Case Report Sample

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Internship Case Reports
Submitted by:
Name
Roll No
Student of Bachelor of Science in Psychology
Semester: 7th
Session:
Dated:
Submitted to:
Ms. ------
Lecturer
Department of Psychology
Government College Women University Sialkot

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Case Summary
The client F.M. was a 12 years old female child, taken by the trainee psychologist
from the community as part of her coursework requirement with the presenting complaints of
feelings of being unloved, being a failure, and, feelings of inferiority over the last 1.5 years. The
assessment was done both on the informal level and formal level. For informal assessment clinical
interview, behavior observation, and subjective ratings of the problematic behaviors were done.
For formal assessment, the Rosenberg Self-esteem Scale (RSES) was administered. The
conclusion was made on the basis of an informal and formal assessment that the client had low
self-esteem. The techniques, Psychoeducation, Examining the evidence, Positive statements, and
Distinguishing progress from perfection were recommended to the client. Only two sessions were
conducted with the client.

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Biodata
Name F.M
Age 12 years old
Gender Female
Religion Islam
Education 5th class
No. of Siblings 2 sisters
Birth order 2nd born
Marital Status Unmarried
Occupation Student
Socioeconomic Status Middle Class
Informant Client herself
Source of Referral and Presenting Complaints
The client was taken by the trainee psychologist from the community as a part of her
coursework requirement.
Table No. 1
Table of Presenting Complaints According to the Client
Duration Presenting Complaints Sr. No.
1.5 years Mjhy lgta h k koi mjhsy pyr nh 1.
krta
1.5 years Mjhy lgta h k main failure ho 2.
1.5 years Mjhy lgta h k m kmtr ho 3.

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Interview Information
History of Presenting Complaints:
The age of client was 12 years old with complaints of a feeling of inferiority, being unloved,
and being a failure for the last 1.5 years. The client reported that at the age of 10 when she was in
class 3, she did not get 1st position in her class and stood 5th in her class because she changed her
school and found difficulty in understanding the oxford syllabus. Her parents did not appreciate
her and compare her with her sister who always stood first in her class. When she came home she
was somehow fearful and went to her mother and showed her the result card and appreciation
certificate. The client reported that her mother rebuked her and said, “Learn something from your
sister, she always stood first, and you!” The client got hurt, went to her room, started weeping, and
thought that no one loved her, why my mother did not consider the cause of my 5th position. At
night when her father came home from his job, he did the same with her. The client felt ashamed
of herself and thought that she was a loser. The client reported that in class 4 she got 8 th position.
According to the client, her sister also discouraged her by saying “I’m better than you”, and the
client felt inferior herself. The client reported that her family always compared her with her sister
every time, even on small household chores. When the trainee psychologist asked the client about
any incidence, she reported that once a glass was broken by her by mistake, her mother rebuked
her and told her that she always did wrong.
The trainee psychologist asked her that did she ever feel like that she was being compared
with her sister before 1.5 years. She reported that she was being compared but only in some little
mistakes. She told that she did not get hurt much more than now because her position in class 4
down due to inconvenience in understanding the oxford syllabus and parents did not consider this
reason. When the trainee psychologist asked the client that did she think she had negative
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thoughts? She claimed that sometimes she thought that she had negative thoughts such as, “I am
not good at all and no one loves me”, which caused problems but most of the time the behavior of
my family proved me right that I am a failure and inferior to others.
Background Information
Family History
The client lived in a nuclear family. The mother of the client was 45 years old. She was a
housewife. She was matriculated. The mother of the client was physically fit. She did not have a
congenial relationship with the client but she had a congenial relationship with another daughter.
Because the client’s family gave much importance to education and was strict to get the highest
marks in the class. As the client did not get the first position (highest grade) after grade 3 due to
adjustment issues in the new school. So the mother of the client often rebuked her on educational
tasks as well as household chores.
The father of the client was 47 years old and worked in the private sector. He was an F.A.
He took charge of the family. He also did not have a congenial relationship with the client and
compared the client with her elder sister. He often rebuked the client. He had a congenial
relationship with his wife and another daughter.
The client’s sister was 16 years old and studied in the 10th class in a government school.
She was an intelligent student and a topper in her class. She often taunted the client and considered
herself superior to the client because she got the first position in every class and did her household
tasks more effectively and the parents praised her more than the client. She did not have a
congenial relationship with the client.
Marital History
As the client was unmarried so she had no marital history.

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General Home Environment
The socioeconomic status of the client was middle class which was observed by the
estimated amount of the client’s family income. The client reported that they spent less time
together. The mother was busy the whole day in household chores and the father came late at night
from his job after having dinner and went to the bedroom to rest. It happened rarely they sat
together and spent quality time with each other. They did dinner together sometimes and most of
the time the client and the sister of the client had dinner before the father reached home from his
job.
Personal History
According to the client, the mode of birth was a cesarean section. Her weight was normal
at the time of birth. There was no injury or medical illness. According to the client she had achieved
her milestones as a normal person. The client reported that once he heard from her mother that her
first cry was present. The client was easy child and started schooling at the age of 5 years.
Educational History
At the age of 5 years in 2014, the client started schooling. She reported that her first
experience at school was good. She was an intelligent student. Sometimes she took part in
extracurricular activities. The client reported that she stood 1st in the class till class 2, but in class
3 she got 5th position due to the oxford syllabus. She got 8th position in class 4 because she started
to consider herself inferior and could not focus on her studies as much as before, as her parents
always compared her with her sister and told her that her sister was better than she. Her relationship
with teachers was congenial. She had only 2 friends with whom she also had a congenial
relationship.
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Occupational History
There was no record of occupational history because the client belonged to a well-off
family and he was a student.
Sexual History
Sexual history was not recorded because the client did not get puberty yet.
Behavior during Session
The client’s dressing was weather appropriate. She was sitting on the chair comfortably.
She did not show any neurotic behavior. She actively respond to every question that the trainee
psychologist asked. She maintained eye contact. Her voice tone was low-pitched. The client was
cooperative throughout the session and had a congruent mood and affect.
Psychological Assessment
A psychological assessment is a process used to test an individual’s mental health and
emotional well-being. It is used to identify problems and potential concerns, as well as to
recommend treatments or therapies (Reynolds, 2021).
It was done on two levels:
i. Informal Assessment
ii. Formal Assessment
Informal Assessment
Informal assessments are assessment procedures that are used in informal situations. These
settings include settings that are not structured in nature. Informal assessments are developed to
assess certain aspects of a situation (Neukrug & Fawcett, 2010). The following methods of
informal assessment were used:
 Clinical interview
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 Subjective rating
Clinical Interview
A clinical interview is a tool that helps physicians, psychologists, and researchers to make
an accurate diagnosis of a variety of illnesses (Kelly, 2019). It is the type of informal assessment
in which the client or informant gives detailed information about the presenting complaints and
their causes. The client was ensured confidentiality. On the willingness of the client, the history of
presenting complaints and background information was taken by the trainee psychologist.
Subjective Rating
A subjective rating is a rating that a person gives based on their opinions, feelings,
etc. It is generally done on a scale from 0, no significance to 10, highly significant (Allen, 2022).
Table No. 2
Table of Subjective Ratings According to the Client
Problems Severity
1. Feeling of being unloved 9
2. Feeling of failure 8
3. Feeling of inferiority 10
Formal Assessment
For formal assessment, the trainee psychologist used the Rosenberg Self-esteem Scale
(RSES).
Rosenberg Self-esteem Scale
The Rosenberg self-esteem scale is a ten-item self-report measure of global self-esteem
developed by Dr. Morris Rosenberg in 1965. It was developed by Dr. Morris Rosenberg as a
measure of global self-esteem, one’s overall sense of being a worthy and valuable person
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(Rosenberg 1965). It was originally developed as a Guttman scale but is typically administered
with a 4-point Likert response format (with scale points corresponding to Strongly Agree, Agree,
Disagree, and Strongly Disagree). The internal consistency ranges from 0.77 to 0.88 and the
criterion validity is 0.55. The cut-off score of the scale is below 15.
Quantitative Analysis
Table No. 3
Table of Quantitative Analysis of Rosenberg Self-Esteem Scale
Total Score Client’s score Category
30 7 Low self-esteem
Qualitative Analysis
The item no. 3 which measured the feeling of failure ensured the presenting complaint,
being failure, of the client. The 7 score of client on the Rosenberg Self-esteem Scale indicates that
the client had low self-esteem.
Conclusion
Through the formal and informal assessment of the client and on the basis of the presenting
complaints such as a feeling of inferiority, being unloved, and failure it is concluded that the client
has low self-esteem.
Prognosis
On the basis of the client’s social support and insight of the client, the prognosis is 50%. It
may be 100% if the family support of the client will be good.

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Recommendations
Table No. 4
Table of Recommendations for the client by the trainee psychologist
Short Term Goals Techniques
Aim to provide knowledge to the client and the Psychoeducation
family about the illness, so that better It is the process of teaching clients with mental
outcomes will come out. illness and their family members about the
nature of the illness, including its etiology,
progression, consequences, prognosis,
treatment, and alternatives (Sarkhel, Singh &
Arora, 2020).
Aim to change the negative thought of being Examining the evidence
unloved by examining the evidence of that This is the CBT technique in which the
automatic thought. therapist asks the client to examine the
evidence for and evidence against the
automatic thoughts. (Leahy, 2017)
Aim to change negative thoughts, such as Positive statements
being a failure and inferiority, of the client The purpose of positive statements is to put a
which lead to low self-esteem. stop to the thoughts that lead to low self-
esteem and to replace those thoughts with
realistic, rational thoughts (Damme, 2008).

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Aim to help the client and her parents to realize Distinguish progress from perfection
that being productive is better and different This technique examines the advantages of
from being perfect trying to improve rather than trying to be
perfect. (Leahy,2017)
Limitations
 Formal setting was not available to conduct sessions because interview was conducted in
client’s house.
 The environment where interview was conducted contained too many distractions such as
client’s sister came in the room in the middle of the interview.

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Differential Diagnosis of low self-esteem
Depressive disorder
Depression is characterized by a sad mood, loss of interest, and feelings of worthlessness.
The client had feelings of worthlessness and failure but she did not have a depressed mood or lack
of interest in activities.
Generalized anxiety disorder
It is characterized by excessive worry and anxiety with physiological symptoms such as
irritability, muscle tension, and restlessness. The client had worries about the future but she did
not have physiological symptoms of anxiety

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References
Allen, D. (2022). Subjective Rating and Ranking. Retrieved from
https://www.isixsigma.com/dictionary/subjective-rating-and-
ranking/#:~:text=Subjective%20rating%20is%20a%20rating%20that%20a%20person,a%
20set%20of%20items%20according%20to%20given%20criteria.
Ed Neukrug, R. C. (2010). Essentials of Testing and Assessment: A Practical Guide for
Counselors, Social Workers, and Psychologists (2 ed.). Thomson/Brooks/Cole, 2010.
Retrieved from
https://books.google.com.pk/books/about/Essentials_of_Testing_and_Assessment.html?i
d=GcO0PwAACAAJ&redir_esc=y
Kelly, O. (2019). How Clinical Interviews Help Diagnose Mental Illness. Verywell Mind.
https://www.verywellmind.com/structured-clinical-interview-2510532
Leahy, R. L. (2017). Cognitive Therapy Techniques: A Practioner's Guide. New York: The
Guilford Press.
Reynolds, C.R., Altmann, R.A., Allen, D.N. (2021). The Problem of Bias in
Psychological Assessment. In: Mastering Modern Psychological Testing. Springer, Cham.
https://doi.org/10.1007/978-3-030-59455-8_15
Rosenberg, M. (1965). Rosenberg Self-Esteem Scale (RSES) [Database record]. APA PsycTests.
https://doi.org/10.1037/t01038-000
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Sarkhel,S., Singh, O.P. & Arora,M. (2020). Clinical Practice Guidelines for Psychoeducation in
Psychiatric Disorders General Principles of Psychoeducation. Indian J. Psychiatry, Vol. 62
(2). 10.4103/psychiatry. Indian. J psychiatry _780_19.

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Daily Session Report
Client: F.M Session:
Trainee Psychologist: Tentative Diagnosis: Low Self-Esteem
Date Summary of Session Sign. Of
Supervisor
28-11-22 The first session was conducted on 28th Nov 2022 at the
client’s house. In this session, the trainee psychologist first
introduce herself to the client, and then assured the client
about the confidentiality of her information. On the
willingness of the client, the trainee psychologist started the
session. In first session, presenting complaints of the client,
causes of symptoms, and background history were taken.
The client was informed that only 2 sessions will be
conducted. The session was ended after 45 minutes.
29-11-22 This was the last session which was held on the 29th of Nov,
2022. In this session, the formal and informal assessment
was done and the client was psycho-educated the client
about the presenting complaints. The duration of the session
was 40 minutes.
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Case Summary
The client A.I. was a 21 years old male, taken by the trainee psychologist from the
rehabilitation center as part of her coursework requirement with the presented complaints of
craving for cannabis, anger, and reduced social activities from the last 1.5 years. The assessment
was done on both informal level and formal level. For informal assessment clinical interview,
behavior observation, subjective ratings of the problematic behaviors and mini-mental-state
examination (MMSE). For the formal level the Cannabis Use Problem Identification Test (CUPIT)
was administered. The conclusion was made on the basis of an informal and formal assessment
that the client had a 305.20 (F12.10) cannabis use disorder with mild severity and specify with, in
a controlled environment. The techniques, Psycho-education, Aversive therapy, Relapse
prevention, and Detoxification were recommended to the client for the betterment of life. Only 1
session was conducted with the client.

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Bio data
Name A.I
Age 21 years
Gender Male
Religion Islam
Education F.A.
No. of Siblings 1 child only
Birth order 1st born
Marital Status Single
Occupation None
Informant Client himself
The client is taken by the trainee psychologist from the rehabilitation center, as a part of
her course requirement.
Table No. 1
1.5 years Chars lny ka bar bar dil krta h 1.
1.5 years Gussa ata hai 2.
1.5 years Chars ki wja sy social 3.
activities km ho gai hai

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History of Presenting Complaints
The client was 21 years old using cannabis for the past 1.5 years. He was admitted in the
rehabilitation center almost one week ago with the presenting complaints of carvings for cannabis,
anger issues and reduced social activities. The client reported that when he was studying in the 3rd
semester of BS he made friends older than he. They were senior students studying at her university.
According to the client, his friends smoked cigarettes filled with cannabis and they often persuaded
him to smoke. One day on his friend’s birthday, they were playing and his friends dared him to
smoke a cigarette filled with cannabis. He refused to complete the dare but his friends told him
that it’s just like a common cigarette and it is not a big deal to smoke. On friends’ pressure, he
smoked. After smoking, he had nausea and headache. On his condition, his friends were trying to
calm down him and saying that it was the first time that’s why you experienced this and when
you’ll be used to then you’ll feel pleasure. The next day, he again smoked at his friends’ demand.
His body eventually developed a tolerance for cannabis. He bunked classes most days and sat with
friends to smoke. His performance became poor and dropped out due to F grades. Day by day he
had a strong urge for cannabis and had anger issues. He showed aggression toward his family and
throw things on the floor. His relationship with his friends became worse because of his aggressive
behavior and it reduced his social activities. Due to behavioral changes such as anger, his parents
came to know about his substance use i.e. cannabis. His parents became shocked after knowing
this because he was an apple of his parent’s eye and they were nourishing him very well. His father
took him to the rehabilitation center for the betterment of his life.
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Family History
The client lived in a nuclear family. The age of client’s father was 55 years old and he was
the source of income. He had his own crockery shop. He had a congenial relationship with the
client even after knowing about the use of a drug.
The mother of the client was 50 years old and she was a housewife. She showed more love
and care toward the client even after knowing about her son’s use of a drug. She had a congenial
relationship with the client.
Marital History
The client has no marital history as he was unmarried.
The socioeconomic status of the client was upper middle class. The client’s father was the
source of income for his family and took decisions. His mother managed household chores. They
spent quality time with each other before the use of cannabis. Now he was in the rehabilitation
center. His father came there to meet him.
Personal History
The birth mode of the client was normal. There was no physical injury or illness during
childhood. His mother did not face any complications during and after birth. The first cry of the
client was present. The client reported that he achieved his milestone as a normal person. His
socialization was good before the use of cannabis.
Educational History
The client started schooling at the age of 5 years in 2006. He did not like to go to school
that’s why he showed stubborn behavior, cried, and refused to go to school. He was an average
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student. He scored passing marks in school. He had many friends. His relationship with friends
and teachers was congenial.
He did his matriculation with 69% marks at the age of 16 years in 2017 and passed his
intermediate examination with 71% marks in 2020. He joined a government university at the age
of 19 years in 2021. He was in 3rd semester of BS Urdu when he dropped out due to F grades. His
relationship was not congenial with friends after using cannabis due to anger issues.
The client had no occupational history because he was admitted to the hospital and before
admitting the hospital he also did not work anywhere.
Sexual History
The client achieved puberty at the age of 16 years. He reported that his friends guided him.
His behavior in response to puberty was normal.
Premorbid Personality
The client reported that before the use of cannabis, he had healthy relationships with family
and friends. He had a calm personality and could not get angry easily. He played video games in
his leisure time.
Behavior during session
The client was cooperative throughout the session. He was sitting comfortably on the chair.
His dressing was weather appropriate. He actively answered every question to the trainee
psychologist. There was not any neurotic behavior.

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A psychological assessment is a process used to test an individual’s mental health
and emotional well-being. It is used to identify problems and potential concerns, as well as to
iii. Informal Assessment
iv. Formal Assessment
Informal Assessment
settings include settings that are not structured in nature. Informal assessments are developed,
aimed at assessing certain aspects of a situation (Neukrug & Fawcett, 2010).
Clinical Interview
their causes. Information about the family background history and personal history is also
collected.
The client was ensured confidentiality. On the willingness of the client, the history of
Subjective Rating
A subjective rating is a rating that a person gives based on their opinions, feelings,
etc. It is generally done on a scale from 0, no significance to 10, highly significant (Allen, 2022).
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Table No. 2
Table of Subjective Rating According to the Client
Problems Severity
1. Cravings for cannabis 9
2. Anger 7
3. Reduced social activities 6
Mini-Mental State Examination (MMSE)
The Mini-Mental State Examination (MMSE) first developed by Folstein in 1975, has
become the most recognized tool for assessing an individual's cognitive state. It assesses six areas
of cognitive ability for a maximal score of 30 points (Ciolek, C.H. & Lee, S.Y., 2020).
Table No. 3
Table of Quantitative Analysis of Mini-Mental State Examination (MMSE)
Total Score Client’s Score Category
30 30 No cognitive impairment
The score of the client on the Mini-Mental State Examination (MMSE) indicates that the client
has no cognitive impairment. The client was well aware of the time, place, and location. He
answered all the questions accurately.
Formal Assessment
For the formal assessment, the trainee psychologist used Cannabis Use Problems
Identification Test (CUPIT).

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Cannabis Use Problems Identification Test (CUPIT)
It is a brief self-report screening instrument for the detection of current and potentially
problematic cannabis use (Bashford, Flett & Copeland, 2010). It consists of 16 items. The cutoff
score is 12. This scale has 0.92 reliability.
Table No. 4
Table of Quantitative Analysis of Cannabis Use Problems Identification Test
Total Score Client’s score Category
82 37 Adult or adolescent meets the
criteria of current Cannabis
Use Disorder.
The client scored 37 on Cannabis Use Problem Identification Test (CUPIT) which falls under the
category where adult or adolescent meets the criteria for Cannabis Use Disorder.
Conclusion
According to the client’s presenting complaints, it was concluded that he presented
symptoms of 305.20 (F12.10) Cannabis Use Disorder with a mild severity and specify with in a
controlled environment.
Prognosis
The prognosis of the client was good because he had parental support and good insight.
There were no financial issues for treatment. As the client was admitted to the rehabilitation center
and the severity of the disorder was mild which showed that the client had a good prognosis.
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Recommendation
The techniques primarily based on Behavior Therapy were used for the management of the
client’s problematic behavior.
Table No. 5
Table of the Recommendations to the Client by the Trainee Psychologist
Short-term Goals Techniques
Assisting the client and her family for a better Psychoeducation
understanding of his problem. It is the process of teaching clients with mental
illness and their family members about the
nature of the illness, including its etiology,
progression, consequences, prognosis,
treatment, and alternatives (Sarkhel, Singh &
Arora, 2020).
Pair the substance use with some aversive Aversive Therapy
stimulus to reduce the cravings for cannabis. It is used to help a person give up a behavior
or habit by having them associate it with
something unpleasant (Plaud, 2020).
Help the client to give control over his Relapse Prevention
substance-related behavior and to build It is a type of cognitive-behavioral therapy that
awareness about triggers. aims to limit or prevent relapses by helping the
therapy participant to anticipate circumstances

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that are likely to provoke a relapse (Marlatt &
Donovan, 2005).
Help the client to decrease the amount of Detoxification
substance use by taking smaller doses until he Detoxification is a set of interventions aimed
is off the drug at managing acute intoxication and
withdrawal. It denotes a clearing of toxins
from the body of the patient who is acutely
intoxicated and/or dependent on substances of
abuse (Kleiner, 2018).
Limitations
 Due to only 1 session, rapport could not be built with the client.
 Due to limited time and only 1 session, an informal assessment could not be done in detail.
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Differential Diagnosis of Cannabis Use Disorder
Non-problematic use of cannabis
In non-problematic use of cannabis, the individual has no behavioral problems or
impairment in relationships but the client had interpersonal problems with friends and family.
Other mental disorders
Cannabis use disorder may be characterized by the symptoms that resemble primary mental
disorders such as lack of social activities resembles depressive disorder but the client had these
symptoms due to the use of cannabis.
Alcohol use disorder
It is characterized by problematic behavioral or psychological changes such as aggressive
behavior or impaired judgment due to the use of alcohol. But the client showed problematic
behaviors such as anger due to the use of cannabis.
Stimulant use disorder
It is characterized by behavioral and psychological changes along with somatic
disturbances due to the excessive use of stimulants. The client had behavioral changes due to canis
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References
Arévalo‐Rodríguez, I. (2015). Mini‐Mental State Examination (MMSE) for the detection of
Alzheimer's disease and other dementias in people with mild cognitive impairment (MCI).
Cochrane Database of Systematic Reviews, 1.
doi:https://doi.org/10.1002/14651858.CD010783.pub2
Bashford, J., Flett, R., & Copeland, J. (2010). The Cannabis Use Problems Identification Test
(CUPIT): development, reliability, concurrent and predictive validity among adolescents
and adults. Addiction, 105(4), 615–625. https://doi.org/10.1111/j.1360-
0443.2009.02859.x
Coker, A. O. (2018, July 16). Psychometric properties of the 21-item Depression Anxiety Stress
Scale (DASS-21) | African Research Review.
https://www.ajol.info/index.php/afrrev/article/view/174532
Retrieved from
Kleiner. P. (2018) .https://www.jospt.org/doi/full/10.2519/jospt.2018.7432

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https://doi.org/10.1007/978-3-030-59455-8_15
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DAILY SESSION REPORT
Name of Client: A.I. Tentative Diagnosis: Cannabis
Use Disorder with moderate severity
Name of Therapist: Date of Intake: 7th Dec, 2022
Sr.No Date Summary of Session Sig.
1 07,12,2022 The session started in the office of the rehabilitation center.
The trainee psychologist introduced herself and ensured
confidentiality to the client. The trainee psychologist took the
client’s history of presenting complaints and background
history. As it was only one session, the informal and formal
assessment was also done. For the informal assessment
subjective ratings of the presenting complaints by the client
were taken and MMSE was used. CUPIT scale was used for
formal assessment. The client was informed that it will be the
only session and again ensured confidentiality.

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Case Summary
The client R.N. was a 22 years old female, taken by the trainee psychologist from the
community as part of her coursework requirement with the presenting complaints of stress,
irritable mood, fear of failure, and fear of least amount of time to complete tasks, from the last 2
years. The assessment was done on both informal and formal level. For the informal assessment
clinical interview, behavior observation, subjective ratings of the problematic behaviors and mini-
mental-state examination (MMSE) were done. Depression Anxiety and Stress Scale-21 (DASS-
21) was used for the formal assessment. The conclusion was made on the basis of an informal and
formal assessment that the client had severe stress. The techniques, Psycho-education, Deep
breathing for relaxation in a time of stress, and the Eisenhower Matrix for time management are
recommended to the client. Only two sessions were conducted with the client.
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Biodata
Name R.N
Age 22 years old
Gender Female
Religion Islam
Education BS 7th Semester (English)
No. of Siblings 2 (sisters)
Birth order 3rd born
Marital Status Unmarried
Occupation Student
Informant Client herself
The client was taken by the trainee psychologist from the community as a part of her
coursework requirement.
Table No. 1
2 years Stress hota hai 1.
2 years Chircharapan hota hai 2.
2 years Nakami ka khoof hota hai 3.
2 years Jab koi kam karny ky liye khas 4.
waqt dia jata hai to lagta hai k

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wqt guzarta ja rha hai or kam
wqt reh gya hai
History of Presenting Complaints
The client was 22 years old female with the symptoms of stress, irritable mood, fear of
failure, and fear of the least amount of time to complete tasks, from the last 2 years. When trainee
psychologists asked her to explain when these symptoms started, she reported that online education
started during the period of covid-19, and she faced such problems. She could not study at home
as there were some distractions such as internet issues, interruptions from outside the house, and
household work. She also added that she got stressed when her internet was not working well
during the lecture. She thought that something important will be missed by her. When the call
disconnected just before the end of the lecture due to poor connection, she stressed and thought
that the teacher would not consider her present even though she was present in the class and would
be marked as absent. During a stressful period of online classes when her call disconnected, she
started to cry and she thought that she was mistreated because the teacher did not consider her
presence during the whole lecture. But later she shared her feelings that she was mistreated and
the teacher did not consider her presence, with her best friend. When she talked about stress, she
felt relaxed.
She also had some time management issues. As she faced difficulty in completing tasks
within deadlines, she reported that she had a fear of failure when a certain time period is associated
with any task. She thought that she will not be able to submit her task and will have regret for that.
Even though the task is very simple but due to time specifications that simple task became
complicated. According to the client, the time management issues started when her teacher gave
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an assignment with a very short deadline of 2 hours and she could not complete her assignment
timely because electricity had gone and her mobile internet was not working well too. The teacher
insulted her for a late submission. It had happened to her during the pandemic situation of covid-
19.
She reported that if 2 hours are given to complete a single assignment, she was starting to
be worried when even though only half an hour has passed and one and a half hours were left.
When the trainee psychologist asked what she felt and how she behaves in a time of stress, she
reported that she had an irritable mood. She added that she tried to reduce such symptoms by self-
motivation, asking herself, “You can do it,” and by deep breathing. According to the client, her
level of stress became low by doing this.
Family History
The client lived in a nuclear family. The client’s mother was 52 years old and s a housewife.
Her education was F.A. She was a BP patient and used medicines to control her BP. The client
reported that she was much concerned about her mother’s illness and always tried to make her
mother happy. Her mother was polite and had a congenial relationship with the client.
The age of the client’s father was 60 years. Her father worked in a factory. He had a
congenial relationship with her daughters. As client reported that her father had a moderate level
of depression and got treatment from a doctor. The history of depression in her father started before
her birth because her father was jobless and there were many financial crises.
The client had 2 sisters. One of her sisters was 26 years old and she had completed her 16
years of education. She taught in a private school. Another sister was married and 30 years old.
They lived friendly with each other and had a congenial relationship with each other.
34
Marital History
As the client was unmarried so she had no marital history.
The socioeconomic status of the client was middle class. According to the client, the home
environment was friendly. Her father was the source of income. Her mother took the charge of the
house and managed all the expenses with limited resources. Her mother and father took the
decisions with mutual understanding. Her relationships with her parents and siblings were
congenial. According to her, whenever her parents and her siblings were worried she also became
worried. As part of normal life, siblings quarrel with each other and after a while, everything got
better by mutual understanding. The client reported that sometimes she felt that nobody understood
her, but her thoughts became clear at another moment when she understood that she was wrong.
According to the client, she spent her quality time with her siblings and parents. Every weekend
she played indoor games with her father and helped her mother in making food. Her sisters guided
her about daily life situations.
Personal History
The client’s mode of birth was normal. The client reported that her first cry was present.
Her mother did not face any complications during and after her birth. When trainee psychologists
asked about her weight at the time of birth, she reported that she did not know. There was no illness
or injury during childhood for the client. According to the client, she achieved her milestones as a
normal person and was an easy child. Her socialization throughout her life was good.
Educational History
The client started schooling at the age of 5 years in 2005. On the first day of school, she
cried and refused to sit in the classroom. But after 1 week she went to school happily because she
35
made 4 friends. She reported that she was one of the brilliant students in her class. She did her
matriculation in 2016 with 80% marks. She joined the college at the age of 17 years on a
scholarship in 2017. She passed the intermediate exams in 2019 with 79%. In 2019, at the age of
19, she got admission to a university. She always took part in extracurricular activities and worked
hard to achieve her desired goals. Her relationship with friends was congenial. She also reported
that her relationship with peers and teachers were going well during college but in university, her
relationship with teachers became reserved because she experienced the over-strict behavior of
one teacher, and then she generalized it to all other teachers and hesitated to ask a question in the
class. Her grades at university are also good but faced difficulty in managing time for study since
the time of pandemic when she missed the due date of her submission. After that, she had the fear
of least amount of time to complete any task.
As the client was completing her education and did not do any job, that’s why she did not have
occupational history.
Sexual History
The client achieved puberty at the age of 13 years. She reported that her reaction to puberty
was surprising. She thought, at the time of puberty, that a serious illness had occurred. Her mother
educated her. At the start, she felt shy in front of her mother and sisters but after a period of time,
she adjusted herself. The client had no romantic relationships.
Premorbid Personality
Before the symptoms, the client managed her daily tasks without being stressed. She had
not faced any time managing problems. She was more extroverted than now. She could easily
36
express her feelings in front of others. Her mood mostly remained cheerful. She preferred to spend
time with her family in her leisure time.
Behavior during sessions
Her behavior was cooperative throughout the session. She understood all the questions and
respond according to them. But she took a time to answer the questions which seemed that she
tried to extract some information from her unconscious mind. The client was well dressed. She
maintained eye contact. Her pitch of sound was neither loud nor slow and comfortably seated on
a chair. She had a congruent mood and affect.
A psychological assessment is a process used to test an individual’s mental health
and emotional well-being. It is used to identify problems and potential concerns, as well as to
v. Informal Assessment
vi. Formal Assessment
Informal Assessment
settings include settings that are not structured in nature. Informal assessments are developed,
aimed at assessing certain aspects of a situation (Neukrug & Fawcett, 2010). The following
informal assessment was done:
 Clinical interview
 Subjective rating
 Mini-mental state examination

37
Clinical Interview
their causes. Information about the family background history and personal history was also
collected. The client was ensured confidentiality. On the willingness of the client, the history of
Subjective Rating
A subjective rating is a rating that a person gives based on their opinions, feelings, etc. It
is generally done on a scale from 0, no significance to 10, highly significant (Allen, 2022).
Table No. 2
Table of Subjective Ratings According to the Client
Problems Severity
1. Stress 10
2. Irritability 7
3. Fear of failure 8
4. Fear of the least amount of time 9
Mini-Mental State Examination (MMSE)
The Mini-Mental State Examination (MMSE) first developed by Folstein in 1975, has
become the most recognized tool for assessing an individual's cognitive state. It assesses six areas
of cognitive ability for a maximal score of 30 points (Arévalo‐Rodríguez, 2015).

38
Table No. 3
Table of Quantitative Analysis of Mini-Mental State Examination (MMSE)
Total Score Client’s Score Category
30 30 No cognitive impairment
The 30 scores of the client on the Mini-Mental State Examination (MMSE) indicates that
the client had no cognitive impairment. She was well aware about time, place and location. She
answered all the questions accurately that the trainee psychologist asked.
Formal Assessment
For the formal assessment, the trainee psychologist used DASS-21 (Depression Anxiety
and Stress Scale-21).
Depression Anxiety and Stress Scale (DASS-21)
The DASS-21 is a 21-item self-report questionnaire developed by Lovibond and Lovibond
in 1995, designed to measure the emotional states of depression, anxiety, and stress. In completing
the DASS, the individual is required to indicate the presence of a symptom over the previous week.
Each item is scored from 0 (did not apply to me at all over the last week) to 3 (applied to me very
much or most of the time over the past week). The reliability of DASS-21 showed that it has
excellent Cronbach’s alpha values of 0.81, 0.89, and 0.78 for the subscales of depression, anxiety,
and stress respectively (Coker, 2018)

39
Table No. 4: Quantitative Analysis of Depression Anxiety Stress Scale-21 (DASS-21)
Domains Client’s Score Range Category
Depression 6 0-9 Normal
Anxiety 6 0-7 Normal
Stress 26 26-33 Severe
The score for stress on DASS-21 (Depression Anxiety and Stress Scale-21) is 26 which
indicated that the client had severe stress.
Conclusion
Through the formal and informal assessment of the client and on the basis of the presenting
complaints such as stress, irritable mood, fear of failure, and fear of the least amount of time to
complete tasks, it was concluded that the client was suffering from a severe level of stress.
Prognosis
The client had good family support and good insight. She tried to overcome her problems
and motivate herself and did not give up. All these positive factors lead to a good prognosis.
Recommendation
Table No. 5
Table of Recommendations for the client by the trainee psychologist
Short Term Goals Techniques
Aim to reduce the irritable mood and anger of Deep Breathing
the client during stress Deep breathing, also sometimes called
diaphragmatic breathing, involves taking deep

40
breaths in, with air coming in through the nose
to fully fill the lungs, causing the lower belly
to rise. Deep breathing can lower blood
pressure by allowing the muscles to relax,
improving blood circulation, & regulating
heart rate.
Aim to manage the time by prioritizing tasks Eisenhower Matrix
by urgency and importance and tackling them The Eisenhower Matrix is a productivity,
in the optimal order prioritization, and time-management
framework designed to help prioritize a list of
tasks or agenda items by first categorizing
those items according to their urgency and
importance. (Product plan, n.d.).
Limitations
The environment in which the session was conducted contained too many distractions such
as noise and interruption of people nearby the place. Because the sessions were conducted in a
room of the academy.

41
Differential Diagnosis of Stress
Anxiety
The client had stress in the presence of a stressor (deadlines of tasks) only. Anxiety, on the
other hand, is defined by persistent, excessive worries that don’t go away even in the absence of a
stressor.
Adjustment Disorder
As the client’s symptoms did not cause significant distress in her social and personal areas
of life, which is necessary for the diagnosis of adjustment disorder. The client had impairment only
when the time was bound to perform task and caused distress in her academic life.
42
References
Arévalo‐Rodríguez, I. (2015). Mini‐Mental State Examination (MMSE) for the detection of
Alzheimer's disease and other dementias in people with mild cognitive impairment (MCI).
Cochrane Database of Systematic Reviews, 1.
doi:https://doi.org/10.1002/14651858.CD010783.pub2
Coker, A. O. (2018, July 16). Psychometric properties of the 21-item Depression Anxiety Stress
Scale (DASS-21) | African Research Review.
https://www.ajol.info/index.php/afrrev/article/view/174532
Retrieved from
Product plan. (n.d.). Eisenhower Matrix | Prioritization Framework | Definition and Examples.
Www.productplan.com. https://www.productplan.com/glossary/eisenhower-matrix/
43
https://doi.org/10.1007/978-3-030-59455-8_15
What are the benefits of deep breathing? (n.d.). Www.prudential.co.th. Retrieved January 23,
2023, from https://www.prudential.co.th/corp/prudential-th/en/we-do-pulse/health-
wellness/benefits-of-deep-
breathing/#:~:text=Deep%20breathing%20can%20lower%20blood
44
Daily Session Report
Client: R.N Session:
Trainee Psychologist: Tentative Diagnosis: Severe level of Stress
Date Summary of Session Sign. Of
Supervisor
09-10-22 The first session started in a room of the academy where the client
studied. This was the first session with the client so the trainee
psychologist introduced herself and ensured confidentiality to the
client. Rapport was built in this session. The history of presenting
complaints of the client was taken. The client’s background history
was also taken in this session and the client was ensured confidentiality
many times during the session. This session was of 45 minutes.
10-10-22 The second session was conducted in the same place. In this session,
the formal and informal assessment was done. Subjective ratings of the
client were taken and MMSE was used as an informal assessment. For
the formal assessment, DASS-21 was used. The client was psycho-
educated regarding the complaints and the session was ended after 45
minutes.

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Internship Case Reports

Government College Women University Sialkot

conducted with the client.

Age 12 years old

Education 5th class

No. of Siblings 2 sisters

Birth order 2nd born

Marital Status Unmarried

Socioeconomic Status Middle Class

Informant Client herself

Source of Referral and Presenting Complaints

Table of Presenting Complaints According to the Client

Duration Presenting Complaints Sr. No.

1.5 years Mjhy lgta h k koi mjhsy pyr nh 1.

1.5 years Mjhy lgta h k main failure ho 2.

1.5 years Mjhy lgta h k m kmtr ho 3.

History of Presenting Complaints:

her and told her that she always did wrong.

my family proved me right that I am a failure and inferior to others.

tasks as well as household chores.

relationship with his wife and another daughter.

congenial relationship with the client.

As the client was unmarried so she had no marital history.

General Home Environment

family and he was a student.

Behavior during Session

A psychological assessment is a process used to test an individual’s mental health and

emotional well-being. It is used to identify problems and potential concerns, as well as to

recommend treatments or therapies (Reynolds, 2021).

It was done on two levels:

ii. Formal Assessment

informal assessment were used:

Table of Subjective Ratings According to the Client

1. Feeling of being unloved 9

Rosenberg Self-esteem Scale

The Rosenberg self-esteem scale is a ten-item self-report measure of global self-esteem

Table of Quantitative Analysis of Rosenberg Self-Esteem Scale

Total Score Client’s score Category

the client had low self-esteem.

has low self-esteem.

may be 100% if the family support of the client will be good.

Table of Recommendations for the client by the trainee psychologist

Short Term Goals Techniques

Aim to provide knowledge to the client and the Psychoeducation

nature of the illness, including its etiology,

progression, consequences, prognosis,

treatment, and alternatives (Sarkhel, Singh &

Aim to change the negative thought of being Examining the evidence

automatic thought. therapist asks the client to examine the

evidence for and evidence against the

automatic thoughts. (Leahy, 2017)

Aim to change negative thoughts, such as Positive statements

esteem and to replace those thoughts with

realistic, rational thoughts (Damme, 2008).

from being perfect trying to improve rather than trying to be

client’s sister came in the room in the middle of the interview.

Differential Diagnosis of low self-esteem

Depression is characterized by a sad mood, loss of interest, and feelings of worthlessness.

Generalized anxiety disorder

It is characterized by excessive worry and anxiety with physiological symptoms such as

not have physiological symptoms of anxiety

Allen, D. (2022). Subjective Rating and Ranking. Retrieved from