1

Summary
The client is 21 years old girl and university going. She is going to completing her
graduation in few months. She has four siblings. Her birth order is 3rd. She belongs to
Faisalabad. Client reported the symptoms of shortness of breath sweating. a fear of fainting ,a
fear of losing control .M.B grew up in a stable and supportive family environment. She used
to have a cat as a pet. According to her parents, she had a neutral or slightly positive attitude
towards cats during this period. There were no notable incidents involving cats during this
time. Around the age of 6, A neighbor's cat, which was known to be aggressive, scratched her
arm when she attempted to pet it. This incident left her with a physical scar and a growing
sense of unease around cats. Client comes from a stable and supportive family environment
characterized by strong bonds and healthy relationships. She has a positive and nurturing
relationship with both her mother and father, as well as with her siblings. Psychological
assessment applied on the patient are HFD and Severity measure or specific phobia – adults.
Based on the psychological assessment and the observed symptoms of the client the tentative
diagnosis made according to the DSM VTR is 300.29 (F40.218) Specific phobias
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Biodata

Name M.B
Gender B.A.
Age 21 year
Birth Order 3rd
Qualification BS (Sociology)
Profession Student
Marital Status Single

Identifying Data
The client is 21 years old girl and university going. She is going to completing her
graduation in few months. She has four siblings. Her birth order is 3rd. She belongs to
Faisalabad.

Reason and Source of Referral

She was referred by her sister
Presenting Complaints
Table 1
Self-Reported Presenting Compaints and Duration

‫ت‬
Duration Presenting Complaints
‫ت‬
‫ے‬‫دھڑکن ی ز ہ و ج ا ہ‬
‫ی‬ ‫دل کین‬
‫ن‬
‫ے‬ ‫پ سی ہ نآے لگت ا ہ‬
‫ہت ت‬
‫ت‬ ‫ں‬ ‫ی‬ ‫ہ‬ ‫ے‬‫ت ا ھ کا پ‬
‫ت‬
15 year ‫ھوڑی دیر ب عد ہ ا ھ سن ہ و ج اے ہ ی ں‬

Developmental History of the Problem

M.B grew up in a stable and supportive family environment. She used to have a cat as
a pet. According to her parents, she had a neutral or slightly positive attitude towards cats
during this period. There were no notable incidents involving cats during this time. Around
the age of 6, a neighbor's cat, which was known to be aggressive, scratched her arm when she
attempted to pet it. This incident left her with a physical scar and a growing sense of unease
around cats. M.A cat phobia became more pronounced during her teenage years. She actively
avoided any situations involving cats, even refusing invitations to friends' houses if they had
cats as pets. Her fear intensified with time, leading to panic attacks and extreme anxiety when
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encountering cats or even pictures of them. . M.A social life began to suffer, as she felt
isolated and misunderstood by her peers. M.A cat phobia has led to significant impairment in
her daily life. She avoids visiting friends and family who has cats, limits her outdoor
activities, and experiences heightened anxiety when she sees or hears about cats.
Background Information
Development History
Her mother had a healthy pregnancy with no complications. Prenatal care was
initiated early, and all medical check-ups were normal. M.B was delivered normally at a
local hospital. Her milestones were completely normal.

Family History
Client comes from a stable and supportive family environment characterized by
strong bonds and healthy relationships. She has a positive and nurturing relationship with
both her mother and father, as well as with her siblings Overall, the patient's family history is
marked by a loving, close-knit, and supportive family unit. The presence of caring and
nurturing parents, as well as harmonious relationships with siblings, has likely contributed
positively to the patient's emotional and psychological development. These familial
relationships may serve as a valuable resource in her ongoing psychological well-being and
coping mechanisms.

Educational History
She commenced her schooling journey at the tender age of 5, demonstrating early
signs of brilliance in her academic endeavors. Throughout her school years, she enjoyed
spending quality time with her friends, fostering meaningful relationships. Notably, she
expressed a particular fondness for Mathematics, considering it her favorite subject.
Social History
The client shared that she maintains a wide circle of friends, consistently seeking
opportunities to socialize and engage with her peers. Her sociable nature is evident in her
inclination to spend time with friends regularly.
However, it's important to note that the client has a unique preference regarding her social
interactions. She actively avoids situations or places where she anticipates encountering cats,
despite her otherwise outgoing demeanor. For instance, she mentioned a friend who owns a
cat, and she consistently opts not to visit this friend's home due to her discomfort around
felines
Premorbid Personality
The patient was described as sociable and made friends easily. She actively engaged
in school activities and maintained good relationships with teachers and peers. The family
environment appeared to be nurturing and supportive. There were no reports of significant
family conflicts or adverse experiences that could account for the development of the cat
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phobia. Overall, the patient's premorbid history suggests a well-adjusted and sociable
individual with the exception of her persistent and unexplained phobia of cats. Further
evaluation and treatment are needed to understand and manage this specific fear and its
impact on her life.

Psychological Assessment

Behavioral Observation
Upon entering the designated area, the patient displayed visible signs of distress
consistent with their specific phobia trigger. They exhibited heightened anxiety, as evidenced
by tense body language, increased heart rate, and shallow breathing. The patient's facial
expressions conveyed fear and discomfort. Throughout the observation, the patient verbally
articulated their fear and discomfort related to the specific phobia trigger. They expressed
their distress through phrases such as "I can't handle this," "It's too much," and "I need to
leave." The patient's verbalizations were focused on their fear, and they struggled to engage
in conversation or address other topics. The behavioral observation of [Patient's Name] in the
presence of their specific phobia trigger provided valuable insight into the nature and severity
of their specific phobia. The patient's reactions were characterized by marked distress,
avoidance behaviors, and a significant physiological response. This observation underscores
the significant impact that their specific phobia has on their daily life and functioning.
Mental Status Examination
Appearance and Behavior:
Client presented as a 21-year-old female with neat and clean appearance. She is well
dressed and exhibit a formal dress. They appeared visibly anxious, displaying signs of
restlessness, fidgeting, and frequent shifts in posture. Eye contact was limited, and they often
averted their gaze, especially when discussing anxiety-related topics.
Mood and Affect:
Client mood fluctuated during the session. They reported feeling predominantly anxious but
also expressed moments of sadness, frustration, and fear. Affect appeared congruent with
their reported mood, characterized by signs of tension, worry, and distress.
Thought Process:
Client’s thought process appeared organized and coherent overall, with no evidence of
thought disorder or loose associations.
Perception:
Client did not report any perceptual disturbances or unusual sensory experiences.
Cognition:
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Cognitive functioning appeared intact, with no evidence of significant memory

deficits or impaired reasoning abilities. They were able to provide coherent responses to
questions and engage in meaningful conversation.
Insight and Judgment:
Client demonstrated insight into their anxiety-related issues, acknowledging the
impact of anxiety on their daily life and functioning. Their judgment, when discussing their
anxiety management strategies, appeared reasonable.
Psychomotor Activity:
Client displayed signs of psychomotor agitation, including restlessness, frequent hand
movements, and an inability to sit still.
Speech:
Speech was soft-spoken and hesitant at times, with occasional stuttering when
expressing thoughts or emotions.

Psychological Testing
1-Human Figure Drawing (HFD)
Qualitative Analysis
HFD is used to diagnose emotional indicators of patient .The HFD applied on a client
reveals insecurity , anxiety , poor inner control, not clear sense of reality , fantasies and OCD
like symptoms because of the perfection of face features that she has drawn in the HFD. The
HFD figure reveals that emotional disturbance and feeling of withdrawal. The figure also
reveals the unexpected behaviours and helplessness.

2-Severity Measure for Specific Phobia—Adult

Qualitative interpretation

My client client score on the severity measure for specific phobia is 30 that indicate
that the client has severe level of Specific phobia.

Case Conceptualization
The client is 21 years old girl and university going. She is going to completing her
graduation in few months. She has four siblings. Her birth order is 3rd. She belongs to
Faisalabad. M.B grew up in a stable and supportive family environment. She used to have a
cat as a pet. According to her parents, she had a neutral or slightly positive attitude towards
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cats during this period. There were no notable incidents involving cats during this time.
Around the age of 6, A neighbor's cat, which was known to be aggressive, scratched her arm
when she attempted to pet it. This incident left her with a physical scar and a growing sense
of unease around cats
Predisposing factors

There is no predisposing factor for the client.

Precipitating factors

There is a incident where a aggressive cat scratches her arm from her neighbors’ that
trigger the phobia of cats.

Perpetuating factor

There’s no perpetuating factor for the client.

Protecting factor

Client grew up in a stable and supportive family environment which serves as a

protective factor for her.

Summary of Case Formulation

Presenting complaints:

shortness of breath,sweating,a fear of fainting, a fear of

losing control

Predisposing factors: Precipitating factors:

There is no predisposing factor for There is a incident where a

her Adult aggressive cat scratches her arm
from her neighbors’ that trigger
Mrs A.A, 29 years old
the phobia of cats.
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Perpetuating/Maintaining factors:
There’s no perpetuating factor for the client.

Protective factors:

Supporting environment of her family

Assessment:

HFD, ,Severity measure for specific phobia-adults

Diagnosis
Based on the psychological assessment and the observed symptoms of the client the
tentative diagnosis made according to the DSM VTR is 300.29 (F40.218) Specific phobias
Prognosis
Based on the assessment and treatment progress observed during therapy sessions, it
is reasonable to be cautiously optimistic about the prognosis for M.B phobia of cats. It's
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important to note that the prognosis may vary depending on the individual's willingness to
engage in treatment and their commitment to managing their condition.
Case Management and Treatment Plan
Treatment Plan

Case No 01 Client’s Name M.B Age 21 Gender Female

Symptoms  shortness of breath

 sweating.
 a fear of fainting
 a fear of losing control

Diagnosis 300.29(F40.218) Specific phobia

Target Symptoms  shortness of breath

 a fear of losing control
 a fear of fainting

Treatment approach Systematic desentization and implosive therapy applied for the treatment
of fear of losing control and fear fainting and shortness of breath
whenever in the exposure of cat.

Frequency of sessions 10 Proposed number of 10 to 11

required sessions to achieve goals

 Goal: To decrease the patient's overall level of anxiety related to

cats.
Major
 Goal: To gradually expose the patient imaginally to cat-related
Treatment stimuli in a controlled and systematic manner to reduce their fear.
 Goal: To ensure that the progress made in therapy is maintained
Goals
and that the patient is prepared to prevent relapses.

Number Expected
Time
Interim Treatment
To achieve
Goals for target
1. Goal: To decrease the patient's overall level of anxiety 2
Symptoms
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related to cats
2. To gradually expose the patient to cat-related stimuli 2
in a controlled and systematic manner to reduce their
fear.
3 To reduce the emotional and physiological response to 4/5
cat-related stimuli.
4. o empower the patient with tools for managing 3/4
anxiety and panic attacks.
To ensure that the progress made in therapy is 11/13
maintained and that the patient is prepared to prevent
relapses.
1. Therapeutic Alliance and Support:
 To establish a strong therapeutic relationship and support
Initial Phase
system. Foster open communication, trust, and rapport
between the patient and therapist to ensure that the patient
feels safe and supported throughout the treatment process.

Anxiety Reduction:
Middle Phase To decrease the patient's overall level of anxiety related to cats.Strategies:
Use relaxation techniques, such as deep breathing exercises or progressive
muscle relaxation, to help the patient manage their anxiety.
Implosive Therapy:
To gradually expose the patient imaginally to cat-related stimuli in a
controlled and systematic manner to reduce their fear.
Strategies: Develop a hierarchy of feared situations involving cats,
starting with less anxiety-inducing scenarios and gradually progressing to
more challenging ones. Encourage the patient to confront these situations
step by step, with the support of a therapist.
Desensitization:
To reduce the emotional and physiological response to cat-related stimuli.
Strategies: Use exposure therapy to help the patient become accustomed
to cats, beginning with indirect exposure (e.g., pictures or videos of cats)
and eventually progressing to direct contact with cats under controlled
circumstances.
Improving Quality of Life:
To help the patient lead a more fulfilling and unrestricted life despite their
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phobia.
Strategies: Encourage the patient to set and work toward personal goals
that may involve cats indirectly, such as visiting friends with cats or
volunteering at an animal shelter.

Termination Phase Maintenance and Relapse Prevention:

To ensure that the progress made in therapy is maintained and that the
patient is prepared to prevent relapses.
Strategies: Develop a plan for the patient to continue practicing exposure
exercises independently and provide them with strategies to recognize and
manage signs of anxiety or phobia recurrence.

Summary of Therapeutic Interventions

Intervention no 1
Anxiety Reduction:
To decrease the patient's overall level of anxiety related to cats.Strategies: Use
relaxation techniques, such as deep breathing exercises or progressive muscle relaxation, to
help the patient manage their anxiety.
Intervention no 2
Implosive Therapy:
To gradually expose the patient imaginally to cat-related stimuli in a controlled and
systematic manner to reduce their fear.
Strategies: Develop a hierarchy of feared situations involving cats, starting with less anxiety-
inducing scenarios and gradually progressing to more challenging ones. Encourage the
patient to confront these situations step by step, with the support of a therapist.
Intervention no 3
Desensitization:
To reduce the emotional and physiological response to cat-related stimuli.
Strategies: Use exposure therapy to help the patient become accustomed to cats,
beginning with indirect exposure (e.g., pictures or videos of cats) and eventually progressing
to direct contact with cats under controlled circumstances.
Intervention no 4
Improving Quality of Life:
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To help the patient lead a more fulfilling and unrestricted life despite their phobia.
Strategies: Encourage the patient to set and work toward personal goals that may involve cats
indirectly, such as visiting friends with cats or volunteering at an animal shelter.

Sessional Report
Session 1-
The initial session focused on gathering background information and assessing the
severity of the client's cat phobia and anxiety.Client reported a long-standing fear of cats,
which had intensified over the past few years. Noted symptoms included rapid heartbeat,
shortness of breath, and avoidance behavior when encountering a cat.
Session 2
Discussed the nature of specific phobias and how they can escalate into anxiety
disorders.Introduced relaxation techniques and encouraged client to practice deep breathing
exercises.Assigned homework: Maintain a journal to track anxiety symptoms.psychological
assessment HFD has been applied to the client.
Session 3
Discussed the principles of exposure therapy and how it can help desensitize the
client to their fear. Conducted a guided visualization exercise of encountering a cat.Client
expressed initial apprehension but agreed to proceed with gradual exposure exercises.
Psychological assessment severity measure for specific phibia has been applied.

Session 4:
Began systematic desensitization through exposure to pictures of cats. Client reported
increased anxiety during exposure but was able to manage symptoms using relaxation
techniques.Homework: Continue exposure to cat images daily.
Session 5
Conducted in vivo exposure by having a therapy cat present in the room.Client showed
significant anxiety but remained in the room, demonstrating improved tolerance compared to
initial sessions.Discussed progress and identified remaining triggers.
Session 6
Explored client's cognitive distortions related to cats and phobia triggers.Identified
irrational beliefs and began cognitive restructuring exercises.Encouraged positive self-talk
during exposure exercises.

Session 7
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Reviewed progress made throughout the therapy process.Client reported reduced

anxiety and avoidance behaviors in real-life cat encounters.Discussed relapse prevention
strategies and coping mechanisms for future situations.

Limitations
1-Time Constraints: Due to time limitations, a comprehensive exploration of all aspects
of the patient's specific phobia and related factors may not be feasible within the scope of
a single session or limited treatment duration.

2-Limited Intervention: Shortages of time can restrict the extent to which specific
therapeutic interventions, such as prolonged exposure therapy and cognitive restructuring
of the client.

Recommendations
1. Practice Exposure Exercises: Encourage the patient to continue engaging in ERP
exercises to gradually confront and desensitize themselves to specific phobia
symptoms
2. Utilize Coping Strategies: Recommend the ongoing use of coping strategies learned
in therapy to manage stress, anxiety, and triggers effectively.
3. Maintain a Support System: Stress the importance of involving friends and family
in their treatment journey, educating them about phobia, and seeking their
understanding about them.s

_____________________ ______________________
Trainee Examiner
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Appendices