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CLINICAL CASE – 1

DEMOGRAPHIC INFORMATION

Mr. X, 30 years old unmarried man brought up in a middle class Muslim family
at rural area in Rajshahi. At present he live in Rajshahi City. He was 2nd child
in his family. He has one brother and two sisters. He completed B.Sc honours
(pass) from national university. He is an unemployed man.

REASON FOR REFERRAL

Client was referred from the outdoor department of RMC (Rajshahi Medical
College).He had complains of excessive feelings of low mood, lose of interest,
sleep disturbance. His problem was diagnosed as depressed by psychiatrist and
prescribed medication for managing symptoms. Then the psychiatrist referred
him for taking psycho-therapy.

ASSESSMENT

Assessment is simply the collecting relevant information, in an effort to reach a

conclusion. Assessment is an ongoing process. Clinical assessment involves an
evaluation of individual‟s strengths and weaknesses, a conceptualization of the
problem at hand, and generation of recommendations for alleviating the
problem. The entire assessment procedure was done using following three broad
tools:

Subjective Assessment

The main tools of subjective assessment were in-depth clinical interview,

observation of client in the session and thought diary. In-depth clinical
interview was done by the therapist through open-ended and closed questions,
empathetic listening, and active listening. Observation was focused on the
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attention of client, his appearance, eye contact, gesture, congruency of mood

and speech, instant mood swing in the session.

Objective Rating

Several questionnaires and inventories are available to assess clients they are
not intended to be a substitute for clinical assessment they supplement interview
assessment and also provide quantified scores. Two scales are used as follow-

Depression scale developed by Md. Zahir Uddin and Dr. Mahmudur Rahman
(2005) was administered to assess the severity level of depression.

Anxiety scale which is developed by Farah Deeba and Dr. Roquia Begum
(2004) was administered in the session to get objective rating of anxiety.

Subjective Ratings

In this regard the client was asked to rate his mood and overall problems from
0-10 where 0 means lowest level of well being and 10 means highest level of
well being.

1 2 3 4 5 6 7 8 9 10

Figure: Subjective Ratings scale

PROBLEM DESCRIPTION

When Mr. X came, he mentioned some problems which caused significant

suffering and impairment in his family, social, and other important areas of
functioning. These problems were behavioral, emotional, motivational,
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cognitive and physical. In the assessment sessions X‟s problems was explored
in-details along with relevant history. The problems were as follows:

Behavioral

Mr. X mentioned that his activity level was decreased day by day and find no
interest and pleasure in daily activities. He did not attend any social or family
functions. Gradually he withdrew from friends and family. He has relationship
problem with his family and others. He was irregular to go home, he had less
conversation with his parents. He also had social avoidance tendency.

Emotional

He had depressed mood and excessive guilt all the time („it was only me who
was responsible for that unemployment). He reported that he had uncontrollable
emotion and a low capacity for pleasure in everyday life (he could not enjoy
gathering with his friends). He also felt helpless and hopeless about his future
life and was feeling insecure.

Cognitive

He had negative perception about himself, about his future and about the world.
He had a number of negative automatic thoughts (I have no hope in my life, I
am not capable to be happy in my life). He also had low self-esteem (he could
not participate of any social function) along with fear of evaluation. He was
unhappy and he blamed himself for all the misfortune that occurred in his life,
he always criticized him as a failure in every aspect of life. Suicidal ideation
was not in my client, but he was thinking in a way that his all problems would
go if he died. He also reported having difficulties in concentration, making
decisions and lack of confidence in every aspect of life.
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Physiological

Mr. X also complained that he had a variety of physical complaints such as

fatigue, low energetic, appetite disturbance, headache, sleep disturbance etc.

Motivational:

Mr. X mention that “Nothing seems interesting to me”. He did not find any
pleasure from recreational playing, movie watching, gossiping with friends or
talking in phone.

HISTORY OF PRESENT ILLNESS

According to the client‟s statement, he was reasonably well six months back.
Recently his girl friend was married with other. And he had no contact with his
family because unemployment problem. As a result he gradually feel
depressed most of the day, nearly every day and find no interest and pleasure
in usual activities. Which was impaired his daily life functioning. He also
complained that he had a variety of physical complaints such as appetite
disturbance, headache, and sleep disturbance. He also developed an excessive
tension, fatigue, sweating, muscle tension, difficulty in concentrating. These
variety of symptoms were impaired his social & daily life functioning.

FAMILY HISTORY

The Client developed in an unsupported family environment with middle socio-

economic status in a rural area. His father was a farmer and mother was a
housewife. Client had a very poor relationship with parents. They are one
brother & 2 sisters and he is number 2nd. Client had a very conflicting
relationship with his siblings even he don‟t talk with them. Client has a long
separation from his family members and relatives.
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PERSONAL HISTORY

Birth: no birth complications.

Educational history: Schooling was good. He completed both S.S.C & H.

S.C. result with GPA 5.

Occupation: Student.

Social circumstances: Not so active in social interaction and he had limited

friends.

Forensic history/Drug history: No

PREMORBID PERSONALITY

Relationship: relationship with family members, friends, neighbors and

relatives were very poor.

Leisure activities: Laying on the bed

Prevailing mood: Depressed, worry.

Character: He was introvert in nature.

Habits: Reading novels

HISTORY OF PAST ILLNESS

Past Medical History: Nothing contributory but Mrs. X mention that during
childhood he frequently suffer from fiver & headache as result he always suffer
from weight problem.

Past Psychiatric History: There is no past psychiatric history of my client.

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MENTAL STATE EXAMINATION

General Appearance & Facial Appearance: A young man with average body
build, wore appropriate dress up. He was depressed in facial expression.

Rapport: Eye to eye contact was present. Rapport was established properly.

Posture & Movement: His posture and movement was normal.

Social Behavior: Culturally appropriate social behavior was present.

Motor Behavior: No abnormal motor behavior was found.

Speech:

- Rate & Quantity: normally responsive

- Rhythm: Average

- Volume: below Average

- Content: Relevant
Mood: Depressed or feeling sad.

Thought

- Form - normal

- Content - Suicidal ideation, delusion was not found, obsession thought was
not elicited.

- Stream - normal

Perception:

- Illusion- no Illusion.
- Hallucination –no hallucination.
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Cognition:
- Oriented to time, place and person.

- Attention & concentration were focused.

- Immediate, recent and remote memories were intact.

Insight

Client stated that he understood his psychological problems and want to get
better treatment.

DIAGNOSIS

According to Diagnostic and Statistical Manual of Mental Disorder-V (DSM-

V), the client was suffering from

Major Depressive Disorder (MDD)

 Following Symptoms‟ Have been present during the disturbance

 Depressed mood most of the day.

 Loss of interest and pleasure in all activities.

 loss of desire to eat

 Difficulties in sleeping

 Fatigue/Loss of energy
 Feelings of worthlessness

 Indecisiveness

 The symptoms were not directly caused by a medical illness or by

using substance or drug abuse or any other psychotic disorder.
 Caused significant suffering and impairment in his social,
occupational and other important areas of functioning.
 Never been a manic or hypo manic episode.
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FORMULATION

PPP/PPM Formulation

Predisposing Factors :

Mr. X develop in a chaotic family environment where very poor relationship

with parents and their siblings. He had an experience of bullying, frequent
criticize in failure. Moyle And Kellet (2011) found that Lower self esteem,
poorer family function, bullying in school increase the incidence of depression.
Repeated failure in job exam made his core belief as “I am failure” which
made his dysfunctional assumption as “If I would be a govt. employer,” then
nobody will criticize or underestimate me” Such assumption lead him
predispose to depression. According to Beck, depressed individuals feel as they
do because their thinking is biased toward negative interpretations. Client had a
long separation from family members as well as out of social network and
passed a stressful life(Corona virus) that also predispose him to depression.

Precipitating Factors:

Break-up with girlfriend and she married another guy.

Maintaining Factors:

Expired age for govt. job examination maintained the depression state.
According to Beck, depressed individuals feel as they do because their thinking
is biased toward negative interpretations. Client avoid social gathering, have
lower activity level and lack of emotional support my client also maintain this
problems.
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On the basis of this, the problem of X can be formulated:

Early Experience
Chaotic family environment
Physical punishment
Criticize about ill health & failure

Core Beliefs
Self- I am incompetent
Others- Everybody criticize me
Future- Future is very hard

Dysfunctional Assumption
‘If I would be a BCS cadre, then nobody will criticize or underestimate me”

Critical Incident
Lose of girlfriend

Negative Automatic Thought

“I am not able to win”
“Nothing good will happen to me”
“I am worthless”

Symptoms
Behavioral: Lowered activity, withdrawal from friends
Motivational: Loss of pleasure and interest, procrastination
Affective: Sadness, anxiety, guilt, insecurity, hopeless
Cognitive: Poor concentration, indecisiveness, self-criticism
Somatic: insomnia, fatigue

Figure: Problem formulation of the client using case conceptualization

model for Depression by A.T. Beck (1993)
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TREATMENT GOALS:

Short Term Goals Long Term Goals

To reduce self-harm behavior.

To alter negative thoughts and beliefs
Providing rationale
Anger management
To teach relaxation techniques and
To reduce low mood
mindfulness
State no longer having thoughts
To increase interpersonal skills
To reduce anxiety
To increase problem solving strategy
To reduce sleep disturbance
To prevent relapse
To increase activities & interest Improving family and social
relationship
To increase self confidence

To reduce indecisiveness

To reduce guilty feeling

INTERVENTION

Cognitive Behavior Therapy was focused to intervene and break the vicious
circle of problems where the client was trapped. Before the intervention started,
the therapist and the client collaboratively set the goals of the treatment. His
therapy continued for a total of 10 sessions. Usually he was provided a 50-60
minutes session per week. Agenda were set collaboratively before starting each
day‟s sessions. Several cognitive and behavioral techniques were used in the
intervention. The ultimate goal of the intervention was to diminish the problems
through achieving some goals. The goals of the intervention were:
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The following intervention techniques were planned and applied to X‟s

problems. Before applying the specific technique, the rationale for using that
was explained. And feedback from the client was taken to check his
understanding.

Pharmacological Management by Psychiatrist:

 Zosert 10mg………………………1+0+0
 Propanol 10mg……………………1+0+1
 Clorat 10mg……………………….0+0+1

Psychological Management by Therapist:

Goals Treatment Plan

For emotional healing Ventilation, empathetic listening,

To increase activity level
To reduce anxiety
To reduce guilty feelings
paraphrasing, summarizing.
Physical activity, Graded task
assignment, mastery and pleasure
work exercise,
PMR, breathing relaxation, imagery
relaxation
Psycho-education, pie chart

To reduce sleep disturbance Relaxation, sleep schedule, sleep

hygiene.
To reduce self-harm behavior angry Anger management
feeling
To reduce Dysfunctional assumptions Thought challenge and modification.
& NATs
To reduce indecisiveness Pros and cons

To Increase confidence level Positive data log, find out own

strengths
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To Increase communication Strategies of transactional

skills analyses

To increase insight Five-factor model

To Increase Problem Solving Skills Problem solving strategy

Relapse prevention Follow up sessions

Normalizing

Mr. X was normalized that depression is one of the most common and most
disabling psychological condition; at any one time approximately 5% of the
population meet criteria for major depression (Blazer et al. 1994), with 10%-
20% of the people suffering from major depression within their life time (Blazer
et al. 1994). Around 18 percent of all adults experience an episode of severe
unipolar depression at some point in their lives (Bromet et al., 2011).

Suicidal contract:

Suicidal contract was taken from the client that he will not commit any suicidal
attempt and any self harm behavior to him or others during the therapy sessions.

Ventilation

Ventilation was done and empathy was given aiming to open up and release his
anxiety. The client did not have close relation with his friends and relatives. He
could not share his problem with any one because he felt that he would be
negligible to everyone. Ventilation was used to facilitate sharing and releasing
pent up emotion as pent up emotion was helping to maintain the presenting
problem.
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Psycho-Education:

Describing five part model psycho-education was provided to explain the

interaction between thought, emotion, behavior and physical reactions in a
certain context. It facilitates client to realize the link the role of cognition and
emotion in regulating his somatic symptoms and reduced activity. Thus, the
client got rationale about the underlying philosophy of her problems as well as
mode of treatment.

Thought

Behavior
Situation Emotion

Physiology

Figure: Five factors model.

Physical Activity:

Client was invited to use regularly scheduled periods of between 15 and 30

minutes of daily physical activity like walking, to activate them to reduce her
lethargic state.
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Activities Scheduling

Activities schedule was used to plan each day in advance on an hour-by-hour

basis. The goal was to increase his activity levels and to maximize mastery and
pleasure. It also helps him to increase sense of control over his lives.

Breathing Relaxation and PMR

Breathing Relaxation:

Deep breathing is one of the best ways to lower stress in the body. This is
because when you breathe deeply, it sends a message to your brain to calm
down and relax. The brain then sends this message to your body. Those things
that happen when you are stressed, such as increased heart rate, fast breathing,
and high blood pressure, all decrease as we breathe deeply to relax.

Before get started, these tips were kept in mind:

 Choose a place to do your breathing exercise. It could be in your bed, on

your living room floor, or in a comfortable chair.
 Don't force it. This can make you feel more stressed.
 Try to do it at the same time once or twice a day.
 Wear comfortable clothes.

Practice of breathing relaxation

Following instructions were given to practice breathing relaxation:

 Sit with your legs uncrossed, good posture, and place your hands on your
thighs.
 Close your eyes if they're open.
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 Inhale deeply through your nose into your abdomen for a long count of
five seconds. As you do that, imagine that the air is filled with a sense of
peace and calm. Try to feel it throughout your body.
 Hold for sometimes and feel the pressure on your chest, and then breathe
out slowly through your mouth for a long count of five. While you're
doing it, imagine that the air leaves with your stress and tension and you
feel better.
 Wait 2-3 seconds before taking another breath.
 Continue for several times. Stop briefly if you feel light-headed.

Progressive muscle relaxation (PMR):

During stress situation our muscles will unconsciously become tense. If we

make a point to pay attention, we feel this change all throughout our body. With
enough time, this tension can cause muscle pain and soreness. PMR works by
increasing awareness of the tension that occurs during stress, and then
consciously releasing that tension. This process creates a feeling of relaxation-
both physically and emotionally.

General Instruction:

 The setting for relaxation is quiet and of distraction noises. You will be kept
physically comfortable in a position, slow down your breathing and give
yourself permission to relax. Keep your body loose, light and free.
 Loosen any tight clothing, take off your shoes, and get comfortable.
 Keep your eye closed.
 Avoid stray thoughts.
 Avoid extra movements of the body.
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 During the part of the exercise cycle tense the muscle tightly and hold for
slow count of 10 seconds but not so much that you feel a great deal of pain.
(Repeat silently 1001, 1002, 1003…)
 During the relation part of exercise cycle relaxes the muscle quickly and
completely, let your mind relax and appreciate how relaxed the muscle is
feeling for 10 seconds. It may be helpful to say something like “Relax” as
you relax the muscle.
 Try to keep all other muscles relaxed as you exercise specific muscle group.
 Relax by taking three deep breaths inhaling through nose and exhaling
through mouth after each step.
 Let us being your exercise.
 The procedure of Progressive Muscle Relaxation techniques are described
below table:
SI. No. Procedure Of Progressive Muscle Relaxation Techniques
1. Hands
Clench each fist separately (right & left), feel the tension
a) in the fist and forearm respectively for 5 seconds.
Release the fist , relax and feel relaxation for 10 seconds
2. Arms
Bend each arm separately (right &left) up at the elbow and
a) tense the biceps, keeping the hand relaxed,
feel the tension for 5 seconds.
Release the arm, relax and feel relaxation for 10 seconds
Straighten the arm separately (right &left) and tense the
b) triceps leaving the lower arms supported by the chair with
the hands relaxed, feel the tension for 5 seconds.
Release the arm, relax and feel relaxation for 10 seconds
3. Facial Muscles
Wrinkle your forehead; try to make your eyebrows touch
a) your hairline which produces tension,
feel the tension for 5 seconds.
Release the eye brows relax and feel relaxation for 10
seconds.
Close your eyes and screw the muscles around the eyes
b) for 5 seconds.
Release, relax and feel relaxation for 10 seconds.
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Open your mouth wide enough to stretch the hinges of your

c) jaw which produces tension, feel the tension for 5 seconds.
Release the mouth, relax and feel relaxation for 10 seconds.
4. Neck & Shoulder
Push the head back as far as it will go (against a chair),
a) feel the tension for 5 seconds.
Bring head to its position, relax and feel relaxation for
10 seconds.
Bring the head down and press the chin down on to the
b) chest for 5 seconds.
Bring the head to its position, relax and feel relaxation for
10 seconds.
Tense shoulder by lifting your shoulders up as if they could
c) touch your ears, feel the tension for 5 seconds.
Release, relax and feel relaxation for 10 seconds.
Tense your upper back by pulling your shoulders back
d) trying to make your shoulder blades touch. Hold for about
5 seconds, and feel the tension.
Release, relax and feel relaxation for 10 seconds.
5. Chest
Tighten your chest by taking a deep breath in, completely
a) filling the lungs, hold for about 5 seconds, and exhale,
blowing out all the tension.
Relax and feel relaxation for 10 seconds.
6. Stomach
Pull in the stomach and tense the stomach muscle for
a) 5 seconds.
Release the stomach, relax and feel relaxation
for 10 seconds
7. Back
Arch your lower back away from the chair,
a) feel the tension for 5 seconds.
Relax and feel relaxation for 10 seconds.
8. Thighs & Buttocks
Tense both thigh muscles and buttocks by squeezing
a) muscles together and feel the tension for 5 seconds.
Release the muscles, relax and feel relaxation for 10
seconds.
9. Lower Legs
Point toes towards your head, producing tension in calf
a) muscles, feel the tension for 5 seconds.
Relax and feel relaxation for 10 seconds.
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Point the toes away from the head, feel the tension for 5
b) seconds.
Relax and feel relaxation for 10 seconds
10. After Exercises
Now imagine a wave of relaxation slowly spreading
a) through your body beginning at your head and going all the
way down to your feet.
b) Keep your eyes closed and let yourself remain in the relax
position.
c) Open your eyes and enjoy renewed energy, feel relaxed and
refreshed.
d) Sit up, stretch, and stand up slowly.

Graded Task Assignment

Graded task is the procedure to break a task in a convenient part and accomplish
them sequentially. Through accomplishment of small parts client achieve a
sense of success which was seems difficult to him in past and considered as
boring or unattractive. The following steps were followed for going through the
graded task assignment:

1. Make a list of all the things that you have been putting off.
2. Number the tasks in order of priority
3. Taking the first task and breaking it down into small steps.
4. Rehearsal the task mentally, step by step.
5. Write down any negative thoughts that come to you about doing the task,
and answer them if you can and if cannot then simply note down the
thoughts for later discussion with the therapist.
6. Take the task step by step.
7. Write down what you have done on your activity schedule and rate it.
8. Focus on what you have achieved
9. Take the next task and tackle it the same way
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Pros and Cons

The client was asked to make lists including the advantages and disadvantages
of his choices. Then helped him to devise a system for weighting each item and
drawing a conclusion about which option seems best. Pros and cons were
designed to take decision.

Statement: „whether I continue job preparation or not‟

Advantages Disadvantages
1. enrich myself. Nothing
2. it would prove my skill
3. book is the best friend.
4. life is a field of learning.

Socratic Questioning

Socratic questioning was used to help him identify, evaluate and respond to
negative automatic thoughts about himself and others.

Problem Solving

Problem solving method was designed to deal real life problems, such as having
no tuition.

1. Decides which problem(s) to be tackled first.

2. Agree goal(s)
3. Work out steps necessary to achieve goal(s)
4. Decides tasks necessary to tackle steps
5. Implementation of decided tasks
6. Review progress at next session, including difficulties that have been
encountered
7. Decide next step depending on progress
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8. Proceed, as above, to agreed goal(s), or to redefine problems and goals

9. Work on further problems if necessary

Pie-chart Analysis

As Mr. X had high level of guilt feelings, he was invited to indicate on a pie
chart (Beck, 1995) the percentage of the responsibility that each of the other
person involved in the situation had. He had a thought as „I am responsible for
my current condition‟ and belief rate was 85%.

15%

me
others
85%

Figure: the pie chart analysis of X’s belief before intervention.

15

30 55 Corona virus
Friends
Self

Figure: The pie chart analysis of X’s belief after intervention.

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Thought Challenge

It is an effective cognitive technique of CBT for fighting irrational and negative

thoughts. The original thought challenge procedure depicted by Beck (1995)
was used after modifying it into a simplified six steps procedure presented in
the following,

i) What is the worst that will happen?

ii) What are the evidences for this idea?
iii) What are the evidences against this idea?
iv) What are the benefits of thinking in this idea (the worst thing will
happen)?
v) What are the costs of thinking in this way?
vi) What should I do about it?

These six steps of thought challenge procedure were applied to challenge and
diminish irrational and negative thoughts, for example, “„I am hopeless and
nothing good in my future”. Before challenge the belief strength of that thought
was 80% but after challenge the belief strength was 30%. X was asked to
practice this procedure as homework assignment to fight with this and other
negative irrational thoughts that he faced.

Sleep schedule & hygiene

The term „sleep hygiene‟ was first used by Dr. Peter Hauri around 20 years ago
to describe what patients themselves can do to eliminate sleep-interfering
factors, and to promote good sleep. Sleep hygiene refers to things about lifestyle
and preparation for bed that can be changed to improve sleep pattern.
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Component of sleep scheduling and their implementation issues:

 Restrict your time in bed:

 Establish your rising time:
 Establish your “threshold time” for bed:
 Go to bed only when sleepy:
 Follow a 7-night-per-week schedule:
 Observe the 15-minute rule:
 Make adjustments to the schedule:.
 Make the connection between bed and sleep:
 Avoid daytime naps:


Relapse Prevention:

Relapse prevention was also in the treatment plan to help the client to deal with
future possible problems through a treatment blueprint. Potential relapse factors
were explored from the clients and worked with these factors how she will deal
if these come in her future life.
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RESULTS

Objective Measure

For objective assessment anxiety, depression, and scales were used. Scores of
theses scales are given below:

Ten sessions were given to the client. The client reported improvement in his
problems.

Sessions Depression Scale Anxiety Scale

1st 127 (severe) 103 (profound)

3rd 115 (Moderate 71(Severe)

7th 91 ( Minimal) 59(Moderate)

10th 76 (Minimal) 49 (Moderate)

Table-: Scores of Depression Scale, Anxiety of different sessions.

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Subjective Wellbeing:

In this procedure the client was asked to rate his overall problems and mood as
he was considering. He was asked to rate his mood and overall problems from
0%-100% where 0% means lowest level of well being and 100% means highest
level of well being.

Sessions Wellbeing %

1st 15

2nd 25

3rd 40

4th 45

5th 50

6th 50

7th 60

8th 70

9th 70

10th 80

Table-: Scores of Subjective Wellbeing

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PROGNOSIS

Cognitive behavior therapy for depression, as developed by Beck and his

colleagues in Philadelphia (Beck, Rush, Shaw, Emery 1979), is now one of the
most widely adopted, extensively evaluated and influential treatment
approaches. CBT is very effective treatment for acute depression (Dobson,
1989), atypical depression (Jarrett et al., 1999) and chronic depression (Keller et
al., 2000).

Mr. X was motivated and regular in session. He tried to do homework regularly.

These helped him to progress in session quickly. Process of Cognitive behavior
therapy, five factor model, Beck‟s cognitive model of depression shared he
understood and accept how this problem was started and maintained. A recent
large scale, well controlled study found that CBT was better than pill placebo
and as effective as antidepressant medication at treating moderate-to-severe
depression (DeRubeis et al., 2005) but there are also criticism by Parker et al.,
2000.

Factors that predict a greater risk of future episodes are (Gelder, M., Harrison,
P., and Cowen, P., 2006):

 Incomplete symptomatic remission

 Bipolar disorder
 Early age of onset
 Poor social support
 Poor physical health
 Co-morbid substance misuse
 Co-morbid personality disorder
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The client does not have bipolar above co morbid disorder and have a good
physical health. But he does not have good social support, high level of
environmental stress as well as poor social support were existed which may lead
his progress slow (Carr, A, 2006).

DISCUSSION

Mr. X came to therapist with some psychological problems as Depressed mood,

Loss of interest & pleasure in all activities, difficulties in sleeping, loss of desire
to eat, Loss of energy/fatigue, low self-esteem, excessive guilt, lower level of
confidence, decision making problem and relationship problem. His symptom
has reduced in 10th sessions after applying some CBT techniques.

As a graduate student of the department of clinical psychology, it was a

relatively difficult as well as challenging role for me to deal with client. It was
quite difficult for me to deal with a depressed man. I truly enjoy the experience
and learned a lot which essentially enhance my experience and thus enrich
myself.

Relapses/recurrence is a greater problem for patients with major depression

(Judd, 1997). Though relapse prevention was in treatment plan and client attend
the follow-up session. Maintenance CBT was as effective at preventing the
recurrence of depression as continued antidepressant medication (Blackburn &
Moore, 1997). Patient withdrawn from CBT has significantly fewer replases
than who withdrawn from antidepressant medication & didn‟t differ
significantly from patients maintained on antidepressant medication (Hollon et
al.,2005). After 2 months follow up, relapse rate for CBT are lower than for
pharmacotherapy, when both treatments are stopped at termination.
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REFERENCES:

Beck, J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press.
New York.

Blackburn, I. and Devison, K. M.(1900, 1995). Cognitive Therapy for

Depression and Anxiety. A practitioner‟s guide.

Carr ,A. and Mcnulty, M,. (2006). The Handbook of Adult Clinical Psychology.
New York.

Gelder, M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of

Psychiatry, 5th edition. Oxford University Press.

Lindsay, S. & Powell, G. (eds.) (2007). The Handbook of Clinical Adult

Psychology. Third Edition. London: Routlrdge.

The Diagnostic and Statistical Manual of Mental Disorder, 4th edition ( DSM-
V). The American Psychiatric Association. Washington. DC.
 P a g e | 28

CLINICAL CASE -2

DEMOGRAPHIC INFORMATION

Miss P, 19 year old woman, belongs to a middle class Hindu family in Bogura
town. She is the first child in her family. She has an only a younger brother. She
got GPA 5.00 in both SSC and HSC. She studies in Botany dept. in B.Sc. at
Azizul Haque Govt. College.

Reason for referral

I got this client from Bogura Medical College Hospital outdoor from the
psychiatrist. She had “obsessive compulsive disorder” diagnosed by
Psychiatrist.

ASSESSMENT TOOLS

Subjective Assessment
The main tools of subjective assessment were in-depth clinical interview,
observation of client in the session and thought-diary. In-depth clinical
interview was done by the therapist through open-ended and closed questions,
empathetic listening, and active listening. Observation was focused on the
attention of client, his appearance, eye contact, gesture, congruency of mood
and speech, instant mood swing in the session.

Objective Rating
Established obsessive compulsive disorder (OCD) scale and Anxiety was used.
 P a g e | 29

Subjective Ratings of Mood and Overall Problems

In this procedure the client was asked to rate his mood and overall problems
from 0-10 where 0 means lowest level of well being and 10 means highest level
of well being.

1 2 3 4 5 6 7 8 9 10

Figure: subjective rating scale.

DESCRIPTION OF THE PROBLEM

a) Behavioral Symptoms

Usually, she is less active and less productive. She washed hand frequently. She
spends more time alone any may stay in bed for long period. She sleeps
excessively. She also moves and even speaks more slowly.

b) Cognitive Symptoms

She holds extremely negative views of her. She thinks herself inadequate,
undesirable, and inferior. She blames herself for nearly every unfortunate event,
even things that have nothing to do with her, and rarely credit her for positive
achievement. She feels confused, easily distracted.

c) Physiological Symptoms

She frequently feels some physical ailments as headaches, loss of energy, sleep
excessively.
 P a g e | 30

d) Emotional Symptoms

She feels sad and dejected. She also feels empty. She reports getting little
pleasure from anything and an in ability to experience any pleasure at all
(anhedonia). She experiences anxiety, anger.

e) Motivational Symptoms

She reports a lack of drive, initiative and spontaneously. She feel repeated urge
to washing hand.

Motivation for clinical care and preconception about mental health

Miss P was unconscious about her mental health. Then she knows Clinical
Psychologist as either counselor or Psychiatrist.

She expects that she will become more confident about success; she will not
feel helplessness and loss of interest from mental health clinic.

HISTORY OF PRESENT ILLNESS

According to the client‟s statement, she was reasonably well two months back.
She travelled by bus and vomited excessively. Then the very next day she had
diarrhea. These awkward situations lead her to excessive washing and taking
bath. She also developed an excessive tension, fatigue, difficulty in
concentrating. These variety of symptoms were impaired her social & daily life
functioning.

FAMILY HISTORY

She has weak relationship with parents and siblings. Her father is the leader of
the family. She is the first child in her family. She has an only a younger
brother. Miss “P” feels responsibility for her family. Failure of this, she feels
anxiety and depression. She does not like her family of origin.
 P a g e | 31

PERSONAL HISTORY

Birth: no birth complications.

Educational history: Schooling was good. She completed both S.S.C & H.
S.C. with GPA 5.

Occupation: Student

Social circumstances: Not so active in social interaction and she had limited
friends.

Forensic history/Drug history: No

PREMORBID PERSONALITY

Relationship: relationship with family members, friends, neighbours and

relatives were very poor.

Leisure activities: Browsing internet, facebooking, watching TV.

Prevailing mood: Anxious & depressed.

Character: She was introvert in nature.

Habits: Browsing internet.

HISTORY OF PAST ILLNESS

Past Medical History

Nothing contributory but Appendicitis operation was done at the age of 9. And
she suffered from double typhoid at the age of 13. She has menstrual problem.

Past Psychiatric History

No significant Psychiatric history.

 P a g e | 32

Mental Status Examination

General appearance & facial appearance: The client appeared as physically

and mentally sick, were not well dress up. She was anxious in facial expression.

Rapport: Eye to eye contact was present. Rapport was established properly.

Posture & movement: Arms were locked legs were crossed.

Social behaviour: Normal.

Motor behaviour: No abnormal motor behaviour was present.

Speech:--

 Rate & quantity: Low responsive

 Rhythm: Average
 Volume: Low
 Content: Relevant

Mood: Depressed & anxious

Thought:--

 Form: Normal
 Content: Suicidal ideation, delusion was not found, obsessional thought
was not elicited.

Perception:--
 Illusion: No Illusion
 Hallucination: No Hallucination

Cognition: Oriented to time, place and person. Attention and concentration

deficiency.

Insight: Client stated that he understood his psychological problems and want
to get treatment.
 P a g e | 33

DIAGNOSIS

According to Diagnostic and Statistical Manual of Mental Disorder-V (DSM-

V), the client was suffering from

Obsessive-Compulsive Disorder (OCD):

Obsessive-Compulsive Disorder Presence of both obsessions & Compulsions.

Obsessions- Recurrent & persistent thought & images as intrusive and

unwanted. Attempt to ignore such thoughts & Images

Compulsions- Repetitive behaviors (washing,)

The obsessions & Compulsions are time consuming.

The symptoms were not directly caused by a medical illness or by using

substance or drug abuse.

Caused significant suffering and impairment in his social, educational and other
important areas of functioning.

FORMULATION

Predisposing Factors

Her family relationship is weak. Then relationships with friends are also weak.
She is socially withdrawal and egocentric.

Precipitating Factors

Excessive vomiting while on a journey by bus plus had diarrhoea at next day.

Maintaining factors

She has menstrual problem. To failure make new friends.

 P a g e | 34

Treatment Goals

Short term goals

 Normalizing the client

 To increase activity level & reducing anxiety
 To reduce frequency of compulsive behaviors
 To reduce avoidance & Reassurances seeking behaviors
 Modifying dysfunctional beliefs and NATs
 To increase self confidence
 To improve low mood
 To reduce sleep disturbance

Long term goals

 Reducing obsessional thoughts

 To increase interpersonal skills
 To increase problem solving strategy
 To prevent relapse
 Improving family and social relationship
 Back to educational life.

INTERVENTION

Pharmacological Management by Psychiatrist:

 Nexcital 10mg………………………1+0+0
 Indever 10mg……………………….1+0+1
 P a g e | 35

Psychological Management by Therapist

Goals Treatment plan

For emotional healing Ventilation, empathetic listening,
paraphrasing, summarizing.
To increase activity level Physical activity, Graded task
assignment, mastery and pleasure work
exercise,
To reduce anxiety PMR, breathing relaxation, imagery
relaxation
To reduce compulsive behavior Psycho-education, Exposure and
response preventions
Guilt feelings Psycho-education, pie chart
To reduce fear of disaster Psycho-education , imaginal exposure
To reduce sleep disturbance Relaxations sleep schedule, sleep hygiene.
To reduce obsessional Psycho-education, Distracting, thought
thought/doubt stopping, Habituation, evidence for &
against, reality testing.
To reduce obsessional images Psycho-education, Distracting,
habitation, reality testing,
Zoom in zoom out testing.
To reduce Dysfunctional Thought challenge and modification.
assumptions &
NATs
To reduce indecisiveness Pros and cons
Relapse prevention hand out, follow up sessions
 P a g e | 36

Normalizing

Miss P was normalized that obsessional thoughts occur about 90% percents of
individuals (Rachman and De Silva, 1978, Salkovskis and Harrison, 1984) and
the content of these thoughts are also similar.

Ventilation

Ventilation was done and empathy was given aiming to open up and release her
anxiety. The client did not have close relation with her friends and relatives. She
could not share her problem with any one because she felt that she would be
negligible to everyone. Ventilation was used to facilitate sharing and releasing
pent up emotion as pent up emotion was helping to maintain the presenting
problem.

Physical activity

Client was encouraged to daily physical activity like walking, to activate her to
order to reduce her lethargic state using regularly scheduled periods of between
20 and 30 minutes.

Breathing Relaxation and PMR

Breathing Relaxation

Deep breathing is one of the best ways to lower stress in the body. This is
because when you breathe deeply, it sends a message to your brain to calm
down and relax. The brain then sends this message to your body. Those things
that happen when you are stressed, such as increased heart rate, fast breathing,
and high blood pressure, all decrease as we breathe deeply to relax.
 P a g e | 37

Before get started, these tips were kept in mind:

 Choose a place to do your breathing exercise. It could be in your bed, on

your living room floor, or in a comfortable chair.
 Don't force it. This can make you feel more stressed.
 Try to do it at the same time once or twice a day.
 Wear comfortable clothes.

Practice of breathing relaxation

Following instructions were given to practice breathing relaxation:

 Sit with your legs uncrossed, good posture, and place your hands on your
thighs.
 Close your eyes if they're open.
 Inhale deeply through your nose into your abdomen for a long count of
five seconds. As you do that, imagine that the air is filled with a sense of
peace and calm. Try to feel it throughout your body.
 Hold for sometimes and feel the pressure on your chest, and then breathe
out slowly through your mouth for a long count of five. While you're
doing it, imagine that the air leaves with your stress and tension and you
feel better.
 Wait 2-3 seconds before taking another breath.
 Continue for several times. Stop briefly if you feel light-headed.

Progressive muscle relaxation (PMR)

During stress situation our muscles will unconsciously become tense. If we

make a point to pay attention, we feel this change all throughout our body. With
enough time, this tension can cause muscle pain and soreness. PMR works by
increasing awareness of the tension that occurs during stress, and then
 P a g e | 38

consciously releasing that tension. This process creates a feeling of relaxation-

both physically and emotionally.

General Instruction:

 The setting for relaxation is quiet and of distraction noises. You will be
kept physically comfortable in a position, slow down your breathing and
give yourself permission to relax. Keep your body loose, light and free.

 Loosen any tight clothing, take off your shoes, and get comfortable.

 Keep your eye closed.

 Avoid stray thoughts.

 Avoid extra movements of the body.

 During the part of the exercise cycle tense the muscle tightly and hold for
slow count of 10 seconds but not so much that you feel a great deal of
pain. (Repeat silently 1001, 1002, 1003…)

 During the relation part of exercise cycle relaxes the muscle quickly and
completely, let your mind relax and appreciate how relaxed the muscle is
feeling for 10 seconds. It may be helpful to say something like “Relax” as
you relax the muscle.
 Try to keep all other muscles relaxed as you exercise specific muscle
group.
 Relax by taking three deep breaths inhaling through nose and exhaling
through mouth after each step.
 Let us being your exercise.
 The procedure of Progressive Muscle Relaxation techniques are described
below table:
 P a g e | 39

SI. No. Procedure Of Progressive Muscle Relaxation Techniques

1. Hands

Clench each fist separately (right & left), feel the tension
in the fist and forearm respectively for 5 seconds.
a) Release the fist , relax and feel relaxation for 10 seconds

2. Arms

Bend each arm separately (right &left) up at the elbow and

tense the biceps, keeping the hand relaxed,
a) feel the tension for 5 seconds.
Release the arm, relax and feel relaxation for 10 seconds

Straighten the arm separately (right &left) and tense the

triceps leaving the lower arms supported by the chair with
b) the hands relaxed, feel the tension for 5 seconds.
Release the arm, relax and feel relaxation for 10 seconds

3. Facial Muscles

Wrinkle your forehead; try to make your eyebrows touch

your hairline which produces tension,
a) feel the tension for 5 seconds.
Release the eye brows relax and feel relaxation for 10
seconds.

Close your eyes and screw the muscles around the eyes
for 5 seconds.
b) Release, relax and feel relaxation for 10 seconds.

Open your mouth wide enough to stretch the hinges of your

jaw which produces tension, feel the tension for 5 seconds.
c) Release the mouth, relax and feel relaxation for 10 seconds.
 P a g e | 40

4. Neck & Shoulder

Push the head back as far as it will go (against a chair),

feel the tension for 5 seconds.
a) Bring head to its position, relax and feel relaxation for
10 seconds.

Bring the head down and press the chin down on to the
chest for 5 seconds.
b) Bring the head to its position, relax and feel relaxation for
10 seconds.

Tense shoulder by lifting your shoulders up as if they could

touch your ears, feel the tension for 5 seconds.
c) Release, relax and feel relaxation for 10 seconds.

Tense your upper back by pulling your shoulders back

trying to make your shoulder blades touch. Hold for about
d) 5 seconds, and feel the tension.
Release, relax and feel relaxation for 10 seconds.

5. Chest

Tighten your chest by taking a deep breath in, completely

filling the lungs, hold for about 5 seconds, and exhale,
a) blowing out all the tension.
Relax and feel relaxation for 10 seconds.

6. Stomach

Pull in the stomach and tense the stomach muscle for

5 seconds.
a) Release the stomach, relax and feel relaxation
for 10 seconds

7. Back
 P a g e | 41

Arch your lower back away from the chair,

feel the tension for 5 seconds.
a) Relax and feel relaxation for 10 seconds.

8. Thighs & Buttocks

Tense both thigh muscles and buttocks by squeezing

muscles together and feel the tension for 5 seconds.
a) Release the muscles, relax and feel relaxation for 10
seconds.

9. Lower Legs

Point toes towards your head, producing tension in calf

muscles, feel the tension for 5 seconds.
a) Relax and feel relaxation for 10 seconds.

Point the toes away from the head, feel the tension for 5
seconds.
b) Relax and feel relaxation for 10 seconds

10. After Exercises

Now imagine a wave of relaxation slowly spreading

through your body beginning at your head and going all the
a) way down to your feet.

b) Keep your eyes closed and let yourself remain in the relax
position.

c) Open your eyes and enjoy renewed energy, feel relaxed and
refreshed.

d) Sit up, stretch, and stand up slowly.

 P a g e | 42

Activities Scheduling

Once accurate information is available on what the client is doing and what
satisfaction he obtain from her activities, the activities schedule was used to
plan each day in advance on an hour-by-hour basis. The goal was to increase
her activity levels and to maximize mastery and pleasure. It also helps her to
increase sense of control over her lives.

Psycho-education

Psycho education was provided and formulation was shared to help hers
understands the problems and mode of treatment. The client was educated about
obsessive compulsive disorder, its symptoms, causes and mode of treatment.

Explanation about the maintaining circle obsessive compulsive disorder was

also provided his own symptoms.

Triggers Obsession
After using Discomfort
Dirt will be attached
bathroom Anxiety, tension
with my body

Temporary relief Compulsion Compulsive urge

No anxiety & Wash and bath
Urge to wash and bath
discomfort repeatedly

Figure: A sequence of events in an obsessive compulsive experience.

Exposure with Response Prevention (ERP)

In the mid 1960 a psychologist in London, Victor Meyer, began to treat patients
who had compulsive rituals with what he called “apotrepic Therapy”. This
consist of two element: 1.Placing the man in real-life situation that generate
anxiety or discomfort and provoke compulsive urges. 2. Preventing the patients
 P a g e | 43

from carrying out the compulsive behaviors. This combination of real-life

exposure plus response prevention was farther developed by Rachman and
colleagues and soon become well established as a technique for treating patient
with overt compulsion behaviors.

Rational-Before describing the details of this form of treatment, the rational

behind the treatment is descried to client. When patients engage in the
compulsive behaviors the level of discomfort and compulsive urges go down.
What would happen if the discomfort and compulsive urges to engage in the
compulsive behaviors were provoked, but the patients then refrained from
carrying out the compulsion? Several studies shown that, in this situation the
level of discomfort and strength of compulsive urges still go down, but much
more slowly. When this is done in repeated session there will be a cumulative
effect.(Rachman et.al. 1996).

The therapist and client then collaborately constructed a list how difficult these
trigger or cues are for the client to face. This is usually on a scale of 0-10
(where 0 means “no anxiety” 10 means “extreme anxiety”). To reduce anxiety
washing compulsive urges was rated on a scale of 0-10 (where 0 means “no
urge” 10 means “extreme urge”).
 P a g e | 44

Sl. Trigger event Discomfort Compulsive

No. (0-10) urge (0-10)

1. Using the toilet 10 10

2. Picking up something from floor 9 9

3. When came in house from outside 8 7.5

4. Touching kitchen materials 6 6

5. Touching door handle 4.5 4.5

6. Shaking with friends & others 4 4

i) P was asked to select from the hierarchy the highest item she can allow to be
exposed in and she agreed in start from 40% anxiety level.

ii) She was exposed to that situation and was asked to prevent her overt
responses like washing, cleaning and reassurance seeking to that situation.

iii) She was asked to continue until her arousal is diminished.

iv) She was asked to evaluate the situation by rating anxiety level.

v) ERP is continued to the next item in the hierarchy when, after successive
ERP trial, the specific item fails to produce any compulsive urge.

She was asked to practice ERP as a homework assignment. It is well known that
intervention for OCD works best if a co-therapist can be engaged (Castle et al.,
 P a g e | 45

1994). With the consent from her, her mother and sister was engaged in the
therapy for helping and monitoring her in the home during practice ERP and
instructed not provide any reassurance.

Sleep schedule

The term „sleep hygiene‟ was first used by Dr. Peter Hauri around 20 years ago
to describe what patients themselves can do to eliminate sleep-interfering
factors, and to promote good sleep. Sleep hygiene refers to things about lifestyle
and preparation for bed that can be changed to improve sleep pattern.

Component of sleep scheduling and their implementation issues:

 Restrict your time in bed.

 Establish your rising time.
 Establish your “threshold time” for bed.
 Go to bed only when sleepy.
 Follow a 7-night-per-week schedule.
 Observe the 15-minute rule.
 Make adjustments to the schedule.
 Make the connection between bed and sleep.
 Avoid daytime naps

Modifying fear of intrusive thought

Fear of intrusive thought was identified from the initial assessment through
interviewing and self-monitoring form for obsessive compulsive disorder
(OCD).
 P a g e | 46

Thought Challenge

It is an effective cognitive technique of CBT for fighting irrational and negative

thoughts. The original thought challenge procedure depicted by Beck (1995)
was used after modifying it into a simplified six steps procedure presented in
the following:

i) What is the worst that will happen?

ii) What are the evidences for this idea?

iii) What are the evidences against this idea?

iv) What are the benefits of thinking in this idea (the worst thing will happen)?

v) What are the costs of thinking in this way?

vi) What should I do about it?
These six steps of thought challenge procedure was applied to challenge and
diminish irrational and negative thoughts, for example, „Thought is equal to
believing”. Before challenge the belief strength of that thought was 80% but
after challenge the belief strength was 30%. P was asked to practice this
procedure as homework assignment to fight with this and other negative
irrational thoughts that she had.

Thought Stopping

Thought Stopping has been used to treat obsessional thoughts and images. The
client is asked to verbalize the obsessional thought or images. When she does
this therapist shout “STOP” quite loudly. This procedure is repeated several
times. In the final stage the client herself will shout “STOP” and after some
trials she will make her stop command silently to herself. She was asked to
practice Thought Stopping as a homework assignment.
 P a g e | 47

Distraction

Distraction is often a useful strategy for dealing with obsessional thoughts and
images. Client are asked to seek out company, start a conversation, listening
music or reading, make a telephone call and so on when disturbing obsessional
thoughts and images.

RESULTS
Objective Measure
For objective assessment Anxiety, Depression, and DUOCS scales were used.
Scores of theses scales are given below:
Ten sessions were given to the client. The client reported improvement in her
problems.
session Anxiety scale DUOCS
1st 66 (moderate) 60 (profound)
3rd
5th 46 (Moderate) 46 (severe)
7th
9th 32 (Mild) 32(moderate)

Table: Scores of Depression, Anxiety and DUOCS Scale in different session.

Subjective Wellbeing

In this procedure the client was asked to rate his overall problems and mood as
he was considering. He was asked to rate his mood and overall problems from
0%-100% where 0% means lowest level of wellbeing and 100% means highest
level of wellbeing.
 P a g e | 48

sessions Wellbeing %
1st 20
2nd 20
3rd 30
4th 50
5th 50
6th 60
7th 60
8th 75
9th 90

Table: Scores of Subjective Wellbeing.

PROGNOSIS

A large body of evidence shows that ERP became well established technique for
treating overt compulsive behavior (Rachman and Hodgson, 1980). According
to Nimesh G. Desa (2002) poor prognosis for OCD is usually due to poor
treatment compliance, delay in starting treatment. But my client compliance
with medicine. A major study carried out in London in the 1970 observe that
Clomipramine did reduce both depression and obsessive compulsive problems
in a group of people who suffer from both. Client is motivated to therapeutic
procedure and motivated to reduce her problems that made her prognosis quite
good. Evidence support by Steketee, et al,. 1982. Absence of psychotic
symptoms was also good for client prognosis. Client mother and sister also
work as a co-therapist at home which made her good prognosis. According to
Castle et al (1994) OCD works best if a co-therapist can be engaged. P‟s mother
was very co-operative and worked as her co-therapist, which helped in therapy
progress and her symptoms reduction.
 P a g e | 49

Factors that predict a greater risk of future episodes are (Gelder, M., Harrison,
P., and Cowen, P., 2006):

 Incomplete symptomatic remission

 Bipolar disorder
 Early age of onset
 Poor social support
 Poor physical health
 Co morbid substance misuse
 Co morbid personality disorder

The client does not have bipolar above co morbid disorder and have a good
physical health. But client Irregular in session, did not do homework regularly,
care givers job life may lead her progress slow.

DISCUSSION

Miss P came to therapist with some intrusive thoughts/doubt, images and

washing, cleaning, avoidance and reassurance seeking behavior. Her symptoms
have reduced in 9th sessions after applying some CBT techniques. Miss P was
motivated and regular in sessions as well as compliance to medicine. That‟s
make her prognosis good in therapy.

As a under graduate student of the department of clinical psychology, it was a

relatively difficult as well as challenging role to deal with client. It was quite
difficult for me to deal with an anxious man. I truly enjoy the experience and
learned a lot which essentially enhance my experience and thus enrich myself.
Though relapse prevention was in treatment plan and client attend the follow-up
session. So, it is really tough to be optimistic that she will never fall in OCD
symptoms again. Because according to Foa et al (2005) to relapse rate of OCD
is 12% in CBT respondents (with or without medication).
 P a g e | 50

REFERENCES

Beck, J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press.
New York.

Carr ,A. and Mcnulty, M,. (2006). The Handbook of Adult Clinical Psychology.
New York.

Comer R J. Abnormal Psychology. Ninth edition ,worth publishers. 41 Madison

Avenue, New York, NY 10010.

Gelder, M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of

Psychiatry, 5th edition. Oxford University Press.

Lindsay, S. & Powell, G. (eds.) (2007).The Handbook of Clinical Adult

Psychology.Third Edition. London: Routlrdge.
 P a g e | 51

CLINICAL CASE – 3

DEMOGRAPHIC INFORMATION

Mr. Z, 26 years old unmarried man brought up in a middle class Muslim family
at rural area in Rajshahi. At present he lives in Rajshahi City . He was 1st child
in his family. He has only brother and two sister. He completed B.Sc honours
(pass) from national university. He is a Businessman.

REASON FOR REFERRAL

Client was referred from the outdoor department of RMCH (Rajshahi Medical
College Hospital). Then the psychiatrist referred him for taking psycho-therapy.

ASSESSMENT

Assessment is simply the collecting relevant information, in an effort to reach a

conclusion. Assessment is an ongoing process. Clinical assessment involves an
evaluation of individual‟s strengths and weaknesses, a conceptualization of the
problem at hand, and generation of recommendations for alleviating the
problem. The entire assessment procedure was done using following three broad
tools:

Subjective Assessment

The main tools of subjective assessment were in-depth clinical interview,

observation of client in the session and thought diary. In-depth clinical
interview was done by the therapist through open-ended and closed questions,
empathetic listening, and active listening. Observation was focused on the
attention of client, his appearance, eye contact, gesture, congruency of mood
and speech, instant mood swing in the session.
 P a g e | 52

Objective Rating

Several questionnaires and inventories are available to assess clients they are
not intended to be a substitute for clinical assessment they supplement interview
assessment and also provide quantified scores. Two scales are used as follow-

Depression scale developed by Md. Zahir Uddin and Dr. Mahmudur Rahman
(2005) was administered to assess the severity level of depression.

Anxiety scale which is developed by Farah Deeba and Dr. Roquia Begum
(2004) was administered in the session to get objective rating of anxiety.

Subjective Ratings

In this regard the client was asked to rate his mood and overall problems from
0-10 where 0 means lowest level of well being and 10 means highest level of
well being.

1 2 3 4 5 6 7 8 9 10

Figure: Subjective Ratings scale

PROBLEM DESCRIPTION

When Mr. Z came, he mentioned some problems which caused significant

suffering and impairment in his family, social, and other important areas of
functioning. These problems were behavioral, emotional, motivational,
cognitive and physical. In the assessment sessions X‟s problems was explored
in-details along with relevant history. The problems were as follows:
 P a g e | 53

Behavioral

 Avoidance behaviors such as avoiding anxiety-producing situations

(e.g., avoiding social situations) or places (e.g., using the stairs instead
of an elevator).
 Escaping from an anxiety-producing situation (like a crowded lecture
hall).
 Engaging in unhealthy, risky, or self-destructive behaviors (such as
excessive drinking or drug use to deal with the anxiety).
 Feeling compelled to limit the amount and scope of one's daily
activities to reduce the overall level of anxiety (e.g., remaining in the
safety of one's home).
 Becoming overly attached to a safety object or person (e.g., refusing to
go out, away from home, to school, or to work in order to avoid
separation).

Emotional

 distress,
 dread,
 nervousness,
 feeling overwhelmed,
 panic,
 uneasiness,
 worry,
 fear or terror,
 Edginess.
 P a g e | 54

Cognitive

 negative perception about himself, about his future and about the
world
 had a number of negative automatic thoughts
 had low self-esteem (he could not participate of any social function)
 fear of evaluation
 blamed himself for all the misfortune that occurred in his life

Physiological

 A feeling of restlessness, feeling "keyed up," or "on-edge;"

 Shortness of breath, or a feeling of choking;
 Sweaty palms;
 A racing heart;
 Chest pain or discomfort;
 Muscle tension, trembling, feeling shaky;
 Nausea and/or diarrhea;

Motivational

 mention that “Nothing seems interesting to me”

 did not find any pleasure from recreational playing, movie
watching, gossiping with friends or talking in phone.

HISTORY OF PRESENT ILLNESS

Mr Z, brought up in the lower-middle class family, where he was the direct

spectator of poverty. Due to his father‟s illness he had to backup for his family,
at e very early maturation he had to encounter to the cruel reality. To keep
happy his family he entered to the business world just after completed his
graduation. But whatever the income was not sufficient for running the family
 P a g e | 55

as the demand of the requirement. These things push him the excessive worry
and negative thought, after some while this thought turn into turmoil for him as
he felt, living in the world is quite boring. His house area were surrounded by
the village local mills and factories, the environment were often quite noisy and
loudness.

FAMILY HISTORY

The Client developed in an unsupported family environment with lower-middle

socio-economic status in a rural area. His father was a farmer and mother was a
housewife. They are only brother & 2 sisters and he is number 1 st child of his
family. Client had a very conflicting relationship with his neighbor even he
don‟t talk with them.

PERSONAL HISTORY

Birth: no birth complications.

Educational history: Schooling was not good. Completed both S.S.C & H.
S.C. result with 3rd class.

Occupation: Business

Social circumstances: Not so active in social interaction and he had limited

friends.

Forensic history/Drug history: No

PREMORBID PERSONALITY

Relationship: relationship with family members, friends, neighbors and

relatives were very poor.

Leisure activities: Laying on the bed

Prevailing mood: anxious and worry.

Character: He was introvert in nature.

 P a g e | 56

Habits: Playing card

HISTORY OF PAST ILLNESS

Past Medical History: Nothing contributory but Mr. Z, mention that during
childhood he frequently suffer from polypus & headache as result he always
suffer from weight problem.

Past Psychiatric History

There is no past psychiatric history of my client.

MENTAL STATE EXAMINATION

General Appearance & Facial Appearance: A young man with not average
body structure; wore appropriate dress up. He was anxious in facial expression.

Rapport: Eye to eye contact was present. Rapport was established properly.

Posture & Movement: His posture and movement was normal.

Social Behavior: Culturally appropriate social behavior was present.

Motor Behavior: No abnormal motor behavior was found.

Speech:

- Rate & Quantity: normally responsive

- Rhythm: Average

- Volume: below Average

- Content: Relevant

Mood: Anxious or feeling sad.

Thought

- Form - normal
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- Content - Suicidal ideation, delusion was not found, obsession thought was
not elicited.

- Stream - normal

Perception:

- Illusion- no Illusion.

- Hallucination –no hallucination.

Cognition:

- Oriented to time, place and person.

- Attention & concentration were focused.

- Immediate, recent and remote memories were intact.

Insight

Client stated that he understood his psychological problems and want to get
better treatment.

DIAGNOSIS

According to Diagnostic and Statistical Manual of Mental Disorders (DSM-V),

the client was suffering from Generalized Anxiety Disorder.

Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectations), occuring more

days than not for at least 6 months, about a number of events or activities.

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following
six symptoms (with at least some symptoms having been present for more days
than not for the past 6 months).
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 Restlessness or feeling keyed up or on edge.

 Being easily fatigued.
 Difficulty concentrating or mind going blank
 Irritability
 Muscle tension
 Sleep disturbance.

D. The anxiety, worry, or physical symptoms cause clinically significant

distress or impairment in social, occupational, or other important areas of
functioning.

E. The disturbance is not attributable to the physiological effects of a substance

or another medical condition.

F. The disturbance is not better explained by another mental disorder.

PPP/PPM FORMULATION

Predisposing Factors

Mr. Z, brought up in the lower-middle class family, where he was the direct
spectator of poverty. Due to his father‟s illness he had to backup for his family,
at very early maturation he had to encounter to the cruel reality. To keep happy
his family he entered to the business world just after completed his graduation.
But whatever the income was not sufficient for running the family as the
demand of the requirement. These things push his the excessive worry and
negative thought, after some while this thought turn into a turmoil for him as he
felt ,living in the world is quite boring .his house area were surrounded by the
village local mills and factories, the environment were often quite noisy and
loudness.
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Precipitating Factors

Nothing specific and it seems that the entire incidence seems to develop his
problem gradually.

Maintaining Factors

The client came from lower middle class family. He saw various difficulties in
the adjustment of family matter. At a very early maturity he got the full
responsibility of directing his family. But he wanted to be a established
businessman. His expectation was high to live a luxurious life, but the fate he
cannot denied at all. Because of pressure, he felt like fatigue, anxious, nervous
and lower motor function due to muscle tension at the peripheral organs of the
body. he got some somatic symptom also as like, sweating ,nausea, feeling
distress all time as well as sleep disturbance .he became introvert type while he
was a social figure, communicating with other person living in the society.
Lacking in this social skilled area maintained his problem.

Pharmacological Management by Psychiatrist

 Lexotanil 3mg……………………….0+0+1
 Alprax 0.5mg………………………..1+0+0
 Reelife 10mg………………………...0+0+1

TREATMENT GOALS

Cognitive Behavior Therapy was focused to intervene and break the vicious
circle of problems where the client was trapped. Before the intervention started,
the therapist and the client collaboratively set the goals of the treatment. His
therapy continued for a total of 9 sessions. Usually he was provided a 45-50
minutes session per week. Several cognitive and behavioral techniques were
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used in the intervention to achieving some goals. Following goals and treatment
plans are discussed below:

Goals Treatment Plan

For emotional healing Normalizing, Ventilation, empathetic

listening.
To increase activity level Physical activity, Graded task
assignment.
To reduce anxiety PMR, breathing relaxation.

Guilt feelings Psycho-education, pie chart

To reduce sleep disturbance Relaxation, sleep schedule.

To Increase Problem Solving Skills Problem solving strategy

To reduce Dysfunctional assumptions Thought challenge and modification.

& NATs
To Increase confidence level Positive data log, find out own
strengths

To Increase social skills Social skill training

Relapse prevention hand out, follow up sessions

INTERVENTION

Normalizing

Mr. Z, normalize that anxiety is one of the most common psychological

condition. Survey suggests that 4 percent of the population has the symptoms of
this disorder in any given area (Kessler et al., 2012, 2010). More than 6 percent
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of all people develop generalized anxiety disorder sometime during their live
(NIMH, 2011).

Ventilation
Ventilation was done and empathy was given aiming to open up and release his
anxiety. The client did not have close relation with his friends and relatives. He
could not share his problem with any one because he felt that he would be
negligible to everyone. Ventilation was used to facilitate sharing and releasing
pent up emotion as pent up emotion was helping to maintain the presenting
problem.

Psycho-Education
Psycho education was provided to explain the interaction between thought,
emotion, behavior and physical reactions by using five part model. It helps
client to understand the link the role of cognition and emotion in regulating his
somatic symptoms and reduced activity. The client was educated about
Generalized Anxiety Disorder and its symptoms, causes and mode of treatment.
Explanation about the cognitive model of generalized anxiety disorder within
his own symptoms.
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Thought

Behavior Feeling
Situation

Physiology

Figure: five factors model.

Physical Activity

Client was invited to use regularly scheduled periods of between 15 and 30

minutes of daily physical activity like walking, to reduce him lethargic state.

Activities Scheduling

Once accurate information is available on what the client is doing and what
satisfaction he obtain from his activities, the activities schedule was used to plan
each day in advance on an hour-by-hour basis. The goal was to increase his
activity levels and to maximize mastery and pleasure. It also helps him to
increase sense of control over him lives.
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Breathing Relaxation and PMR

Pevels and Jhonson (1986) found that relaxation increase the accessibility of
positive memory in the brain. Breathing relaxation and PMR training was given
to reduce level of anxiety and reduce sleep problem.

Graded Task Assignment

Graded task is the procedure to break a task in a convenient part and accomplish
them sequentially. Through accomplishment of small parts a client achieve a
sense of success which was seems difficult to him in past and considered as
boring or unattractive. The following steps were followed for going through the
graded task assignment:

 Make a list of all the things that you have been putting off.
 Number the tasks in order of priority.
 Taking the first task and breaking it down into small steps.
 Rehearsal the task mentally, step by step.
 Write down any negative thoughts that come to you about doing the
task, and answer them if you can and if cannot then simply note down
the thoughts for later discussion with the therapist.
 Take the task step by step.
 Write down what you have done on your activity schedule and rate it.
 Focus on what you have achieved.
 Take the next task and tackle it the same way.

Pros and Cons

Pros and cons were designed to take decision. The client‟s was asked to list the
advantages and disadvantages of his choices then helped him to devise a system
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for weighting each item and drawing a conclusion about which option seems
best.

Statement: „I will cut off communication with her completely‟.

Advantages Disadvantages

1. Release of anxious Nothing

2. I will be able to adapt myself over

time.

3. Remove guilty feelings.

4.would feel good

Socratic Questioning

Socratic questioning was used to help her identify, evaluate and respond to
negative automatic thoughts about herself and others.

Problem Solving

Problem solving method was designed to deal real life problems, such as having
no job.

 Decides which problem(s) to be tackled first.

 Agree goal(s).
 Work out steps necessary to achieve goal(s).
 Decides tasks necessary to tackle steps.
 Implementation of decided tasks.
 Review progress at next session, including difficulties that have been
encountered.
 Decide next step depending on progress.
 Proceed, as above, to agreed goal(s), or to redefine problems and goals.
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 Work on further problems if necessary.

Thought Challenge

It is an effective cognitive technique of CBT for fighting irrational and negative

thoughts. The original thought challenge procedure depicted by Beck (1995)
was used after modifying it into a simplified six steps procedure presented in
the following:

 What is the worst that will happen?

 What are the evidences for this idea?
 What are the evidences against this idea?
 What are the benefits of thinking in this idea (the worst thing will
happen)?
 What are the costs of thinking in this way?
 What should I do about it?

These six steps of thought challenge procedure was applied to challenge and
diminish irrational and negative thoughts, for example, “„I am helpless and my
future will be very hard”. Before challenge the belief strength of that thought
was 80% but after challenge the belief strength was 30%. Z‟ was asked to
practice this procedure as homework assignment to fight with this and other
negative irrational thoughts that he had.
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Pie chart analysis

Feelings of guilt

10

Me
Others

90

Figure: pie chart analysis of Z‟ before intervention.

Feeling of guilt

Me
Family
Friends

Figure: pie chart analysis of Z‟ after intervention.

Sleep schedule& hygiene

The term „sleep hygiene‟ was first used by Dr. Peter Hauri around 20 years ago
to describe what patients themselves can do to eliminate sleep-interfering
factors, and to promote good sleep. Sleep hygiene refers to things about lifestyle
and preparation for bed that can be changed to improve sleep pattern.
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Component of sleep scheduling and their Implementation issues:

 Restrict your time in bed.

 Establish your rising time.
 Establish your “threshold time” for bed.
 Go to bed only when sleepy.
 Follow a 7-night-per-week schedule.
 Observe the 15-minute rule.
 Make adjustments to the schedule.
 Make the connection between bed and sleep.
 Avoid daytime naps.
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RESULTS

Objective Measure

For objective assessment anxiety, depression scales were used. Scores of theses
scales are given below:

Nine sessions were given to the client. The client reported improvement in his
problems.

sessions Depression scale Anxiety scale

1st 121 ( Moderate ) 110 ( profound)

3rd 73 (Severe)

5th 89 ( Minimal) 60 (Moderate)

7th 56 ( Moderate)

9th 70 ( Minimal) 50( Mild)

Table: Scores of Depression Scale & Anxiety Scale in different sessions.

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Subjective Wellbeing

In this procedure the client was asked to rate her overall problems and mood as
she was considering. She was asked to rate her mood and overall problems
from 0%-100% where 0% means lowest level of wellbeing and 100% means
highest level of wellbeing.

sessions Wellbeing %
1st 20
2nd 25
3rd 30
4th 40
5th 45
6th 60
7th 65
8th 70
9th 90

Table: Scores of Subjective Wellbeing.

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PROGNOSIS

Cognitive behavior therapy developed by Beck and his colleagues in

Philadelphia (Beck, Rush, Shaw, Emery 1979), is now one of the most widely
adopted, extensively evaluated and influential treatment approaches. CBT is
very effective treatment for acute depression (Dobson, 1989), atypical
depression (Jarrett et al., 1999) and chronic depression (Keller et al., 2000).
Some techniques of CBT is more helpful for anxiety related disorder.
Combination of behavior and cognitive therapy used in this case.

Mr. X was motivated and regular in session. He tried to do homework regularly.

These helped him to progress in session quickly. Process of Cognitive behavior
therapy, five factor model, Beck‟s cognitive model of shared he understood and
accept how this problem was started and maintained.

DISCUSSION

Mr. X came to therapist with some psychological problems as anxious mood,

Loss of interest & pleasure in all activities, difficulties in sleeping, loss of desire
to eat, Loss of energy/fatigue, low self-esteem, lower level of confidence,
decision making problem and relationship problem. His symptoms were
reduced in 9th sessions after applying some CBT techniques. As a under
graduate student of the department of clinical psychology, it was a relatively
difficult as well as challenging role to deal with client. It was quite difficult for
me to deal with an anxious man. I truly enjoy the experience and learned a lot
which essentially enhance my experience and thus enrich myself.
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REFERENCES

Beck, J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press.
New York.

Carr ,A. and Mcnulty, M,. (2006). The Handbook of Adult Clinical Psychology.
New York.

Comer R J. Abnormal Psychology. Ninth edition ,worth publishers. 41 Madison

Avenue, New York, NY 10010.

Gelder, M. Harrison, P. & Cowen, P. (2006). Shorter Oxford Textbook of

Psychiatry, 5th edition. Oxford University Press.

Lindsay, S. & Powell, G. (eds.) (2007).The Handbook of Clinical Adult

Psychology.Third Edition. London: Routlrdge.
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APPENDICES