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CASE REPORT ON DEPRESSION

RAHEEN RAFIQUE
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TABLE OF CONTENT

1……………………………………...…..CASE HISTORY

1.1…………………………………..INTRODUCTION
1.2………………………………......HISTORY OF PRESENTING COMPLAINS
1.3…………………………………..PAST MEDICAL HISTORY
1.4…………………………………..FAMILY HISTORY
1.5…………………………………..PERSONAL HISTORY

2…………………………………………MENTAL STATE EXAMINATION

3…………………………………………PHYSICAL EXAMINATION

4…………………………………………DIAGNOSIS

5…………………………………………BIOPSYCHOSOCIAL MODEL

6…………………………………………FORMULATION

7………………………………………...MANAGEMENT PLAN

CASE HISTORY
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 NAME MA
 AGE 32
 MARITAL STATUS SINGLE
 OCCUPATIONAL LAB ASSISTANCE

MA, a 32 years old lab assistance in private school, lives with his family. He was referred by his
brother friend with an abrupt onset of depressive symptoms. This followed months of lowered
mood after conflict in office.

PRESENTING COMPLAINS

 Sleep disturbance
 Reduced appetite and weight loss
 Agitation
 Hopelessness
 Feelings of worthlessness
 Thoughts of death
 Body pain

Duration of these presenting complains greater than 7 month when he was 29 years old.

PAST MEDICAL HISTORY

He is suffering with cancer disease, medical clinic reported pain in his shoulders, arm and
headache and loss of appetite. The result showed that, he just suffer with cancer or lack of
nutrition so that was why he felt physically ill and also no having any genetic problems of organs
according to medical.

FAMILY HISTORY

He lives with his family, parents are alive, father suffer with brain tumor, and retired from work
his mother is house wife and sick mentally, he is having 4 siblings, he is in 4 th no. He gets ill due
to genetic component his brother also having same complains of depression.

PERSONAL HISTORY
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MA, 32 years old, he was done graduation in accounting and then start job as lab assistance in
private school. When he was 29 years old, his symptoms showed such as loss of appetite,
headache. One day he felt unconscious during the job then his is father and brother admitted him
at General Hospital. His Doctor was diagnosis cancer so that’s why he is having hopeless
feelings and no more talk with family and also having a fear of death

MENTAL STATE EXAMINATION

 Worthless
 Flat emotionally
 Mood affect
 Suicide
 Hopeless
 Monotone
 Bizarre gesture
 Good hygiene
 Impaired concentration

PHYSICAL EXAMINATION

 Cancer of brain
 Brain tumor
 Genetic components
 Imbalance hormones of brain
 Dysfunction of neurons
 No MR features
 Headache
 Body pain

PSYCHOLOGIAL ASSESSMENT TOOLS

 Back Depression Inventory ( BDI)

DIAGNOSE
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Medically reported cancer

Reported depression according to DSM-5

BIOPSYCHOSOCIAL MODEL

BIOLOGICAL FACTORS PSYCHOLOGICAL

FACTORS
 Male age 32
 Medical issues (cancer,  Depression
sleep disturbance, headache,  Family functioning
back pain)  Low self-worth
 Genetic component  Hopeless for future
 Fear of death, loss of
SOCIAL appetite.

FACTORS

 Middle class
 Economic status
 Bad body figure
 Lack of social interaction
 No social support

Biological factors
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The patient suffers with cancer due to mutation in a biological factor, specifically a genetic
component. As a result of this mutation, the patient began experiencing symptoms continuously
since when he was 29 years old. When the doctor diagnosed his, it was revealed that he had
cancer or brain tumor, which caused him to become unconscious. The symptoms include
headache and back pain.

Psychological Factors

MA, 32 Years old he is suffer with cancer so that’s why he ill psychologically according to
DSM-5 he reported depression symptoms. Since MA suffers with cancer, he has become
depressed and often experiences a fear of death. He has peculiar thoughts that he is sick and will
die because of cancer. Due to depressive symptoms, his activities have ceased, and he does not
go out of the house or engage in social gathering with friends. He sits alone in his room, which
intensifies his feelings of loneliness. He does not communicate with anyone in house and
remains sad. The depression has also caused a loss of appetite and hair fall. As a result, he feels
worthless and is unable to concentrate on anything.

Social Factors

MA suffers with both biological (cancer) and psychological (depression) illness. For healthy
lifestyle economic status plays an significant role and for treatment. He belong with normal
family so that’s why his family not able to take recommendation action. He has loss of appetite
due to cancer according to social point of view his lack of social interaction because he think that
I am not having good look.

CASE FORMULATION
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PRESENTING COMPLAINS
Initial History
 Sleep disturbance
 Name; MA
 Reduce appetite and loss
 Age; 32
weight
 Marital status; Single
 Hopelessness
 Occupation; lab assistance
 Agitation
 Headache and back pain
 Fear of death

PRE-DISPOSING PRECIPITATING PERPITUATING

FACTORS FACTORS FACTORS

 Genetic component  Loss of job  Overgeneralization

 Chronic illness  Cancer  Poor coping strategies
 Unhealthy lifestyle  Social isolation  Hopeless for future
 Depression due to  Engagement broken  Sleep disturbance
having cancer  pain  Lack of treatment
disease. support
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PROTECTING
FACTORS

 Family support
 Insight
 Medication and
therapy
 Healthy diet
 Healthy activities
 Social support

DIAGNOSIS

 Reported depression according to DSM-5

 Reported cancer according to medically

TREATMENT

 According to medical point of view give medicines of brain tumor and

therapy (chemotherapy, radiotherapy, and immunotherapy)
 According to psychological point of view
 Test administered
 BDI
 short term goals
 Medicine adherence
 Rapport building
 Develop insight
 Scheduling his activities
 Long term goals
 Continuity of short term goals
 Relaxation technique
 Counseling of client and family
 Acceptance and change
 Anger management
 Main therapies
 CBT
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MANAGEMENT PLAN

Name MA
Age 32
Presenting Complains Sleep disturbance, reduce appetite and loss weight,
hopelessness, agitation, headache and back pain, fear of death.
Test Administered  Back Depression Inventory ( BDI)
Short Term Goals  Medicine Adherence
 Rapport building
 Developing insight in client
 Scheduling his activities
 Sleep Hygiene Chart

Long Term Goals  Continuity of short term goals

 Relaxation techniques
 Counseling of client and family
 Cognitive restructuring
 Acceptance and change
 Anger management
Main Therapies Cognitive Behavioral therapy, Deep breathing, Activity
Scheduling.
Total Sessions Total 10 sessions planned in which first 4 sessions are planned
for rapport building, developing insight, history taking and
assessment. Next 4 sessions are planned for behavioral and
cognitive interventions that include treatment. And at the last
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final 2 sessions assigned for termination of therapy and

relapse management. Overall it’s a good experienced and I am
happy my patient become stable.

Short term goals

 Medicine Adherence
 Selective Serotonin Reuptake Inhibitors( SSRIs)
 Atypical Antidepressants
 Rapport building
Warm and friendly greeting: begin by greeting the patient with a warm and
friendly demeanor. Use a smile, maintain eye contact, and I offer a welcoming
tone to help put him at ease. Treat him with respect, dignity, and professionalism.
Use his preferred name, maintain privacy and confidentiality, and avoid judgment
or assumptions. Show that I value your opinions and involve him in decisions-
making regarding his healthcare.
 Developing insight
After rapport building I am focus on my patient to develop his insight in which I
give awareness him how is illness effect on his health and also effect on his
social, psychological and in physical life that help him to take recommendation
action for treatment.
 Goal setting
 After rapport building I am focus on my patient to develop his insight in which I give
awareness him how is illness effect on his health and also effect on his social,
psychological and in physical life that help him to take recommendation action for
treatment.
 Scheduling activities
Making a schedule of daily routine that help to divert his fear and irrational
thoughts about death in activities include his work activities of job, walk, healthy
food intake, medicines intake time, awake up, take shower, and also making the
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schedule about thoughts timing just think about it 10mints before bed time and
then take 10mints to find out the solution if it is irrational you letting go it and
take deep sleep at night.

 Sleep hygiene chart

Creating a sleep hygiene chart for a patient can help establish healthy sleep habits
and improve his overall sleep quality. Go to bed and wake up at the same time
every day, even on weekends.
• Aim for 7-9 hours of sleep per night
• Start winding down at least 30minutes before bedtime.
• Engage in clamming activities such as reading book, taking a warm bath,
or practicing relaxation techniques like deep breathing.

Long term goals

 Relaxation technique
Relaxation techniques can be beneficial for his experiencing depression as it can
help him to reduce stress, promote a sense of calmness, and improve overall well-
being.
Deep breathing: Encourage slow, deep breaths to activate the body relaxation
response. Instruct him to inhale deeply through his nose, hold the breath for a few
seconds, and then exhale slowly through the mouth. Repeat this several times,
focusing on the breath and letting go of tension with each exhale.
Body Scan: Guide the patient to systematically scan his body from head to toe,
paying attention to any areas of tension or discomfort.
Encourage him to relax and release tension in each area, one at a time, by
focusing his attention on that specific part of the body.
 Counseling of client and family
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Counseling of client with depression and his family can be a valuable support in
managing the condition and fostering understanding and communication within
the family unit.
Provide Psycho education: Start by educating both the patient and his family
members about depression. Explain the nature of the condition, its symptoms,
cause, and treatment options. This knowledge helps reduce stigma, promotes
empathy, and sets realistic expectations for recovery.

 Cognitive restructuring
Encourage the patient to become aware of his negative thoughts and beliefs that
contribute to his depressive feelings. Help him to recognize common cognitive
distortions such as all-or-nothing thinking, overgeneralization, and
personalization.
Help the patient challenge his negative thoughts by considering alternative
interpretations or explanations and help to reframe negative thoughts by looking
at a situation from a different, more positive or objective viewpoint.

 Anger management
Help the patient identify specific situations, thoughts, or events that trigger his
anger. Explore any underlying emotional or cognitive patterns that contribute to
anger outbursts.
Develop awareness of anger sign and psychoeducate him that how this anger
affect on your mental and physical health.
Teach and practice relaxation techniques such as deep breathing, progressive
muscle relaxation, or guided imagery to help the patient manage anger in the
moment.
Engage in physical activity such as exercise as a healthy outlet for anger and a
way to reduce stress and tension about cancer.

SESSIONS MANAGEMENT PLAN

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SESSION 1-4

Total 10 sessions planned in which 1-4 sessions are planned for rapport building, developing
insight, history taking and assessment.

Rapport building

Warm and friendly greeting: begin by greeting the patient with a warm and friendly demeanor.
Use a smile, maintain eye contact, and I offer a welcoming tone to help put him at ease. Treat
him with respect, dignity, and professionalism. Use his preferred name, maintain privacy and
confidentiality, and avoid judgment or assumptions. Show that I value your opinions and involve
him in decisions- making regarding his healthcare.

Developing insight

After rapport building I am focus on my patient to develop his insight in which I give awareness
him how is illness effect on his health and also effect on his social, psychological and in physical
life that help him to take recommendation action for treatment.

History taking

Taking history of patient with suspected depression, its important to approach the conversation
with empathy and sensitivity. In which take history about his personal life, medical history,
substance uses history, history of presenting complaint, psychosocial history also include to take
functional assessment.

ASSESSMENT

 Assessment tool: Use Back Depression Inventory ( BDI) on depressive patient.

 Psycho education: Start by educating both the patient about depression. Explain the
nature of the condition, its symptoms, cause, and treatment options. That helps him to
take recommendation action for early treatment.
 Develop insight: After rapport building I am focus on my patient to develop his insight
in which I give awareness him how is illness effect on his health and also effect on his
social, psychological and in physical life that help him to take recommendation action for
treatment.
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 Setting goals: After rapport building I am focus on my patient to develop his insight in
which I give awareness him how is illness effect on his health and also effect on his
social, psychological and in physical life that help him to take recommendation action for
treatment.
 Early treatment plan

SESSION 5

Reviewing progress: Begin the session by assessing the patient's response to treatment so far.
Discuss any changes in symptoms, functioning, or side effects of medications.

Identifying negative thinking patterns: Help the patient recognize and challenge negative
automatic thoughts and cognitive distortions associated with his depressive symptoms.

Behavioral activation: Explore activities and interests that the patient used to enjoy or find
fulfilling. Encourage them to engage in these activities, even if they don't feel motivated, as a
way to counteract withdrawal and isolation.

Problem-solving: Assist the patient in identifying and developing strategies to overcome

specific problems or obstacles that may contribute to his depression.

Homework assignment: Assign tasks related to challenging negative thoughts, engaging in

pleasurable activities, or practicing relaxation techniques. Encourage the patient to track to his
progress and any changes in mood or symptoms.

SESSION 6

Reviewing homework: Discuss the completion of assigned tasks and encourage the patient to
share his experiences and any challenges encountered.

Interpersonal issues: Explore the patient's interpersonal relationships and conflicts. Focus on
improving communication skills, setting boundaries, and enhancing social support.
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Addressing self-esteem: Help the patient identify and challenge negative beliefs about himself
and develop a more realistic and compassionate self-view.

Developing coping skills: Teach the patient various coping strategies, such as relaxation
exercises, deep breathing techniques, and mindfulness practices. Practice these skills together
during the session.

SESSION 7

Reviewing progress: Evaluate the patient's response to the interventions and discuss any changes
in symptoms, functioning, or medication adjustments.

Cognitive restructuring: Continue to identify and challenge negative thinking patterns, working
towards replacing them with more adaptive and realistic thoughts.

Goal setting: Collaborate with the patient to establish short-term and long-term goals, fostering
a sense of direction and purpose.

Relapse prevention: Discuss strategies to prevent relapse, including recognizing early warning
signs, utilizing coping skills, and maintaining healthy lifestyle habits.

Enhancing social support: Encourage the patient to seek and maintain social connections,
fostering a supportive network.

SESSION 8

Reviewing homework and progress: Discuss the patient's experiences with previous
assignments and their impact on his mood and functioning.

Grief and loss: If relevant, address any unresolved grief or losses that may be contributing to
the patient's depressive symptoms

Continuing skill-building: Reinforce and expand upon coping skills, problem-solving

techniques, and cognitive restructuring.
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Future planning: Discuss the transition from active treatment to maintenance and relapse
prevention. Develop a plan for ongoing self-care and strategies to address setbacks or potential
challenges.

SESSION 9

Reviewing progress and relapse prevention: Assess the patient response to treatment and discuss
any improvements or setbacks. Emphasize the importance of ongoing relapse prevention
strategies. Identifying and addressing cognitive distortions: Continue to work on challenging and
reframing distorted thinking patterns that contribute to the patient depressive symptoms. Self-
compassion and acceptance: Help the patient cultivate self-compassion and develop a non-
judgmental attitude towards himself . Encourage acceptance of their emotions and thoughts
while working towards positive change. Behavioral experiments: Conduct behavioral
experiments to help the patient test and challenge their beliefs and assumptions. This can involve
trying new activities or approaching situations differently to gather evidence that contradicts
negative thinking.

SESSION 10

Reviewing progress and treatment goals: Reflect on the patient's progress throughout the
treatment process, celebrating achievements and identifying areas that may require further
attention.

Termination or transition planning: Discuss the possibility of terminating therapy or

transitioning to less frequent sessions. Address any feelings of loss or concerns about
maintaining progress outside of therapy.

Relapse prevention and coping strategies: Review and reinforce relapse prevention strategies,
including recognizing triggers, utilizing coping skills, and maintaining a healthy lifestyle.
Planning for ongoing self-care: Collaborate with the patient to develop a personalized self-care
plan that includes strategies for maintaining mental well-being, social support, and regular
monitoring of symptoms.
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