St. Scholastica’s College Tacloban, Inc.

Maharlika Highway, Brgy. Campetic

Palo, Leyte 6501, Philippines

CASE
FORMULATION
REPORT
FINAL OUTPUT FOR PSYCH 9
(ABNORMAL PSYCHOLOGY)
1st Semester AY 2024-2025

Presented by:
Alyanna Jhanine B. Velasco
BS Psychology 3A

Presented to:
Mary Grace Nonay, RPm
 CASE FORMULATION REPORT
——————————————————————————
I. Identifying Information, Referral Problem, and Background

Name : John Nash

Chronological Age : 30s
Biological Sex : Male
Gender : Male
Sexual Orientation : Heterosexual
Religious Affiliation : Not stated
Marital Status : Married
Children : One
Occupation : Mathematician and Professor

Referral Problem: John was experiencing delusions and hallucinations regarding people he often
interacted with and the job he believed he had. However, it was confirmed that they did not exist.
The misalignment between his perception of reality and what was real impacted his mental
well-being, career, and social relationships, especially with his wife. John continued facing these
paranoia symptoms, which affected his behavior, raising concerns to his colleagues, friends, and
wife, hence resulting in the need for a psychiatric intervention.

Background: John was a mathematical prodigy considered a "genius" by the people around him.
His personality was considered arrogant, blunt, eccentric, obsessive, socially awkward, and
emotionally reserved, posing a great struggle when socializing with others. Additionally, he made
significant contributions to mathematics during his final years in college and then was offered a
position at the Massachusetts Institute of Technology (MIT). There, he built his career as a
mathematician and a professor. During his early 30s, his symptoms of delusions and paranoia
heightened, making him believe that he was a government spy who cracked soviet codes to help
uncover hidden messages in newspapers and magazines. John's obsession with finding and
solving codes persisted, often filling his office walls with papers. Also, his mental health started
to decline as he believed that Russian individuals were persecuting him due to his work as a
government spy. He was constantly anxious, whether at home or work, affecting his relationships
and professional career.

II. DSM-5-TR Diagnosis

Diagnosis: Schizophrenia (DSM-5-TR Code: 295.90 [F20.9])

Specifiers:
● First episode, currently in an acute episode: This indicates the initial, current
manifestations of symptoms. John is experiencing evident delusions: the belief that he is
a government spy who is being persecuted due to his work and seeing and interacting
 with people who do not exist; and auditory hallucinations: hearing and conversing with
people who do not exist.
● With prominent delusions and hallucinations: Delusions and hallucinations are present
at this stage.
● Severity: Severe: John's symptoms greatly affected his mental well-being, capacity to
reason, emotion regulation, social relationships, and professional career, hindering his
ability to function optimally.

Relevant V Codes:
● V62.3 (Z55.9) Academic or Educational Problem: John faced significant challenges in
his academic environment due to his progressing symptoms, which affected his behavior
and consequently negatively impacted his focus and ability to work and study.
● V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner: John also
struggled to manage his relationship with his wife. He refused to seek her help, convinced
that he was protecting her from the repercussions of his job to the point of isolating
himself from her.

III. Rationale of Diagnosis

A. Characteristic Symptoms
Two or more of the necessary symptoms must be present for a significant portion of time
during 1 month (or less if successfully treated) to diagnose John Nash with
Schizophrenia. The symptoms that manifested in John Nash are the following:
1. Delusions: John exhibited persistent and severe delusions that greatly affected
his cognitive functioning and physical activity. His delusions consist of his belief
that he is a government spy who works with top-secret missions by cracking
soviet codes to uncover hidden messages and produce conspiracies to avoid an
impending calamity. John's delusions persisted and convinced him of his
imagined reality and created a sense of paranoia.
2. Hallucinations: John interacts with different people who are confirmed to be
nonexistent: his best friend and roommate since college, that friend's young
niece, and a government agent. His auditory and visual hallucinations of these
people add up to his symptoms of Schizophrenia.
3. Disorganized thinking (speech): John is a mathematical genius considered
arrogant and socially awkward. His cognitive functions revolve around his erratic
perception of the world. His struggle to converse with women and difficulty in
coherent speech drive is key to his lack of interpersonal relations.
4. Gross disorganized or abnormal motor behavior: John exhibited eccentric and
erratic behavior, mainly due to his obsession with cracking Soviet codes and
making conspiracies of what he finds. He usually acts unconventionally, which
sets him apart from his peers and labels him weird and different.
5. Negative symptoms: John's personality became more withdrawn as he struggled
with his interpersonal relationships and maintained his social relationships. As
his symptoms progressed, he isolated himself while refusing to seek help and talk
 about his anxieties. He always had difficulty expressing his emotions, and this
heightened during the progress of his disorder.

B. Social or Occupational Dysfunction: John's symptoms affected his capability to work

optimally and function well both in academic and social settings. Although considered an
academic genius, his well-known intellect and academic prowess led to his struggles. His
symptoms were anchored on his mathematical abilities as he was solving and deciphering
codes for most of his time. Also, his relationship with his wife became weary, evident
when he was in fear for his life, believing that Russian individuals were persecuting him.
He was not able to form a meaningful and healthy connection as he mostly isolated
himself while distracted by keeping track of his believed persecutors. Due to this, his
work was significantly affected. Convinced by his imagined reality, his paranoia led him
to fail to present properly during a talk, gaining judgment from his audience about his
performance.

C. Duration: John's symptoms occurred over the minimum month duration of the diagnostic
criteria for Schizophrenia, exhibiting persistent symptoms, not acute. Also, his symptoms
initially manifested during his years at college and continued as he worked professionally.

D. Exclusion Criteria: There are no evident indications that John's symptoms are related to
other psychological disorders, such as mood disorder with psychotic features,
schizoaffective disorder, or substance abuse. The diagnosis of Schizophrenia aligns with
John's symptoms since they mostly dwell on his symptoms of delusions and
hallucinations.

IV. Case Formulation

The cognitive-behavioral perspective is a theoretical framework that focuses on how
people's thoughts, feelings, and behaviors interact and relate to their experiences (Beck, 1976). Its
model emphasizes how distorted thought processes and dysfunctional beliefs cause psychological
distress. Additionally, this model explains how delusions and hallucinations possibly arise from
cognitive misinterpretations and learned behavior, thus further affecting the symptoms of
Schizophrenia. In John Nash's case, this model provides insightful understanding regarding the
development and maintenance of his condition. When individuals experience cognitive distortions
and dysfunctions tend to interpret situations in ways that deviate from reality, aligning with the
principle in cognitive psychology (Beck, 1976; Chadwick et al., 1996).

In cases such as Schizophrenia, several key cognitive distortions contribute to the

manifestation and persistence of symptoms. One is jumping to conclusions, which involves
creating perceptions of something without any credible support to back it up, such as how John
misattributed people from the psychiatric hospital as people who are Soviet spies, attempting to
threaten his life. Another is personalization, which refers to attributing external events to oneself
despite no apparent connection, such as how John misinterpreted information from newspapers
and magazines, believing they were codes for him to decipher as a government agent. Lastly,
catastrophizing, which involves anticipating the worst possible outcome when faced with any
situation, such as how John feared and tried to isolate himself from social interactions after
stressing about a possible academic failure, wherein he was struggling to make an original
academic paper for him to get a prestigious opportunity in the future.

Furthermore, John's stressful environment, which constantly interacts with biological

vulnerabilities, further exacerbates the manifestation and maintenance of various symptoms of
Schizophrenia. Stressors include the academic and career pressures of being a professional
mathematician who persistently strives for intellectual originality and has difficulty in his
interpersonal relationships, believing he is alone and facing threats to his life. John's
manifestation of positive symptoms, such as hallucinations and delusions, refers to symptoms that
are in ​excess or added to normal mental functioning (Preda, 2024). This influenced John
significantly as he failed to interpret and recognize imagination and reality. Hallucinations
involve sensory experiences without external stimuli, where individuals may hear, see, feel,
smell, or taste things that are not technically present. This relates to how John might
misinterpreted his inner voice belonging to someone who is not real, which convinces him
otherwise. This provides a risk of danger to himself and other people around him, specifically his
wife and son. On the other hand, his delusions that likely stemmed from his obsession with
mathematical equations, numbers, and abstract concepts may have led him to misattribute his
environment and misinterpret the information and patterns from newspapers and magazines as
codes that he needed to unravel for cryptic messages from people who attempt to bring disaster to
the USA. This manifestation of his symptoms aligns with the cognitive bias with CBT's
explanation of Schizophrenia.

In terms of unfavorable symptoms, which include volitional or motivational impairment

manifesting as avolition, anhedonia, social withdrawal, and emotional disorders such as alogia
and affective flattening (Mosolov & Yaltonskaya, 2022), represent a decrease or absence of
typical functions. John Nash experienced social withdrawal, where he isolated himself from his
peers, acknowledged himself as superior to the rest, and usually called his peers' papers
"unoriginal," giving him great difficulty when forming and maintaining social relationships. He
also isolated himself from his wife, convincing himself not to seek her help to protect her from
his imaginative threats. He also displayed flat affect, showing limited emotional expression,
especially when socializing with others. John usually appears detached or indifferent, especially
before meeting his wife, making him appear arrogant and eccentric, which aligns with the
negative symptoms of Schizophrenia. Additionally, he exhibited alogia, whereas he often speaks
minimally, reflecting a cognitive and emotional disengagement.

To conclude, the cognitive-behavioral perspective and model provide a comprehensive

framework for understanding the etiology of John Nash's case of Schizophrenia, wherein his
cognitive distortions, stressors, and symptoms raised his delusions and hallucinations that reflect
misalignment from reality and a decline in his mental well-being. John's decline in his cognitive
functions was driven by his distorted thinking patterns, exacerbated by environmental stressors
and the negative and positive symptoms of Schizophrenia. Due to this, John's challenges as he
grappled with cognitive dysfunction affected his behavior as well, where the cognitive-behavioral
perspective heightens its significant role. The interrelations of his thought processes, behaviors,
 and environmental factors provide a perspective for determining key insights in addressing John's
complex condition. Hence, this model highlights the essence of emphasizing the cognitive
functions and the influence of stress in therapeutic interventions for Schizophrenia.

V. Recommendations
● Cognitive Behavioral Therapy for Psychosis - CBTp involves changing appraisals and
behavior through new learning and in the context of a good therapeutic relationship
(Johns et al., 2020). John's condition could be helped through CBTp, specifically in
identifying and challenging his thoughts and beliefs that are focused on his positive
symptoms: delusions and hallucinations. This intervention would help him rationalize his
delusions and come to terms with his symptoms, gaining control, strategizing, and
developing healthy patterns in managing his condition, such as acknowledging that he
sees people who do not exist and persist in not paying them any attention.
● Social Skills Training - SST is a widely applied and effective treatment for a range of
psychosocial problems that include depression, anxiety, Schizophrenia, loneliness, and
marital distress (Segrin, 2009). This intervention would greatly help John with his social
awkwardness, inability to open up and seek help, converse appropriately with his wife,
and improve his interpersonal relationships. This will enhance his need for relationship
and emotion regulation, understanding social cues, and considering other people's
emotions other than his own.
● Stress Management Programs - John's trigger for his hallucinations and delusions was
stress. When he feels distressed, his symptoms go rampant, affecting his overall
well-being. By acknowledging and managing his stressors, he may mediate and regulate
his symptoms and avoid being triggered altogether. This will significantly help him when
socializing in public and when he encounters unpleasant stimuli in his daily living.
● Behavioral Activation - This psychological intervention encourages individuals like
John Nash to go outside and avoid isolation. It also motivates John to engage in
meaningful activities that align with improving his lifestyle, lessening his anxiety and
promoting comfort, potentially reducing stressors, and mediating his symptoms, such as
going on a walk, socializing, and just being outside of a closed space (Lejuez et al., 2001;
Veale, 2008).
References

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: International
Universities Press.
Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices and paranoia.
New York, NY: Wiley.
Johns, L., Isham, L., & Manser, R. (2020). Cognitive behavioural therapies for psychosis. In J. C.
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psychologists and neuropsychologists (pp. 343–377). Elsevier Academic Press.
[Link]
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