Bio-Data

Ms.S.Z

33 year of age

Educated till metric

House wife

Married

broter sister

(last born) birth order

Lived in Lahore

Visited OPD

Reason of referal: for taking the treatment of depression

Presenting Complaints

Ms.S.Z came to OPD with the presenting complaints of

headache

anger issues

disturbed sleep

low mood

increase of appetite

loss of interest

heart palpitation

body aches

History of presnt illness

Client's problem start 2.5 years ago. When her conflicts increase with her husband. After
some time she start taking treatment from a private clinic. With the passage of time her health
issues start getting better. Last january after the death of her father she again having the
symptoms of depression but se continoued her medication. From last 2 months she stopped
taking the tr eatment beacuse she thought that my health is not improving.
Family History

Her mother is alive while her father died last year due to high blood pressure

She had one brother and two sisters and had good relation with her siblings.

She was the youngest one in her family and very attached with her mother

Marital History

She got married at the age of 19 before her she likes another guy.

She had 2 sons and 1 daugter

She had some conflicts with her husband

She also had unsatisfactory relationship with her in-laws

Personal History

Developmental milestones were at appropriate age

In childhood she taken interest in different activites and competitions

She had few friends in her school life

She started school at 5 years. She studied till matric. She wants to do further studies but

her father quit her studies beacuse she was in relationship with her classmate.

Orientation

Her orientation of time place and person was intact. She had good insigt about her present
illness.

Premorbid Personality

Introvert

Sensetive

Low-confidence

Like to do baking

Take intersest in household work

She had few friends but she was very sincere to them
 She was very attached to her mother

Psychological Assessment

Formal: Clinical interview, Mental status examination

Informal:

Bender Gastalt Test: Client scored 22 on BGT which was below the average which indicate her
level of impairment. She completed the test in 15 minutes.

2 emotional indicators were present confuse order, small size od design 9

Test of non-verbal intelligence: Client scored 22 on TONI which indicates her level of
intelligence and aptitude which was below the average.

Beck Depression Inventory: Client scored 25 which indicates moderate level of depression

Rotter Incomplete sentence blank: Client scored 136 wich shows that she was slightly
maladjusted.

Behavioral Observation

Client was 33 years old female sitting in an appropriate posture. Her head and shoulders
were down.and continously tooking at her shoes. She crossed her legs. Her hygiene was
properly maintained. Her eye contact was made but not maintained. Her mood was dysphoric
and agitated. She was looking very low and tired while discussing problematic events. Her
orientaion was intact. She had good insight about her problem.

Tentative Diagnosis:

296.32(F33.1) Major Depressive Disorder, with anxious distress.

Management Plan

Short term goals:

History taking

Psychological Assessment

Medication Adherence

Behavioral Activation

Deep muscles relaxation

ABC Model
Anger thermometer and anger management

Stress management

Dysfunctional Thought record

Cost benefit analysis

Problem solving skills

Long term goals

Continoue short term goals

Building new habbit

Assertiveness traning

Couple therapy

Case Formulation
Presenting complaints: headache

anger issues,disturbed sleep, low mood, increase of appetite, loss of interest, heart palpitation ,
body aches

Predisposing factors: No genetic factor found, father's authoritative behavior, repressed desires

Precipitating factors: Conflicts with her husband

Perpetuating Factors: Father's death

Protective Factors: Insight about illness

Prognosis
Good prognostic factors

Willing to overcome the problem/ positive response towards therapy or session homework

Husband and siblings support

Insight

Less choronic

Open towards therapy treatment

Cosistence use of medication and psychotheraputic intervention

Bad Prognostic factors

Conflicts with in-laws

Functional impairment is present which is below the average

Long term goals regarding purpose of techniques

Enable her to solve the problems and enhance her concentration

Increase her capacity of functioning by behavioral functioning

Social skill traning

Practicing alernative cognition by using DTR

Challenging dysfunctional cognition