1. A case of schizophrenia with non compliance issues
CHAIR PERSON:
MR. ASHOK KORI
PSYCHIATRIC SOCIAL WORKER
DIMHANS, DHARWAD
PRESENTOR:
RANJANI H. G. VAKODA
1ST YEAR MPHIL SCHOLAR
DIMHANS, DHARWAD
2. DEMOGRAPHIC DETAILS
• Name: P
• Age: 40
• Gender: Female
• Religion: Hindu
• Education: 10th Std
• Marital Status: Married
• Occupation Status: Home Maker
• Languages Known: Kannada
• Type of Family: Nuclear Family
• Family Size: 05
• Socio – Economic Status: lower middle socio economic status as per modified Kuppuswamy Scale
4. REASON FOR REFERRAL
To do family assessment.
Insight facilitation to the patient
Psychoeducation about Drug Adherence
5. HISTORY OF PRESENT ILLNESS
A 40 year old woman hailed from nuclear family of the rural background of Haveri
district. Studied up to 7th std. Came with husband and daughter with the chief
complaints of self talk, hearing voices, suspiciousness towards family members as
well as neighbors, poor self care, wandering tendency, lack of sleep and appetite.
The patient was apparently normal 7 years ago. Then it was noticed by family
members that she would talking to self and when she was asked she would tell that
she can hear some unknown voice so that she is responding to that voice. She has
suspiciousness towards her husband that he had an extra marital affair and also she
suspect that her children are supporting to father. By this as she grown up under step
mother, she use to do same thing for her children what are all the difficulties faced
by herself in the childhood. Also she is not take any food cooked by their family
members; not even a glass of water given by family members. She suspect that they
might have mix the poison with food and water.
6. HOPI Continued..
Apart from these in recent days she developed wandering tendency. She would go
out from the home without informing anyone. Once she went and missing up to 15
days and she found at Shirdi near temple. Second time she went and found few days
after at Sirsi near the temple. Last and the recent one was she was missing and found
at Hubli Bus stand in a poor kempt situation. Family members brought directly to
hospital.
7. PAST HISTORY
• History of previous consultation with psychiatrist. Daughter told that patient was
refused to take the medications and hence it is always continuous - progressive
course of illness. And children don’t even remember that their mother’s normal
condition. They saw always as a symptomatic.
• No history of head injury or unconsciousness.
• No history of any major physical illness.
8. Major Findings of MSE
• GAB: Pt seen with her daughter, appropriately dressed, non co operative, ETEC
occasionally maintained, rapport not well established.
• PMA: normal
• Speech: T/T/V slight decreased, non spontaneous, RT: more
• Further MSE not done due non cooperative nature of patient.
10. FAMILY HISTORY
• Nuclear family
• Non-Consanguineous Marriage
• Patient’s mother had similar symptoms. But exact details were not found.
• Patient’s father got separated from patient’s mother during her birth. And after 3
moths of her birth father took the baby and left her mother. As her mother was
mentally ill. Pt. was bought up by her step mother with elder sister and step
brothers.
11. Family constellation
Sl. No NAME AGE GENDER EDUCATION OCCUPATION HEALTH
STATUS
1 P 40 Female 10th Std Home Maker Index patient
2 H 45 Male 10th Std Driver -
3 D 20 Female PUC Student -
4 S 15 Male 10th Std Student -
5 YD 13 Female 9th Std Student -
12. Brief Description about Family Members
• Family of origin
• Patients father had 2 wives. In that patient is second born child to first wife. After few months of
her birth, he took the child with him and married to another women. Her mother who is mentally ill
remain alone in her mother’s home. The index patient was brought up by her step mother.
• Family of Procreation
• Initially it was joint family but due to patient’s gossiping nature and stubborn attitude her husband
left from that family and started to live with wife and children independently.
• Index Patient: A 40 year old woman. Studied up to 10th Std. currently symptomatic, suffering from
schizophrenia from past 7 years. With poor drug compliance.
• Husband: A 45 year old man, Studied up to 10th Std. Driver by profession. He is the nominal and
functional head of the family. Look after his family in a good way. Concerns more about children.
Although he is aware about his wife’s illness sometimes, he avoids to speak with her because of
her aggressiveness and suspiciousness.
13. Brief Description about Family Members
• Elder daughter: A 20 year old girl. She is too good in managing the both studies and
household works. She is good in studies completed her PUC and preparing for NEET. She
looks after the younger siblings and mother very carefully. She knows about her mother’s
illness and also, she explained to other family members about schizophrenia.
• Son: A 15 year old boy. He is less interactive person in nature. Very close towards his
sisters. Good in studies and currently he is in 10th std. He thinks practically rather than
emotionally. Mother is very much affectionate towards him, as he is the only boy child in
the family.
• Younger Daughter: A 13 year old girl. She is good in studies. She is in 9th std. Very much
attached towards her brother and also close with elder sister. In absence of elder sister, she
use to cook and maintain the household works along with her studies.
14. Family Dynamics
• Boundaries: Clear/Open between father and children. Father allows children to
carryout their Function without any interference. Closed/Rigid between mother
and children. As mother is symptomatic she restricts her children and ask
questions over small things in each and every day to day activities.
• Subsystem: 3 children have their own Siblings subsystem, father and elder
daughter has their own subsystem, patient had subsystem with her spouse and also
with children but in recent days due to symptomatic it is absent however she
shower little affectionate towards son.
• Alignments: Initially alliance were there as each and every members of family had
healthy relationship but now it damaged due to pt’s illness. How ever rest of the
family members are allied with each other except the pt.
15. Family Dynamics Cont...
• Family developmental Stages: According to Duvall’s family life cycle 1977, the
family is in 5th Stage. Families with teenagers – oldest child 13 to 20 years.
• Leadership Patterns:
Power Structure – Patient’s husband is functional and nominal head. And it is
accepted by all the family members.
Decision Making Process – Democratic as the Father discuss with children
each and everything before decide something, but the final decision was by father
only. Previously he used to discuss with his wife (the pt) but now due to her illness
it is not possible.
16. Family Dynamics Cont...
• Role Structure and Functioning:
Elder daughter have multiple roles. There’s no complementary roles found in the
family.
As patient is symptomatic she is not performing her role as expected.
Except patient, rest of the family members accepted their role and performing well
according to their role.
• Communication:
Direct communication between father and children, also within siblings.
Switch board communication from pt to her husband.
Both welfare and emergency feelings are present within the family. Welfare
feelings such as love, affection, happiness and emergency feelings such as fear,
sadness and disappointment
17. Family Dynamics Cont...
• Reinforcement: positive reinforcement present within the family. They use to
appraise her even if she done small work in home and also support her to do it
again.
• Cohesiveness: healthy connectedness among family members except the patient.
• Family Rituals: initially they had a practice of all the family members to sit
together for meals. But now pt. is symptomatic and this practice has break down.
Initially they are going to trip once in every year. But now this practice also not
carried out by family members.
• Adaptive Patterns:
Conflict Resolution: in problem solving, some of the things they avoid which are
financially burden such as purchasing dress and cloths, outside foods, going out
with friends etc.
18. Family Dynamics Cont...
Coping Strategies: cracking jokes, all together watching any comedy movie once
in a month, before going to bed each and everyday all three children will sit
together and discuss what happened today also what should do tomorrow.
• Social Support System: adequate social system in all three levels primary,
secondary and tertiary.
19. Family Interaction Pattern
• Patient and husband – switchboard communication
• Patient with children – direct communication
• Patient with sibling and step brothers – no communication
• Patient with step mother – no communication
• Family members with patient’s step brothers – direct communication
• Family members with patient’s step mother – switch board communication
20. Personal History
• Birth and developmental history: Patient is second born for a non consanguineous
marriage. Other details of birth and developmental history is not reliable as
informants don’t know about that.
• School: She was studied up to 10th Std. During her school days she was average in
her studies and her nature is always gossiping, no long term – friendships,
Stubborn and always want to take revenge one who insults her. In home during her
childhood she use to dominate other siblings, always had quarrel with her step
mother.
• Occupation history: after completing studies few years she remained at home and
she is not went to any job. Then she got married and remained as a home maker.
• Menstrual History: Regular menstrual cycle
21. PERSONAL HISTORY
• Sexual history was not revealed by the pt
• Marital history: She got married when she was 18. Initially they were in joint family. And
she was happy with her in – laws. But due to her gossiping nature everyone started to
avoid her. And at the same time her husband’s sister – in – law got a job as pre nursery
teacher, her husband brought a letter related to that job and give it to her sister – in – law.
This incident started the early symptoms on her. By this she developed delusion of
infidelity. By this her husband came out from that joint family along with wife and
children. After this her symptoms gradually increased.
• Substance use : nil
• Sibling Rivalry : present from childhood, till today. Only with her sister and one of her
step brothers.
Z91.1 – Personal history of non compliance with medical treatment and regimen.
(ICD-10)
22. Premorbid Personality
• Social Relations: well maintained with family members but not so well maintained
with neighbors and relatives.
• Intellectual activities, hobbies and interests: listening to devotional songs and
Rangoli art
• Mood: usually the pt. was irritable for others. But no mood fluctuation reported
• Fantasy life: pt denies any fantasy life
• Habits: nil
• Personality type: well adjusted with family members.
23. Social Analysis and Diagnosis
A 40year old married women, educated up to SSLC, from lower middle socio
economic status of rural background of Haveri district, staying with husband and
children brought to DIMHANS with 7 years history of Schizophrenia, with family
history of psychiatric illness in pt’s mother.
Pt’s husband is the head and main bread winner of the family, all the 3 children are
still small and focusing towards their education and career. Pt has poor drug
adherence. Elder daughter took a break from education to look after her mother and
now again she is stepping towards continuing of her education.
Family has financial burden, as pt’s husband has no regular income. Although
adequate social support was there friends and family relatives were fed up by pt’s
behaviour. And they are not visiting their home. But they are helping by maintaining
distance from this family.
Z61 – problems related to negative life events in childhood (ICD-10)
24. DIAGRAMMATIC REPRESENTATION OF SOCIALANALYSIS AND DIGNOSIS
Factors involved in patient’s current condition
Individual Factors Family Factors Community Factors
Risk Factors
Poor Drug Compliance,
Low Self Confidence
Maintaining Factors
Long term mental
illness, Poor Coping
Skills
Proactive Factors
Potential to work
Risk Factors
Pt’s husband don’t have
regular income
Maintaining Factors
Financial Stressors
Proactive Factors
Good cordial
relationship within
family members
Risk Factors
No one can visit to
home in case of
emergency
Maintaining Factor
Suspicious and
aggressive towards
community people
Proactive Factor
All the 3 social support
system are adequate.
25. Functionality Issues
• Self Care
Self care was poor in the time of admission. But at the time of discharge self care is
appropriate , she can do by herself but some one has to instruct her.
• Interpersonal activities
Poor interpersonal activities carried out by the patient
• Communication and Understanding
At the time of admission as she is symptomatic she don’t have well communication
skills. But at the time of discharge her aggressiveness was comparatively less. Her
understanding was poor and little bit improved at the time of discharge.
• Work
Less interest towards work.
26. Psycho social intervention
• Psychoeducation regard illness
Significance of Psycho education: The popularization and development of the term psychoeducation
into its current form is widely attributed to the American researcher C.M. Anderson in 1980 in the context
of the treatment of schizophrenia. Her research concentrated on educating relatives concerning the
symptoms and the process of the schizophrenia.
Psychoeducation provides, tools, skills, and strategies for tracking and managing symptoms and improving
overall wellness and quality of life.
• Psycho education about treatment adherence
• Insight facilitation
Significance of insight facilitation: Although people can certainly attain insight on their own,
counseling and psychotherapy have become the socially sanctioned forums in modern society for pursuing
healing through self-understanding (Frank & Frank, 1991). Relatedly, Castonguay and Hill (2007) have
suggested that insight is fundamental to the therapy process. Hence, it seems appropriate to examine what
we know about insight within counseling and psychotherapy.
27. Psycho social intervention
WITH CLIENT
SESSIONS CONTENT
01 Focused on rapport establishment, to explore their model of
knowledge regard illness.
02 Psychoeducation regard their illness to facilitate insight
03 Insight facilitation and educate them about drug adherence and told
importance of medication
04 Educated them about off medication and its affect
05 Pt accepted that she had physical illness and that lead to mental
illness
06 Adopted moral scale drug adherence
07 Pre discharge counselling (with both client and caregiver)
28. Psycho social intervention
WITH CAREGIVER
SESSION CONTENT
01 Focused on rapport establishment and to assess their model of
knowledge regard illness
02 Educated them about illness, it’s causes and symptoms
03 Educated about prevalence of schizophrenia
04 Adopted Mc Masters family functioning scale
05 Educated them about ECT
06 Adopted modified Kuppuswamy scale and interacted about their
financial stressors
07 Interacted regarding multidisciplinary approach and care givers role as a
part of treatment team
08 Pre discharge counseling (with both client and caregiver)
29. Tools used
• Modified Kuppuswamy Scale
• Family Assessment Scale
• Moral Scale Drug Adherence
30. Future plan
• Review session to assess drug compliance
• Discuss with unit head regard patent’s condition.
• Educate them about referral for DMHP
31. Reference
• Chaotic Enby Psychoeducation: Revision History, 12 January 2024
• Clifford T. Morgan, Richard A King Introduction to Psychology, Seventh Edition
Tata McGraw publication New Delhi
• Hill, C. E., & Knox, S. (2008). Facilitating insight in counseling and
psychotherapy. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling
psychology (4th ed., pp. 284–302). John Wiley & Sons, Inc..
• ICD – 10
• ICD - 11
• Seema P Uthaman and Anwar Sadath April 2018 Indian Journal of Psychiatric
Social Work Psychiatric Social Work Interventions in Schizophrenia: A case
Report https://www.researchgate.net/publication/325292966
