CASE NO.

GENERALIZED ANXIETY DISORDER

1. Bio-Data:

Name: QWA

Age: 19

Occupation: Student

Gender: Male

No of Siblings: 3 brothers, 2 sisters

Birth Order: 4th

Marital Status: Single

Language: Urdu, English

Education of father: N/A

Education of mother: N/A

Home town: Layya, Punjab

Brought by: Self

2. Referral Source:
The referral source of client was his father.
3. Presenting Complaints:
 Memory
 Difficult understanding teachers
 Distracted thoughts
 Excessive ongoing tensions and worry
 Sweating
 Difficulty concentration
4. Previous Treatment History:
i. Personal History:
There was no childhood illness reported as all was well with client.
Childhood stressors were somehow told by the client and they were teachers.
His education is Fsc. No employment history responds.
ii. Developmental History:
His birth was normal, all the developmental milestones were normal.
iii. Family History:
Client has a nuclear family system. They are living under supervision
of their father and have a happy family. Father and mother were reported to be
very caring, love and supportive.
iv. Medical History:
No medical history has found.
v. Psychiatric History:
No psychiatric history has found.

5. Mental State Examination:

Appearance and Behavior: A well-dressed person, well behaved and cool.

Thought Content: Thoughts were logical and goal oriented.

Orientation: Client’s orientation of Time, Place and Person was normal.

Attitude: His attitude about questions was very good and cooperative.

Mood: The client was feeling relaxed while giving interview.

Speech: Speech was quite relevant and in polite way.

Memory: The client was responding well to all the questions asked.

6. Tentative Diagnosis:
 Generalized Anxiety Disorder
 Poor academic performance
7. Psychological Tests Battery:
 Beck Anxiety Scale
 The Generalized Anxiety Disorder 7-item Scale
8. Psychological Test Result:
The range 5 and interpretation of severity level of anxiety of client is Severe
Anxiety and obtained score is 16. (GAD scale)
The range 31 and above and interpretation of severity level of anxiety of client is
Severe Anxiety and obtained score is 31. (BAS scale)
9. Case Formulation:
A young boy, who was under the supervision of a loving father developed
carelessness about thing to be done with great care, he never do his tasks on time as
all the tasks are kept pending till the end at the very main time when the task is
required it get stressed which leads him to Generalized anxiety disorder during time
of work required.
10. Co morbidity:
Individuals whose presentation meets criteria for GAD are likely to have met,
or currently meet, criteria for other anxiety and unipolar depressive disorders.
11. Principal Diagnosis:
The client was diagnosed with Generalized Anxiety Disorder.
12. Treatment Plan:
 Deep breathing
 Deep muscle relaxation
 Cognitive Behavior Therapy (thought channelizing)
 Daily activity schedule
13. Psychotherapeutic Sessions Report:
Session No.1:
This session was taken with client on 13th Sep, 2019. It lasts for 40 minutes. In
this session rapport building was established and detailed history was taken from the
client. The client was cooperative around giving information.
Session No.2:
This was second session taken with client on 20th Sep, 2019. It lasts for 1 hour.
For proper assessment The Generalized Anxiety Disorder 7-item Scale and Beck
Anxiety Scale was applied to client.
Session No. 3:
The session was on 2nd Nov, 2019. In therapy, thought channelizing modifies
thought patterns in order to change moods and behaviors. The client was cooperative
to complete his improvement. It lasts for 30 minutes.
14. Termination:
This is the final stage of counseling. Termination is in between a counselor
and a client. There should be a good recovery with Cognitive Behavioral Therapy.
Termination seems to be very good.
15. Fallow up:
Follow up involves communicating with the client to ensure his stability and
wellbeing. If rapport is not fully developed with the client then contact with the
referral will be proved beneficial. The client was given instructions to come and meet
his psychologist and psychiatrist once in a week for recheck up and further
counseling. In this case, the client was getting help from family and he was so
cooperative to reach goals in therapy. So he was continuously coming to sessions.