Psychological Assessment Report:

Name: Sana Irshad

Date of birth: 20/04/1997

Father’s Name: M. Arshad Asi

Dates of Assessment: 16.04.2018-17.04.2018

Examiner: Noor-ul-ain haider

 Identifying Information:

Ms. Sana Irshad, 21 years old, single, she is last born among siblings (1 sister, 2 brothers). She is
doing DHMS, 3rd year from private institute. She belongs to middle socio-economic class,
Punjabi speaking, Muslim family, living with parents and resides in Rawalpindi.

 Referral sources & presenting complaints:

Ms. Sana was referred by a psychiatrist for psychological assessment and psychotherapeutic
work-up. Her presenting complaints were headache, palpitations, irritability, lack of
concentration and crying spells.

 Interviewed Information:

Client reported that, her problems were started 3 years back when her one of neighborhood aunt,
accused her for having telephonic relationship with some boy, that aunt asked her to show her
truthfulness by placing her hand on Holy Quran. As she denied the blame. She placed her hand
on Holy book and that situation was dismissed. Only her mother and sister were present and
none of any male member has knowledge of this event till to date. Later on, she revealed that she
had telephonic conversation with same boy and she only recused herself in that situation. With
the passage of time, her remorse and guilt increased. She started having conversion fits which
lasted for about 6 months. She took treatment from psychiatrist and recovered to some extent.

Her symptoms had a relapse one and half years ago, when she went with her family to perform
Umrah. According to her, there was a non-Muslim lady at Madinah, who was involved in some
blasphemy activity and was disrespected to the Holy book. It was triggering event for relapse, as
according to her she also showed disrespect to Holy book 3 years back. She is having
apprehension, guilt’s and episodes of low mood, throughout the day. Her mother and sister are in
confidence of knowing all details of her illness’s precipitating and maintain events. Both of them
are supporting her for management of her symptoms.

According to client, her studies and family life is affected greatly due to her illness.
  Tests Administrated:
1- BGT- Bender Gestalt Test.
2- HFD- Human Figure Drawing Test.
3- SPM- Standard Progressive Matrices.

1) Behavior during Testing Sessions:

It seems that Miss Sana was relaxed through tests sessions. She was cooperative and motivated
to perform on Psychological tests.

2) Psychological Evaluations:

On Psycho-neurological screening tests named Bender Gestalt, client’s visual motor perceptual
ability seemed appropriate yet it depicts a strong desire for security and re-assurance.

Standard Progressive Matrices (SPM) which is a test of abstract reasoning (non-verbal) that is
one aspect of intelligence, her abstract reasoning ability falls within intellectuality average range.

Projective Testing reveals that she is having strong desire for social approval. Yet elements of
apprehension and anger outbursts may be prevalent.

Protocol revealed that, she seemed to have difficulty in controlling her emotions, or probability
of having low frustration tolerance along with poor impulse control may be seen.

 Recommendations:

Treatment should be aimed at applying behavioral techniques include relaxation, interpersonal

skills, improvement, cognitive restructuring and working on un-finished businesses of past.

 Conclusion:

Miss Sana protocols indicate that she has apprehensive and aggressive feelings. Having
conflicting aspects in her past which are creating trouble in present time. In conclusion, her
symptoms may direct a diagnosis of general anxiety along with depressive themes.

Supervisor Examiner

Dr. Noshi Iram Zaman Miss Noor-ul-Ain Haider

Assistant Professor PHD Scholar (PP)
BUIC-PP BUIC
Treatment plan:

Based on the format of Prochaska model

Pre-contemplation:

 Detailed History taking

 Psychometric assessment
 Insight checking
 Rapport building

Contemplation:

 Imparting insight
 Psycho education
 Goal making
 Re- assurance encouragement for active participation in therapeutic session.
 Therapeutic alliance by addressing client’s problems.
 Positive and negatives of taking therapy.
 Discussion or requirement of medication, if any.

Preparation:

 Little introduction to therapeutic techniques

 Identifications of barriers and problems
 Targeted symptom discussion step by step.
 Misconceptions and eradication of confusion regarding therapy, if any.

Action:

Techniques:

 Crises intervention, Psycho-education and self-awareness reassurance.

 Deep breathing exercise
 Progressive muscle, relaxation exercise.
 Hypnotherapy- safe place induction
 Self-hypnosis
 Eidetic psycho therapy (re-experiencing the traumatic event).
 Metaphors
 Rationalization & Insight regarding symptoms.
 Feedback sessions.
Maintenance:

 Re-assurance of working performance of client.

 Addressing the concerns, if any.

Relapse:

 Relapse assistance,
 Checking the pre-cursors for possible relapse.