Name: Khadija Akhtar

Semester: 7
Section: B
Subject: Case Report 1&2
Summary

The client is a 42 year old woman who came for a psych evaluation. She has symptoms

of loss of interest in daily life, social withdrawal, loss of appetite, loss of sleep and migraines

whenever she does household chores. She has mentioned the symptoms of depression have

prevailed since her adulthood and became more prominent over the years. She shows to have

insight into her illness and is able to communicate articulately throughout the session. She has a

lack of expressionism in her voice or her face but seems to concentrate and listen. She has

trouble recalling incidents of her childhood or past. Her family is aware of her condition and

seem to be a part of her life but emotionally distanced. In-detail interview was taken along with

Mental Status Examination (MSE) for understanding the prevailing condition of the client.

Beck’s Depression Inventory (BDI-II) was conducted receiving score of 23 which showed

moderate depression. Hamilton’s Depression Rating Scale (HDRS) indicated moderate

depression in severity of 20. The interpretation of Rotter’s Incomplete Blank Test (RISB)

indicated score of 139 for maladjustment which was in accordance with being maladjusted in her

social, personal and work related domains of life. Tentative diagnosis of Persistent Depressive

Disorder (F34.1) with mild anxious distress was given. The therapeutic recommendations

involved trying to establish healthy eating habits, progressive muscle relaxation technique,

minimizing screen time, slowly incorporate exercise like taking walks in her daily life, deep

breathing techniques and daily positive affirmations.

Demographics

Name: Syra Anjum

Age: 42

Gender: female

Marital Status: unmarried

Father: works at construction site

Mother: Housewife

No. of Siblings: 2 sisters

Birth order: youngest

Socio-economic Status: Lower middle class

Family Structure: Nuclear

Heritage: Punjabi

Religion: Islam

Language: Urdu

Education: BA

Source of Referral: self-referred

Verbatim

Symptoms

Low mood

Social withdrawal

Trouble sleeping

Loss of appetite

Migraines

Difficulty performing daily tasks (low motivation)

History of problems
 4 months ago uncle passed away, soon after 2 months later another distant relative passed

away which made her bereave the loss and experience current symptoms of headaches, low

motivation and lack of appetite. Before this the client mentioned she had experienced a lot of

familial deaths that she couldn’t begin to speak of over the past 5 years and she was afraid of

getting close to others as a result of them at this point in her life. She has lost weight since the

past few months.

Personal history

The client did not have any problems during her birth as a child, her mother did not have

any complications pre-natal or post natal as well, she was born a healthy baby. She did not have

any such medical history however she did have a psychiatric admission that lasted 2 weeks

around 2 months ago when her symptoms had worsened for her depression. She has had

symptoms of depression since young adult years, she would think of death frequently in her

family and felt that people dying around her had something to do with her; she felt guilty and

avoided people because she felt misunderstood and judged from an early age. She did not have a

good relationship with her parents and also felt distanced by them. She had a diminished self-

esteem because she was critiqued for not having the same values as her mother. She’s had

periods of suicidal ideation from adulthood as well. When she was 22 she had to get married but

did not come to her own wedding to avoid the commitment. She claims she does not like men.

She says she will be a good person if she keeps to herself and doesn’t interact with others. Syra
has a family history of psychological illnesses like depression from her mother’s side. During her

BA she says she didn’t interact with many people and preferred being by herself or with a few

friends, she was also an average student.

Behavioral observation

The client is not too clean nor tidy but is dressed neatly. She is slow with her body

movements and will try to maintain eye contact. She was being defensive by being in denial

about her behaviour by masking it with good points about herself “main achi insaan hoon kabhi

kisi ko nahi tang karti”. She would listen to you completely before making her next point but she

did not want to be inquired too much. Her concentration and intellect was sound but had trouble

recalling events of history. She would lean in to listen and would look away to pay attention but

would lean away to answer.

Observation during session

 The client was cooperative

 Her voice was monotone and not too eager to answer questions

 She would lean in to listen to what you had to say but she would sit back when she had to

speak herself.
  She wouldn’t explain too much but she would self-victimize in her stories and exhibited

low self-esteem.

 She did not have many hand gestures, she would keep her hands close to her body when

speaking.

 She wouldn’t turn to you completely when answering or talking to you.

Psychological Assessment

Beck’s Depression Inventory (BDI):

The client’s score on BDI II indicated moderate depression of score 23.

Hamilton Depression Rating Scale (HDRS):

The client’s score on HDRS indicated moderate severity of 20.

RISB: (Rotter Incomplete Sentences Blank Test)

Psychological evaluation:

Syra is a maladjusted personality in the domains of life with a score of 139.

 She has seemingly faced familial issues since in item number 11 she wrote “sukh nahi

mila” indicating strains in the relationship. In CBT she mentioned having self-esteem issues due

to her life at home and how she didn’t want to communicate her issues to anyone. She has used

the same answer for referring to her father in item 35.

In her social domain she appears to be withdrawn from people. In item 4 she mentions

she enjoys being home. She mentions she doesn’t require anyone in item 25. She has an aversion

from males in her life and faces commitment issues for all her relationships in every domain

since she has a dissonance from the way people cannot understand her and how they don’t try to.

She mentions about this in item 10 where she is afraid of people

She is seen to be a religious person but she isn’t engaged in her faith and so has more

doubt than reliance or hope. She downplays herself and her worth as a human, she doesn’t

consider or expect a lot from herself and is demotivated from doing tasks that allow self-care,

she mentions in item 12: “main faaltu hoon” and item 37 “main a’am aurat hoon”

Syra in her overall analysis is seen to be a person with low self-esteem and poor social

relations with others, her insight into herself is low with a negative self-perception. She doesn’t

have a lot of faith in her future and tries to avoid thinking of it.

Prognosis

The client’s symptoms seem to be on the severe side because of the duration of the illness

but currently they are moderate. She seems to be aware of her symptoms being of fair intensity.
She believes she will manage with time. Her family is aware of the condition but seem absent

from her reports of their support for her.

Tentative Diagnosis

Persistent Depressive Disorder (F34.1) in partial remission with mild anxious distress. It is of

late onset with intermittent major depressive episodes, with current episode

Diagnostic criteria for Persistent Depressive Disorder

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective

account or observation by others, for at least 2 years. Note: In children and adolescents, mood

can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating.

2. Insomnia or hypersomnia.

3. Low energy or fatigue.

4. Low self-esteem.

5. Poor concentration or difficulty making decisions.

6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the

individual has never been without the symptoms in Criteria A and B for more than 2 months at a

time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia,

delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic

disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

Therapeutic recommendations

 Progressive muscle relaxation (PMR):It is a technique where a person tenses and

relaxes different muscles in their body to relieve tension and induce a relaxation

response.

 Deep breathing exercise: Deep breathing (sometimes called diaphragmatic breathing) is

a practice that enables more air to flow into your body and can help calm your nerves,

reducing stress and anxiety.

 Establishing healthy eating habits and avoiding junk food

 Establishing healthy exercise habits such as going for walks

 Daily positive affirmations to improve self-esteem

Appendix