms drawn from body show externalized aggression.Arms are thin and weak which depicts lack of achievement.Fingers are drawn without hand that show assaultiveness and intentional aggression.Pointed fingers show aggression.Figure drawn in middle show aggression.

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Abdominal area omitted that indicates severe detoriation, psychotic tendencies, organicity, and hypochondriasis.Absence of feet shows child abuse.Lack of detailing shows withdrawl, reduction of energy.Shading on face show self-consciousness regarding facial complexion.HouseMissing chimney depicts passive, lack of psychological warmth in client’s home life.Too little size show rejection of home life.Strong lines depict problems with anxiety and need protection.Absence of window, large geometric figures depict child abuse.Absence of pathway depict client may be closed, distant and removed.

4. Bender Gestalt Test (BGT)The Bender Visual Motor Gestalt test (or Bender-Gestalt test) is a

psychological assessment used to evaluate visual-motor functioning, visual-perceptual skills, neurological impairment, and emotional disturbances in children and adults ages three and older.The original Bender Visual Motor Gestalt test was developed in 1938 by psychiatrist Lauretta Bender (Bender Gestalt Test as cited inHutt, 1985).

The standard Bender Visual Motor Gestalt test consists of nine figures, each on its own 3 × 5 card. An examiner presents each figure to the test subject one at a time and asks the subject to copy it onto a single piece of blank paper. The only instruction given to the subject is that he or she should make the best reproduction of the figure possible. The test is not timed, although standard administration time is typically 10-20 minutes. After testing is complete, the results are scored based on accuracy and organization. Interpretation depends on the form of the test in use. Common features considered in evaluating the drawings are rotation, distortion, symmetry, and perseveration(Bender Gestalt Test as cited in Hutt, 1985).

Client has scored 5 on BGT. Client has committed error of Angulations, Rotation, Impotence, Overlapping difficulty and Motor

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Incoordination. His score depicts that he has some evidence of brain impairment.

His error of rotation shows his degree of dysfunction and psychosis. His error of overlap indicates that he has potential for aggressive acting out. His error of angulations indicates that he has problems with controlling affects i.e. restricted emotional expressions. Client’s error of impotence and motor incoordination are also indicate inability to concentrate, feelings of anxiety and poor coordinationCase Formulation

The client was a man 32 years old. Client’s relation with his family were good. Client didn’t continue his studies he left the school after 7th

class and went to Karachi at the age of 14. Client had good school friends he was still in contact with his friends. Client got married in 2001, it lasted for one year after which his wife died. Client is unwaged for the past 10 years, he used to work earlier no matter how much tensed he was. Client was extremely tensed about his work and irritation in chest starts, and because of this irritation he was mentally tensed. Client took medicines when he felt restless and lie down to sleep.

Place where client used to work a man made the client drink water, client didn’t knew that whether it is acid or some powder. After drinking water client had a quarrel with that man client had a teapot in his hand he smashed it on his head and he left the place crying. After this incident client started to remain tensed, everybody who used to sit there started to remain aggressive, after 2 3 days client started feeling irritation in his chest. Client take both medicines prescribed by Doctor as well as the medicines prescribed by Doctor in Kotli. When client feels tired he wander here and there to find place for sleep. Client said that Declamation comes in his mind that people who are sitting are talking such things and then client start taking tension. Declamation are related to good people like client’s master or teacher. Client feels irritation in chest.Freud mentions three different kind of anxieties: Realistic anxiety, moral anxiety and neurotic anxiety. Moral anxiety

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This is what one feel when the threat comes not from the outer, physical world, but from the internalized social world of the superego. It is, in fact, just another word for feelings like shame and guilt and the fear of punishment(Freud as cited in Neil, 2004).In case of client he felt guilty and ashamed. He mentioned that he doesn’t know why people leave the place where he arrives. He felt as if he had committed a sin, he mentioned that his relatives changed their way if they saw him coming in front of them.The defense mechanisms

The ego deals with the demands of reality, the id, and the superego as best as it can. But when the anxiety becomes overwhelming, the ego must defend itself. It does so by unconsciously blocking the impulses or distorting them into a more acceptable, less threatening form. The techniques are called the ego defense mechanisms, and Freud, his daughter Anna, and other disciples have discovered quite a few(Freud as cited in Neil, 2004).

Denial involves blocking external events from awareness. If some situation is just too much to handle, the person just refuses to experience it. It operates by itself or, more commonly, in combination with other, more subtle mechanisms that support it (Freud as cited in Neil, 2004).Client was in a denial phase. Client had been a victim of child abuse but he was not willing to admit the incident that happened, when he went to karchi at the age of 14. Place where client worked a person made him drink water which contained a drug. After that incident client lost interest in his work and withdrew himself from society and friends. He complained about stomach problems these all symptoms are related to those children who have been sexually abused and such children in their late adolescent get involved in frequent use of drugs and alcohol and client was in a habit of taking niswar.

Erikson's stages of psychosocial development, as articulated by Erik Erikson, explain eight stages through which a healthily developing human should pass from infancy to late adulthood. In each stage, the person confronts, and hopefully masters, new challenges. Each stage builds upon

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the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future(Erickson as cited in Comer, 1998).Intimacy v Isolation

Reciprocal love for and with another person. Intimacy means the process of achieving relationships with family and marital or mating partner(s). Erikson explained this stage also in terms of sexual mutuality the giving and receiving of physical and emotional connection, support, love, comfort, trust, and all the other elements that we would typically associate with healthy adult relationships conducive to mating and child-rearing. There is a strong reciprocal feature in the intimacy experienced during this stage - giving and receiving - especially between sexual or marital partners (Erickson as cited in Comer, 1998).

Isolation conversely means being and feeling excluded from the usual life experiences of dating and mating and mutually loving relationships. This logically is characterised by feelings of loneliness, alienation, social withdrawal or non-participation(Erickson as cited in Comer, 1998).

Client resembled closely to what Erickson called as Isolation. Client’s wife died which was a very depressing moment in his life, client missed his wife a lot, and in other words client was now deprived of experiences of love and mutual relationships. Client also preffered isolation when his family argued with him he felt like leaving the home. Client had no social circle because people left him because of his illness, and client’s attitude towards them was also a bit hostile he believed that every individual leaves the place because of his arrival. Client had extreme lack of energy he was unable to do any work.

Although all neurosis is, for Adler, a matter of insufficient social interest, he did note that three types could be distinguished based on the different levels of energy they involved(Alfred Adler as cited in Ansbacher, 1956).

Psychological types

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The first is the ruling type. They are, from childhood on, characterized by a tendency to be rather aggressive and dominant over others. Their energy the strength of their striving after personal power is so great that they tend to push over anything or anybody who gets in their way (Alfred Adler as cited in Ansbacher, 1956).

The second is the leaning type. They are sensitive people who have developed a shell around themselves which protects them, but they must rely on others to carry them through life's difficulties. They have low energy levels and so become dependent (Alfred Adler as cited in Ansbacher, 1956).

The third type is the avoiding type. These have the lowest levels of energy and only survive by essentially avoiding life especially other people. When pushed to the limits, they tend to become psychotic, retreating finally into their own personal worlds(Alfred Adler as cited in Ansbacher, 1956).

Client fit into third of Adler’s psychological types. Client had extremely low level of energy and he always felt lethargic and seeked places to sleep. Client after the incident Client’s relatives ignored him and didn’t like to conersate or sit with him. Client also had mood congruent hallucinations and declamations came in his mind. Client felt like leaving home when his family argued with him he felt extremely aggressive. Client also had social maladjustment and occupational dys-function he was unwaged for past ten years.Tentative DiagnosisAxis I 295.70 Schizoaffective Bipolar type Use of drugs (niswaar)Axis II None, frequent use of denialAxis III NoneAxis IV Problems with primary support group Problems related to the social environment Occupational problems Axis VGAF= 33 (current)Therapeutic Suggestions

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Following therapies can prove to be effective in client’s case:Mood stabilizers 

These can smooth out the highs and lows of bipolar disorder (manic depression) which affect client with the bipolar-type of schizoaffective disorder (Drug Therapy as cited in Comer, 1998).Group Therapy

Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with schizoaffective outpatients. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; on social and work roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on some practical recreational or work activity (Group Therapy as cited in Neale, 2001).This supportive group therapy can be especially helpful in decreasing client’s social isolation and increasing reality testing.Behavior Therapy

Behavior therapy in hospital often involves rewarding desired behaviors with specific privileges, such as ground privileges or weekend passes (Behavior Therapy as cited in Neale, 2001). When the schizoaffective client is no longer floridly psychotic or distractible, behavior therapy usually can successfully teach much needed social and occupational skills.Supportive Psychotherapy

Traditional insight-oriented psychotherapy is not recommended in treating schizoaffective patients, whose egos are too fragile. Supportive therapy, which may include advice, reassurance, education, modeling, limit setting, and reality testing, is generally the therapy of choice (Psychotherapy as cited in Neale, 2001). It can be helpful in order to inform the client about his psychiatric illness.Family Therapy

Family therapy can significantly decrease relapse rates for the schizoaffective family member. Supportive family therapy can reduce this relapse rate to below 10 percent. This therapy encourages the family to

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convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to select and implement the consensual best solution (Family Therapy as cited in Neale, 2001). Self-Help groups in which family members of schizoaffective client discuss and share issues, have been particularly helpful in this regard.

PrognosisPeople with schizoaffective disorder have a better prognosis than

people with schizophrenia, but not as well as people with mood disorders only. Long-term treatment is necessary, and the prognosis varies from person to person. In this case, the prognosis of the client seemed less favorable as he had darkly elevated mood but he still wanted to be healthy again and spend a normal life as others do. It requires some effort to be healthy again and client didn’t seem to do much effort and just wants to rest.

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References American Psychiatric Association. (1994). Diagnostic and Statistical

Manual of Mental Disorders. (4th ed.).Washington, DC: American Psychiatric Press, Inc.

Murray, H. A., et al. (1939). Explorations in personality. New York, NY: Oxford University Press.

Groth-Marnat, Gary. (1997). Handbook of Psychological Assessment. (3rd ed.). New York,

NY: John Wiley and Sons.

Hutt, M. L. (1985). The Hutt Adaptation of the Bender Gestalt Test. New York, NY:

Riverside Publishing.

Adler, A. H. L. & R. R. Ansbacher. (1956). The Individual Psychology of Alfred Adler. New York, NY: Harper Torch books.

Neil R. Carlson. (2004). Foundation of Physiological Psychology. (6thed.). University of Massachusetts, Amherst.

Comer, R.J. (1998). Abnormal Psychology. (2nded.). New York, NY: W.H Freeman & Company.

Neale, G.C &Davison, J.M. (2001). Abnormal Psychology. (8thed.). United States of America: John Wiley & Sons.

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