CASE REPORTS

Submitted to

Dr. Rabia Maryam

Submitted by

Hooria Amer (230617)

Registration number

( )

Semester 3rd

Session 2023-2025

Report submitted in partial fulfillment of

the requirements for the degree of MS Clinical Psychology

MASTER OF SCIENCE

IN

CLINICAL PSYCHOLOGY

DEPARTMENT OF APPLIED PSYCHOLOGY

GOVERNMENT COLLEGE UNIVERSITY FAISALABAD

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DECLARATION

I am Hooria Amer, Roll No. 230617, student of MS Clinical Psychology,

Session 2023-2025 hereby declare that the matter presented in this case
report is my original work.

Dated: _____________ Signature of Deponent

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CASE REPORTS COMPLETION CERTIFICATE

It is certified that the work contained in these Case Reports has been
completed by Ms. Hooria Amer, Roll No.230617 under my supervision.

Dated: _________________ Supervisor

Dr. Asma Riaz

Assistant Professor,

Department of Applied Psychology

Govt. College University, Faisalabad

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Table of Contents
Sr. No Title Page No.

1 Case 1
Appendix
2 Case 2
Appendix
3 Case 3
Appendix
4 Case 4
Appendix
5 Case 5
Appendix
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Case No. 1
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CASE 1
Bio Data
Name F.I
Father Name M.I
Age 36
Gender Male
Education B.COM
Religion Islam
Birth Order 1st
Siblings 2 Bro+4 Sis
Parents Alive
Father Occupation Laborer
Mother Occupation House wife
Social Economic Status Lower class
Address Faisalabad
Examiner Initial

Identifying Information
The client’s name is F.I. His father’s name is M.I. He is male and 36 years old. He is an employee in factory. He
has 2 brothers and 4 sisters. His birth order is 1st. He belongs to a lower-class family. He is married. He has four
children. He lives in Faisalabad.
Reason and Source of Referral
The client was referred to me by DR. Imtiaz Dogar for the assessment of psychological problem
Presenting Complaints
Presenting Complaints Duration
According to the patient he had not been feeling well. The duration of illness is for one month.
According to the informant the patient had been
talking to self, increased activity, reduced sleep and
reduced appetite. the following prominent symptoms
• Auditory Hallucination
• Visual Hallucination
7 months
• Self-Talk
• Self-laugh
• Delusions
7 months
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• Beating others.
• Isolation
• Stubbornness
• Decreased Sleep

Clinical Interview
 Clinical history
The patient was well before one month. The time of onset was one month back. The symptoms were
talking to self, increased activity, reduced sleep and reduced appetite. No suicidal ideas.

 Developmental History
Delivery was normal and client was born in house. No history of birth defects. Development milestones
were achieved on time.

 Personal History
Client was brought up by his father and mother. Breast feeding was adequate and weaning startedon 6th
month of age. No history of maternal deprivation. Milestones were normal and had temper tantrum during
childhood.

 Family History
Client belongs to a nuclear family. He is married and staying separately with his wife and son. He has 18
months old son. Client is the only son is the family and share good bond with them. Hisgrandfather had
some psychotic symptoms but not much information could be elicited.

 Educational History
Client’s formal education was started at the age of 5 years. He had good relationship with his peer group
and teachers during the school life. He had no school phobia.

 Social History
Client had good relation with family members, workmates, friends and superiors. He is introverted. He
had less social interaction. He uses his leisure time watching television. He has good self-confidence and
self-esteem. He never abused drugs or alcohol.

 Occupational History
Client worked as a accountant. Now he had no job due to illness. He had no job
Satisfaction.
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 History of Drug Use/Abuse: (if applicable)

Nill

 History of Psychiatric/ Medical Illnesses

The first episode of illness started when client was 25-year-old. At that time the client ran away from home
and after 1 year came back with mental illness. So, no history of precipitating factor isavailable. At that time, he
was treated in hospital. After that his condition got better and he went back home. 1 year back he again had
relapse and had been on medication.
Mental Status Examination
GENERAL APPEARANCE & BEHAVIOR: -
General appearance is well dressed. Facial expression was apathetic. mannerism was present. he maintains eye
contact. Gait and posture are normal. Hygiene was poor. Attitude towards the examiner was cooperative and
attentive.
MOVEMENT AND BEHAVIOR:
Motor disturbance present (stereotype movement, hyperactivity and compulsion).
SPEECH:
Pressure of speech was accelerated. Flight of ideas was present. Thought block was absent.
Monotonous pitch was observed. Speed was increase and reaction time was slow.
MOOD / AFFECT:
• Subjectively: “I am happy and joyful”
• Objectively: laughing
• Pleasurable affect: present, Euphoric.
THOUGHT:
Form of thought disorder: absent
Delusion: present
Client says, “I am the CEO of many companies”.
PERCEPTION
Hallucination is present. client says he can see and talk with God.
COGNITIVE FUNCTIONS:
• Not oriented to time, place and person.
• Attention & Concentration is aroused and sustained
• Memory:
Immediate memory: intact Recent memory
• Abstract thinking impaired.
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• Intelligence is impaired
• General fund of knowledge: adequate
• Judgment: Personal: Social: impaired
INSIGHT:
Insight absent
Psychological Assessment
I assess client’s condition by clinical interview and by administering some psychological tests according to the
client’s condition and her consent.
Test Administered: -

 Schizophrenia test and Early Psychosis Indicator (STEP) question.

 Human Figure Drawing.
 Pannas

Test Result: -

Schizophrenia Test and Early Psychosis Indicator (STEP) Questionnaire.

Quantitative analysis

Score Category
27 Severe

Qualitative analysis: -

Client has 27 score in (STEP) which shows that the client has severe level of schizophrenia.
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Human figure drawing (HFD)

35 years old figure drawing with 6 emotional Indicators (Monster figure, Broken lines, asymmetric Arms and
Legs, Omissions of Neck, Poor Coordinator of Body and Arms clinging to body) shows instability,
aggressiveness, immaturity and schizophrenia in the client.
Case Formulation
The interview was conducted with the client and his mother to get the information about the present complaints,
history and nature of presenting complaints and background information, also to have a clear picture of client’s
problem. According to client's mother. He has two brothers and four sisters. He is married and has four children.
The client's mother further mentioned that he has some irrational beliefs and he sticks to it. He thinks that
someone out of the is controlling him and can even hear commands from them. The client suddenly becomes
aggressive and suddenly starts beating his children and others without any reason. After every passing day his
behavior was getting more and more aggressive. He also lost his appetite and his sleep was also disturbed. He
often forgets everything that he has done. Everyone from his family is disturbed with his behavior and aggression.
His children are also getting effected.

PAANAS

Diagnosis
Schizophrenia (Severe level)
Differential Diagnosis
Schizoaffective Disorder:

Consideration of this disorder is due to the presence of mood symptoms (euphoric affect) alongside psychotic
symptoms.

Bipolar Disorder with Psychotic Features:

The client’s increased activity and euphoric mood could be indicative of a manic episode with psychotic features.

Substance-Induced Psychotic Disorder:

Although there is no history of substance abuse, this should be ruled out.

Major Depressive Disorder with Psychotic Features:

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While less likely given the absence of depressive symptoms, this could be considered if further depressive
episodes are observed.

Prognosis
The client is cooperative and has motivation to recover that's why his prognosis seems to be better.
Treatment Plan
 Target goals
Short term goals
 Symptom Stabilization:
Reduce psychotic symptoms (hallucinations, delusions).
 Improve sleep and appetite.
 Safety:
Ensure the client's safety and the safety of others around him.
Develop a crisis plan to manage aggressive outbursts.
 Medication Adherence:
Initiate or adjust antipsychotic medication.
Monitor and manage side effects.
 Psychoeducation:
Educate the client and family about the illness, treatment options, and the importance of medication
adherence.
Long Term Goals:
 Functional Improvement:
Improve overall functioning and quality of life.
 Assist in returning to a structured daily routine and possibly resuming work.
 Relapse Prevention:
Develop a relapse prevention plan.
 Regular follow-ups to monitor for early signs of relapse.
 Social Integration:
Enhance social skills and increase social interactions.
Reintegrate the client into family and community activities.
 Psychotherapy:
Engage in long-term psychotherapy to address underlying issues, improve coping mechanisms, and
enhance insight.

Sessions
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Session 1 to 3
In the first session, we will focus on establishing a therapeutic relationship with the client. This will involve
conducting a comprehensive assessment of his current symptoms, medical history, family background, and other
relevant information. We will also discuss the treatment plan, outline the goals of therapy, and ensure that the
client and his family understand the process and expectations.
The second session will be dedicated to educating the client and his family about schizophrenia. We will discuss
the nature of the disorder, its symptoms, and the importance of treatment adherence. This session aims to provide
a solid understanding of the illness, reduce stigma, and emphasize the role of medication and therapy in managing
the condition.
In the third session, we will develop a safety plan to manage the client's aggressive behaviors. This will involve
identifying potential triggers, outlining steps to de-escalate situations, and providing the family with strategies to
handle crises. The goal is to ensure the safety of the client and those around him, creating a structured approach to
managing potential outbursts.
Session 4 to 6:
During this session, we will discuss medication options with the psychiatrist and closely monitor the client's
response to treatment. We will address any side effects and concerns the client may have about his medication.
This session aims to ensure that the client adheres to his medication regimen and understands its importance in
managing his symptoms.
The fifth session will introduce the client to the basic concepts of Cognitive Behavioral Therapy (CBT). We will
start addressing distorted thoughts and beliefs that contribute to his symptoms, such as delusions and
hallucinations. The goal is to help the client develop a more realistic and balanced perspective, reducing the
impact of psychotic symptoms.
In this session, we will teach the client various coping strategies to manage stress and psychotic symptoms. This
will include relaxation techniques, grounding exercises, and other methods to reduce anxiety and improve
emotional regulation. The goal is to equip the client with practical tools to handle distressing situations.
Session 7 to 9:
The seventh session will focus on improving the client's social interactions. We will work on enhancing his
communication skills, practicing common social situations, and role-playing appropriate responses. This session
aims to help the client build better relationships with family, friends, and colleagues.
During this session, we will identify potential triggers and early warning signs of relapse. We will develop a
detailed relapse prevention plan, outlining steps the client and his family can take to prevent a recurrence of
symptoms. The goal is to empower the client and his support system to recognize and address issues before they
escalate.
The ninth session will involve a family therapy session to address family dynamics and provide support to the
client's relatives. We will discuss the impact of the client's illness on the family, improve communication, and
offer strategies for managing stress and supporting the client. This session aims to strengthen the family unit and
enhance their ability to cope with the challenges of the illness.
Session 10:
In the final session, we will review the progress made during the previous sessions and adjust the treatment plan
as necessary. We will set future goals, discuss ongoing therapy needs, and plan for regular follow-up
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appointments. The goal is to ensure that the client continues to receive support and maintains the gains made
during therapy.
Limitations and Recommendations
Psycho - education to the client: -
Psycho-education to the Client's regarding his problem will be useful to treat him and reduce the intensity of
problem.
Psycho - education to the family: -
Family Therapy can bring a change in the client behavior. It will be useful.
Deep breathing: -
Deep breathing exercise can be useful to reduce the anxiety and aggressive.
Art Therapy: -
Art Therapy will also be useful to reduce anxiety and stress and it will help the client to relax.
1) Medications: Medications are the cornerstone of schizophrenia treatment, and antipsychotic medications
are the most commonly prescribed drugs. They're thought to control symptoms by affecting the brain
neurotransmitter dopamine. The goal of treatment with antipsychotic medications is to effectively manage signs
and symptoms at the lowest possible dose.
2) Psychosocial interventions: - Once psychosis recedes, in addition to continuing on medication,
psychological and social (psychosocial) interventions are important. These may include:
• Individual therapy -Psychotherapy may help to normalize thought patterns. Also, learning to cope with
stress and identify early warning signs of relapse can help people with schizophrenia manage their illness.
• Social skills training - This focuses on improving communication and social interactions and improving
the ability to participate in daily activities.
• Family therapy- This provides support and education to families dealing with schizophrenia.
• Vocational rehabilitation and supported employment- This focuses on helping people with
schizophrenia prepare for, find and keep jobs.
3) During crisis periods or times of severe symptoms, hospitalization may benecessary to ensure safety,
proper nutrition, adequate sleep and basic hygiene.
4) Electroconvulsive therapy: - For adults with schizophrenia who do not respond to drug therapy,
electroconvulsive therapy (ECT) may be considered. ECT may be helpful for someone who also has depression.
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APPENDIX
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Case No. 2
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CASE 2
Bio Data
Name Z.A
Father Name A.F
Age 28
Gender Female
Education MBA
Religion Islam
Birth Order 1st
Siblings 3 Sis
Parents Alive
Father Occupation Business man
Mother Occupation House wife
Social Economic Status Middle Class
Address Faisalabad
Examiner H.A
Identifying Information
A Female age 28 years old. She is a house wife. Her education is M.A. She has 2 sisters. Her father is a
businessman. Her birth order is 1st. She belongs to an upper middle-class family. She is married. She has two
children. She lives in Faisalabad.
Reason and Source of Referral
The client was referred to me by DR. Imtiaz Dogar for the assessment of psychological problem
Presenting Complaints
According to client
The client is dealing with continuous sadness, stress, worthlessness, helplessness, loss of interest from last 7-8
months. The restricted environment of her home is her main problem. She wants to run away from the house and
little of time feels suicidal.
According to informant
Husband reported that he is not sleeping and eating well. He sits alone in room most of time and talks with
himself. The symptoms started 2 months ago when client’s father died in an accident.

After the accident he didn’t talk with anyone for long time and slowly started behaving differently. The client was
referred to me with the following complaints:
Presenting Complaints Duration
Sadness
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Tearfulness
7-8 months

Low appetite
7-8 months

Insomnia
7-8 months

Worthlessness
7-8 months

Loss of interest
7-8 months

Depressive mood
7-8 months

Clinical Interview
 Clinical history
Patient was very restless and agitated. She was not in position to answer anything. She kept repeating that
I want to be normal. Patient was accompanied by his husband. According to husband she became quiet
and distant after his father’s death. She couldn’t sleep well so he took sleeping pills which helped her in
getting sleep. Recently before 1 week she stopped going to anywhere restricted to just room for most of
the time. From last 2 days she was not slept for 24 hours.
Mode of onset: insidious
Duration of illness: - 7-8 months
 Developmental history
Data not available

 Personal History
Birth order: 1st
Birth and development history: normal delivery and milestones were achieved on, time no childhood
disorder present.

 Family History
There is no consanguinity between parents of the client. Patient lives with her mother-in-law and husband
and she had arranged marriage 2.5 years ago. She does not have any child.
 Educational History
The client was very good in academic. She felt anxious when she had to talk or give presentation in front
of people. She once fainted in school because she was asked to give speech. she likes to go on solo trip.
 Social History
The client has been very introverted since childhood. She didn’t have any friends growing up. She talked
very less and focused on his studies. She does not share much with anyone and talk very less with his
mother and husband. She prefers to go on a solo trip.
 Occupational History
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Client has been working as house wife after being married, and she did not have any job before that.

 History of Drug Use/Abuse: (if applicable)

Occasionally consume alcohol.
 History of Psychiatric/ Medical Illnesses
Client does not have any prior psychiatric or medical history
 TREATMENT HISTORY
The client took sleeping pills from few days

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOR:

General appearance was untidy. She hadn’t combed for two days. Today she didn’t brush and bath. She
was staring at one place and constantly blinking. Client was lean and looked unhealthy. No eye contact
maintained. Rapport could not be established with the client and there was rude attitude towards the
examiner. Client was not cooperative.

MOVEMENT AND BEHAVIOR:

Slow psychomotor movement was observed from the client. She was staring at one place and
movement was slow. But she was blinking constantly.

SPEECH:

Thought block was absent. Monotonous pitch was observed. Speed was increase and reaction time was
slow.

MOOD / AFFECT:

• Subjectively: “I am worried about my life”

• Objectively: cautious

THOUGHT:

Form of thought disorder:

absent Delusion: present

Client says, “I don’t want to do anything”.

PERCEPTION

Hallucination is absent.

COGNITIVE FUNCTIONS:
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• Oriented to time, place and person.

• Attention & Concentration around but not sustained

• Memory: Immediate memory: intact Recent memory: intact Remote memory: intact

• Abstract thinking impaired.

• Intelligence is impaired
• General fund of knowledge: adequate
JUDGMENT:
Personal: impaired
Social: impaired
INSIGHT:
Level 2- slight awareness of being sick and needing help, but denying it at the same time.

PSYCHLOGICAL ASSESSMENT:

I assess client’s condition by clinical interview and by administering some psychological tests

according to the client’s condition and her consent.

TEST ADMINISTERED

1. Human Figure Drawing Test (HFD)

2. Depression, Anxiety and Stress Scale (DASS)
3. Zung self-rating Depression Scale.
4. Beck’s Depression Inventory (BDI)

Human Figure Drawing Test (HFD)

Depression, Anxiety and Stress Scale (DASS)

Quantitative Interpretation:

Scoring Level
Depression 24 Severe
Anxiety 12 Moderate
Stress 33 Severe
Total 69
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Qualitative Interpretation:
Depression Anxiety & Stress Scale reveals that the client has severe level of depression but suffering from
moderate level of anxiety and severe level of stress due to her current conditions.

Zung Self-Rating Depression Scale

Given below is the qualitative and quantitative analysis of the test administered on the client

Quantitative Analysis:

Scoring Category
64 Moderate Depression

Qualitative Analysis:
Zung Self-Rating Test reveals that the client lies in the category of moderately depressed.

Beck’s Depression Inventory

Given below is the qualitative and quantitative analysis of the test administered on the client

Quantitative Analysis:

Score Range category

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38 31-40 Severe Depression

Qualitative Analysis:
Client has 38 score in BDI which shows that the client has severe level of depression.

Case Formulation:

The interview was reported by client herself and her sister. According to client her education is MA. She has
two sisters. Both of her sisters are unmarried. She was a good student at school. She always passed her
examinations with good grades. There was problem to her home environment because of which she could not
stay in touch with her friends. Her relationship with her sisters and mother was good but had a little conflict with
her father. After completing her M.A she got married at the age of 25. The client had a very restricted
atmosphere at her home before marriage. They were not given permission for outings or going anywhere alone.
But she was not really affected by this when she was unmarried. She used to have the hope that after marriage
her life will be change and restrictions will be finished. When she got married, she was happy in the beginning
thinking that she is now going to live her ideal life. What happened was totally different from what she assumed.
Her husband was supportive and humble but her mother-in-law was totally different from what she was before.
She had no restrictions from her husband but her mother-in-law was very strict about this. She had to even wear
the clothes of her mother in law’s choice otherwise mother-in-law would create issue and disturb the atmosphere
of house. Her desire to have freedom and liberty was doomed. The first child of a client was a daughter but her
mother- in-law was not so happy about it and forced her to have a second child as soon as possible. Luckily her
second kid was a baby boy. Meanwhile the environment her own home was transformed. Her sisters got
freedom and were allowed to go on tours and have outings with friends and was doing job. She was not even
allowed to do job. This made her more depressed. She used to feel left out. Her daily life and activities were
disturbed. She became passive aggressive. She showed her anger on her children and fought with her husband.
Her husband supports her but also cannot stand against her mother. All these situations lead her to the stage of
clinical depression. But now she decided to cope with this and discussed all these things with her sister. Her
sister supported her and brought her to the psychologist.

Diagnosis:

Major Depressive Disorder (Severe Level)

Differential Diagnosis
.
Adjustment Disorder with Depressed Mood:
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Considering the recent significant stressor (the death of her father), the symptoms could be a maladaptive
response to this event.
Generalized Anxiety Disorder (GAD): Although the primary symptoms are depressive, the client also shows
moderate levels of anxiety, which could be part of GAD.
Dysthymia (Persistent Depressive Disorder): Given the duration of symptoms, it’s important to consider a
chronic form of depression like dysthymia.
Post-Traumatic Stress Disorder (PTSD): The trauma of her father's sudden death and subsequent behavioral
changes might suggest PTSD.

Prognosis:
She has good chances of recovery if proper attention and diet provide to her. Her prognosis is possible she has
insight of her problem and she is motivated enough to solve her problem.

Treatment plan

Short-Term Goals

 Stabilize Mood: Reduce the severity of depressive symptoms and improve overall mood.
 Improve Sleep and Appetite: Establish healthier sleep patterns and nutritional intake.
 Enhance Safety: Address and manage any suicidal thoughts or behaviors.
 Increase Engagement: Encourage participation in daily activities and therapy sessions.

Long-Term Goals

 Achieve Symptom Remission: Aim for full remission of depressive and anxiety symptoms.
 Improve Functioning: Enhance her ability to function in daily life, including social interactions and
household responsibilities.
 Enhance Coping Skills: Develop and strengthen coping mechanisms to handle stressors and prevent
relapse.
 Increase Autonomy: Empower the client to make decisions about her life and gain independence within
her family dynamics.

Limitations and Recommendations:

 Proper diet and eat healthy food.
 Have a cup of tea with her husband at evening.
 Spend quality time with her children
 Catharsis
 At least give 15 minutes to her in a day
 Relaxation Techniques
 Cognitive behavior therapy
Through cognitive therapy maladaptive mood and behavior can be changed by replacing distorted or
inappropriate ways of thinking with thought pattern that are healthier and more realistic.
 Interpersonal therapy
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Sessions:
Sessions 1-3:
In the first session I tried to Establish a therapeutic relationship and gather comprehensive information about the
client’s symptoms, history, and current situation.
Second session moves to educate the client and her family about depression, its symptoms, and the importance of
treatment adherence. Discuss the impact of recent life events and the significance of her environment.
And the third session works on developing a safety plan to manage suicidal ideation. Identify triggers and provide
the family with strategies to handle crises and ensure the client’s safety.
Sessions 4-6:
Introduce the basic concepts of CBT. Start addressing distorted thoughts and beliefs contributing to depressive
symptoms.
Teached the client techniques to manage and stabilize mood, such as identifying negative thought patterns and
replacing them with more balanced thoughts.
Encouraged participation in pleasurable and meaningful activities to counteract the tendency to withdraw and
isolate.
Sessions 7-9:
Equip the client with practical coping strategies to manage stress and anxiety. Techniques may include relaxation
exercises, deep breathing. Address sources of stress in the client’s life and develop a plan to reduce and manage
stressors. This may involve setting boundaries and assertiveness training.
Teach the client problem-solving skills to address challenges in her daily life and improve her ability to handle
difficult situations.
Sessions 10-12:
Work on enhancing the client’s social interactions and communication skills. Practice common social situations
and role-play appropriate responses. Involve the client’s husband and sister in a session to improve family
dynamics and support systems. Discuss ways to create a more supportive home environment. Review the progress
made during the sessions. Adjust the treatment plan as necessary and set future goals. Plan for regular follow-up
appointments to ensure ongoing support.
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Case No:3
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CASE NO: 3

Bio-Data:

Name: MH
Age: 35
Marital status: unmarried
Gender: Male
Occupation: Student
Education: Masters (MS)
Religion: Islam
Mother tongue: Urdu
Location of residence Samundri, Faisalabad
Socioeconomic status: Upper
Informant: father and Cousin
Reliability: Reliable and consistent but inadequate

Identifying Information
Mr. MH 35 years of age, single, student of bachelors, having seven siblings, and he is last among them.
Reason and Source of Referral
The client was referred to me by DR. Imtiaz Dogar for the assessment of psychological problem.
Presenting Complaints
According to the patient
“I have no problem. My mind is super-fast and no one can match it.”
According to the informant
“He has become very aggressive and started abusing people. He had fights with his friends and brother. He thinks
that he is very intelligent and looks down on others.”
1. Aggressive behavior with every family member without any reason. Irrelevant talk complaints informed by
the family members.
2. No one understands me.
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Symptoms:
The client was referred to me with the following presenting complaints:
Presenting Complaints Duration

Aggression
4 weeks
Over talkative
Over sleep
4 weeks

Over familiarity 4 weeks

Irritability 4 weeks

Clinical Interview:
• Clinical History

The onset of the illness is acute. The client was apparently well a week ago. Three days before he got to
know that he cleared his entrance exam. He had been very ecstatic about it. Later in the evening he got
aggressive to his younger brother who jokingly said that he may have cheated in entrance exams. He
responded him saying that his mind is super-fast and he does not cheat like he does. Next day while
returning back home at bus station he abused his best friend and asked him to jump off in front of bus. he
even tried to push him. Next day he again abused his friend and got aggressive he kept repeating that no one
can match him. His father decided to bring him to the hospital. Currently there is no significant change in
his sleep pattern; he can maintain hygiene however his energy level increased his appetite has decreased
from past 2 days.
• Developmental History

Birth history was normal, Birth cry was present, Birth weight 2 kilo, Developmental milestones achieved
before handed, and no emotional or physical problems were present in childhood.
 Personal History
Birth order: first born, he has one younger brother.
 Family History
The patient family is a nuclear family. His father is a bank manager and brother are doing his graduation.
Family atmosphere is good. The patient financial status is also good.
 Educational History
The patient was good in school and used to score good marks.
 Social History
He had many friends growing up and is an extrovert..
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 Occupational History
The patient was extrovert and had many friends; he never showed any kind of resistance earlier or
aggressiveness
 History of Psychiatric/ Medical Illnesses
The patient does not have any kind of past illness/psychiatric illness.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOUR:

He was good wearing a check shirt and pant, hair was properly made well dressed and groomed,
Behavior was restless was wringing his hands and the patient was uncooperative, hyperactive, restlessbut
well dressed. Attitude towards examines- uncooperative, Rapport could not be established.
MOVEMENT AND BEHAVIOUR:
Agitation was present and the patient was constantly moving his hands.
SPEECH:
Rapid, pressure of speech was observed

productivity–high

Reaction time was decreased

MOOD / AFFECT:
Mood - irritable, euphoric

Affect- broad–congruent with mood

PERCEPTION:

No perceptual disturbances are seen from the client

THOUGHT:

• Content- Ideas of grandiosity,

• Form- flight of ideas, rapid thinking, tangentially (where the patient does not come to the point.

COGNITIVE FUNCTIONS:

• The client is oriented to time, place and date

• Attention & Concentration is aroused and sustained
• Memory:
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Immediate memory: intact Recent memory: intact Remote memory: intact

• Abstraction:
Similarities: adequate Differences: adequate Proverb: adequate General fund of knowledge: adequate
JUDGMENT:
Personal: intact

Social: intact Test: intact

INSIGHT:
Complete denial of the illness

Psychological Assessment:
I assess client’s condition by clinical interview and by administering some psychological tests according to the
client’s condition and her consent.
Test Administered:
 Bipolar Depression Rating Scale (BDRS)
 Human Figure Drawing Test (HFD)
 Depression Anxiety and Stress Scale (DASS)
 Young mania rating scale(YMRS)

Test Results:

Human Figure Drawing (HFD Emotional Indicator):

Human figure drawing test score shows that client has poor inner control and aggressiveness. HFD scores shows
that the client’s interpersonal relationships are poor. HFD score also shows that the client is mentally retarded,
poor self-concept and inadequacy seems to perceive themselves different from others.

The Depression Anxiety and Stress Scale (DASS):

 Quantitative Analysis:

Scoring level
Depression 11 Moderate
Anxiety 6 Normal
Stress 30 Severe
Total 47

 Qualitative Analysis:
Depression Anxiety and Stress scale reveals that client has moderate level of depression. Normal level of anxiety
and severe level of stress.

Bipolar Depression Rating Scale:

Given below is the qualitative and quantitative analysis of the test administered on the client.

 Quantitative Analysis:

Scoring Actual score Category

 29

0-60 38 Moderate depression

 Qualitative Analysis:
Bipolar depression rating scale reveals that the client has moderate level of depression according to his current
conditions.

Young mania rating scale interpretation (YMRS):

The Young Mania Rating Scale (YMRS) is one of the most frequently utilized rating scales to assess manic symptoms. The
scale has 11 items and is based on the patient’s subjective report of his or her clinical condition over the previous 48 hours.
Additional information is based upon clinical observations made during the course of the clinical interview. There are four
items that are graded on a 0 to 8 scale (Irritability, speech, thought content, and disruptive/aggressive behavior), while the
remaining seven items are graded on a 0 to 4 scale. As client total score was of on the base line of 35 that mean client was
under severe level and currently suffering from manic episode of bipolar disorder which is followed and precede by
depression as this scale mainly assess the patients’ manic symptoms.

Case Formulation:

Client and his brothers to get an information about the presenting complaints, history and nature of presenting
complaints and background information of the client and to have clear picture of client's problem. According to
client his education is Masters. He has 5 brothers and 1 sister. All the five brothers are married. He is on the 6th
order. His family wanted him to marry but he is not willing to marry. All his problems related to his brothers. His
relationship with his brothers is very bad. At the age of 23 he got severe typhoid due to which he got admit at DHQ
hospital. According to his brothers all her illness symptoms started at that time. This is his 2nd admission in the
hospital. Patient's nephew forcefully brought him to the hospital. His behavior got changed after that illness told by
his brothers. He shows aggressiveness towards his family specially his brothers. By the time he also has the
symptoms of grandiosity like he gave money to the people who came to meet him. He said I have that much power
that no one could stands in front of me. His mother wants him to marry but he always refused. 4 weeks ago, his
condition was very bad. His behavior with the family and friends was not so good. He used to beat the people
without any reason. He used abusive language with the people he talked. All his brothers are separated after their
marriages.
 30

Diagnosis:

Bipolar 1 Currently severe Mania 296.43(F31.13)

Differential Diagnosis:

Schizophrenia: Given the grandiose delusions and behavioral changes, schizophrenia could be considered,
though the client's symptoms align more closely with mania.
Substance-Induced Mood Disorder: Consider whether any substances could be contributing to the manic
symptoms, although there's no evidence of substance use provided.
Personality Disorders (e.g., Narcissistic or Borderline): Some features like grandiosity and aggression might
suggest a personality disorder, but the acute onset and episodic nature point more towards Bipolar I.

Prognosis:

His prognosis seems to be average because he has low motivation to recover and to solve the problems with his
brothers and not understanding about the problem are not healthy signs of his better prognosis.

Treatment Plan
Short Term Goals
Stabilize Mood: Reduce manic symptoms through medication management and therapy.
Ensure Safety: Manage aggression and prevent harm to self and others.
Increase Insight: Help the client recognize and accept his condition.
Long-Term Goals
Achieve and Maintain Mood Stability: Prevent future manic and depressive episodes.
Improve Interpersonal Relationships: Enhance relationships with family and peers.
Enhance Functioning: Improve academic performance and daily functioning.
Develop Coping Strategies: Equip the client with skills to manage stress and triggers.

Limitations and Recommendations:

He was prescribed mood stabilizers. He was asked to come after a week. Based on his condition he will be given
various psychosocial treatments such as cognitive behavior therapy, interpersonal therapy etc.
Following are the treatment plans which are helpful for bipolar patient.

Medication – Medication is the cornerstone of bipolar disorder treatment. Taking a mood stabilizing medication
 31

can help minimize the highs and lows of bipolar disorder and keep symptoms under control.
Psychotherapy – Therapy is essential for dealing with bipolar disorder and the problems it has caused. Working
with a therapist, patient can learn how to cope with difficult or uncomfortable feelings, manage stress, and
regulate mood.

Education – Managing symptoms and preventing complications begins with a thorough knowledge of illness.
The more patient and his family know about bipolar disorder, the better they will be able to avoid problems and
deal with setbacks.
Lifestyle management – By carefully regulating lifestyle, patient can keep symptoms and mood episodes to a
minimum. This involves maintaining a regular sleep schedule, avoiding alcohol and drugs, eating a mood-
boosting diet, following a consistent exercise program, minimizing stress, and keeping sunlight exposure stable
year-round. Support – Living with bipolar disorder can be challenging, and having a solid support system in
place can make all the difference in outlook and motivation of the patient. The support of friends and family is
invaluable.
 Psycho education to the family:
Psycho education to the client's family regarding his problem and condition will be useful to reduce
the problem of the client. Family therapy can bring a change in the behavior of client.
 Deep breathing:
Deep breathing exercise can be useful to reduce the aggression and depression of the client.
 Cognitive Behavior Technique:
Cognitive Behavior Therapy will also be useful to reduce the problem of the client.
 Anger management techniques:
Think before you speak, identify possible solutions, use humor to release tension and many other
ways are helpful to control your anger.
Sessions
Session 1 to 3
During the initial sessions, the focus will be on establishing a therapeutic relationship with Mr. MH, ensuring he
feels comfortable and safe within the therapeutic environment. A comprehensive history will be gathered, covering
his personal and family background, current symptoms, and the impact of these symptoms on his daily life. The
severity of his Bipolar Disorder symptoms will be assessed using standardized tools, providing a detailed
understanding of his condition. This thorough assessment will lay the foundation for an effective treatment plan
tailored to his specific needs.
 32

The second session will center around psychoeducation for both Mr. MH and his family. They will be educated
about Bipolar Disorder, including its symptoms, causes, and the critical importance of adhering to the prescribed
treatment plan. The session will also discuss the impact of recent life events and the significance of manic episodes
on his overall well-being. By understanding the nature of the disorder, Mr. MH and his family can better manage
symptoms and support each other through the treatment process.
In the third session, a safety plan will be developed to manage any potential aggression and ensure Mr. MH’s safety.
This plan will include strategies to prevent harm and address any aggressive behaviors that may arise. Involving the
family in this process is essential, as they play a crucial role in monitoring Mr. MH's behavior and providing a
supportive environment. This session aims to create a comprehensive plan that ensures the safety and well-being of
Mr. MH and his family, laying the groundwork for successful ongoing treatment.

Session 4 to 6
During the fourth session, collaboration with a psychiatrist will be a key focus to start or adjust Mr. MH’s
medication regimen aimed at managing his manic symptoms. Monitoring for side effects and effectiveness will be an
ongoing process, ensuring that the medication is providing the intended benefits without causing significant adverse
effects. This session will involve regular check-ins and adjustments as needed to optimize the treatment.
In the fifth session, the basic concepts of Cognitive Behavioral Therapy (CBT) will be introduced. This will include
helping Mr. MH understand how his thoughts, feelings, and behaviors are interconnected. The session will begin
addressing distorted thoughts and beliefs that contribute to both manic and depressive symptoms. By recognizing
these patterns, Mr. MH can start to develop healthier thinking habits.
The sixth session will focus on teaching Mr. MH techniques to manage his mood swings effectively. This includes
identifying triggers for mood changes and implementing coping strategies such as mindfulness exercises, grounding
techniques, and relaxation methods. These skills will help Mr. MH maintain a more stable mood and reduce the
impact of his symptoms on daily life.

Sessions 7-9:
The seventh session will equip Mr. MH with practical coping strategies to manage stress and anxiety. Techniques
such as relaxation exercises, deep breathing, and grounding exercises will be practiced. These skills are essential for
helping Mr. MH handle everyday stressors and prevent them from exacerbating his Bipolar Disorder symptoms.
In the eighth session, sources of stress in Mr. MH’s life will be addressed, and a plan will be developed to reduce
and manage these stressors. This may involve setting boundaries, learning time management skills, and engaging in
assertiveness training. Reducing stress will play a crucial role in stabilizing Mr. MH’s mood and overall mental
 33

health.
The ninth session will focus on teaching Mr. MH problem-solving skills to address challenges in his daily life. By
improving his ability to handle difficult situations, Mr. MH can reduce feelings of helplessness and increase his
sense of control over his circumstances. This session will involve practical exercises and role-playing to develop
these skills.

Sessions 10-12:
The tenth session will work on enhancing Mr. MH’s social interactions and communication skills. Common social
situations will be practiced, and appropriate responses will be role-played. Improving these skills will help Mr. MH
build and maintain positive relationships, which is vital for his emotional support and well-being.
In the eleventh session, Mr. MH’s family, especially his siblings and parents, will be involved to improve family
dynamics and support systems. This session will discuss ways to create a more supportive home environment and
address any familial issues that may be contributing to Mr. MH’s symptoms. Family therapy is crucial for ensuring
that Mr. MH has a solid support network.
The twelfth session will review the progress made during the therapy sessions. The treatment plan will be adjusted as
necessary, and future goals will be set. Planning for regular follow-up appointments will ensure ongoing support and
help maintain the progress achieved. This session aims to consolidate gains and prepare for long-term management.
Session 13:
The thirteenth session will involve a comprehensive assessment of Mr. MH’s progress. Goals will be revisited, and a
plan for continued support and maintenance of mood stability will be established. Emphasis will be placed on the
importance of ongoing therapy and medication adherence to prevent relapse and ensure sustained improvement. This
session will also involve setting long-term goals and strategies for maintaining the progress made during therapy.
 34

APPENDIX
 35

Case No.4
 36

CASE 4
Bio-Data:
Name: Mr. SK
Age: 55
Marital status: Married
Gender: Male
Occupation: Businessman
Education: 12th pass
Religion: Hindu
Mother tongue: Bengali
Location of residence Kolkata, West Bengal
Socioeconomic status: Upper
Informant: Brother
Reliability: Reliable and consistent

Identifying Information:
Mr. SK was age of 55 years old, having 8 siblings (4 brothers and 4 sisters), 5th in siblings, her education
was B.A, her religion Islam, and patient was self-referred.
Reason and Source of Referral:
The patient was referred to me from physician for psychological assessment and counseling.
Presenting Complaints:
According to patient
“Whenever I am in crowd or I think about being in crowd then I feel uneasy and get sensation of cold feet
and hands. I feel like I will die”
“I have problem to be in closed places like lifts and planes. But I also feel anxious when I am alone at
home.”
Informant states that
“His condition is causing a lot of distress to his family and they are ready to do anything to get him treated”
Presenting Complaints Duration

racing hearts, cold hands and feet, chest pain,

difficulty breathing and palpitation. He also
6 months
 37

5 years
experiences anxiety before sleeping and live in fear
that he may have attack any time.
He feels that lift will be closed and he will be stuck in
lift.

Clinical Interview:
 Clinical history
Five years ago the patient had started showing symptoms of anxiety and panic attacks. he would
have such attacks when he is in closed space or is alone at home. He would experience racing
hearts, cold hands and feet, chest pain, difficulty breathing and palpitation. He thought he had
heart problem. As a result, he had many physical examinations like ECG etc. But everything
came out normal. He had gone to many doctors for treatment including homeopathy, naturopathy
etc. Six months back he was alone at home and fainted in bathroom after panic attack as a result
general physician advised him to see a psychiatrist. He has travelled all the way from Kolkata to
see a psychiatrist. Since he is afraid of travelling in plane he came by train whereas his brother
came by plane. He feels that lift will be closed and he will be stuck in lift. He also experiences
anxiety before sleeping and live in fear that he may have attack any time as a result he feels
stressed and restless most of the time which is causing a lot of distress to family as well. He is
the only breadwinner of the house. he has done treatment from many doctors but nothing helped.
 38

Mode of onset: insidious

Course of illness: fluctuating
Progress of illness: static
Duration of illness: 5 years
Predisposing factors: Being in closed places or alone at
home
limiting factors: when patient goes to open space, deep
breath, rub his hands and drink water

Associated disturbance: lack of sleep, restlessness and stress

perpetuating factors: anxiety in psychological factors

 Developmental history
Data not available

 Personal History
The client stated that he had always been anxious growing up. He used to worry a lot during exams
and would not be able to sleep and eat properly.
 Family History
There is no consanguinity between parents of the client. The client’s mother is a housewife and his
father has retired from his business as he is not keeping well. He has two elder brother and they share
a good bond. The client has a son who is pursuing his higher education from USA.
 Educational History
Client is 12th pass. He didn’t have much interest in studying as a result he joined his family business
after 12th class. He liked playing cricket when he was in school.
 Social History
The client is introverted and anxious person. He is spiritual. he has difficulty bonding with people..
He used to be introvert child and had trouble talking with strangers. He described himself as a shy
person. He didn’t have many friends but he shared close bond with few people.

 History of Drug Use/Abuse: (if applicable)

Data Not available
 39

 History of Psychiatric/ Medical Illnesses

Patient is currently not taking any medication. But in the past he had gone to many doctors to treat
his physical symptoms but nothing had helped him

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOUR:

Appearance is neatly dressed. The client has touch with the surrounding. Gait and gesture is normal.
Rapport could be established and has a positive attitude towards examiner.

MOVEMENT AND BEHAVIOUR:

The psychomotor movement is normal.
SPEECH:
Speech is normal. The intensity / Tone is normal and Productivity is also normal. The client’s speech
is coherent and goal directed. Rate of speed is normal and there is no pressure or poverty of speech is
observed.

MOOD / AFFECT:
• Subjectively: “I am worried”
• Objectively: The client is concerned about his health.
The depth and the intensity of the affect is normal. Mood is observed as congruent to the thought,
communicable and appropriate to the situation.

THOUGHT:
• Content- the client had preoccupation about fear of closed spaces.

PERCEPTION:
No perceptual disturbances is seen from the client

COGNITIVE FUNCTIONS:

• The client is oriented to time, place and date

• Attention & Concentration is aroused and sustained
• Memory: Immediate memory: intact Recent memory: intact
Remote memory: intact
• Abstraction:
Similarities: adequate Differences: adequate Proverb: adequate
• General fund of knowledge: adequate
• Judgment:
Personal: intact Social : intact Test: intact
 40

JUDGMENT:
o Personal:
o Social: Intact
o Test: INSIGHT:
Level 6- true emotional insight: emotional awareness of the motives and feelings of illness which
leads to changes in behavior or lifestyle
.
Psychological Assessment:
I assess my client on the basis of Clinical interview and administering following scales that are used to
diagnose severity of anxiety patient.

• Human Figure Drawing Test (HFD)

• Clinical anxiety scale
• Hamilton anxiety scale
• State trait anxiety scale
On the basis of clinical anxiety scale, the client total score was of 60 as it’s interpreted on this basis 0–9,
normal or no anxiety; 10–18, mild to moderate anxiety; 19–29, moderate to severe anxiety; and 30–63,
severe anxiety. So, the client lies under sever anxiety level. On the basis of Hamilton Anxiety scale, the
client total score was of 27 Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score
range of 0–56, where <17 indicates mild severity, 18–24 mild to moderate severity and 25–30 moderate to
severe. That means client was under the moderate severity. On the basis of state trait anxiety, as The State-
Trait Anxiety Inventory (STAI) is a commonly used measure of trait and state anxiety (Spielberger,
Gorsuch, Lushene, Vagg, & Jacobs, 1983). It can be used in clinical settings to diagnose anxiety and to
distinguish it from depressive syndromes.it is a psychological inventory based on a 4-point Likert scale and
consists of 40 questions on a self-report basis. As the client scored 59 on STATE form and 61 on TRAIT
form which shows that client was suffering from anxiety and panic symptoms .

Case Formulation
Diagnosis:
The patient was diagnosed with Agoraphobia 300.22(F40.00). The patient also exhibits symptoms of hot
flashes, panic attacks, tension, sweating, nausea and fainting.
Differential Diagnosis:
Panic Disorder: Frequent panic attacks and fear of having panic attacks suggest panic disorder, which often
co-occurs with agoraphobia.
 41

Generalized Anxiety Disorder (GAD): Chronic anxiety and worry about various aspects of life might
indicate GAD, though the specific phobias point more towards agoraphobia.
Social Anxiety Disorder: Fear and avoidance of social situations could be considered, but the specific fears
of crowds and closed spaces are more indicative of agoraphobia.
Prognosis
The prognosis for Mr. SK is moderate. His longstanding symptoms and the significant impact on his daily
functioning present challenges, but his willingness to seek help and the support from his family are positive
factors. With consistent treatment, including therapy and possibly medication, improvement in his
symptoms and quality of life is achievable.
TREATMENT PLAN

Long-Term Goals
Reduce Anxiety Symptoms: Achieve a significant reduction in anxiety and panic symptoms.
Increase Functionality: Improve the client's ability to function in daily life, including social and occupational
settings.
Enhance Coping Skills: Develop effective coping strategies to manage anxiety and prevent future episodes.
Improve Quality of Life: Enhance overall well-being and reduce distress for both the client and his family.
Short-Term Goals
Identify Triggers: Recognize specific situations and thoughts that trigger anxiety and panic attacks.
Teach Relaxation Techniques: Implement relaxation strategies to manage immediate anxiety symptoms.
Challenge Negative Thoughts: Address and reframe irrational beliefs contributing to anxiety.
Gradual Exposure: Begin gradual exposure to feared situations to reduce avoidance behaviors.
Develop Support System: Strengthen the client's support network, including family involvement in therapy.
Case Formulation
Mr. SK, a 55-year-old man, presents with severe anxiety symptoms, particularly in crowded or closed spaces
and when alone. His anxiety manifests as physical symptoms such as racing heart, cold hands and feet, chest
pain, difficulty breathing, and palpitations. These symptoms have persisted for five years, with recent
exacerbations leading to significant distress for both him and his family. The client's anxiety has a
fluctuating course, with insidious onset and static progression. Predisposing factors include his long-
standing anxious personality and specific fears of enclosed spaces. Limiting factors involve his use of open
spaces and relaxation techniques to manage symptoms. The client has a history of extensive medical
evaluations, all of which returned normal results, reinforcing the psychological nature of his symptoms. The
client's condition is diagnosed as agoraphobia with associated panic attacks.
 42

The client was prescribed medicine to reduce the symptoms of anxiety. He was advised to start
psychotherapy as soon as possible. Doctor advised him to come again after two weeks.

Sessions

Sessions 1-2:

Initial Assessment: Conduct a comprehensive assessment to gather detailed history and understand the
severity of symptoms. Establish a therapeutic relationship and build rapport with the client.
Psychoeducation: Educate the client and his family about agoraphobia, panic disorder, and the treatment
process. Explain the role of anxiety and panic symptoms and the importance of therapy.
Sessions 3-4: Identifying Triggers and Introducing Relaxation Techniques
3. Identify Triggers: Help the client identify specific triggers for his anxiety and panic attacks. Use tools like
anxiety diaries to track situations and thoughts associated with anxiety.
4. Relaxation Techniques: Teach the client relaxation techniques such as deep breathing exercises,
progressive muscle relaxation, and mindfulness practices to manage acute anxiety symptoms.

Sessions 5-6: Cognitive Restructuring and Exposure Therapy Introduction

5. Cognitive Restructuring: Introduce cognitive-behavioral techniques to challenge and reframe irrational
thoughts contributing to anxiety. Work on developing more realistic and positive thought patterns.
6. Exposure Therapy Introduction: Introduce the concept of gradual exposure therapy. Develop a hierarchy
of feared situations, starting with less anxiety-provoking scenarios.

Sessions 7-8:
7. Gradual Exposure: Begin gradual exposure to feared situations, starting with less challenging ones. Use in
vivo or imaginal exposure techniques and provide support and encouragement during the process.
8. Coping Skills Development: Teach and practice additional coping skills, such as problem-solving
techniques, assertiveness training, and stress management strategies.

Sessions 9-10:
9. Strengthen Support System: Involve the client's family in therapy to create a supportive environment.
Provide guidance to family members on how to support the client effectively and reduce their own distress.
10. Review Progress: Evaluate the client's progress towards treatment goals. Adjust the treatment plan as
 43

necessary and set future goals. Plan for regular follow-up appointments to ensure ongoing support.

Limitations and Recommendations

Limitations: The client's long-standing anxiety and the significant impact on his daily functioning present
challenges. Limited data on developmental history and drug use/abuse may affect comprehensive
assessment.
Recommendations: Regular follow-up sessions are essential to monitor progress and make necessary
adjustments. Consider involving a psychiatrist for medication management if therapy alone is insufficient.
Continue to involve the family in treatment to provide a supportive environment and reduce distress for all
parties involved.

SEVEN COLUMN THOUGHT RECORD

Event Identify Identify What What Other What How Much

your automatic Evidence Perspective Evidence Do Do
mood (%) thoughts or Do You You You Have You Still
images Have To Can Take On To Support Believe
Support This? This Your Initial
This Alternative Thoughts?
Thought? Perspective? (%)
 44

Going in 90% I feel that lift Once That there I haven’t 60 %

lift will stop and I when I could be heard anyone
would faint. I went to some dying inside
feel like I will mall the technical the lift
die in lift. lift power issues and it because it
went off rarely was crowded
and lift happens. or power
stopped Even if it went off for
for 2 happens that few minutes
minutes does not
mean I will
die of
suffocation .
 45

FUTURE TREATMENT PLAN

Future treatment plan is to give exposure therapy to client after a couple of sessions.
It s a type of behavioral therapy that is designed to help people manage problematic
fears. Through the use of various systematic techniques, a person is gradually
exposed to the situation that causes them distress. The goal of exposure therapy is to
create a safe environment in which a person can reduce anxiety, decrease avoidance
of dreaded situations, and improve one's quality of life. Psychologist is focused to
give systematic desensitization technique to client. It is a technique incorporates
relaxation training, the development of an anxiety hierarchy, and gradual exposure to
the feared item or situation. The relaxation training might include progressive muscle
relaxation and guided imagery. The anxiety hierarchy might use something like
Wolpe's Subjective Units of Discomfort Scale (SUDS) to create a list of anxiety-
producing events on a scale from 0-100. Then, during the gradual exposure to the
ranked items, the learned relaxation techniques are applied to offset stress and
anxiety.
 46

APPENDIX
 47

Case No.5
 48

CASE 5
Biodata:
Name: NM
Age: 53
Marital status: widow
Gender: Female
Occupation: Housewife
Education: Graduate
Religion: Muslim
Mother tongue: urdu
Location of residence Faisalabad
Socioeconomic status: Upper
Informant: Son
Reliability: Reliable and consistent

Identifying Information

Reason and Source of Referral

The Client was referred from psychiatrist for further psychological assessment and diagnosis.
Presenting Complaints:
Presenting Complaints Duration

The client was reported to have forgetfulness.

1 year
She worries a lot and get panic very often. She
washes her hands and perform her task very
slow. She spends most of the time in kitchen
where she would keep washing utensils and
cleaning the floor of the kitchen. She also
spends a lot of time in bathroom to bath and
go toilet. If any guest comes at home she gets
panic
 49

Clinical Interview
 Clinical History
The client has started to show the symptoms one year ago when she started to
forget things. she feels that something is falling (dust) so she washes hands
frequently. She has two sons .one of them is living separately with the wife and
other one got divorced and living with client. She worries a lot about his second
son. She reports that praying helps her a lot and she does not have any thoughts of
washing or cleaning at that time Even though she was not much social but had 2
close friends with whom she used to meet but recently she has lost interest in
everything and does not want to meet anyone. She has arthritis and she find it
difficult to do chores but cannot help. if guests come at home she gets panic.

 Developmental history
Birth order: first child
Birth and development history: normal delivery and milestones were achieved on time,
no childhood disorder present.
 Personal History
Client shared good bond with her parents. In school she felt isolated and had low self
esteem. She had very few friends growing up. She was overweight and felt that she is not
as good looking as her cousin. As a result, she had low self confidence. She was good in
academic. Her parents encouraged her to focus on household chores than study because it
will be useful for him after marriage and not her qualification.

 Family History
There is no consanguinity between parents of the client. The client’s parents have died.
The client’s younger brother lives in same city. The client has 2 sons. One of them is
married and live separately whereas other son is divorced and live with his mother.
The communication in the family is seen normal. There is good cohesiveness in the
family. There is seen negative expressed emotions from the family towards the client.
 50

 Educational History
The client was good in academic. However, she never participated in any social activity
because she thought she was overweight and people will make fun of her. Her hobbies
were reading and writing.
 Sexual History
She shared good relation with her husband .and never had any romantic relation other
than her husband
 Social History
The client is introverted, organized and systematic in nature. She finds it difficult to talk
with strangers. Client is religious and prays 2 to 3 hours in a day.
 History of Drug Use/Abuse: (if applicable)
Data Not available

 History of Psychiatric/ Medical Illnesses

Patient has arthritis and diabetes and no history of medical illness
MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOR:

General appearance is neatly dressed, normal gait and gesture was present. Client
was overweight. The client has touch with the surrounding. Proper eye contact is
maintained. Rapport could be established with the client and there was positive
attitude towards the examiner. The client was comprehensive to simple rules from
the clinician and was cooperative for the session.

MOVEMENT AND BEHAVIOR:

slow psychomotor movement is observed from the client.

SPEECH:
The speech was normal. Intensity and speed of communication of the client was
 51

normal. There was no pressure of speech and it was coherent and goal directed.

MOOD / AFFECT:
• Subjectively: “I am anxious”,
• Objectively: the client is anxious and tired
The depth or intensity of mood is normal. The mood is stable. They are congruent
to the thought and communicable and appropriate to the situation

THOUGHT:
Content: The patient has preoccupation of illness.
PERCEPTION:
No perceptual disturbances could be elicited from the client.

COGNITIVE FUNCTIONS:
• The client is oriented to time, place and date
• Attention & Concentration is aroused and sustained
• Memory:
Immediate memory: intact Recent memory: intact Remote memory: intact
• Abstraction : intact
• General fund of knowledge: adequate
• Judgment:
Personal: intact Social : intact Test: intact

INSIGHT:
The client has insight level of 6 which means she had true emotional insight.
Psychological Assessment
HFD
YBOCS
 52

RISB
BAI

Case Formulation
NM, a 53-year-old widow, presents with symptoms of obsessive-compulsive
disorder, characterized by frequent hand washing, excessive cleaning, and
preoccupation with cleanliness. These behaviors began a year ago and are
accompanied by anxiety and panic, particularly when guests visit. Her condition
has led to social withdrawal and a significant impact on her daily functioning. NM
has a history of feeling isolated and having low self-esteem, which may contribute
to her current symptoms. She also has physical health issues (arthritis, diabetes)
that exacerbate her distress. The client lives with her divorced son and has some
family support, though negative expressed emotions from family members are
noted.

DIAGNOSIS
Patient exhibited symptoms of OCD (obsessive compulsive disorder) F42. The
client washes hands frequently and worries about germs. Because of arthritis she is
having difficulty working but still she can’t help cleaning because of the fear of
germs.

Differential Diagnosis
Generalized Anxiety Disorder (GAD): Chronic worry and anxiety about her son
and general life situations may point to GAD, but the specific compulsive
behaviors lean more towards OCD.
Depressive Disorder: The client’s loss of interest in social activities and feelings of
isolation could indicate a depressive disorder, though these symptoms are
secondary to her OCD.
 53

Somatic Symptom Disorder: The client’s focus on her physical ailments (arthritis,
diabetes) could suggest somatic symptom disorder, but the primary issue remains
the obsessive-compulsive behaviors.
Prognosis
The prognosis for NM is moderate. While her symptoms have persisted for a year
and significantly impact her daily functioning, her willingness to seek help and the
support from her son are positive indicators for successful treatment. With
appropriate psychological intervention and possibly medication, significant
improvement in her symptoms is achievable.

Treatment Plan
Long-Term Goals
Reduce OCD Symptoms: Achieve a significant reduction in obsessive-compulsive
behaviors.
Enhance Daily Functioning: Improve the client’s ability to perform daily tasks
without excessive cleaning or worrying.
Increase Social Engagement: Encourage participation in social activities and
improve overall social functioning.
Improve Quality of Life: Enhance overall well-being and reduce distress for both
the client and her family.
Short-Term Goals
Identify OCD Triggers: Recognize specific situations and thoughts that trigger
obsessive-compulsive behaviors.
Teach Relaxation Techniques: Implement relaxation strategies to manage anxiety
symptoms.
Challenge Obsessive Thoughts: Address and reframe irrational beliefs contributing
to OCD.
Gradual Exposure and Response Prevention: Begin gradual exposure to feared
situations and prevent compulsive responses.
 54

Develop Support System: Strengthen the client’s support network, including

family involvement in therapy.
Sessions
Sessions 1-2:
Initial Assessment: Conduct a comprehensive assessment to gather detailed history
and understand the severity of symptoms. Establish a therapeutic relationship and
build rapport with the client.
Psychoeducation: Educate the client and her son about OCD and the treatment
process. Explain the role of anxiety and compulsive behaviors and the importance
of therapy.
Sessions 3-4:
Help the client identify specific triggers for her obsessive-compulsive behaviors.
Use tools like anxiety diaries to track situations and thoughts associated with
OCD.
Teach the client relaxation techniques such as deep breathing exercises,
progressive muscle relaxation, and mindfulness practices to manage anxiety
symptoms.

Sessions 5-6:
Introduce cognitive-behavioral techniques to challenge and reframe irrational
thoughts contributing to OCD. Work on developing more realistic and positive
thought patterns.
Introduce the concept of ERP. Develop a hierarchy of feared situations, starting
with less anxiety-provoking scenarios.

Sessions 7-8:
Begin gradual exposure to feared situations, starting with less challenging ones.
Prevent the client from engaging in compulsive behaviors and provide support
during the process.
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Teach and practice additional coping skills, such as problem-solving techniques,

assertiveness training, and stress management strategies.

Sessions 9-10:
Involve the client’s family in therapy to create a supportive environment. Provide
guidance to family members on how to support the client effectively and reduce
their own distress.
Evaluate the client’s progress towards treatment goals. Adjust the treatment plan
as necessary and set future goals. Plan for regular follow-up appointments to
ensure ongoing support.

Limitations and Recommendations

Limitations: The client’s physical health issues (arthritis, diabetes) may limit her
ability to engage in certain activities. The presence of negative expressed emotions
from family members may also affect treatment progress.
Recommendations: Regular follow-up sessions are essential to monitor progress
and make necessary adjustments. Consider involving a psychiatrist for medication
management if therapy alone is insufficient. Continue to involve the family in
treatment to provide a supportive environment and reduce distress for all parties
involved.