Paras Report-1

CLINICAL CASE STUDY
Internship Report
Paras Hameed
Roll no. FA19BV009
BS Applied Psychology
Session 2019-2023
Department of Applied Psychology
Islamia University of Bahawalpur
Rahim Yar Khan Campus

DECLARATION
I state that the project report CLINICAL CASE STUDY is based on my own work
carried out during the course of our study under the supervision of Dr. Rana
Muhammad Naeem I assert the statements made and conclusions drawn are an
outcome of my research work.
Paras Hameed.
Date………… Signature of Department: …………………

APPROVAL CERTIFICATE
This research entitled “CLINICAL CASE STUDY” submitted by Paras Hameed

(2021-23) is partial fulfillment of the requirement for the degree BS. Applied
Psychology, Islamia University of Bahawalpur, Rahim Yar Khan Campus, is hereby
approved.
SIGNATURES
INTERNAL EXAMINER____________________
EXTERNAL EXAMINER __________________
HEAD OF DEPARTMENT ___________________
DATE _________________
ACKNOWLEDGEMENT
First of all, thanks to ALLAH ALMIGHTY who gave me strength and for providing
me with everything I needed to complete this report.
I am highly obliged to my incharge in hospital Dr. Rana Muhammad Naeem and I

would especially acknowledge her for her teaching expertise.
I would like to express my gratitude towards my parents for their kind cooperation
and encouragement which helped me in the completion of this report.
Table of Contents
Case no. 1…………………………………………..Substance use
Case no. 2……………………………………………………..Schizophrenia
Case no. 3…………………………………………………….Schizophrenia
Case no. 4………………………………………………………Bipolar 1 Disorder
Case no. 5………………………………………………Major Depressive Disorder

Case#1
Identifying Information
Name: W. R
Age: 30 Years
Gender: Male
Education: Inter-mediate
Marital Status: Single
Sources and Reason for Referral
Client was referred by psychiatrist, from Drug Rehabilitation Center, sheikh zyed
hospital for psychological assessment and management of the problem of client.
Presenting Complaints
Duration Complaints
‫اٹھارہ سال سے ۔‬ ‫چیزے چرانا۔‬
‫نو سال سے ۔‬ ‫نشا کرتا ہے ۔‬
‫تین سال سے ۔‬ ‫اداس رہتا ہے ۔‬
‫بیس سال سے ۔‬ ‫توجہ چاہتا تھا ۔‬
Observational assessment:
The client was an educated heighted man with average weight. His personal hygiene
was good and was wearing neat and tidy clothes. He appears active, energetic, and
was in good mood. He was maintaining good eye contact. His sitting posture was
much relaxed. The client seems quiet motivated to seek treatment.
History of present problem:
According to the client he started stealing for about 18 years ago. At the start he just
use to steal the things that were client’s needs, as according to him he belongs to a
lower middle class family and his parents cannot fulfill his expenditures.Other than
his parents were very neglecting, and no attention was provided to the children, so the
client started to make friendships outside home. He uses to go to smoker club and
internet cafe with his friends and spend hours there. According to the client he seeks
pleasure and excitement in everything that he does with his friends. He had realized
that his company is not good and appreciated by society, but he don’t want to leave
then as he was getting all the emotional and social support from them, and don’t
wanted to lose the support and break the circle at any cost.He started smoking
cigarette in 2003 under the influence of his company.He moved a step forward and
stopped smoking as for him it was not the source of relief, and pleasure for him. In
2005, he started taking Hash, he use to take it in friend’s gathering, as he was already
vulnerable of it. According to the client, that was the best time of his life when he got
emotionally attached with a girl to whom he decided that he will marry in the future,
but unfortunately the relationship lasted for 4 years, and they had a break-up. Now it’s
been 3 years of client’s breakup but he is unable to forget her, and also is unable to
move forward in life. After the break up in 2012, he stopped taking hash and started
taking heroine that provided him more relief than hash, as he reported.
Personal history
Birth and childhood
Birth of the client was normal as she heard from his mother. There were no
complications reported by the client. He achieved all his developmental milestones at
appropriate age levels. No significant illness was reported in his childhood.
Family history
The client belongs to a lower middle class family. Total family members is five. He
has two sisters and one brother. He lives in a nuclear family system. Client’s father is
a government servant, and is by nature a strict person and the authoritarian figure of
the family.
Educational history
Throughout the period, client’s schooling was of a government school. He was a good
student, and always got good grades. He likes reading and exploring different books.
His education was till intermediate, he was unable to continue his studies because the
family cannot afford the further expenditures.
Psychological assessment
In order to assess client’s problem two types of assessment was carried out that is:
1. Informal Assessment
1 Subjective Rating of Symptoms
2. Formal Assessment
The formal assessment comprised of:
1. Drug abuse screening test(DAST)
Total item 22
Obtained score 21
Category Sever
Total time taken 15 minutes
Quantitative interpretation
Sum scores for all 22 items, higher scores indicate higher addict of substance use.
Scoring
4 to 7= normal
16 to 20= moderate
20 to 22 = severity
According to this scale he had sever level of addiction of substance use.
Qualitative interpretation
The DAST was administered to know the previous severity level of the problem of the
client when he was involved in substance abuse. Client’s score on DAST is 22, that
falls in the maximum category of range. The score suggests that the client was in
severe level of problem before the withdrawal occurs. Client’s score suggest his
marked decline in functioning, relationship problems, lack of self-control, and
involvement in illegal activities like stealing. Client’s background information is also
supporting the test results.
Provisional formulation
It is provisionally hypothesized that the client has Cannabis withdrawal and inhalant
intoxication effect, as he was using multiple addictive substances, and after leaving
drugs he had showed withdrawal symptoms for a month.
Familial factors
• low socioeconomic status
• conflicting home environment
• neglecting him
Assessment
• subjective ratings
• The drug abusing screening test(DAST)
• Perceived substance use Scale
Management
1. Talk therapy
2. CBT
3. Motivational interviewing
4. Yoga and medication
5. Family therapy
Counselling plan
The counselling plan was on the basis of multiple substance use management.
Psycho education
Psycho education is offered to people who live with a psychological disturbance. A
goal is for the patient to understand and be better able to deal with the presented
illness. Also, the patient’s own strengths, resources and coping skills are reinforced, in
order to avoid relapse and contribute to their own health and wellness on a long-term
basis.
Outcome
After comparing pre and post assessment of subjective rating scale it is clear that
outcome is positive now withdrawal the substance abuse behavior moved from
moderate to low level and with more time it will extinct.
Recommendations
• Change environment of home.
• There should be more care providers for teaching how to live in society.
• There should be better relationship with parents
Diagnosis
Drug addict with multiple substance use.
Case formulation:
The client was 30 years old male was referred with the complaints of stealing habit,
carving of drug, sadness, worthlessness, and self-dislike passivity and muscle pains.
The history of client suggests that his childhood was not good and he didn’t have
attention, love and affection from his parents, and was a neglected child. He also
belongs to a lower middle class family where his needs and desires were not fulfilled.
These factors proved to be the predisposing factors of client’s problem. The
background information of client showed that the client doesn’t take the responsibility
of anything or issue to himself, as he continuously blame his parents and external
environment for his problem. The client is not ready to accept his fault, and for social
approval he wanted people to feel sorry about him.
Case#2
Identifying data:
Name : M. I
Age : 19
Gender : Male
Grade : 12th
No. of siblings : 3
Birth order : 3rd
Father : alive
Mother : alive
Informant : client father and mother
Source and reason of referral
The client as referred by OPD of sheikh zayed hospital to me for taking a detailed
case history on her sudden mood switches from happy to sad and anger to calm. Her
disturbed morning and night routine for the purpose of psychological assessment and
counselling of her problems.
Presenting problems
Complaints as reported by client :
Duration Complaints
‫دو سال سے ۔‬ ‫غلط یقین رکھنا ۔‬
‫ایک مہینے سے ۔‬ ‫عجیب وغریب حرکتیں کرنا ۔‬
‫ایک مہینے سے ۔‬ ‫بے معنی بات کرنا ۔‬
‫دو ہفتوں سے۔‬ ‫غصا زیادہ آتا ہے ۔‬
‫ایک مہینے سے ۔‬ ‫اپنی صفائی کا خیال نا رکھنا ۔‬
Observational assessment
Client was 19 years old boy. She entered in session room with his family. The client’s
appearance was not well dressed, not neat and clean. She looked bright but
somewhere deep inside was worried.
History of present problem
He admit in hospital before 1 month ago. 2 years before first time he had a delusions
according to family his relationship with family is good. He is very obedient.
According to him the family would not buy him things. He is going to school on daily
base. Before came to hospital he had aggression, family said the son used to like his
cousin and after 2 years he got engaged then he went to a depression and later he will
be in a bad condition and now his cousin become married and he is sick again. His
cousin says they have a issues with his uncle.now the patient is aggressive and he
want to go home also he had a disillusion. he had a disorganized speech and irrelevant
talk. He is not self hygienic till from one month he did not taking shower.
Personal history
Birth and childhood
Birth of the client was normal as he heard from his mother. There were no
complications reported by the client. He achieved all his developmental milestones at
appropriate age levels. No significant illness was reported in his childhood.
Family history
He was born as 3rd child in family. His father and mother are alive. He is a
responsible boy. His family is financially not good. His relationship with family is
good.
Educational history
She is studying in 12th grade. His education is disturbed due to his illness. Although
he is good in study.
counselling plan for the client’s problem. Following list shows the assessment plan
for the client.
Informal assessment
Subjective ratings
Formal assessment
Schizophrenia questionnaire (PANSS)
Quantitative scoring
Total item 30
Obtained score 77
category Moderate
Sum scores for all ten items, higher scores indicate higher delusion problem.
Scoring
65=normal
75=moderate
85=sever
According to this scale he has moderate level of aggressive behavior and delusions
Subjective rating scale on schizophrenia is my self creates scale according to client’s
situation. The rating he gave to each problem describes nature of problem and his
personality. The rating he give on problem 77 that had a moderate schizophrenia he
had a aggressive behavior and delusion And on daily routine he is going through
major problems because of it and it is also affecting his mental health as well as
physical health.
• On the basis of initial information, it is hypothesized that client have behavioral
problems such as aggression and delusion and also disorganized speech.
• Client is also suffering from high stress level and this is causing aggressive
behavior.
Familial factors
• attitude of relatives
Assessment
• schizophrenia Questionnaire (PANSS)
• Perceived Schizophrenia Scale
Management
1. Individual therapy. Psychotherapy may help to normalize thought patterns.
2. Social skills training. This focuses on improving communication and social
interactions and improving the ability to participate in daily activities.
3. Family therapy.
4. Golden rules of sleep.
Counselling plan
The counselling plan was on the basis of schizophrenia and aggressive management.
Psycho education
1. Deep breathing exercise on stress and Anger management
2. Problem solving
3. Coping skills
Outcome
outcome is positive now aggressive behavior moved from moderate to low level and
with more time it will extinct.
Recommendations
• There should be better plan to support the children.
Diagnosis
Schizophrenia
Case Formulation
According to DSM V, schizophrenia disorder with psychotic . A psychotic episode is
a state of mind characterized by disorganized speech, disillusion, and not hygienic
also aggressive behavior over a sustained period of time. It's an extreme change in
mood and cognition that can interfere with school, work, or home life. According to
behavioral theorists the maintaining antecedents play an important role in
strengthening any behavior. Setting events are environmental conditions that elicit a
behavior.According to psycho dynamic perspective they claim that when parents fail
to satisfy a young child’s need for maturate the child is likely to grow up depending
excessively on others for help and comfort. In the present case the client’s family's
and parents attention's towards the patient was indifferent. His parents always bond to
him in home and he did not makes the friends.
Case#3
Identifying data:
Name : M
Age : 27
Gender : Female
Grade : non
No. of siblings : 12
Birth order : 1st
Father : alive
Mother : alive
Informant : client herself
The client as referred by ward of sheikh zayed hospital to me for taking a detailed
Presenting problems
Duration Complaints
‫ایک مہینے سے ۔‬ ‫ نہیں آتی ہے ۔‬€‫نیند‬
‫دو ہفتوں سے ۔‬ ‫غصا زیادہ آتا ہے ۔‬
‫ایک مہینے سے ۔‬ ‫غیر متعلقہ بات کرتا ہے ۔‬
‫ایک مہینے سے ۔‬ ‫ڈر لگتا ہے ۔‬
‫ایک مہینے سے ۔‬ ‫شک کرتی ہے ۔‬
‫ایک ہفتے سے ۔‬ ‫سر درد کرتا ہے ۔‬
‫دو ہفتوں سے ۔‬ ‫بھوک نہیں لگتی ہے ۔‬
Client was 45 years old women. She entered in session room with fear. The client’s
appearance was well dressed, neat and clean. She looked aggressive but somewhere
deep inside was worried.
History of present problem
The client came to hospital with his husband and mother. She had a fear she did not
want to stay in hospital she want to go home she is very aggressive. She said please
forgive me my family nothing to do for you.The client mother said my husband have
a enemies they want to kill us. Mother said they set our house on fire once than she
became more afraid she says everyone wants to kill us. that’s why he became afraid
from his husband enemies Her mother said husband relationship with wife is not
good. The client not want to told something she is very suspicious every person is
want to kill him. She had also a family issues to take to property.she denial she said
am not ill am fine Client relationship with children is good. Client said she was
admitted previous year in fifth month with this condition. She is not self hygienic. She
had a headache all the time when psychiatrist talk to him or any family member she
response with irrelevant talk.she had a lack of sleep because of fear.she had a very
aggressive behavior with husband. She had a lack of appetite.
Personal history
Birth and childhood
Birth of the client was normal as she heard from her mother. There were no
complications reported by the client. He achieved all her developmental milestones at
appropriate age levels. No significant illness was reported in her childhood.
Family history
She was born as 1st child in family. Her father and mother are alive. His family is
financially not good. His relationship with family is not good.
Educational history
She is not educated.
Informal assessment
Subjective ratings
Formal assessment
Schizophrenia questionnaire (PANSS)
Quantitative scoring
Total item 30
Obtained score 75
Category moderate
Sum scores for all ten items, higher scores indicate higher delusion problem.
Scoring
65=normal
75=moderate
85=sever
According to this scale he has moderate level of aggressive behavior and delusions
Subjective rating scale on schizophrenia is my self creates scale according to client’s
situation. The rating she gave to each problem describes nature of problem and his
personality. The rating she give on problem75 that had a moderate schizophrenia he
had a aggressive behavior and delusion And on daily routine she is going through
major problems because of it and it is also affecting her mental health as well as
physical health.
problems such as aggression and suspicious.
behavior.
Familial factors
• husband conflicts with other
Assessment
• schizophrenia Questionnaire (PANSS)
• Perceived positive and negative syndrome Scale
Management
1 .Individual therapy. Psychotherapy may help to normalize thought patterns.
2. Social skills training. This focuses on improving communication and social
interactions and improving the ability to participate in daily activities.
3. Family therapy.
4. Golden rules of sleep.
Counselling plan
The counselling plan was on the basis of schizophrenia and aggressive management.
Psych education
4. Deep breathing exercise on stress and Anger management
5. Problem solving
6. Coping skills
Outcome
outcome is positive now aggressive behavior moved from moderate to low level and
with more time it will extinct.
Recommendations
• makes better relationship with others.
Diagnosis
Schizophrenia
Case Formulation
According to DSM V, schizophrenia disorder with psychotic . A psychotic episode is
a state of mind characterized by disorganized speech, disillusion, and not hygienic
also aggressive behavior over a sustained period of time. It's an extreme change in
mood and cognition that can interfere with , work, or home life. According to
behavioral theorists the maintaining antecedents play an important role in
strengthening any behavior. Setting events are environmental conditions that elicit a
behavior.. In the present case the client’s family's and parents attention's towards the
patient was indifferent. She had a conflicts with husband
Case#4
Identifying data:
Name : W.A
Age : 18
Gender : male
Grade : 8th
No. of siblings : 3
Birth order : 2nd
Father : dead
Mother : alive
Martial status: married
Informant : client mother
Presenting problems
‫ سے زیادہ ۔‬€‫ایک مہینے‬ ‫غصا زیادہ آتا ہے ۔‬
‫کبھی کبھار ۔‬ ‫بھوک نہیں لگتی ہے ۔‬
‫ہر وقت ۔‬ ‫چڑ چڑاپن رہتا ہے ۔‬
‫ایک مہینے سے‬ ‫بہت چست رہتا ہے۔‬
‫ سے زیادہ ۔‬€‫ایک مہینے‬ ‫اپنے آپ کو عظیم الشان سمجھتا ہے۔‬
‫ سے زیادہ ۔‬€‫ایک مہینے‬ ‫نیند نہیں آتی ہے ۔‬
‫کبھی کبھار ۔‬ ‫بہت بولتا ہے ۔‬
Client was 18 years old boy. He entered in session room with aggressive behavior.
The client’s appearance was well dressed, neat and clean. He is very hyperactive.

The client is 18 years old . his father is died before 2 years ago his sister is big than
him he is on 2nd number and also big brother his family faces many financially crises.
His elder brother is leave the study because after the death of father he can not afford .
the client education is 8th according to his mother the client feel depressed how can I
manage and support facially to my family. His father have a vegetable shop and he
carry this shop but he borrow some money to buy vegetables and the client now
depressed how can he menage the money and give them that’s why he become
depressed and worry about this. Due to stress these things effect on his physical and
mental health. After one week his condition is not good.he is very obedient and caring
person his mother said he loved to others and also he said give the money to beggars I
have a lot of money indirectly he had a no money. His relationship with family is
good.
Personal history
Birth and childhood
complications reported by the client. He achieved all her developmental milestones at
Family history
He was born as 2nd child in family.his father is died before 2 years his relationship
with mother is excellent. His relationship with family is good.
Educational history
He is good in study. His performance is very appreciable.But he end her study after
class 8th.
Formal and informal assessment was done with the client in order to access and to
decide a counselling plan for the client’s problem. Following list shows the
assessment plan for the client:
Informal assessment
Subjective ratings
Formal assessment
Bipolar questionnaire ( YMRS ) Perceived Young mania Scale
Informal assessment
Subjective ratings of the problem
Subjective rating of the problem by client on bipolar ( pre – assessment ) Subjective
rating scale is attaches in appendix*
Total item 11
Obtained score 25
category moderate
Sum scores for all eleven items, scores indicate moderate mania problem.
Scoring
13-19 Minimal
20-25 Mild mania
26-37 Moderate mania
38-60 sever mania
According to this scale she has moderate level mania.
Subjective rating scale on bipolar is my self creates scale according to client’s
situation. The rating he gave to each problem describes nature of problem and his
personality. The rating he give on problem describes he is on moderate level. And in
daily routine he is going through face problems because of it and it is also affecting
his mental health as well as physical health.
problems such as aggression.
behavior.
Familial factors
• father grief of dead
• feel hopeless
Assessment
• bipolar Questionnaire (YMRS)
• Perceived young mania questionnaire
Management
• CBT
• Psych-education
• family focused therapy
• Deep breathing exercises
• Golden rules of sleep
Counselling plan
The counselling plan was on the basis of anger and stress management.
Recommendations
Diagnosis
Bipolar mania with depression
Case Formulation
According to DSM V, Bipolar 1 disorder refers to recurrent episodes of Mania . A
Manic episode is a state of mind characterized by high energy, excitement, and
euphoria over a sustained period of time. It's an extreme change in mood and
cognition that can interfere with school, work, or home life. According to behavioral
theorists the maintaining antecedents play an important role in strengthening any
behavior. Setting events are environmental conditions that elicit a behavior.
Case#5
Identifying data:
Name : S
Age : 24
Gender : female
Grade : six
No. of siblings : 5
Birth order : 5
Father : alive
Mother : alive
Informant : client herself
Presenting problems
Complaints as reported by client :
‫ سے زیادہ ۔‬€‫ایک مہینے‬ ‫اداس رہتا ہے ۔‬
‫ سے زیادہ ۔‬€‫ایک مہینے‬ ‫کسی چیز میں دلچسپی نہیں لیتی ۔‬
‫دو ہفتوں سے ۔‬ ‫اداس محسوس کرتا ہے ۔‬
‫دو ہفتوں سے‬ ‫بھوک نہیں لگتی ہے ۔‬
‫کبھی کبھار‬ ‫تھکاوٹ رہتی ہے ۔‬
‫کبھی کبھار ۔‬ ‫خود کشی کرنے کا سوچتی ہے ۔‬
Client was 24years women. She entered in session room with his husband. The
client’s appearance was well dressed, neat and clean. He looked bright but somewhere
deep inside was worried.
The client is 14 years old women. She lived with his husband she become married in
2011. she have a four children. She said 2 years ago in accident I lost my brother and
his wife. Due to this accident am become in trauma and the flashbacks am
remembered. After the time am become alright but few weeks a History of present
problem go again am face the accident she said all family members are safe in car.
But now am depressed again I have a lack of interest in thing and lack of pleasure I
have a lock of sleep and lack of appetite am sad all the time and sometime the suicidal
thoughts come in to my mind.
Personal history:
Birth and childhood
complications reported by the client. she achieved all her developmental milestones at
Family history
The client belongs to a lower middle class family. Total family members is six. she
has two sisters and two brother. she lives in a nuclear family system. Her relationship
with family is good.
Educational history
Not educated
In order to assess client’s problem two types of assessment was carried out that is:
1. Informal Assessment
1 Subjective Rating of Symptoms
2. Formal Assessment
The formal assessment comprised of:
3. Drug abuse screening test(BPRS)
Total item 24
Obtained score 15
Category mild
The range of possible BPRS total scores is from 18 to 126.As with the BPRS, the time
span considered is the week before the rating, and the following scores can be given:
1, normal, not at all ill
2, borderline mentally ill
3, mildly ill
4, moderately ill
5, markedly ill
6, severely ill
7, among the most extremely ill
The BPRS was administered to know the previous severity level of the problem of the
client. Client’s score on BPRS is 15, that falls in the mild category of range. The score
suggests that the client was in mild level of problem.
problems such as aggression ,depressed behavior and fear.
• Client is also suffering from high stress level and this is causing depressed behavior.
Assessment
• The brief psychiatric scale (BPRS)
Management
a) Talk therapy
b) CBT
c) Motivational interviewing
d) Yoga and medication
e) Family therapy
Counselling plan
The counselling plan was on the basis of multiple therapies.
Psycho education
Psycho education is offered to people who live with a psychological disturbance. A
goal is for the patient to understand and be better able to deal with the presented
illness. Also, the patient’s own strengths, resources and coping skills are reinforced, in
order to avoid relapse and contribute to their own health and wellness on a long-term
basis.
Outcome
outcome is positive the behavior moved from moderate to low level and with more
time it will extinct.
Recommendations
• There should be better relationship with others
Diagnosis
Major depressive disorder
Case formulation:
The client was 24 years women was referred with the complaints of depressed mood,
lack of pleasure, sadness, worthlessness, and self-dislike passivity and muscle pains.
The history of client suggests that he passes from trauma that's why he become tensed
and affaird from traveling or any type of satiation which she feel unsafe. That’s why
she become depressed.

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CLINICAL CASE STUDY

Roll no. FA19BV009

Department of Applied Psychology

Islamia University of Bahawalpur

Rahim Yar Khan Campus

Date………… Signature of Department: …………………

This research entitled “CLINICAL CASE STUDY” submitted by Paras Hameed

EXTERNAL EXAMINER __________________

HEAD OF DEPARTMENT ___________________

I am highly obliged to my incharge in hospital Dr. Rana Muhammad Naeem and I

Case no. 1…………………………………………..Substance use

Case no. 2……………………………………………………..Schizophrenia

Case no. 3…………………………………………………….Schizophrenia

Case no. 4………………………………………………………Bipolar 1 Disorder

Case no. 5………………………………………………Major Depressive Disorder

Total time taken 20 minutes

Total time taken 14 minutes

History of present problem:

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