Case Summary

Mr M.k was a 26-year-old unmarried male, educated up to FSC and only few exams
away from doing graduation belonged to a middle socio-economic class. He has three siblings,
and among them, he has 2nd birth order. He came with the presenting complaints of body pains,
headaches, tension, frustration, worry, inadequacy, and anxiety. Moreover, his sleep was so
disturbed. He was already year behind his university degree program. His symptoms are
centered on arranging, organizing (exactness). He controls all mechanical or electronic objects
he uses, and when he has finished using them, he ensures that everything is in place. His
symptoms are focused on immediately avoiding the feeling of having left something not
perfectly in place.

In the initial sessions, rapport-building was done, and initial assessment was done.
Socialization to CBT model was done. At first, deep breathing and relaxation exercise was
taught to him. The number of sessions taken with the patient were 4.
Bio Data

Name: M.K

Age: 26 years

Gender: Male

Occupation: Freelancing

Siblings: 3

Birth Order: 2nd

Marital Status: Unmarried

Informant: Client

Reason for Referral

The patient was referred from Dr Ali. His presenting complaints were lack of sleep

disturbance and anxiety.

Presenting Complaints

Client reported certain complains.

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History of Present Illness

According to the client, his problems dates to childhood around 2008. The client
remembers his father’s hurtful comment when he received his fifth-grade report card. His father
was quite furious at him and him though he stood 3 rd in class but father wanted him to have
first position instead because he was always considered the intelligent one among siblings. As
a child, the patient was often worried that his mother might feel unloved. For instance, he
recalled that once we were travelling by train and my brother and I sat on the same seat as our
father, and our mother was alone in another compartment; I remember feeling that I had
betrayed her, and after a while I made an excuse and moved next to her.

He reported that at time, he was around 15 years old in 2012 he was continually
reminded of his brilliance by his extended family. His aunts were particularly partial to him;
they praised his qualities, especially his intelligence and his good grades. Furthermore, he had
the feeling that he always received the best gifts, which he remembers with feelings of guilt
toward his brother, who was less brilliant at school and more [Link] home he
remembers that he always felt like he had a guilty conscience and that he was being judged;
for example: he said If I was watching a film on TV and my father or brother passed, I
immediately felt guilty. He perceives his father as unaffectionate and generally critical and a
person who is very disciplined because he was an army officer and always very disciplined and
organized, he expected the same discipline from his family. Again, when his matriculation
result came, he scored 85% but his father was not happy and said you could have done better.
Client reported that all the family members were extremely disciplined and organized because
his father would create a huge fuss out of small things.
He had gone to private elementary and middle schools but attended a public university.
After this change, the patient said he realized he was normal and not a genius. Compared with
his companions and based on his first test results, the client realized he was no longer able to
distinguish himself with ease as he had in middle school. This realization also influenced his
relationships with his companions, as he was no longer able to make himself known as the
really smart one and tended to isolate himself.

When he was 25 years old, the clients’ obsessive symptoms worsened significantly
following the news of his mother’s terminal cancer. This news acts as a triggering factor for
the manifestation of his anxiety he just can’t focus lately. He makes sure things are organized
properly before starting any activity and it takes hours to get organized. He failed two courses;

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his sleep was disturbed. His father’s behavior is much worse after the diagnosis of his mother.
Lately he has extreme headaches, body pains, cant focus and anxious thoughts.

Family History

Father

His father was 65years old man who worked as an Army officer was a very strict and

disciplined man. His relationship with the client was very dry. Father used to be very critical

towards the client and have a lot of expectations from him.

Mother

His mother was 55 years old who served as a housewife. She was very kind. The

client was very attached with his mother. Mother was terminally ill with cancer.

Siblings

The client had 3 siblings i.e., 1sisters and 2 brothers (including him).

Brothers. The client has 1 brother. The brother has 1st birth order and 28 years old

doing job after completing MBA degree. He had a distant relationship with the client.

Sisters. His sister having third birth order was 20 years old studying is a student of

medical. Client cares for his sister and have a good relationship.

General Home Atmosphere

The general home atmosphere was very strict and disciplined since father was an

army officer strict routine was followed at home. They had allotted time for breakfast, dinner

and lunch and a person who does not follow won’t get food. He belonged to middle

socioeconomic status and lived in a nuclear family system.

History of Physical and Psychiatric Illness in the Family

He had reported that both of his parents have issue of blood pressure.

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Personal History

Birth and Childhood

The patient was born through normal delivery. He passed all his developmental

milestones at an appropriate age. He reported that he was above average student in school and

considered very intelligent. He used to be perfect and behaved like a good child all the time

trying to make his father proud. He was quite attached with his mother and used to share a

lot with her. He was always an introvert and does not have a big friend circle.

Educational History

At the age of 3 years, he started his schooling. He was a very bright student. Everybody

praised him for his grades. He got admission in engineering university but was unable to

complete his degree on time. He must pass few exams to complete his graduation.

Occupational History

He was doing some online job on freelancer.

Sexual History

He reached puberty at the age of 15 years. He got psychoeducation regarding

hormonal changes from his friends. By 23 he started to have interest in one of his class

fellows.

Religious Inclination

He is a normal practicing Muslim.

Pre-morbid Personality

According to the client, he was known for his meticulous attention to detail and

perfectionistic tendencies, client often found it challenging to delegate tasks, fearing that others

may not meet his standards. He used to do all his group work alone. Anxiety sensitivity is a

constant companion, causing an unease that manifests as a need for order and control in both

personal and educational spheres. clients’ colleagues admire his creativity but also notice the

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meticulous way in which he arranges his workspace and the time-consuming rituals before

finalizing any project. While these characteristics contribute to the client’s success, they become

more pronounced over time.

Preliminary Investigation

To assess the severity, course, co-morbid factors, perpetuating, precipitating and

maintaining factors, informal psychological assessment was done. This would ultimately help

in developing an adequate management plan for him.

• Clinical Interview

• Mental status examination

Clinical Interview

During the start of the therapy, a semi-structured interview was performed which was
helpful in longitudinal analysis of the client’s problem. A detailed account about the history
of present illness, background information, nature of relationships, personal history along-
with the childhood factors, educational history, sexual history, and pre-morbid personality of
the client was obtained. It ultimately helped in diagnosis and formulating the management
plan of the patient. During this clinical interview, his previous experiences (stressors
particularly), and coping strategies were also tackled. The predisposing, precipitating, and
maintaining factors were also probed.
Mental Status Examination

The client was hygienic and properly dressed up. He was having above average height
and looked fine. He did not make an adequate eye-contact. Rapport was effectively built. Client
displayed cues of tension, frustration, worry, and anxiety. However, the client's conduct was
observed to show that the client's speech was coherent, spontaneous, and normal in rate,
volume, and articulation. Positive mood was evident through facial expression and general
conduct. He disputed any thoughts of suicide. His demeanor matched his mood. Associations
were complete and sensible. Suicidal ideas or intentions were denied. Homicidal ideas or
intentions were denied. Cognitive functioning and fund of knowledge were intact and age
appropriate. Short- and long-term memory were intact, as is ability to abstract and do arithmetic
calculations. This client was fully oriented. Vocabulary and fund of knowledge indicate

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cognitive functioning in the normal range. Insight into problems appeared fair. Judgment
appeared fair.

Psychological Assessment
Standardized Assessment tools
Brief Obsessive-Compulsive Scale (BOCS)

Psycho-diagnostic Assessment
Brief Obsessive-Compulsive Scale (BOCS). The Brief Obsessive-Compulsive Scale
(BOCS) was used to assess for the presence of obsessive-compulsive symptoms based on the
observation. The client total score on (BOCS) was 9 which suggests moderate severity of
OCD symptoms with having 70% obsessions and 90% compulsions.

Diagnosis

The test results in conjunction with the history and observation, indicate that the client
meets the criteria for the following tentative diagnosis: Obsessive-Compulsive Disorder:
(Severity: Moderate) DSM- 5 (300.3: F42).

Provisional Hypothesis

This hypothesis was designed according to cognitive behavioural model so that those
psychological and cognitive mechanisms that precipitate and maintain the patient’s symptoms
become clear.
• The patient’s schema about “symmetry and exactness” (things should be arranged,
aligned) had been maintained and he continued to develop his symptoms such as he
have developed the habit of continually arranging and organizing things.
• The patient’s problem was maintained by urge to arrange and organize things in
perfect order.
• The patient’s performance anxiety also contributed to his negative thinking as he
thought that he should always be above average.

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Short Term Goals

Table 1

Short term goals of the client and associated therapy technique to achieve them

Short-term goals Therapy technique

In order to develop effective rapport with Supportive work

the client so that he would be in comfort

zone, able to respond well and follow the

therapist at adequate pace.

He was explained in detail about all his Psycho-education

problems, methods, way of implementing

different modes of therapy along-with the

target goals to clear his queries and

importance of treatment.

He was also told about how his case was Case conceptualization

formulated to aware him about his illness in

an adequate manner

This was done to aid him in understanding Socialization to CBT model

the therapeutic way of treatment in detail.

He was explained the procedure of deep Deep breathing

breathing so that he was able to relax

himself whenever he become uneasy

Long-term Goals

• Continuation of short-term goals will be done.

• Continuation of follow-up sessions will be done.

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 • Stress-management was taught.

Case Formulation

This was the formulation of a 26-year-old man, who is an engineering student and had
2nd birth order among siblings. After taking detailed history, and assessment, he was diagnosed
as having obsessive compulsive disorder. He was constantly experiencing body pains,
headaches, anxiety, sleep disturbance, constantly involved in arranging and organizing things.
The predisposing factors was his father behaviour towards him, as father was very strict and
demanding. Client had a great pressure to perform this performance pressure was taking a toll
on his mental health. Moreover, he tried very hard to make his father proud, but he was never
happy, resulting in his delay in degree because of the rituals he got involved in. he was unable
to stay focused and give time to studies.
Study conducted by Timpano et al., (2010) suggests that the authoritarian parenting
style was significantly associated with both OC symptoms and OC beliefs (e.g., beliefs about
the importance of thoughts and personal responsibility), even after controlling for general
distress. Hence, as mentioned in the history, the client had faced the stressful life in his early
childhood. He faced extreme performance pressure from his father. Mother used to be his
protective factor. But she was diagnosed with last stage cancer he failed two courses after this
news he was totally shattered it served as precipitating factor for his present condition. Because
of failing his course his degree got delayed. In this crucial time, he did not have any support
because he used to discuss everything with his mother. The perpetuating factor is Father’s
strictness and neglect.

Case Conceptualization

The present case was conceptualized according to Aron Beck’s (1976) cognitive
behaviour model and cognitive behavioural model for obsessive compulsive disorder by
Salkovskis, Forrester and Richard (1998). The model stated that it is the client’s interpretation
of the intrusions which derive distress and maladaptive responses. Individual differences in the
maladaptive thinking process and negative appraisal of the life events that lead to the
development of dysfunctional cognitive reactions.
Client was 26 years old when he was diagnosed with obsessive compulsive disorder
(exactness type). The role of early childhood experiences along with the life events and how
current situations along with them contributed to client’s symptomology are given in the model.

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 Client’s childhood was traumatic because his father was very strict and used to beat
him occasionally and especially on getting good grades. Father’s strictness made him distress.
He was always considered intelligent therefore father had so many expectations from him
which put extra pressure on the client and induced performance anxiety. His father needs for
things to be perfect was induced in the client, so he feels so anxious and try to avoid it.
The client had persistent, distressing thoughts about making mistakes or imperfections because
he was predisposed to such an environment of perfectionism. His mother’s illness served as a
precipitating factor in in his condition.

Figure 1

cognitive model of obsessive-compulsive behaviour

strict father, extreme

discipline

physical/verbal abuse
Continuous strictness from father Terminal illness of mother

Extreme punctuality, demanding precipitating cancer

father

General negative beliefs

not intelligent enough

Intrusive thoughts images, urges

obsession

Things should be arranged in order.

cant focus, failed courses crying, anxious

Compulsions

Organizing things for hours, organizing

books and notes Physical symptoms

Trouble sleeping 9
Tiredness ,body aches
 Session Wise Recommended Treatment Plan

Session I

Session Goals

• Rapport Building

• Informed consent

• History taking (History of Present Illness)

• Mental Status Examination (MSE)

Rapport Building. The target of the first session was to build rapport with the client.

Rapport Building was done so that he could come in his comfort zone and discusses all his

problems with ease with the therapist. To build rapport with the client, he was asked about

his interests and hobbies as well. In the end, client was comfortable to discuss his problems

with the therapist

Informed Consent. The patient was explained about the therapeutic way of treatment, its

duration and outcome. Next, he was given the chance to withdraw/quit anytime from the

treatment whenever possible. He was also given the authority to take part in the treatment or

not. At the end, signatures were also taken upon his commitment.

History Taking. He was asked that how his problem starts and when he started to notice

the problem. To identify the triggering and maintaining factors of his illness, detailed history

of his present illness was taken. The main stressors were also revealed in this session.

Session II

Session Goals

• Background and Family History

• Psycho-diagnostic Assessment

• Socialization to CBT model

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 Background and Family History. The patient was asked in detail about his premorbid

personality, siblings, general home atmosphere, hobbies, and educational history.

Occupational history was also inculcated in this part. As the rapport was efficiently built, the

patient easily narrates all the information.

Socialization to CBT model. In the start of the session, the CBT model will be explained

to the client so that he understands the rational and procedure of the therapeutic technique.

The therapy would focus on client’s negative self-thoughts, poor self-evaluation, and

thoughts of in-efficiency and insufficiency. He would be then able to evaluate beliefs about

criticism he received and to dis-credit that. The negative thought pattern would be replaced

with a more positive and adaptive ways of thinking.

Session III and IV

Session Goals

• Feedback from the Previous Session

• Deep breathing

• Relaxation Exercise

• Psychoeducation

Feedback from the Previous Session. According to the client, he effectively understood

the therapeutic process and it ultimately boost him to continue the sessions.

Deep Breathing. In order to make the client calm and relax, he was explained the process

of deep breathing in detail. He was asked to practice this whenever he felt anxiety or

restlessness. The whole of the process was first modelled and explained by the therapist and

secondly, he was asked to practice it during the session.

Relaxation Exercise. In the session, the client was first explained about the importance

of this exercise so that he was motivated to practice this. Verbally, directions were given and

then the therapist explained each step to the patient i.e., 16 muscles of our body are involved

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in this process (hands, elbows, shoulders, forehead, eyes, nose, jaw muscles, neck, chest,

stomach, abdomen, upper thighs, calf muscles, and feet. He was asked to first tense each

muscle and then relax it, while his eyes remain closed during that time. He was also guided to

feel the difference between the state of relaxation and tension. Finally, the client was given

homework to do this relaxation exercise at home 2-3 times as well. During the session, the

patient reported that he felt quite stress free after doing this exercise.

Psycho Education

Client must be provided with psychoeducation about his causes, the symptoms and impact of
depression in his life. This would give him better understanding of his condition and would
give him an upper edge to step-up for himself.
Homework Assignment

• Practice relaxation exercise and deep breathing twice daily.

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 References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities
Press.

Salkovskis PM, Forrester E, Richards C. Cognitive–behavioural approach to understanding

Timpano, Kiara & Keough, Meghan & Ms, & Mahaffey, Brittain & Schmidt, Norman & Abramowitz,
Jonathan. (2010). Parenting and Obsessive Compulsive Symptoms: Implications of
Authoritarian Parenting. Journal of Cognitive Psychotherapy. 24. 10.1891/0889-
8391.24.3.151.

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Annexures

(BOCS)

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