Case Presentation 1
Case Presentation Assignment
Schizoaffective Disorder- Bipolar Type
Brittany Richardson
Liberty University: School Counseling Program
CEFS-546_D04 – Psychopathology
Dr. James Zapf
December12, 2022
Case Presentation 2
Basic Case Summary
Identifying Information
Date of Initial Assessment: 12/1/2022
Name: Anna Smith
Employment Status: Part-time at a Starbucks
School Status: High school graduate w/ some college classes
Age: 25
Gender: Female
Race/Ethnicity: Caucasian
Marital Status: Divorced
Presenting Concern: “I am meeting with you today because I’m not sure what’s going on with
me. I have been having, what I like to call ‘episodes’ for a while now and my mom encouraged
me to talk with someone, or she threatened commitment. She says I have been delusional and
acting out of character ‘again’. I have recently been hearing and seeing things that aren’t there
but I’ve just always related it to my lack of sleep”.
Presenting Concern
Anna is a 25-year old Caucasian female. Anna appears to be appropriately dressed, but
her hair is unwashed, and hygiene is concerning. When asked to tell about herself Anna states,
“Are you ready for this? I feel that I’m about to make you need therapy. I have a lot to unload,
and am completely delusional according to my mom”. Anna stated that her mother dropped her
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off at her appointment because she has not allowed Anna to drive for the past week due to her
lack of sleep, and what her mother thinks is her being delusional. Anna’s mother made a deal
with her that if she agreed to schedule an appointment and not go anywhere without her she
would not try for a commitment. Anna did not want to go to the hospital, so she agreed. Anna
explains that she works at Starbucks part time, but misses a lot of work due to her episodes that
she has. Anna did not want to be hospitalized due to her needing to work since she has missed so
much in the past few weeks. Anna has missed work due to her mood fluctuation, belief that her
husband is following her everywhere she goes, and her lack of sleep. This has happened
persistently for months and, on and off, since her separation. Anna says that the lack of sleep
stems from her staying up all night to make sure her husband isn’t outside. She believes that he
comes by the home late at night to make sure she isn’t going anywhere, and that her mother may
be a part in his plan. Anna says that she loves her mother and wants to think that she wouldn’t do
this but she says that at this point she is very untrusting. Anna says that she would like to talk to
someone to heal some of her trauma, and get her mother off her case. Anna states “Sometimes I
have good days, and I feel normal and in the midst of it, others think I’m crazy so I don’t know
what to do. Anna says that she also has times where she feels nothing. She said that she tries to
feel, and feels nothing other than irritability. During those times she sleeps a lot and has a hard
time getting motivated. Anna states “About 9 months ago I was feeling the best I had in a long
time and every time I would pass over this bridge to work I would actually hear someone calling
my name for help, and I would get out to help them but couldn’t find them. This happened for 2
½ weeks and they finally stopped. This has happened other times with different situations.
Sometimes I think I have a gift to talk to spirits, but I’m not really sure”. I think I need an
unbiased opinion and some sleep meds and I’ll be fine”. Anna does not present with any current
Case Presentation 4
medical conditions and is not on any medication. Anna states that she has not experienced life
the same way she used to in years. When I ask Anna what she means by this she says “I don’t
enjoy really anything anymore, and when I start to feel excited or what I think is joy, others tell
me I am too much and must be going through something”. Anna is not in school, and hasn’t
taken any classes since last semester, and she dropped out of those.
History
Anna lives in the uptown parts of Charlotte, NC. Anna was born and raised in Belmont, a
smaller town on the outskirts of the city. Anna currently resides with her mother. She has one
sister that lives close by and has a daughter, which is Anna’s niece. Anna enjoys spending time
with her sister and her niece, and doesn’t mind living back in her mother’s home. Anna
expresses, “it is good to be at my Moms especially when I am having one of my episodes”. Anna
talks with her father weekly at a minimum and they have a fairly good relationship. Anna says
that since her parent’s divorce when she was 18 her relationship with her dad became a little less
involved. Anna states “my father doesn’t know how to handle me when I’m not myself because
he has his own issues, and this makes it hard to talk with him when things return to normal”.
Anna’s father was diagnosed with bipolar I disorder at age 46 which Anna states led to her
parent’s divorce. Anna states “My father was always mentally ill, but it was unaddressed for
years”.
Anna married her high school sweetheart at age 20. Three years after being married Anna
started experiencing what she calls very high moods, and very low moods. Anna states “my
husband was not supportive, and started to make my illness into a joke. He would follow me, and
have people follow me because he thought I was cheating on him. During that time I was
working for the government, but no one believed me. They all said I was crazy. After my job was
Case Presentation 5
done, I was put on stand-by until needed again”. During this time Anna would stay up for days at
a time and would paint pictures that she told her husband she was going to sell at an art show.
This went on for 2 months. After 2 months of her feeling like she could do anything she wanted,
sharing her plans with her husband, she crashed. Anna stated that all she wanted to do was sleep
for days, and had no motivation to do anything, including bathing. Anna said that she was not
happy, even when it came to spending time with her niece. She felt that nothing brought her joy
during this time. Eight months after this happened Anna’s husband told her he wasn’t happy and
he no longer wanted to be married. Anna was okay with this because she believed at this point he
was just in her life to create turmoil, and he wanted her savings that was left to her by her
grandfather. Anna and her husband’s divorce was finalized 4 months ago. Anna states “for the
last month and a half my ex-husband has been following me everywhere I go, in different cars. I
see him follow me home after work and when I tell my mom she says I’m delusional. I know that
he works at a corporate office and I’m not sure how he has the time to do this, but I know I’m not
crazy”. Anna reports that she is currently not sleeping again, and will stay up for days at a time
looking to make sure her husband isn’t outside of her home. Anna has thought about writing a
book about her marriage and feels that she could really help others that may be going through the
same thing. Anna and her husband do not have any children together, and he is currently dating
but not in a steady relationship. Anna states that she had a few weeks where all she did was lay in
bed and cry about her divorce after her husband’s confession and moving to her mom’s.
Anna is employed at Starbucks. She has worked here for 4 years while trying to go to
school at the local community college. Anna’s boss is one of her good friends, and works with
Anna when she has her ‘episodes’ that prevent her from making it to work. On average Anna
calls into work at least 2 of her 4 shifts a week and sometimes misses work altogether for weeks
Case Presentation 6
at a time. Although Anna has been in and out of school for 7 years she has not completed a
degree. Anna states “I just haven’t found anything I’m really interested in and it’s hard to focus. I
don’t sleep well and it makes it hard to complete assignments and wake up in time for class.
There was also a class that I couldn’t keep attending because every time I was in there I would
hear someone whispering my name and couldn’t focus on the class. This was about 3 months ago
and I wonder if my ex-husband was doing this somehow, but I couldn’t figure it out so I dropped
out of that course”.
Anna does not have any physical health issues, and is not on any medication. Anna states
that she used to have an occasional drink with her friends, but she does not go out a lot anymore
because she feels like her ex-husband is always lurking. Anna states she has probably only went
out with her friends twice in the last year. Anna’s family identify as Christians but do not attend
church, and has not been since she was 16 years old. Anna’s mother still attends a church in her
hometown but her father does not. Anna states “I believe in God, and have a strong faith but I
just don’t attend church. I would like to incorporate my beliefs in to my healing journey. I feel
that this would help create some peace for me with my divorce and the last few years of
hardships I have encountered”. Anna went to a therapist once for about 6 months when her
husband made her go about 3 years ago. Anna stated that she liked it but she just lost motivation
to go. Anna states “I want to heal from my divorce, and hopefully please my mother by being
here today”.
Mental Status Exam
Anna appears to be worn down, and tired. Her gait is normal, and she didn’t seem to have
trouble with coordination. Her hygiene does not look kept up and she is wearing lounge clothes
with her hair in a messy bun. Anna came in with a purse and another tote bag that she said she
Case Presentation 7
likes to keep with her for painting if she finds herself in a place that she wants to paint. Anna
keeps pretty good eye contact when she is speaking but when I am talking I watch her look
around the room. I used silence multiple times to give her a chance to re-engage. This worked a
few times but not every time. I can tell that Anna is very tired and is slow to respond. She tries to
respond promptly but she has to rephrase multiple times before stating what she wants to say.
Her speech is slightly faster than normal, but quiet. Anna appears receptive to my words when
she is looking at me but when she isn’t, she zones out. Anna did not experience any
hallucinations, auditory or visual, in the office. She did talk about her ex-husband following her
and her mother calling her delusional multiple times. Anna displays intelligence and knowledge
in many subject. I observed that she is very artsy and could easily pick up on a new skill if she
was in the right mindset. Anna’s mood is very neutral and melancholy. She doesn’t express very
much emotion at all throughout the course of the hour we are together. I do not observe any risk
of violence toward herself or anyone else. I asked Anna about any suicidal or homicidal ideation
and she states that she does not have either. Anna was able to recall memories that she has from
years past, but it’s hard for me to tell if they are actual memories, or ones she has created in her
mind.
Answer Key
DSM-5-TR Criterion: Schizoaffective Signs/Symtoms:
Disorder- Bi-polar Type
Criterion A: An uninterrupted period of illnessAnna has a very apparent major mood
during which there is a major mood episode episode which was manic, and crashed into a
(major depressive or manic) concurrent with depressive state. She had impaired
Criterion A of schizophrenia.functioning in her work life. During her
Note: The major depressive episode must delusions she believed she worked for the
include Criterion A1: Depressed mood.government and her husband was framing her.
Criterion B: Delusions or hallucinations for 2 Anna experienced auditory hallucinations
or more weeks in the absence of a major when going to work and crossing the bridge
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mood episode (depressive or manic) during
the lifetime duration of the illness.
Criterion C: Symptoms that meet criteria for a
major mood episode are present for the
majority of the total duration of the active and
residual portions of the illness.
Criterion D: The disturbance is not
attributable to the effects of a substance (e.g.,
a drug of abuse, a medication) or another
medical condition.
Specify whether:
(F25.0) Bipolar type: This subtype applies if
a manic episode is part of the presentation.
Major depressive episodes may also occur.
(F25.1) Depressive type: This subtype
applies if only major depressive episodes are
part of the presentation.
those few weeks.
Anna seems to experience either manic
episodes, or depression symptoms the
majority of the past few years that she has
explained to me.
Anna does not use drugs, or medication. She
does not have any other medication
conditions.
Anna has experienced multiple manic
episodes that she has discussed.
Treatment Recommendations
I would choose to use medication in combination with psychotherapy for Anna. I would
choose to use medication to stabilize Anna and hopefully get her out of her current delusional
state before it gets worse. NAMI (2022) states, “the only medication approved by the FDA to
treat schizoaffective disorder is the antipsychotic drug paliperidone (Invega)”. This is a shot that
is administered monthly by an injection and is controlled at a mental health facility. This will
benefit Anna by requiring monthly and hopefully more frequent check-ins. I would also require
individual therapy as well as family or peer or group therapy for Anna. The individual therapy
can help Anna work through things she’s went through with her husband, and her parent’s
divorce. These things seem like things that she needs to deal with to alleviate some stressors that
could be provoking her symptoms even more. Individual therapy will also help ease some of the
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worry that comes with a new diagnosis, and help her to educate and learn coping skills. Stanford
Medical Children’s Health (2022) states, “family involvement is crucial in the treatment of this
schizoaffective disorder. Family education aids in compliance with medications and
appointments and helps provide structure throughout the patient's life, given the dynamic nature
of the schizoaffective disorder. Supportive group programs can also help if the patient has been
in social isolation and provides a sense of shared experiences among participants”. I think it
would be very beneficial for all of Anna’s family members that are part of her support group
(mom, sister and dad) be a part of her treatment plan. With all of these things combined I feel
confident that Anna can live a functional, and normal life as long as she stays consistent and has
support.
Case Presentation 10
References
Psychiatry online. DSM Library. (n.d.). Retrieved November 6, 2022, from
https://dsm.psychiatryonline.org/
Schizoaffective disorder. NAMI. (2022). Retrieved December 13, 2022, from
https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-
Disorder/Treatment
Stanford Medicine Children's health. Stanford Medicine Children's Health - Lucile Packard
Children's Hospital Stanford. (2022). Retrieved December 12, 2022, from
https://www.stanfordchildrens.org/en/topic/default?id=oppositional-defiant-disorder-90-
P02573
