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Case Report 1

Submitted to: Dr Urooj

Submitted b: Maria Amin Bhatti

Roll No: L1F16MSSY0021

Case 01
Name of the client: M.A (female)

Fathers name: L.M

Date of assessment: March, 15, 2017

Case No: 01

Examiner: M.A.B

Identifying information:

M.A is 40 years old. Client is married. She is 1 st born among 2 siblings, 2 brothers. She is house

wife and belongs to urdu speaking family, she is Muslim. Clients parents are alive and they

belong to middle class family. Her father is 65 years old. He has done a textile administration

course, and was a well-paid managing director until retirement. And her mother is 58 years old,

and is a housewife. The clients husband is 46 years old, and is currently working as an

administrator at Allama Iqbal Medical College. The client has two brothers. The older brother is

36 years old. He did not take a lot of interest in studies and only completed Intermediate. He has

his own pharmacy. He is married, and has three kids.

Reasons for Referral & Presenting Complaints

The patient was brought to Jinnah hospital by her husband with the complaints of chronic

depression, which has worsened over the course of the last few months. She was referred by the

clinical psychologist for the management of the aforementioned problem.


Interview information:

The patient was referred because of severe depression punctuated with several suicidal attempts.

The patient reports she has been a patient of depression ever since shes been married, i.e. since

20 years. When her first child (daughter) was born she was especially depressed and admitted in

hospital for 3 months. This happened because she was made to work excessively by her sister-in-

law, who made her cook day and night and clean the house, too. The patient suffered from

extreme vomiting and pains during her pregnancy, and went into depression after that. She stayed

symptom free for 1 year, but soon relapsed, because of her sister-in-law, and the psychological

torture she inflicted upon the patient. Consequently she visited a consulting psychiatrist at Jinnah

Hospital for one year, but her condition did not improve.

Soon after that, they left their sister-in-laws house and moved into their own house. The patient

was then able to function normally, and according to the patient although there were times when

she felt depressed, this was not the most prevalent feeling, until some five years back when she

experienced severe depression and a year later also started having incessant and recurrent

suicidal thoughts, punctuated with episodes of self-harm.

The patient reports that her suicidal thoughts are activated when somebody is rude, because she

says that she tries to keep everybody happy. She is immensely disappointed by the behavior of

her brothers specifically. The patient has tried cutting veins, and the mark was prominent on her
right hand. She used to inflict cuts on her forearms, and legs. Some of these cuts were so deep,

she had to go and get herself stitched up, but she never felt pain, and felt relaxed after doing it,

when probed, she added: main ye iss liye karti thi kyun k mera aur meray bhaiyoh ka khoon ek

hi hai. Jab mera khoon girta tha tu mujhay lagta tha unka khoon zaya ho raha hai, tu yeh un hi

ka nuksan hai.

No guilt after these suicide attempts was reported and all of these attempts were made either in

the presence of people or the episodes were narrated later in great detail. She has also tried

jumping in front of a train, and the patient says that is the perfect way to commit suicide. She has

also run on roads on a number of occasions, in front of cars. Moreover, she has tried burning

herself and she drank phenyl on one occasion too. She reports: Im very sensitive, which is why

when my brothers mean to me, I feel like committing suicide, because these people will only be

happy when I am gone. I feel they are troubled because of me. Albeit, she acknowledges the

underlying assumption that they might realize her importance once she is dead.

After marriage suicidal attempts, she went to see a consulting psychiatrist at Combined Military

Hospital (CMH) in 2009, for 1.5 years and his treatment proved efficacious for the patient, and

suicidal attempts stopped. However, when the same psychiatrist said that Escitalopram was not

really working and suggested trying ECT, the patient terminated therapy. This happened in 2011.

Her husband then took her to the consulting psychiatrist at Jinnah Hospital again in August 2012,

when she made another attempt to take her life using a razor blade. Now she is under going

treatment from psychiatrist of Jinnah hospital for her treatment. She is currently on Ciproxin and

Quetapine and the patient has reported marked improvement in the quality of sleep and increase

in appetite.
The client shares a warm relationship with her father. She says her father is her ideal, and

that she had an amazing childhood. Also, she says her father was the one she was very close to,

when she had anything to say, she would say that to her father. Her father would pamper her, and

see to all her needs. On the other hand, her father was very strict with his sons, and her brothers

were very afraid of their father. Even now, she says she can share anything with her father, and

hes always very understanding and considerate towards her.

The client shares a somewhat ambivalent relationship with her mother. According to her,

her mother always preferred her sons over her, but she did see to her needs and was considerate

most of the time. Sometimes, she would beat her up, and her father would usually save her, and

take her side. After her marriage, however, she says her mother and her relationship strengthened

and they understood each other better. She reports having a friendlier relationship with her

mother now.

The client says that her parents have always had a very warm, balanced relationship. She says

her mother was dominating and controlling, while her father was very compromising. However,

when making decisions, her fathers word was the last. They did fight, but no more than anybody

else does. Most of the time, they were supportive of each other.

The client says she gets along with her sister-in-law and loves their children like her own. But

she says her brother is very rude to her, and even to her husband and her children. Also she feels,

that her sister-in-law is not as kind to her children, as she is to hers. The client says she becomes

very upset when her brother is rude to her and she keeps thinking about it day in and day out.

The clients younger brother has done ACCA. He is currently working in a prominent business

firm. He is 32 years old and is unmarried. The clients hares a congenial relationship with him,
and she says the younger brother behaves in a better manner, and is usually civil and courteous

towards her. However, sometimes he too says something that upsets her.

The client reported history of depression in the family. According to the client, her

mother suffered from severe depression 2.5 years back, when her brother went away to London,

for giving his ACCA exams, and her mother fell ill. She would often hear her sons voice, was

irritable most of the time and sometimes would sit alone and cry for hours. She had trouble

falling asleep and would hardly eat anything. She was treated for a year at Iqra Complex. Some

improvement was witnessed, but she recovered completely when her son returned after two

years. No other noteworthy history in family.

The client says the home atmosphere was pleasant and very comforting. They were

financially stable and they never had any money problems. They did not fight a lot amongst

themselves, except for the occasional fights between her brothers, or with herself. They were

sympathetic and compassionate to each other.

According to the patient, no birth complications were experienced by the clients mother.

Her birth was a normal and she was delivered by a midwife at home. The developmental

milestones of walking, sphincter control and talking were achieved at time. The patient recalls

that as the eldest child, she was spoilt and pampered by her parents. However, when her brother

was born, her mothers attention shifted to him, but her father still showered her with attention.

She also adds that she did not have a lot of fights with her brother during their early childhood,

because there was considerable age difference between them that assured respect and

subservience.
The patient says that she was an intelligent student and worked hard. In her earlier

classes, she was one of the top students, however, at college level, she was an average student,

because she there was a lot of competition, and even though she worked hard, she still

maintained an average student status. No truancy incidents were reported.

The patient says her depression worsened when she married her husband. The patient has

been married for 20 years. Her husband was her fathers choice and she complied with it, even

though one of her cousins wanted her hand in marriage. She says her maternal uncle wanted her

to marry his son, but her father and paternal grandfather were against it, her mother was also

reluctant, so she ended up marrying the man her parents had selected for her. She adds that her

husbands behavior is often rude to her. She recalls that her mother-in-law died one year after

engagement, and her father-in-law died when her husband was very young, and her husband had

to live with his elder brother. Her husbands sister-in-law was a very mean, selfish, and

manipulative woman. She used to throw them out of the house when her husband was away, and

would not give them any food. The patient had to stay with her sister-in-law for three years and

she said that this time period was more traumatic than her entire life put together. She reports this

as the trigger for her depression. She says she had to clean the whole house when she was seven

months pregnant, and then her sister-in-law would intentionally make the house messy. She says

she has always supported her husband through thick and thin and been very nice to her in laws,

however her husband has never appreciated her. Also, she says they used to go to their sister-in-

laws house to continue contact, but her sister-in-law and her children completely ignored her,

and shed remain in depression for days, sometimes a week, after visiting their home.

They managed to construct a house of their own 3 years later, and their situation has been better

since then, but she still feels that her husband takes pleasure in taunting her and is often harsh
and mean. She says the reason for this is her reluctance to engage in sexual relations with him

since a year. She reports feeling impure and dirty after engaging in sexual intercourse, and often

took hour long baths and scrubbed herself, specifically her genitals. She also said prayers seeking

forgiveness after this act and would perform ablution again and again. She says her husband has

maintained an even stern demeanor since her refusal to engage in sexual intimacies with him.

She says she never felt a need or a sexual desire ever in life, but performed it as a duty to her

husband, but now she cannot bring herself to engage in this act again. No court or police cases

reported.

The patient worked as a primary school teacher in a private school near her home for 2.5

years, seven years back. She says she liked to work and found a lot of satisfaction in teaching.

But she says since her illness worsened she stopped working.

The patient describes herself as reserved but confident, introvert and inhibited even

before her illness, but she was also self-reliant and independent. She says she liked working

before she got ill, and liked watching TV, reading books. She says she liked to visit friends and

relatives too, but now she does not like to meet people on a regular basis. She adds that before

her illness, she was religious, but ever since she has been depressed her faith has strengthened

and she has become even more religious.

Tests Administered

Human Figure Drawing Test(HFD)

Rotter Incomplete Sentence Blank(RISB)

Beck Depression Inventory(BDI)


Behavior during sessions:

During the initial sessions, the client was not willing to share the information, she was

aggressive and secretive, but gradually she developed trust on the psychologist and then she was

open about her problem and history and showed compliance. She had a sad and low mood, but in

later sessions, she was getting better and happy. She was talkative. Her motor movements were

mostly lethargic and slow. She maintained eye contact throughout the sessions. She got very sad

when she told about her previous experiences and telling conflicts with the family members. She

was very hopeless while talking about her marriage. Her level of attention and concentration

were intact.

Psychological Evaluation:

Human Figure Drawing test was administered on client. The patient was very much

hesitant to draw the pictures in the beginning. The drawings were mostly inclined towards left

side of the page showing impulsivity in behavior for gratification of needs. The stiff drawing of

human figure showed rigidity traits as well. The analysis of the human drawing figure is that she

is striving for achievement. She is anxious over interpersonal relationship, as it was also noted

that her needs of autonomy were hampered by the constricting domestic and martial situation at

home. Her feeling of inferiority, inadequacy, tension and helplessness were clearly shown by tiny

shoulders, arms extended outwards and also by small hands and arms.

RISB reveals that the patient has obtained a score of 159. The cut-off for RISB for females is set

at 121, thus this slight elevation is indicative of some maladjustment on part of the individual.

The social and sexual as apparent in the sentence-completion of the individual indicates that the

patient is somewhat disturbed because of her marital relationship; she has also expressed some
concern about not being a good mother. The sentence-completion shows that the individual

indicates that she does not enjoy being in overwhelming social environments, (especially when

shes ill). In her sentences, she has expressed concern about not being good enough for other

people. The general attitude as indicated by sentence-completion is worry about the future, and

failure to get better. The most dominant theme is worry about not getting completely cured, and

regrets about thinking negatively and doing self-harm. The character traits that are evident in the

sentence-completion of the individual are self-righteousness, vulnerability to worry and an

inclination towards self-critique.

Beck Depression Inventory (BDI) in this patient scored a total of 38 in BDI (Beck, 1996). This

signifies severe depression.

Tentative Diagnosis

296.23 (F32.2) Major Depressive Disorder, Recurrent, Severe without Psychotic Features

Prognosis:

The patients prognosis is guarded. The prognosis is favorable because the patient has:

Insight of the problem and illness

Motivation to get better and is willing to work for it

Strong social support system

The prognosis seems to be unfavorable because the patient has:


Strained marital relationship

Oversensitive, volatile nature

Perfectionistic tendency

Overwhelming need for social approval

Poor stress coping skills

Recommendation

Cognitive behavioral therapy may use as the principle therapeutic intervention.

Case Summary

Patient M.A., 40-year old female, was referred to trainee clinical psychologist with

presenting complaints of depressed and sad mood, lack of pleasure and history of self-harm.

Depressed mood had been experienced since twenty years, and self-harm history since the last

2.5 years. The patients psychological assessment included informal (Clinical Interview, Mental

State Exam) and formal (Beck Depression Inventory, Rotters incomplete Sentence Blank,

Human Figure Drawing). The results of psychological assessment along with the subjective and

objective symptoms indicated Major Depression. The patients strained relationship with

husband and oversensitive nature might have been acting as maintain stressors of her depression.

The patients management plan consisted of Cognitive Behavior Therapy (Cognitive

Restructuring, Positive Self Coping Statements, Mastery and Pleasure, Mood diary, Paper

Tearing, Activity Schedule, Identifying Cognitive Distortions, and Homework Assignments) and
Relaxation Techniques (Progressive Muscle Relaxation, Guided Imagery, and Deep Breathing).

The 13 therapeutic sessions proved to be effective in stopping self-harm acts, and coping with

depressed mood, lack of pleasure, sadness and hopelessness.


Management Plan

Patients Name M.A, 40years old

Presenting Complaints Dizziness, social withdrawal, isolation, suicidal ideation

Test Administration Human Figure Drawing(HFD)

Router Incomplete Sentence Blank (RISB)

Beck Depression inventory


296.23 (F32.2) Major Depressive Disorder, Recurrent, Severe
Tentative Diagnosis without Psychotic Features

Goals of Therapy Short Term Goals

Rapport will be built and maintained to facilitate the


therapeutic process. The interview technique, active
listening and supportive techniques helped achieve this
goal.

The patient will be psycho-educated in order to help them


understand and comprehend the nuances, etiology, and
manifestations of her illness, and also to help induce
motivation in her to willingly engage in therapy for her
own good, and to be compliant.

Socialization will be done, and the CBT model was sold to


the patient, in order to help them understand the complex
interplay between cognitions, behaviors, thoughts, feelings
and emotions.
Activity schedules and pleasure seeking activities will be
scheduled in order to keep the individual busy and
participate in daily life activities.

Relaxation exercises will be used in order to help the


individual calm done and think clearly, and gain
perspective on daily life problems.

ABC technique will be used with the patient in order to


help her understand the connection between event,
subsequent thoughts and how that effects the
consequences.

Depressed mood can be managed temporarily via the use of


positive imagery.

Negative Automatic Thoughts will be elicited using


dysfunctional thought record.

Cognitive restructuring will be subsequently applied in


order to help the patient gain perspective and identify and
challenge negative automatic thoughts.

Positive coping statements will be used in order to help the


patient ward off upsetting thoughts.

Homework assignments such as mood diary, cost benefit


analysis, activity schedule, and mastery and pleasure
techniques will be given in order to help the patient
independently work for her betterment and strive for
improvement.

Relapse prevention will be used.

Long Term Goals

Concentrating on short term goals, and taking it one day at


time.

Booster sessions and follow up sessions.


Psycho-education of family and counseling.

Social skills and assertiveness training.

Main Therapies Initial Phase

Rapport building

Clinical interview

Administration of psychological tests

Middle Phase

Cognitive Restructuring

Positive Self Coping Statements

Mastery and Pleasure

Mood Diary

Paper Tearing

Activity Schedule

Identifying Cognitive Distortions

Homework Assignments

Relaxation Techniques (Progressive Muscle Relaxation,


Guided Imagery, and Deep Breathing)

Termination Phase

Relapse prevention

Self-management planning

Reducing the number of sessions per week


No of session planned 14

Initial phase 1-5

Middle 6-11

Termination 12-14

Individual Session

Patients name M.A, 40 years old


Presenting Dizziness, social withdrawal, isolation, suicidal ideation
Complaints
Session 1

Goals To build rapport and a bond with the client


To obtain history in order to gain in depth information
To complete Symptom Checklist in order to separate
clinically significant symptoms

Psychotherapeutic Techniques Rapport Building


Implemented Clinical Interview
Outcome Rapport was built with the patient during the clinical
interview. The patient was asked about their principle
problems, and the history of their current illness. Moreover,
relevant family and personal history was also taken.
Confidentiality was ensured in order to put the patient at ease
and facilitate the reporting of history. This helped in reaching
upon a diagnosis and a therapeutic model that is suited to the
patients unique needs.

Session 2

Goals Clarifying diagnosis by making relevant queries


Assessing patients current Mental State
Using assessment tool human drawing figure.
Teaching Deep breathing in order to calm her down.
Psychotherapeutic techniques
implemented Deep breathing
Assessment tools (HFD)
Outcome The patient was taught the correct manner, and step-by-
step process of deep breathing. She was also given a
take home reading pamphlet in order to give her the
basic guidelines.
Assessment tools were used in order to reach a decision
about the patients diagnosis, and other associated
problems.
Client resist to drawing image but later she draws a
person
Homework Assignment The patient was asked to practice deep breathing, at
least five times a day.

Session 3

Goals To psycho-educate the patient about her illness,


cognitive behavioral model, etiology from a bio-
psycho-social perspective, and the management plan as
well.
Assessment tool RISB.
Formulate an activity schedule with the help of the
patient
Teach different relaxation exercise in order to cope with
symptoms of anxiety
Psychotherapeutic techniques Psycho education
implemented Activity Schedule
RISB
Progressive Muscle Relaxation (PMR)
Outcome The patient was psycho-educated regarding the nature
of her illness, supposed etiology from a bio-psycho-
social perspective and the basics of the cognitive
behavioral model.
The patient was also involved in making an activity
schedule and was asked to strictly act upon it.
The patient was taught the sixteen-steps of PMR, and
was also given it in writing in order to help her
understand and read the instructions whenever she
forgets. The patient was made to practice it, and she felt
the release and built up of tension after engaging in
PMR.
Homework Assignment The patient was asked to practice PMR, at least once
daily.
She was also asked to follow the activity schedule and
make appropriate marks against the respective
activities.
Session 4

Goals Assessment tool BDI


psych educate the client
formulate activity schedule
Psychotherapeutic techniques Catharsis
implemented
Outcome The patient had a fit at around 9:30 this morning. She
was crying and saying that she will die because she
couldnt breathe. Her husband and a female attendant
along with other ward patients were there with her.
They were dispersed and the patient was asked to
relax.
She was made to practice deep breathing, and
counseled. Belief in Allah was the approach that was
used to pacify her, and she was checked for
understanding at regular intervals.
The patient soon calmed down and participated in the
conversation. She was asked to practice self-coping
statements during the remainder of her time at the
hospital; these were taught to her during this same
session.
The patient was then administered a benzodiazepine
by a medical professional and asked to rest.

Session 5

Goals To help the patient understand the connection


between thoughts and feelings
To help the patient gain insight into her positive
qualities
To help motivate the client and increase compliance
Administer tool BDI
Psychotherapeutic techniques A-B-C technique
implemented Identifying Positive Qualities
Cost-benefit Analyses
Positive Self Coping Statements
Dysfunctional Thought Record
BDI
Outcome The A-B-C model was taught and practiced to the
client and the connection between thoughts, feelings
and behavioral reactions (consequences) was
explained. The client was taught that how an event
may lead to different consequences based upon
variability of beliefs. If we learn to monitor our
beliefs, negative events may not disturb us
immensely. A chart was made for the clients ease
and she was taught how to complete it, and the rest
of the chart was given to her as homework.
Next, another activity was done which required that
the client identify her positive qualities in order to
increase her self-confidence. This was a healthy
activity that the client enjoyed and she successfully
identified many of her positive qualities herself (e.g.
Ive a good aesthetic sense in dressing, Im a very
good cook, Im very kind to people and I make
friends very easily, Im a very good mother, etc.).
She was given a copy of these so that she can review
them whenever she feels a drought of self-worth.
Later, the client collaborated in doing cost-benefit
analyses of illness and treatment, the client
participated fully, it was completed and the client
was given a copy to add anything later on when it
comes to mind and to review it at certain intervals.
A dysfunctional thought record was made, practiced
and partially filled for the clients ease, which
included columns for events, feelings (rate intensity
0-10) and thoughts. It was given as homework too.

Homework Assignments
Last sessions homework assignments were reviewed,
and an updated activity schedule was provided to
them.
A-B-C worksheet, Cost-benefit analyses, DTR, and
positive quality identification worksheet was given
as homework.
Session6

Goals The patient was made to identify negative


automatic thoughts and investigate their
belief in these thoughts and the factual
component of these beliefs was evaluated
Feelings of happiness and fulfillment were
targeted for increase
Psychotherapeutic techniques implemented Socratic Questioning
Daily Gratitude Technique
Outcome The patients core beliefs, and negative
automatic thoughts were identified and
evaluated and the patient was made to
investigate their factual content and
rationally assess them
The patient identified all those activities
and things that induce pleasure and
gratitude in her. She found it very effective.
Homework Assignments The patients homework was reviewed, and
previous homework assignments were
advised to continue
The patient was given daily gratitude diary
as homework.

Session 7
Goals Sleep hygiene was briefed to the patient,
because her quality of sleep had suffered
Mood diary was briefed and given to the
patient
Psychotherapeutic techniques implemented Mood Diary
Sleep hygiene
Outcome The patient was briefed upon sleep hygiene
in order to improve the quality of her sleep
The patient was briefed and administered a
mood diary. They were then given this
dairy for homework in order to better
monitor their progress and mood
Homework Assignment The previous assignments were reviewed
and advised to continue
Mood diary was given as additional
homework.