Abstract

This report presents a special case of a highly educated and intelligent patient diagnosed with simple schizophrenia and depression. This patient attended psychotherapy sessions regularly with the therapist (the author) which helped him to express his thoughts and ventilate his emotions. This report aims is to reinforce the importance of psychotherapy and family interventions in the management of a schizophrenic patient. The patient has adequate insight into the effects of schizophrenia on his self-reflection that have ended up leaving him frustrated with poor achievements in life. The patient’s symptoms were tracked using rehabilitative approaches and techniques. Counseling with the patient and his family completed 50 sessions treatment period. This resulted in a significant improvement in the patient's and family's functioning because they were able to recognize their problems, find appropriate solutions, and place them into action. The therapeutic experience of the schizophrenic patient is presented in this report.

1. Introduction

Schizophrenia is a severe and chronic mental illness that affects approximately 1% of the population, characterized by a complex of clinical syndromes and a wide range of psychopathologic manifestations ¹. Symptoms of schizophrenia are classified into positive and negative categories, including distortions in thinking, concentration, cognition, emotions, language, and sense of self, motivation, and behavioral abnormalities ^{2, 3}. It is a disease that markedly affects social and occupational functioning, interpersonal relationship, and morbidity ⁴. Schizophrenic patients believe they have lost the touch with reality and may also lose interest in the most fundamental demands of existence. When these symptoms are treated with antipsychotics, including both typical and atypical, as well as psychotherapy and psychosocial, most persons with schizophrenia recover significantly over time. ²

Schizophrenia is a debilitating neuropsychiatric and long course disorder, covering alterations in thought manifested in the failure to understand reality, The sufferer often lacks the connection with real-world and lives in an imaginary world perception manifested in false belief, confusion, auditory hallucination, and emotions ^{5, 6, 7}, cognitive deficits have been shown to have a consequential impact on prolonged functionality. Cognitive deficits include predicaments with attention, executive function, memory, and metacognition ⁸. Schizophrenia is often misunderstood as a split personality by many people ⁹, and is heavily populated in the Egyptian Mental Health hospitals; so, it is important to understand what the disorder is about to provide the best course of treatment for the patients. ¹⁰

Symptoms of schizophrenia can be divided into positives, such as delusions (having false beliefs), and hallucinations (hearing voices and seeing things), disorganized and negatives, such as (blunted affect, tiredness, apathy, alogia, avolition), A person who has at least two of the above symptoms for about one month will be diagnosed as a schizophrenic patient ¹³.

The disorganized symptoms may occur depending on the patient's previous characteristics and the duration of the disorder, in addition, the chronic cumulative consequences of schizophrenia are often severe and long-lasting with marked social disengagement. ⁶. The lack of sufficient knowledge about the condition increases the occurrence of frequent relapses due to poor drug compliance, negative side effects, negative expressed emotions, and problematic coping strategies which lead the patient to become socially isolated and a burden to the family ¹⁴. According to systematic reviews, family intervention reduces re-hospitalization and makes the family's life easier. ¹⁵. Not all the domains of schizophrenia are presented by the patients, but a patient may have some symptoms in each category.

Collaboration with patients, caregivers, and treatment providers is required to better understand schizophrenia. ¹⁶. The onset of the disorder mostly begins in the second decade, and while the symptoms vary from one patient to another, the consequences are usually severe and long-lasting. Women are more likely than men to develop schizophrenia in late adolescence and early adulthood ¹⁷. It usually appears between the ages of 15 years to 35 years. ¹⁸.

Men's incidence peaks b at 15 and 25 years of age, whereas women's incidence peaks at 25 and 35 years of age.

The exact etiology of schizophrenia remains uncertain, there are many theories, but there is still no consensus ^{19, 20}, however, different theories are presented for understanding its pathophysiology. This includes genetic theory, dopaminergic theory specifically the increased presynaptic dopamine synthesis which contributes to altered chemistry and structure of the brain in the mesolimbic system, which is responsible for positive symptoms, whereas the mesocortical pathway responsible for negative symptoms complemented by the glutamatergic hypothesis which considers changes in prefrontal neuronal connectivity involving glutamatergic neurotransmission at NMDA receptor ^{11, 12}, non-developmental theory, and psychosocial theory. Biological vulnerability, severe stress, poor coping skills, and the lack of social support are all thought to be contributors to the development of schizophrenia. ²¹

Many other psychiatric disturbances share the characteristics of schizophrenia. ²². On the contrary, many studies have found that schizophrenia patients are prone to comorbidities. Depression has a significant impact on schizophrenic patients, despite its high prevalence and frequent under diagnosis. The prevalence of depression in schizophrenia patients varies widely over the world, ranging from 7% to 70%, with a median of 25%. ²³. There is plenty of evidence in the literature about the impact of depressive symptoms on the quality of life in schizophrenic patients ²⁴. There is plenty of evidence in the literature concerning the effect of depressive symptoms on schizophrenic patients' quality of life. Anxiety and depressive symptoms presented by schizophrenic patients require special attention schizophrenic, as these manifestations have a major influence on their quality of life than schizophrenia's negative and positive symptoms ²⁵, but with proper treatment, mortality associated with depression can decrease about 70%. ²⁶

Comprehensive treatment programs for schizophrenia should include a variety of ongoing services, such as medication administration, access to proper psychosocial therapy, housing and employment assistance, and financial resources ^{27, 28}.

Specific therapeutic approaches have a considerable improvement to the quality of schizophrenic patient’s lives. The goals of the treatment program focus on the elimination of symptoms, relapse of disorder, and improving the quality of life. Antipsychotics medications are the cornerstone in pharmacotherapy for their effectiveness in reducing symptoms and risk of relapse. They are further divided into two main classes: Typical antipsychotics and atypical antipsychotics, but they may be associated with many undesirable effects. ²⁹. The new generation of antipsychotics medications has been proven to have fewer side effects as compared to the conventional typical antipsychotics. After treating the acute symptom, many schizophrenia patients experience major functional and social deficits, necessitating follow-up with a psychotherapist to address the remaining symptoms.

Many researchers were concerned because of the recurrent nature of the condition and the severity of functional psychosocial deficits led to a greater focus on the necessity of empirically validated psychotherapies that can support recovery beyond symptom reduction. ^{28, 30, 31, 32}. They help schizophrenic patients in learning how to live effectively with vulnerabilities, eliminate symptoms, improve interpersonal and social adaptation impairments, and enhance overall life functioning ³³. The outcomes of the treatment work towards achieving life milestones, staying safe from destructive behaviors, increasing physical activity, improving quality of life, finding work, developing a positive sense of self, and developing psychosocial skills ^{34, 35}. It is recommended to have continuous treatment for all diagnosed patients. ^{36, 37}

This report presents a case of an adult man diagnosed with simple schizophrenia and depression. The aims of this report are: (A) to demonstrate the importance of individualistic psychotherapy interventions (B) to illustrates the positive outcomes of the psychotherapy interventions on the improvement of the patient's life (C) to emphasize the importance of family therapy in schizophrenia patient treatment (D) to illustrate the influence of life experience particularly based on child abuse, education, and intelligence on the prognosis of the illness.

2. Case Report

The client’s profile including the history of personal, medical, family, and social was prepared through psychotherapy sessions.

Personal history Mr. X presented for treatment of simple schizophrenia, is a 34-year-old, Muslim, Egyptian male, with a high level of education, unemployed, right-handed. The patient’s birth was by normal delivery. He was born in the seventh month of pregnancy in Saudi Arabia on the 12th of December 1986, and he has a twin brother, Single, who lives with his father, stepmother, and his siblings.

The patient claimed that he remembers every detail of his early life, he reported that his developmental phases were normal and rapid, he could speak and walk at the age of one. He reported having the habit of nail-biting from the age of five till the age of eleven, he reported being a quiet child. He reported he was being abused emotionally and physically by his father, receiving punishment for no reason, and when he screamed, he had been beaten up more aggressively. He reported he never hit or harm his siblings or other children. He reported being neglected and abandoned by his both parents, he stated he had been complaining from inequality and maltreatment from his parents since his childhood, his father prefers his twin brother over him, while his mother was preferring his elder sister, he started seeing how his parents treat his siblings led him to isolate himself, feeling depressed, and frustrated. ^{38, 39, 40, 41, 42, 43}

He reported having poor physical health, he wasn’t eating properly as a child, and his parents never cared for him. He reported suffering from constipation most of the time, consistently complaining of having the anal worm since he was two years old till the age five, he stated he was using the toilet bidet, pushing it hard inside his anus area to get rid of the anal worm, he stated his mother sometimes was helping him in this removal process. ^{44, 45, 46}.

He reported he used to stay most of the time alone, imagining good scenarios where he plays with other children happily, and buying his favorite toys during his childhood, he reported that he never had classmates or friends. ⁴⁷

He reported being bullied in his elementary school. ⁴⁸. He reported he liked the taste of salt, so he used to add a lot of salt to his food, he liked its taste to an extent that he was tasting his urine. ⁴⁹. He reported having homosexual orientation since his childhood and when he grew up he was involved in random homosexual relationships through online websites and applications, he stated that he imagines himself having sex with the same sex during his masturbation, he stated that he never was in a relationship with a girl because he feels inadequate to fulfill a girl needs, besides he decided since he knew his medical condition that he will not marry not to transfer the psychosis genes to his children, so he stated that he stops himself from thinking of having any emotional or sexual relationship with girls, whenever it comes to his mind. ^{50, 51, 52, 53}

Regarding the patient’s premorbid personality, he was an Introvert with nearly no friends, reacts to stress by isolation and dissociation. Muslim, Believer, without practicing. The patient reached puberty at the age of 11 years with male gender identity and role, and homosexual orientation. Regarding the patient’s educational record, he entered a private school at age 6, with very poor relations with teachers and peers, he was an excellent student with excellent scholastic achievements until he reached the university, his academic performance started to be very poor during the first year of college that it took him almost 9 years to get his bachelor’s degree of engineering. ⁵⁴

Regarding the patient’s work record, he worked as an engineer in a private company for two years, but they fired him from work because of his intense hand shivers while doing any work tasks, and his low volume voice, and a small amount of speech due to the side effects of antipsychotic medications. ⁵⁵

The case medical history was identified with schizophrenia characterized by a history of characterized by a history of psychotic episodes in which he displayed signs and symptoms of schizophrenia, but the patient is currently having no positive symptoms (delusions, hallucinations, disorganized speech, or behavior). Recently he has been diagnosed with simple schizophrenia, he represents negative symptoms including the inability to express emotions, indifference, slurred speech, communication difficulties, and withdrawal from social situations and relationship. The patient reported 16-year history characterized by ongoing persecutory delusions, as well as auditory and visual hallucinations, the condition started 16 years ago, since 2005, he reported that it started one year after losing the academic performance in college, continuous fights, and clashes with his family especially his father. He reported experiencing auditory and visual hallucinations. He started writing an unknown language ⁵⁶, drawing awkward sketches, creating a religion, visually hallucinating seeing pictures on the walls, talking to them as if they are real, also auditory hallucinations hearing voices, and engaging himself in conversations involving his family and strangers. He claimed to hear people talking about him and insulting him, a few of whom he knew. Therefore, he was suspicious of others and uncomfortable. As a result, he spent the night with an imaginative friend and refused to get along with his family because he felt unsafe either at home or outside. The content of his thoughts revealed delusions of persecution, visual and auditory hallucinations. ⁵⁷

He became depressed most of the time, staying always alone in his room with spontaneous bouts of crying and continuous death wishes with a sense of worthlessness. Also, he lost his interest in previously pleasurable activities, decreased sleep hours by nearly 3h per day with a marked decrease in his appetite up to that he lost 10 kgs within a month. The patient also had proper insight since the beginning of treatment. He reported that one month later to his hallucinations, he informed his family about his strange issues, but at the beginning, they didn't believe him, so he was left without treatment. He reported that his family claimed that they don’t notice anything wrong with him other than being different and having odd behaviors, he reported his family were so neglectful of his torture and didn’t care to treat him, so he tried to seek professional help himself behind them and decided to take the medications prescribed by the psychiatrist at the age of 18 behind his family who wasn’t admitting his disorder. ^{58, 59}.

He reported the first psychiatrists he visited didn’t diagnose him correctly then finally he went to another psychiatrist who diagnosed him with schizophrenia. Two months later, he started taking the medications regularly and he felt much better under medications, finally, his family believed that he has schizophrenia and supported him financially to be treated. He reported having the medications on time until he felt some undesirable side effects, so he went to a private psychiatric hospital from the age of 25 till now. He reported the symptoms became increasingly debilitating over time, negatively affecting his relationship with his family, especially his father and stepmother. He reported he wasn’t hospitalized at any period of his life, meanwhile, during the recent period of treatment, the patient developed complaints of acute Prostate Hyperplasia, so he started to follow up under the guidance of an Andrology specialist, he also complained of experiencing fine tremors which resulted as side effects from having the antipsychotic medications. ⁶⁰

He reported that he stopped taking the medications regularly to avoid such complications, and sometimes he forgets to take them, he reported being depressed and isolated at times when he stops or changes the medications for better ones. In the four months leading up to his appointment with the therapist, he stopped taking the prescribed medications to avoid its complications. ⁶¹

The patient had shown signs of medical adherence issues since he had Prostate Hyperplasia, he stated multiple times he was concerned about the side effects of medications and believed it is the reason for his suffering during masturbation or while having sex, so he was therefore placed under directly observed therapy at home. ^{62, 63, 64}, his lifestyle data showed that he is a heavy smoker and uses drugs, particularly Hash and Alcohol. ^{65, 66}

The patient reported he didn’t undergo electroconvulsive therapy (ECT), because the psychiatrist didn’t prescribe it. He reported also he had never been in any psychotherapy before. He was brought by his sister who is reliable, living with the patient, very concerned about his behavior and case to the therapist for his attempts suicide many times during the past period, his sister reported he is mentally abnormal for the past 16 years with irregularly taking antipsychotics under the guidance of the psychiatrist, she reported two weeks before to the visit to the psychotherapist, which was on (5th of September of 2020), he became depressed all day with recurrent bouts of spontaneous crying and persistent sense of worthlessness, with noticeably decreased sleep hours than usual, decreased social interaction with his family than usual, loss of interests in watching TV and staying with his siblings, especially his sister whom he prefers among other siblings. Meanwhile, his sister also reported recently she discovered him being involved in random homosexual relationships which ended up leaving him with HIV, she also stated he had experienced horrible physical abuse by a gang, whom he contacted online through a dating website to have sexual affairs after reaching the agreed place, they caught him and beaten him up causing profound injuries all over his body till he bled profusely, his siblings insisted to perform blood tests to find out if he had used any illegal drugs or not before the onset of his current symptoms and the patient’s blood samples showed his infection with HIV and drug use. Moreover, his sister reported currently he feels angry, suffocated, being isolated at home, and developed a marked decrease in appetite with persistent death wishes.

When the patient was first seen by the therapist, the patient exhibited complaints of difficulties sleeping, loss of appetite, depressed mood, and affect constricted among the relevant indications. Meanwhile, he was dressing properly and exhibited appropriate behavior. He reported attempts to commit suicide because he wanted to die ^{67, 68, 69, 70, 71}, especially after knowing that he got infected with HIV, stating that he never had a life and will never have, besides being upset for causing a lot of trouble to his family, so he wants to die to make them relieved and happy with their own lives ⁷². The patient did not display positive symptoms like delusions or hallucinations during the period of treatment with the therapist. He reported being preoccupied with spirituality and believes he has an imagined and unique place, people, language, and religion including different prayers and rituals that he created himself to feel safe away from that abusive world. He was practicing an unknown religion although he claims to believe in God.

Family history there was a family history of both mental and physical illnesses. The patient’s parents are non-consanguineous, his father is 65-year-old, from a high-grade position in a private job, he stated his father is aggressive, unfair, stubborn, neglectful, nervous, hardworking, dominant, organized, assertive, and serious, he stated he never could talk to him, he reported having a poor relationship with his father with a relevant medical and psychiatric history, he reported his uncle is a schizophrenic patient who is totally collapsed and hospitalized for more than 10 years ago. He reported his mother with a relevant medical but non-psychiatric history who was a highly educated housewife and died 10 years ago at the age of 56 years due to breast cancer, and asthma, he reported his mother was kind-hearted, calm, fair, caring, generous, honest, family-oriented, sensitive, religious, flexible, wise, and friendly. He had a harmonious relationship with his mother. The patient is a twin at third in the series of 3 siblings (1 sister and 2 brothers). The patient’s sister is a 38-year-old, high educated, worker, single, diagnosed with bipolar disorder, and he has a harmonious relationship with his sister. The twin brother is highly educated, single with features of schizoid personality disorder, and he has a harmonious relationship with him. The elder brother is 37-year-old, high educated, married with two twin’s offspring, and living abroad with Irrelevant PH, he has a very poor relationship with him.

Social history revealed he lives in an apartment with his siblings while his father, and stepmother live in a separate apartment in the same building. The family has vast social contact with their other maternal and paternal relatives. He didn’t have any friends in the past but currently, he has very few friends.

Psychological assessments were used to formulate the appropriate treatment and management plan

Rationale 1: To assess the severity of psychopathology

The positive and negative syndrome scale (PANSS) for schizophrenia ⁷³: positive signs are absent, whereas negative symptoms are present, according to the results of the tests. The scores were moderate in both the affective blunting and anhedonia-asociality, mild in both alogia, avolition-apathy, and absence of attentional impairment.

The Schizotypal Personality Questionnaire (SPQ): The presence of schizotypal traits is indicated by test results. Unusual perceptual experiences are presented in the cognitive-perceptual area. High social anxiety and constricted effect were presented in the interpersonal aspect and absence of disorganization which includes odd behavior and odd speech.

Beck Depression Inventory (BDI): test findings indicated the presence of mild depression.

Personality diagnostic questionnaire-4 (PDQ-4): The results of the test pointed to a possible diagnosis of schizotypal personality, depressed personality, and avoidant personality.

Rationale 2: To assess Cognitive Functioning

Eysenck Personality Questionnaire (EPQ): tested showed low scores on psychoticism, and extroversion, and high scores on neuroticism, and Impulsivity.

Stanford-Binet Intelligence Scales (SB-5): test findings showed the full-scale Intelligence quotient score (132) which is classified as gifted or very advanced intelligence level.

Rationale 3: To elicit diagnostic indicators and personality traits

(A). Objective Tests: The Minnesota Multiphasic Personality Inventory (MMPI): the results of the test revealed a valid and interpretable profile. His scores were high in Depression, Schizophrenia, and Social Introversion, while the score was low on the Masculinity/Femininity subscale which refers to his homosexual tendencies, poor identification with stereotypical male gender roles, and Moderate in psychasthenia.

(B). Projective Tests: Goodenough–Harris Draw-a-Person Test (DAPT): The patient was found to be very intelligent, with male inadequacy, poor social skills, poor interpersonal relationships, dependency, oral erotic tendencies, sexual role conflict, sexual inadequacy and difficulties, depressed mood, psychotic tendency, anxiety, impulsivity, insecurity, lack of status and low self-esteem, preoccupation with sex to compensate for weakness feelings, according to the test results.

The Thematic Apperception Test (TAT): By using TAT techniques, it was interpreted the development of the disorder was due to family circumstances and within the family itself. his father had abused the patient emotionally, psychologically, and physically. The father used to name-calling him, cursing at him in public and in private most of the time, yelling at him, insulting him, constantly rejecting his thoughts, ideas, and opinions, making him doubt his feelings and thoughts, and even his sanity, by manipulating the truth, neglecting his basic needs, being mistreated and always blamed for everything happens in his surroundings, which disappointed him and led to his isolation, uncertainty, and depression. Cards revealed the patient is constantly seeking to achieve more than is reasonable given his current resources, especially regarding his high intelligence level, but due to the disorder and the side effects of antipsychotics, the failure to meet goals becomes more likely, resulting in frustration. He could possibly be having an unusual thought pattern, which is frequently triggered by the existence of unmet demands. Cards revealed also he had been forced to do activities he never enjoyed in his past, having difficulties concentrating, and achieve higher competence growing old, difficulties living and communicating with other people, feeling depressed and guilty, experiencing isolation and abandonment. Sexual difficulties in establishing a man-woman relationship because he feels inadequate, he seemed to have homosexuality which was revealed from his attitudes toward members of the same sex. He also appeared to have an excessive internalization of feelings, preferring to externalize them which was manifested in his attitudes toward some external controlling forces, leading him to anxiety. Cards revealed his struggles with authority especially with the paternal figure while having positive feelings and attitudes towards his maternal figure. He appeared to be prone to abnormal behavior, which is most likely caused by mediational dysfunction. He also seemed to have features of obsessive-compulsive disorder. He seemed to have so unique imaginative abilities. He lacks the hope and the motives to live effectively, which led him to the path of self-destructive behaviors, he seemed to be in a need to better control his impulses, also his attitude toward death was calm and quiet, revealing his desire to die peacefully, he doesn't fear death, as he thinks that death is eternal peace. He has negative attitudes toward his body images, he thinks he lacks physical attractiveness, and his body shape is distorted which led to the presence of anxiety and insecurity.

Therapeutic interventions

A structured clinical interview was conducted with the patient and his siblings based on the DSM-IV-TR to provide comprehensive coverage of Axis I disorders. ^{74, 75}. The psychotherapy period lasted 9 months and consisted of weekly sessions

The first therapeutic approach is family therapy which is important due to the fact the patient spends most of his time with his family who would be primarily responsible for providing support, medication, several factors, and activities in the patient’s life. The patient's family reported that they feel guilty because they are unknowledgeable of the patient needs and how can they help him. The aim of applying family therapy was to increase the collective family collaboration and enhance the relationships, which is extremely beneficial for the patient. Therefore, it was crucial to provide family therapy intervention to improve their coping, problem-solving skills, and enhance their communication skills with each other, because poor family care affects the patient’s situation negatively. The family therapy resulted in effective stress reduction, which could significantly influence relapse rates. Additionally, they could aid the patient in emotional processing and cognitive reappraisal, thereby enhancing his overall mental and psychological states. Throughout the years, the finding of more than 50 studies indicated that family therapy has a positive impact on the patient’s recovery and reduces rates of readmission, relapses, and the improvement of the patient clinically. ^{76, 77}

The second therapeutic approach is Psychodynamic therapy, which considers an important individual treatment modality for schizophrenics provided in combination with pharmacotherapy. ^{78, 79, 80, 81, 82, 83, 84}. According to the psychodynamic approach, Schizophrenia develops because of the ego's disintegration. The ego will be ‘broken apart' by its attempt to maintain the desires of Id, leaving the Id in full control of the psyche, and the person eventually loses contact with reality. They regress to a state of ‘primary narcissism’ where they are ruled by their animal instincts, unable of regulating their behaviors, and hallucinating due to their inability to distinguish between their imaginations and reality ⁸⁵. The main goal of applying this approach was to elicit his past emotional experiences and improve his self-awareness so that he could recognize how they influenced his current mental state and behaviors, foster new positive relationship experiences, identifying his conflicts and defense mechanisms that have preceded his pathologic mental state. The interventions included variety of strategies, such as explorative insight-oriented, free association, supportive and directive activity, Interpretation of transference, dreams, and resistance phenomena, all of which were applied in a flexible manner, ⁸⁶. In addition, the family psychodynamics were considered through a deep understanding of the complex dynamics of blame and guilt in psychosis which allowed the therapist to better deal with the patient and his family members and help them with the difficult interpersonal processes ⁸⁷. Psychoanalysis was a highly effective therapy for treating the patient's deep-seated psychological issues. ^{88, 89, 90}

The third therapeutic approach is cognitive-behavioral therapy (CBT), which was applied to provide the patient with several tools that could decrease the intensity of the negative symptoms, increase social skills, maintain a higher living quality, enhance his ability to function independently and effectively, reduced daily life stress, managing anxiety, and depression ⁹¹. Techniques of CBT used are Simulation and Roleplaying, Cognitive restructuring of the style in which the person views himself and the others and gets rid of negative automatic thoughts and negative unrealistic assumptions, Ice Breaking, Guided discovery, Engaging, Goal Setting (Smart Goals), Graded Exposure Assignments, Behavioral Coping Skills (Activity scheduling and behavior activation), Behavioral experiments in which he could form a hypothesis then perform a mini-experiment to determine to what extent are his assumptions true, which could be highly beneficial with psychotic symptoms, Rehearsals, and Practices, ABC Model, Mindfulness Practice, Relaxation and Stress reduction tools.

CBT techniques were effective with the patient, it helped him to understand and cope with difficulties, struggles, and situations that he finds challenging for him. Educated him how to set appropriate and realistic goals, developed a wider understanding of his mental condition and cognitive functioning, ability reconstruction, symptom reduction, and management, reduced negative schemas, effective management for stressful situations, changing cognitive biases by using therapy-assisted disconfirmation strategies, as well as through a detailed consideration of the entire body of data. ^{92, 93, 94, 95, 96}.

The fourth psychosocial approach is social skills training. Schizophrenia patients can improve their interpersonal skills when given structured behavioral training that focuses on well-defined actions, contexts, and issues ⁹⁷. The patient had deficiencies in the skills necessary for daily activities. He was provided social skills training to help him improve his social interactions that are necessary to live independently. Skills training plans included behaviorally based instruction, employment skills, self-care, relationships, medications and symptoms management skills, communication skills, positive reinforcement, role modeling, rehearsing, and corrective feedback to function effectively in life ⁹⁸. It was provided opportunities to the patient for practice in implementing abilities in a real-world setting. The patient practiced these skills with the therapist first multiple times while getting feedback, then he started applying them in real-life settings. The skills developed during the sessions were generalized to other situations important to the patient's daily life, resulting in significant effects on proximal assessments. ^{30, 99, 100, 101, 102}

The fifth psychosocial approach is Psychoeducation, which emphasizes coping strategies, and empowerment ability ^{103, 104}. Psychoeducation helped the patient and his family to understand the disorder, as the better informed the patient and caregivers are, the better the patient's and caregivers' health outcomes. They were also educated on positive reinforcement techniques, the management of medications and crisis, timely and flexible perception of current experiences, family conflicts, communication, and the social and clinical needs for the patient. Psychoeducation programs were effective in explaining symptoms, treatment options, recovery, and services that can help. The psychoeducation strategies included written information, videos, websites, meetings, and discussions. The psychoeducation was beneficial for the patient and all family members to communicate better and solve problems. ^{105, 106, 107, 108}

The sixth psychosocial approach is Psychosocial Interventions for Alcohol and Substance Use Disorders which are considered an important part of any comprehensive substance abuse treatment plan for promoting behavior change, they were applied to help the patient realize how his substance usage puts him at risk and to encourage him to cut back or stop using drugs.

Psychosocial Interventions were implemented intensively and individually. Aimed at utilizing the relationship between the therapist and the patient to promote positive changes in the patient's drug-taking behaviors as well as other aspects of cognition and mood. ^{109, 110, 111, 112, 113}.

Psychosocial programs included motivational enhancement (MI), brief interventions (BIs) for alcohol and tobacco, behavioral techniques that emphasize engagement in therapy, coping strategies, relapse prevention training (RP), contingency management (CM),feedback, accepting responsibility, counselling, list of options, sympathy, and self-efficacy and integration ^{114, 115, 116}. The Psychosocial Interventions were effective in the management of the patient's consumption of alcohol and drug use. ^{102, 117, 118}. It resulted in an 80% reduction in alcohol consumption and completely quitting substance use. ^{119, 120, 121, 122, 123, 124}

Finally, the psychotherapy interventions were effective in the management of the patient, without intervention and treatment, the patient’s brain would keep deteriorating, his ventricles would expand, and his brain will shrink till he loses most of his cognitive functions, Therefore, it is important for all who are diagnosed with schizophrenia to have early prevention, recognition of early signs, receiving the proper psychotherapy interventions, receiving the proper and appropriate medications from the start of the diagnosis.

Progress and outcomes:

Over the 9-month individualistic and family therapy period. The patient's disorder progressed in an ‘episodic with stable deficiency pattern’. Psychotherapy interventions were effective in achieving life milestones, decreasing negative symptoms of schizophrenia, depression, and anxiety, improving his physical activity, cognitive abilities, and raising his awareness about the disorder and its complications. His communication skills have improved effectively with his family and others. He could feel a positive sense of self, body image, security, and normalize his thought patterns. Quality of life has improved and safety from harmful and destructive behaviors is achieved, he learned to cope with stressful situations, and identify early warning signs of relapse to be able to manage the disorder. The patient complied and was on medication, His complaining behavior was managed to keep him functioning normally at home and in society.

3. Discussion

This report presents a case of simple schizophrenia, which meets all ICD-10 and DSM-5 criteria and seems like a typical insidious psychosocial deterioration without obvious psychotic symptoms ¹²⁵. Simple schizophrenia is described mostly by negative schizophrenia symptoms, including anhedonia-asociality, avolition-apathy, affective flattening, or blunting, alogia, inattentiveness ^{126, 127, 128} the patient had most of these symptoms, along with self-neglect which is one of the most specific and observable simple schizophrenia symptoms ^{129, 130, 131}, Therefore, simple schizophrenia is insidious and life-destructive mental disorder. Through this publication, I focused on the importance of both the individualistic psychotherapy and family therapy interventions in treating a case diagnosed with simple schizophrenia who was similar to the other patients who are often brought into psychotherapy sessions by their relatives as in this case ^{132, 133, 134, 135}. Also, focused on confirming the positive outcomes of psychotherapy and family interventions in the treatment of a patient who demonstrates negative symptoms, along with the antipsychotics under the supervision of a psychiatrist. The patient's biography and history, as reported by him and his siblings, could probably justify and fundaments the etiology of the schizophrenia prodromal opens with supposedly stress-induced acute psychotic episodes. Experiencing child abuse, poor parenting behaviors familiar negligence, double-bind communication, psychiatric disorders in the family. He lived under considerable situational-related stress since his early childhood; this impacted his overall functioning and led him to be defiant against authority figures, blaming family members for his problems, which resulted in poor interpersonal relationships, all such factors were potential triggers for his schizophrenia and depression ^{136, 137, 138, 139, 140}. The patient seemed to be slow, having troubles with social interactions since early childhood leading to increased social isolation ¹⁴¹. Identical social withdrawal and interests were lost in this case after losing his high academic achievements. Identical social withdrawal and interests were lost in this case after losing his high academic achievements ¹⁴². He seemed to have difficulty speaking due to disorganized thinking (alogia), so he doesn’t like to talk much especially in social situations. Unfortunately, almost every case diagnosed with schizophrenia end up with total social life and functional breakdown. ¹³¹. The patient seemed to have a good level of attention, concentration and visual-motor coordination. Due to his lack of impulse control, he appeared to have a difficulty modulating emotions which results in striving for immediate gratification of impulses and sensation-seeking, which was manifested in his desires to have random homosexual relationships, alcohol, and drug use. He seemed to be experiencing unusual thought content, but those thoughts are far from delusional thinking along with some odd behaviors ^{143, 144}. He seemed to be experiencing episodes of muttering, unmotivated laugh and anger manifested in his inability to feel or express pleasure (anhedonia). He seemed to have depression-anxiety alike symptoms ^{145, 146, 147, 148, 149} manifested in a decreased sense of purpose and lacking motivation (avolition). He seemed to have a negative self-perception that led to a pessimistic view of himself and the world. He seemed also to be dissatisfied, insecure, restless, irritable, inadequate, inferior, and disappointed. The outcomes of psychotherapy interventions were successful and effective because of his ability in self-reflection and abstract thinking due to his high intelligence level.

The therapeutic approaches as well as physical and psychological improvements were successful, and the patient was able to live a healthy life, along with medication usage. Finally, this case shows the importance of this kind of individual and multi-holistic approach on the management of schizophrenic patients ^{1, 150, 151, 152}, because only in that way the psychotherapists can maximize the effectiveness of the interventions.

4. Conclusion

Schizophrenia is a very frequent mental disorder, and one of the most severe and impairing medical disorders. A diagnosis of simple schizophrenia and depression was considered in this case. In this case, the disorder progressed gradually and peaked during a vital stage of life, the adolescence phase. The age of onset for the patient was at the age of 18 which was the most critical period for him regarding his educational, occupational, and social development, the consequences of the disorders led to a lifelong deficit. psychotherapy interventions were effective in the management and reduction of the negative symptoms and depression after conducting 50 sessions. In this case, the stress on the family and lack of awareness about the condition were important factors in the disorder's progression, his family was instructed to accommodate the surroundings in the home setting to improve the patient's comfort. He became normal, engaged himself in social situations effectively, improved his interpersonal relationship, and could find a suitable job, due to his high cognitive level, the patient has appropriate and adequate insight into his condition, which is a good prognosis factor. The bad prognostic factors are the lack of family support and the long duration of the disorder. It is important to mention that to maintain anonymity, I have concealed specific details about his life and family's occupations.

Ethical Considerations

This study violates no ethical considerations. The participant signed written consent before starting this research, and anonymity was applied to ensure confidentiality and beneficence. The participant also had the right to refuse to participate or not continue when started.

Conflict of Interests

Regarding the publication of this paper, the author claims no conflict of interest.

References