Case Report

_________________________________________

Submitted by

Rabia Imran

19101090015

Submitted to

Mam Ayesha Tanveer

BS-Clinical Psychology

PSY-314 Clinical Internship III

____________________________________________

Humanities and Social Sciences

 Summary

Client was 40-year-old women who was suffering from stress disorder. She had 5 children. The

client was having anger issues. She was irritated due to relationship conflicts with her husband. She had

trust issues and indecisiveness in her personality. She was facing sleep disturbance and poor concentration.

Her husband did not support her and involved in another relation; it was a trauma for her. The assessment

was done by formal and informal. In informal assessment, therapist conducted clinical interview with

client. In informal assessment, client behavior was observed by behavioral observation. The subjective

rating scale and mental status examination were also done with the client. In formal assessment, therapist

apply DASS-42 depression anxiety stress scale for the purpose of diagnosis. According to DSM-5, client was

diagnosed with stress disorder. In proposed management plan, CBT with relaxation exercises, stress

management skills will be done.

 Bio data

Name N.A

Age 40

Gender F

Education B.A

Number of siblings 5

Birth order 1

Religion Islam

Marital status Married

Informant Client

Source and Reason for referral

To psychological assessment and treatment, the client was referred to trainee clinical psychologist at

Allama Iqbal Trust Hospital. She came with symptoms including headache, asthma, BP, indecisiveness,

relationship conflicts, trust issues, anger and irritability and frustrating behavior.
Presenting complaints

Table 1- According to psychologist, presenting complaints

‫دورانیہ‬ ‫عالمات‬

‫چھ ماہ سے‬ ‫غصہ اور چڑچڑاہٹ محسوس ہوتی ہے‬

‫چھ ماہ سے‬ ‫اکیلے رہنے کو دل کرتا ہے‬

‫چھ ماہ سے‬ ‫کسی سے بات چیت نہ کروں‬

‫چھ ماہ سے‬ ‫زندگی دھوکا ہے کوئ مجھے نہیں سمجھتا‬

‫چھ ماہ سے‬ ‫کسی پر یقین نہیں کرنا چاہیے‬

‫چھ ماہ سے‬ ‫رونے کو جی کرتا ہے‬

‫چھ ماہ سے‬ ‫سر میں درد رہتا ہے پریشانی کی وجہ سے‬

‫دو سال سے‬ ‫سانس نہیں ٹھیک دہتا‬

Initial observation

The client was an introvert person. When I entered the room, she was on stretcher and having her

treatment. She was little bit nervous but answer all the questions.

History of present illness

Client was 40 years old women and had been stressed from 6 month. She had relationship issues

with her husband. He did not support her and criticized her most of the time. Client faces a lot of problem

due to trust issues. She had great stress about her situation. Therefore, she became too much stressed and

these two reasons make her ill. She is weak now. Her sleep was also disturbed with excessive stress and

crying spell.
Background information

Personal history

Client was a housewife. The client used to get up early in the morning for making breakfast. She

completed 26 years of her marriage. She was well educated and decent lady. She was suffering from stress

due to conflicts between her in laws and husband. She had insomnia and restlessness. She felt tiredness

and she just love to complete her responsibilities.

Premorbid personality

Client was sensitive, impulsive, emotional. She had trust issues, conflicts and she had worry about it.

She was also suffered from asthma and get her treatment for the betterment.

Family history

Client belonged to a nuclear family system, and she was living with her 4 children and husband in

this house. She had 5 siblings. Her marriage has been of 26 years. Her husband was doing a job. He did not

support her and used to criticized her and control her. He had abusive nature towards her. He did not

communicate with her and did not fulfill her basic needs. Her children were studying in school. They all

were under teen age. She was raising her children with a good ethics, and they were well-mannered and

obeyed their parents.

Educational history

The client was well educated lady. She was graduated in B.A.

Social history

The client was good women by heart. She had humble and polite nature. She felt hesitation to

communicate with others. She liked to help poor by giving charity.

Sexual history

The client reached to the puberty at the age of 13 and her reaction was normal. Before her

marriage, she did not indulge in sexual activities.

General home environment

The client stayed in a normal house. Her home had a clean atmosphere. She was living with her

husband and children.

Occupational history

She had no occupational history.

History pf psychiatry/medical illness

There was no history of psychiatry and medical illness in her family. She was facing these problems

due to criticism and relationship conflicts.

Drug history

She had no drug history.

Marital history

She was a married woman. She had 26 years of her marriage. She was facing lots of problems in her

married life. She had trust issues. She had relationship conflicts. Her husband used to criticise her and

mostly in front of others. He did not communicate with her because of this she feels lonely. She was having

these problems from 6 months.

Provisional formulation

The client was referred for the assessment by the hospital. After some observation, we got to know

about her, she had stress disorder. She had anger issues. She used to get irritated and frustrated because

of stress. She had less sleep and low appetite from past 6 months.

Assessment

Psychological assessment is a process of testing that uses a combination of techniques to help

arrive at some hypotheses about a person’s behavior, personality and capabilities. Psychological

assessment is also referred to as psychological testing or performing a psychological battery on a person

(Framingham, 2016). Both formal and informal psychological assessment procedure was used to assess the

client’s various areas of dysfunction aroused due to symptomatic behavior.

Assessment was completed with the help of following assessment modalities.

• Informal

• Formal

Informal assessment

Informal assessment is a way of collecting information about client’s behaviour in normal condition.

This is done without establishing test condition such as in the case of formal assessment. Informal

assessment is sometimes referred to as continuous assessment as it is done over a period. Informal

assessment methods are subjective, and these methods are often developed treatment specific assessment

needs, they will also normally require less time, money and expertise than nationally developed techniques

(Cardozo & Megdalena, 1978). It includes the following:

• Behavioural Observation

• Clinical Interview

• Mental status examination

 Behavioral observation. Behaviour observation is a used to observe the data of client, this method is

used to collect quantitative and objective data which is used to make an intervention plan for the betterment

of behaviour.

Client was 40 years old, and her height was 5’4. She was wearing neat and clean clothes. She was

reported by breathing problem, anger issues, irritation, restlessness. She was cooperative and friendly. She

had made good eye contact during the session. Her voice tone was average. The client reported she fell

irritability, loss of self-control and sleep disturbance.

Clinical interview. Clinical interview is a method in which dialogues between psychologist and

patient are held which help them to provide a treatment plan. It helps us for getting information about client,

his family history, social history, personal history. This information is used for further management plan.

The Clinical Diagnostic interview attempts to maximize the reliability while making use of

procedure’s clinicians rely on in practice. Clinicians report, across theoretical orientations, that although they

rely on direct questions about symptoms in part, they also rely on multiple other factors in everyday

assessment and diagnosis, including observing patients’ interaction with them and listening to their

narratives about their lives. The CDI provides systemic guidelines for obtaining such information from

which to draw inferences about patients’ characteristic behaviour, affective states, emotion regulation

processes, cognitive patterns, and implicit and explicit motives, fears, and goals. For research purposes, the

CDI provides a systemic interviewing structure. In practice, clinicians can use it while relying on all

available data to increase clinical utility while maintaining the advantages of standardized assessment

protocols, which facilitate high reliability and validity.

The interview was conducted to understand the nature, severity and etiology of the patient’s problem.

He was asked about his present complaints and history of present illness to know about the duration of

problem along with predisposing, precipitating and maintaining factors. The tone of voice was slow and no

pressure of speech. Overall good rapport was established.

 Mental status examination. The mental status examination is a structured assessment of the

patient’s behavioural and cognitive functioning. It includes descriptions of the patient’s appearance and

general behaviour, level of consciousness and attentiveness, motor and speech activity, mood and affect,

thought and perception, attitude and insight. The specific cognitive functions of alertness, memory and

abstract reasoning are the most clinically relevant (Martin, 1990 as cited in Walker, Hall, & Hurst, 1990).

The client was 40 years old. She was much stressed. She wore simple but neat clothes. She was

talking normally and in normal voice during the conversation. Client’s abstract thinking was not good. Her

concentration was neither good nor bad. The good thing is that she wanted to get rid of al her problems.

Formal assessment

Formal assessment methods are more objective. The FPA is a new methodology potentially capable

of maximizing the advantages of both semi- structured interviews and self-report questionnaires by

overcoming the limitations of these tools and managing the problems of traditional assessment. The ability

to analyze clinical symptoms is important when evaluating the responses to a questionnaire. Formal

assessment involves the use of tools such as tests, Questionnaires, checklist and rating scales. The purpose

of evaluation is to determine the client’s personality, problems which impair the client’s normal functioning

and severity of disorder.

DASS-42

The DASS-42 is a 42 item self-report scale designed to measure the negative emotional states of

depression, anxiety and stress. The principal value of the DASS in a clinical setting is to clarify the locus of

emotional disturbance, as part of the broader task of clinical assessment.

Administration

The client took 12 minutes to complete DASS-42. A calm and comfortable environment was

provided for the completion of DASS-42.

 Behavioral observation

The purpose of applying this test to the client was clarified. Therefore, the client was little bit

stressed. She was giving the answers with little bit delay. She was very confident. She was totally involved

in the completion of test. She remained stressed at the end of completion.

Quantitative analysis

Table 3- is showing client age, raw score, range and result of client.

Age Raw score Range Result

15-18(Mild)

40 31 19-25(Moderate) Severe stress

26-33(Severe)

Qualitative Analysis

The client obtained scores is 31 on depression anxiety stress scale – 42 which fall in severe anxiety

category and according to DSM-V it’s come in stress disorder.

Quantitative analysis

Table 4- Following scores are showing the results of DASS-42 applied on client.

Depression Anxiety Stress

0-9 0-7 0-14

10-13 8-9 15-18

14-20 10-14 19-25

21-27 15-19 26-33

 28+ 20+ 34+

Cut off score = 33 Total =31

Qualitative Analysis

The test is measuring adjustment level of a person. The score of the client was 33 which indicate

the level. She was worried about herself. She wanted to know about her life experiences. Her life was very

good before this criticism. She might be diagnosed with stress disorder. Ands, she wanted to overcome on

their behaviour and hopeful that she will be recovered by his disorder.

Case formulation

The client was 40 years old. She developed the symptoms of anxiety disorder after some traumatic

event with symptoms sleep disturbance, irritation, frustration, trust issues, conflicts, loss of self-control,

headache, worry. The client was brought for informal assessment which includes clinical interview,

behavioral observation, subjective rating scale, in formal assessment standardized test were administered.

DSM-5 checklist was used. The client was diagnosed with “stress disorder”. As per mentioned

criteria in DSM-V for stress are low mood, irritability, emotional ups and downs, sleep disturbance and

poor concentration etc. Different techniques including Behavioral Techniques, Social Skill Training,

Cognitive Behavior Therapy, was used.

The formulation was done according to bio-psycho social model. MSE was applied on him for

checking his behavior and intellectual functioning at the time of his interview. One other test was

administered on him were DASS-42 to measure the level of adjustment, it was used to measure the level of

stress in the client.

The predisposing factor is her temperament, life event psychological problems are often caused by

dysfunctional ways symptoms of stress. In psychology, stress is a feeling of emotional strain and pressure.

Stress is a type of psychological pain. Small amounts of stress may be beneficial, as it can improve athletic

performance, motivation and reaction to the environment.

 The Precipitating Factor was the client remained frustrated fear of being compared and unhappy

because of her husband critisicm.

The perpetuating factors of the client disorder were irritability, anger, hyper tension, poor

concentration, and emotional ups and downs.

The protective factor of the client was her children.

Case Conceptualization

Presenting complaints
Anger
Irritation
Sleep disturbance
Worry
Relationship conflicts
Trust issues
Isolation

Predisposing Precipitatin Perpetuating

factor g factor factor Protective factor
Life event Criticism Irritability, Children
Temperament Frustration anger, poor
concentration

Diagnosis
Stress Disorder (DSM-5)
 Proposed management plan
CBT and relaxation exercises.

Diagnosis

According to DSM-5, client was diagnosed with stress disorder 308.3 (F30.0).

DSM-5 Diagnostic Criteria

• Experiencing traumatic event.

• Sleep disturbance

• Irritable behavior

• Problem with concentration

• Hypervigilance

• Problem in forgetting negative thoughts

• Avoid external environment

Prognosis

After the observations, the diagnosis of the client was that she was suffering from anger issues due to

stress. But can be managed through the different therapeutic techniques, the client at least able to manage

herself with good hope, and physiological help.

Proposed management plan

A proposed management plan devised for the client was using the behaviours modification

techniques to learn the desired behaviors that can be applied in the daily routine using those techniques. The

methods would help the client understand basic concepts and the functioning of everyday lives. It also helps

the client learn and improve learning readiness skills (attention span, eye contact, non-compliance, and onset

behaviours), which were taught to the client in different sessions.

• Rapport building

• Psycho Education
 • Cognitive Behavior Therapy

• Relaxation exercises

Rapport building. Rapport has been described as “the relative harmony and smoothness of relation

between peoples”. It is a highly valued part of clinical practice rapport is often viewed as an exchange of the

pleasantries. It is seen as something to be fostered early in a therapy session so that the more important

therapy goals can be more easily accomplished (Spencer, 2005). The rational was of the rapport building to

develop the trust and self-belief of the client. Rapport building was necessary for understanding the client’s

feelings, thoughts and problems, as the rapport was developed with the client in the first session by

introducing the client with trainee clinical psychologist, by clarifying the purpose of session, and assuring

her about the privacy and confidentiality of the problem.

Psycho-Education. Psycho education refers to the education offered to individuals with a mental

health condition and their families to help empower problem and illness. The client was psycho-educated to

some extent about her problem. Psycho education to this client was given according to the cognitive

behavioral model of panic disorder. The client reports them and deal with their condition in an optimal way.

During the session, the client received psychoeducation regarding major worry, which they find

difficult to control and find distressing. Other typical symptoms include poor sleep, muscle tension,

difficulty concentrating, bodily arousal, and restlessness. There are numerous models of panic disorder.

. Early models conceptualized panic disorder in the relatively generic cognitive terms of an

individual’s heightened preoccupation with danger and underestimation of their ability to cope (e.g., Butler

et al, 1987; Borkovec et al, 1993).

The Cognitive Behavioral Model of Panic Disorder presented here describes four factors which are

thought to be important in the maintenance of panic disorder. It has seen that clients with anxiety, or stress

they mostly complaints about their thoughts, fears and emotions associated with the particular event, so in

therapy session it was necessary to teach them the basic DTR of cognitive behavior therapy (CBT) proposed

by Albert Ellis.
 Cognitive Behavior Therapy. CBT was developed by Aron T. beck in 1960. Cognitive therapy is a

good and time limited therapy. In CBT the negative thoughts and beliefs of patients are tend to change. This

therapy helps the patient to overcome his difficulties by identifying and changing dysfunctional changes and

emotional responses. Thought changing and cognitive restructuring is a technique in CBT. It is process in

which you challenge the negative thinking patterns that contribute to your anxiety, replacing them with more

positive, realistic thoughts.

This involves three steps:

• Identifying your negative thoughts, the strategy to ask to ask yourself what you are thinking,

when you started feeling anxious. Your therapist will help you with this step.

• Challenging your negative thoughts. In second step, your therapist will teach you how to evaluate

your anxiety provoking thoughts.

• Replacing your negative thoughts with realistic thoughts. Once you have identified the irrational

predictions and negative distortions in your anxious thoughts, you can replace them with new

thoughts that are more accurate and positive.

• DTR is also use under the CBT. It collects information about specific situations.

Automatic Thoughts and emotions are recorded that occurred with the situation. Then the client is

asked to determine an alternative response and then re-evaluate how they feel.

Relaxation Exercises. Relaxation techniques are strategies. One set of skills used to supplement

other CBT skills (such as exposure and cognitive skills) are relaxation skills. Relaxation skills address

anxiety from the standpoint of the body by reducing muscle tension, slowing down breathing, and calming

the mind. Client was suffering most disturbing psychological state due to his anxiety so relaxation exercises

were necessary for him. The procedure which was applied to the client during the session was slow

diaphragmatic breathing and mindfulness. Slow diaphragmatic breathing is one relaxation skill used in CBT.

It is best used as a daily practice, like exercise, or as a way to get through a tough situation without leaving

or making things worse. For best results, practice slow breathing twice a day for around 10 minutes each

time. The purpose of applying this technique was used to relax the body and calm the mind and emotions.
 Deep breathing techniques were explained to the client. These actions were taken during the first

session's slow diaphragmatic breathing procedure. Put your feet up on the floor and relax on a chair. If you

want to, you can lie down. on your belly with your hands folded. Inhale softly and steadily. With a regular

breath, fill the tummy. Avoid taking in too much air. When you breathe in, the hands should rise as if you

were filling a balloon. Instead of raising your shoulders as you inhale, breathe into your stomach. Exhale

slowly while counting to five. Make an effort to exhale more slowly. Hold for two to three seconds after

exhaling before taking another breath. Work will proceed gradually.

Relaxation exercises, deep breathing and mindfulness are two ways to help people to relax and

combat symptoms of anxiety (Manzoni, 2008). Mindfulness is a type of meditation to cope with depression

symptoms, in which you focus on being intensely aware of what you're sensing and feeling in the moment,

without interpretation or judgment. Practicing mindfulness involves breathing methods, guided imagery, and

other practices to relax the body and mind. PMR (Progressive Muscle relaxation) is a technique for learning

to monitor and control the state of muscular tension. The rationale of using this technique was to relax the

body muscles as client reported that she had pain in his body (Jacobson, 1938). In the first phase the client

was told to tense each muscle group step by step before relaxing it. This procedure will make the client

aware of sensation associated with relaxation and will teach her to differentiate between two sensations, pain

and relaxation. This technique benefits the client physically and psychologically.

Intervention plan

Short term goal

• Establish a healthy rapport building with clients.

• Psychoeducation for management.

• Deep breathing exercises.

• Stress management skills will teach to client for emotional ups and downs.

• Goal setting to be done.

Long term goal

• Continued short term goal for the maintenance of behavior.

• Apply CBT.
 • Improve physical functioning.

Limitations

● Sessions with the client was very limited.

● Did not communicate with the family.

● Difficult to complete administration because of disturbance.

Recommendation

● Time period should be exceeded.

● Involve family members in session.

● Involve in different activities

● Family spent most of their time with client.

 Reference

Anderson, C. A and Bushman, B.J. (2002). Human aggression. Annu. Rev.Psychol.53, 27-51.

Anderson,C.A.,and Bushman,B.J.(1997). External validity of "trivial" experiments:the case of

laboratory aggression. Rev.Gen.Psychol.1,19- 41.

Buss, A.H., & Perry, M. (1992). The Aggression Questionnaire. Journal of Personality and Social

Psychology, 63, 452-459.