Patient is predominantly mute. No spontaneous verbal output observed during initial and subsequent sessions. Communication is primarily non-verbal, including prolonged eye contact, minimal head movements (nods/shakes) and occasional written responses when prompted.
When verbalization does occur, it is extremely limited, typically restricted to single word responses such as “yes,” “no,” or “maybe.” Speech, when present, is low in volume, delayed, and appears effortful.
No evidence of pressured speech, disorganization, or formal thought disorder can be reliably assessed due to the severely reduced verbal output.
Selective mutism versus negative symptoms associated with schizophrenia should be considered.
Mood (subjective)
“Neutral” (incongruent)
Affect
Constricted, occasionally blunted; emotional expression markedly reduced
Thought Form
Coherent but abstract, with symbolic substitutions
Thought Content
Persistent paranoid ideation (being watched, evaluated, anticipated)
Passive death ideation remains present post-attempt
Perception
No overt hallucinations reported, though patient describes “presence-like awareness”
Insight
Limited
Judgment
Impaired
Diagnostic Formulation (DSM-5 / ICD-10 aligned)
Schizophrenia, Paranoid Type (Primary, chronic, severe)
Major Depressive Disorder, Severe, recurrent
Generalized Anxiety Disorder (chronic)
Insomnia Disorder (severe, persistent)
Complex Post-Traumatic Stress Disorder (CPTSD) – strongly indicated
Clinical Course
Across repeated sessions, the patient presents with:
Persistent internalized distress masked by controlled exterior
High cognitive function with detached emotional processing
Ongoing hypervigilance and environmental scanning
