Name: A.

F
Age: 27
Gender: Female
Education: B.A
No. of Siblings: 4
Birth Order: First
Informant: Mother
Residence: Rawalpindi

Reason and Source of Referral:

The client came with the presenting complaints of fatigue, loss of

motivation, insomnia and suicidal thoughts.

Duration Complaints
8 months fatigue
8 months loss of motivation
7 months social isolation, hallucination
8 months insomnia, sleep disturbance
5 months suicidal attempts
7 months negativity

Family History:
The client father was 52 years old. He was a government employee. Her father was a very friendly

and loving person. Her mother was also very humble and loving. The general home atmosphere is

very open and friendly.

After Marriage:

The client was married one year ago, It was an arrange marriage. The general home

atmosphere was completely different from her parents’ home. There was strictness on her

regarding everything.

Personal History:

The client was born through a normal delivery. The health of both mother and child was

satisfactory. The client did cry after birth. She did not suffer from any accident or other medical

illness in her past. She achieved the milestones of the development. She have not suffered from

any psychological illness in her childhood.

Educational History:

The client first attended the school at the age of 5 years. She was an average student. Her

relationship with teachers and peers were healthy. She completed her graduation with average

grades.
Sexual History:

The client sexual history was quite satisfactory for few months after her marriage. But

soon as she got the symptoms, her sexual relationship got disturbed.

Occupational History:

She never occupied anything.

Marital History:

The client was married and her relationship with her in laws was good but from last 2 months she

was living with her parents.

Premorbid History:

The client was a happy child. She was social and friendly. She was not much interested in her

studies, that’s why she was an average student.

History of Present Illness:

The client got the symptoms of present illness 8 months ago.

 Psychological Assessment:

Informal Assessment:

Clinical Interview:

For exploring the important factors of client’s illness and psychological analysis, a clinical

interview was conducted by a trainee psychologist. The client did not answer every question

frequently.

Behavioral Observation:

The client was not cooperative. She was staring at everyone. She was asking questions

about everyone.

Mental Status Examination:

Client was wearing neat and clean dress. She had good hygiene.

Defense Mechanism Used:

The client did not use any defense mechanism.

 Formal Assessment:

HTP:

HTP interpretation showed that the client was insecure, isolated and confused.

Beck Depression Inventory:

The client scored 38 which indicates that she is suffering from severe depression.

Diagnosis:

The test interpretation showed that client has severe depression.

Prognosis:

The client prognosis was quite complicated because she was not willing for treatment but

her family wants her to be treated.

Summary:

The client is the patient of depression. She is suffering from depression since 8 months. The

trainee psychologist decided to give her the treatment as per requirement.