ASSIGNMENT # 01

Submitted To: Miss Anum

Course: Internship Case
Submitted By: Beenish Maqbool
Reg# NUML- F21-28679

DEPARTMENT OF PSYCHOLOGY

NATIONAL UNIVERSITY OF MODERN LANGUAGES, RAWALPINDI

FALL-2021
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Table of Contents

Topic:- Case History......................................................................................................................2

Demographics.................................................................................................................................2
History of presenting Complaint..................................................................................................3
According to the patient:...............................................................................................................3
According to attendant:................................................................................................................3
History of present Illness...............................................................................................................3
Past psychiatric history.................................................................................................................4
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Topic:- Case History

Demographics
Fozia is a 33 year-old divorced, living with her family, Having 4 brother and 3 sisters in
siblings, doing Masters and teaching in nearby school. Fozia was referred to the Fouji
Foundation Hospital by her general practice with a 1-week history of temperature and
Compulsions with hand washing, the symptoms of which were so bad that she was forced to
leave her husband’s house.

History of presenting Complaint

According to the patient:

 I am having temperature from one week

 If I do something I feel like I should do it again. I do everything for even times.
 I do my hand wash daily for maximum 35 times since 3years.
 I think that if people get to know about my condition they may mock at me so I keep my
self isolated most of the times.
 I always crying being isolated
 I used to experience negative thoughts and somehow suicidal thoughts as well including
aggression

According to attendant:

 My daughter is washing his hands frequently.

 She is checking everything for twice.
 She blames herself and her parents for everything.
 She is sitting alone.

History of present Illness

Client was apparently alright before 3 years. She had fight with her mother after her
divorce because she thinks her mother is responsible for all this matter. She is feeling stressed for
the rest of her life. She is taking medication for the mental illness from a local doctor. She has
compulsions with washing her hands after 30minutes for 10 to 15 minutes, even her hands
become red and the observer can see the severe rashes between her fingers. She is crying always
and facing negative thoughts.

Past psychiatric history

Client’s one of the siblings had some mental issue (undiagnosed) and they lost him
somewhere, he ran out of the house. Other than there is no family history of any mental illness.
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CHILDHOOD HISTORY

It was reported by mother that client was well mannered. His developmental milestones
were age appropriate. She was good in childhood, having friends and use to play with them.

EDUCATIONAL HISTORY

The client is 33 year’s old woman with 14years educational history and also doing
Masters. She just stopped her teaching due to her thoughts and low self-esteem. Before that she
was outstanding in his studies.

FAMILY HISTORY

The client belong to middle class family and lives in nuclear family. The client has one 4
brothers and 3 sisters. She is last born in the family. Her father has his own business. Her mother
is uneducated and house wife. Client’s family is not supportive and loveable according to client.

SOCIAL HISTORY

Client engages with siblings in talk moments. But, from now she start avoiding others
and stop talking to her friends.

SEXUAL HISTORY

She don’t have good relationship with her husband so he gave her divorce. The client
reported that she do not have any other sexual or abusive history.

SUBSTANCE ABUSE HISTORY

The client has no history of substance abuse.

PREMORBID PERSONALITY

Mother reported that she was good before 2 to 3 years when she was in school. She
studied well and respond actively to everyone in school while teaching and at home with family
as well.

PSYCHOLOGICAL ASSESSMENT

Informal Assessment Formal Assessment

Clinical Interview OCS (Y-Bocs)
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Behavioral Observation Beck Depression Inventory (BDI)

Mini Mental State Examination

INFORMAL ASSESSMENT

Clinical interview

F.F’s informant (mother) reported that client’s problem started 2 years ago. She took him
to the Fouji Foundation Hospital for treatment. She had satisfactory relationships with her
siblings but unsatisfactory relationships with mother. She was not happy with her mother. Her
mother didn’t tell her in-laws about her problem and they divorced her because of which there
were conflicts among them. She reported that her mother spoiled her life.

She had temperature from 1 week. She engaged in self-talk, self-laugh and
suspiciousness. She also had low mood. She also had shivering hands as he felt fearful while
communicating with others or who came to see her. Furthermore, she blamed her mother for
everything.

BEHAVIORAL OBSERVATION

Throughout assessment sessions she didn’t face difficulty in maintaining his attention and
concentration. She sat in one pose and showed clear expression. she was cooperative and did not
distract easily. she had blunt effect and showed minimum level of alertness. Her volume was
good, and tone was little bit rigid while talking to her mother. Her thought process was not
satisfactory as she was switching from one positive story to another negative one regarding how
her mother spoil her life. The client had insight and judge-ment about her problem.

MENTAL STATE EXAMINATION

General appearance
Appearance was normal.
Behavior
Behavior was cooperative, had insight of illness.
Speech
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Speech was fluent.

Mood
Sad & Depressed
Thought
Irrational thought. Negative thought about life.
Perception
Body pain and negative feelings regarding mother. She is blaming others for everything having bad in her
life.
Cognitive state
Cognitive state is normal, aware about person lace and time.
Insight
Having enough insight of illness.

FORMAL ASSESSMENT (Psychometric Properties of Test)

Yale–Brown Obsessive–Compulsive Scale (YBOCS)

The YBOCS (Goodman et al., 1989) is the gold standard structured interview measure
for the assessment of obsessive–compulsive disorder (OCD). It is currently in its second edition,
the YBOCS-II (Storch et al., 2010). It gives equal weighting to obsessions and compulsions and
can be scored for any obsessive or compulsive symptom or symptoms, rates severity of OCD-
related symptoms and behaviors and includes a checklist of 54 common obsessions and
compulsions, as well as items querying common associated factors. She scored 18 for
Obsessions and 18 for Compulsions which indicates that she has extreme level of OCD.

Beck’s depression inventory (BDI):

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures
characteristic attitudes and symptoms of depression including mood, guilt, punishment, crying, social
withdrawal, insomnia, fatigability, loss of appetite, increase in weight. My client score 24 on beck
depression inventory, which indicates that he is suffering through moderate depression. She marked tick
on many statement that shows his loss of interest in life and in other people, and depressed mood. My
client has regret for her past and feels guilty most of the time, she is disappointed from herself and feel
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hopeless about the future. By viewing all the statement on which she marks tick it is obvious that she is
suffering through moderate depression.