Persistent Depressive Disorder

Case summary

The client 28 year’s old male was referred with the presenting complaints of nervousness,

sad and irritated mood, headache, lack of interest and pleasure in daily activities, disturbed

appetite, fatigue, and hopelessness, and sleep disturbance, difficulty in concentration. Formal and

informal assessment was done for understanding the problems of the patient. Informal assessment

included Clinical Interview, Behavioral Observation, Mini Mental Status Examination, symptom

rating and DSM-V check list. Formal Assessment was carried out using psychological assessment

tools. A management plan was devised keeping in view the condition of the client which includes

cognitive restructuring, regular exercise, social support, setting realistic goals lifestyle choice.

1
Identifying Data

Name: S.B

Age: 28Years

Gender: Male

Education Matric

Occupation shopkeeper

Socio-economic status Middle-class

Birth order Middle

Siblings 5

Marital status: unmarried

Family structure: Nuclear

Reasons for referral and resource

The client was referred by his father to the rehabilitation center. He was assessed in his

home because of the conditions as his mood was disturbed or sad, feeling tired all the time and

often anger burst out, emotions were scattered and crying, disturbed sleep, headache and upset

stomach.

2
Presenting complaints

According to the client.

‫میرادل بہت اداس رہتا ہے۔کچھ اچھا نہیں لگتا۔‬

‫کسی کام کو کرنے کا دل نہیں کرتاخوشی نہیں ہوتی۔‬

‫کسی سے ملنے کا دل بھی نہیں کرتا ـ‬

‫میں خود سے بہت مایوس ہوں زندگی میں جو چاہا حا صل نہیں کر سکی۔‬

‫محسوس نہیں کرتی۔ہروقت تھکاوٹ رہتی‬refresh ‫نیند بھی اچھے سے نہیں آتی صبح سوکراٹھوں بھی تو‬

‫ہےاورہرچیزسے چرچری ہوجاتی ہوں۔‬

History of Present Problems

The client came with the presenting complaints of, nervousness, sad and irritated mood,

headache, lack of interest and pleasure in daily activities, disturbed appetite, fatigue, and

hopelessness, and sleep disturbance, difficulty in concentration. According to the client, the onset

of his problem started when his mother died. He was very attached to his mother so after the

death of his mother he locked himself in a room he didn’t talk with anyone he said I feel like I

am alone in this whole world. Everyone was busy in their life and no one had time for me when I

needed the most. Gradually he lost interest in everything and always stayed in the room. He

reported that he was very depressed and remained in extreme grief for six months but did not

take any medical treatment

According to the client, his present problems were aroused and became severe last year

when he was going to another city to do work but he didn’t find it. He searched so many places

but no one hired him. He said at that time I felt so regretted why I left the study and from that

3
time I always see myself as a person who is worthless, valueless and can’t do anything. Also due

to this transition, he separated from his old friends, and that made him sad too. The client further

reported that he did not feel pleasure in daily life, he was burdened by reckless thoughts and

most of the time he felt body aches. He was now disappointed in himself as he did not remain a

talented person like he was in the past. He thought that he was worthless and couldn’t get good

in his life. His current situation was very much affecting his life. He was not able to get out of his

problems and this problem worsened his life badly.

Background history

Family History

The client was 23 years old boy belonging to a middle-class family and living in a

nuclear family setup. Client had seven members in his family two brothers, three sisters, and

their parents. His father was a shopkeeper and his mother was a housewife. He had a good

relationship with his father as his mother had died. The relationship between his father and

mother was good. Both had some medical illnesses as his father was a diabetic patient and his

mother was a cardiac patient. He was 3rd born of a total of 5 siblings and had one brother and

three sisters. All my siblings were studying. He had good relations with his siblings and more

closer to his older brother. He often gets upset with his family members as they did not spend

much time together and he does not share much of his feelings with his family. He does not have

a strong bond and relationship with his family and he does not spend time with them. He was not

much inclined towards other family relatives; rarely interacting with them. There was no history

of psychological illness found in his family.

4
Personal history

The client was born with a normal delivery. The client’s mother's health was good at the

birth of him. He had no prenatal or postnatal problems. He achieved all the milestones at the

appropriate age. No developmental delay was found. Currently, the client is doing work in a

utility store. He had a good relationship with his manager and co-worker and everyone was

happy with him. He had a friendly and good relationship with his colleagues. He was very

confident before this phase and now he said he was not the same person as before, more

energetic and active. The client further reported that his school life was also very good,

energetic, and happy. He did well in his school. After he had done Middle he lost interest in

studies so he left it. Before the onset of the problem client was socially active and living a

healthy social life he was having healthy relations with others. His familial relationship was also

healthy and he was enjoying all the events joyfully with his family. And now he was feeling very

irritated and not feeling interested in anything. The client had chicken pox in his childhood and

survived the illness successfully. Often he had a fever. He had no allergy problems. The client

had reported no past psychiatric history.

Premorbid Personality

The client was living a healthy and normal life. He was free from all pain and suffering

before the death of his mother. He has stable relations with his father and siblings. He was

actively engaged in arts and crafts activities in the school. He was active and lively. He was quite

sensitive in nature and always wanted to do things as he liked to do. He was a little aggressive in

nature. He was confident, talkative, and energetic and had a happy mood.

5
Educational history

The client studied till 10th class after that he left study and do nothing. He said he are not

much interested in studies so he left.

Preliminary investigation

 Formal assessment

 informal assessment

Informal assessment includes following non-standardized tools.

1. Mental State Examination (MSE)

2. Clinical interview and Behavioral observation

Clinical interview

An interview was conducted with the client and information about his presenting

problems, family and personal history, educational history and social history was gathered.

Behavioral observation

During interview his behavior was normal, he was not in a state of aggression, but he was

having low mood most of the time and find to be irritated some time. He seems to be restless and

was talking too much. His attitude during assessment was normal he was answering all the

questions very clearly and in cooperative manners. He frequently switches from one topic to

another during interview. When he was telling about her dreams and failures, he became teary

eyes and took few pauses then continues the conversation. During interview he seems to be

fatigued. He was maintaining eye contact and sitting on the sofa with ease. Sometimes he used to

shake his legs in response to stress during assessment. Sometime it was difficult for him to

6
pronounce some words during the interview, but overall his behavior was cooperative and

interactive.

Mental state examination (MSE).

A mental State Examination was administered to the client. The client was tall and fair,

wearing a salwar kameez. When he came in the room he seemed as appropriate. The tone of his

voice was high. His attitude was cooperative. His behavior was normal and he seated in a normal

way. He was confident and openly answered each question. Rapport was built after some time.

The client was well-oriented with time, place, and person.

Formal assessment.

1. Mini Mental State Examination (MMSE)

2. Hospital Anxiety Depression scale (HADS)

3. House Tree Person (HTP)

Mini mental state examination (MMSE).

Table 01

Quantitative analysis

Maximum score Obtained score Interpretation

30 27 Normal cognitive function

Qualitative analysis

7
The client performed test in the rehabilitation center and gave responses without delay. The

client scored 27 which lie in normal range and shows no cognitive impairment and has good

orientation.

Hospital Anxiety Depression Scale (HADS)

Table 02

Quantitative analysis

Obtained score Cut off score Interpretation

15 0-21 Moderate lev el of depression

Qualitative analysis

The client's score on anxiety items is 04 and on the depression scale 11 by summing the

score of both the total score obtained is 15 which indicates the client had a moderate level of

depression

House tree person (HTP)

Interpretation

The figure drawn at the lower placement indicates low energy and feelings of insecurity

and depression. The tree is six years old and shading on only specific head regions shows his

over-concern about his thoughts cloud-like tree unrealistic thoughts. Sketchy and faint lines

show anxiety and depression. The client draws a central and slightly small house showing a lack

of energy and depression. The closed door, windows, and lack of details indicate withdrawal

defensive behavior. Excessive smoke in the chimney indicates inner tension, aggression,

8
 conflicts, and emotional disturbance. Little shading shows anxiety and faint sketchy lines show

depression. The figure drawn at the center of the paper that indicate person's need for support

figure is of Same-sex which shows restlessness in behavior the face figure indicates social

Tentative Diagnosis

300.4 (F34.1) Moderate Persistent Depressive Disorder (Dysthymia)

Case conceptualization

Client, male Age, 28

a

Age

Perpetuating factors Protective factors

Predisposing factor Negative thoughts,
Precipitating factors
Hopelessness, social isolation Strong family support, healthy
Death of his mother Unemployment
coping mechanism

9
Case formulation

Humanists believe that there are needs that are unique to the human species. According to

Maslow (1962) the most important of these is the need for self-actualization (achieving out

potential or achieving the goal). The self-actualizing human being has a meaningful life.

Anything that blocks our striving to fulfill this need can be a cause of depression. In this case he

was not able to achieve his goal, faced failure and not able to fulfill his dreams and needed so

develop a negative self-image and feel depressed because of a failure to live up to desired

standards.

Behaviorism emphasizes the importance of the environment in shaping behavior.

Therefore depression was the result of a person's interaction with their environment. Operant

conditioning states that depression was caused by the removal of positive reinforcement from the

environment according to Lewinsohn in 1974. Certain events, such as losing your job or failure

in examination, induce depression because they reduce positive reinforcement from others.

Depressed people usually become much less socially active. In this case event of failure in entry

examination induced depression in his as it reduce the positive reinforcement and appreciation

from self or others by not getting admission in the desired field or institution

Cognitive approach this approach focuses on people’s beliefs rather than their behavior.

Depression results from systematic negative bias in thinking processes. The major cognitive

theorist Beck (1967) studied people suffering from depression and found that they negatively

appraised events. He identified that the cognitive triad is three forms of negative thinking (i.e.

helpless and critical) that are typical of individuals with depression: namely negative thoughts

about the self, the world and the future.

10
 These thoughts tended to be automatic in depressed people as they occurred

spontaneously. For example, depressed individuals tend to view themselves as helpless,

worthless, and inadequate. They interpret events in the world in a unrealistically negative and

defeatist way, and they see the world as posing obstacles that can’t be handled. Finally, they see

the future as totally hopeless because their worthlessness will prevent their situation improving.

In this case failure event of client negatively influencing her thinking process that he view

herself worthless and inadequate, can’t achieve good in his future, this results in developing

depressive tendencies in him

Short Term Goals

 Establishing rapport through empathy and active listening

 Psycho-educating the client about the drug and associated problems

 Learn Anger and Stress Management Skills.

 Individual and group counseling sessions.

Long Term Goals

 Continuation of short-term goals.

 Develop healthy stress-free management skills

 Follow-up sessions

11
Management Plan

Cognitive restructuring

It is a therapeutic process used in CBT to identify, challenge, and change negative or distorted

thought patterns. In this technique, we used a thought record sheet with the client to recognize his

negative thoughts and then challenge their negative thoughts after that client was asked to replace

their negative thoughts with positive ones. The patient was told that he had negative views about

the world, about herself, and about the future which are the main reasons for her hopelessness. He

was told that it is all in his thoughts and that he was in control of it all. he was told that he thinks

that he has no care-taker which is a ‘negative view about the world’, he also thinks that he can’t

work which is a ‘negative view about himself’ and he views that there is no betterment in the future

for his part of his ‘negative view about the world’.

Mindfulness techniques

In this technique client was asked to close their eyes and deep breaths while doing so client

inhaled for 5 seconds and then exhaled slowly. A progressive muscle relaxation technique was

also used with the client. This helps the client to manage their feeling of irritation and sadness

promote relaxation and reduce the intensity of emotions.

Regular Exercise

The client was asked to incorporate regular exercise into his routine. Physical activity

releases endorphins which act as natural mood lifters reducing feelings of sadness and anxiety

improving mood and reducing stress. Exercise can also enhance the quality of sleep as better sleep

contributes to improved mood and well-being. Activities include walking, dancing, and musical

chairs, yoga.

Social Support

12
 The client was asked to make connections with friends and family. As Social support

provides comfort, reduces isolation, and offers a sense of belonging. For that purpose, the client

was asked to be involved in the group class, discussion, and other activities. This helps the client

to overcome their stress and negative thoughts.

Healthy Lifestyle Choice

A healthy lifestyle doesn’t solely treat depression but it creates a supportive environment

that complements therapy. The client was asked to adopt a balanced diet, ensuring adequate sleep

so that he can actively participate during the therapy and overcome their stress.

Setting Realistic Goals

In this technique, set achievable short-term and long-term goals, and foster a sense of

accomplishment and purpose. This helps the client to be on track and more focused on their goal

in this way the client is concerned about his next step and prevents him from devaluing themselves.

Summary of Sessions

There are tenth sessions of the client and every session is 30 minute. Formal assessment

(applied different tests) and informal assessment (unstructured interview and behavioral

observation). Management plan for the client and different techniques that are very helpful for

therapist to modifying the client behaviors. According to presenting complains and symptoms of

the client, organized the sessions for the client, therapist first session, demographic information

and brief history was taken, when it was done successfully then try to build rapport with the client.

Then a detailed history and used techniques. After that work on the goals to maintain behavior,

moods personal issues resolve, negative thoughts and behavior that contribute to depression, and

positive change in his life. The session was terminated after his therapies. He was asked to come

for follow-up sessions.

13
Pre and post-intervention

The pre and post-intervention scoring is based on the subjective rating scale.

Targeted behavior Pre-intervention Post-intervention

Sadness 9 6

Loss of interest 8 4

Hopelessness 9 5

Sleep issues 8 3

Irritability 8 4.5

10

9
9 9
8
8 8 8
7

6
6
5
5
4 4.5
4
3
3
2

0 pre-intervention post - intervention Column1

sadness loss of interest hoplessness sleep issues irritibility

14
References

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper

& Row.

Lewinsohn, P. M. (1974). A behavioral approach to depression. The psychology of depression:

Contemporary theory and research. FriedmanR. J. KatzM. M.(Eds.), The psychology of

depression: Contemporary theory and research, 318.

Maslow, A. (1962). Toward a psychology of being. D Van

Nostrand. [Link]

15
Annexures

16
17
18
19
20
Session No. 1

In the first session, Demographic details and history were taken from the attendant. Patient

was informed about consent and rapport was tried to establish but the patient was very guarded.

The family was given informational care.

Session No. 2

Session 2 was taken with the attendant and the client. Rapport was a key element in this

session which was established using the techniques of empathy and by ensuring social support.

Rapport was necessary to establish because the patient was very unresponsive and information was

required to properly establish therapeutic alliance. The patient had started informing a bit about his

life. He reported that he thinks that he is worthless and that he has no energy to work which is a

great source of stress for him.

Session No. 3

In the third session formal assessment was conducted. BDI was conducted to check the level of

depression of the client. As the client has also anxiety problem so BAI is scheduled for the next

session.

Session No. 4

In this session client was informed about the purpose of the test and give instructions to complete

the test. Beck Anxiety Inventory was conducted on the client to measure the level of Anxiety.

House Tree Person is scheduled for the next session.

Session No. 5

21
 In this session to assess the client HTP was conducted. Client are asked to draw a picture of

house person, and tree. Client are instructed to perform the whole test.

Session No. 6

Management plan was organized for the client according to the problematic behavior of the

client. First technique is used to overcome the negative thinking of the client. In this session client

was asked to replace his negative thinking with positive one by challenging the distorted thoughts.

Session No. 7

In this session mindfulness technique was used with the client to reduce their stress and intensity

of emotions. Client are asked to deep breathe whenever he feels anxiety and tension. Client was

guided about the PMR technique.

Session .08

In this session progressive muscles relaxation technique is properly applied on the client. Firstly

client informed about the steps of PMR then one by one each step is done by the client. This helps

the client to relax his body and reduce muscles tension.

Session .09

In this session client was instructed to incorporate regular exercise in their routine. Do walk,

cycling, yoga and also asked to get involved in the group class don’t isolate themselves with the

other take part in activities. Client are asked to meet with others share new ideas discuss things.

Client is also asked to maintain healthy life style and take proper diet.

Session .10

22
 In this session client are asked to set short term and long term goals for himself and start working

on it. So that his attention will remain focused and do not interrupt his routine. As client was already

admitted person in the rehabilitation center so after taken 10 session with him his behavior was

managed enough and therapy was terminated.

23
 Obsessive Compulsive Disorder

Case summary

N.S. was a 24-year-old unmarried male currently doing a master's. He was accompanied

by his mother with complaints of preoccupied thoughts and repetitive acts like overthinking

about repetitive hand washing and bathing, cleaning furniture, and changing bedsheets for 1 year.

He was diagnosed with 300.3 (F42) Obsessive Compulsive Disorder based on formal and

informal assessments which include, a mini-mental status examination, Yale-Brown Obsessive

Compulsive Scale informal assessment including clinical interview, behavioral observation, and

mental state examination. A management plan was developed for the client in which different

techniques are applied are Exposure and response prevention, Acceptance and commitment

therapy, and Cognitive restructuring.

24
Bio Data

Name N.S.

Age 24 years

Sex Male

Education Master's

No of siblings 3

Birth order Middle born

Marital Status Single

Religion Islam

Family System Nuclear

Residence Islamabad

Informant Mother

Reason and source of referral

He was accompanied by his mother with complaints of preoccupied thoughts and repetitive

acts like overthinking about repetitive hand washing and bathing, which disturbed his daily life

activities. He was referred to a trainee psychologist for the management of his problems.

Presenting Complaints (by client)

‫بار بار بیڈ شیٹ ٹھیک کرتا ھوں۔‬

‫میں بار بار ہاتھ دھوتا ہوں۔‬

‫بار بار فرنیچر کی جھاڑ پونچھ کرتا ھوں۔‬

‫میں جب تک چیزوں کو دو سے تین بار دھو نہ لوں مجھے بےچینی محسوس ھوتی ہے۔‬

25
History of present illness

The client’s history of present illness dates back to 2022. The client reported that their

symptoms began starts gradually 6 months ago when he suffered from a severe throat infection.

After that intrusive thoughts about germs and contamination started. He spends much time in

washing their hands and cleaning their house. He also started avoiding social situations because

he was afraid of getting sick. He starts cleaning furniture and changing his bedsheets. The client

reported that he tried to restrain his thoughts and told himself that these things were clear but still

his mind was preoccupied with such thoughts. This overthinking caused him a big deal of stress.

He reported that he spent a lot of time thinking about such useless things and could not focus on

their studies. It affected his studies and resulted in poor performance in exams. It caused him

much stress and he started overthinking about his poor performance. He tried to control these

thoughts but had no control over them.

After passing the final exams, he started focusing on his studies. It was making it hard for

him to keep his attention on other tasks like attending lectures. He reported that he tried to

distract himself from these thoughts by doing some work but he couldn’t control the thoughts

and causes dissatisfaction and mental stress. He discussed this situation with his family but they

did not considered it as a problem as they have no awareness about it. He did not go for any help

as he reported that he didn’t know if it was a problem or not. When he was doing FSc he said I

liked to arrange my books and set them properly in the cupboard but after the problem, he

thought that there is dust everywhere and wanted to clean them despite those things being

cleaned. He started washing his hands many times a day. He reported that he had urged to do

these acts because his mind could not be satisfied unless these acts were performed. . He said

that these acts were increasing day by day and time to the extent that he sometimes forgot the

26
actual work to be done in that time. Meanwhile, he met one of his friends who doing a master's

in psychology client said I discussed my problem with my friend and he suggested me to consult

with a psychiatrist. He told him that he had symptoms of OCD. He was referred to trainee

psychologist for his management. He told his family members. The client searched and read

about OCD on Internet so that he got insight about their problem and motivated for treatment

Background history

Family history

The client belongs to an upper-middle-class family. He lives in a nuclear family with his

parents and siblings. His father is a government employee. As reported by the client, he has a

rigid and stubborn personality. The client had good relations with his parents. The client’s

mother is a housewife. She has a friendly nature. The client reported being more attached to his

mother, he shared problems with his mother and had a satisfactory relationship with his mother.

He used to help his mother with household chores but after the worsening of his condition, he

became aggressive towards his mother and elder siblings as well. But before he was a good

person.

Personal history

the client was born through normal delivery, had first cry at the time of birth, and his

mother did not suffer through any pre or post-natal complications. All the developmental

milestones were achieved at age-appropriate levels. The client reported that he had a habit of leg

shaking since childhood. He said that he had an active imagination. He was naughty and

confident. He was friendly and lively child who liked to spend time with friends and family. He

27
was also a responsible person. He reported no history of any physical illness or head injury.

Educational history

The client was admitted to the school at the age of 4 years. He was obedient and

compliant student. He has been hard-working since childhood. He was a high achiever and

participated in all extra-curricular activities. According to the client, after the onset of symptoms,

his education was severely affected. He could not pay attention and concentrate on his studies

due to overthinking and performing compulsive acts.

Premorbid Personality

The client himself was an active and extroverted person. He was naughty since childhood.

He was outgoing, confident, and friendly by nature. He enjoyed the company of his friends and

family. He was not shy but he became sensitive when it came to family issues. Since he is a

brilliant student, he has a bossy nature when it comes to work. He liked to lead when working in

a group. He had an active imagination and reported that he used to live in his fantasies. He liked

to watch English movies and series. When asked about religious inclination, he reported that he

was regular in prayers, 5 times a day.

Preliminary Investigation

Informal assessment

Formal assessment

Informal Assessment

An informal assessment was carried out to assess the client’s problem and plan

therapeutic intervention based on his problems. The following measures were used for this

28
purpose

Clinical interview

A clinical interview was conducted with the client to get information about the client’s

problematic behaviors and complaints and to find out possible causes underlying these problems.

It is used as a way to gather information to help determine the appropriate course of treatment.

Before conducting the clinical interview, consent was taken from the client and he was assured

of the confidentiality of information. A detailed clinical interview was conducted with the client

and his mother who told about the presenting complaints, the history of the client’s illness,

information about the family background, and the client’s personal history.

Behavioral observation

During the interview client's behavior was not normal, he was not in a state of relaxation,

but he was having a low mood. He seemed to be restless and was talking too much. His attitude

during the assessment was normal he answered all the questions very clearly and cooperatively.

When he was telling about their problem it shows that the client had good insight about their

problem. During the interview, he seemed to be fatigued. He was maintaining eye contact and

sitting on the sofa with ease. Overall his behavior was cooperative and interactive.

Mental state examination (MSE).

A mental State Examination was administered to the client. The client was of normal

height and fair, wearing a salwar qameez. When he came in the room he seemed as appropriate.

The tone of his voice was low. His attitude was cooperative. His behavior was normal and the

setting position was not relaxed. He was confident and openly answered each question. Rapport

29
was built after some time. The client was well-oriented with time, place, and person. The client

was also motivated toward his treatment as the repetitive pattern of his daily routines worsened.

Formal Assessment

The procedure of formal assessment included the following steps:

 Mini-Mental Status Examination (MMSE)

 Yale-Brown Obsessive Compulsive Scale ( Y-BOCS)

Mini-Mental State Examination

Table 01

Quantitative analysis

Maximum score Obtained score Interpretation

30 30 Normal cognitive function

Qualitative analysis

The client performed tests in the rehabilitation center and gave responses without delay.

The client scored 30 which lies in the normal range shows no cognitive impairment and has good

orientation.

30
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Quantitative analysis

Table 02

Obtained score Cut-off score Interpretation

22 16- 23 Moderate symptoms

Qualitative analysis

It involves a structured interview where the individual rates the time spent on obsessions

and compulsions, distressed caused, resistance to thoughts, and interference in daily functioning

According to the test the client scored 22 which falls within the criteria of moderate obsessions

and compulsions.

Tentative Diagnosis

300.3(F42) Obsessive Compulsive Disorder with good or fair insight

31
 Case Conceptualization

Client, male, age, 24

Predisposing factor Perpetuating factor Protective factor strong

Biological factor Precipitating factor overthinking reinforce social support, self -
Persistent thoughts about medical cause which clients negative or awareness, healthy coping
having germs and triggered OCD symptoms disturbing thoughts mechanism
contamination

Case formulation

Obsessive-Compulsive Disorder (OCD) is a common psychiatric disorder defined as

obsession compulsion, or both, which causes marked disturbances or interferes with daily

functioning. Obsessions are repetitive thoughts, desires, or ideas that are experienced in a

disturbing and unwanted way. Obsessions are repetitive behaviors or mental acts that a person

feels perform in response to an obsession in a ritualistic way (American Psychiatric Association,

2013).

The content of obsessions and compulsions varies from person to person; however, recent

research on the multidimensional structure of OCD identified 4 common symptoms: Obsession

32
with contamination compulsion to wash; Accountability for annoying obsessions/compulsion to

check; Unacceptable thoughts (sexual, religious, or aggressive); Obsessions of symmetry,

completion or order/coercion adjustment. Various studies have emphasized the fundamental role

of executive functions in the etiology and persistence of OCD symptoms (Hekmati, 2012). The

ability to manage the intervening components in goal-oriented behaviors and predict the

consequences of performance is called the executive function. Cognitive flexibility is one of the

executive functions involved in OCD (Abramovitch et al., 2013) which is the capacity to change

and modify active memory and attention and choose a response to internal and external demands

(Deák & Wiseheart, 2015).

Cognitive flexibility is the ability to change cognitive sets to adapt to changing

environmental stimuli, i.e. abilities, such as changing one’s perspective or adapting oneself to

new laws, requirements, or environmental conditions (Dennis & Vander Wal, 2010). Poor

performance in tasks that require flexible behavior is often one of the specific clinical symptoms

of OCD (Vaghi et al., 2017). Studies have shown that the integrity of basal ganglia and their

relationship to the frontal cortex plays a vital role in the emotional, cognitive, and motor

flexibility required for goal-oriented behaviors. Also, evidence from obsession neuroimaging

studies suggests that performance in cognitive flexibility tests may be moderated by the

dorsolateral prefrontal cortex and frontal-striatal circuitry branches (Francazio & Flessner, 2015).

These brain areas are known as potentially dysfunctional areas in disorders characterized by

OCD-related behavior.

A study (Kang et al., 2012) showed that patients with OCD had a significant reduction in

perspective-taking compared with the control group and experienced perceptual bias of hate in

response to ambiguous facial expressions.

33
 The effects of OCD on children and adolescents are considerable. They include agitation,

poor attention span, lack of concentration, slow performance, and problems linked to poor

academic functioning and difficulty maintaining relationships If OCD is left untreated there may

be many negative effects on a child's learning. The rituals OCD students engage in could cause

attendance problems. They may avoid situations that increase their obsessive thoughts and,

therefore, miss learning time. Many times the compulsive behaviors of the student with OCD

result in bullying or victimization by other students (Paige, 2007). It is crucial for students with

OCD that school personnel be aware of the symptoms and inform other staff members so the

student receives the proper help. The most beneficial way for school personnel to help students

with OCD is with clear expectations, smooth transitions, and a calm climate School personnel

may need to provide classroom accommodations such as allowing extra time to take a test,

having one staff member that the student with OCD can always turn to, and providing a haven

for the student when he or she is having intense thoughts or feelings due to their OCD. Under

Section 504 or Individuals with Disabilities Education Act (IDEA), students may qualify for

special education services if the disorder impairs learning to a significant degree. School

personnel should be aware of these special education services and above all else provide a safe

and supportive environment (Paige, 2007).

Short Term Goals

• for starting treatment and developing trustworthy therapeutic relationships, rapport building

will be done by giving unconditional positive regard and empathy to the client.

• Normalization will be done to remove the alien effect associated with the symptoms.

• Detach mindfulness / letting go technique will be used to help client to reduce his habit of

suppressing thoughts regarding obsessions.

34
• Coping statements (Leahy, 1996) will be given to the client to control his compulsive

behaviors.

• Relaxation techniques like deep breathing and progressive muscle relaxationx will be used for

stress and anger management.

• Cognitive restructuring will be done to change negative beliefs.

• Exposure and response prevention will be used to reduce the rituals.

• Attention training technique will be used to enhance and improve his attention and

concentration.

Long Term Goals

• Continuation of the short term goals

• Continuing follow up session will be conducted to monitor the changes brought by therapy

and to keep check and balance.

Management Plan

A management plan was devised consisting of both short and long term goals stated below

Exposure and response prevention (ERP)

Acceptance and commitment therapy (ACT)

Cognitive restructuring

Exposure and response prevention (ERP)

During exposure and response prevention (ERP), the client is gradually exposed to

situations that trigger their obsession, without allowing them to engage in the compulsion of

hand washing. At first, I asked the client to touch a dusty surface with his hands for a brief

period and then resist the urge to wash their hands. Over time, I gradually increase the duration

of contact and continue to resist the compulsion. Through repeated exposure to the trigger

35
without giving in to the compulsion, the client learns that their anxiety decreases naturally and

that they don't need to rely on the compulsion to feel relief.

Cognitive restructuring

As clients have an obsession with having germs he always cleans their house being

contaminated and believes that if they don't clean it excessively, something terrible will happen.

Through cognitive restructuring, identify and challenge these negative thoughts. I discussed

some examples related to daily life that contradict their belief, such as instances where they

didn't clean their house excessively daily and nothing negative occurred. It also helps him

develop more balanced and realistic thoughts, like acknowledging that it's normal for a house to

have some level of germs and that excessive cleaning doesn't guarantee safety. By challenging

and replacing these negative thoughts with more rational ones, individuals can gradually reduce

the anxiety and compulsive behaviors associated with their OCD.

Acceptance and commitment therapy

When working with ACT, client are also encouraged to identify their values and commit

to taking actions that align with those values, despite the presence of OCD symptoms. I taught

him that if his value is spending quality time with loved ones, he must choose to engage in

activities with their family or friends, even if their OCD tells them to isolate themselves due to

contamination fears. By practicing acceptance and committing to meaningful actions client

reduces the impact of OCD on his daily life and focuses on what truly matters to him.

Summary of session

There are tenth sessions of the client and every session is 30 minute. Formal assessment

(applied different tests) and informal assessment (unstructured interview and behavioral

36
observation). Management plan are develop for the client and different techniques that are very

helpful to modifying the client's behaviors. According to presenting complains and symptoms of

the client, organized the sessions for the client, therapist first session, demographic information

and brief history was taken, when it was done successfully then try to build rapport with the client.

Then a detailed history was taken and used techniques. After that work on the goals to maintain

behavior, negative thoughts and behavior that contribute to OCD symptoms and disturbed his daily

routine. Session was terminated after his therapies. He was asked to come for follow up sessions.

37
Pre and post-subjective rating

Targeted behavior Pre-intervention Post-intervention

Washing hands 9 4

Thought of bathing 8 3

Cleaning furniture 8 2

Anxiety 9 5

Graphical representation

10

0
washing hands thoughts of bathing cleaning furniture anxitey

pre intervention post intervention

38
References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(DSM-5). Washington, DC: American Psychiatric Association Publishing.

[DOI:10.1176/appi. books.9780890425596]

Abramovitch, A., Abramowitz, J. S., & Mittelman, A. (2013). The neuropsychology of adult

obsessive-compulsive disorder: A meta-analysis. Clinical Psychology Review, 33(8),

1163-71. [DOI:10.1016/[Link].2013.09.004] [PMID]

Hekmati, I. (2012). [Comparison of executive functions in subclinical obsessive-compulsive

disorder without depressive symptoms (Persian)]. International Journal of Behavioral

Science, 6(1), 39-47. [Link]

Deák, G. O., & Wiseheart, M. (2015). Cognitive flexibility in young children: General or task-

specific capacity? Journal of Experimental Child Psychology, 138, 31-53.

[DOI:10.1016/[Link].2015.04.003] [PMID]

Francazio, S. K., & Flessner, C. A. (2015). Cognitive flexibility differentiates young adults

exhibiting obsessive-compulsive behaviors from controls. Psychiatry Research, 228(2),

185-90. [DOI:10.1016/j. psychres.2015.04.038] [PMID]

Kang, J. I., Namkoong, K., Yoo, S. W., Jhung, K., & Kim, S. J. (2012). Abnormalities of

emotional awareness and perception in patients with obsessive-compulsive disorder.

Journal of Affective Disorders, 141(2-3), 286-93. [DOI:10.1016/[Link].2012.04.001]

[PMID]

Paige, L. Z. (2007). Obsessive-compulsive disorder. Retrieved June 28, 2009, from:

[Link]/resources/principals/nassp_obsessive.

39
Annexures

40
41
42
43
Session 01

In the first session, Demographic details and history were taken from the attendant. The

patient was informed about consent and rapport was tried to establish but the patient was very

guarded. The family was given informational care.

Session No. 2

Rapport was a key element. In this session using the techniques of empathy and ensuring

social support rapport was built with the client so that the client could share their problems openly.

Educate the patient about what OCD is and how it manifests. The patient had started informing a

bit about his life and his problems. He reported that his repetitive thoughts and behaviors disturbed

his personal life as well as his academic.

Session No. 3

In the third session, a formal assessment was conducted. YBOCS was conducted to check the

severity of the problem of the client. To check if there is any cognitive impairment MMSE was

also applied.

Session NO.4

In the fourth session, a mini-mental state examination was conducted on the client to check if

there is any cognitive impairment the client had that triggered his symptoms more. The

management plan was also organized for the client.

Session 5

In this session Introduce cognitive restructuring techniques to challenge negative thoughts and

44
beliefs that helps the patient to identify and reframe irrational thoughts related to their OCD.

Session 6

In this session introduce the concept of ERP, which involves gradually exposing the

patient to their feared thoughts or situations. Collaboratively develop an exposure hierarchy and

create a plan for implementing ERP exercises.

Session 7

In this session encourage the client the accept intrusive thoughts and uncomfortable

feelings associated with OCD and teach the client how to focus on the present situation and get

rid of his negative thinking patterns by engaging in group discussion.

Session 8

In this session asked the patient to identify their values and goals and discuss how OCD

interferes with his life? If they don’t accept the reality and focus on those unrealistic thoughts

their life worsen day by day.

Session 9

In this session review the progress made throughout the therapy process and consolidate

the skills and techniques learned so far.

Session 10

Discuss termination of therapy and create a plan for ongoing self-care and support and

also provide resources for continued support, such as support groups or self-help materials.

45
 Cannabis withdrawal disorder

Case Summary

The client 36 year’s old male was referred with the presenting complaints of anger,

restlessness, body aches, cravings, sadness and watery eyes and nose. Formal and informal

assessment was done for understanding the problems of the patient. Informal assessment included

Clinical Interview, Behavioral Observation, Mini Mental Status Examination, symptom rating and

DSM-V check list. Formal Assessment was carried out using Drug Use Disorder Identification

Test (DUDIT) and House Tree Person (HTP). Based on psychological assessment of the client, he

was diagnosed with Cannabin’s Use Disorder .A management plan was devised keeping in view

the condition of the client.

46
Biodata

Name MT

Age 36 Years

Gender Male

Education Uneducated

No. of siblings 5 (2 brothers and 3 sisters)

Birth order 2nd born

Marital Status Married

Religion Islam

Informant Patient and his brother

Reason and Source of Referral

The patient was brought to the rehabilitation center because of excessive use of Marijuana.

He consumed Marijuana and heroin by inhalation and smoked and the quantity was twice a week.

He came with presenting complaints of anger, restlessness, difficulty in daily tasks, irritability and

relationship issues, and sleep deprivation he was referred to a psychologist for psychological

assessment and management of his symptoms.

47
Presenting Complaints

‫میں چرس کے ساتھ سگریٹ کے بغیر نہیں رہ سکتا‬

‫جب مجھے یہ نہیں ملتا تو میں جارحانہ ہو جاتا ہوں۔‬

‫کبی کبی سر درد اور جسم میں درد ہوتا ہے اور ناک اور آنکھوں سے پانی آتا ہے‬

‫مجھے بیچنی ہوتی ہے اور چرچراپن مہسوس ہوتا‬

‫جب میں اسے نہیں لیتا ہوں تو میں روزانہ کام نہیں کرسکتا‬

‫میری نیند بھی خراب ہی ہے‬

History of Present Illness

The history of the drug intake of the patient dates back to 2015, when under the influence

of his friend’s company he started taking Marijuana, it gave him a sense of pleasure and strength

so he started taking it regularly, he used to take marijuana by putting it in cigarette, once someone

in his social circle on purpose gave him heroin in cigarette. It gave him more power and strength

so he became addicted. He mentioned that the drug’s use helped him by providing him immense

strength and helped him increase his focus so he started taking it on a regular base.

He also started to take opium through injection; however the intensity was only once in

month, but he soon realized that this was not appropriate, and wasn’t something of his level, so he

left it. Thus the patient had a history of multiple drug intake, however, from the previous few

months he was mainly using Marijuana through inhalation or smoking and he was unable to get

48
rid of that. initially, he tried to do that on his own, but cravings were so intense for him to manage,

so he had multiple relapses, 3 months ago he started to seek medical help to get rid of addiction,

multiple medicines including Velium, livotril, brouphen were suggested to him, but he reported

that the side effect of this drug was his extreme aggressive behavior, so he left those medications.

Background History

Family History

The patient’s father is 60 years old. He runs his own business; his relation with his father

is healthy. He didn’t have any psychological illness. The patient mother is 50 years old women.

She is a house wife. She has a very healthy relationship with the patient. The patient report that his

mother is simple and loving lady. She didn’t have any psychological illness.

The patient had 5 siblings, 2 brothers and 3 sisters. He has good relation with his all siblings. When

he was used drugs his relation with his brother was spoil, but he was used hidden. The patient

belonged to middle socioeconomic status and lived in a joined family system with his father,

mother, and other 5 siblings. Presently overall the home environment was comfortable, supportive

and cooperative.

Personal History

Patient was born through normal delivery without any complications. He was achieved all

his developmental milestones at an appropriate age level, he reported that he was aggressive in

childhood. He was many friends and he was very fond of making new friends. Client was not

interested in studies so he started his business with his father and brothers. Client was properly

started working at the age of 24 years. He had 3 girlfriends; he had history of multiple sexual

relationships.

49
Premorbid Personality

The patient was an outgoing person he had jolly nature. He had many friends. He was also

liked to play football and basketball in his spare time.

Preliminary investigation

Informal Assessment

 Clinical Interview

 Mental Status Examination

Formal Assessment

 Drug Use Disorder Identification Test (DUDIT)

 House Tree Person (HTP)

 Mini-Mental state examination

Informal Assessment

Clinical Interview:

Clinical interview was conducted with the client to get detailed information about her

personal, family, and the history of psychiatric problems. The client had poor insight about her

problem, and he was not very motivated.

Behavioral observation

Client behavior was not good during first three session but gradually became normal.

Firstly he was not cooperative and didn’t respond to question properly. His answer was restricted

Mental Status examination

50
 The client was a male with the age of 36 years. Client appeared to be thin and heighted

man. He was properly well-dressed. He was wearing clean clothes. He was not bit comfortably

sitting on the chair. The client was not sitting in the same posture, level of activity of the client

was normal. His speech was clear and easily understandable. Client was not defensive and he

openly tells about his problematic issues and circumstances. He did maintained eye contact

properly throughout the interview. His orientation about time, place and person was good.

Formal Assessment

Drug Use Disorder Identification Test

Table 01

Quantitative analysis

Obtained Score Range Severity Level

18 0-44 Heavily dependent

Qualitative analysis

Client obtained score is 18 on DUDIT test which indicate client had moderate level of drug

dependency.

Mini-mental state examination

Quantitative analysis

Maximum score Obtained score Interpretation

30 20 Mild cognitive impairment

51
Qualitative analysis

The client performed test in the rehabilitation center and gave responses without delay.

The client scored 20 which lie in mild range and shows mild cognitive impairment.

House Tree Person:

The third test administered was HTP. The drawing showed that the client had good contact

with reality. On HTP the client might show the some feature of restlessness, helplessness,

precarious level of adjustment, low level of energy, psychological disturbance, poor judgement,

Aggression, anxious, organic neurological condition or preoccupation with headache pain, weak

ego strength, impulsive, lack of enjoyment from interpersonal relationship.

Diagnosis

304.30(F12.20).Moderate Cannabis Use Disorder

52
 Case conceptualization

Presenting complaints
Anger out-bust, restlessness, watery nose
and eyes, flushed face, carving, muscle
twitching, physical violence,
sadness/hopelessness
Predisposing Factors
Perpetuating Factors
Peer influence, social pressure
Harsh society, pressure of
social norms, guilt stressful
events.

Client

Precipitating Factors , MT, 36 male Protecting Factors

Forced by friends, to over-come Parents love

the guilt, stress. Sibling’s supports

Diagnosis
Cannabis Use Disorder

Case Formulation

In treatment of cannabis use disorder, Clark and Sherman (2016) suggested certain

clinical trials of various treatments for CUD have likewise increased, focusing primarily on

psychotherapy treatments, specifically motivational enhancement therapy, cognitive behavioral

therapy, and contingency management. Their findings suggest that a combination of these three

modalities produces the best abstinence outcomes, although abstinence rates remain modest and

53
decline after treatment. More recently, pharmacotherapy trials have been conducted as adjunctive

interventions to psychosocial treatment.

Hurd and Ferland (2020) describe the neurobiology of cannabis use disorder. There have

been dramatic changes worldwide in the attitudes toward and consumption of recreational and

medical cannabis. Cannabinoid receptors, which mediate the actions of cannabis, are abundantly

expressed in brain regions known to mediate neural processes underlying reward, cognition,

emotional regulation and stress responsivity relevant to addiction vulnerability. Despite debates

regarding potential pathological consequences of cannabis use, cannabis use disorder is a clinical

diagnosis with high prevalence in the general population and that often has its genesis in

adolescence and in vulnerable individuals associated with psychiatric comorbidity, genetic and

environmental factors. Integrated information from human and animal studies is beginning to

expand insights regarding neurobiological systems associated with cannabis use disorder, which

often share common neural characteristics with other substance use disorders, that could inform

prevention and treatment strategies.

According to cognitive theorists, some people find that drug taking provides temporary

relief from anxiety, tension, sadness or boredom. These individuals develop the belief that they

can weather the frustration and stresses of life better, if they can turn to drugs for a period of

escape or oblivion (Beck et al, 1993).

Wendy Swift (2009) provides an overview of the epidemiology of cannabis use, cannabis

use disorders and its treatment. Cannabis is the most commonly used illicit drug internationally.

While use is decreasing in the developed world, it appears to be stable or increasing in

developing countries and some indigenous communities. Early initiation and regular adolescent

use have been identified as particular risk factors for later problematic cannabis (and other drug)

54
use, impaired mental health, delinquency, lower educational achievement, risky sexual behavior

and criminal offending in a range of studies. It is estimated that approximately one in ten people

who had ever used cannabis will become dependent with risk increasing markedly with

frequency of use.

There has been an increase in the proportion of treatment provided for cannabis use.

There are as yet no evidence-based pharmacotherapies available for the management of cannabis

withdrawal and craving. Relatively brief cognitive behavioral therapy and contingency

management have the strongest evidence of success, and structured, family-based interventions,

provide potent treatment options for adolescents. With criminally involved young people and

those with severe, persistent mental illness, longer and more intensive therapies provided by

interdisciplinary teams may be required. (Swift, 2009)

In addition, cognitive theorists argue that such rewards eventually produce an expectancy

that substances will be rewarding, and this expectation helps motivate individuals to increase

drug use at times of tension (Sussman, 2010). These findings are consistent with the present case,

the patient could not stop the craving, especially whenever he got tense or required some energy.

Becoming physiologically dependent on a substance is a developmental process for some

people. That is, for some people, they begin with a positive attitude toward a substance, then

begin to experiment with using it, then begin using it regularly, then use it heavily, and finally

become dependent on it. In the present case, the patient experimentally used the drugs with

friends which according to him, provided him with energy to perform actions and eventually

enabled him to use heavily and finally become dependent on it with high doses

Short term goal

55
  Attend one support group meeting per week.

 Schedule regular appointments with a counselor.

 Improve sleep hygiene and engage in healthy relaxation activities.

 Reconnect with loved ones or participate in social activities.

 Set realistic goals for academic or professional performance.

Long term goal

 Develop a strong and supportive relationship with a partner.

 Continuation of short term goal to reduce the client problematic behavior.

Management Plan

A management plan basically comprising of cognitive techniques was formulated for the client

to help him deal with his symptoms. It consisted of the short term and long term goals which will

be implemented on the client. Following strategies will be used as short term and long term goals

with the client as an intervention plan and will be implemented on him to help resolve his

symptoms.

 Psychoeducation

 Deep breathing

 Sleep hygiene

 Activity scheduling

 Anger management

56
Psycho-education

Psycho-educate the patient about the potential health risks of cannabis use, especially

concerning the reported symptoms Provide information on healthier coping mechanisms and

stress management.

Deep Breathing

To overcome the client's anxiety and irritability this technique was used asked the client to

have control of his breath, when the client controls his breath asked to inhale a long breath from

the nose and hold it for 5 sec and after that exhale it from the mouth slowly. It helped them to calm

themselves and feel better. In this technique, the client was to close your eyes and just to the voice

ignore all the surrounding voices, and focus on what you are saying, Deep breathing/relaxation

was taught to the client to help him relax when he is getting anxious and irritated.

Anger management technique

The anger management technique was adapted to help him control his anger and convert

his energy into productive behaviors so that he consumes his bodily strength to improve their

condition. Asked the client to when he is feeling angry to take a pause and to take a deep breath to

control his emotions also encouraged him to observe his thoughts and feelings without judgement

to gain insight into what triggers his anger. He was also told that whenever he felt angry he started

coloring the book, this activity improved his artistic abilities. He was told to drink water whenever

he had an episode of anger.

57
Activity Scheduling

Activity scheduling was done with the client to mobilize and involve the client in daily

routine activities. By involving the client chart for daily activities was constructed to engage the

client. This helped the client very much to set a routine.

Sleep Hygiene

Sleep hygiene was explained to the client to help him have a better sleep cycle.

Relapse prevention

Asked the client to involve himself with positive influences like supportive family, friends,

or group. Consider the people who understand him and encourage him during challenging times

this helps him a lot to prevent from indulging in drugs and asked him to come for a follow-up

session after fifteen days

58
Pre and post-subjective rating

Targeted behavior Pre-intervention Post-intervention

Anger 8 3.5

Restlessness 7 4.5

Sadness 7.5 5

Watery eyes and nose 6 3

Body aches 8 5

Subjective Rating Scale of Pre and Post Intervention

graphical representation
9

0
Anger restlessness sadness watery eyes & nose body aches

pre intervention post intervetion Column1

59
References

Substance Abuse and Mental Health Services Administration. (2014). Results from the

2013 National Survey on Drug Use and Health: Summary of national

findings. NSDUH Series H-48, HHS Publication No.(SMA) 14-4863, 1-143.

Feingold, D., Fox, J., Rehm, J., & Lev‐Ran, S. (2015). Natural outcome of cannabis use

disorder: A 3‐year longitudinal follow‐up. Addiction, 110(12), 1963-1974.

Beck, A. T. (1993). Cognitive therapy: past, present, and future. Journal of consulting and

clinical psychology, 61(2), 194.

Copeland, J., & Swift, W. (2009). Cannabis use disorder: epidemiology and

management. International Review of Psychiatry, 21(2), 96-103.

Dvir, H., Silman, I., Harel, M., Rosenberry, T. L., & Sussman, J. L. (2010).

Acetylcholinesterase: from 3D structure to function. Chemico-biological

interactions, 187(1-3), 10-22.

60
Annexures

61
62
63
64
 Session 01

In the first session establish rapport with the client and create a safe space for the patient

to share their experiences. After that conduct a comprehensive assessment of their cannabis use

history and withdrawal symptoms.

Session 2

psych educate the patient about the potential symptoms and challenges associated with

cannabis withdrawal and discuss the physiological and psychological effects of cannabis and how

it can impact the body and mind.

Session 3

In the third session teach the patient various coping strategies to manage withdrawal

symptoms such as irritability, insomnia, and cravings. Explore healthy alternatives and activities

that can help distract from cravings.

Session 4

In the fourth session help the patient identify their triggers for cannabis use and high-risk

situations that may lead to relapse and develop strategies to avoid or cope with these triggers

effectively.

Session 5

In this session different techniques were Introduce like deep breathing, maintain sleep

hygiene, relaxation techniques to keep themselves relaxed and calm whenever feels irritability

Session 6

65
 Building a Support network and discuss the importance of a support system during the

recovery process also help the patient identify supportive individuals in their life and explore

additional support options such as support groups or counseling.

Session 7

Develop a relapse prevention plan with the patient to anticipate and manage potential

relapse situations and discuss strategies for coping with cravings and maintaining motivation for

long-term abstinence.

Session 8

In this session explore any underlying issues or co-occurring mental health conditions that

may have contributed to cannabis use and incorporate appropriate therapeutic interventions to

address these issues.

Session 9

Discuss the importance of adopting a healthy lifestyle to support recovery and explore

strategies for improving sleep, nutrition, exercise, and stress management.

Session 10

In this session review progress made throughout the therapy process by client and develop

a plan for ongoing support and maintenance of abstinence beyond therapy sessions.

66
 Schizophrenia

Case Summary

T.M. is a 24-year-old male who belongs to a lower class residing in Lahore. He studied

till class 12th. The client has 7 brothers and 3 sisters. The history was given by his elder brother

he seemed well-informed and reliable. The client was admitted to Lahore Psychiatric Hospital

with the symptoms of visual hallucinations and delusion (he sees and talks to his despite his

death) disorganized behavior,( excessive spitting, laughing violently without any obvious cause,

aggressive behavior) inappropriate effect of crying and laughing spells, and breathlessness. The

client was assessed formally and informally. Formally he was assessed by Positive And Negative

Syndrome Scale (PANSS) and MMSE. Informal assessment includes clinical interview,

behavioral observation, and mental state examination. Findings show that the client is suffering

from (F20.0) Schizophrenia. The therapy that was assigned to him was stress coping skills,

problem-solving social support, and stress coping skills.

67
Bio data

Name T.M.

Age 24years

Gender male

Marital status Single

Siblings: 10(7 brothers and 3 sisters)

Birth order 4th born

Residence Lahore

Informant Brother and the patient himself

Reason and sources of reference

T.M. was referred to the psychiatry ward by his mother for consultation with a

psychologist. He presented the following complaints to a psychologist, visual hallucinations and

delusion (he sees and talks to his despite his death) disorganized behavior,( excessive spitting,

laughing violently without any obvious cause, aggressive behavior) inappropriate effect of crying

and laughing spells, and breathlessness.

68
Presenting complaints

‫میں اپنے باپ کی آواز سنتا ہوں۔‬

‫وہ ہر جگہ تھوکتا ہے اور بالوجہ ہنستا ہے۔‬

‫مجھے مختلف قسم کی آوازیں سنائی دیتی ہیں جن میں میرے باپ مجھے پکارتے ہیں۔‬

‫وہ گھر سے بھاگتا ہے اور غیر معقول باتیں کرتا ہے‬

History of present illness

The patient is a known case of psychiatric illness from the last 01 year, the illness started

insidiously, is progressive, and is episodic in nature. The current episode started 2 weeks ago

because of his non-compliance to medication. Currently, he has presented with 2 weeks history of

physical and verbal aggression towards his family members, especially her mother, both provoked

and unprovoked. He has beaten his mother and broke the table. Once he jumped from the portion

of his house and got some injuries. The patient reported that he did not want to jump to harm

themselves but someone provoked me to do so. There is also a history of running away from home

several times without informing the family. According to his mother, most of the show

inappropriate behaviour crying loudly or laughing loudly without any known reason. He didn’t

care of himself spitting every, didn’t maintain hygiene. These problems worsen day by day and

also disturb the whole family. His mood remains high and elevated almost every day by day.

Patient verbally abuse people around without any reason, behave aggressively, tore off his clothes

in front of other people, ran out of the house and have to be brought back forcefully. The client

reported to see his father talking and laughing with him and wants to take him out to a park and

for shopping His brother also went to multiple faith healers as well but he didn’t get any recovery.

69
Background information

Family History

The client lives in the nuclear family system. He has 10 siblings and his birth order is 4 th.

His father died of a cardiac problem. The client’s mother is a Nobel lady and she is a housewife.

He has 7 brothers and 3 sisters. The patient has a good relationship with her parents and other

siblings as reported. The client belonged to a middle socioeconomic status. His home

environment was also good. The client's family is very supportive and cooperative.

Personal history

He was born with a normal delivery at home with no prenatal and postnatal

complications as reported. The client achieved all the milestones at the appropriate age. He

reported that he was normal and good during childhood. He had many friends and also had a

long social circle. The client was interested during the session and disclosed their information

easily. He had been in a relationship with a girl for the last 2 years.

Educational history

He started school at the age of four. He was an average student during his school time.

He had many friends and had a friendly nature. He never failed in any class. He studied till class

12th and then left because he had no interest in studies. he tried to adjust themselves in college

but he could not.

Family Psychiatry History

His paternal aunty (phopo ) is suffering from epilepsy and his uncle was also had these

issues. No other psychiatric illness is present in the family of the client.

70
Premorbid personality

He was described as friendly but very choosy and introverted before illness. He had good

religious beliefs premorbid as reported by his brother. However, his stress-coping skills are not

up to the mark.

Assessment

The assessment was conducted in two stages: formal and informal.

Informal assessment

The informal assessment was done on the following basis i.e. clinical interview and behavioral

observation.

Clinical interview

The interview started by asking questions about his present symptoms and the onset of

his illness. Keeping in mind the predisposing factors and stressors that maintained his illness and

prognosis. His brother was well aware of his illness and described his symptoms properly. The

client was not well aware of his condition he was continuously crying and hitting himself. He

was not cooperating at all. He was not answering any questions.

Behavioral observation

The client's mood was very low during the session. He didn't sit properly and

continuously tapped his feet on the floor. The first two sessions were very tough with the client

because the client showed a non-sense attitude and didn’t cooperate with their psychologist.

Later on, his behavior became normal gradually. His orientation of time and place person was a

little bit good. He had some delusions and hallucinations.

71
Mental state examination

A mental State Examination was administered to the client. The client was of normal

height and fair, wearing a salwar kameez. When he came into the room he seemed inappropriate.

The tone of his voice was very loud. His attitude was not cooperative. His behavior was odd and

the setting position was not relaxed. He was confident and gave restricted answers to each

question. Rapport was built after some time. The client's orientation of time, place, and person

was a little bit disturbed.

Formal assessment

The formal assessment was conducted on some psychological tests i.e. mini-mental examination,

PANSS, and, HTP.

Mini-mental examination

Quantitative analysis

Table 01

Maximum score Obtained score Severity

30 20 Moderate

Qualitative Analysis

MMSE was applied to the client. He completed his test in 10 minutes. He got 20 out of

30 which shows that there are moderate levels of cognitive impairment

72
Positive and negative symptoms (PANSS)

Quantitative analysis

Table 02

positive symptoms 24

Negative symptoms 30

General pathology 25

Total score 79

Total score =95, obtained score =79

Qualitative analysis

The positive and negative syndrome scale (PANSS) indicates that clients had a score of

79 which showed that the client had maladjustment and severe issues. Further on the positive

syndrome scale client scored 24 which indicates a moderate level of hallucinations, delusion,

disorganized behavior, suspiciousness, and hostility. On the negative syndrome scale, clients had

a score of 30 which indicates the presence of negative symptoms. The general pathology scale

score is 25 which indicates severe pathology. This shows the presence of symptoms like lack of

insight, unusual thought content, anger, and poor impulse control.

House Tree Person test

House in HTP represents belongingness, nurturance, stability, and interpersonal

relationships. The test by the client reveals the poor interpersonal relationships reflected from the

demarcation of the rooms, tree reflects the ego development and functioning, limited ego, and

aggressiveness. The person reflects the individual’s self-perception and perception of the other

gender. The asymmetry of the figure reflects impulsivity, omitted legs show withdrawal, the

73
 presence of teeth depicts aggression, omitted hands show inadequacy, body distortions show a

psychotic tendency, the impaired nose shows genital inadequacy and emphasis on ears shows

auditory hallucinations and impaired arms reflects anger

Tentative diagnosis

295.90(F20.0) Schizophrenia disorder (with recurrent episodes).

Case conceptualization

Client, male, age, 24

Perpetuating factor Protective factor

Predisposing factor Precipitating factor
family history of Lack of insight, social Supportive family,
death of father
psychotic disorder withdrawal engagement in therapy

Case formulation

Many psychological mechanisms have been implicated in the development and

maintenance of schizophrenia. Cognitive biases have been identified in those with the diagnosis

or those at risk, especially when under stress or in confusing situations (Broome et al., 2005).

Some cognitive features may reflect global neurocognitive deficits such as memory loss, while

74
others may be related to particular issues and experiences. Some evidence suggests that the

content of delusional beliefs and psychotic experiences can reflect the emotional causes of the

disorder, and that how a person interprets such experiences can influence symptomatology.

Understanding schizophrenia requires consideration of patients’ interactions in the social world.

Misinterpretation of other peoples’ behavior is a key feature of persecutory ideation. The

occurrence and intensity of hallucinations is affected by the social context. Negative symptoms

such as anhedonia, sociality, and blunted affect reflect difficulties in social interactions.

Withdrawal and avoidance of other people is frequent in schizophrenia, leading to isolation and

itself (Anon., 2008).

Schizophrenia is said to be caused by unnaturally high levels of dopamine in the brain.

Dopamine is a neurotransmitter of the catecholamine family, along with norepinephrine, released

from the hypothalamus. It is the brain’s sense of reward. When a person experiences a pleasant

event, dopamine is the chemical that tells the brain it is being rewarded. Dopamine is created by

the hydroxylation of the amino acid L-tyrosine to L-DOPA. L-DOPA, not dopamine, is allowed

to cross the blood-brain barrier (Carlsson, 2000). The blood-brain barrier is a group of cells that

protects the CNS (central nervous system) from large molecules which could potentially contain

viruses and cause infections. L-DOPA, once into the brain and spinal cord, can turn into

dopamine by the decarboxylation by aromatic L-amino acid decarboxylase (Anon., 2009).

Dopamine is then passed from neuron to neuron. Then receptors at the synapse on a neuron react

to the dopamine. In theory, these receptors are more prone to accepting dopamine than blocking

the chemical. This causes for an excess of dopamine. The brain could also can have a high

amount of dopamine receptors, or the brain could be over-producing dopamine from a gene

mutation that could cause the brain to create more dopamine than needed. Modern antipsychotics

75
do not contain dopamine blockers and patients are still seeing improvements. This could

disprove the dopamine theory of dopamine, but the results do not completely disprove the theory.

This study was carried out by Arvid Carlsson as a review of The dopamine Hypothesis of

schizophrenia and an analysis of the possible role of a different neurotransmitter, glutamate, as a

biological explanation for schizophrenia. A recent meta-analysis and systematic review has

confirmed that patients with schizophrenia have smaller whole brain volumes and larger lateral

ventricles. Furthermore, these volume changes have greatest impact on grey matter in the frontal

and temporal lobes. These deficits appear to be present even at the earliest stages of the illness,

though whether they progressively worsen over the course of the illness remains contentious

(Steen et. Al, 2006). Researchers hypothesize that schizophrenia is caused by a gene mutation.

However, it is still not known if the disorder is caused by one single mutated gene, a series of

mutated genes, or a mutated gene passed from parent to offspring. Some researchers say that a

combination of mutated genes creates a greater likelihood of having the disorder. According to

the stress trigger theory clients might have all the gene mutations that would cause

schizophrenia, but if there is no stress trigger, a patient might be able to go their entire life

without exhibiting any symptoms. A stress trigger can be defined as a traumatic event or stressful

situation that can cause a psychotic break (Anon., 2008).

Short term goals

 Reduce the intensity and frequency of hallucinations, delusions, and other symptoms

through medication and therapy.

 Learn and practice effective coping strategies to manage stress, anxiety, and symptoms.

 Build a support network of family, friends, and mental health professionals to provide

encouragement and understanding.

76
  Identify early warning signs of relapse and create a plan to manage and prevent relapses.

 Enhance the ability to complete daily tasks, such as personal hygiene, cooking, and

managing finances.

Long-term goals

 Maintain a level of symptom control that allows for a fulfilling and functional life.

 Develop the skills and confidence to live independently and manage daily

responsibilities.

 Continuation of short term goal

Management plan

Psychoeducation

Enhancing the patient's understanding of his symptoms, causes, and available treatment and also

providing him information about the nature of hallucinations and delusions, potential triggers,

and the role of therapy in the management of symptoms.

Behavioral Activation

By working with the client create a behavioral activation plan, aiming to increase his

engagement in purposeful and structured activities. Firstly we collaboratively identify activities

that are personally meaningful and align with his interests. These may include hobbies, self-care

tasks, and social interactions. Then encouraged him to set realistic and achievable goals for each

day. Goals are broken down into smaller, manageable steps to avoid feeling overwhelmed.

Then create a daily schedule that incorporates the identified activities and goals. The schedule

provides structure and helps client to organize his day more effectively and engaged in the

77
planned activities to prevent from performing disorganized behavior. Client is encouraged to

follow the daily schedule.

Deep breathing

the client was told to try sitting in a chair, sitting cross-legged, or lying on your back with a

a small pillow under your head and another under your knees.

1. Place one hand on your upper chest and the other hand on your belly, below the ribcage.

2. Allow your belly to relax, without forcing it inward by squeezing or clenching your muscles.

3. Breathe in slowly through your nose. The air should move into your nose and downward so

that you feel your stomach rise with your other hand and fall inward (toward your spine).

4. Exhale slowly through slightly pursed lips. Take note of the hand on your chest,

which should remain relatively still

Progressive muscle relaxation

Progressive Muscle Relaxation teaches you how to relax your muscles through a two-step

process. First, you systematically tense particular muscle groups in your body, such as your neck

and shoulders. Next, you release the tension and notice how your muscles feel when you relax

them. This exercise will help you to lower your overall tension and stress levels, and help you

relax when you are feeling anxious. Progressive muscle relaxation was taught to the client. The

client was asked to sit in a comfortable position, with eyes closed. Take a few deep breaths,

expanding her belly as you breathe air in and contracting it as you exhale. For each muscle

group, tense for 10 seconds and release, taking a few deep breaths as you notice the sensation

that comes as those muscles relax, before moving on to the next muscle group. The patient was

asked to begin at the top of your body and go down. Start with your head, then facial muscles,

eyes, mouth and jaw. Hold, then release and breathe. Then he was asked to tense shoulders and

78
release followed by clenching fists and releasing as well. Then patient was asked to repeat these

steps on her stomach and finally tightening toes and release starting from the right foot and then

the left foot.

Pre and post-subjective rating

Targeted behavior Pre-intervention Post–intervention

Aggressive behavior 8 6

Hallucination 8 3.5

Delusions 8 3.5

Inappropriate behavior 9 4

10

0
aggressive behavior hallucinations delusions inaapropriate behavior

pre intervention post intervention Column1

79
References

Sutherland I. The Ultimate Display. Proceedings of the International Federation of Information

Processing Congress. 1965;2:506–[Link] I. A Head-Mounted Three Dimensional

Display. Proceedings of the Joint Computer Conference. 1968;33:757–764.

Rheingold H. Virtual Reality. New York, NY: Simon & Schuster; [Link] B. Virtual

Worlds. London, UK: Penguin; 1993.

Sanchez-Vives MV, Slater M. From presence to consciousness through virtual reality. Nat Rev

Neurosci. 2005;6:332–339. – PubMed R Grant Steen et al. Br J Psychiatry. 2006 Jun.

Broome et al., 2005;Giacco et al., 2012;Lee &Seo, 2020).

By A Carlsson · 1999 · Cited by 222 — Carlsson, A., Hansson, L. O., Waters, N., et al (1997)

80
Annexures

81
82
83
Sessions

Session 1

during these sessions intake information was taken and the history form was filled. Information

from her informants was taken regarding his current condition because the client wasn’t able to

provide information himself. The therapist observed the client in this session, it was observed

that the client was not in the condition to respond and was talking continuously to himself.

Session 2

In the session, unconditional positive regard was shown to the client about his problems and

show unconditional and empathy, client was in state of withdrawal to share his problems. he was

little bit confused. The therapist assured that all the information were kept in secret and

confidential and be relax and confident.

Session 3

Formal assessment was used on the client which showed that he was suffering from mild

level of schizophrenia. The family was psycho-educated about client’s illness, aggression and

other behavioral disturbances. Awareness provided that she is suffering from a mental disorder

called schizophrenia and they were informed to take care of him.

Session 4

The client was disturbed in this session, he was screaming constantly so the therapist tried to

calm him down, and towards the end of the session client practiced deep breathing exercises. The

client was guided to slowly inhale and exhale whilst holding her stomach.

Session 5

The client couldn’t sleep at night due to which psycho-education provided about a disturbance

in the sleep cycle and suggestions given about sleep hygiene improvement. He was suggested to

84
avoid tea or coffee before sleeping. He was asked to make his bed before sleeping and fix a

sleep time to regulate her sleep. The patient was also asked to practice deep breathing before

going to bed. He was also suggested that if he still feels difficulty falling asleep then instead of

laying down for hours he should get up from bed and sit on side to avoid over-thinking and again

lay down after 20 minutes.

Session 6

In this session, client’s diet plan was made because the client had not been eating properly

so a time table was made for him which consisted of timings to eat and when to perform other

exercises like walking etc.

Session 7

In this session, progressive muscle relaxation was taught to the client. Client was asked

to sit in a comfortable position, with eyes closed. Take a few deep breaths, expanding his belly as

you breathe air in and contracting it as you exhale. For each muscle group, tense for 10 seconds

and release, taking a few deep breaths as you notice the sensation that comes as those muscles

relax, before moving on to the next muscle group. The patient was asked to begin at the top of

your body, and go down. Start with your head, then facial muscles, eyes, mouth, and jaw. Hold,

then release and breathe. Then she was asked to tense shoulders and release followed by

clenching fists and releasing as well. Then patient was asked to repeat these steps on her stomach

and finally tighten his toes and release starting from his right foot then left foot.

Session 8

Social skill training the client was conducted in this session, the client was taught how

to interact with people and shake hands when she meets others, the main goal of this session was

85
to work on his social skills and bring about changes in his social life.

Session 9

The client’s symptoms were rated after the therapies were conducted on her, there was an

improvement found in his behavior so decided to terminate the sessions after the next session

was held.

Session 10.

He was asked to take his pharmacological treatment and seek psychological help as soon as he

needed it and the session was terminated.

86
PRELIMINARY CASES

87
Case 01

Demographic Data

Name A.S

Sex Female

Age 43 years

Education Middle

Occupation House Wife

Marital status Married

Children 4

Reason and source of Referral

The patient was referred to the hospital, due to complaints of pain in heart, chest, joints,

backache and headache. The patient considers herself ill and has difficulty in breathing,

weakness, nausea, diarrhea and excessive concerns about her illness.

History of present illness

A.S client was forty three year old and belonged to a middle-class family living at Rawalpindi.

She got education only middle class level. But she has desire to study. The client reported that

when she was fifteen years old, her parents got her married which was totally arranged marriage.

She was not happy with her marriage because she was not in the favor of getting married at very

young age. But after the conception of first, she adjusted herself. Her husband was not caring and

loving person and was not too much concerned about his family affairs and economic issues. Her

husband was an administration manager in a private organization. His earning was not enough to

88
carry out the needs of a large family. He used to spend most of his time with his friends. The

client felt too much depressed because of her husband's careless behavior. The client had two

sons and two daughters. Her two sons were married and unemployed. She remained very upset

due to her son’s unemployment. Her daughter was not happy with her married life because she

was often beaten and abused by her in-laws. The client was under a lot of stress due to her

daughter's marriage and son’s unemployment. When the client was thirty-eight years old she

underwent the birth control operation. She never wanted to go for it but circumstances and

financial stress made her compromise. She sometimes felt depressed and does not enjoy sexual

relationships. For this reason she consulted a lady doctor to a checkup who advised her for birth

control operation. After that she underwent for birth control operation. All her piled-up worries

and tensions met their climax after her operation and she turned their direction towards herself

by overly being concerned about her health. She started experiencing physical problems such as

headaches, backache, pain in chest, nausea etc. She has been visiting the hospital for last seven

years after her operation but has not found any relief so far.

Reason of termination

Only two sessions were conducted with the client as her time was completed and her symptoms

were managed

89
Case 02

Biodata

Name U.B.

Age 38

Gender male

Marital status married

Birth order middle

Residence Islamabad

Education intermediate

Family system nuclear

Reason and source

U.B. was a 38-year-old male and he was referred by His family doctor's Hospital. Due to his

psychiatric symptoms is depressed mood, Hallucinations, Illusions, Aggressive

behavior, Irritability, Lack of interest.

Presenting complaints

Main apni maah ko dekh sakta houn.

Main apni maah ko sun skta hun.

Muja rat ko nend nahi ati.

90
History of present illness

• Depressed mood

• Hallucinations

• Illusions

• Aggressive behavior

S• Irritability

• Lack of interest

Family history

The patient belongs to a middle-class family. He has five siblings. He is middle among them. He

has two sisters and two brothers. The patient's father was a government officer. Her father was a

loving and supportive man and she was very close to her father. Her mother is a housewife. She

has a strict but caring personality. The general home atmosphere is normal and well-managed.

Educational history

He went to school at the age of early years. He was very talkative in childhood and was

always curious to learn something new in school but he was an introvert. He had done his

intermediate in arts after that he stopped it because of dropped out.

Reason of termination

The client were not cooperative and didn’t take interest in the session so it was very difficult to

disclose information from them due to the shortage of time.

91
Case 03

Biodata

Name Z.Q

Age 31

Gender male

Marital status unmarried

Birth order second

Residence Islamabad

Education masters

Family system nuclear

Reason and source of referral

Client was referred by his brother with complaints of feeling sad all the time, guilt, nightmares,

suicidal ideation, insomnia.

Presenting complaints

Symptoms

 Nightmares

 Insomnia

92
  Guilt

 Loss of interest in life activities

 Numbness

 Startling

 Fatigue

 Suicidal ideation

 Crying spells

 Low mood

 Weight loss

Background history

Family History

Z.Q. belongs to upper middle-class family. He has 5 siblings, 3 sisters and 2brother. The

patient is 2nd born child in the family. All his siblings are physical and mentally healthy. Financially

his family is very strong. Patient is very close to her elder sister and has good relations with his

other siblings. According to the respondent, his parent’s relationship was healthy and cooperative.

All his siblings are married except him and at present, he is residing with her elder sister. He has

a close relationship with siblings and the relationship among siblings is caring and supportive.

Personal History

According to the sister, the client’s birth was normal. He completed all developmental

milestones like crawling, walking, and talking normally. The client had no particular childhood

handicap. According to the client, when his parents were alive that was the most pleasant period

of his life. The client has achieved the degree of Masters in Islamiat and for a year he has worked

93
as a teacher of Islamiat in Army public school Sargodha Cantt. he also enjoyed healthy friendships

in his childhood and before the illness, he was social and enjoyed good relations with her friends.

The client’s father was a Brigadier in the Pakistan Army. According to the informant he retired

from Army when his last posting was in Sargodha and client was residing with his father and it

was almost 5 years since his mother had passed away. Afterward, client’s family moved to

Rawalpindi after his father’s retirement. He became even closer to his father as both of them had

ample time to spend with each other. According to the client it was the most pleasant time as both

of them previously have not spend that much time together. His other siblings were also residing

in the same city so there used to be family gatherings often. The client’s father was caring towards

his son. However the traumatic murder of her father affected the client in a worse manner. It was

just six months that the family moved to Rawalpindi that her father was murdered by some

unidentified individuals. Client believes that she could have saved his father’s life if she had not

retaliated.

Premorbid personality

Before the onset of the illness the client reported that she was physically healthy. He was

energetic and has interest to do all domestic chores and was quite social.

History of present illness

After the retirement of client’s father, the family moved to Rawalpindi. According to the

client it was the most memorable time period as he used to miss her other siblings and the intimacy

between the client and his father increased even more. There used to be family gatherings a lot

According to the informant the precipitating event was the murder of his father. The informant

reported that at the middle of the night about four unidentified individuals broke into the house

and at that particular time only client and his father were at home and only his father was sleeping

94
while client was awake. The criminals roam into the house and the client sensed that someone is

walking into the house and he came out of his room and when she reached at the dining room of

the house, she came face to face with the criminals. On the spot she started yelling out and two of

them just grabbed his mouth and slapped on his face, afterwards they tied the client on a chair but

she continue to retaliate and cried for help that made his father woke up and he came running out

of his room and in front of his father, client was beaten badly that made his father furious and he

tried to save her daughter but one of the criminals grabbed him and fired on his forehead.

According to the informant they seemed professionals as there was silencer attached to the

pistol, so there was no audible sound of firing. Afterwards criminals took away her father’s dead

body along with them and left the client helpless in the house. It was the next day at the evening

around 5 pm that one of his sisters visited the house with her family and upon no response after

repeated ringing of the bell, his brother jumped from the neighbor’s wall into the house and upon

entering into the house they found client unconscious and tied up on a chair, who was shortly taken

to the hospital. The family searched the whole house but they were unable to find his father.

Afterwards client’s condition was worse, as there was yelling crying, nightmares and fear.

Afterwards family tried to help the client but his condition was worsening.

Reason of termination

Three sessions were conducted with the client, as the client was managed so he is going to home

and session was ended.

95
Case 04

Bio data

Name: A.S

Age: 53 years

Gender: Male

Education: Graduation

No. of Siblings: 04

Occupation: Teacher

Marital Status Married

No of children: 04

Religion: Islam

Birth Order: 1st

Informant: The client himself and his brother

96
Reason and source of referral

The client was brought to the indoor department of psychiatry at PIMH with the complaints

of aggression, grandiosity, inflated self-esteem, pressured speech, Irritable mood, and increased

activity, decrease sleep, more talkative and paranoid against wife. He was referred through in door

patients for psychological evaluation and management of his complaints.

According to the client

Symptoms (According to DSMV)

 Grandiosity

 Decreased need for sleep

 Flight of ideas

History of present illness

The illness history of the client dated in 1980 back when he took admission in Pakistan Air

Force Sargodha [Link] that time his age was 18 years old. His father insisted him to take

admission in aeronautical engineering. But he wanted to become a pilot. Then he said to his father

that bring for me Air Gun then I will took admission in that area he wanted as reported by his

brother as the client was demanding and used to black male his parents. Then his father gave him

air gun. He studied there for 2 years but according to client as he reported (Asal tarqe or thrill pilot

bannay main hi ha).Then he tired a lot to change that subject but he could not do it after passing

hisintermediateform PAF. He did not want to continue it later in life and move back towards

civilian life.

97
 In 1984 he quit form PAF and took admission in FC College. He studied there for 3 years.

Client brother reported that he used to shifted his choice very soon as he shifted from one

department to another again and [Link] reported by the client he chose to studied double math’s

with physics but according to client he was not satisfied there then he changed the department and

join computer science. At that time his age was 23 years old again he shifted from computer science

to math’s but he left that college as he reported (Bus asy he chor dia) .At that time he also started

hunting with his friends. According to client brother he had every type of weapons. He was very

much interested to collect weapons.

According to client in my whole life the best thing that happened to me was my relationship

with his cousin. According to client may be we loved with each other from childhood rather than

puberty age. Everyone knows in family that they both were interested in each other. When he told

about his relationship their family members accept their proposal and engaged them.

After 2 years in 1987 when he was 26 years old he took admission in Punjab University

for post graduate diploma in system analysis. While he was studying at PU his fiancé took

admission in Government College University. Problem started when his fiancé took admission in

GC University .As client reported ( Jo 2 sall us ny GC main guzary wo hmysha say mujy napasnd

rahy ) because she showed her picture with his male class mate. The client did not like that event

he got aggressive after that event as his brother [Link] sleep was also disturbed and then he

was excessively involved in his [Link] he reported after that event (us ky bad say who myry

dil say otar gai).According to client he didnot talk with his fiancé for two year. The client brother

reported that he did not meet with his fiancé nor he talked with her.

After two year in 1989 he passed diploma form PU and his fiancé passed MSC form PU.

Their family members decide to married the client with his fiancé. But according to client after

98
that event he did not want to married her but his parents forced him to get marry with his fiancé.

As his brother reported that (Jis say mohabt karta tha bad main us say hi shadi say inkar kr dia).

After one year in 1990 finally he got married with his fiancé.After marriage their

relationship was satisfactory with each other but as client reported (myry dil say wo bat kabi nahi

nikle).

After one year in 1991 their daughter was born. Client reported that he was happy at the

birth of her daughter but his brother reported that he become angry at that time and blamed on his

wife that she was character less women. Their family members then resolved that issue and no

problem was reported till the birth of second daughter as client brother reported that on the birth

of his second daughter again he react like [Link] according to the client he was happy at the time

of his second daughter birth but he wish for baby boy.

The Client’s brother reported that during these years he used to beat his wife and daughters

too. At the time of his son’s birth he was happy as reported by the client brother. According to

client at the birth of his sons he was thankful. The client used to be rigid in his ideas over talkative

and aggressive, irritable most of time. He developed authoritative personality. He was disturbed

on minor issue. The family and the client did not focused that it could be some psychological

illness. So they never consulted for psychiatrist treatment.

Client brother reported that their relationship with his wife and children’s was not

satisfactory because client as previously reported he used to beat his wife and children. According

to client brotherwith passage of time he became over religious and that’s the reason he fight with

his wife and children to do religious practice .As he became very strict about children’s relationship

with opposite gender. He put strict instructions for family not to mix up with [Link] to

client I want that my wife and daughters did parda but my wife did not accept what I said to her

99
so that’s the main reason of our [Link] his home there is no television and he did not allow his

children’s to talk with cousin. He said that this is right path and according to father this is my

responsibility to keep my children in pressure. So that they will successes. Problem started again

in September 2017 when the client families were invited in his brother house who lived in

Denmark. He came to Pakistan for vacation. On the end of his vacation he invited all family

members at dinner. According to client as he reported ( mujy pata tha ky wo ludo or tash ,yaso

panjo khy gy or phir hath chalaki b hote ha) he said to wife that we had to go for home. When

their family members knew that they were going to home they asked her to stay there at that time

client became aggressive and beated his wife when her eldest son try to saved his mother he also

beated him to and gave threats that I will kill as reported by the client brother. He had also different

kind of weapons. According to client brother every time he had pistol in his pocket when his family

members asked him why you took this he said (Yah mard ki shan hote ha).The client reported that

I am alone in my family because I insisted my wife and children’s to follow Islam [Link]

client problem got worsened every time his quarrels ,aggressive ,mood swings ,religiousness were

very prominent as he was out of control and unmanageable so for the first time family decided to

consult for psychiatrist help.

A.S was referred through indoor department of psychiatry at PIMH with the complaints

ofaggression, grandiosity, inflated self esteem, Irritable mood, increased activity, decrease sleep,

more talkative. He was referred through in door patients for psychological evaluation and

management of his complaints.

Reason of termination

The client didn’t provide the authentic information and show non serious attitude towards

session

100
Case 05

Identifying Data

Name F.F

Gender Female

Age 27 Years

Marital status Unmarried

Education Masters

Siblings 03

Birth order 01 ST

Referred by Family

101
Reason for Referral

The patient came to the psychiatry department of the District Headquarter hospital Attock

with complaints of excessive fear, fainting and anxiety regarding giving blood sample for test. She

avoids and delayed the blood test. She was referred by family.

Presenting Complaints

History of Present illness

Client was 21 years old unmarried female and resident of Attock. She was student of [Link].

Problem was started when the client was asked to check up her blood group for some educational

purpose. But when she went hospital she had faint there after saw a needle which will be injected

to take blood of the client. Before this event the client was faint at that time when her teacher

sudden got a prick of needle and had bleeding. It was very difficult to her to test her blood. She

had taken very much time to prepare herself for giving blood sample but failed. Her family was so

distressed regarding this issue and they brought her in psychiatry OPD for the treatment. Her

father told that on that morning when they were going to hospital for testing blood the client was

so anxious and fearful and continuously wants to delay it.

Family history

Both parents were alive and she belonged to a nuclear family. Her father was an electrical

engineer and mother was a house wife. She had 3 siblings younger to them and she was a first born

102
child. She was not a responsible elder sister. She did not have any interest in the home works. And

other all siblings were studying also.

Personal History

Her birth was normal. She had achieved milestones at appropriate ages. Menarche was in

the age of 13. She had disturbed menstrual cycles. She felt much anxiety over small situations

since her adulthood. She had a reserved nature. She was not very social. She was a shy child during

childhood.

Educational History

She started school at the age of 4. She started religious education in the age of [Link] was

intelligent student. She had so much interest in studies.

Sexual History

Patient reports no pre maritaland homosexual relationships.

Premorbid personality

The premorbid personality of client was average. She had good relationships with her age

fellows and cousins. She was not very social. She had limited friends. She had not any history of

any mental illness in past life.

Psychological Assessment

Preliminary investigations were done at formal and informal level using the following

measures.

103
Informal assessment

Clinical interview

The clinical interview was conducted with the client to understand her problems and the

severity of problem. At first the rapport was built with empathy and active listening. With open

ended questions all the information related to patient had taken. The client was in normal mood

while giving information. History taking and detail intake was done with the client. The client was

open in giving information. She did not show any resistance while giving information.

Behavioral observation

The client was looking normal in appearance. She was seated relaxed. She was open in

interview and less talkative. She was attentive and her orientation was good. She maintained eye

contact and did test with interest.

Formal Assessment

Beck Anxiety Inventory

Beck Anxiety Inventory developed by Beck is a self-report inventory of 21 items. It was

used to measure the anxiety level of the client. . It is a 4 point likert scale with ranges from 0 to 3.

0 shows no anxiety and 3 severe Anxiety. This test was developed to reduce the overlap between

anxiety and depression by measuring anxiety symptoms minimally shared with depression. It

measure physical; and psychological symptoms of [Link] was administered on the client for

assessment of severity of anxiety level.

104
Quantitative Analysis

The Range and interpretation of severity level of anxiety of the patient’s score on Beck’s

depression inventory

Range Interpretation of severity level Obtained Score

30-69 Severe anxiety 33

Qualitative Analysis

The obtained score of the client showed that the patient was having anxiety. Also critical

evaluation of the patient’s profile reveals that her anxious features were severe as she was unable

to fulfill her daily tasks along with his difficulty interacting with others. Her mood, sleep and

concentration were disturbed. The qualitative analysis of the symptoms in which the client scored

high shows descriptive representation of her anxious symptoms. The score on BAI correlated with

her presenting complaints.

Tentative Diagnosis

300.29(F40.23x) Specific Phobia Blood injection injury

Reason of termination

My duration of internship was ended so I can’t further proceed it.

105
106