Case HISTORY Format

Internship (clinical psychology)

BIO Data …………………………………

Name …………………………….Asad

Age …………………………………32

Sex ………………………………….Male

Education………………………..MBA

Profession……………………..Business

Marital status ……………………married

No.of children ……………………2

No.of sibling ……………………….4

Birth order ………………………….1

Source of information ………………his wife

Place of referral……………………..civil hospital

Resident of:…………………………………

No of treatment …………………………

Out patent /Admission Date …………………..29 October 2017

PRESENTING PROBILMS

Rose was a 39-year-old woman, mother of two children, and recipient of employment insurance. She
decided to consult a psychologist ito receive help with her severe CH problem. She revealed that she
had suffered from this problem for 20 years now and was no longer able to face it on her own. She had
never undertaken psychotherapy for this specific problem. However, she had tried several
pharmacological treatments , which were not effective. She feared that her problem would become as
severe as her father’s problem, for which he had never received help. She described her father as a
packrat, cluttered in a house full of junk.

INTITAL BEHAVIOR OBESERVATION

My client has very cooperative with me .his behave was normal and my all question
giving the answer very carefully. He was communicate very strongly because he went to
treatment.

HISTORY OF THE PROBLAMS

PSYCHOLOGICAL COMPIANES

mpact. Rose emphasized that her hoarding behavior had had many consequences in her life. She
specified that her situation had led her to avoid inviting friends and family to her house because
she feared that they would judge her negatively. She said the overcrowding in her house
interfered with her daily activities, as approximately 75% of the household was difficultly
accessible. Clutter. She complained primarily of her bedroom and kitchen being cluttered with
food cans, empty boxes, little appliances, and so on. However, she admitted that her exterior
shed as well as the storage space that she rented close to her house were full with other objects.
Regarding the kitchen, she mentioned that the stove was covered with items, which did not allow
her to cook. Concerning her bedroom, she said that there was no more room in her closet and
 therefore that it was not very functional. A part of her bed was also covered with clothes and
empty boxes, which seemed to cause her great distress because she conceded that she was not
capable of discarding any of these items at this time. Furthermore, she had received a warning
letter from her landlord threatening her to evict her if she did not take action. During the
pretreatment evaluation, pictures from different rooms of the house were taken. There were no
rooms that were easily accessible, with the exception of the bathroom. Furniture surfaces were
often covered (dressers, washer–dryer appliances, tables, desks, chairs, etc.) and floors were
completely or partially crowded by objects. Closets were no longer functional because many
items were piled up. Half of the bed was cluttered and the bedroom floor was covered with
magazines, newspapers, bills, and post-it notes. Boxes and items piled up everywhere made most
sections of her home inaccessible. It was impossible to eat in her dining room because the chairs
and the table were buried under all the items she has collected over the years. Finally, boxes,
televisions, lamps, and garbage bags were stacked and covered her entire basement floor. Rose
admitted many rooms of her house were unusable because of this clutter.

PERSONAL HISTORY

 BIRTH;

He was born in 1985 in 9 April

 CHILDHOOD;

Client said that most of his life he is not good enough and less worthwhile than others.

He stated that during his childhood he was shy and remembers feeling sad and anxious a great
deal of the time; he didn’t have many friends. Client said this was mainly due to believing that he
was fundamentally flawed, different from others and didn’t fit.

Client described his father as being highly critical, unaffectionate and distant. He said his father
was prone to mood swings and was often angry and unpredictable. Client said he felt very
anxious around his father and would avoid being in his presence.

He said he believed his father did not love or care for him.

 EDUCATIONAL HISTORY
His school life was normal and he was a average student although he faced some problems
during his school life. He is criticized by his father that’s why he could not show better
performance

 VOCATIONAL HISTRORY

Client said he has self-doubt and a growing lack of confidence in work and social situations
when trying to develop relationships. In business and social interactions, he becomes anxious
and believes he is unlikable and not good enough. The client stated that he continuously worries
about failing and how catastrophic his future will become. But he is intelligent enough inspite of
all these problem due intelligence he become a successful businessman.

 MARIATAL HISTORY

Married and reports that his marriage is very stable and his wife is understanding and
supportive; the family dynamic is egalitarian. They have two children.

 MEDICAL HISTORY

Major depressive disorder – recurrent, with a co-morbidity of Social anxiety with

associated features of Generalized anxiety disorder

 RELIGIOUS HISTORY
 Islam
 PSYCHATRIC HISTORY
Client has had previously seen by a psychiatrist who suggested a diagnosis of a Major
Depressive episode with associated features of anxiety, the client was prescribed
medication.
 FAMILY HISTORY
The client is belong to low level family of bhagetpur, a village of duska. Total members of the
family were 7and his father was only the source of income. Expenditures of their family was
more than his father income so he faced many problems during his childhood.
 Past medical/ psychiatric history:
Depression for 9 months several years ago treated by means of antidepressants and ECT. That
affected her memory badly.
  Assessment
Since her childhood she was facing lots of psychological problem with behaviour of her father
who used to behave badly, strict and harsh to client. Mr. A remembers that she saw her mother
mostly weeping and unhappy with her life and due to her own problems she also never tried to
give due attention, love and care to her son (Client) and she also behaved badly to Mr. A. he was
continuously ignored by his parents due to which badly effect the personality of Mr. A.
 Behaviour
Focus on notes, focus sensation, speak fast, and plan on ways to shorten the presentation, look
for ways to escape.
 Clinical interview
I have asked open ended question so that client could share his problems easily. I made cross
questioning with him about his past history of his childhood and I focused behaviour of his father
specially in his childhood. In next sessions I asked him to write about father . while he was
writing, he felt very difficult to write about his father because his all symptoms were appeared
like burden on her shoulder which showing resistance of her unconscious level of mind. Next
day when I made cross questioning after analyzing her writing and her behaviour, during this
session of cross questioning, her all symptoms were again strongly appeared although
consciously he tried to avoid any negative remarks about his father (this because of traditions,
customs and religiously most people can’t be able to say anything negatively about their
parents). In next session, I continued cross questioning with him about his father and at last he
admitted that he did not like his father at all since his childhood. he also admitted that he disliked
his father since his childhood and he has been keeping negative feelings and hate about his father
since childhood even sometimes he had in her mind some abuses in very bad wording but he
never expressed these sought of feeling to anyone else tried to get rid of these negative feelings
consciously. After analyzing his writing, I made cross questioning to him in next session and it
was known that the lack of confidence associated with his father’s ignorance.

MSE
 Appearance and behavior
My clint was a good looking 33 years old man. He was well dressed
  Talk At our first meeting, Jim was very shy and averted his eyes from me, but he did
shake hands, respond, and smile a genuine smile.  A few minutes into our session and Jim
was noticeably more relaxed and start to answering my question more comfortably.
Mood
he was in very sad mood
Thoughts His strong thinking and belief that he wouldn’t do well at social interactions and in
social events. They think I am boring, I have nothing interesting to say, they don’t really like, I
sound stupid.
Perception
His biggest real-life fear, speaking to another person in public, was not really a speaking
problem; it was an anxiety problem.  There was nothing wrong with Jim’s voice, his reading
ability, or his speaking ability. My client was a bright man who had associated great anxiety
around these social events in public situations.

Subjective observation
My client presented a very typical case of generalized social anxiety.  His strong
anticipation and belief that he wouldn’t do well at social interactions and in social events and his
belief came true: he didn’t do well.  The more nervous and anxious he got over a situation, and
the more attention he paid to it, the more he could not perform well.  This was a very negative
paradox or "vicious cycle" that all people with social anxiety get stuck in.  If your beliefs are
strong that you will NOT do well, then it is likely you will not do well.  Therefore, thoughts,
beliefs, and emotions need to be changed.
So I sugest him to change his belief and thoughts more over I give him confidence that he can do
well in his life. He can make friend and solve all his problems
Case formulation
Client was a patient of generalized social anxiety. Basic reason was behavior of her father.
Clients mother became unwell and died of cancer when he was in his late teens. The gap between
his father, his brother and himself grew to the point. He was ignored by his parents. Which is the
basic reason of his anxiety.
Treatment could not be possible without deep analysis of his unconscious level of mind that what
was the stimulus and references for fear instinct.
It was necessary to explore all positive possibilities about his stimulus and references to make
him personality unsuppressed and make it at normal.
When all other positive possibilities were realized by her unconscious level of mind and negative
association with stimulus and reference removed so there was no need of any shelter so the role
of shelter was also wiped out.
Minimum 5 sessions per week required for treatment because if there was gap between each
session and next session may not be conducted on consecutive day, the fear which was explored
in one session may again suppressed and resistance level of the client may also again suppressed.
So continuity in sessions without having gap is very important in treatment for proper cure.

Suspected problem
Major depressive disorder – recurrent, with a co-morbidity of Social anxiety with associated
features of GAD
Intervention
DSM-IV was consulted to decide the nature or type of disorder.
In the subsequent sessions Mr A. was asked to write on specific topics. Cross-questioning was
carried out over the ideas mentioned in the writings.
"It is expected that the CBT herapy would effectively cure the generalized social anxiety from
which the above referred person Mrs A. is suffering."

Anti-anxiety medication.