Case Analysis: Using An Integrative Approach

Case Analysis: Using An Integrative Approach

Fourteen-year-old Lisa. Prior to the onset of treatment, Lisa was assessed via structured clinical interview that included validated measures of symptoms, functioning and neurocognitive performance. The patient's mother provided collateral information that contributed to clinician ratings. A panel of experts determined Lisa's diagnosis to be schizophrenia, paranoid type, rather than an affective psychosis. The patient was reassessed with the same measures at the end of treatment (6 months after her intake) and 1 year after her baseline assessment (follow-up).

Her scores on the Psychotic Symptom Rating Scales reflect considerable psychotic disturbance. Although Lisa did not report auditory hallucinations, she held several delusional beliefs. Specifically, she believed that the devil was out to get him, and that many of her fellow students and colleagues were CIA agents meeting about him in secret. Lisa's conviction was 100%, and she experienced the beliefs as both persistent and pervasive, leading to considerable distress. As is often the case with patients suffering from schizophrenia, positive symptoms are associated with significant negative and affective symptoms.

In Lisa's case, while affective flattening and alogia (i.e. reduced verbal expressivity) were minimal, she showed significant withdrawal from constructive activity, indexed by elevated scores on both the Avolition-Apathy and Anhedonia-Asociality subscales of Scale for the Assessment of Negative Symptoms.

During her long hours of inactivity, Lisa experienced acute affective distress, as can be seen in her severe level of depressive symptoms, self-reported on the Beck Depression Inventory II, and moderate level of anxiety, self-reported on the Beck Anxiety Inventory. Lisa's neurocognitive functioning was assessed via a computerized battery that has been validated in patients and controls and taps domains such as mental flexibility, verbal memory, and attention. Lisa scored in the normal range on all of the neurocognitive tests.

Lisa's mother reported that she had been previously diagnosed with anxiety and depression, and that there was no psychosis on either side of the family. She described Lisa as a quiet girl with few friends. She reported a tense relationship with Lisa's father that, at times, resulted in fights during Lisa's youth. Lisa remembers hiding in her room when they yelled at each other. Lisa reported a strained relationship with her parents and brother. Her father was often absent as she traveled a lot for her work. Her mother was a homemaker who was withdrawn, depressed, and often sleeping. Lisa spent much of her childhood playing alone. Lisa recalls being frightened of her brother, who would often torment him.

Lisa attended a total of 38 individual cognitive-behavioral therapy sessions. The therapy sessions initially focused upon Lisa's negative symptoms. The therapist and patient collaboratively set a list of goals Lisa hoped to achieve. This collaboration and early progress increased Lisa's engagement. Early sessions were also used by the therapist to develop an understanding of Lisa's delusions. The middle sessions were dominated by traditional cognitive therapy techniques aimed at helping Lisa test her delusional ideas, such as looking at evidence for and against her belief and considering the pros ...