Bio Data:

Name S.G
Father Name J.A
Age 23 years
Gender Female
Birth order 1st
Siblings. 1 (sister)
Education. BS Sociology
Marital status. Single
Parents Alive/not alive

Source of Referral:
I approached the client for my academic purpose.
Presenting complaints:
2 year ‫مجھے بار بار میری بہن کے خیال اتے ہیں‬

1.5 year ‫مجھے شور برا لگتا ہے‬

1.5 year ‫کوئی مجھے کسی کام سے روکے تو غصہ اتا ہے‬

1 year ‫مجھے سوتے ہوئے ڈر لگتا ہے اور عجیب خواب اتے ہیں‬

2 year ‫میں بہت پریشان رہتی ہوں‬

History of Present Illness:

Her reported symptoms, as relayed by she, encompass feelings of
anxiety, inferiority, irritability, sensitivity, nocturnal terrors, excessive nocturnal
emissions leading to physical debilitation, palpitations, dry mouth, sweating, trembling,
pervasive thoughts of death, and uncontrolled ruminations persisting for the past 2-3
years. Additionally, she experiences flashbacks of her sister's death. As per her medical
records, these issues began at the age of 19. Her mental well-being appears to
deteriorate progressively. Furthermore, her mother notes an increase in aggression
towards her peers.
Background Information:
Family History:

The age of my client was 23 years. She has one sister who died in an accident . Her birth
order was 1st . They are 4 family members in their house client`s father was a asthama patient her
mother was alive and the patient of Hypertension. Her father work in WAPDA.

Birth and Early Development:

According to mother, her developmental millstones were completed on time. But her
mother said he had pnemonia in her childhood which made she very weak., she did not speak
enough then at the age of 4 years he began to speak. she was very irritable. shee did not play with
other children. she was very sensitive well as emotional.

Educational History:
she was an average student. He had a good relationship with her teachers but he didn’t get
along well with the children. The client felt more difficulty to communicate in social
environment she did not like to study much but still he passed with good marks and he studied
matriculation only. After that he also stopped studying because her father’s death and due to
financial issues.
Occupational History:
The client said that he is not interested in any work but he works with her sisters to run
the house and meet the expenses of the house and Now he has got a job in WAPDA instead of
her father because after the death of her father she got that place. But because of her anxiety and
her mental state, he mostly does not pay attention to her work and takes a lot of vacations which
also causes she to complain from her job.
Pre-morbid Personality:
Client reported that during her childhood he used to play with her friends and siblings.
she had friendly behavior with her siblings and few childhood friends. After death of her father,
family had to face a difficult time regarding finances and relationship with relatives. she was
very much attached with her father and her death was a great stress for she, He really missed
her father. she wants to share things with her father like others children.

History of Psychiatric Illness in Family:

Her mother was suffering from and hypertension. There was no any significant history of
psychiatric Illness her family.
Psychological Assessment
Behavioral observation
The patient were dressed up properly. Her body language was looked nervous . He
couldn’t maintain eye contact. Her overall appearance was good and he showed good manners
throughout the time. Her facial expressions was very sad. Her mood was low. He was not active
despite of her effort to remain alert.

Mental status Examination (MSE)

General Appearance and Behavior
General appearance of my client was good. Also he seems to be very hygienic.
Speech and Thought
My client’s way of talking was good and slow. He was disturbed due to many people of hospital.
Mood and talk
Her mood was low during the first two sessions. He talked less.
Consciousness and Perception
Client seems to be fully conscious, attentive and in her senses. He answered me after thinking of
my questions.
Orientation
To check orientation of my client I asked she about what the time is. He answered correctly, her
orientation examination was intact.
Attention and Concentration
My client was attentive and concentrated toward me during whole assessment as I explained to
she.
Insight and Judgment
The insight and judgment of my client was not much clear he knew it very well why she is with
me and what is her condition right now.
Psychological testing
1-Solloson Drawing Coordination Test (SDCT)

The Client’s score is 85% which indicates that his eye hand coordination is intact.
2-Standard progressive matrices (SPM):

Client’s score on SPM is 44 which indicates that client’s level of intelligence falls on the
average level of intelligence.

3-Post traumatic stress disorder checklist (PCL-5)

According to ther PCL-5 the client’s score is 45 which indicates extreme have PTSD AT extreme
level
4-Rotter’s Incomplete Sentence Blank (RISB):
The results indicated that the grand score is 172 and the cut score of ther test is 135, thus the
client seems to be maladjusted.
Qualitative analysis
The RISB measured the different aspect of her personality such as,
• Familial attitude.
• Social and sexual attitude.
• General attitude.
• Character traits.
Familial attitude
The statement no.4 shows client negative attitude towards her home. Statement no.11
shows Statement no. 35 shows that he has positive attitude towards her father. Statement no.39
shows her biggest tension is loss of her loved ones.
Social and sexual attitude
My client also has negative experience towards other people. Statement no.7, and 10, 19
shows that the people should be helpful and they should not show injustice. Statement no. 29 and
30 indicates that she has grief of her loved ones and she hates liars. Statement no. 40 indicates
that show women are careless. Statement no. 26 he reported that marriage is a big deal.
General attitude
Statement no. 1 and 2 indicates that he likes sports. Statement 16 indicates that sports
reduces the stress and grief. Statement no. 34 indicates that he wished she wouldn’t be alone.
Statement no. 8 indicates that silence is best answer. Statement 27 indicates that she is best when
he is healthy.
Character traits
Statement no.32 indicates he remains sad. And 37 indicates that she is upset due to her
loneliness. Statement no. 12 indicates thats he is very lonely. Statement 6 shows that she makes
dua before sleeping. Statement 5 shows that at the time of sleep there were many weird thoughts
run in my mind. Statement no 24 and 25 indicates that she wants to be a successful person and he
reported that he needs psychological treatment.
Thematic Apperception Test (TAT):

The client seems to have the need of achievement , aggression , construction and
autonomy. The client seems to have the presses of acquisition , retention, imposed task and duty,
Aggression, Dominance, Rejection , Loss and Lack. The inner state of my client seems to be lack
and loss. She wants affection and affliation.

Diagnosis According to DSM-5:

Based on the psychological assessment and the observed symptoms of the client the
tentative diagnosis made according to the DSM VTR is 309.81 (F43. 10) Posttraumatic Stress
Disorder (PTSD)

Case Management and Treatment Plan

Treatment Plan

Case No 01 Client’s Name S.G Age 23 Gender female

Symptoms Anxiety, inferiority, irritability, sensitivity, nocturnal terrors,

excessive nocturnal emissions leading to physical debilitation,
palpitations, dry mouth, sweating, trembling, pervasive thoughts
of death, and uncontrolled ruminations persisting for the past 2-3
years
Diagnosis 309.81 (F43. 10) Posttraumatic Stress Disorder (PTSD)

Target Symptoms  diminish interest or pleasure in almost all activities

 feeling of worthlessness.

Treatment approach  Behavior activation therapy

 Deep breathing exercise
  Identify negative thoughts

Frequency of sessions 8 Proposed number of 16

required sessions to achieve goals

 Coping with feeling of worthlessness

Major  Increase interest in pleasure ativities

 Coping with crying spells
Treatment
 Conident behavior in home and social set
Goals

Number Expected
Time
Interim Treatment
To achieve
Goals for target
1. reduce hopelessness 2
Symptoms
2. social anxiety 2

3 enhance self esteem 4/5

4.built self confidence 3/4

1. Therapeutic Alliance and Support:

To establish a strong therapeutic relationship and support system.
Initial Phase
Foster open communication, trust, and rapport between the patient
and therapist to ensure that the patient feels safe and supported
 throughout the treatment process

-Behavioural activation therapy is applied during the middle phase

Middle Phase  Activity Monitoring

 Activity Scheduling
 Setting Meaningful Goals
 Graded Task Assignment
 Pleasurable Activities

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
.

Summary of Therapeutic Interventions

Intervention 1

Behavior activation therapy :

Depression often leads to a lack of motivation and withdrawal from activities.

Encourage the client to engage in activities they used to enjoy, even if they don't feel like it
initially. Gradually increasing the level of activity can help improve mood and counteract
depressive symptoms. Behavioral Activation Therapy (BAT) was selected as the therapeutic
approach to address the client's loss of interest in pleasurable activities. BAT is a structured and
evidence-based therapeutic intervention that aims to increase positive reinforcement by assisting
individuals in identifying and engaging in rewarding activities.
The therapeutic process involved the following steps

Assessment: A thorough assessment was conducted to identify activities that the client
previously enjoyed and to gain insights into any barriers that may have contributed to their
reduced engagement in these activities.

Activity Monitoring :Client was encouraged to track their daily activities and associated mood.
This monitoring helped identify patterns between their activities and mood states.

Activity Scheduling : I developed a list of pleasurable activities that aligned with the client's
interests and values into a activity scheduling chart . These activities were then prioritized and
scheduled into the client's daily routine that is mentioned into the activity schedculing chart
thoroughly

Positive Reinforcement: As the client began to engage in pleasurable activities, she was
encouraged to pay attention to any positive changes in their mood and overall well-being. This
positive reinforcement helped reinforce the connection between activity engagement and mood
improvement. As a clinical psychologist trainee I have identified her positive reinforcer that was
a verbal appraisal .