Final Case Report- I

Ayesha Arshad (362475)

Internship-I

Submitted to:

Dr. Salma Siddiqui

January 15, 2022

Department of Behavioral Sciences

School of social sciences and humanities, NUST

 Summary

A.A was 23 years old unmarried female from a lower middle socioeconomic class family in

Gilgit Baltistan. She was the 2nd born among three sisters. She was a 3rd semester student of

masters (environmental sciences) in a public sector university in Islamabad, currently

residing in university’s hostel. Client presented with symptoms of Panic Attack (unexpected

surge of intense fear and discomfort peaking within minutes, accompanied by sweating,

trembling, palpitation and light headedness twice during the last three to four months)

avoidance of certain activities (going out, playing sports), fear of getting a panic attack and

embarrassing herself, restlessness, excessive worry, difficulty initiating sleep, irritability,

difficulty concentrating in academics. Clinically these symptoms were suggestive of Panic

disorder. Additionally, low self-image, excessive calorie monitoring and restrictive food

intake due to fear of gaining weigh puts client at risk for eating disorder. However, the

intensity and duration of current symptoms do not meet the criteria for a full-blown

diagnosis. This report is intended to synthesize the data gathered from the case to provide

clinical presentation of client’s problems keeping in mind the nature and context of these

problems.
Identifying information

Name A.A.

Gender Female

Age 23 years

Number of Siblings 2

Birth Order 2nd born

Family system joint

Family’s socio-economic status Lower middle class

Qualification Masters (environmental sciences)

Occupation Student

Marital Status Unmarried

Current residence Hostel

Religion Islam

Date of interview 1st-January-2023

Trainee Ayesha Arshad

Referral and Context

A.A was 23 years old unmarried female from a lower middle socioeconomic class

family in Gilgit Baltistan. She was the 2nd born among three sisters. She was a 3rd semester

student of masters (environmental sciences) in a public sector university in Islamabad,

currently residing in university’s hostel. Client was approached to take part in clinical

interview for educational purpose. The purpose of this interview was to complete the writer’s
educational requirement for course of Clinical Internship-I. Informed consent obtained from

client is attached in Appendix A.

Client presented with symptoms of disturbed functionality however, information

provided by her was informed and reliable therefore, she was a credible historian.

Presenting complaints

During the interview client reported experiencing unexpected surge of intense fear and

discomfort peaking within minutes, accompanied by sweating, trembling, palpitation and

light headedness (Panic Attack) twice during the last three to four months. She also reported

Avoidance of certain activities (going out, playing sports), and fear of getting a panic attack

and embarrassing herself. She further reported “restlessness, excessive worry, palpitation

along with sinking feeling in the pit of her”. “Difficulty initiating sleep, irritability, difficulty

concentrating in academics” were also reported by client. She reported that occasionally he

goes “blank and zone out” when she is in class and sometime even with her friend. Low self-

image excessive calorie monitoring and restrictive food intake due to fear of gaining weight

were also reported. These symptoms appeared to have caused significant impairment in the

client’s daily functioning i.e., social, familial, and academic.

History of presenting complaints

Client reported living in a “critical” household where her parents always

demanded the best from her. Moreover, she was always compared to her sister who

was considered “prettier and better” in everything. Client reported that she used to get

“upset and disappointed” because of this. Whenever someone would Comment on her

looks she would wish to be pretty like other girls. She reported that while growing up

academics was the only thing in her hand which would bring her positive remarks and
therefore she always tried her best to get good grades. She reported that the praise

would further motivate her to do her best.

In 2019 during the wedding ceremony of her sister she reported being "bullied

by her relatives”, due to her weight. This incident upset her a lot and she started

feeling worthless and ugly. after this incident she started following strict diet plans.

Client reported that when she was in 2020 she was contracted COVID and she fell

sick, after recovering she lost a drastic amount of weight. When she went back to

university everyone praised her, she was flattered and decide to maintain that weight.

After that she started following strict dieting plans, which have her inner satisfaction.

She started feeling weak and she could notice that was nutrient deficient however she

decided to follow that plan. She was hospitalized once because of weakness and

doctor had prescribed her some nutrients. However, she did not leave abandon her

dieting plan.

At the same time, she was achieving highest grades in her class which

“boasted her self-esteem”. Client reported that since last year she was unable to get a

hold of her academics, she was struggling in some subjects and she was lagging

behind everyone. Client for the first time noticed the symptoms of "anxiety" when she

got a C grade in one of the subjects. “She could feel her heart beating very fast in her

ribcage, her hands were trembling, her mind was blank and she was unable to think

of anything”. She sat blankly for half an hour and then went to her hostel room. Client

reported that the next day she had her proposal defense and she was unable to defend

her topic, faculty had recommended her to revisit her topic and present again in next

semester (other students had defended their proposals). Client felt very "low of

herself" after that and felt that she was not "capable of doing anything". She was

scared that she might not be able to complete her degree. Client reported that she
would feel her "heartbeat escalating, she could feel her heart pounding in her chest

and butterflies in her stomach, she was facing difficulty in breathing properly", she

could feel dizziness and her thinking was cloudy. She could not focus on her

surroundings. One of her class fellows approached her and took her to her hostel. She

reported that she was too “numb” to think of anything and just kept lying in her bed.

She reported that the next day she was too embarrassed to face anyone; therefore, she

took a day off. After this incident she started ignoring everyone, she thought that they

would make fun of her. She reported that in December 2020, she was talking to her

younger sister on phone when suddenly everything went “blank and she could feel her

breathing getting ragged” she re-experienced all the symptoms that she experienced

on the day of her defense. She fainted and hostel management took her to medical

center where she was treated with “intravenous injections (did not know the name)

and GP advised her not to take any stress. She reported that she was too ashamed to

face her roommates and hostel management. However, they tried to put her at ease.

She reported that after that incident she would feel everyone’s eyes on her and they

would give her weird looks. Whenever she would feel any change in her body she

would be worried about having the symptoms again. She would imagine worst case

scenarios and avoided everyone.

Risk Assessment

Client reported rumination and hopeless ness however suicidal tendencies or self

harm behaviors were denied

Premorbid Personality

Client reported that she was a "reserved and shy" person before coming to university.

He would get "worried over small things very easily". He had a small circle of friends,
because everyone bullied her for her looks. She would deliberately avoid social situations and

she would use every bit of time he would find to study.

Personal History

Social History

Client reported having a small circle of friends. Growing up she reported being

bullied by others in school and college. However, in university she reported that she had lost

a significant amount of weight and the “bullying stopped”.

Academic History

Client reported that she had been a dedicated student since childhood. She would

always strive for the best. She never wanted to let her parents down therefore she would give

her hundred percent. She used to be the favorite student of her teachers. She got one of the

top positions in matric and inter exams and her parents were happy, they appreciated her a

lot. Her father wanted her to take admission in the university where she is currently studying.

She reported that after coming to university he struggled a lot here. Everything was disparate

here. She felt out of place and sometime even regretted her decision. He also reported that the

relative grading was a source of stressor for her, and she had difficulty competing with

others. The fact that she could not get the desired scores and she was unable to defend her

proposal topic was a source of constant distress for her. She seemed to be disappointed in

herself.

Sexual history

Client was in her late teenage. She reported she had never been in a romantic

relationship. She had studies in all girls’ school and college and had minimal interaction with

boys. While growing up she felt disguised by her appearance and she was “sure that no one
would like her ever”. This belief was perpetuated by critical remarks of her relatives. Now

there a lot of boys at her university she feels nervous talking to anyone and tries to avoid any

contact.

Health and Medical History

The client reported to have no major illness since her childhood. Even now he only

had some seasonal flu or fever. However, she did contract COVID in 2020 after which she

felt changes in her appetite, body shape and energy levels. No major psychological history

was reported in his family. The client’s father was a patient of hypertension. The client

reported no accidents and head injuries.

Family history

Client reported that her father was a businessman. Client reported that he had an

aggressive temperament, he was very religious and maintained discipline, and he was strict

with all of the family including client’s mother and cousins, and they were scared to talk to

him. Most of the discussions with him were mostly around academics or performance in

other activities. He demanded client to always get top position and client would get scolded

for not being able to do so. Client reported that she was scared to disappoint him, and she

would try his best to fulfill his expectations. Client's mother on the other hand was timid and

would rarely interfere in the matters. she would usually support his father and tried to

maintain discipline as she did not want to anger him.

Client had younger and an elder sister. She had a congenial relationship with both of

them. However, she was always compared with them and they were considered to be prettier,

which would disappoint her. Overall she considered to home environment be critical and

judgmental.
Strength and Coping strategies

Client appeared to be an ambitious and motivated person. She had been able to handle

all the stress during his inter and managed his studies and other activities even with certain

distress. Although she was well aware of her distress, she tried to alleviate it by improving

herself. Avoidant coping strategies and rumination was evident.

Mental status examination

The client appeared well kempt and on the interview day. Her appearance seemed to

be consistent with her reported age. She seemed to be well-mannered, and her personal

hygiene was maintained. Her gait seemed to be lazy. She kept fidgeting and shaking her leg.

She was occasionally squirming on her seat. Although she seemed to be much cooperative,

attentive, interested in session. She avoided eye contact most of the time. She was seemed to

be vigilant and listening actively. Her orientation of time and place was accurate. Her speech

was normal, and tone was soft. The quality of speech was emotional. Client’s mood was

appropriate with her affect; she was in dysthymic mood. Her thoughts were logical, goal

directed, appropriate, and relevant with the situation. It seemed that she was vigilant to

provide correct answers. Perceptual disturbances (hallucinations, delusions) were denied. she

had a fair insight about his problem, but she did not know what to do about it. she seemed to

hopeful about her future and concerns about suicidal ideation or self-harm not identified.

Client’s judgement appeared to be intact and information provided by her seemed to be

credible and informed.

Summary and conclusion

 A.A was 23 years old unmarried female from a lower middle socioeconomic class

family in Gilgit Baltistan. She was the 2nd born among three sisters. She was a 3rd semester

student of masters (environmental sciences) in a public sector university in Islamabad,

currently residing in university’s hostel. Client presented with symptoms of Panic Attack

(twice during the last three to four months) avoidance of certain activities (going out, playing

sports), fear of getting a panic attack and embarrassing herself, restlessness, excessive worry,

difficulty initiating sleep, irritability, difficulty concentrating in academics.

Client’s history and MSE revealed several factors which can be attributed to his

presenting complaints i.e social, familial, personal. Avoidant coping strategies were noted

which were also contributing to his current symptoms.

Diagnostic Formulation

The presenting complaints of the client are suggestive of 300.01 (F41.0) Panic

Disorder indicated by

• Unexpected surge of intense fear and discomfort peaking within minutes,

accompanied by sweating, trembling, palpitation and light headedness

• preoccupation with thoughts pertaining to her studies and future,

• Avoidance of certain activities (going out,

• Fear of getting a panic attack and embarrassing herself

• excessive worry and restlessness,

• lack of energy

• difficulty initiating sleep

• difficulty concentrating and occasionally zoning out

• These symptoms appear to have caused significant impairment in the client’s daily

functioning i.e., social, familial, and academic.

Keeping all of the above-mentioned symptoms in view and the duration (two full blown panic

attacks in past four to five months, followed by dizziness and hospitalization), the provisional

diagnosis can be Panic Disorder.

Additionally, preoccupation with self-image, excessive calorie monitoring and restrictive

food intake puts client at risk for eating disorder. However, the intensity and duration of

current symptoms do not meet the criteria for a full-blown diagnosis.

Differential Diagnosis

Depressive disorders could be accessed as client reported rumination, sleep

disturbance and lack of energy however, they appeared in the context of symptoms of anxiety

and they appeared be presentation of panic disorder. Moreover, pertinent features of

depressive disorders i.e., low mood, hopelessness or lack of interest were not reported.

Social Anxiety can also be accessed as client reported excessive worry and

restlessness pertaining to social situations. However, client’s worry was pertinent of having a

panic attack and embarrassing herself rather then fear of negative evaluation as in SAD,

therefor these symptoms appeared to be presentation of panic disorder.

GAD can also be assessed as client exhibited excessive worry and difficulty

concentrating however client’s symptoms were less pervasive and generalized as in GAD.

Client’s anxiety was pertinent to specified areas i.e., self-image, grades and fear of having a

panic attack.

The client was assessed for manic episode with irritable mood or mixed episodes as

she had reported “irritated mood”. However, he denied any history of elevated mood, inflated

self-esteem, decreased need for sleep, more talkative than usual or any of the related

symptoms. Therefore, Bipolar Affective disorder was ruled out.

Client was assessed for obsessive-compulsive disorder as he reported being

preoccupied with thoughts and they were causing significant distress. However, these

thoughts did not appear to be intrusive, they seemed to be a manifestation of rumination their

focus was mainly the forthcoming event rather than unwanted and intrusive images and urges

in OCD. The thoughts were mood congruent, as she had those thoughts mostly when he was

“anxious”. Therefore, OCD was ruled out.

Case conceptualization

A.A was 23 years old unmarried female from a lower middle socioeconomic class

family in Gilgit Baltistan. She was the 2nd born among three sisters. She was a 3rd semester

student of masters (environmental sciences) in a public sector university in Islamabad,

currently residing in university’s hostel. Client presented with symptoms of Panic Attack

(twice during the last three to four months) avoidance of certain activities (going out, playing

sports), fear of getting a panic attack and embarrassing herself, restlessness, excessive worry,

difficulty initiating sleep, irritability, difficulty concentrating in academics. Clinically these

symptoms were suggestive of Panic disorder. Additionally, low self-image, excessive calorie

monitoring and restrictive food intake due to fear of gaining weigh puts client at risk for

eating disorder.

Client’s vulnerability can be traced back to her early life experiences, home

environment as well as her temperament. Client was always “required” to do her best in

academics, she was always compared to her sister who was considered to be “prettier”.

Critical remarks about her looks might had generated feelings of “self-inadequacy” which she

tried to compensate with academic achievement. Academic success and “perseverance and

effort to achieve highest grades” was the only source of praise as well as social recognition.

This reinforced her to strive for perfectionism. Client started avoiding social contacts to avoid

“criticism” about her looks, this avoidance gave her short term relief and reinforced long term

unhealthy behaviors. Client also started monitoring her diet and calories intake to lose her

weight. Client tended to foster an external locus, and started identifying happiness in terms of

behavioral control (academic success and monitored calories intake). This also seemed to

contribute to development of rigid thinking patterns i.e., need to control thoughts and

deficient learning, difficulty facing contingencies, overgeneralization, selective abstraction.

Client also seemed to adopt a shy and reserve temperament and avoided unnecessary social
contact which appeared to be another predisposing factor for her. She also seemed become

vigilant about signs of rejection and tried to avoid them by altering herself according to the

situational demands. This long-standing strategy about having to stay vigilant against

rejection, coupled with beliefs that her internal resources were not enough to cope with, could

have contributed towards feelings of foreboding for the future. Further. negative views about

herself (I am not good enough) others, (they are judgmental and critical) and the world (world

is so unfair and cruel) tended to develop.

Client’s concerns about her looks were triggered during the wedding ceremony of her

elder sister where she was criticized by her relatives for not being as prettier as her sister and

not getting any proposal for because of her looks. Client was embarrassed about these

remarks and she started to further control her diet and because more conscious of her looks

after this incident. Client adopted a series of safety behaviors to shun critical remarks i.e.,

wearing full sleeves, avoiding social contact which further exacerbated the situation.

Universities environment further perpetuate her negative beliefs about herself. Not being able

to make friends fed negative belief (not being good enough) about herself at the same time

not being able to get the “perfect grades” further contributed to lower self-esteem. Client’s

symptoms peaked after she was unable to perform well in her end of semester exams which

also became the trigger for her panic attack for the first time. The loop of panic, sensation to

catastrophic cognitions, back to heightened sensations led to a full blown panic attack.

Anticipatory anxiety and heightened vigilance towards the physical sensations further

perpetuated problem. Fear of having a panic attack in future (embarrassing herself in hostel)

led to pervasive avoidance, which consolidated the fear response. This avoidance appeared to

serve as negative reinforcement as it served as short-term effective solution for the problems

and exacerbated the problems in longer run. As client’s semesters proceeded to end, she

became more worried about not being able to completer her research work, her overall
distress peaked, rumination and catastrophizing made her more anxious and at the same time

encouraged avoidance, perpetuating the cyclic process. Avoidant coping strategies and low

social support were additional concerns.

Treatment Formulation

Treatment plan can be formulated based upon the following factors:

• Psychoeducation about symptoms of panic attack and its biological basis.

Understanding of panic as a false alarm and fear response to protect the body

• Reduction of physical symptoms of anxiety via breathing exercises and mindfulness

• Identification and reduction of attentional biases

• Fostering social skills to make friends

• Identification and evaluation of catastrophic cognitions and their interpretation i.e., I

will faint, I will embarrass myself

• Identification and evaluation of negative views about self, to improve her self-image

(improving eating behaviors)

• Reduction of conditioned anxiety response and fear of somatic sensations

• problem solving strategies including distress management.

• Resumption of recreational activities i.e., sports to form healthy coping strategies.

• client's symptoms appear to be a presentation of her "trait" more than state as

indicated by her premorbid history; therefore, the personality features need to be

further examined and kept into consideration for treatment planning.