Identifying Data
| Name | F.H |
| Age | 52 |
| Gender | Female |
| Education | Middle |
| Siblings | 4 |
| Birth order | 2nd |
Source and Reason for Referral
The client was referred by the psychiatrist to the psychologist from indoor inpatient department for psychological assessment and management.
Present Complaints
| Presenting Complaints |
| Self talk and self-laugh |
| Visual hallucinations |
| Disorganized Speech |
| Self-talk and self-laugh |
Initial Observation
F.H. was a female of 52 years old. Her hygiene was not good as she was not wearing neat and clean clothes. Her hairs were not combed, and her teeth were not brushed. Moreover, her posture was appropriate as she was sitting straight in the chair. Eye contact was avoidant. Speech was disorganized, and tone was low. She was avoiding answering the questions. Rapport-building process at the start was difficult, but it was established by sharing lipstick with the client as she pointed out that the psychologist’s lipstick color is beautiful. So, rapport was built by asking the client’s favorite color.
History of Present Problem
The client’s mental health struggles began 38 years ago, when she was just 14. After her mother passed away, everything changed. She became isolated and eventually dropped out of school. At home, things didn’t get better. Her father and stepmother constantly criticized her for failing in her studies.
As time passed, her behavior shifted. She grew aggressive, withdrew from daily activities, and her sleep became disturbed. Recognizing the need for help, her elder brother took her to a psychiatrist in Faisalabad. She started medication and continued treatment for a year. Gradually, she improved and began participating in household chores again.
However, that progress didn’t last long.
Six months later, her brother left for education abroad. Once again, she felt abandoned. She had no emotional connection with her stepmother or step-siblings. The taunting and criticism from her stepmother continued, and her father pressured her to return to school—something she was unwilling to do.
As a result, she withdrew even further. She isolated herself in her room, stopped eating properly, and struggled with sleep. Soon, her condition worsened. Psychotic symptoms appeared. She began hearing voices—auditory hallucinations that disrupted her thoughts and behavior.
Her father sought psychiatric treatment again, and she remained under care for two more years. But despite the treatment, her condition deteriorated. Visual hallucinations and disorganized speech developed alongside the auditory hallucinations, making her symptoms more complex and severe.
Background History
Personal history
She was born through a normal delivery. She could not achieve the milestone properly. According to the client, she was the second-born child among her siblings. She had learned all his religious obligations during her childhood. Moreover, she was closely attached to her mother. The client was not socialized; she did not like to make friends. The client had only one friend with whom the client liked to play. After her mother’s death, she became isolated and used to spend time alone in a room.
Family history
The client belonged to a middle-class family. She has a nuclear family system. The number of family members is six. The client’s father was not alive. He was educated till intermediate. Her relationship with her father was conflicting because he had always forced her to achieve good grades, but client was not interested in studies, as her other siblings were achieving good marks. The client’s mother was not alive. Her mother died when the client was 14 years old. Her relationships with her biological mother were satisfactory. The client’s parents had satisfactory relationships.
When the client was 15 years old, her father got a second marriage. The client’s relationships with her stepmother were conflicting because the client did not accept her stepmother. After all, he was attached to her biological mother. The client has one biological elder brother. Her relationships with her elder brother were congenial. Client has two siblings, one brother and one sister, from step stepmother. Her relationships with them were conflicting as she was not considering them her siblings. The relationships between all the siblings were good.
The home environment was good, but her father and her stepmother most of the time criticized the client because the client did not take an interest in studies, and she did not accept her stepmother.
Educational history
The client started his informal education at the age of 5 years old with his mother, and her formal education when she was 6 years old. The client was not interested in studies as she reported that she always forgot the lessons she learned. So, she studied till seventh grade. According to the client, she had no happy memories in school. She gave up studies in 8th grade due to failure in mid-term exams. Moreover, she was much criticized and pressured by her family, especially her father.
Family Psychiatry/medical illness
Client’s grandfather had psychotic symptoms of Schizophrenia.
Provisional Formulation
Based on initial observation and history of the client, it can be assumed that the client is suffering from psychotic symptoms of Schizophrenia. Client’s predisposing factors are genetic, as her grandfather had psychotic symptoms. Another predisposing factor is her critical behavior of her father and neglecting and comparing her with her siblings. Client’s precipitating factors are her mother’s death second marriage of her father. Maintaining factors are the conflicting relationships with her family and loneliness. A protective factor is her therapist, who is trying to manage her problems.
Assessment
An informal assessment was done.
- Behavioral observation
- Clinical interview
- MSC
Behavioral observation
Behavioral observation was conducted to assess the client’s attitude, activities, and manners to reflect her personality, level of cooperation, and orientation. The primary goal was to monitor changes in her mood from the initial sessions through to the final sessions.
Initially, the client appeared disinterested in group sessions. Upon entering the room, she walked with a normal gait. However, her hygiene was poor—she wore untidy clothes and her hair was uncombed. She avoided eye contact, and her speech was disorganized with a consistently low tone. Her mood appeared dull and unresponsive. Additionally, she walked slowly, and her movement was unsteady. She resisted social interaction, avoided communication, and showed no compliance with the psychologist. Notably, she engaged in self-talking and self-laughing behaviors.
Her orientation to time, place, and person was impaired. During the first three sessions, she was uncooperative. However, over time, there was a noticeable change. She gradually began to show cooperation and became more open to communicating. Although her mood continued to fluctuate throughout the sessions, she slowly developed insight into her condition. Eventually, she started engaging in discussions about her issues and began participating in group activities.
Clinical interview
A clinical interview is more than just a conversation—it’s a purposeful exchange between a client and a trainee or clinician. It helps build a communication bridge that supports trust and understanding. Typically, the goal is to gather essential information and work toward a diagnosis.
These interviews can be structured, semi-structured, or unstructured, depending on the needs of the case. They’re often combined with other tools to fully understand the client’s condition.
In this case, conducting a clinical interview with both the client and her informants was crucial. It helped identify the root causes of her psychological issues and shed light on the factors that triggered her condition. Through this process, we gathered a detailed history of her current concerns.
Moreover, the interview also helped uncover protective factors—those that may have prevented her symptoms from worsening. This step was key in shaping her treatment and support plan.
MSE
The Mental Status Examination (MSE) is a structured way to assess a client’s behavior, appearance, and cognitive functioning. It gives a snapshot of how a person is thinking, feeling, and acting at a particular moment. This tool is essential in forming an accurate diagnosis when paired with the client’s personal and medical history.
During the MSE, we observed the client’s attitude, activity level, and general behavior to better understand her personality, orientation, and level of cooperation.
At first glance, her hygiene was poor. She wore unclean clothes, her hair was uncombed, and her teeth were not brushed. However, her posture was upright, and she sat straight in the chair. Despite this, her eye contact was avoidant, and she rarely responded to questions. Her speech was disorganized and her tone remained consistently low.
She often avoided interaction, resisted talking to others, and showed no engagement with the psychologist. She also displayed unusual behaviors such as self-talking and laughing without a clear reason. Her walking pace was slow and unsteady, suggesting issues with coordination.
Cognitively, her orientation to time, person, and place was impaired. She struggled to stay present and aware during the initial sessions. Her behavior was uncooperative for the first three meetings. Over time, though, she began to engage more.
Even as her cooperation improved, her mood remained inconsistent throughout the sessions. In the beginning, she lacked insight into her condition, but gradually, she began to recognize and talk about her problems.
