JARAH ABIMAEL O.

DELA CRUZ
MA in COUNSELING PSYCHOLOGY

Case Presentation

I. Demographics

Name: “Ben”
Date of Birth: January 6, 1999
Age: 23 yrs. old
Gender: Male
Civil Status: Single
Birth Order: First Child

II. Presenting Problem

The client was introduced to me by his cousin, Ben’s parents said that they are worried about
their son’s condition and they don’t know how will they going to help him because of their age and
financial capacity. His parents decided to let Ben stay at home for his safety. Accordingly, the client
say that he is dead and he is just a living ghost. He didn’t consume any food since he believed that
he’s immortal and the client also don’t sleep because he said that he don’t need anything to live in this
world. He also sometimes wander to the point that he lost his way back to their house, to prevent this
to happen again his parents decided to let Ben stay at home to avoid something bad to happen. His
parents said that Ben started acting this way when his twin brother succumbed to death due to
vehicular accident 2 years ago.

III. Mental Status Examination

The client has a skinny body build. He has brown complexion with poor grooming. During the
interview the client seems that can’t maintain his attention his eyes wander, he scratch his skin a lot of
times that resulted to inattention during the interview. His mood is fine during the interview there is no
sudden explosive behavior. However, the client is shy to answer my question. The client’s speech is
sometimes not congruent to the question that I’m asking he has an out of this world thoughts. He told
us that he is a ghost and that he also a spirit like his brother. According to him when his brother died it
feels like that he died also, he refuse to eat and sleep because the spirit of his brother don’t eat and
sleep as well and that he said they are immortals because they are both dead. Hallucination is observed
during the interview since he said that his brother’s spirit is sitting beside him watching. Sometimes he
interrupt me and the he started to face his right side and talk like he was talking to his brother. This
behavior of him repeated a lot of times during the entire span of interview process.
IV. Background

On the beginning years of Ben’s condition his parents brought him in small clinic here in our
province to seek medical attention. However, there is no mental health facility and clinical
professionals practicing here in our province specializing Psychiatry or clinical psychology. The
Doctor who checked Ben’s situation only gave him Alprazolam a psychotic drug that manage his
psychotic symptoms however due to financial capacity of his parents they can no longer continue to
support his medication that lead to his condition to be more worst. His parents told me that in the
absence of medication the client became more out of control his thoughts became more disorganized
and he stopped performing everyday skills. The client also refrained from talking to other people and
became more silent.

V. Clinical Case Formulation/DSM-5-TR Diagnosis

Schizophrenia

For a significant portion of the time since the onset of the disturbance, level of functioning in 1
or more areas (eg, work, interpersonal relations, or self-care) is markedly below the level achieved
prior to the onset (or when the onset is in childhood or adolescence, there is a failure to achieve
expected level of interpersonal, academic, or occupational functioning). Continuous signs of
disturbance persist for at least 6 months. This 6-month period must include at least 1 month of
symptoms (or less if successfully treated) that meet Criterion A and may include periods of prodromal
or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be
manifested by only negative symptoms or by 2 or more symptoms listed in Criterion A present in an
attenuated form (eg, odd beliefs, unusual perceptual experiences). The client exhibit signs of delusion
an odd belief that he is dead and that he is a spirit. The client also shows signs of hallucination in
which he sees his brother and some instance he was to talking to him. The client also has disorganized
thinking and speech as observed during the interview. Moreover the client exhibited a negative
symptoms called avolition in which it is the inability to initiate or persist activities shows little interest
in performing most basic day to day functions, including those associated with personal hygiene. The
following symptoms are being observed in the last 2 years. It is also clarify that the client didn’t
undergo any influence of illegal drug use.
VI. Interventions and Plans

The goal of schizophrenia treatment is to ease the symptoms and to cut the chances of a
relapse, or return of symptoms. Treatment for schizophrenia may include:

Primary medications used to treat schizophrenia are called antipsychotics. These drugs don’t
cure schizophrenia but help relieve the most troubling symptoms, including delusions, hallucinations,
and thinking problems. Clozapine is the only FDA-approved medication for treating schizophrenia that
is resistant to other treatments. It’s also used to lessen suicidal behaviors in those with schizophrenia
who are at risk. Psychosocial therapy while medication may help relieve symptoms of schizophrenia,
various psychosocial treatments can help with the behavioral, psychological, social, and occupational
problems that go with the illness. Through therapy, patients also can learn to manage their symptoms,
identify early warning signs of relapse, and come up with a relapse prevention plan. Lastly,
Hospitalization many people with schizophrenia may be treated as outpatients. But hospitalization may
be the best option for people with severe symptoms, who might harm themselves or others, who can’t
take care of themselves at home.

VII. Reason for Presentation

I choose to present this case because it is my first time to encounter a person experiencing
schizophrenia here in our province. At first, I was thinking maybe he’s having a Cotard’s syndrome in
which it is characterized by the delusion that a person is dead or dying. To be honest it is very hard for
me to analyze his symptoms since in some point maybe he’s symptoms implies possible depression
because of the passing of his twin brother years ago. But with the help of DSM 5 TR and almost a
week of analyzing the case I come up with the diagnosis of Schizophrenia. The sad part here is that
there is no specialist that could help him with his condition because there is no clinical professional
practicing psychiatry and clinical psychology here in our province as well as mental health facility that
could help him. The only thing that I can do is to refer them in other place to cater the condition of
their son. However, his parent can’t afford to send him to other place because of their financial
capacity and his parents are getting old. It was challenging for me since I’m still not in the position to
help him since I’m still currently studying my Master’s degree in which I am not yet capable of
helping him since I am not yet knowledgeable enough. This case open my perspective in the fact that
Mental health services herein our province are lacking and it gave me a motivation to finish this course
and to be a mental health practitioner soon here in our province.