Case No: 01

Major Depressive Disorder

 Case Summary

The client was 22 years old girl. Client’s mother faced no birth complications It was a normal delivery with no

reported complications. Client’s weight was normal at birth time No perinatal complications or hypoxic events

reported No extended NICU stay required Mother reported mild postpartum depression that resolved without

treatment.

Client achieved developmental milestones of independent functioning and communication skills were achieved at

appropriate expected age level. Strong early academic performance (elementary through middle school) declining

during high school years.

Parental relationship characterized by high expectations and achievement orientation. Parenting style described as

achievement-focused with high academic expectations Limited emotional expressiveness reported within family.

Financial stability, upper-middle socioeconomic status. No reported physical or sexual abuse.

Emotional neglect was reported in terms of validation of feelings and emotional [Link]’s psychological

assessments showed significant anhedonia, sleep disturbance, appetite changes, fatigue and low energy most days,

feelings of worthlessness and excessive guilt and difficulty concentrating and making. Client’s psychological

evaluation revealed that client was suffering from Major Depressive Disorder.
Identifying Data

Name. ABC

Age. 22 years

Gender. Female

Education. Graduation

Religion. Islam

Siblings. 2

Birth order. 2nd

Mother. Alive
Father. Alive

Marital status. Single

Family Structure. Nuclear

Socioeconomic status. Middle class

Informant. Mother
 Reasons for Referral

The client visited for consultation in CMH and was referred by psychiatrist for detailed psychological evaluation.

Client was brought to hospital by her mother with presenting complaint of anhedonia, sleep disturbance, appetite

changes, feelings of worthlessness and excessive guilt, difficulty in concentrating and decision making and fatigue

and low energy most of the Client had been suffering from these symptoms for last two month but problems

aggravated from last one month. The client’s informant reported that client feel lost most of day and doesn’t do

routine activities that client used to do.

Presenting complaints

According to client

‫مجھے اکثر اداسی محسوس ہوتی ہے‬

‫مجھے خالی پن محسوس ہوتاہے‬

‫مجھے بھوک نہیں محسوس نہیں ہوتی‬

‫مجھے لگتا ہے میری کوئی اہمیت نہیں‬

‫میں لوگوں سے گھلتی ملتی نہیں‬

‫مجھے روزان کے کام کرنے میں مشکل ہوتی ہے‬

According to Informant

‫اس کے رویے میں نمایاں تبدیلی آئی ہے‬

‫لوگوں کے ساتھ گھلنا ملنا چھوڑ چکی ہیں‬

‫اکثر اداس رہتی ہیں‬

‫اس کے چڑ چڑاپن میں اضافہ ہوا ہے‬

‫یہ خودکو دوسروں پر بوجھ سمجھتی ہیں‬

History of present illness

Client had come to CMH Rawalakot on 15th of January [Link] had complaints of persistent feelings of

sadness and emptiness, loss of interest in previously enjoyed activities, significant changes in sleep patterns,

difficulty concentrating and making decisions, feelings of worthlessness or excessive guilt, social withdrawal and

isolation and difficulty managing daily responsibilities. The client’s informant reported observable changes in

mood and behavior of client, reduced self care or neglect of appearance, increased irritability or emotional

sensitivity and expressions of hopelessness or negative outlook.

Back ground information

Personal history

The information about client’s personal history was reported by client’s informant her mother and client herself.

The client is 22 years old.

Developmental history

According to that information client birth was normal. Client’s mother faced no birth complications and client’s

birth weight was normal. Client achieved her developmental milestones of physical development, adaptive

functioning, toilet training and communication skills at expected age Client had significant social skills in

[Link] has no significant report of head injury or any neurological problem.

Home environment

Client’s Relationship with her father was very healthy and client relationship with her mother is very healthy client

is very much overprotective about Her family the client’s relation with her siblings is reported to be very healthy

and client is very much concerned about her siblings and girt worried and tense if any siblings have any problem.

The client's relation with her siblings was reported to be very healthy and client was very much concerned about

her siblings and girt varied and tense if any siblings have any problem.
Educational history

Educational history of client reveals that Client’s schooling started at the age of four . Client consistently an

average student with some struggle in maths.

Social history

Clients was not involved in any extra curricular activities as client get worried that something bad will happen.

Client had limited friend circle and faced difficult in eastablishing and maintaining relationships.

Religious history

Client’s Religious beliefs are appropriate to the context and pray five times in a day as reported by the client’s

mother. Moreover client had no history of substance addiction or any sort of drug taking. According to the client’s

information client’s sleep has increased from one end half month and feel fatigue and lost most of the day.

Family history

Client lived-in two-parent household with one elder sibling. Parental relationship was characterized by high

expectations and achievement orientation. Father was described as emotionally reserved, high-achieving

professional. Mother was described as anxious, perfectionistic, with history of untreated anxiety. Parenting style

described as achievement-focused with high academic expectations. Limited emotional expressiveness was

reported within family. Financial stability, upper-middle socioeconomic status. Emotional neglect reported in terms

of validation of feelings and emotional needs.

Premorbid history

Client’s family moved frequently during her childhood due to her father’s job, resulting in difficulty forming and

maintaining friendships. Client’s parents were described as strict and critical, with high expectations for academic

and extracurricular [Link] was a shy and anxious child.

This premorbid history provides a comprehensive understanding of client’s background, personality, and coping

mechanisms, which can inform her diagnosis and treatments.

Theoretical orientation

Based on the client’s presentation and diagnostic assessment, the following theoretical orientations may be

applicable

Cognitive-Behavioral Theory

Negative Cognitive Triad

The client’s depressive symptoms may be maintained by a negative cognitive triad, consisting of negative views of

themselves, the world, and the future.

Cognitive Distortions

The client may exhibit cognitive distortions, such as all-or-nothing thinking, overgeneralization, and selective

abstraction, which contribute to their depressive symptoms.

Learned Helplessness

The client may have learned helplessness, feeling that they have no control over their environment or outcomes,

leading to depressive symptoms.

Psychodynamic Theory

Unconscious Conflict

The client’s depressive symptoms may be related to unconscious conflicts, such as unresolved grief, unconscious

anger, or unmet emotional needs.

Defense Mechanisms

The client may employ defense mechanisms, such as repression, denial, or projection, to avoid dealing with

uncomfortable emotions or conflicts.

Humanistic Theory

Self-Actualization

The client’s depressive symptoms may be related to a lack of self-actualization, feeling unfulfilled or disconnected

from their values and goals.

Conditions of Worth

The client may have internalized conditions of worth, feeling that they are only worthy if they meet certain

standards or expectations.

Family Systems Theory

Family Dynamics

The client’s depressive symptoms may be influenced by family dynamics, such as enmeshment, conflict, or lack of

emotional support .

Family Roles
The client may be stuck in a family role, such as the “identified patient” or “caretaker,” which contributes to their

depressive symptoms.

Psychological Assessment

Formal Assessment

Beck Depression Inventory

Client score 49 on BDI which shows severe depression.

Total Score Obtained Score Interpretation

40 35 Extreme

Patient Health Questionnaire

Client scores 20 on PHQ which shows moderate to Severe depression.

Total score Obtained Score Interpretation

27 20 Moderate to severe depression

Hamilton Depression Rating Scale

Client scores 39on Hamilton Depression Rating Scale which shows severe depression.
 Total score Obtained Score Interpretation

52 39 Extreme

House Tree Person (HTP)

Lack of windows and door indicated feelings of isolation or disconnection. Lack of leaves or branches symbolized

feelings of hopelessness or despair.

Slumped and bent posture represented feelings of sadness, hopelessness, or defeat. Lack of facial features or

expressions indicated emotional numbness or disconnection.

Informal Assessments

Clinical Interview

Client reported feeling stuck and hopelessness since her breakup six months ago. She expressed difficulty

sleeping, loss of appetite, and fatigue.

Mental Status Examination

Client presented with a depressed mood, flat affect, and slowed speech.

Observational Assessment
Client appeared disheveled and had difficulty maintaining eye contact during the assessment.

Case formulation

Client’s presenting complaints were that of sadness, loss of interest in activities that client used to enjoy, feelings of

worthlessness and excessive guilt, fatigue and loss of energy and social withdrawal and isolation. Clients presents

with Major Depressive Disorder (MDD), characterized by a complex interplay of predisposing, precipitating, and

maintaining factors. Her genetic predisposition, childhood experiences, and personality traits have increased her

vulnerability to depression. Growing up with critical and emotionally distant parents. Client developed low self-

esteem and a people-pleasing tendency, which has contributed to her stress levels and decreased ability to cope

with negative emotions. Her limited social support network and difficulty forming and maintaining relationships

have also contributed to her feelings of loneliness and disconnection.

Client’s depression is further complicated by her perfectionism and self-criticism, which reinforce her negative

self-image and increase her stress levels. Her avoidance of social activities and hobbies has resulted in a lack of

pleasure and fulfillment, perpetuating her depressive symptoms.

Predisposing Precipitating Maintaining

factors factors factors

 Genetic .Stress .Negative

makeup and .Use of social thought

childhood media pattern

experiences .Avoidance

behavior

Tentative Diagnosis

Major Depressive Disorder,F32.9

Prognosis

Client had a guarded prognosis. While she was expected to experience symptomatic improvement with treatment,

her moderate to severe symptoms, and presence of co-occurring conditions, such as anxiety may impact her

response to treatment. Additionally, her limited social support network and difficulty forming and maintaining

relationships may hinder her recovery. With ongoing treatment, including psychotherapy and medication

management client can expect to experience improvement in her depressive symptoms and functional abilities.

However, she was at risk for relapse, particularly if she does not adhere to treatment or experiences significant

stressors. To mitigate this risk client should prioritize building and maintaining a social support network, engaging

in regular exercise and healthy eating, and developing stress management techniques. By working closely with her
treatment team and adhering to her treatment plan client can optimize her prognosis and achieve meaningful

improvement in her mental health and overall well-being.

Treatment plan

The client with presenting problem of Major Depressive Disorder showed symptoms of depression such as

sadness ,loss of interest, fatigue and loss of energy, feelings of worthlessness and guilt and difficulty managing

daily responsibilities.

Treatment Goals

Symptom Reduction

Decrease severity of depressive symptoms ,establish regular sleep schedule and increase daily activities by

implementing 2-3 pleasurable activities per week were initial treatment goals.

Safety plan

Help client developing crisis response plan ,identify three healthy coping skills to use during emotional distress and

establish emergency contacts and resources were also part of initial treatment goals.

Lifestyle Changes

Implement 30 minutes of physical activity 3x weekly, establish consistent daily routine and reduce isolation by

having at least 2 social interactions per week were part of treatment goals.
Symptom Management

Reduce PHQ-9 score to mild range (5-9) or below, maintain consistent sleep and activity patterns and develop and

utilize 5+ effective coping strategies were part of long term goals.

Cognitive Restructuring

Identify and challenge negative thought patterns, develop more balanced/flexible thinking and reduce self-critical

thoughts were long term goals.

Interpersonal Functioning

Improve communication skills in relationships, increase social network by joining groups/activities and set up and

maintain healthy boundaries in relationships were also part of long term treatment goals.

Identity & Future Orientation

Identify personal strengths and values, develop meaningful short and long-term life goals and increase confidence

in ability to manage future depressive episodes

Treatment Interventions

Primary Treatment Modality

Cognitive Behavioral Therapy (CBT) with elements of behavioral Activation and Interpersonal therapy and

Mindfulness-Based Cognitive Therapy

Adjunctive Treatments

Medication management if prescribed (coordination with psychiatrist) and Physical exercise program and sleep

hygiene education

Specific Techniques

Behavioral Activation, activity scheduling, graded task assignments and pleasure and mastery monitoring.,

Cognitive Restructuring

Thought records, cognitive distortion identification, evidence examination and development of alternative

perspectives.

Mindfulness Practices

Guided meditation exercises, present-moment awareness training and self-compassion exercises

Interpersonal Skills

Communication training, boundary setting, practice, social skills development and assertiveness training.

Therapeutic sessions
Session 1: History Taking and Rapport Building

The client’s history was taken as per reported by client and informant.

In order to develop good therapeutic relationship client was actively listened and given support and advice. A

collaborative communication way was developed and it was communicated to client that client and therapist will

work together.

Session 2: Assessment and Treatment planning

Comprehensive clinical assessment PHQ-9 and other relevant measures were used. Session involved psycho

education about depression. Goals of treatment were collaboratively developed. CBT model was introduced.

Assignment :Mood and activity monitoring .

Session 3: Behavioral Activation & Sleep Hygiene

Reviewed mood and activity monitoring. Identified patterns between activities and mood.

Psychoeducation on sleep and depression was involved and collaboratively developed sleep hygiene plan.

Assignment: Continue activity scheduling, implement sleep routine.

Session 4:Cognitive Model Introduction

Introduced cognitive model of depression and identified automatic thoughts and cognitive distortions.

Helped client learning thought recording and connect thoughts feelings and behaviors.

Assignment: Daily thought records

Session 5:Cognitive Restructuring

Reviewed thought records and developed balanced alternative thoughts. Core beliefs were identified that

contributed to problem.

Assignment: Challenge 2-3 negative thoughts daily

Session 6:Mindfulness and Emotion Regulation

Introduced mindfulness concepts and practiced basic mindfulness exercises. Helped client develop emotion

awareness skills. Client was asked to tolerate distress.

Assignment: Daily 10-minute mindfulness practice

Session 7: Interpersonal Skills & Social Support

Assessed interpersonal patterns and helped client learn effective communication Collaboratively identified

opportunities for social connection. Practiced assertiveness and boundary setting.

Assignment: Implement 1-2 social interactions with new skills

Session 8:Relapse Prevention l

Identified personal warning signs of depression. Created wellness toolbox of coping strategies. Developed

maintenance of gains plan.

Assignment: Draft personal wellness plan

Session 9:Relapse Prevention ll & Termination

Finalized wellness and relapse prevention plan, reviewed treatment progress and goals. Celebrated successes and

growth and addressed feelings about termination.

References

Beck, A. T. (1977). Cognitive therapy: A new approach to the treatment of depression. New York: Guilford Press.

Bowen, M. (1966). Family therapy in clinical practice. New York: Jason Aronson.

Freud, S. (1915). The unconscious. International Journal of Psycho-Analysis, 6(2), 131-154.

Freud, S. (1917). Mourning and melancholia. International Journal of Psycho-Analysis, 4(2), 137-154.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton

Mifflin.

Seligman, M. E. P. (1975). Helplessness: On depression, development, and death. San Francisco: W.H. Freeman.
Case No :02

Generalized anxiety Disorder

Case summary

The client was a 24-year-old female presenting with excessive, persistent, and uncontrollable worry about multiple

areas of her life including health, relationships, career, and academic performance. Symptoms had been ongoing

for more than 6 months and had resulted in functional impairment. She met the diagnostic criteria for Generalized

Anxiety Disorder (GAD) as per DSM-5.

Identifying Data

Name. ABC

Age. 24 years

Gender. Female

Education. Graduation

Religion. Islam
Siblings. 3

Birth order. 1st

Mother. Alive

Father. Alive

Marital status. Single

Family structure: Nuclear

Socioeconomic status. Middle

class

Informant. Mother
Reasons for Referral

The client visited for consultation in CMH and was referred by psychiatrist for detailed psychological evaluation.

Client was brought to hospital by her mother with presenting complaint of excessive, persistent and uncomfortable

worry, difficulty relaxing, muscle tension difficulty concentrating, restlessness fatigue and trouble falling and

staying asleep for past 6 months but problems aggravated from last 2 months .

Presenting complaints

According to client

‫مجھے اکثر بے چینی ہوتی ہے‬

‫مجھے اکثر تھکاوٹ محسوس ہوتی ہے‬

‫مجھے نیند نہیں آتی‬

‫مجھے ڈر ہے کہ کچھ برا ہو جائے گا‬

HISTORY OF PRESENT ILLNESS

The client began experiencing heightened levels of anxiety approximately 8–9 months ago during her final year of

university. Initially, the worry was centered on academic performance but progressively extended to finances,

health, family issues, and future uncertainty. She reported the symptoms of chronic worry, hard to control,

restlessness and difficulty relaxing, muscle tension and headaches, difficulty concentrating, fatigue and trouble

falling and staying asleep. There were no reported panic attacks, compulsions, or hallucinations. She denied

substance use or suicidal ideation.

Back ground information

Personal history

The information about client’s personal history was reported by client’s informant her mother and client herself .

Developmental history

According to that information client birth was normal. Client’s mother faced no birth complications and client’s

birth weight was normal. Client achieved her developmental milestones of physical development, adaptive

functioning, toilet training and communication skills at expected age.

Home environment

Client’s relationship with her father and mother was very healthy and client was very much overprotective about

her family. Client’s relationship about her siblings was reported to be very healthy.

Educational history

Educational history of client revealed that client schooling started at the age of four and client in her school was

bright student but her academic performance started decline after secondary education.

Social history

Client was not involved in any extra curricular activities and had limited friend circle.
Religious history

Client’s Religious beliefs were appropriate to the context as reported by client’s mother.

Family History

Mother had history of anxiety, but never formally diagnosed.

Theoretical orientation

Based on the client’s presentation and diagnostic assessment, the following theoretical orientations may be

applicable

Cognitive-Behavioral Theory

Negative Automatic Thoughts The client’s generalized anxiety symptoms may be maintained by negative

automatic thoughts, such as catastrophic thinking, overestimation of danger, and intolerance of uncertainty.

Cognitive Distortions

The client may exhibit cognitive distortions, such as all-or-nothing thinking, overgeneralization, and selective

abstraction, which contribute to their anxiety symptoms.

Avoidance Behaviors
The client may engage in avoidance behaviors, such as avoiding situations or activities that trigger anxiety, which

can reinforce and maintain their anxiety symptoms.

Psychodynamic Theory

Unconscious Conflict

The client’s generalized anxiety symptoms may be related to unconscious conflicts, such as unresolved childhood

trauma, unconscious anger, or unmet emotional needs (Freud, 1917).

Defense Mechanisms

The client may employ defense mechanisms, such as repression, denial, or projection, to avoid dealing with

uncomfortable emotions or conflicts.

Humanistic Theory

Self-Actualization

The client’s generalized anxiety symptoms may be related to a lack of self-actualization, feeling unfulfilled or

disconnected from their values and goals.

Conditions of Worth

The client may have internalized conditions of worth, feeling that they are only worthy if they meet certain

standards or expectations.

Acceptance and Commitment Therapy (ACT)

Experiential Avoidance
The client’s generalized anxiety symptoms may be maintained by experiential avoidance, avoiding or escaping

from uncomfortable emotions, thoughts, or physical sensations.

Cognitive Fusion

The client may exhibit cognitive fusion, becoming overly identified with their thoughts.

Psychological Assessment

Formal Assessment

Generalized Anxiety Disorder 7-item scale (GAD -7)

Total Obtained Interpretation

score score

21 17 Severe

anxiety

Patient Health Questionnaire-9(PHQ -9)

Total Obtained Interpretation

 score score

27 17 Moderate to

severe

anxiety

Beck Anxiety Inventory BAI

Total Obtained Interpretation

score score

63 49 Severe

anxiety

Informal assessment

Clinical interviews

Client reported feelings of restlessness, excessive worry, muscle tension, difficulty concentrating, fatigue and

difficulty relaxing.

Mental Status Examination

Client reported with excessive worry, restlessness fatigue and muscle tension.

Observational Assessment

Client appeared disheveled and had difficulty maintaining eye contact during the assessment.

CASE FORMULATION

Using a cognitive-behavioral framework, the client’s generalized anxiety is maintained by maladaptive thought

patterns (e.g., catastrophizing, intolerance of uncertainty), perfectionism, and avoidance behaviors. Her early

environment likely reinforced hyper-responsibility and fear of failure. These patterns became entrenched under

academic and life pressures, maintaining her relationships.

Tentative Diagnosis

Generalized Anxiety Disorder,F41.1

PROGNOSIS
Prognosis is good, especially with early intervention, motivation for treatment, and the absence of comorbid

conditions. Engagement in therapy and consistency with treatment will likely lead to significant symptom

reduction and improved functioning.

Treatment Goals

Reduce anxiety symptoms Decrease the frequency, intensity, and duration of anxiety episodes.

Improve sleep quality Establish a consistent sleep schedule and improve sleep hygiene.

Enhance coping skills

Develop effective coping strategies to manage anxiety-provoking situations.

Increase self-esteem

Improve self-confidence and self-worth.

Achieve remission
Significantly reduce or eliminate anxiety symptoms.

Improve relationships

Enhance interpersonal relationships and social connections.

Increase productivity:

Improve work or school performance and daily functioning.

Develop relapse prevention skills

Learn strategies to maintain progress and prevent relapse.

Treatment Interventions

Exposure therapy

Gradually expose the client to feared situations or stimuli.

Relaxation techniques

Teach relaxation skills, such as deep breathing, progressive muscle relaxation, or visualization.

Mindfulness-Based Interventions

Mindfulness meditation Practice mindfulness meditation to increase self-awareness and reduce anxiety.

Yoga

Incorporate yoga to promote relaxation and reduce symptoms.

Behavioral Activation
Activity scheduling

Schedule activities to promote engagement and reduce avoidance.

Pleasure prediction

Identify and engage in activities that bring pleasure and enjoyment.

Psychodynamic Therapy

Exploration of underlying issues Identify and explore underlying issues contributing to anxiety symptoms.

Therapeutic relationship Develop a supportive therapeutic relationship to promote emotional regulation.

Lifestyle Changes

Encourage regular exercise to reduce anxiety symptoms.

Establish consistent sleep habits and a relaxing bedtime routine.

Promote a balanced diet and healthy eating habits.

Therapeutic sessions

Session 1:Intake and Rapport Building

Conducted clinical interview and administered GAD-7 and BAI. Discussed confidentiality, therapy process and

identified goals
Assigned worry log as homework

Session 2: Psychoeducation and Problem Mapping

Explained CBT model and cycle of anxiety and identified specific worry themes. Taught basics of thought

monitoring.

Continued use of worry log

Session 3:Cognitive Restructuring

Introduced concept of automatic thoughts and identified negative thought patterns. Practiced challenging anxious

predictions

Assigned thought record worksheet

Session 4:Exposure and Behavior Change

Discussed avoidance behavior and planned small behavioral experiment. Introduced progressive muscle relaxation

Session 5: Emotional Regulation and Mindfulness

Taught mindfulness-based techniques and discussed emotion labeling. Introduced breathing and grounding

strategies. Practiced meditation in session

Session 6:Review and Reinforcement

Reviewed progress and symptom improvement of client.

References

Beck, A. T. (1977). Cognitive therapy: A new approach to the treatment of depression. New York: Guilford Press.

Freud, S. (1915). The unconscious. International Journal of Psycho-Analysis, 6(2), 131-154.

Freud, S. (1917). Mourning and melancholia. International Journal of Psycho-Analysis, 4(2), 137-154.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential

approach to behavior change. New York: Guilford Press.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral

therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(2), 103-110.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton

Mifflin.

Case No: 03
Obsessive Compulsive Disorder

Case summary

The client was a 25-year-old unmarried male who presented with distressing intrusive thoughts related to

contamination and repeated compulsive hand washing behavior. Symptoms had progressively worsened over the

past two years, significantly impairing his social functioning and daily activities. He was aware of the irrational

nature of his thoughts but felt compelled to perform the rituals to reduce his anxiety.

Identifying Data

Name. ABC

Age. 25

Gender. Male

Education. Masters
Religion. Islam

Siblings. 3

Birth order. 2nd

Mother. Alive

Father. Alive

Marital status. Single

Family structure. Nuclear

Socioeconomic status. Middle

Class

Informant. Father
Reason for Referral

The client was referred by his psychiatrist for a comprehensive psychological assessment and therapy after

pharmacological treatment alone yielded limited success in managing his OCD symptoms. The aim was to

establish a structured therapeutic intervention to reduce compulsive behaviors and improve functioning.

Presenting complaints

According to client

“‫ جنہیں میں روک نہیں ساکتا۔‬،‫میرے دماغ میں بار بار ناپسندیدہ اور خوفناک خیالات آتے ہیں‬

“‫ اس لیے میں بار بار ہاتھ دھوتا ہو‬،‫مجھے لگتا ہے کہ میرے ہاتھ گندے ہیں یا جراثیم لگ گئے ہیں‬

“‫مجھے سکون نہیں ملتا جب تک ہر چیز مکمل ترتیب سے نہ ہو۔‬

“‫ گیس یا تالے چیک کرتا ہوں کہ کہیں بند کرنا بھول نہ گیا ہو‬،‫میں بار بار دروازہ‬

“‫مجھے مسلسل ڈر لگا رہتا ہے کہ اگر میں نے کچھ خاص طریقے سے نہ کیا تو کچھ ُبرا ہو جائے‬
History of present illness

The client began experiencing intrusive thoughts about contamination approximately two years ago, initially

triggered by an illness in the family. He gradually developed compulsive behaviors, including excessive hand

washing (30–40 times a day), avoidance of public places, and repeated cleaning of personal items. These behaviors

began affecting his academic performance and interpersonal relationships.

Background Information

Personal history

The information about client personal history was reported by client’s informant his father and client himself.

Developmental history
Client birth was normal and client mother faced no significant birth complications. Client achieved his

developmental milestones of physical development, adaptive functioning, toilet training, and communication skills

at expected age.

Home environment

The client home environment was good and his relationship with his parents and siblings was reported to be

healthy.

Educational history

Educational history of client revealed that his schooling started at the age of [Link] had been good student

throughout his academic career.

Social history

Client was involved in extra curricular activities and had good friend circle.

Religious history

Client’s religious beliefs were appropriate to context as reported by client father and client himself.

Family History

No known family history of OCD, but maternal history of generalized anxiety.

Theoretical Orientation

Based on the client’s presentation and diagnostic assessment, the following theoretical orientations may be

applicable:
Cognitive-Behavioral Theory

Negative Automatic Thoughts The client’s obsessive compulsive symptoms may be maintained by negative

automatic thoughts, such as I’ll get sick if I don’t wash my hands” or I’ll harm someone if I don’t check the stove.

Cognitive Distortions

The client may exhibit cognitive distortions, such as all-or-nothing thinking, overestimation of danger, and

intolerance of uncertainty, which contribute to their obsessive-compulsive symptoms.

Exposure and Response Prevention

The client may benefit from exposure and response prevention (ERP), a cognitive-behavioral therapy technique

that involves gradually exposing the client to feared situations or stimuli while preventing them from engaging in

compulsive behaviors.

Psychodynamic Theory

Unconscious Conflict

The client’s obsessive compulsive symptoms may be related to unconscious conflicts, such as unresolved

childhood trauma, unconscious anger or unmet emotional needs.

Defense Mechanisms

The client may employ defense mechanisms, such as repression, denial, or projection, to avoid dealing with

uncomfortable emotions or conflicts.

Acceptance and Commitment Theory (ACT)

Experiential Avoidance
The client’s obsessive-compulsive symptoms may be maintained by experiential avoidance, avoiding or escaping

from uncomfortable emotions, thoughts, or physical sensations.

Cognitive Fusion

The client may exhibit cognitive fusion, becoming overly identified with their thoughts and losing contact with the

present moment.

Neurobiological Theory

Serotonin Hypothesis

The client’s obsessive-compulsive symptoms may be related to abnormalities in serotonin neurotransmission,

which can contribute to the development and maintenance of obsessive-compulsive disorder.

Brain Structure and Function The client’s obsessive compulsive symptoms may be related to abnormalities in

brain structure and function, particularly in the orbitofrontal cortex, anterior cingulate cortex, and basal ganglia.

Psychological Assessment

Formal Assessment

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Total Obtained Interpretation

score score

40 30 Extreme
Beck Anxiety Inventory (BAI)

Total Obtained Interpretation

score score

63 49 Extreme

Beck Depression Inventory (BDI)

Total Obtained Interpretation

score score

63 41 Moderate to

severe

depression

Informal Assessment

Clinical interviews

Clinical interviews revealed significant distress and preoccupation with contamination.

Observational Assessment
Observations during sessions showed noticeable discomfort with touching shared surfaces.

Insight was present but limited and patient acknowledged irrationality but felt helpless.

Case Formulation

Client’s OCD was likely developed in response to heightened stress and fear of illness during a critical life

transition. His compulsions served as maladaptive coping mechanisms to manage anxiety triggered by intrusive

thoughts. Cognitive distortions such as “magical thinking” and inflated responsibility sustain the OCD cycle.

Avoidance behaviors had reinforced the obsession-compulsion loop.

Tentative Diagnosis

Obsessive Compulsive Disorder,F42.

Prognosis

With appropriate cognitive-behavioral therapy (CBT), including Exposure and Response Prevention (ERP), and

continued pharmacotherapy the prognosis is fair to good. Patient motivation and insight are strengths that favor

treatment engagement.

Treatment Goals

Reduce the frequency and intensity of obsessions and compulsions.

Improve functioning in daily life, including work, social, and personal domains.

Enhance insight into OCD symptoms and increase motivation for change.
Reduce distress and anxiety associated with intrusive thoughts.

Develop effective coping strategies and relapse prevention skills.

Treatment Interventions:

Psychoeducation

Educate the client about OCD, its cycle, and the rationale for ERP.

Normalize intrusive thoughts and explain the difference between thoughts and action.

Mindfulness and Acceptance Based Strategies

Teach mindfulness practices to increase tolerance of discomfort and reduce compulsive behavior.

Acceptance and Commitment Therapy

ACT techniques are used to distance from obsessive thoughts.

Skills Training and Supportive Counseling

Teach stress management, emotion regulation, and assertiveness skills.

Address comorbid issues such as depression or social anxiety if present.

Relapse Prevention

Create a written relapse prevention plan

Identify early warning signs and coping strategies.

Therapeutic Sessions

Session :1 Initial Assessment and Psychoeducation

Rapport building, detailed intake interview and introduction to OCD and CBT [Link] therapy goals and

treatment structure.

Session 2: Identifying Obsessions and Compulsions

Patient listed common triggers and rituals and thought records was started to track intrusive thoughts.

Assigned homework: monitor compulsive behaviors.

Session 3: Cognitive Restructuring Introduction

Identified cognitive distortions e.g if I don’t wash my hands, i,ll fall [Link] irrational beliefs of client.

Session 4: Introduction to ERP

Explained rationale and structure of [Link] of feared situations developed e.g. touching doorknob without

washing and practiced relaxation techniques.

Session 5: Initial Exposure Exercise

Conducted low-level exposure in session. Prevented response like hand washing .Reflected on anxiety levels

before, during, and after.

Session 6: Continued ERP and Processing

Increased intensity of exposure. Noted initial anxiety spike but reduction over time. Positive reinforcement

provided, discussed success and challenges.

References

Beck, A. T. (1977). Cognitive therapy: A new approach to the treatment of depression. New York: Guilford Press.

Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., … & Simpson, H. B. (2005).

Randomized trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of

obsessive-compulsive disorder. Journal of Clinical Psychopharmacology, 25(2), 109-116.

Freud, S. (1915). The unconscious. International Journal of Psycho-Analysis, 6(2), 131-154.

Freud, S. (1917). Mourning and melancholia. International Journal of Psycho-Analysis, 4(2), 137-154.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential

approach to behavior change. New York: Guilford Press.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2003). The prevalence and

correlates of serious mental illness (SMI) in the World Health Organization’s World Mental Health Survey

Initiative. World Psychiatry, 2(2), 114-125.

Saxena, S., Bota, R. G., & Brody, A. L. (2001). Brain-behavior relationships in obsessive-compulsive disorder.

Journal of Neuropsychiatry and Clinical Neurosciences, 13(3), 379-386.

Case No: 04

Social Anxiety Disorder

Case Summary

The client was a 24-year-old university student, presented with significant distress and avoidance behavior in social

situations, particularly those involving public speaking or unfamiliar people. The client reported excessive worry

about being judged, humiliated, or embarrassed, leading to withdrawal from academic and social engagements.

Identifying Data

Name . ABC

Age . 24

Gender. Female

Education. Graduation
Religion. Islam

Siblings. 2

Birth order. 1st

Mother. Alive

Father. Alive

Marital status. Single

Family structure. Nuclear

Socioeconomic status. Middle class

Informant. Mother
Reason for Referral

Client was referred by her physician following complaints of persistent anxiety, physical symptoms sweating,

trembling, palpitations and avoidance behaviors in social contexts, particularly in academic settings .

Presenting complaints

According to client

‫مجمع یا لوگوں کے درمیان بے چینی محسوس ہوتی ہے۔‬

‫لوگوں سے بات کرتے ہوئے دل کی دھڑکن تیز ہو جاتی ہے۔‬

‫نئے لوگوں سے ملنے یا بات کرنے سے ڈر لگتا ہے۔‬

‫لوگوں کی توجہ کا مرکز بننے سے خوف محسوس ہوتا ہے۔‬

‫مجھے لگتا ہے کہ لوگ میری طرف دیکھ کر میرا مذاق اڑائیں گے۔‬
‫کلاس میں پریزنٹیشن یا بات کرنا بہت مشکل لگتا ہے۔‬

‫کسی میٹنگ یا تقریب میں جانے سے پہلے گھبراہٹ اور پسینہ آنا شروع ہو جاتا ہے۔‬

‫اکثر میں تنہائی کو ترجیح دیتی ہوں کیونکہ لوگوں سے میل جول میں خوف محسوس ہوتا ہے۔‬

History of present illness

The client reported that her symptoms began in late adolescence, around age 17, but worsened significantly after

entering college. She experienced intense anxiety before and during social interactions, resulting in missed

presentations, reduced classroom participation, and strained peer relationships. She avoided eye contact, parties,

and group work. There was no history of substance use, psychotic symptoms, or mood episodes, although she had

reported occasional low mood secondary to isolation.

Background Information

Personal history

The information about client personal history was reported by client mother and client herself. The client is 24 year

old.

Home environment

Client’s relationship with her parents and siblings was good. She had a healthy home environment.
Family History

Eldest of two siblings. Raised in a middle-class family with supportive parents. Mother reported to have “nervous

tendencies.”

Developmental History Client birth was normal and her mother faced no significant birth complication. Client

weight was normal at the time of birth. Client achieved all developmental milestones at time.

Educational History

Bright student, academically inclined. Difficulties began during college presentations.

Social History

Limited circle of friends. Prefers solitary activities.

Occupational History: Currently enrolled in university. Avoids participation in seminars.

Theoretical Orientation

Based on the client’s presentation and diagnostic assessment, the following theoretical orientations may be

applicable
Cognitive-Behavioral Theory

Negative Self-Statements

The client’s social anxiety symptoms may be maintained by negative self-statements, such as I’m not good enough

or I’ll embarrass myself.

Cognitive Distortions

The client may exhibit cognitive distortions, such as all-or-nothing thinking, overestimation of danger, and

intolerance of uncertainty, which contribute to their social anxiety symptoms .

Social Skills Deficits

The client may have social skills deficits, such as difficulty initiating or maintaining conversations, which can

contribute to their social anxiety symptoms.

Psychodynamic Theory

Unconscious Conflict

The client’s social anxiety symptoms may be related to unconscious conflicts, such as unresolved childhood

trauma, unconscious anger, or unmet emotional needs.

Defense Mechanisms

The client may employ defense mechanisms, such as repression, denial, or projection, to avoid dealing with

uncomfortable emotions or conflicts.

Humanistic Theory

Self-Actualization
The client’s social anxiety symptoms may be related to a lack of self-actualization, feeling unfulfilled or

disconnected from their values and goals.

Conditions of Worth

The client may have internalized conditions of worth, feeling that they are only worthy if they meet certain

standards or expectations.

Acceptance and Commitment Therapy (ACT)

Experiential Avoidance

The client’s social anxiety symptoms may be maintained by experiential avoidance, avoiding or escaping from

uncomfortable emotions, thoughts, or physical sensations.

Cognitive Fusion

The client may exhibit cognitive fusion, becoming overly identified with their thoughts and losing contact with the

present moment .

Interpersonal Theory

Interpersonal Conflict

The client’s social anxiety symptoms may be related to interpersonal conflict, such as difficulties with

assertiveness or intimacy.

Social Support

The client may benefit from increasing their social support network, which can help to reduce their social anxiety

symptoms.
Psychological Assessment

Formal Assessment

Social Phobia Inventory (SPIN)

Total Obtained Interpretation

score score

68 50 Extreme

Beck Anxiety Inventory (BAI)

Total Obtained Interpretation

score score

63 49 Severe

anxiety

Generalized Anxiety disorder 7- item scale GAD-7

Total Score Obtained score Interpretation

 21 17 Severe

anxiety

Informal Assessment

Behavioral observations

Behavioral observation during sessions showed signs of tension fidgeting, soft voice, poor eye contact. Client was

cooperative but hesitant to engage initially.

Clinical interviews

Self-report during interviews indicates avoidance behavior, safety behaviors (e.g., overpreparing, avoiding

questions), and anticipatory anxiety.

Case Formulation

Using the Cognitive-Behavioral Model, A.B social anxiety was maintained by negative core beliefs like I’ll

embarrass myself and People will judge me safety behaviors like avoiding eye contact, overpreparing andd

avoidance of feared situations. Her anxiety was reinforced by immediate relief upon avoidance, preventing

disconfirmation of her fears.

Tentative Diagnosis

Social Anxiety Disorder,F40.10

Prognosis

Prognosis was favorable with consistent therapy. Client was motivated and has insight into her difficulties. No

comorbid disorders or substance use issues were reported.

Treatment Plan

Treatment Goals

Reduce social anxiety symptoms

And increase social interaction and confidence.

Modify maladaptive thoughts and beliefs.

Improve functional academic and social behavior

Therapeutic Approach

Cognitive Behavioral Therapy

(CBT)

CBT was used to help client overcome her feelings of social anxiety and improve overall functioning.

Psychoeducation

Client was educated about her thoughts and beliefs that cause anxiety.
Cognitive Reconstructing

Client was asked to change his beliefs that cause anxiety like fear of judgement by people and making mistakes in

social situations.

Exposure Therapy

Client was helped to overcome her fear by gradual exposure to social situations.

Relaxation Training

Deep breathing exercises and Progressive Muscle Relaxation techniques were used to overcome client’s anxiety.

Therapeutic Sessions

Session 1:Rapport Building & Psychoeducation

Therapeutic alliance was built and CBT model was introduced.

Educated client about anxiety and its physiological, cognitive, and behavioral components.

Session 2:Identification of Triggers and Thought Monitoring

Social triggers and negative automatic thoughts were identified collaboratively.

Thought record worksheet was introduced

Session 3:Cognitive Restructuring

Client was taught how to challenge and reframe irrational Client was asked to change her thinking and practiced

realistic thinking.

Session 4:Exposure Hierarchy Creation

Hierarchy of feared social situations was created started with lower anxiety-provoking scenarios e.g asking a

question in class.

Session 5:Behavioral Experiments and In-Vivo Exposure

Client performed exposure task initiating small talk with a classmate.

Reviewed and processed experience.

Session 6:Review and Relapse Prevention

Client learnt consolidated skills and potential setbacks and coping strategies were discussed.

Client reported decreased anxiety and improved confidence.

References

Beck, A. T. (1977). Cognitive therapy: A new approach to the treatment of depression. New York: Guilford Press.
Cohen, S., Gottlieb, B. H., & Underwood, L. G. (2015). Social relationships and mortality: An analysis of the

National Longitudinal Study of Adolescent Health. Social and Personality Psychology Compass, 9(2), 142-155.

Freud, S. (1915). The unconscious. International Journal of Psycho-Analysis, 6(2), 131-154.

Freud, S. (1917). Mourning and melancholia. International Journal of Psycho-Analysis, 4(2), 137-154.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential

approach to behavior change. New York: Guilford Press.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral

therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(2), 103-110.

Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal psychotherapy of

depression. New York: Basic Books.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton

Mifflin.

Case No :05
Panic Disorder

Case summary

The client was a 28-year-old woman referred for psychological evaluation and treatment due to recurrent panic

attacks, avoidance behaviors, and intense fear of future attacks for past 10 months .. Her symptoms had

significantly impacted her work performance and social life. She reported frequent visits to the ER, fearing she was

experiencing a heart attack.

Identifying Data

Name . ABC

Age. 28

Gender. Female

Education. Graduation

Religion. Islam

Siblings. 3
Birth order. 2nd

Father. Alive

Mother. Alive

Marital status. Single

Family structure. Nuclear

Informant. Mother

Reason for Referral

Client was referred by her primary care physician after multiple emergency visits where no physical causes were

found for her chest pain, palpitations, or shortness of breath. The physician suspected a psychological origin and

recommended a psychological evaluation.

Presenting complaints
‫‪According to client‬‬

‫اچانک دل کی دھڑکن تیز ہو جاتی ہے اور سانس لینے میں دقت ہوتی ہے۔‬

‫ایسا لگتا ہے جیسے ابھی موت واقع ہو جائے گی یا دل کا دورہ پڑنے والا ہے۔‬

‫بغیر کسی وجہ کے شدید گھبراہٹ یا خوف کا حملہ ہو جاتا ہے۔‬

‫سینے میں درد یا گھٹن کا احساس ہوتا ہے۔‬

‫ہاتھ پاؤں کانپنے لگتے ہیں اور پسینہ آتا ہے۔‬

‫چکر آتے ہیں یا بے ہوشی محسوس ہوتی ہے۔‬

‫دماغ سن سا ہو جاتا ہے یا حقیقت غیر حقیقی محسوس ہوتی ہے‬

‫بار بار ایسا حملہ آنے کے خوف سے گھر سے نکلنے سے ڈرتی ہوں۔‬
 History of present illness

Client reported experiencing sudden panic attacks for the past 10 months, occurring 2–3 times weekly. These

episodes involve palpitations, sweating, trembling, chest pain, shortness of breath, dizziness, and fear of dying or

“going crazy.” Initially, she believed these were signs of a heart attack. Over time, she developed anticipatory

anxiety and began avoiding crowded places and public transport.

Background Information

Personal history

The information about client personal history was reported by client mother and client herself.

Developmental history

Client birth was normal and client’s mother faced no significant birth complications. Client weight was normal at

the time of birth. Client achieved all developmental milestones at time.

Educational history

Educational history of client revealed that client schooling was started at the age of 5 and client had been a good

student.

Home environment
Client was living with her parents and siblings. Her home environment was good and her relationship with parents

and siblings was reported to be healthy.

Medical History:

No significant medical illness normal cardiac workup.

Family History

Father with Generalized Anxiety Disorder, mother with no psychiatric history.

Social history client was living with parents and had supportive friends but had withdrawn socially .

Religious history

Client’s religious beliefs were appropriate to the context as per reported by client herself.

Theoretical Orientation

Based on the client’s presentation and diagnostic assessment, the following theoretical orientations may be

applicable

Cognitive-Behavioral Theory

Negative Automatic Thoughts

The client’s panic symptoms may be maintained by negative automatic thoughts, such as I’m having a heart attack

or I’m going to die.

Cognitive Distortions

The client may exhibit cognitive distortions, such as all-or-nothing thinking, overestimation of danger, and

intolerance of uncertainty, which contribute to their panic symptoms.

Fear of Fear

The client may have a fear of fear itself, which can perpetuate a cycle of anxiety and panic.

Psychodynamic Theory

Unconscious Conflict

The client’s panic symptoms may be related to unconscious conflicts, such as unresolved childhood trauma,

unconscious anger, or unmet emotional needs.

Defense Mechanisms

The client may employ defense mechanisms, such as repression, denial, or projection, to avoid dealing with

uncomfortable emotions or conflicts.

Humanistic Theory

Self-Actualization

The client’s panic symptoms may be related to a lack of self-actualization, feeling unfulfilled or disconnected from

their values and goals.

Conditions of Worth
The client may have internalized conditions of worth, feeling that they are only worthy if they meet certain

standards or expectations.

Acceptance and Commitment Therapy (ACT)

Experiential Avoidance

The client’s panic symptoms may be maintained by experiential avoidance, avoiding or escaping from

uncomfortable emotions, thoughts, or physical sensations.

Cognitive Fusion

The client may exhibit cognitive fusion, becoming overly identified with their thoughts and losing contact with the

present moment.

Neurobiological Theory

Serotonin Hypothesis

The client’s panic symptoms may be related to abnormalities in serotonin neurotransmission, which can contribute

to the development and maintenance of panic disorder.

Brain Structure and Function

The client’s panic symptoms may be related to abnormalities in brain structure and function, particularly in the

amygdala, hippocampus.

Psychological Assessment
Informal Assessment:

Clinical interview

Clinical interviews revealed avoidance behaviors, catastrophic thinking, and elevated physiological arousal.

Behavioral observations Behavioral observations indicated hypervigilance and restlessness during the session.

Formal Assessment:

Panic Disorder Severity Scale (PDSS)

Total Obtained score Interpretation

score

40 34 Severe symptoms

Beck Anxiety Inventory (BAI)

 Total Obtained score Interpretation

score

63 49 Extreme

Generalized Anxiety disorder 7 time scale GAD-7

Total score Obtained score Interpretation

21 17 Severe

Case Formulation

Client symptoms were best understood through a Cognitive Behavioral model. Her panic attacks likely stem from a

combination of genetic predisposition and stress. Cognitive distortions e.g catastrophizing bodily sensations and
avoidance behaviors reinforced the disorder. Her anticipatory anxiety and avoidance maintained and exacerbated

her symptoms.

Tentative Diagnosis

Panic Disorder,F41.0

Prognosis

Fair to Good. With consistent treatment, individuals with Panic Disorder typically showed significant

improvement. Client’s insight, motivation, and support system were positive prognostic indicators.

Treatment Goals

Reduce the frequency and severity of panic attacks.

Decrease avoidance behaviors and anticipatory anxiety.

Develop coping strategies for bodily sensations and cognitive distortions.

Resume normal functioning at work and in social settings.

Treatment Interventions:

Psychoeducation

Client was educated about Panic Disorder and triggers were identified
Relaxation and breathing techniques

Relaxation and breathing techniques were used to help client overcome symptoms of panic disorder

Cognitive reconstructing

Client was asked to challenge and change her irrational thoughts and beliefs that are contributing to problem

Therapeutic Sessions

Session 1:Psychoeducation & Rapport Building

Client was educated about panic disorder, the fight-or-flight response. Therapeutic alliance was established.

Assigned homework: Panic diary.

Session 2:Identifying Triggers & Cognitive Distortions

Automatic thoughts and common triggers were identified and cognitive distortions e.g catastrophizing were

introduced.
Began thought records.

Session 3: Breathing Retraining & Relaxation Techniques

Client was taught diaphragmatic breathing and progressive muscle relaxation and were practiced in session;

assigned daily practice.

Reinforced anxiety tracking.

Session 4:Interoceptive Exposure

Panic symptoms were stimulated e.g hyperventilation, spinning aimed to reduce fear of bodily sensations.

Discussed client reactions and cognitive restructuring.

Session 5:In Vivo Exposure

Client was asked to face avoidant situation through gradual exposure to avoided situations e.g using public

transport. Experiences and emotional responses were reviewed.

Built hierarchy of feared situations.

Session 6:Relapse Prevention &Maintenance

Progress and remaining challenges were reviewed and coping plan for future stressors was developed .
Relapse and booster sessions were discussed.

References

Beck, A. T. (1977). Cognitive therapy: A new approach to the treatment of depression. New York: Guilford Press.

Cohen, S., Gottlieb, B. H., & Underwood, L. G. (2015). Social relationships and mortality: An analysis of the

National Longitudinal Study of Adolescent Health. Social and Personality Psychology Compass, 9(2), 142-155.

Freud, S. (1915). The unconscious. International Journal of Psycho-Analysis, 6(2), 131-154.

Freud, S. (1917). Mourning and melancholia. International Journal of Psycho-Analysis, 4(2), 137-154.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential

approach to behavior change. New York: Guilford Press.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral

therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(2), 103-110.

Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal psychotherapy of

depression. New York: Basic Books.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton

Mifflin.