CONFIDENTIAL CASE REPORT-1

REASON FOR REFERRAL:

Mr. A is suffering from present problem for 4 months and diagnosed as Major Depressive
Disorder by psychiatrist. Client was referred from outpatient department of Mental Hospital,
Pabna and assigned to me for psychotherapy.

DEMOGRAPHIC INFORMATION:

Mr. A, 25 years old male student brought up in middle class Muslim educated family at urban
area in Sirajganj. He is undergraduate student of Pabna University of Science and
[Link] present he lives in Pabna in a mess. He is third child in his family .He has two
older sisters and they are happily married. His father is non government employee and mother is
housewife.

Genogram of A family:

49

ASSRSSMENT:

Initial assessment was started with client’s demographic information and gradually went through
symptoms, severity, mood and relevant history, present situation problem in different areas of
functioning.
The whole assessment had done by using subjective assessment, subjective and objective rating.

Subjective Assessment:

The main tools of subjective assessment were In-depth clinical interview, Observation of client
in the session. In-depth interview was done by me through open-ended and closed questions,
empathetic listening. Observation was focused on the attention of client, his appearance eye
contact, gesture, congruency of mood instant mood swing, speech, expression and behavior in
the session.

Subjective mood checking:

In this procedure, the client was asked to rate his mood as he was considering. He was said to
rate his mood from 0-10 where 0 means lowest level of well-being and 10 means highest level of
well-being.

0 2 4 6 8 10

Figure: rating scale

Subjective problem checking:

He was told to rate his problem overall problem from 0-10 where o means lowest level of
problem and 10 means highest level of problem.

Objective rating:
The main tools of objective assessment, I used, were depression scale that is developed by Md.
Zahir Uddin and Dr. Mahmudur Rahman(2005) and anxiety scale that is developed by Farah
Deeba and Dr. Roquia Begum (2004). The test results of depression scale is 126 that is severe
level according to Uddin and Rahman(2005) and the test results of anxiety scale is 92 that is
profound level.

PROBLEM DESCRIPION

When Mr. A came then he mentioned some problems which caused significant suffering and
impairment in social occupational and other important areas of functioning .

This problems were behavioral, emotional, motivational, cognitive and physical, interpersonal.

Behavioral:

Mr.A reported that he was crying without any solid reason, excessive sleeping,avoiding social
gathering because he had no interest and feelings to attend any circumstance. Even if his
roommate asked any questions abut his daily life, he has no interest and become bored to answer
the questions. Most of the time he spent by sleeping. He could not concentrate on his [Link]
also reported that he did not remember any simple things, for example: just where she put his
pen/ring,stark heating and gradually his memory disturbance increased. He mentioned that
recently he started smoking. He needs 10 to 12 cigarette everyday. He also addicted to
musterbation and pornography.

Emotional:

He reported that he felt fear and depressed,shame and guilt, and worring. He had uncontrolled
emotion and low capacity for pleasure in everyday life. He also felt hopeless and helpless. He
can’t enjoy any gathering with [Link] was worried about his career and relationships.

Motivational:

He reported that he is gradually loss of interest in activities. He didn’t get pleasure from any
activity. He had no motivation to do any work. He stoped to go to varsity. He thought that every
things is finished and he could not get out from his situation. He is gradually loss of confidence
and feels hopeless. He did not find any pleasure from recreational activities. He was a good
cricketer but he avoid it [Link] did not have any motive to established relationship.
Cognitive:

He had negative perception about himself, his future and relationship with his girlfriend, he had a
core belief( I am a failure,people can not be trusted) and he had a number of intermediate beliefs(
I must have pass university and get a government job).He also had low self esteem. His
confidence level is very low. He had concentration problems and couldn’t make any decision.

Physiological:

Mr. A complained that he had a variety of physical complaints such as fatigue ,less energetic,
appetite disturbance, excessive unexplained chest pain. He also reported that he had breathing
problem and changes in weight decreasingly. He also mentioned that he could not get energy to
complete his work.

Interpersonal:

Client’s interpersonal relationship was getting worst day by day with his friends. He have no
friend circle in the university. But he had big friend circle in college life and school life, but
now-a-days he had no connection with [Link] have good relationship with his family member.

HISTORY OF PRESENT ILLNESS

Mr. A was relatively normal 7-8 months ago. He was a very bright student and had a very good
friend circle and good relationship with his girl friend. His girlfrend is his batchmate. Most of the
time he spent with his girlfrend. Actually he was depended on his girlfrend. As a result his friend
circle become smaller and smaller . In the mean time he and his girlfrend started physical
relation. They were very happy. The problem arise when he started to talk with others girl. His
girlfrend knows the news somehow. When she asked him, he confessed and become shamed for
his [Link] apologies to his girfriend. They started his relation again. But this time his
girlfriend start relationship with another boy. Mr. A can not tolerate it. His girlfriend started to
ignore him. He tried many time to fix the relation but every time he became fail. Then he sarted
smoking . As a result, he gradually felt depressed everyday and find no interest and pleasure in
usual activities. He started to avoid his varsity and friends and hardly eat food. These activities
impaired his daily life functioning. He also complained that he had a variety of physical
complaints such as headache, severe chest pain, sleep disturbance( excessive sleeping). He also
developed an excessive tension, fatigue, difficulty in concentration. .He thought that he was
responsible for his problem but he wanted to get remedy from his recent condition.
 RELEVANT BECKGROUND HISTORY

FAMILY HISTORY:

The client was developed in very supportive family environment with middle socioeconomic
status in a urban area. his father was a non government employee and his mother was a house
wife. Client had a good relationship with them. He had two older sisters .He is free with the
family members and they are very supportive. But he couldn’t share his emotion and feelings
with them about relationships problems. He thought that if he shared everything with them, they
would be anxious.

There is no family history of psychological illness,epilepsy and drug abuse.

PERSONAL HISTORY:

Birth: no birth complications

Early development: normal

Childhood: no separation, no medical illness

Educational history:

She completed his primary, secondary, higher secondary education in general with ordinary
results. But first time he could not get chance any varsity. But with second attempts he got
chance in Pubna University of science and Technology. Bulling experience was not present. But
some of his relatives and friends criticized him for his fail because he did not get chance in
varsity with his first attempt. Now he is BSS (hons.) fourth year student.

Occupation: student

Significant relationship: He has good relationship with parents and siblings and other relatives

Social circumstance: Now he has no interest to attend any program

Forensic history: Orthopedic surgery (breakdown of hand bone)

Past psychiatric history: no history

Past medical history: Pneumonia

Sexual history: not contributory

Drug history: Chain Smoker

PREMORBID PERSONALITY:

Relationship: relationship with family and others were very good.

Leisure activities: Playing cricket, football and badminton, travelling and gossiping with others
and internet browsing.

Prevailing mood: anxious.

Character: He was extrovert in nature.

Attitudes and standards: religious

Habits: Playing cricket and football

MENTAL STATUS EXAMINATION

General appearance and behavior: Mr. A had a normal body build. He looked gloomy but his
behavior and appearance was culturally appropriate. He was depressed in facial expression and
sometimes she was also crying when she talked about her critical incidence.

Rapport: firstly he was not co-operative. Then rapport was established with the client. Eye to
eye contact was presented.

Posture and movement: His movement was normal, most of the time, he sit with hunched
shoulders with the head.

Social behavior: Culturally appropriate social behavior was present. But he reported that he had
no interest to attend any social circumstance and had no motivation to talk with other.

Motor behavior: Sometimes she was shaking things in her hand and drawing on the table with a
pen. But no abnormal motor behavior was found.

Speech:

Rate and quantity: at first she didn’t say anything then normally responsive.
 -Rhythm: average

-Volume: average

-Content: Relevant

-Mood: depressed and anxious

Thought:

-Form: He thought about his girlfriend that is related with past experience.

-Content: Thought about past traumatic experience. Suicidal ideation, delusion was not found.
Obsessional thought was not elicited.

-Stream: normal

Perception:

Illusion and hallucination was not present.

Cognitive function:

-Orientation: Client had appropriate orientation of time, place, person.

-Attention and concentration: attention and concentration were disturbed, not focused

-Memory: immediate memories were not intact and recent and remote memories were intact.

Insight:

The client stated that he was aware of his psychological problem and desired better treatment.

DIAGNOSIS

PROVISIONAL DIANOSIS:

The symtomps of client:

 Diagnosis Inclusion Criteria
1. depressed mood, most of the day during 7-
8 month
[Link] of interest or pleasure in all activities,
nearly everyday
3. significant weight loss
Major Depressive Disorder [Link] everyday
[Link] or loss of energy almost everyday
6. feelings of worthlessness
[Link] guilt
[Link] of concentration
[Link] distress in all area of
functioning

According to DSM-5,the client was suffering from Major Depressive Disorder.

COMORBID DIAGNOSIS:

According to DSM-5,the client was also suffering from generalized anxiety disorder.

the symptoms are-

Inclusion Criteria Exclusion croteria

1. depressed mood, most of the day during 7-8 [Link] anxiety and worry and worry
month during 7-8 months
[Link] of interest or pleasure in all activities, [Link] can’t control her worry feelings
nearly everyday [Link] fatigue easily and excessive tiredness
3. significant weight loss [Link]’t concentrate
[Link] everyday [Link] disturbance
[Link] or loss of energy almost everyday 6. significant distress in all area of functioning.
6. feelings of worthlessness
[Link] guilt
[Link] of concentration
[Link] distress in all area of functioning

FORMULATION
Miss A’s problems can be best explained by cognitive behavioral theoretical view developed by
Aaron Beck(1993):

figure: problem formulation of client using case conceptualization model for depression by
[Link](1993.

Mr. A’s problems can be explained by cognitive behavioral theoretical view developed by Wells
(1997):

figure: problem formulation of client using case conceptualization model for generalized anxiety
disorder by wells (1997)

I have used PPM (predisposing, precipitating, maintaining) formulation:

1. Predisposing factor:

Mr.A used to get average results in exams but did not get a chance in any public university at his
first timethe time . Earlier everyone appreciated him but then everyone was disappointed. Even if
no one gave him any pressure, he would feel very guilty and feel bad about his performance. He
cut off contact with all his friends as then got admission in very good places. Then after enrolling
in university. From earlier part of his life, although every one support him but he could not
express his emotion to his family member. In university he was depended on his girlfrend only
and he had a few friends. As a result when there is a breakup with his girlfrend he felt lonly and
he could not share with any one.

2. Precipitating factor:

Breakup with his girlfriend is the main causes his problem.

[Link] /perpetuating factor:

His girlfrend is his batchmate . They attend class in same class room. But he can not talk with
her. On the other hand she spend time with her new boyfriend. Mr. A observe it daly he get pain.
But he could not share it with others.

Mr. A was worried about his career. He spent most of the time in his relation and he could not
study properly. He thought that he could not get good job. He also thought that he could not over
come from this situation.

He withdraws and avoids everything because he doesn't like anything.

The client face these situations that lead to activate her negative automatic thoughts which is
responsible to maintain her disorder.

TREATMET GOALS:

Short Term Goals

 To reduce low mood

 To reduce anxiety

 To reduce sleep disturbance

 To increase activities & interest

 To increase self confidence

 To reduce indecisiveness

Long Term Goals

✓ To alter negative thoughts and beliefs

✓ To increase interpersonal skills

✓ To increase problem solving strategy

✓ To prevent relapse

Improving family and social relationship

INTERVENTION
Cognitive Behavior Therapy was focused to intervene and break the vicious circle of problems
where the client was trapped. Before the intervention started, the therapist and the client
collaboratively set the goals of the treatment. His therapy continued for a total of 11 sessions.
Usually he was provided a 50-60 minutes session per week. Agenda were set collaboratively
before starting each day's sessions. Several cognitive and behavioral techniques were used in the
intervention. The ultimate goal of the intervention was to diminish the problems through
achieving some goals. The goals of the intervention were:

The following intervention techniques were planned and applied to X's problems. Before
applying the specific technique, the rationale for using that was explained. And feedback from
the client was taken to check his understanding.

Psychological Management By Therapist:

Goals Treatment Plan

For emotional healing Ventilation, empathetic listening,

paraphrasing, summarizing.

To increase activity level Physical activity, Graded task

assignment, mastery and pleasure work
exercise,
To reduce anxiety
PMR, breathing relaxation, imagery relaxation
Guilt feelings
Psycho-education, pie chart
To reduce sleep disturbance Relaxation, sleep schedule, sleep hygiene.

To Increase Problem Solving Skills .

Problem solving strategy

To reduce Dysfunctional assumptions & Thought challenge and modification.

NATS

To reduce indecisiveness Pros and cons

To Increase confidence level Positive data log, find out own strengths

hand out, follow up sessions

To Increase social skills Social skill training

Relapse prevention hand out, follow up sessions

Normalizing

Mr. A normalize that depression is one of the most common and most disabling psychological
condition: at any one time approximately 5% of the population meet criteria for major
depression(Blazer et al. 1994), with 10%-20% of the people suffering from major depression
within their life time (Blazer et al. 1994).

Suicidal contract:

Suicidal contract was taken from the client that he will not commit any suicidal attempt and any
self harm behavior to him or others during the therapy sessions.

Ventilation

Ventilation was done and empathy was given aiming to open up and release his anxiety. The
client did not have close relation with his friends and relatives. He could not share his problem
with any one because he felt that he would be negligible to everyone. Ventilation was used to
facilitate sharing and releasing pent up emotion as pent up emotion was helping to maintain the
presenting problem.

Psycho-Education:

Psycho education was provided to explain the interaction between thought, emotion, behavior
and physical reactions by using five part model. It helps client to understand the link the role of
cognition and emotion in regulating his somatic symptoms and reduced activity. The client was
educated about Depressive disorder and its symptoms, causes and mode of treatment.
Explanation about the cognitive model of Depressive disorder within his own symptoms.

Thoughts

Behaviour Situation emotion

physical reaction
Physical Activity:

Client was invited to use regularly scheduled periods of between 15 and 30 minutes of daily
physical activity like walking, to activate them to reduce her lethargic state.

Activities Scheduling

Once accurate information is available on what the client is doing and what satisfaction he obtain
from his activities, the activities schedule was used to plan each day in advance on an hour-by-
hour basis. The goal was to increase his activity levels and to maximize mastery and pleasure. It
also helps him to increase sense of control over his lives.

Breathing Relaxation and PMR

Pevels and Jhonson (1986) found that relaxation increase the accessibility of positive memory in
the brain. Breathing relaxation and PMR training was given to reduce level of anxiety and reduce
sleep problem.

Graded Task Assignment

Graded task is the procedure to break a task in a convenient part and accomplish them
sequentially. Through accomplishment of small parts a client achieve a sense of success which
was seems difficult to him in past and considered as boring or unattractive. The following steps
were followed for going through the graded task assignment:

1. Make a list of all the things that you have been putting off.
2. Number the tasks in order of priority
3. Taking the first task and breaking it down into small steps.
4. Rehearsal the task mentally, step by step.
5. Write down any negative thoughts that come to you about doing the task, and answer them if
you can and if cannot then simply note down the thoughts for later discussion with the therapist.
6.. Take the task step by step.
7. Write down what you have done on your activity schedule and rate it.
8. Focus on what you have achieved
9. Take the next task and tackle it the same way

Pros And Cons:

Pros and cons were designed to take decision. The client's was asked to list the advantages and
disadvantages of his choices then helped him to devise a system for weighting each item and
drawing a conclusion about which option seems best.

Statement: 'whether I talk with the man or not'.

 Advantages Disadvantages

1. it would prove my social skill Nothing

2. Build a social network.
3. would have a company
[Link] feel good

Socratic Questioning

Socratic questioning was used to help him identify, evaluate and respond to negative automatic
thoughts about himself and others.

Problem Solving

Problem solving method was designed to deal real life problems, such as having no tuition.

1. Decides which problem(s) to be tackled first.

2. Agree goal(s)
3. Work out steps necessary to achieve goal(s)
4. Decides tasks necessary to tackle steps
5. Implementation of decided tasks
6. Review progress at next session, including difficulties that have been encountered
7. Decide next step depending on progress
8. Proceed, as above, to agreed goal(s), or to redefine problems and goals

9. Work on further problems if necessary

As Mr. A had high level of guilt feelings, he was invited to indicate on a pie chart (Beck, 1995)
the percentage of the responsibility that each of the other person involved in the situation had. He
had a thought as 'I am responsible for my business loss' and belief rate was 90%.

Thought Challenge
It is an effective cognitive technique of CBT for fighting irrational and negative thoughts. The
original thought challenge procedure depicted by Beck (1995) was used after modifying it into a
simplified six steps procedure presented in the following,

i) What are the evidence for this idea?

ii) What are the evidences against this idea?
iii) What is the worst that will happen?
iv) What are the benefits of thinking in this idea (the worst thing will happen)?
v) What are the costs of thinking in this way?
vi) What suggetion do you give to your close on who under the same problem?
vii) Why do not you do it?

These seven steps of thought challenge procedure was applied to challenge and diminish
irrational and negative thoughts, for example, "I am hopeless and nothing good in my future".
Before challenge the belief strength of that thought was 80% but after challenge the belief
strength was 30%. X was asked to practice this procedure as homework assignment to fight with
this and other negative irrational thoughts that he had.

Sleep schedule & hygiene

The term 'sleep hygiene' was first used by Dr. Peter Hauri around 20 years ago to describe what
patients themselves can do to eliminate sleep-interfering factors, and to promote good sleep.
Sleep hygiene refers to things about lifestyle and preparation for bed that can be changed to
improve sleep pattern.

Component of sleep scheduling and their Implementation issues:

 Restrict your time in bed:

 Establish your rising time:
 Establish your "threshold time" for bed:
 Go to bed only when sleepy:
 Follow a 7-night-per-week schedule:
 Observe the 15-minute rule:
 Make adjustments to the schedule:.
 Make the connection between bed and sleep:
 Avoid daytime naps:

Social Skill Training

Client's communication pattern was responsible for maintenance of this relationship oriented
problems. So It was also in plan to use social skill training course.
PROGNOSIS

Cognitive behavior therapy for depression, as developed by Beck and his colleagues in
Philadelphia (Beck, Rush, Shaw, Emery 1979), is now one of the most widely adopted,
extensively evaluated and influential treatment approaches. CBT is very effective treatment for
acute depression (Dobson, 1989), atypical depression (Jarrett et al., 1999) and chronic depression
(Keller et al., 2000).

Mr. A was motivated and regular in session. He tried to do homework regularly. These helped
him to progress in session quickly. Process of Cognitive behavior therapy, five factor model,
Beck's cognitive model of depression shared he understood and accept how this problem was
started and maintained. A recent large scale, well controlled study found that CBT was better
than pill placebo and as effective as antidepressant medication at treating moderate-to-severe
depression (DeRubeis et al., 2005) but there are also criticism by Parker et al., 2000. Factors that
predict a greater risk of future episodes are (Gelder, M., Harrison, P., and Cowen, P., 2006):

 Incomplete symptomatic remission

 Bipolar disorder

 Early age of onset

 Poor social support

 Poor physical health

 Co morbid substance misuse

 Co morbid personality disorder

The client does not have bipolar above co morbid disorder and have a good physical health. But
he does not have good social support, high level of environmental stress as well as poor social
support were existed which may lead his progress slow (Carr, A, 2006).

DISCUSSION

Mr. A came to therapist with some psychological problems as Depressed mood, Loss of interest
& pleasure in all activities, difficulties in sleeping, loss of desire to eat, Loss of energy/fatigue,
low self-esteem, excessive guilt, lower level of confidence, decision making problem and
relationship problem. His symptom has reduced in 11th sessions after applying some CBT
techniques.
As a graduate student of the department of clinical psychology, it was a relatively difficult as
well as challenging role to deal with client. It was quite difficult for me to deal with a depressed
man. I truly enjoy the experience and learned a lot which essentially enhance my experience and
thus enrich myself.

Relapses/recurrence is a greater problem for patients with major depression (Judd,

1997). Though relapse prevention was in treatment plan and client attend the follow-up session.
Maintenance CBT was as effective at preventing the recurrence of Patient withdrawn from CBT
has significantly fewer replases than who withdrawn from antidepressant medication & didn't
differ significantly from patients maintained on antidepressant medication (Hollon et al., 2005).
After 12 years follow up, relapse rate for CBT are lower than for pharmacotherapy, when both
treatments are stopped at termination (Kovacs et al., 1981; Simons et al., 1986; Thase et al.,
1991;Evans et al., 1992; Shea et al., 1992; Gortner et al., 1998; Gloaguenet al., 1998).

Reference

1. The Diagnostic and Statistical Manual of mental disorders, 5th edition (DSM-V).

2. Comer, R.J. Abnormal Psychology, 9th edition, Worth Publishers, New York.

3. Carr, A. and McNulty, M. (2006). The Handbook of Adult Clinical Psychology. New York.

[Link], J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press. New York.

[Link], I. and Devison, K. M.(1900, 1995). Cognitive Therapy for Depression and
Anxiety.A practitioner’s guide.

[Link], E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., de Girolamo, G. &
Kessler, R. C. (2011). Cross-national epidemiology of DSM-IV major depressive
[Link] Central.

[Link], M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry, 5th
edition. Oxford University Press.

[Link], S. & Powell, G. (eds.) (2007). The Handbook of Clinical Adult [Link]
Edition. London: Routlrdge.

CONFIDENTIAL CASE REPORT-2

REASON FOR REFERRAL:

Mr. A is suffering from present problem for 12 months and diagnosed as Social Anxiety
Disorder by psychiatrist. Client was referred from outpatient department of Mental Hospital,
Pabna and assigned to me for psychotherapy.

DEMOGRAPHIC INFORMATION:

Mr. A ,24 years old male student brought up in middle class Muslim educated family at urban
area in Pabna. He is Diploma (4th year) student of Pabna Polytehcnic Institute. At present he lives
in Pabna with his family. He is younger child in his family .He has an older brother and he is
happily married. His father is tea seller and mother is housewife.

Genogram of A family:

19

ASSRSSMENT:

Initial assessment was started with client’s demographic information and gradually went through
symptoms, severity, mood and relevant history, present situation problem in different areas of
functioning.

The whole assessment had done by using subjective assessment, subjective and objective rating.

Subjective Assessment:
The main tools of subjective assessment were In-depth clinical interview, Observation of client
in the session. In-depth interview was done by me through open-ended and closed questions,
empathetic listening. Observation was focused on the attention of client, his appearance eye
contact, gesture, congruency of mood instant mood swing, speech, expression and behavior in
the session.

Subjective mood checking:

In this procedure, the client was asked to rate his mood as he was considering. He was asked to
rate his mood from 0-10 where 0 means lowest level of well-being and 10 means highest level of
well-being.

0 2 4 6 8 10

Figure: rating scale

Subjective problem checking:

He was asked to rate his problem out of ( 0-10) where 0 means lowest level of problem and 10
means highest level of problem.

Objective rating:

The main tools of objective assessment, I used, were depression scale that is developed by Md.
Zahir Uddin and Dr. Mahmudur Rahman(2005) and anxiety scale that is developed by Farah
Deeba and Dr. Roquia Begum (2004). The test results of depression scale is 60 that is mild level
according to Uddin and Rahman(2005) and the test results of anxiety scale is 92 that is profound
level.

PROBLEM DESCRIPION

When Mr. X came then he mentioned some problems which caused significant suffering and
impairment in social occupational and other important areas of functioning .

This problems were behavioral, emotional, motivational, cognitive and physical, interpersonal.

Behavioral:

Mr.A reported that he avoid social gathering because his confidence level is very low. He is
connected with some non profit organization and he has to communicate with many people
everyday. But he can not communicate with them properly. Actually he has to provide speech
in front of many people but he can not it. Not only Unfamilar people but also infront of his class
friends, he can not provide lecture. As a result he is so anxious . His academic result decrease
continuously. He has problem in sleeping. He could not concentrate on his study. He also
reported that he had problem in remembering. He mentioned that recently he started smoking. He
needs 10 to 12 cigarette everyday. He also addicted to musterbation and pornography.

Emotional:

He reported that he felt fear and anxious,shame and guilt, and worring. He had uncontrolled
emotion and low capacity of mood. He can’t enjoy any gathering with [Link] was worried
about his career and relationships.

Motivational:

He reported that he is gradually loss of interest in activity. He had no motivation to do any work.
He thought that things will be worse and he could not get out from his situation. He is gradually
loss of confidence. He did not find any pleasure from recreational activities. He was a good
cricketer but he avoid it [Link] did not have any motive to established relationship.
Cognitive:

He had negative perception about himself, his future and relationship with his girlfriend, he had a
core belief( I am a failure, people can not be trusted) and he had a number of intermediate
beliefs( I must have pass and get a government job).He also had low self esteem. His
confidence level is very low. He had concentration problems and couldn’t make any decision.

Physiological:

Mr. A complained that he had a variety of physical complaints such as fatigue ,less energetic,
appetite disturbance, excessive unexplained chest pain. He also reported that he had breathing
problem and changes in weight decreasingly. He also mentioned that he could not get energy to
complete his work.

Interpersonal:

Client’s interpersonal relationship was getting worst day by day with his friends. He had big
friend circle in college life and school life, but now-a-days he had no connection with them. He
have good relationship with his family member but he can not share his feelings with them. His
relation with his girlfriend was good and he somehow depends on her.

HISTORY OF PRESENT ILLNESS

Mr. A was relatively normal 4/5 years back. He was a very bright student and had a very good
friend circle and good relationship with his girl friend. But there is a problem in his area. there is
a gangt [Link] was connected with gang . In 2019, he was attacted by opposite gang
members and he was severly injured. His problem start from this time. After that he come out
from this gang culture and was normal and happy. In the mean time, he had a girlfriend. But she
cheated with Mr.A. After that his confidence level was break down. He was disconnected with
every things. He closed him self in a dark room. Few days later he was affected by Hepatitis B
virus. He sarted smoking . He started to avoid his friends and hardly eat food. After the
recovery of this situation, he started a relationship with another girl. Now his relationship is quite
good. But he thought that his present girlfriend will ncheat him again. He stayed anxious about
it. He thought that he is incompitent. He can not to do any work properly. So he started to avoid
people. When he speaks infront of people, he thought he can not perform properly. On this time
he had developed breathing [Link] activities impaired his daily life functioning. He also
complained that he had a variety of physical complaints such as headache, severe chest pain,
sleep disturbance. He also developed an excessive tension, fatigue, difficulty in
concentration. .He wanted to get remedy from his recent condition.

RELEVANT BECKGROUND HISTORY

FAMILY HISTORY:

The client was developed in very supportive family environment with middle socioeconomic
status in a urban area. His father is a tea seller and his mother is a house wife. Client had a good
relationship with them. He has older brother .He is free with the family members and they are
very supportive. But he couldn’t share his emotion and feelings with them about relationships
problems and other problem( like gang culture). He thought that if he shared everything with
them, they would be anxious.

There is no family history of psychological illness,epilepsy and drug abuse.

PERSONAL HISTORY:

Birth: no birth complications

Early development: normal

Childhood: no separation,no medical illness

Educational history:

He completed his primary and secondary education in general with ordinary results. After that
he got admited to Pabna Polytechnic Institute. Bulling experience was not present. But some of
his friends criticized him. . Now he is diploma fourth year student.

Occupation: student

Significant relationship: He had good relationship with parents and siblings and other relatives

Social circumstance: Now he has no interest to attend any program

Forensic history: Attacted by gang members and have to admited hospital.

Past psychiatric history: No significant psychiatric history present.

Past medical history: Hepatitis B positive

Sexual history: not contributory

Drug history: Chain Smoker

PREMORBID PERSONALITY:

Relationship: relationship with family and others were very good.

Leisure activities: Playing cricket, football and badminton, travelling and gossiping with others
and internet browsing.

Prevailing mood: anxious.

Character: He was extrovert in nature.

Attitudes and standards: religious

Habits: Playing cricket and football

MENTAL STATUS EXAMINATION

General appearance and behavior: Mr. A had a normal body build. He looked gloomy but his
behavior and appearance was culturally appropriate. He was depressed in facial expression and
sometimes she was also crying when she talked about her critical incidence.

Rapport: firstly he was not co-operative. Then rapport was established with the client. Eye to
eye contact was presented.

Posture and movement: His movement was normal, most of the time, he sit with hunched
shoulders with the head.

Social behavior: Culturally appropriate social behavior was present. But he reported that he had
no interest to attend any social circumstance and had no motivation to talk with other.

Motor behavior: Sometimes she was shaking things in her hand and drawing on the table with a
pen. But no abnormal motor behavior was found.
Speech:

Rate and quantity: at first she didn’t say anything then normally responsive.

-Rhythm:average

-Volume: average

-Content: Relevent

-Mood: depressed and anxious

Thought:

-Form: He thought about his girlfriend that is related with past experience.

-Content: Thought about past traumatic experience. Suicidal ideation, delusion was not found.
Obsessional thought was not elicited.

-Stream: normal

Perception:

Illusion and hallucination was not present.

Cognitive function:

-Orientation:client had appropriate orientation of time, place,person

-Attention and concentration: attention and concentration were disturbed, not focused

-Memory: immediate memories were not intact and recent and remote memories were intact.

Insight:

The client stated that he was aware of her psychological treatment and desired better treatment.
DIAGNOSIS

PROVISIONAL DIANOSIS:

The symtoms of client:

Diagnosis Inclusion Criteria

1. Intense fear of social situation
[Link] of social situation
3. Sweating , increase heart rate , trembling
in social situation
[Link] about performance.
[Link] self esteem and feelings of inadequacy.
6. Fear that other will notice while he will
Social Anxiety Disorder perform.
[Link] of situation where he might be the
center of attention.
[Link] in concentration.
[Link] distress in all area of
functioning

According to DSM-5,the client was suffering from Social Anxiety Disorder.

COMORBID DIAGNOSIS:

According to DSM-5, the client was also suffering from generalized anxiety disorder.

the symptoms are-

Inclusion critea Exclusion Criteria

[Link] anxiety and worry and worry
during 7-8 months
[Link] can’t control her worry feelings
[Link] fatigue easily and excessive tiredness
Generalized Anxiety Disorder [Link]’t concentrate
[Link] disturbance
6. significant distress in all area of
functioning.
FORMULATION

Miss X’s problems can be best explained by cognitive behavioral theoretical view developed by
Aaron Beck(1993):

figure: problem formulation of client using case conceptualization model for depression by
[Link](1993.

Mr. A’s problems can be explained by cognitive behavioral theoretical view developed by Wells
(1997):

I have used PPM (predisposing, precipitating, maintaining) formulation:

1. Predisposing factor:

Although Mr.A born in a supportive family but he could not share his emotions with his family
members. As a result he was engaged with gang culture. He was also criticized by his friends.
When he was engaged with gang , they attacted many people even his opposite gang members.
he was always afraid that he might attacted by his enemy.

He had a relatinship but he could not continue with her. He felt that he was incompitent.

2. Precipitating factor:

He was attacted by opposite gang members. He had a Breakup with his girlfriend. He was also
affected by hepatitis B virus.

[Link] /perpetuating factor:

He lives in a same place where he was born. He was attacted on this place. He saw those people
regural.

He was bully by his friend circle.

Mr. A was worried about his career. He thought that he could not get good job. He also thought
that he could not overcome from this situation.
He withdraws and avoids everything because he doesn't like anything.

The client face these situations that lead to activate her negative automatic thoughts which is
responsible to maintain her disorder.

TREATMET GOALS:

Short Term Goals

To reduce low mood

 To reduce anxiety

 To reduce sleep disturbance

 To increase activities & interest

 To increase self confidence

 To reduce indecisiveness

Long Term Goals

✓ To alter negative thoughts and beliefs

✓ To increase interpersonal skills

✓ To increase problem solving strategy

✓ To prevent relapse

Improving family and social relationship

INTERVENTION

Cognitive Behavior Therapy was focused to intervene and break the vicious circle of problems
where the client was trapped. Before the intervention started, the therapist and the client
collaboratively set the goals of the treatment. His therapy continued for a total of 11 sessions.
Usually he was provided a 50-60 minutes session per week. Agenda were set collaboratively
before starting each day's sessions. Several cognitive and behavioral techniques were used in the
intervention. The ultimate goal of the intervention was to diminish the problems through
achieving some goals. The goals of the intervention were:
The following intervention techniques were planned and applied to X's problems. Before
applying the specific technique, the rationale for using that was explained. And feedback from
the client was taken to check his understanding.

Psychological Management By Therapist:

Goals Treatment Plan

For emotional healing Ventilation, empathetic listening,

paraphrasing, summarizing.

To increase activity level Physical activity, Graded task

assignment, mastery and pleasure work
exercise,
To reduce anxiety
PMR, breathing relaxation, imagery
relaxation
Guilt feelings
Psycho-education, pie chart
To reduce sleep disturbance Relaxation, sleep schedule, sleep hygiene.

To Increase Problem Solving Skills .

Problem solving strategy

To reduce Dysfunctional assumptions & Thought challenge and modification.

NATS

To reduce indecisiveness Pros and cons

To Increase confidence level Positive data log, find out own strengths

hand out, follow up sessions

To Increase social skills Social skill training

Relapse prevention hand out, follow up sessions

Normalizing

Mr. X normalize that anxiety is one of the most common and most disabling psychological
condition: at any one time approximately 5% of the population meet criteria for anxiety(Blazer et
al. 1994), with 10%-20% of the people suffering from major depression within their life time
(Blazer et al. 1994).

Suicidal contract:

Suicidal contract was taken from the client that he will not commit any suicidal attempt and any
self harm behavior to him or others during the therapy sessions.

Ventilation

Ventilation was done and empathy was given aiming to open up and release his anxiety. The
client did not have close relation with his friends and relatives. He could not share his problem
with any one because he felt that he would be negligible to everyone. Ventilation was used to
facilitate sharing and releasing pent up emotion as pent up emotion was helping to maintain the
presenting problem.

Psycho-Education:

Psycho education was provided to explain the interaction between thought, emotion, behavior
and physical reactions by using five part model. It helps client to understand the link the role of
cognition and emotion in regulating his somatic symptoms and reduced activity. The client was
educated about social Anxiety Disorder and its symptoms, causes and mode of treatment.
Explanation about the cognitive model of Social Anxiety disorder within his own symptoms.

Thoughts

Behaviour Situation emotion

physical reaction
Physical Activity:

Client was invited to use regularly scheduled periods of between 15 and 30 minutes of daily
physical activity like walking, to activate them to reduce her lethargic state.

Activities Scheduling

Once accurate information is available on what the client is doing and what satisfaction he obtain
from his activities, the activities schedule was used to plan each day in advance on an hour-by-
hour basis. The goal was to increase his activity levels and to maximize mastery and pleasure. It
also helps him to increase sense of control over his lives.

Breathing Relaxation and PMR

Pevels and Jhonson (1986) found that relaxation increase the accessibility of positive memory in
the brain. Breathing relaxation and PMR training was given to reduce level of anxiety and reduce
sleep problem.

Graded Task Assignment

Graded task is the procedure to break a task in a convenient part and accomplish

them sequentially. Through accomplishment of small parts a client achieve a sense of success
which was seems difficult to him in past and considered as boring or unattractive. The following
steps were followed for going through the graded task assignment:

1. Make a list of all the things that you have been putting off.
2. Number the tasks in order of priority
3. Taking the first task and breaking it down into small steps.
4. Rehearsal the task mentally, step by step.
5. Write down any negative thoughts that come to you about doing the task, and answer them if
you can and if cannot then simply note down the thoughts for later discussion with the therapist.
6. Take the task step by step.
7. Write down what you have done on your activity schedule and rate it.
8. Focus on what you have achieved
9. Take the next task and tackle it the same way

Pros And Cons:

Pros and cons were designed to take decision. The client's was asked to list the advantages and
disadvantages of his choices then helped him to devise a system for weighting each item and
drawing a conclusion about which option seems best.

Statement: 'whether I talk with the man or not'.

Advantages Disadvantages

1. it would prove my social skill Nothing

2. Build a social network.
3. would have a company
[Link] feel good

Socratic Questioning

Socratic questioning was used to help him identify, evaluate and respond to negative automatic
thoughts about himself and others.

Problem Solving

Problem solving method was designed to deal real life problems, such as having no tuition.

1. Decides which problem(s) to be tackled first.

2. Agree goal(s)

3. Work out steps necessary to achieve goal(s)

4. Decides tasks necessary to tackle steps

5. Implementation of decided tasks

6. Review progress at next session, including difficulties that have been encountered

7. Decide next step depending on progress

8. Proceed, as above, to agreed goal(s), or to redefine problems and goals

9. Work on further problems if necessary

As Mr. X had high level of guilt feelings, he was invited to indicate on a pie chart (Beck, 1995)
the percentage of the responsibility that each of the other person involved in the situation had. He
had a thought as 'I am responsible for my business loss' and belief rate was 90%.

Thought Challenge

It is an effective cognitive technique of CBT for fighting irrational and negative thoughts. The
original thought challenge procedure depicted by Beck (1995) was used after modifying it into a
simplified six steps procedure presented in the following,

i) What are the evidence for this idea?

ii) What are the evidences against this idea?
iii) What is the worst that will happen?
iv) What are the benefits of thinking in this idea (the worst thing will happen)?
v) What are the costs of thinking in this way?
vi) What suggetion do you give to your close on who under the same problem?
vii) Why do not you do it?

These seven steps of thought challenge procedure was applied to challenge and diminish
irrational and negative thoughts, for example, "I am hopeless and nothing good in my future".
Before challenge the belief strength of that thought was 80% but after challenge the belief
strength was 30%. X was asked to practice this procedure as homework assignment to fight with
this and other negative irrational thoughts that he had.

Sleep schedule & hygiene

The term 'sleep hygiene' was first used by Dr. Peter Hauri around 20 years ago to describe what
patients themselves can do to eliminate sleep-interfering factors, and to promote good sleep.
Sleep hygiene refers to things about lifestyle and preparation for bed that can be changed to
improve sleep pattern.

 Component of sleep scheduling and their Implementation issues:

 Restrict your time in bed:

 Establish your rising time:

 Establish your "threshold time" for bed:

 Go to bed only when sleepy:

 Follow a 7-night-per-week schedule:

  Observe the 15-minute rule:

 Make adjustments to the schedule:.

 Make the connection between bed and sleep:

 Avoid daytime naps:

Social Skill Training

Client's communication pattern was responsible for maintenance of this relationship oriented
problems. So It was also in plan to use social skill training course.

Reference

1. The Diagnostic and Statistical Manual of mental disorders, 5th edition (DSM-V).

2. Comer, R.J. Abnormal Psychology, 9th edition, Worth Publishers, New York.

3. Carr, A. and McNulty, M. (2006). The Handbook of Adult Clinical Psychology. New York.

[Link], J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press. New York.

[Link], I. and Devison, K. M.(1900, 1995). Cognitive Therapy for Depression and
Anxiety.A practitioner’s guide.

[Link], E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., de Girolamo, G. &
Kessler, R. C. (2011). Cross-national epidemiology of DSM-IV major depressive
[Link] Central.

[Link], M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry, 5th
edition. Oxford University Press.

[Link], S. & Powell, G. (eds.) (2007). The Handbook of Clinical Adult [Link]
Edition. London
 CONFIDENTIAL CASE REPORT-3

REASON FOR REFERRAL:

Miss. X is suffering from present problem for 3 years and diagnosed as Obssesive and
Compulsive Disorder by psychiatrist. Client was referred from outpatient department of Mental
Hospital, Pabna and assigned to me for psychotherapy.

DEMOGRAPHIC INFORMATION:

Miss X, 32 years old women brought up in middle class Muslim educated family at urban area in
Pabna. At present she lives in Gazipur wih his husbend. She was first child in her family. She has
an younger sister. Her sister is a student. She have one baby. She have completed her honours
and masters from Edward College, Pabna under National University.

Genogram of X family:

57
49

29 19
24

ASSRSSMENT:
Initial assessment was started with client’s demographic information and gradually went through
symptoms, severity, mood and relevant history, present situation problem in different areas of
functioning.

The whole assessment had done by using subjective assessment, subjective and objective rating.

Subjective Assessment:

The main tools of subjective assessment were In-depth clinical interview, Observation of client
in the session. In-depth interview was done by me through open-ended and closed questions,
empathetic listening. Observation was focused on the attention of client, her appearance eye
contact, gesture, congruency of mood instant mood swing, speech, expression and behavior in
the session.

Subjective mood checking:

In this procedure, the client was asked to rate his mood as she was considering. She was asked to
rate her mood out of (0-10) where 0 means lowest level of well-being and 10 means highest level
of well-being.

0 2 4 6 8 10

Figure: rating scale

Subjective problem checking:

She was asked to rate her problem from 0-10 where 0 means lowest level of problem and 10
means highest level of problem.

Objective rating:

The main tools of objective assessment,I used,were depression scale that is developed by Md.
Zahir Uddin and Dr. Mahmudur Rahman(2005) and anxiety scale that is developed by Farah
Deeba and Dr. Roquia Begum (2004).the test results of depression scale is 66 that is mild level
according to Uddin and Rahman(2005) and the test results of anxiety scale is 92 that is profound
level.

PROBLEM DESCRIPION

When miss X came then she mentioned some problems which caused significant suffering and
impairment in social occupational and other important areas of functioning .

This problems were behavioral, emotional, motivational, cognitive and physical, interpersonal.

Behavioral:

X reported that she avoid her son, father and father in law because she has sexual thought about
them. when her son come in front of her, sexual thought also come. So she could not care her
child properly. When she touch her son , she felt guilty and thought for her thought her husband
will be haram. So she want to resure it. So she call a Mufti every time to sure it whether her
husband is Halal or Haram. She did it several time. She also avoid her father and father in law
for same thoughts. So she never come in front of them. Most of the time, she spent sleeping and
she couldn’t concentrate and remember. She also reported that she did not remember any simple
things.

Emotional:

She reported that she felt fear and depressed, shame and guilt and worring. She had uncontrolled
emotion and low capacity for pleasure in everyday life. She also felt hopeless and helpless for
her thought. She can’t enjoy any gathering with relatives. She was worried about her thought.
She felt guilty as she cann’t take care her son properly.

Motivational:
She reported that she is gradually loss of interest in activities. She didn’t get pleasure from any
activity. She had no motivation to do any work. She is gradually loss of confidence and feels
hopelessness and loss of motivation in social gathering. She did not find any pleasure from
recreational activities. She did not have any motive to take care her son.

Cognitive:

She had negative perception about herself,her future and relationship with herhusband. She had
sexual thought about her son, father and father in law. Specially about her [Link], she avoid her
[Link] also hought as she have sexual thought about her child ,so her husband is haram for
herself.,she had a core belief( I am a failure, I cheated with my Husband) and she had a number
of intermediate beliefs( I have to be my son, father and father in law).she also had low self
[Link] confidence level is very [Link] had concentration problems and couldn’t make any
decision.

Physiological:

Miss X also complained that she had a variety of physical complaints such as fatigue, less
energetic, appetite disturbance, excessive unexplained chest pain. She also reported that she had
breathing problem and changes in weight decreasingly.

Interpersonal:

Client’s interpersonal relationship was getting worst day by day with her husband and family
members. His husband and others members always support her but she avoid them. Specially she
avoid her son, father and father in law. They are triggering factors for herself. She have no friend
circle. She had friend circle in college life and school life, but now-a-days he had no connection
with them.

HISTORY OF PRESENT ILLNESS

Miss X was relatively normal 4 years ago. But checking behavior was present from her student
life. She checked many times whether she locked the windows and doors before sleeping. After
her marraige she started to live with her husband. During the COVID pandemic washing
behavior devoloped within hersef. She separated her from other people and close her into the
room. She washed her hand several time and take 3/4 hours for shouer. After treatment partial
remission occurs. But when she became mother another problem arise. Sex related thought that
was related with her son came into her mind. She felt guilty for those thought. She also thought
since she had these negative thought her husband will HARAM for herself. Then she started to
meet with Several MUFTI to resure it whether her husband was HALAL OR HARAM. She did
the same things several times. She started to avoid her child . She also had sex related thought
with her father and father in law. But these thought were not severe enough.

As a result, she gradually felt depressed everyday. She always stayed anxious. These activities
impaired his daily life functioning. She also developed an excessive tension, fatigue, difficulty in
concentration. She thought that she was responsible for her problem but she wanted to get
remedy from her recent condition.

RELEVANT BECKGROUND HISTORY

FAMILY HISTORY:

The client was developed in very supportive family environment with middle socioeconomic
status in a urban area of Pabna. Her father was a army solder and her mother was a house wife.
Client had a good relationship with them. She had one yonger sister. She is free with the family
members and they are very supportive. But she couldn’t share her emotion and feelings with
them about relationships problems. She thought that if she shared everything with them, they
would be anxious.

There is no family history of psychological illness, epilepsy and drug abuse.

PERSONAL HISTORY:

Birth: no birth complications

Early development: normal

Childhood: no separation, no medical illness

Educational history:

She completed her primary, secondary, higher secondary education in general with ordinary
result. After that she completed her honours and master from Edward College, Pabna. Bulling
experience was not [Link] appreciated her.
Occupation: Housewife

Significant relationship: She had good relationship with parents and siblings and other
relatives. Specially she have outstanding relation with her husband.

Social circumstance: Now she has no interest to attend any program.

Forensic history: Ceasarian opration

Past psychiatric history: Absent

Past medical history: abset.

Sexual history: not contributory

Drug history: no history

PREMORBID PERSONALITY:

Relationship: relationship with family and others were very good.

Leisure activities: reading book, recitation of Holly Quran and gossiping with others

Prevailing mood: anxious

Character: Introvert in nature

Attitudes and standards: religious

Habits: reading book, Recitation of Holly Quran.

MENTAL STATUS EXAMINATION

General appearance and behavior: miss X had a normal body build. she looked gloomy but his
behavior and appearance was culturally appropriate. she was depressed in facial expression.
sometimes she was also crying when she talked about her critical incidence.

Rapport: firstly she was not co-operative. then rapport was established with the client. eye to
eye contact was presented.
Posture and movement: her movement was [Link] of the times,she sited with hunched
shoulders, with the head.

Social behavior: culturally appropriate social behavior was present. but she reported that she
had no interest to attend any social circumstance and had no motivation to talk with other. she
also had no pleasure.

Motor behavior: sometimes she was shaking things in her hand and drawing on the table with a
pen.

Speech:

Rate and quantity: at first she didn’t say anything then normally responsive.

-Rhythm: average

-Volume: average

-Content: average

-Mood: depressed and anxious

Thought:

-Form: not normal, she did overthinking about her husband that is related with religion.

-Content: thought about past traumatic [Link] ideation, delusion was not found.
obsessional thought was elicited.

-Stream: normal

Perception:

Illusion and hallucination was not present.

Cognitive function:

-Orientation:client had appropriate orientation of time, place,person

-Attention and concentration: attention and concentration was disturbed, not focused

-Memory: immediate memories were not intact and recent and remote memories were intact.

Insight:
 Client had poor insight. She even belive that she has problem and these problem came for her
disorder. After providing psychoeducation client was aware of her psychological problem and
desired better treatment.

DIAGNOSIS

PROVISIONAL DIANOSIS:

According to DSM-v, diagnostic criteria of obsessive compulsive disorder are:

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time

during the disturbance, as intrusive and unwanted, and that in most individuals cause

marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to

neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,

praying, counting, repeating words silently) that the individual feels driven to perform in

response to an obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress,

or preventing some dreaded event or situation; however, these behaviors or mental acts

are not connected in a realistic way with what they are designed to neutralize or prevent,

or are clearly excessive.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per

day) or cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects

of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder.

Diagnosis Inclusion Criteria

 Recurrent and persistent thoughts.
 Recurrent and persistent urges.
 Repetitive and compulsive to meet
Mufti
 Avoid her son, father and father in law
 Inflated responsibility.
 Strong moral thoughts
 Always become fearful about the
condition.
Obsessive Compulsive Disorder  do not trust others, confused and
extremely misunderstood others
 Feel helpless, lonely and do not have
any close friend, experience functional
and
 social impairment.
 Unable to concentrate, collect useless
things, sleep problem and also suffer
from
 headaches, stomach problem.

This symptoms are similar to the main criteria of Obsessive-Compulsive disorder(OCD)

and the disturbance is not better explained by another mental disorder so ,According to

Diagnostic and Statistical Manual of Mental Disorder-5 (DSM-5) the client is suffered

from Obsessive-Compulsive disorder(OCD).

COMORBID DIAGNOSIS:

According to DSM-5,the client was also suffering from generalized anxiety disorder.

the symptom are-

Inclusion criteria Exclusion Criteria

 Recurrent and persistent thoughts. [Link] anxiety and worry and worry
 Recurrent and persistent urges. during 7-8 months
 Repetitive and compulsive to meet [Link] can’t control her worry feelings
Mufti [Link] fatigue easily and excessive tiredness
 Avoid her son, father and father in law [Link]’t concentrate
 Inflated responsibility. [Link] disturbance
 Strong moral thoughts 6. significant distress in all area of
 Always become fearful about the functioning.
condition.
 do not trust others, confused and
extremely misunderstood others
 Feel helpless, lonely and do not have
any close friend, experience functional
and
 social impairment.
 Unable to concentrate, collect useless
things, sleep problem and also suffer
from
 headaches, stomach problem.
FORMULATION

Miss. X problem can be explained by cognitive behavioral theory view of Salkovskis.

Salkovskis’ (1985, 1989, 1996) theory is based on Beck’s (1976) cognitive specificity

hypothesis and Rachman and colleagues’ spontaneous decay experiments (Rachman, De Silva
and Roper, 1976). The cognitive model of OCD, developed by Salkovskis (1985), proposes that
obsessional thinking starts from normal intrusive cognitions. Early experience and critical
incidence format the assumption or general beliefs, from which intrusive thoughts are made.
Obsessions are conceptualized as normal intrusive thoughts that are misinterpreted by the
sufferer. This interpretation has several effects, such as: increased discomfort, including (but not
confined to) anxiety and depression, the focusing of attention both on the intrusions themselves
and triggers in the environment that may increase their occurrence, increased accessibility to and
preoccupation with the original thought and other related ideas behavioral responses. Such
appraisals evoke distress and motivate the individual to try to suppress or remove the unwanted
intrusion (for example, by replacing it with a “good” thought) and to try to prevent any harmful
events associated with the intrusion. According to the cognitive model, compulsions are
conceptualized as efforts to remove intrusions and to prevent any perceived harmful
consequences. Salkovskis advanced 2 main reasons to explain why compulsions become
persistent and excessive. First, they are reinforced by immediate distress reduction and by
temporary removal of the unwanted thought (negative reinforcement, as in the conditioning
models of OCD). Second, they prevent the individual from learning that his or her appraisals are
unrealistic (for example, the individual fails to learn that unwanted harm-related thoughts do not
lead to acts of harm). Compulsions influence the frequency of intrusions by serving as reminders
of intrusions and thereby triggering their reoccurrence. For example, compulsive hand washing
can remind the individual that he or she may have become contaminated. Attempts at distracting
oneself from unwanted intrusions may paradoxically increase their frequency, possibly because
the distractors become reminders (retrieval cues) of the intrusions.

Compulsions can strengthen one’s perceived responsibility. That is, the absence of the feared
consequence after performing the compulsion reinforces the belief that the individual is
responsible for removing the threat.

On the basis of this, the problem of Y can be formulated:

1. Predisposing factor:

Mrs. X was introvert in nature. She had limited number of friends. From her school life she was
religious and she studied many religious books.

2. Precipitating factor:

Actually

[Link] /perpetuating factor:

Her personality is one of the maintaining for her problem.

Treatment Goals

Short term goals:

 Normalized the client.

 Increasing activity level and reducing anxiety.
 Reducing frequency of compulsive behavior.
 Reducing avoidance.
 Increasing self-confidence.
 Improving low mood.
 To increase adaptation ability.
 To increase communication skill.
 Identifying the dysfunctional believe and negative Automatic thought

Long term Goals:

 To reduce her depression and constant anxiety.

 Learn to resist OCD compulsion

 Challenge obsessive thought

 Make life style changes

INTERVENTION
Cognitive Behavior Therapy was focused to intervene and break the vicious circle of

problems where the client was trapped. Before the intervention started, the therapist and

the client collaboratively set the goals of the treatment. Her therapy continued for a total

of 8 sessions. Usually she was provided a 50-60 minutes session two day per week.

Agenda were set collaboratively before starting each day’s sessions. Several cognitive

and behavioral techniques were used in the intervention. The ultimate goal of the

intervention was to diminish the problems through achieving some goals.

The following intervention techniques were planned and applied to Y’s problems. Before

applying the specific technique, the rationale for using that was explained. And feedback

from the client was taken to check her understanding.

Normalizing:

Normalizing is the experience of intrusions, helping the patient to change their

understanding of the significance of the occurrence and content of intrusions. Guided

discovery is used to help Miss Y, consider several important questions:

• who has obsessional thoughts?

• how common are intrusive thoughts?

• do they occur only in people suffering from OCD?

• why are intrusions so common?

• are they of any use?

Mrs. X was normalized that obsessional thoughts occur about 90% percents of individuals

(Rachman and De Silva, 1978, Salkovskis and Harrison, 1984) and the content of these

thoughts are also similar.

Ventilation:

Ventilation was done and empathy was given aiming to open up and release her anxiety.
The client did not have close relation with her friends and relatives. She could not share

his problem with any one because she felt that she would be negligible to everyone.

Ventilation was used to facilitate sharing and releasing pent up emotion as pent up

emotion was helping to maintain the presenting problem.

Physical activity:

Client was encouraged to daily physical activity like walking, to activate her to order to

reduce her lethargic state using a regularly scheduled periods of between 15 and 30

minutes.

Breathing Relaxation and PMR:

Pevels and Jhonson (1986) found that relaxation increase the accessibility of positive

memory in the brain. Breathing relaxation and PMR training was given to reduce level of

anxiety and reduce sleep problem. She also required to practice the technique at home.

Activities Scheduling:

Once accurate information is available on what the client is doing and what satisfaction

he obtain from his activities, the activities schedule was used to plan each day in advance

on an hour-by-hour basis. The goal was to increase his activity levels and to maximize

mastery and pleasure. It also helps him to increase sense of control over his lives.

Psycho-education:

Psycho education was provided and formulation was shared to help his understands the

problems and mode of treatment. The client was educated about obsessive compulsive

disorder, its symptoms, causes and mode of treatment. Explanation about the maintaining
 Thoughts

Behaviour Situation emotion

physical reaction

circle obsessive compulsive disorder was also provided by his own symptoms.

Trigger Obsession Discomfort

Figure3.2: A sequence of events in an obsessive compulsive experience

Exposure and Response Prevention (ERP):

One of the most popular and effective forms of behavioral therapy for OCD is exposure and
response prevention (ERP). ERP involves exposing the client to the anxiety that is provoked by
her obsessions and then preventing the patients from carrying out the compulsive behaviors to
reduce her anxiety. This cycle of exposure and response prevention is repeated until she is no
longer troubled by her obsessions and/or compulsions.

Rational:

Before describing the details of this form of treatment, the rational behind the treatment

is descried to client. When patients engage in the compulsive behaviors the level of

discomfort and compulsive urges go down. What would happen if the discomfort and

compulsive urges to engage in the compulsive behaviors were provoked, but the patients

then refrained from carrying out the compulsion? Several studies shown that, in this
situation the level of discomfort and strength of compulsive urges still go down, but much

more slowly. When this is done in repeated session there will be a cumulative

effect.(Rachman [Link]. 1996).The therapist and client then collaborately constructed a list

how difficult these trigger or cues are for the client to face. This is usually on a scale of

0-100 (where 0 means “no anxiety” 100 means “extreme anxiety”). Similar a list

constructed for the strength of the compulsive urges on a scale of 0-100 (where 0 means

“no urge” 100 means “extreme urge”).

An example of my clients’ list is given below:

Table 3.1: Hierarchy Items

Items of hear hierarchy Discomfort (0-100) Compulsive urge

(0-100)

kiss her son 100 90

hug her son 90 80
Touching her son 80 70

care her son without 60 60

touching
talk face to face 40 40
talk over phone 30 20
thik that she is talking with 20 20
her father and father in law

i) X was asked to select from the hierarchy the highest item she can allow to be exposed

in and she agreed in start from minimal anxiety level.

ii) She was exposed to that situation and was asked to prevent her overt responses like

to meet with MUFTI whether her husband is HALAL OR HARAM.

iii) She was asked to continue until her arousal is diminished.

iv) She was asked to evaluate the situation by rating anxiety level.

v) ERP is continued to the next item in the hierarchy when, after successive ERP trial, the

specific item fails to produce any compulsive urge. She was asked to practice ERP as a

homework assignment.

Modeling:

In this technique, the therapist carries out the action that the client was instructed to do,

by way of demonstration. It was done in calm and controlled way, with no sign of anxiety

or discomfort and models also coping with the exposure.

Sleep schedule and hygiene:

The term ‘sleep hygiene’ was first used by Dr. Peter Hauri around 20 years ago to describe

what patients themselves can do to eliminate sleep-interfering factors, and 15 to promote

good sleep. Sleep hygiene refers to things about lifestyle and preparation for bed that can

be changed to improve sleep pattern.

Component of sleep scheduling and their Implementation issues:

 Restrict your time in bed.

 Establish your rising time.
 Establish your “threshold time” for bed.
 Go to bed only when sleepy.
 Follow a 7-night-per-week schedule.
 Observe the 15-minute rule.
 Make adjustments to the schedule.
 Make the connection between bed and sleep.
 Avoid daytime naps.

Thought Challenge:
It is an effective cognitive technique of CBT for fighting irrational and negative thoughts.

The original thought challenge procedure depicted by Beck (1995) was used after

modifying it into a simplified six steps procedure presented in the following,

i) What is the worst that will happen?

ii) What are the evidence for this idea?

iii) What are the evidences against this idea?

iv) What are the benefits of thinking in this idea (the worst thing will happen)?

v) What are the costs of thinking in this way?

vi) What should I do about it?

These six steps of thought challenge procedure was applied to challenge and diminish

irrational and negative thoughts, for example, ‘Thought is equal to believing”. Before

challenge the belief strength of that thought was 80% but after challenge the belief

strength was 30%. Y was asked to practice this procedure as homework assignment to

fight with this and other negative irrational thoughts that she had.

Graded Task Assignment:

Graded task is the procedure to break a task in a convenient part and accomplish them

sequentially. Through accomplishment of small parts a client achieve a sense of success

which was seems difficult to him in past and considered as boring or unattractive.

Pros And Cons:

Pros and cons were designed to take decision. The client’s was asked to list the advantages

and disadvantages of his choices then helped her to devise a system for weighting each

item and drawing a conclusion about which option seems best.

Relapse Prevention:

Relapse prevention was also in the treatment plan to help the client to deal with future
possible problems through a treatment blueprint. Potential relapse factors were explored

from the clients and worked with these factors how she will deal if these come in her

future life.

RESULTS

Objective Measure

For objective assessment Anxiety, Depression, and DUOCS scales were used. Scores of

theses scales are given below: eight sessions were given to the client. The client reported

improvement in her problems.

Session Depression Anxiety DUOCS

1st 120 70 62
2nd 110 66
3rd 100 60 47
4th 90
6 th 84 48 34

Table 3.2: Scores of Depression, Anxiety and DUOCS Scale in different session

Subjective Wellbeing:

In this procedure the client was asked to rate his overall problems and mood as he was

considering. He was asked to rate his mood and overall problems from 0%-100% where

0% means lowest level of well-being and 100% means highest level of well-being.
 session Subjective Wellbeing
1 st 10
2nd 1o
3rd 30
4h 40
5th 40
6th 60
8 th 70

Table3.3: Scores of Subjective Wellbeing

PROGNOSIS

A large body of evidence shows that ERP became well established technique for treating overt
compulsive behavior(Rachman and Hodgson, 1980). My client is motivated to therapeutic
procedure and motivated to reduce her problems. Which made her prognosis quite good.
Evidence support by Steketee, et al,. 1982. Absence of psychotic symptoms were also good for
client prognosis. Client brother and sister also work as a co-therapist at home which made her
good prognosis. Incomplete symptomatic remission, Bipolar disorder, Early age of onset, Poor
social support, Poor physical health, Co morbid substance misuse, Co morbid personality
disorder are the factors that predict a greater risk of future episodes (Gelder, M., Harrison, P.,
and Cowen, P., 2006) My client does not have bipolar above co morbid disorder and have a good
physical health. But client did not do homework regularly, care givers job life may lead her
progress slow.

DISCUSSION

Miss. Y came to therapist with some intrusive thoughts, images and washing, cleaning,
avoidance and reassurance seeking behavior. Whole assessment procedure was done through
several levels which were clinical interview, observation and some questionnaire (depression
scale, anxiety scale and DUOCS). According to DSM-V my client was suffered from Obsessive
Compulsive Disorder. Her therapy continued for a total of 8 sessions. Usually she was provided
a 50-60 minutes session two day per week. Agenda were set collaboratively before starting each
day’s sessions. Several cognitive and behavioral techniques were used in the intervention. The
client was asked to rate her overall problems and mood as she was considering. Her symptom
was reduced in 8th sessions. Relapse is a greater problem for patients with major depression
(Judd, 1997). Relapse prevention was in treatment plan and the client was asked to attend the
follow-up session.

REFERENCES

Beck, J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press. New York.

Carr ,A. and Mcnulty, M,. (2006). The Handbook of Adult Clinical Psychology. New

York.

Clark, D. A. (2004). Cognitive-behavioural therapy for OCD. New York: Guilford Press

Gelder, M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry, 5th

edition. Oxford University Press.

Lindsay, S. & Powell, G. (eds.) (2007). The Handbook of Clinical Adult Psychology.

Third Edition. London: Routlrdge.

Mozumder, K (2007). Implementation of Cognitive Behavior Therapy in the Treatment

of Obsessive Compulsive Disorder in Bangladesh: A Case Study. Bangladesh

Psychological Studies, Vol, 17, P, 37-48

Rachman, S., De Silva, P., & Roper, G. (1976). The spontaneous decay of compulsive

urges. Behaviour Research and Therapy, 14, 445-453

Rachmen, S and de Silva, P. (1978). Abnormal and normal obsessions. Behaviour

Research and therapy

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural

analysis. Behaviour Research and Therapy, 23, 571-583.

Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive

thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682.

Salkovskis, P. M. (1996). Frontiers of cognitive therapy. New York: Guilford Press.

Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder.

Behaviour Research and Therapy, 37, S29–[Link], Medline, Google Scholar

The Diagnostic and Statistical Manual of Mental Disorder, 4th edition ( DSM-IV). The

American Psychiatric Association. Washington. DC.

Wells, A. (1997). Cognitive Therapy of Anxiety Disorders. A Practical Manual

 CONFIDENTIAL CASE REPORT-4

REASON FOR REFERRAL

Mr.R was suffering from present problem for 3 years and diagnosed as Schizophrenia by
psychiatrist at Mental Hospital, Pabna. He was a admitted patient of Mental Hospital , Pabna.
After partial remission client was referred by Psychiatrist for psychotherapy.

DEMOGRAPHIC INFORMATION

Mr. R is a 31 year old married man brought up in a middle class muslim family at a rural area

in Kustia. He is the 1st child of his parents. He has two children and they are physically and

mentally well enough. He has two younger brothers one sister. They all are well enough. He

completed his primary education only. He is now jobless. His father was farmer and his mother

is housewife.

ASSRSSMENT:

Initial assessment was started with client’s demographic information and gradually went through
symptoms, severity, mood and relevant history, present situation problem in different areas of
functioning.

The whole assessment had done by using subjective assessment, subjective and objective rating.

Subjective Assessment:

The main tools of subjective assessment were In-depth clinical interview, Observation of client
in the session. In-depth interview was done by me through open-ended and closed questions,
empathetic listening. Observation was focused on the attention of client, her appearance eye
contact, gesture, congruency of mood instant mood swing, speech, expression and behavior in
the session.

Subjective mood checking:

In this procedure, the client was asked to rate his mood as she was considering. She was asked to
rate her mood out of (0-10) where 0 means lowest level of well-being and 10 means highest level
of well-being.

0 2 4 6 8 10

Figure: rating scale

Subjective problem checking:

She was asked to rate her problem from 0-10 where 0 means lowest level of problem and 10
means highest level of problem.

Objective rating:

The main tools of objective assessment,I used,were depression scale that is developed by Md.
Zahir Uddin and Dr. Mahmudur Rahman(2005) and anxiety scale that is developed by Farah
Deeba and Dr. Roquia Begum (2004).the test results of depression scale is 66 that is mild level
according to Uddin and Rahman(2005) and the test results of anxiety scale is 30 that is mild
level.

PROBLEM DESCRIPTION

When Mr. R came with his brother and the brother as well as the client himself mentioned some
problems which caused significant sufferingandimpairmentinhisfamily,social,occupational and
other important areas of functioning. These problems were behavioral, emotional, motivational,
cognitive physical and [Link] the assessment sessions his problems was explored in-
details along with relevant history. The problems stated by his and his parents were as follows:
Behavioral:

Some behavioral changes have been seen within the client. He often withdrew himself from

social encounters. He stays inside the house most of the time. His brother reported that
sometimes he does some impulsive behavior like attack other people. He told that his mother will
give him poison. So he try to avoid eating . He does not take his bath regularly.

Emotional:

Mr. R remains depressed, fearful, nervous and anxious all the time. Mr. R also reported that he

feels irritated and experiences no pleasure(anhedonia).

Cognitive:

Auditory hallucination and persecutory delusion was present [Link]. R reported that he
hears voices of people calling names to him and trying to hurt him because he is a big shot or a
great person. His brother reported that he did not take food from his mother. He thought that his
mother wouldl kill him by using poisons. He also has disorganized thinking and difficulty
concentration and attention.

Physiological:

Mr.R , his brother and parents said that client was facing some physical problems as well, like
impulsivity, restlessness, fatigue, muscle tension, fatigue. He also said that he has having
difficulty sleeping too.

Motivational:

Client feels lack of interest in any activities. The same thing occurs for the motivation to do

anything or starting new things. He also said that he cannot perform goal oriented behavior.

Interpersonal Relation:
Client’s interpersonal relationship was getting worst day by day with his family members, wife
and child. Specially with his wife. His wife was trying to divorce him. His child become afraid
when they see their father. He did some odd behavir which no one can tolerate those. So,
sometime his parents and brothers bite him with tree. He had few friend.

HISTORY OF PRESENT ILLNESS

Mr. R was relatively normal three years ago. He was a farmer.

.He sometimes yelled loudly when he heard the voices. His family members could not see

him suffering so they brought him to [Link] islam for treatment about 3 months ago and he

has been taking medicine since then.

FAMILYHISTORY

The client was raised in a middle class family in a rural area in kustia. He has two brother and
one sisters. He is first [Link] father is a farmer and mother is a [Link] client has a bad
relationship with his parents, siblings and specially with his wife. They are not supportive.. But
the relationship gets better sometimes because of his present behavior. There is

no history of OCD,[Link] or drug abuse among family member but had psychotic
problems of client’s grandmother

PERSONAL HISTORY

Birth:no birth complications.

Educational history: He had just completed his primary education. His education is being
greatly hampered due to financial crisis.

Occupation : Unemployed

Social circumstances:

Not so active in social activities and hardly able to make friends now

Peer Relationship: poor

Forensic history/Drug history: Not found

PREMORBID PERSONALITY

Relationship: relationship with family members, friends, neighbors and relatives were not good
enoug.

Prevailing mood: Anxious

Character: He was introvert in nature.

Habits : Playing cricket and Football

HISTORY OF PAST ILLNESS

PastMedicalHistory: Nothing contributory

Past Psychiatric History: He has been continuing his treatment for the last 3 years and taking

medication.

MENTALSTATEEXAMINATION

General Appearance & Facial Appearance: A young man with an average body build but
did not wore culturally appropriate dress .He was anxious and depressed in his facial expression.

Rapport: Eye to eye contact was not maintained properly at first session. But after first session
rapport was establish properly.

Posture & Movement: Abnormal

.Social Behavior: Culturally appropriate social behavior was not present.

Motor Behavior: No abnormal motor behavior was found.

Speech:

- Rate & Quantity : high

- Rhythm: Average

- Volume: high

- Content: Irrelevant

Mood : Anxious and depressed.

Thought

- Form - normal

- Content - Delusion was found but no history of sucidal ideation.

- Stream - normal

Perception:

- Illusion- no Illusion.

- Hallucination –Auditory hallucination was found

Cognition:

- Oriented to time, place and person.

- Attention & concentration were not so focused.

- Immediate, recent and remote memories were slightly hampered.

Insight: The client has poor insight

DIAGNOSIS

According to Diagnostic and Statistical Manual of Mental Disorder-V(DSM-5),the client was

suffering from Schizophrenia.

Diagnosis Inclusion Criteria

 [Link] (3rd person auditory),
delusion( grandiose) were present more than
one month

[Link] a significant portion of time since the

Schizophrenia onset of the disturbance, level of
functioning in
work, interpersonal relations, or selfcare is
markedly below the level achieved prior to
the onset.
[Link] signs of disturbance persist for
3 years
D. Schizoaffective disorder, depressive or
bipolar disorder with psychotic features
have been
ruled out.
[Link] disturbance is not attributable to the
physiological effects of a substance (e.g., a
drug of
abuse, a medication) or another medical
condition.

Differential Diagnosis:
 Inclusion: Exclusion:

Hallucination (3rd person auditory), 1. No major depressive or manic episodes

delusion( grandiose) were present more than have occurred concurrently with the active-
one month phase
symptoms.
[Link] a significant portion of time since the 2. if mood episodes have occurred during
onset of the disturbance, level of active-phase symptoms, they have been
functioning in present for a
work, interpersonal relations, or selfcare is minority of the total duration of the active
markedly below the level achieved prior to and residual periods of the illness.
the onset. [Link] history of autism spectrum disorder.
[Link] signs of disturbance persist for 4. No history of substance abuse disorder.
3 years
D. Schizoaffective disorder, depressive or
bipolar disorder with psychotic features
have been
ruled out.
[Link] disturbance is not attributable to the
physiological effects of a substance (e.g., a
drug of
abuse, a medication) or another medical
condition.

FORMULATION

Mr R’s problem can be explained by A cognitive model of positive symptoms of schia (Garety,
2001):

Treatment Goals

Short Term Goals

❖ Normalizing the client

❖ To reduce anxiety

❖ To increase activity level

❖ To improve low mood

❖ To reduce sleep distrurbances

Long Term Goals

❖ Control or eliminate active psychotic symptoms

❖ Eliminate acute, reactive, psychotic symptoms and return to normal functioning

❖ To increase problem goal directed behaviour.

❖ Back to educational life

❖ Focus thoughts on reality

❖ Normal speech pattern

❖ Communnicate with others with defensiveness or anger.

❖ Active and maintaining an active, personally effective recovery approach.

❖ Improving family and social relationship

❖ To prevent relapse.

INTERVENTION
The following intervention techniques were planned and applied to R’s problems. Before
applying

the specific technique, the rationale for using that was explained. And feedback from the client
was

taken to check his understanding.

Psychological Management By Therapist

Goals Treatment Plan

For emotional healing empathetic listening,

paraphrasing, summarizing.

To make client understand about his Psycho education, formulation Sharing

problem
To reduce auditory hallucination Pros and cons analysis,adaptive coping
strategies to deal with voices

To reduce anxiety PMR, breathing relaxation, imagery

relaxation

To reduce low self esteem Two chair techniques

To reduce proper care of client and psycho Family Intervention .

educate the client’s family

To Increase Problem Solving Skills Problem solving strategy

To increase activity level Physical activity, Graded task

assignment,mastery and pleasure work and
exercise

To reduce delusion Reality testing

To reduce sleep disturbance Sleep schedule, sleep hygiene

 To Increase social skills Social skill training

Relapse prevention hand out, follow up sessions

Normalizing

Mr.R was normalized by assuring that psychotic disorder is quite common disorder in regard to
Bangladesh as well as world. He was informed that, study conducted in a rural community found
the prevalence rate of schizophrenia to be 2.54 per 1000 of the population.

Suicidal contract:

Suicidalcontractwastakenfromtheclientthathewillnotcommitanysuicidalattemptand any self harm

behavior to him or others during the therapy sessions.

Ventilation

Ventilation was done and empathy was given aiming to open up and release his [Link]
client did not have close relation with his friends and relatives. He could not share his problem
with anyone because he felt that he would be negligible to everyone. Ventilation was used to
facilitate sharing and releasing pent up emotion as pent up emotion was helping to maintain the
presenting problem.

Psycho-Education:
Psycho education was provided to explain the interaction between thought, emotion,behavior and
physical reactions by using five part model. It helps client to understand link the role of
cognition and emotion in regulating his somatic symptoms and reduced activity. The client was
educated about

Schizophrenia and its symptoms, causes and mode of treatment.

Physical Activity:

Client was invited to use regularly scheduled periods of between 15 and 30 minutes of daily
physical activity like walking, to activate them to reduce herlying on the bed habit for feeling
good.

Activities Scheduling

Once accurate information is available on what the client is doing and what satisfaction she
obtain from his activities, the activities schedule was used to plan each day in advance on an
hour-by-hour basis. The goal was to increase his activity levels and to maximize mastery
andpleasure. It also helps him to increase sense of control over his lives.

Breathing Relaxation and PMR

Pevels and Jhonson (1986) found that relaxation increase the accessibility of positive memory
the

brain. Breathing relaxation and PMR training was given to reduce level of anxiety and reduce
sleep problem.

Problem Solving

Problem Solving Method was designed to deal real life problems, such as having no tuition.

1. Decides which problem(s) to be tackled first.

2. Agree goal(s)
3. Work out steps necessary to achieve goal(s)

4. Decides tasks necessary to tackle steps

5. Implementation of decided tasks

6. Review progress at next session, including difficulties that have been encountered Decide next
step

depending on progress

7. Proceed, as above, to agreed goal(s), or to redefine problems and goals

8. Work on further problems if necessary

Thought Challenge

The original thought challenge procedure depicted by Beck (1995) was used after modifying it
into

a simplified six steps procedure presented in the following,

i) What is the worst that will happen?

ii) What are the evidence for this idea?

iii) What are the evidences against this idea?

iv) What are the benefits of thinking in this idea (the worst thing will happen)?

v) What are the costs of thinking in this way?

vi) What should I do about it?

Reality Testing

Reality testing is the psychotherapeutic function by which the objective or real world and one;s

relationship to it are reflected on and evaluated by the observer.

Two chair Techniques

In a two‐chair intervention, the client is asked to enact a dialogue between the inner critic and the
experiencing self using two chairs. One chair is for self guilt, anger, shame, failure another is for
self strength ,positive sides of the client. This helps client to find out their strengths beyond low
self-esteem.

Family Intervention

Involvement of family member in the therapy who take care the client and provide financial and
other support. Awareness about the client and his disorder and management is taught to his
family and also taught how to co operate the client as a family member to make recovery soon.

Pros and Cons analysis

A decisional balance sheet or decision balance sheet is a tabular method for representing the pros
and cons of different choices and for helping someone decide what to do in a certain
circumstance. Client will able to identify the pros and cons of hearing a voice and recognize
them as significant or not recognize them.

Sleep schedule & hygiene

The term ‘sleephygiene’ was first used byDr. Peter Hauri around 20 years ago to describe what
patients themselves can do to eliminate sleep-interfering factors, and to promote good sleep.
Sleep hygiene refers to things about lifestyle and preparation for bed that can be changed to
improve sleep patterns.

Component of sleep scheduling and their Implementation issues:

✔Restrict Your time in bed:

✔Establish Your Rising Time:

✔Establish Your“threshold time”for bed:

✔Go to bed only when sleepy:

✔Follow a 7-night-per-week schedule:

✔Observe the 15-minute rule:

✔Make Adjustments To The Schedule:.

✔Make The Connection Between Bed And Sleep:

✔Avoid Daytime Naps:

Social Skill Training

Client’s communication pattern was responsible for maintenance of this relationship oriented

problems. So It was also in plan to use social skill training course.

Relapse Prevention:

Relapse prevention was also in the treatment plan to help the client to deal with future possible

problems through treatment blueprint. Potential Relapse Factors Were explored from the clients
and worked with these factors how she will deal if these come in her future life.

RESULTS

Objective Measure

For Objective Assessment Anxiety Scores was gradually diminished throughout the session.[1st

session 99( profound),2nd session (62 moderate), 3rd session (56 moderate), 4th session (62

moderate) ]

Prognosis

Good Prognosis: Mr R was motivated and regular in session. He tried to do homework

[Link] support was present and client was taking medication properly beside the
Psychotherapy.

Poor prognosis:

● Incomplete symptomatic remission

● Pampering overprotective parenting

● Poor social support

● Withdrawn from society

● Loneliness

DISCUSSION

Mr.R come to me for psychotherapy with positive symptoms of psychosis including delusion and

hallucination . He has been continuing medication. He had quite good insight and his family was
supportive. As undergraduate student of the department of clinical psychology, it was a relatively
difficult as well as challenging role to deal with client specially while the client was with
psychotic disorder. I truly enjoy the experience and learned a lot which essentially enhance my
experience and thus enrich.

REFERENCES

Beck, J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press. New York.

Carr ,A. and Mcnulty, M,. (2006). The Handbook of Adult Clinical Psychology. New

York.

Clark, D. A. (2004). Cognitive-behavioural therapy for OCD. New York: Guilford Press

Gelder, M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry, 5th

edition. Oxford University Press.

Lindsay, S. & Powell, G. (eds.) (2007). The Handbook of Clinical Adult Psychology.

Third Edition. London: Routlrdge.

Mozumder, K (2007). Implementation of Cognitive Behavior Therapy in the Treatment

of Obsessive Compulsive Disorder in Bangladesh: A Case Study. Bangladesh

Psychological Studies, Vol, 17, P, 37-48

Rachman, S., De Silva, P., & Roper, G. (1976). The spontaneous decay of compulsive

urges. Behaviour Research and Therapy, 14, 445-453

Rachmen, S and de Silva, P. (1978). Abnormal and normal obsessions. Behaviour

Research and therapy

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural

analysis. Behaviour Research and Therapy, 23, 571-583.

Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive

thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682.

Salkovskis, P. M. (1996). Frontiers of cognitive therapy. New York: Guilford Press.

Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder.

Behaviour Research and Therapy, 37, S29–[Link], Medline, Google Scholar

The Diagnostic and Statistical Manual of Mental Disorder, 4th edition ( DSM-IV). The

American Psychiatric Association. Washington. DC.

Wells, A. (1997). Cognitive Therapy of Anxiety Disorders. A Practical Manual