1

Case No. 1
Schizophrenia
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Case Summary
Ms. S.A. was a 21-year-old unmarried girl educated up to FSc 1 st year and had taught as a home

tutor. She came into the outpatient department and was admitted to the psychiatric ward

presenting complaints of false belief and perception of hearing the voices of people who ordered

her, according to her she was married to Buhman and got pregnant. Odd behavior, lack of

pleasure in everyday life, aggressive behavior, anger, not being interested in any activity, and

social withdrawal. Because of these assessments, Clinical interview, mental status examination,

subjective rating of the symptoms, and positive and negative syndrome scale (PANSS), the client

was diagnosed with a schizophrenia disorder. Her case was conceptualized as cognitive behavior

therapy, and her management plan was also based on cognitive behavior therapy for psychosis.

The management plan was designed for targeting and treating her problems. The management

techniques used included medication adherence. A total of 12 therapeutic sessions were

conducted to deal with the client’s problem and relapse prevention was taught to her. Through

post assessment as well as the client reported that she experienced a significant improvement in

her symptoms.
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Bio Data:
Name: S.A

Age: 21 years

Gender: Female

Education: FSc (1)

Marital status: unmarried

Father’s name: M.A

Informant: sister

Reason and source for referral:

The client was referred to as the trainee clinical psychologist for the assessment and management

of her problem. The client came to the psychiatry ward presenting false beliefs and perceptions

of hearing the voices, aggressive behavior, insomnia, self-talk, and social withdrawal. Initial

presentation

Presenting Complaints

Table 1.1

Presenting Complaints of the Client According to the Informant

Duration Presenting Complaints
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Table 1.2

Presenting Complaints of the Client According to the Client

Duration Presenting complaints

History of present illness

According to the client, two years before she came to her cousin’s marriage, where the Mehndi

night she liked someone named M, and on the day of Barrat she liked another person name, H.

After their cousin’s marriage she came back to her home and after that symptom started, she sit

lonely and heard a sad song. She reported that she slept on the rooftop with her sister named F

one night when she felt someone touch her body, and unable to sleep. Her appetite was very low.

She was very aggressive.

According to the informant, after this marriage, she sits alone and starts talking and laughing. In

front of others, she was mute. When she sits lonely, she touches herself badly and said she was

married to a B. A name person, he was a man who live in the laws of her cousin. She said she
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was pregnant with his child. She was unable to do any type of homework and stopped her studies

because of her illness. During these two years, a psychiatrist treated her. She was better during

the medications. Six months before she stopped taking medicine and relapsed. And again,

symptoms started. Again, the onset of symptoms two months back.

According to the information, the client has again started self-talk, self-laugh, being mute in

front of others, being out without dress, and all symptoms. Sometimes she was very sad and

depressed and sometimes she was very happy and energetic. She was active in front of males.

Family history:

Her father M.A. was 60 years old. He was a laborer. The client had a satisfactory relationship

with her father. According to the informant, her father was very religious and prayed five times in

the mosque.

The client’s mother was R.B., and she was 55 years old. She was uneducated. She was a

housewife. The client had a satisfactory relationship with her mother. She was a kind-hearted

woman. The marriage of her parents was arranged, and they have a satisfactory relationship.

She had three sisters and two brothers. All siblings are married. She had a satisfactory

relationship with her siblings. The client belonged to a middle-class family. The client lived in a

joint family system with her parents. The general home atmosphere of the client’s home was

good.

Overall, the environment of her family was satisfactory.

Personal history:
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Birth and Early Development

According to the client’s mother, the client was born in the home and her birth was normal.

During pregnancy, the condition of her mother was normal, no complications were reported

during delivery. All the developmental milestones were reported to be achieved at the appropriate

age.

No neurotic traits were reported. The client was very healthy at the time of birth.

Educational history

The client started schooling at the age of 4 years. She was an average student. She did 10th

standard with average marks then she did FSC I in college. She had congenial relations with her

teachers and class fellows. She was not involved in extracurricular activities; she was a shy

student.

Sexual History

The client achieved menarche at the age of 14 years when she was in 8 th class. Her mother

previously guided her about it. She didn’t feel any discomfort in adjusting to this life change and

accepted it as a sign of growth and adulthood.

She got to know about sexual relationships among the opposite gender from her cousin when she

was in 9th class. She was asked about her feelings about the opposite gender.

Occupational history:

The client’s mother reported that after completing her matric she opened home tuition and

started teaching. One year before she stopped teaching because of her problem.

Drug History and Forensic History:

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There was no drug and forensic history reported by the client and her informant.

Premorbid personality:

The informant reported that she was stable before the illness. She was good in her studies and

have a satisfied relationship with her friends. She also has good relations with her parents and

siblings. She used to play a lot with her friends. She was religious and she used to offer prayers.

She was helping in nature. Before the illness, she was quite stable but she was shy in front of

others. She had an interest in studies. Her hobbies were reading books and cooking. Her

temperament was somewhat aggressive, but she was not reluctant in expressing. She was creative

and like to make different things at home.

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Psychological Assessment

• Behavioral Observation

• Clinical interview

• Mental status examination (MSE)

• Subjective Rating of Symptoms

• Positive and Negative syndrome scale (PANSS)

• Young mania rating scale (YMRS)

• House tree person (HTP)

Behavioral Observation

The client was uncooperative and did not talk in an appropriate manner. She maintained eye

contact. And her facial expressions were clear. She was not well dressed, and her hygiene was

poor.

The client S.A. had normal height with a normal weight according to her age.

Clinical Interview

To get complete information about the client, problem, her personal,

developmental, education, and family history, a detailed semi-structured clinical interview was

conducted with clients in a well-ventilated room. The interview was conducted for 45 minutes

for the duration of a session.

A clinical Interview was conducted with the patient in order to gather information

regarding her history of present illness and her current complaints, as well as the nature, severity,

and duration of her symptoms, and other factors such as predisposing, precipitating, maintaining,

and protective factors that contributed to the increase in her present condition.
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The assessment also provided a comprehensive picture of the patient’s life, which helped

determine the diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, 5th

Edition (DSM-5 TR) and the course of treatment.

Mental State Examination (MSE)

The client was a 21-year-old lady with appropriate weight and height. Her dress code was

appropriate according to the weather and age. She looked depressed. She maintained eye contact

with the therapist. Her attitude towards the therapist was cooperative throughout sessions. Her

posture was quite normal. The psychomotor activity of the clients was also normal. Her speech

was proper but incoherent. The pitch of her voice was normal. She had a low mood objectively

and subjectively and her effect was congruent with her mood. She failed to provide answers

regarding general knowledge questions. There was a reported history of perceptual disturbances

like hallucination and illusions as well as depersonalization and derealization. She did also report

delusions. The client had an orientation about time, place, and person. Her remote and recent past

memory was intact, but her recent memory was partially intact. Her attention and concentration

were partially intact. Her abstract thinking and judgment were intact. She had no insight into her

psychological problem.

Perceived Rating of the symptoms

Rating of the symptoms was taken by me for subjective ratings of psychosis and other

symptoms and their severity. Clients simply rate the intensity of the symptoms on a scale of 0-10.

The scale from 0-10 indicated, 0-low severity and 10- high severity.

Quantitative Analysis

Table 1.3
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Shows perceived Rating of the symptoms as reported by the Client from 0-10 at the

pretreatment level

Symptoms Rating

Anger 8

Irritability 10

Sleep disturbance 9

Hallucinations 8

Delusions 9

Odd behavior 8

Positive and negative syndrome scale (PANSS)

PANSS was administered to the client during the third and fourth sessions after the establishment

of rapport. Questions were asked by the client in Urdu and the ratings were marked according to

the client’s response. The administration of PANNS was divided into two days as the client got

irritable after a while. It took 30 minutes each day to administer the test. The client was

uncooperative to each and every question in the first day of test administration inattentive state of

mind

Quantitative Analysis

Table 1.4
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Table below shows the severity levels of the subscale of PANSS

Scales raw scores T scores description

Positive 32 69 much above average

Negative 22 50 Average

General 63 65 above average

Anergia 11 53 average

Thought 19 64 above average

Disturbance

Activation 13 75 very much above average

Paranoid 12 66 much above average

Depression 15 67 much above average

Qualitative analysis

Ms. S.A. scored a high percentile rank on the positive and paranoid domains. Negative and

Anergia domain scores indicate average levels. These scores are fairly in accordance with her

history. Because hallucination and delusions were reported in presenting complaints. And

paranoid behavior towards her family. Activation are significance with very much above average.

Qualitative Analysis
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House Tree Person Test

A house tree person was administered to the client. The instruction was given according to the

manual. The participant was provided with the paper with a pencil and eraser in an achromatic

phrase. The participant completes this test in 30 minutes.

House

The house drawn by the participant has a front door showing accessibility, but it is closed which

may represent defensiveness, hostility, and suspiciousness in the participant. Similarly, the

participant drew two open windows which display openness, but two barred windows indicate

some guardedness and social withdrawal. The presence of the chimney indicates the presence of

psychological warmth at home. The sidewalks represent the willingness to interact with others

and ideas about the environment. The presence of the sun represents emotional valence. The

presence of excessive details in the house exhibits some obsessive-compulsive tendencies or

perfectionism and anxiety in the participant.

Tree

The tree drawn by the participant has central placement which shows that the participant is a

normal and reasonable person. The fruits drawn by the participant indicate a sense of fulfillment

or confidence in individual creative abilities or desire for children. The tiny branches show some

signs of anxiety & indecisiveness. The pointy leaves on the branches reflect aggression or acting

out tendencies and the emphasis on roots reveal a deep personality of the person with concerned

holding the reality for their own security needs. The long and large trunk shows a good ego and

basic power and feeling about oneself

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Person

The person drawn by the participant has open arms which shows willingness to engage with

people. The closed mouth reflects a denial of needs or some passive aggression. The big trunk

drawn by the participant reflects high super-ego. The long neck drawn by the participant

indicates that there is rigidity in controlling needs. Moreover, the broad shoulders indicate the

participant's aggressive defiance which is a cover for the participant's insecurity and neediness.

The ground lines depict that the participant is making efforts to maintain a sense of reality by

creating solid foundations. The emphasis on hair reflects the participant's sexual preoccupation.

The unusual treatment with legs indicates signs of impulsivity, insecurity, and an unbalanced

concept of self.

The large female drawing suggests some hostility toward men or masculine striving.

Case formulation

S.A. was a 21 years-old female who belonged to a middle-class family residing in the village. As

observed in the first interaction with the client, she was an appropriate height but seemed

underweight. It was reported that the client received education till FSc the first year then she left

the study due to her illness. According to the informant, the client’s problematic behavior started

2 years ago. The client showed psychotic symptoms which consisted of hallucinations and
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delusions and other problematic behavior. Firstly, detailed history was taken from her sister. The

therapist that genetic vulnerability, stress and poor coping skills leads to the disorder. They were

explained the predisposing, precipitating and protective factors of the disorder. MS S.A was

paying attention to it.

On cognitive behavior therapy for psychosis, this case conceptualization was developed. This

therapeutic strategy was studied with small patient groups and centered on recognizing and

refuting a set of typical beliefs about voices, beliefs about personal control, and beliefs about

personal purpose. According to Chadwick and Birchwood (1994), one substantial case study

using this strategy had successful results. Additionally, patients who participated in a group-

based form of this therapy showed considerable gains in measures of conviction in beliefs about

omnipotence and control (Chadwick Sambrook et al., 2000). Additionally, a focused cognitive

therapy for delusional beliefs has been created and tested by Chadwick and colleagues

(Chadwick & Lowe, 1999; Chadwick, Lowe, Home, & Higson, 1994). The effectiveness of

verbal challenge and a multiple baseline design were investigated with a limited number of

patients. Collaboration and the therapeutic relationship are key components of cognitive therapy

for delusional beliefs (e.g. Alford & Beck, 1994; Chadwick, Birchwood, & Trower, 1996). They

note that the process of examining and refuting delusional ideas can be upsetting for the patient

and advise that it is crucial to go forward in a collaborative and graded manner (Alford & Beck,

1994). The formation of a solid and collaborative therapy connection is another key component

of the treatment plan.

The four P’s of case formulation (predisposing factor, precipitating factor, perpetuating factor,

and protective factor) also provide a useful framework for the organization of the factors that

may contribute to the development of psychosis with mood instabilities.

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In this case, the Pre-disposing factor can be explained by understanding the early life

experience of S.A. was a very shy girl. She was not socialized. She spends most of her time

alone.

The precipitating factor can be explained by her triggering event, she attended a marriage

ceremony two years ago. She likes someone boy but he doesn’t like her. And another day another

boy but he also doesn’t like her. She is attracted to males.

The Perpetuating factor, in this case, appears to be highly expressed blaming in the family of

S.A. The behavior of her family members (mother and sister) was overly concerned and

humiliated her for the duration of her illness.

The Protective factor in this case client was very punctual she attended sessions very attentively

and completed her daily homework regularly but sometimes she was very sad mood and did not

participate in the session.

Diagnosis

According to the Diagnostic and statistical manual of Mental Disorders (DSM 5 –TR), the client

fulfilled the criteria of schizophrenia disorder (multiple episodes currently in partial remission).

Management plan

The management plan was devised for the client and it comprised Cognitive Behavior therapy.
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Short term goals

• Rapport building with the client. Rapport will be established to have a therapeutic

relationship with the client.

• Psychoeducation makes the client aware of her problem and the management of her

symptoms. It helps the client and family members regarding the client’s disorder and its

problem.

• Social skills training maintaining client’s hygiene

• Progressive muscle relaxation

• Daily activity rescheduling

• Sleep hygiene working on client’s lack of quality

• Medical adherence

• Reality testing working on client’s delusions

• Relapse prevention

Long term goals

• Continuation of the client’s short-term goals in future Continuing

education and setting achievable goals in life

• Arranging follow-up sessions to maintain positive change.

Summary of therapeutic interventions

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Rapport building

In the initial session, Rapport building is the most important step in the process of the treatment

plan. It builds the relationship between the client and the therapist. The better the relationship,

the better the chances of the therapy being successful. In order to make the client follow the

treatment plan successfully the therapist gains the trust of the client and provides them with

unconditional support (Fritscher, 2021)

Rapport building was done with the client to gain her trust and make her comfortable. As the

client was not very vocal, building rapport took 2-3 sessions. Day-to-day conversations were

carried out at first to make the client comfortable before moving on to the sessions.

Psychoeducation

Psychoeducation is the process of teaching the client and their family about mental health and

about the disorder that the client is suffering from. It also discusses the importance of therapy and

medical treatment adherence (Drake, 2021).

The client and her family were educated in detail about Ms. S.A.’s disorder. The role of the client

and family in treatment was also made clear. Moreover, they were normalized by telling that such

symptoms are experienced by other people with the same disorder too. Ms. S.A. was reluctant

and sad initially about engaging in therapy-related tasks.

Progressive Muscle Relaxation

Progressive Muscle Relaxation (PMR) is a deep breathing technique that was devised by

Edmund Jacobson in the 1930s. This technique is effective for anxiety, stress, insomnia,

headaches, digestive disturbances, etc. (Stoppler, 2020).

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PMR was taught to the client to deal with the complaints of headache, weakness, and discomfort

in head. The client was taught to exercise this technique before sleeping. Starting from the

muscles of lower extremities and going upward gradually, the client was taught to tense the

muscle while inhaling and gradually relax them while exhaling imagining the pain, weakness,

and stress flowing out of the body.

Daily Activity Scheduling

Daily activity scheduling was introduced and continued till the end of sessions. It makes S.A.

active and increases her performance in daily activities. Firstly told about the importance of

engaging in activities that would make her feel fresh and relaxed. Personal hygiene-related

activities were also incorporated.

Sleep management

As the client was presented with the problem of not being able to sleep, sleep hygiene tips and

sleep management tips were given to the client to improve the timings and the quality of sleep.

Some of the tips included

• Have a fixed wake-up time

• Don’t overdo daytime naps

• Don’t use your bed for any activity other than sleeping

• Don’t toss and turn in bed. If you‘re unable to sleep during the first 20 minutes, leave

your bed.

• Include physical activity in your routine

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• Maintain a sufficient time gap between your last meal bedtime

Social skill training

Social skill training (SST) is a type of behavioral therapy which is done on patients to improve

their social skills so that they can connect and interact with the world around them (Cunic, 2020).

Assertiveness training was taught to communicate her wants and feelings.

Social skill training was done on the client to target negative symptoms of schizophrenia. It was

initiated with basic social skills including listening to others. When other people know that you

are listening they are more likely to continue talking to you. All these social skills were taught

through role-playing and maintained through reinforcement. Reinforcement was given to the

client to motivate her. Homework and assignments were given to the client in the form of short

story books and was instructed to read them out to other patients who were unable to read. This

helped the client in making friends and carrying out conversations with other patients.

Working with Delusions

Socratic Questioning

Socratic questioning is one of the techniques of cognitive restructuring that helps the therapist to

probe into the client’s irrational beliefs through continuous questioning. As the client did not

respond well in reality testing, Socratic questioning was used to probe into her beliefs and to

make the client talk about her childhood and family which she was not doing before. This helped

the client in opening up more and letting the therapist know about her beliefs in a detailed

manner.
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Verbal challenging of Delusions

In CBT for psychosis, the therapist verbally challenges the patient’s delusions in a gentle manner.

The therapist can gently point out inconsistencies in a patient’s belief system and then elicit

alternative interpretations of the evidence. The therapist encourages the patient to weigh out the

delusional beliefs and alternative beliefs in light of the existing evidence.

In this technique, the therapist verbally challenges the client’s belief of everyone is against her

and wants to harm her. Whom do you understand which person is want to harm her and why they

harm her? The therapist identifies her beliefs and misinterpretations. And to help patients make

sense of and deal with delusions. The therapist told the client to convey that delusions were a

reaction to a puzzling or threatening experience. The therapist portrays that delusions were a

reasonable attempt to find meaning when she was frightened or anxious.

Working with hallucinations

Hallucinations happen when people hear the voices and feelings of smell and aunts on her body,

but there is not anything actually there to account for it. CBT for psychosis aim to work with

distress caused by voices by exploring beliefs about the voices. When working with

hallucinations the therapist and patients collaborate to:

• Gently challenge beliefs about voices

• Identify the voices

• Understand the power of voices

• Learn how to control the voices

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• Uncover the origin of voices

• One way to do this is through reality testing

• If the other people hear then record the voices

Medicine Adherence

S.A. was much concerned about the side effects of antipsychotic medications and therefore she

didn’t take medicine regularly. She left her prescribed medication. Psychoeducation was done to

the S.A. and details to explain the importance of taking medicine and educate her about the

negative implications of not taking medicine and altering the medicine dosage without

consultation with the doctor.

Relapse prevention

Relapse prevention strategies usually include the identification of early warning signs for

relapses and the development of plans for acting in response to these indicators. They have been

used in combination with both pharmacological and psychological treatment regimes, over many

years (Birchwood, 1996). They are also commonly used in the psychosocial treatment of other

severe mental disorders e.g. recurrent depression, bipolar affective disorder.

In the last session, S.A. and her mother and sister were educated about the recognition of

warning signs and symptoms. This technique is learned in the therapy process. S.A. and her

mother were educated that stressful life situations and non-compliance with medication can cause

symptoms to reappear.
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Therapeutic Outcome

In session 11 post assessment was done on subjective rating of presenting complaints and the

PANSS scale. The therapeutic outcome was assessed through the quantitative level to see the

efficacy of the treatment

Subjective Rating of Presenting Complaints

Subjective ratings of the client’s problem were taken at post level to check the efficacy of the

therapy

Table 1.5

Subjective Rating of Client symptoms at Post Treatment level

Symptoms Post-Rating

Anger 5

Irritability 5

Sleep disturbance 4

Hallucinations 4

Delusions 5

Odd behavior 3
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Positive and negative syndrome scale (PANSS)

Table 1.6

Table below shows the severity levels of the subscale of PANSS

Scales raw scores T scores description

Positive 20 50 Average

Negative 22 50 Average

General 42 52 Average

Anergia 9 47 average

Thought 10 45 Average

Disturbance

Activation 7 52 Average

Paranoid 9 55 Average

In post-assessment of positive and negative syndrome scale sores show the efficacy of the

treatment. All subscales levels are non-significant.

Graphical Presentation of Pre and post score of subjective ratings of Client’s symptoms
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10 10
10
9
9
8 8 8
8

0
Hallucinations Delusions Odd behavior Anger insomnia irritability
Series 1 Series 2

Limitations

The following limitations were experienced during the treatment plan

• Despite the constant effort, the client’s family did not pay a visit to the client which

lessened the success of the therapy

• The number of sessions was not enough for the client

• The client showed less compliance in working on homework assignments.

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Session Summary

All sessions were approximately 40-45 minutes

Session 1

• Rapport building

• Brief history taking about complaints

• Psycho education

Session 2

• Rapport building

• Mental status examination

• Daily activity scheduling

Session 3

• Rapport building administration of PANNS

• Progressive muscle relaxation

Session 4

• History taking continued

PANSS continue

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• Social skills training

• Activity scheduling continued

Session 5

• Activity scheduling

• Improving personal hygiene

Session 6

• Rapport building

• Draw HTP

• Progressive muscle relaxation

Session 7

• Social skills training

• Family psychoeducation

• Socratic questioning

Session 8

• Activity scheduling


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Socialization and case conceptualization

Session 9

• Activity scheduling

• Identify beliefs

• Social skills training

Session 10

• Social skills training

• Activity scheduling

• Psychoeducation

• Working with hallucinations

Session 11

• Revision with previously learned techniques

• Family Psychoeducation

• Activity scheduling

• Working with delusions


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Session 12

Activity scheduling


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• Medical adherence

• Social skills training

• Relapse prevention

Reference

Fritscher, L. (2021). What to know about therapeutic rapport. Very well

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Haynes, Brien, W. (2000). Principles and strategies of behavioral observation. Spri

https://www.verywellmind.com/therapeutic-rapport-2671659

Hutton, F. (2021. August 21). Ten point guide to mental state examination in

psychichttps://psychscenehub.com/psychinsights/ten-point-guide-to-mealsat

examination-mse-in-psychiatry/

Mista, S., Gel aye, B., Koenen, K. (2019). Early parental death and risk of psyche

offspring: A six-country case-control study. Journal of Clinical Medicine, 8(7)

10.3390/jcm8071081

Psychscenehub. //(2), 3-11.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3433970/

relapse among individuals with schizophrenia: A qualitative study in Dar es

SaTanzania. BMC Psychiatry, 14. https://doi.org/10.1186/s12888-014-02409Stoppler,

M. (2020). Progressive muscle relaxation for stress and insomma. Web.

https://www.webmd.com/sleep-disorders/muscle-relaxation-for-stressinsomnia

Salich, M. (2004). The genetics of schizophrenia. The Malaysian Journal of Meca

Sariah, A. E., Outwater, A. H., & Malima, K. I. Y. (2014). Risk and protective factor

Science
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Case No. 2
Major Depressive Disorder
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Case Summary
The Client S.Y. was 45 years old male and was uneducated and married. He was 2 nd born of 7

siblings. He was brought by his elder sister with complaints of low mood, insomnia, loss of

energy, decreased appetite, hallucinations, nausea, hopelessness, and loss of interest in

pleasurable activities. He was referred to a trainee clinical psychologist for the psychological

assessment and management of his symptoms. Based on these assessments

Clinical Interview, Mental State examination, Subjective Rating of the presenting Complaint,

and Beck Depression Inventory, the client was diagnosed with Major Depressive Disorder,

according to the DSM-5TR. The case was conceptualized on the Beck model of depression.

Psychological management was also done by using different cognitive and behavioral

techniques; relaxation exercises. A total of 10 therapeutic sessions were conducted to deal

with the client’s problem and relapse prevention was taught to her. Through post-assessment

as well as the client reported that she experienced a significant improvement in her symptoms

of the client at the termination of therapy.

Biodata
Name S.Y
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Age 45 years

Gender Male

Education uneducated

Siblings 7 (3 sisters, 4broehters)

Birth order 2nd born

Occupation marble (shop)

Marital status Married

Religion Islam

Informant Elder Sister

No of sessions 8
Reason for Referral

The patient came with presenting complaints of low mood, decreased sleep, loss of energy,

decreased appetite, hallucinations, nausea, hopelessness, and loss of interest in pleasurable

activities. The clinical psychologist referred the patient to the present trainee clinical

psychologist for psychological assessment and management of his problem.

Presenting Complaints

As reported by an informant

Table 2.1
Duration Presenting complaints
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According to client

Table 2.2

Duration Presenting Complaints

History of Present illness

Mr. S.Y.’s problem started in January 2022 when he suffered from a chronic

disease(Tuberculosis) he complete his treatment after curing this disease and his presenting

complaints started to decrease in sleep, poor appetite, lack of concentration, anger burst, low

mood and loss of interest in pleasurable activities. He was working in a marble store before

his illness about two years ago. Because of illness, he faced a financial crisis. During

financial problems, his symptoms were exaggerated day by day. He became very aggressive.

He was in a low mood every time. Started facing problems his sleep was disturbed, over

thinking stated he had regret why he was ill. He faced a huge loss in business that’s why the

client was worried. He started avoiding socializing he left his friends. His behavior changed
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he became an aggressive person even if any family member try to talk to him he used to beat

them.

His social life was disturbed he had trust issues. His occupational life was also disturbed he

was doing any job. during these months he didn’t give any type of psychological treatment.

Patient’s problem getting increased day by day he had a low appetite he was not taking any

solid food. Food intake was zero he was just taking liquid and he was not able to digest liquid

food too. He was hopeless for his life his life has ended he will not live more. His mood

remained low for 6 months December 2022 to May 2023 he did not talk to anyone even

though he did not talk to his family member. They try to talk but he refuses even though he

used to beat his wife physically. His aggressive level became higher because of his illness.

Background Information

Family History

Mr. S.Y.’s father is alive he is 85 years old. He is not educated and was a farmer. His father

has polite nature. The patient’s relationship with his father was congenial. The patient has

love and respect for his father.

His mother had died at the age of 60 years, she had a heart attack. He was around the age of

35 when his mother died. It was a very sad event for him and took him lot a of time

maximum of 4 months to come out of grief. His mother was loving and caring nature. He had

a deep attachment to his mother. She was a heart patient. He took care of his mother in her

life. He was close to his mother and used to share his feelings with her.

Siblings

The elder sister is 48 years, old she got primary education and got married at the age of
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25years. The patient’s relationship with his sister is very congenial. His sister is very

cooperative and helps with his.Mr. S.Y was 2ndBorn.

The 3rd Born brother is 37 years old, He is uneducated and he used to live in a village. His

relationship with the patient is congenial. Their childhood was good they both used to share

things with each other. They still have a strong bond.

The 4th born sister is 35 years old, She got primary education. She is married. The patient’s

relationship with their sister is satisfactory.

The 5th Born brother is 32 years old, he is uneducated. The patient’s relationship with their

brother had satisfactory.

The 6thBorn brother is 29 years old. He is uneducated. He is married. The patient’s

relationship with his brother is congenial. He is very helpful and he understands all his

matters.

The 7thBorn sister is 25 years old. She just passed 4 th class. She has married the patient’s

relationship with her is very congenial.

History of psychiatry illness in the family

In his family, his uncle (Mamo) was a patient of depression.

Educational History

The patient initially used to live in the village and used to spend his time in games with

friends, he was not interested in studies even his parents wanted him to get an education but

he was not interested. He did not get any education, his other siblings got an education till

primary but he did not get any education because he was interested in games rather than

studies that’s why he could not develop an interest in studies.

 38

Occupational History

The patient started his job at the age of 18 in a hotel as a waiter and at that time his salary

was around 10 to 12 thousand and he did this job for at least 5 years. He had cooperative

relations with his colleagues he worked there for 6 years he left that job due to salary issues

He got another job with a better salary he worked there for 7 years and He was quite satisfied

with this job he was fulfilling all his expenses easily he left this job and started business in

his own marble shop.

Children

1st Born son is 12 years old and he was a student in the 7th class he is shy and he was less

talkative and left school he is naughty and was not interested in studies but his parents

wanted him to be a highly educated person he had a congenial relationship with his father.

2nd Born son is 9 years old, He is in the 5th class he is intelligent he is talkative and clever

he wants to get high education and he wants to become a doctor in the future his relationship

with his father is very good he has a caring and loving nature.

Psychological Assessment:

The psychological assessment was done:

• Clinical Interview

• Behavioral observation
• Subjective Rating of Presenting Complaints
 39

• Mental State Examination (MSE)

• Beck Depression Inventory (BDI)

Clinical interview

The clinical interview is a situation of mainly vocal communication, more or less

voluntarily integrated to explain the patterns of the characteristics of the patient's life, the

patterns that you experience as particularly problematic or especially valuable, and in the

Revelation of which hopes to gain the benefit is called clinical interview. The informal

clinical interview was conducted with the client and his informant to gather information

about the main problematic areas of the patient. It gave detailed and precise information

about the patient's biodata, presenting complaints, history of present illness, personal history,

family history as well as past psychiatric history. The information was then used to devise a

case formulation and management plan for the patient.

Mental State Examination (MSE)

Table 2.3

The mental status examination is a brief evaluation of a client’s behavior and cognitive

functioning (seider, 2014). The purpose is to evaluate, quantitatively and qualitatively, a range

of mental functions and behaviors at a specific point in time.

Appearance The patient was 45 years old male with

average height and weight. He was neatly

dressed up

In a shalwar and kameez, but his hair was

not properly combed.

 40

Motor Psychomotor retardation was observed during

the session from his gait and lethargic sitting
posture

Speech
The rate, rhythm, and volume of speech were
slow and low.

Affect
He was not maintaining

Proper eye contact with the therapist and his

mood was low subjectively and objectively.

Thought content
Delusion is not present but hallucinations
were reported by the patient. Suicidal ideation
was reported by the patient.

Perception
His orientation to time, place, and person was
intact.

Memory
His long-term memory was intact but his
short-term memory was partially impaired.

Insight He was aware of his illness

Subjective Rating of Presenting Complaints

The rating of the patient's symptoms was taken from the informant to get the intensity of the

symptoms at the pre-treatment level in order to compare it with post-treatment levels to check

the effectiveness of the therapy. Rating of the symptoms was t from (0-10) for severity, 0=

not at all, 5-average, 10-intense

Table: 2.4

Table of subjective pre-treatment rating of presenting complaints

Presenting complaints Patient’s Rating (0-10)
 41

Low mood 9

Hallucinations 8

Hopelessness 9

Insomnia 9

Decreased appetite 7

Loss of energy 8

Loss of interest in activities 8

Anger 9
Nausea 7

Beck Depression Inventory (BDI)

Beck depression inventory is a 21-item self-report scale that was used to measure the severity

of patient depressive symptoms at pre- treatment level to check the effectiveness of the

therapy.

Table: 2.5

Showing BDI rating of scale

Raw score Cut off score category

45 29-63 Severe depression

Qualitative Analysis

The patient score on BDI was 45 which falls in the category of severe depression. And the

client’s symptoms supported the BDI scores. His presenting complaints are hopelessness,

decrease in sleep, low appetite, and loss of energy.

Diagnosis

Major Depressive Disorder Severe (F33.2)

 42

Case Conceptualization
 43

Early Experiences

Chronic Disease

Core Belief& Assumption

I will not get better

Critical Incident

Loss in business

Negative Automatic Thoughts

‫ا ب کچ بہتر نہیں ہو گا ۔‬
‫ھ‬

Symptoms of depression

Behavioral Motivational
Cognitive
Symptoms Symptoms Somatic
Symptoms Symptoms
‫اکیال رہنےکو د‬ ‫کس سے ملنے کو اور کا‬
‫ل‬ ‫م‬ ‫ی‬ ‫ مايوسي‬، ‫أ د ا س‬ ‫ج س میںدرد رہتا‬
‫کرنا‬ ‫کرنے کو د نہیںچاہتا ۔‬ ‫ي‬ ‫ہے م‬
‫ل‬
 44

Case formulation

According to DSM 5 TR. Major Depressive Disorder is diagnosed when there is five (or

more) symptoms have been present during the last 2 weeks period and one of the symptoms

is either a depressed mood or loss of interest or pleasure. Depressed mood, markedly

diminished interest or pleasure in all activities (most of the day, nearly every day), significant

weight loss.

Insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, or loss of energy.

Diminished ability to think or concentrate, indecisiveness nearly every day, feelings of

worthlessness or excessive or inappropriate guilt, recurrent thoughts of death. The symptoms

cause clinically significant distress or impairment in social, occupational, or other important

areas of functioning and the episode is not attributable to the physiological effect of a

substance or to another medical condition (APA, 2013). This could be related to the patient's

case as he showed symptoms of low mood, insomnia, loss of energy, decreased appetite,

hopelessness, suicidal ideation, loss of interest in pleasurable activities, crying spells, and

psychomotor retardation. The patient's condition also caused clinically significant distress or

impairment in almost all important areas of functioning and was not attributable to the

physiological effects of a substance or to another medical condition.

Predisposing First-degree family members of individuals with major depressive disorder

have a risk for major depressive disorder two to fourfold higher than that of the general

population. Heritability is approximately 40%, and the personality trait neuroticism accounts

for a substantial portion of this genetic liability (APA, 2013). The patient's family psychiatric

history showed that his maternal uncle (mamo) also suffering from some anxiety or

depression disorder which increased the risk of psychological problems in the patient.

Precipitating Factor: The role of stressful life events in triggering episodes of depression is

well-established Researchers showed evidence that stress can cause major depressive
 45

disorder, common events including loss of jobs. Certain types of life events, such as loss of

humiliation, appear particularly likely to trigger depressive episodes (Davison, & Neale,

2012). In the present case, the patient also faced two stressful events chronic diseases

(tuberculosis) and job loss; this triggered depression in the patient.

Maintaining factor According to cognitive theorists, people with depression frequently have

pessimistic perspectives on events, which contribute to their disease. Albert Ellis suggested

that depression was caused by dysfunctional thinking, although it is actually Beck's idea that

is most frequently connected to the condition. Instead of underlying tensions or a decrease in

rewarding behaviors, according to Aaron Beck, depression is mostly caused by negative

thoughts. According to him, unipolar depression is caused by a combination of cognitive

triads, maladaptive attitudes, automatic thoughts, and errors in thinking (Beck & Weishaar,

2011: Beck 2002, 1991, 1967; as referenced in Davidson & Neale, 2012). In this instance, the

patient also had unfavorable ideas about himself, his future, and the world (others) in general.

"Dysfunctional thought record" findings also revealed several

Protective factors The client seemed to be a little bit hopeful, but his family corporate with

a therapist and good care of their client. The client was given medication on time. His

aggression has been normal due to treatment.

Management Plan

Following therapies were used to develop a management plan for the client

• Cognitive Behavioral Therapy

Short Term Goals

• Rapport building is done to develop rapport and a trustworthy relationship with the

patient to enhance his motivation for the treatment.

• Psycho-Education was done regarding the nature of the illness, his role in therapy,

and to develop realistic goals and expectations.

 46

• Deep Breathing Exercises will be taught in order to help him feel comfortable and

Relaxed.

• Progressive Muscle Relaxation will be taught to him with the rationale of

conditioning

To improve the quality of sleep and relieve muscle tension.

• A behavior Activity Schedule will be made to structure his routine so that he will be

able to use his time effectively.

• Coping Statements will be given to the patient to enhance motivation.

• Sleep Hygiene Tips will be given to the patient in order to improve his sleep quality.

• Cognitive Restructuring will be done to help him identify and change thinking errors

by using different techniques

• Thought clown

• Problem-Solving Techniques will be taught to enhance his skills to solve the path

away rather than avoiding them.

Long Term Goal

• The continent of a short-term goal.

• Relapse prevention.

• To enhance effective problem-solving skills.

Summary of therapeutic interventions

Rapport building:

In clinical assessment, the establishment of a rapport with the client plays a vital role a

creates a smooth relationship based on mutual understanding, acceptance, a feeling of trust,

and regard between the client and therapist (Allen, Montgomery, Tubman, Frazier, &
 47

Escovar,200 Rapport was developed through techniques of active listening, unconditional

positive regard empathy and few techniques of neurolinguistics programming were also

employed specifically the technique of metaphors (Lawley, & Tomkins, 2000).

Rapport building was done with the patient. The purpose was to make the client easy, open,

and compliant towards the therapy. It was through attentive listening and encouraging

expressions of thoughts and feelings, reflecting, showing empathy, demonstrating

genuineness and giving positive regard, maintaining appropriate body language and eye

contact. The client was asked open-ended questions and was encouraged to explain his

symptoms in detail. He was explaining how psychological stress is converted into

psychological problems. He elaborated that when a person is unable to handle stress in an

effective way then the symptoms manifest.

Psychoeducation

Psychoeducation refers to the education offered to people who live with psychological

disturbance. The patient was educated regarding her illness and was given awareness about

the disorder, early detection of warning symptoms, and adherence to medical and

psychological treatment. The patient was also educated about the course of treatment and also

about the chances of recovery. The patient was educated about management and also about

the relapse of the symptoms. The patient was educated regarding coping strategies and was

explained the duration of medical and psychological treatment.

Supportive work was used to maintain a relationship with the patient to break the resistance

and develop trust between therapist and client. Supportive work was continued throughout

the session to help a trustworthy and empathetic relationship, Supportive work was also

undertaken with the patient’s family to maintain their support and help during the session. In

supportive work, the patient trusts the therapist and discusses her problem openly. The family

was cooperative and acted upon the guideline of the therapist thought out the therapy.

(Appendices B1)
 48

Deep breathing

The patient was trained in this so that the patient relaxes whenever he felt disturbed by his

contaminated thoughts and anger. At first, the therapist described the full procedure and basis

of deep breathing. Then, later, the therapist performed it in front of the patient to make it

clear He was asked to close his eyes and put one hand on his chest and one on his stomach.

Then, was taught to take a deep breath through his nose and exhale it through his mouth after

retaining it for 4-5 seconds. It was also told to him that side by side; he was given himself the

message of being relaxed when he exhales the breath as all his tension was coming out from

his body along with the breath. After this exercise, the patient felt much better. (Appendices

B2)

Progressive Muscle Relaxation Exercise

Progressive Muscle Relaxation Exercise is a technique used for learning to monitor and

control the state of muscular tension (Jacobson, 1920). The technique involved learning to

monitor tension in each specific muscle group in the body by deliberately inducing tension in

each group. This tension was then released with attention paid to the contrast between tension

and relaxation. The patient was taught PMR to deal with stress in a more effective manner.

(Appendices B3)

Activity Scheduling

Activity scheduling (AS) is an effective behavioral treatment that addresses social isolation

in clients with depression. It is an approach that actively involves patients by increasing the

number of daily activities in which they participate. Activity scheduling is an established core

component of evidence-based depression treatment that has been shown to be just as effective

as other forms of cognitive behavioral therapy (Riebe et al., 2012). Activity Schedule was

given to the patient to have a directed set of tasks he can perform during the day and thus

distract himself from distressinducing thoughts and images. This involved splitting the day

into a scheduled set of activities at respective times. (Appendices B4)

 49

Pleasure and Mastery Technique

There are two types of activities in their spare-time routines pleasure and mastery. Pleasure

activities are enjoyable and relaxing. Mastery activities are those which entail the

performance of a task that requires the use of your skills and talents. A pleasure and mastery

events schedule is a behavioral technique to help clients engage in activities that give them a

sense of pleasure and achievement in a structured way (Lim, Correia, 2003). Mastery and

Pleasure were explained to the client. It was suggested to the client that he targets his

pleasurable activities like reading, writing, watching a TV Program, etc.

Sleep Hygiene Tips

The sleep hygiene tips were given to the client to improve his sleep. This method of therapy

is used to correct things a person does on a regular basis that disturbs his sleep. Sleep hygiene

consists of basic habits and tips that help the client to develop a pattern of healthy sleep.

Disturbed sleep will often be caused by more than one thing that the client did. To improve

the client's sleep, he will need to improve all of these habits. For example, he begins a regular

exercise routine. He hoped that it will help him sleep better. After a while he becomes

frustrated. He was having a hard time falling asleep at night. 21 This was because he

continues to drink caffeine in the evening. Even though he corrected one habit, the other

actions keep him from sleeping well (Bluth,

2015).(Appendices B5)

Daily Thought Record

Daily thoughts record, a concept in cognitive behavioral therapy is images or mental activity

that occurs as a response to a trigger (like an action or event). They are automatic and 'pop

up' or 'flash' in your mind without conscious thought. (Ally, 2018). A daily thought record

was used to monitor daily thoughts that came into the client's mind and to record the

automatic thoughts of the patient. (Appendices B6)

 50

Coping statement

The coping statements were introduced to enhance the patient’s control over dysfunctional

thoughts and anxiety-provoking situations. Rational coping statements are w states, which are

factual encouraging phrases consistent with the social reality. The patient was encouraged to

repeat them consistently to reinforce the idea for themselves (Ellis & Ma 1998 the patient

was explained that in order to gain control over her negative thought, s practiced rational

coping statements. (Appendices B7)

Mindfulness

The occurrence of an intrusive thought or worry does not necessitate active engagement or

station of the thought. Wells and his colleagues have developed a sophisticated and effective

metacognitive therapy" that addresses the individual's response to intrusive thoughts by

suggesting that the content of the thought is less important than the engagement with the

thought. According to Wells, cognitive attention syndrome (CAS) is activated when an

individual focuses excessively on an intrusive thought (Wells, 2005, 2008). (Appendices B8)

This engagement precipitates worry and rumination and continues unabated, leading to

generalized anxiety and the prolongation of depression. Mindful detachment is a technique

that allows one to stand back, observing, while not engaging in any control, suppression, or

judgment about the validity or importance of thought. This can involve noticing that a

thought occurs, imagining the thought as a cloud that passes, viewing the thought as a

telemarketing call to which one does not respond, or imagining the thought as a series of

trains coming into and departing the station, as one merely watches them pass. This may

appear similar to the use of mindfulness as suggested by Roemer and Orsillo (2002),

although the metacognitive model uses mindful detachment as an illustration that the most

valuable approach to thought is often to do nothing. In the metacognitive model, mindful

 51

detachment is used as a technique to demonstrate that one need not engage in any control of a

thought and that the thought will lose its significance on its own.

Problem-Solving

Problem-solving therapy is a form of therapy that involves providing clients with tools to

identify and solve problems that arise from life stressors, both big and small, to improve the

overall quality of life and reduce the negative impact of psychological and physical illness.

(Gans, 2019) Problem-solving therapy can provide training in adaptive problem-solving

skills as a means of better resolving and/or coping with stressful problems. Such skills

include:

• Making effective decisions

• Generating creative means of dealing with problems

• Accurately identifying barriers to reaching one's goals

Relapse Prevention:

Relapse prevention generally refers to illness management through compliance with

medication regimes. It is widely accepted that people who have been seriously affected by

mental illness are at risk of relapse if they do not take their medication as prescribed.

Consequently, much of the relevant literature focuses on encouraging compliance with

medication regimes through psycho-education and cognitive behavioral techniques (Mueser

et al 2002). The patient was given tips for relapse prevention. He was told that relapse will

provide a chance to practice a skill which you learned in therapy His sister was also educated

about the relapse. She was asked to support him during the period and used the extinction

procedure.
 52

Therapeutic Outcome

In the session, post-assessment was done on the subjective rating of presenting complaints

and the BDI scale. The therapeutic outcome was assessed both quantitatively and

qualitatively level to see the efficacy of the treatment.

Beck Depression Inventory (BDI)

Quantitative Analysis

Table 2.6

Client’s score on the BDI scale at the post-treatment level

Raw score Range Category

25 21-30 Moderate depression

Perceived Rating of the Symptoms

Subjective ratings of the client’s problem were taken at the post level to check the efficacy of

the therapy.

Quantitative Analysis

Table 2.7
Shows perceived rating of the symptom as reported by the client from 1-10 at the post-

treatment level

Presenting complaints Patient’s Rating (0 -10)

Low mood 5

Hallucinations 5

Hopelessness 4

Insomnia 4

Decreased appetite 4

Loss of energy 5

Loss of interest in activities 4

 53

Anger 5

Nausea 3
(For pre and post-treatment comparison see the therapeutic
outcome)

Graphical presentation of pre and post-treatment Assessment

 54

BDI
50
45
40
35
30
25
20
15
10
5
0
Pre Score post score

Series 1 Series 2

Outcome of Therapy

The total no of sessions was 10. The client reported that she felt a significant improvement in

her symptoms and that it was helpful for her to work on her thoughts and see things from

other perspectives.

Limitations

• The gap between sessions was long that was 8 to 12 days which influence the

effectiveness of the therapeutic work.

• An interruption-free environment did not exist that created disturbance in taking

sessions with the client.

Suggestions

• The number of sessions should be increased to better improvement of the client.

• The client should continue the medication till the recommendation of the doctor.

• Psychoeducation and family therapy will further help in improving his condition
 55

Session’s report of (Major depressive disorder)

Session 1:

• Rapport Building
• Brief History taking

Session 2:

• Complete History taking

• Mental status Examination

Session 3:

• Back depression inventory (BDI).

• Deep breathing

Session 4:

• Behavioral Activation chart

• Medical compliance

Session 5:

• Reviewing Of homework
• Psychoeducation

Session 6:

• CBT Model conceptualization

• Worrying thought record

 56

• Questioning the evidence

Session 7:

• Reviewing of homework

• Identification of cognitive distortions

• Questioning the evidence

Session 8:

• Reviewing the homework

• Answer the negative thoughts using cognitive distortion
• Problem-solving skill

Session 9:
• Reviewing of homework
• Cost-benefit analysis
• Problem-solving skills

Session 10:

• Reviewing of homework
• Therapeutic outcome
• Post Assessment
 57

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental

Disorders.

5th Edition, Washington, DC: American Psychiatric Association

Beck, A. T. (1976). Cognitive therapy and the emotional disorders, NY: International
University

Press, Inc.

Cognitive psychotherapy, NY: Springer-Verlag Berlin Heidelberg Davis, M., Eshleman, E.B

McKay, M. (1982). The relaxation and stress education workbook, USA: New

Harbinger publication

Comer R. J. (2004). Abnormal psychology (4th ed.). U.S.A: Worth Publisher American

Psychological Association. (2000). Diagnostic & statistical manual of mental disorder

text revision (4th Ed.).American Psychological Association.

Cognitive therapy techniques: A practitioner's guide, NY: The Guilford Press, Inc Perris, C

Blackburn, I.M. & Perris, H. (1988).

Insomnia: Psychological assessment and management, NY: The Guilford Press, Inc Leahy,
R.L.

(2001).

Spiegler, M.D &Guevremont, D.C. (1998). Contemporary behavior therapy (3rd ed.). U.S.A.

Books/Cole Publishing Company.

 58

Case No. 3
Bipolar Disorder
 59

Case Summary

N.I. was a 21-year-old girl. She was educated. She was 2 nd born among her siblings. She was

referred with presenting complaints of irritable mood, overtalkativeness, aggression,

decreased need for sleep, self-harm, and distractibility. Her mood was mostly irritable. She

was referred to the trainee clinical psychologist for psychological assessment.

The assessment was done by behavioral observation, clinical interview, Mental Status

Examination (MSE), and Subjective Rating of her presenting complaints, Young Mania

Rating Scale (YMRS) was administered assessment tools were used to aid the diagnosis. The

client was diagnosed with Bipolar (F31.12). A total of 8 sessions were done. The techniques

included rapport building, Psychoeducation, deep breathing, progressive muscle relaxation,

mindfulness exercise, anger management techniques, and sleep hygiene tips. Through post-

assessment as well as the client reported that she experienced a significant improvement in

her symptoms of the client at the termination of therapy.

 60

Bio Data
Name N.I

Age 21 years

Gender Female

Education intermediate

Occupation Nurse

Siblings 6 (4 brothers, 2sisters)

Birth order 2nd

Religion Islam

Marital Status Unmarried

Source and reason for referral

The client was referred to a trainee. A clinical psychologist for the assessment and

management of her problem. The client came to the psychiatry ward with presenting

complaints of insomnia, a High level of Aggression, flight of ideas, irritability, lack of

appetite, and self-harm. Presenting complaints

Table 3.1

As reported by a client:
Duration Presenting Complaints
 61

History of present illness.

The client's problem started in December 2022. When her father refused to take admitted in

MBBS. The client was worried about her studies she wanted to become a doctor during this

situation she love her cousin Z and she wants to married with him but her family was against

her decision. Her cousin goes abroad without informing her and has not had any contact with

her for several months. After this client presented complaints of High levels of aggression,

flight of ideas, irritability, Anger outbursts, lack of appetite, self-harm, and self-laugh she was

facing these symptoms for 6 months she became more aggressive because of her family’s

ignorance. She became irritable she started to use to beat herself. She read novels till late at

night because of lack of sleep. She started making overfamiliar relationships with her

colleague’s Client's behavior towards her family was very rude then her best friend suggested

she consult with a psychiatrist and that she should not get proper treatment and was not

willing to come and she did not accept that she is suffering from any psychological illness.

According to the client started hating her family before getting the treatment she became

irritable personality she was becoming aggressive person, it was a very upsetting and serious

issue for her family. When the client came to the psychiatry ward she was not cooperative her

tone was low. The client was highly expressive and aggressive. She harm herself through

injected avil injections. No visual or auditory hallucinations were reported. No derealization

and depersonalization were present. She had no insight into her problem client reported some

physical symptoms she was feeling back pain and leg pain on her left side. The psychiatrist

referred her to a clinical psychologist for assessment and management.

According to the client, her occupational and social functioning was adversely affected

because of her problem. Currently, the client had no medical problems. The client’s

presenting complaints High levels of aggression, excessive talkativeness, flights of ideas,

irritability, Anger outburst, lack of appetite, and self-harm.

 62

Family History:

The client belonged to a middle-class family.

Her Father was 65 years old. He was uneducated and was a labor but did not earn much to

handle his family. He was a strict person. The client’s relationship with her father was not

satisfied.

The client's Mother was 60 years old and she was a housewife. The client’s relationship with

her mother was not so good. The client had not satisfied relationship with her family.

Siblings

She had 6 siblings including 2 sisters and 4 brothers,

The 1st born brother was 25 years old and he works in a garment factory. He had an

education till Matriculation. She was a not satisfactory relationship with her brother. He was

argumentative and conflicting with the client.

She was 2nd born.

The 3rd born brother was 20 years old and he also works in factories as a labour. He was

interested in getting higher education. But due to his financial problems, he could not

continue his studies. He was not a satisfactory relationship with the client.

The 4th born brother was 19 years old. He got primary education and after that, he work with

his elder brother. She had a satisfactory relationship with her brother.

The 5th born brother was 17 years old he studied in 9 th class. Her client’s relationship with her

youngest brother was good.

The 6th born sister was 15 years old, and she also studied in 9 th class with her brother in the

same school. The client’s relationship with her sister was good. Her sister is very supportive

and caring about her. Overall,the client’s home environment was not satisfactory.
 63

History of psychiatry illness in the family

There was no history of psychiatric illness in the family.

Personal History

Birth and early development:

The client was born with a normal delivery in-house. There were no complications during the

client's birth. Her birth weight was normal and the mother didn't suffer from any illness

during pregnancy. According to the client, she achieved all her milestones at the right age,

and no developmental delays were reported.

Educational History

The client passed intermediate. She was an average student. Her teachers were satisfied with

her performance. She also gets Islamic education in her childhood. She used to take part in

extracurricular activities in school. She wants to become a doctor but her father was not

agreed because of financial issues and then she got a diploma in nursing and continue her

studies.

Sexual History

The client started their menstrual cycle when she was fourteen years old. It did not affect her

social functioning. She did not report any negative attitude towards this phase of life. Rather

she regarded it as an important phase of life.

Before starting the menstrual cycle she became aware of sex and sexual relationships. She did

not show any interest in viewing sex-related movies and TV programs and considered the

relationship between men and women to be restricted. The client knew her limits and the

limits of Islam and never tried to cross them.

 64

Occupational History

The client had been working as a home care nurse in Ichra Lahore. The client had

satisfactory relations with her co-workers she never quarreled with others at the workplace

she was satisfied with that job and she did this job maximum of 8 months.

Premorbid personality

According to the client, she was good and had a stable life pre-morbidly. She had no

problem. She was able to perform her daily life activities well without any difficulty. She was

an active girl. She had good and satisfactory relationships with her family members, all

relatives, and friends. The client was very social and had congenial relations with her friend.

She used to play with her siblings in her childhood. She had very satisfactory relations with

her siblings. She also had friends at the workplace and in her colony. She had a congenial

social circle that's why she spent most of her time out of the house in her social circle. Her

sleep and appetite were normal. She was healthy and affectionate toward others. She watched

TV and went out of home with her friends in her spare time. The client's mood was swinging

according to the situation. According to the client, she was well-behaved and well-mannered.

She was normal before the onset of the problem. She took care of her health and avoided

which were not suitable for her health. She belonged to a middle-class family. Her religion

was Islam, and she offered prayers regularly. The client reported that she was very aggressive

now as compared to the past.

Psychological Assessment

The psychological assessment was done on both formal and informal levels that included a

clinical interview, Mental Status Examination, and subjective Rating of present illness. An
 65

assessment is one that does not incorporate psychometrics or data collected for statistical

analysis (Spielberger, 2004). The psychological assessment was done on an informal level.

• Behavioral Observation

• Clinical Interview

• Mental Status Examination (MSE)

• Pre and post Subjective Rating of the present problem

• Young Mania Rating Scale (YMRS)

Behavioral Observation

The client was cooperative and talked in a contained manner. She maintained eye contact.

She was well-dressed and healthy. She was talkative too much and there was a flight of ideas

when she talked. Because she was sleepy. The client maintained eye contact and her facial

expressions were clear. The client N. I had normal height with normal weight according to

her age.

Clinical Interview:
The clinical interview is a situation of mainly vocal communication, more or less

voluntarily integrated to explain the patterns of the characteristics of the patient's life, the

patterns that you experience as particularly problematic or especially valuable, and in the

revelation of which hopes to gain the benefit it called clinical interview.

The clinical interview was conducted to obtain information about the client in detail. First of

all, rapport was developed. Privacy and confidentiality were ensured to him about the

information which he gave during the clinical interview. The client was allowed to talk freely

during the interview and told me about his problem without any hesitation. The initial step

includes to gathering detailed information about the client's problem and symptoms. During

the clinical interview, Information was also taken from the informant to complete the

information about the client which helps to explore the client's problem in depth.

Mental Status Examination (MSE):

 66

The mental status examination is a brief evaluation of a client’s behavior and cognitive

functioning (seider, 2014). The purpose is to evaluate, quantitatively and qualitatively, a

range of mental functions and behaviors at a specific point in time.

Table 3.2

Appearance The client N. I was a 21-year-old girl. She had

average height and seems normal weight and
she was wearing a seasonal neat dress. At first
glance, she looked decent.

Behavior During the interview, she was sitting on a

chair, and she maintained adequate eye

contact. Her facial expression was low. And

she seemed as restless.
Speech Her voice tone was low and not very clear
Mood, Affect
The mood and affect of the client were
elevated

Thought process
Her thought process and content were
adequate

Delusion No delusions were reported

Hallucinations No hallucinations were reported

Orientation
The client had an intact orientation of place,
time, and date.

Memory Recent and remote memory were intact

Insight, judgment The client and good insight into her problem
 67

Subjective Pre Rating of client’s symptoms

Table 3.3
Symptoms Client’s Rating

Irritability 9

Lack of sleep 8

Self-harm 8

aggressiveness 9

distractibility 8
Suicidal ideation 8

Low appetite 8

Young Mania Rating Scale (YMRS)

Young Mania Rating Scale was used to assess the level of mania that the patient was going

through and for the confirmation of diagnosis, is an eleven-item multiple choice diagnostic

questionnaire. It was developed by Vincent E Ziegler and popularized by Robert Young

(Young

at el., 1978).

Quantitative Analysis

Raw Score, Range and Level of Mania on Young Mania Rating Scale

Table3.4
Raw Score Range Level of Mania

26 26-37 Moderate Mania

Qualitative Analysis

The patient's score on YMRS was twenty-six which fell in the category of moderate mania

ranging from 26-37. The patient's maniac was manifested by irritable mood, excessive
 68

talking, aggression, decreased need for sleep, distractibility. The profile of YMRS was

congruent with the presenting complaints of the patient as well as the history of the present

illness that was reported.

Diagnosis

Bipolar Disorder episode moderate 296.42 (F31.12)

69
 70

Case formulation

N.I. was a 21 years old woman, who came to the psychiatric department ward with

complaints of irritable mood, excessive talking, aggression, decreased need for sleep, suicidal

ideation, and distractibility.

According to Bebbington (1993), people with bipolar disorder experience significantly more

critical life events, particularly in the three months prior to the first episode. Stressful life

events that involve social disruption were associated with the onset of manic episode. In the

present case, significant stressful events were the conflict with both of her brother's wives

which might have led to the development of the disorder (Kring et al, 2014).

The four P's of case formulation (predisposing factor, precipitating, perpetuating factor, and

protective factor). Also, provide a useful framework for organizing the factors that may

contribute to the development of bipolar disorder.

In this case, predisposing factors are the conflicts with family. They refused to take

admitted in MMBS. She wants to become a doctor but her parents don’t agree because of

financial problems .

The precipitating factor in this case her family cannot agree her marriage with her cousin.

She love with cousin but her family is against her decision.

The perpetuation factor in this case appears her cousin went abroad without informing her

and stop contact with her. This factor maintained her problem, she was self-harm through

injected avil injections.

The protective factor in this case client was the support of her best friend.

Case conceptualization
 71

Presenting complaints

Irritable mood, excessive talking, aggression, decreased need for sleep,

self-harm

Predisposing factor Perpetuating factors

Family conflicts (parents Her cousin went to abroad
refused for her MBBS) without inform her
admission)
Client

Precipitating factor
Conflicts with family for Protective factor
marriage refusal Diagnosis Her bestfriend support
Bipolar Disorder episode moderate
mania

Management plan
Psychoeducation
Sleep muscle relaxation
Mindfulness
Anger management technique

Management plan:

The intervention was planned to reduce the client's behavioral problems and increase the level

of functioning. Following the below-mentioned goals:

 72

Short Term Goals

• Rapport building to make the client comfortable with the therapist, so it becomes easy

to work with the client

• Psycho-educate and describe regarding diagnosis and management and guide how to

handle problems.

• Understanding of stressors, thoughts, and beliefs through a cognitive model of bipolar

• Providing a basic mental set for understanding the nature of treatment. Reducing

negative thoughts to help the client feel relaxed by regulating the breathing process in

angerprovoking situations

• Improve quality of sleep by giving sleep hygiene tips.

• Relapse Prevention

Long Term Goals

• Continuation of short-term goals.

• Reduce negative thoughts.

• Controlling and identifying thoughts/ beliefs to manage emotionality effectively.

• Become able to deal with problematic life situations without becoming overwhelmed

Therapeutic Techniques

Rapport Building

Rapport is a state of harmonious understanding with another individual that enables greater

and easier communication (Robert & Bouchard, 1989). It was crucial to establish a rapport

with the patient right away. In order to establish a trustworthy relationship between patient

and therapist, rapport was created to give patient confidence in the therapeutic alliance. She

was told about the confidentiality of her information when the therapist was introduced. The

therapist showed him compassion, acceptance and trust.

 73

Psychoeducation

Psychoeducation is defined as an intervention with systematic, structured and didactic

knowledge transfer to an illness and its treatment, integrating emotional and motivational

aspects to enable patients to cope with the illness and to improve its treatment adherence and

efficacy (Ekhitari et al., 2017).

The patient received organized and structured information about the causes or triggering

factors, maintenance factors, and available treatment for her aliment. She received

information on the genetic, psychological and social variables that contributed to her disease.

The value of therapeutic interventions in the management of her sickness was explained to

her. Additionally the patient was informed that there would be 12-14 sessions, each lasting of

45 minute and that the therapy would be structured and collaborative.

Deep Breathing

Deep breathing was thought to the client in order to reduce headaches, increased State and

relief stress Deep breathing is a simple yet powerful relaxation technique. For this exercise

deep breathing involved inhaling deeply and exhaling fully (Robinson. 2017)

The client was instructed to sit in a relaxed position and close her eyes. She was told to take a

deep long breath from his nose and keep the breath in belly for 5 seconds. Then slowly exhale

through mouth. She was asked to do it 5 times at the time of anger.

Progressive Muscle Relaxation Technique (PMR)

Progressive muscle relaxation technique was performed to relive the stress in her body and

reduced certain chronic pain in body (Stoppler, 2020). It was used to increase awareness of

tension throughout the body and allow it to be reduced. Progressive muscle relaxation teaches

how to relax muscle through a two-step process. First, the patient will systematically tense

particular muscle groups in the body, such as neck and shoulders. Text releasing the tension
 74

and noticing how the patient muscle feel when she relaxes em. The process was completed

till the completion of all muscles in the body. laxation exercise was taught to the client to

relax the body. It helped the patient in sleeping as well.

Sleep Hygiene

Sleep Hygiene refers to the notion that specific kinds of behavior are conductive

incompatible with sleep and that modifying behavior may alleviate insomniaer & Gehrman,

2011)

Importance of sleep and disadvantages of not sleeping was explained to the client. The client

was asked to go to the bed and wake up around the same time each day. Changes in sleep

could disrupt the normal functioning of brain parts involved in the processing of emotions.

The following sleep-hygiene recommendations were provided to the clients (a) go to bed only

when sleepy; (b) use the bed and the bedroom only for sleep; (e) get out of bed and go to

another room whenever unable to fall asleep or return to sleep within 15 or 20 minutes, and

return to bed only when sleepy again; (d) maintain a regular rising time in the morning

regardless of sleep duration the previous night; (e) avoid daytime napping; (f) regular

relaxation exercise before going to bed (g) avoid caffeine intake and (h) limited time screen at

night.

Anger Management Techniques

For management of patient's anger and aggressive behavior several techniques were used.

Firstly, the patient was instructed to record her anger episodes in Thought Diary. She was

directed to record the causes and consequences of her anger through self-monitoring.itwas

done to make the patient aware of her triggers of anger, emotions, body sensations, thoughts,

behaviors and consequences due to anger. She was informed about the purpose of the activity

which was to provide the patient access to her 'hot cognitions". Then she was guided to
 75

monitor the potential triggers of her anger which include specific people, comments and

events. She was also directed to make appraisal of the situation which would make her angry.

The patient used the anger diary which helped to detect her triggers, thoughts, emotions, etc.

Her triggers included her cousin don’t, contact with her. Then she was instructed to use self-

instructions to direct in a controlled way i.e. "The cousin maybe busy with his job", "My

muscles are tightening its time to relax". The patient used the self-instruction when he felt she

was going towards anger and she reported great impact of them on her thoughts and behavior.

Punching the pillow was introduced to the client whenever she felt angry. Aimlessly hitting a

pillow, punching bag, or some other in animate object teaches the client to vent her anger at

something neutral.

Secondly, the patient was directed to use the problem solving approach while experiencing

physical arousal of anger. For this she was guided about the steps of problem solving while

included identification of problem objectively, considering possible responses, weighing up

the consequences of each alternative and finally implementing the best solution and

evaluating it. In the same way, the patient identified the problem i.e., inquiry of her family

about her activities, objectively as "my parents is asking me to sleep because they cares for

me". Then she considered possible solutions i.e. shoeing anger to them or simply doing what

they said. And then she weighed both alternatives and decided to simply answering the

question and implement it. Finally, she evaluated the whole sensation scenario and her

solution and showed satisfaction with them. This approach was quite helpful for the patient

and she reported that she gained an adaptive way to manage with her anger.

Further, she was also told to get support from other when she is in angry. Talk through her

feelings and try to work on changing her behaviors. Physical activity like regular exercise is a

way to both improve her mood and release her anger. Listening can help improve
 76

communication and can build trusting feelings between people. This trust can help her deal

with potentially hostile emotions.

Distraction techniques was also used with the client. If she cannot change the situation, it

can help to distract her from whatever is making you angry by counting to 10, listening to

music, taking hot shower, calling a friend to chat about something else, doing housework,

removing yourself from the situation and going to another room or drinking water (Roland,

2003)

Relapse Prevention

N.I was again psycho-educated about her illness and reviewed the therapy techniques taught

to her. The list of skills learned in therapy was made collaboratively to the client and

therapist. All coping strategies were briefly reviewed and then provided a therapy blueprint to

help her remember all she had learned in the therapy sessions.

Therapy Blueprint

In the last session, the patient was again psycho-educated about her illness and all the

therapy techniques of the previous sessions were reviewed. The list of skills learned in

therapy was made collaboratively by the patient and the therapist. It was administered,

consisted on a written summary of techniques the client had learned from the therapy about

etiological, maintain factors and the way of overcoming them and preventing from future

relapse.

Therapeutic Outcome

In session 7 post assessment was done on subjective rating of presenting complaints and

young mania rating scale. The therapeutic outcome was assessed both quantitative and

qualitative level to see the efficacy of the treatment.

 77

Post Assessment Subjective Rating of client's problem

Subjective ratings of the client's problem were taken at the post level to check the

efficacy of the therapy. Quantitative Analysis

Table 3.5

Subjective Ratings of Client at Post Treatment Level.

Symptoms Post Rating

Aggression 5

insomnia 6

Talkative 6

Self-harm 5
Irritable mood 5

distractibility 5

Young Mania Rating Scale (YMRS)

Quantitative Analysis

Raw Score, Range and Level of Mania on Young Mania Rating Scale score on post treatment

level

Table3.6
Raw Score Range Level of Mania

15 19-25 Mild Mania

(For pre and post-treatment comparison see the therapeutic outcome)

Limitations

• The client was reluctant at first and showed guarded behavior.

 78

• The room in which sessions were carried out was noisy which made it difficult for the

client and therapist to understand each other

• The client was not on time.

Suggestion

• It is recommended to the client to come on follow-up sessions on the set schedule.

• The session room should be quiet.

 79

Session Report

Session no 1

• History taking

• Rapport building

• Relaxation exercise- Deep Breathing

Session no 2

• Continue to remaining history taking.

• Mental status examination

• Obtaining subjective ratings of symptoms on a visual analog

Session no 3

• Psychoeducation

• Relaxation exercise- PMR + deep breathing

Session no 4

• Obtaining ratings of the young mania scale

• Dysfunctional thought record

Session no 5

• Activity scheduling

• Sleep hygiene tips

Session no 6

• Psychoeducation

• Reviewing of home work

 80

Session no 7

• Post assessment

• Therapy blueprint

Session no 8

• Feedback of previous sessions

• Relapse prevention
 81

References

American Psychiatric Association. (2013), Diagnostic and Statistical Manual of Mental

Donkers

(DSM-5th ed) United State of America: American Psychiatric Association

Derogatis, LR (1992), SCL-90-R: Administration, Scoring of Procedures Manual-II for the

(Revised) Version and Other Instruments of the Psychopathology Rating Scale Series:

Clinical Psychometric Research Incorporated.

Ekhitari, H., Rezapur, T., Aupperie, R.L., & Paulus, M. P. (2017). Neuroscience-informed

Psychoeducation for addiction medicine: A neurocognitive perspective. Prog Brus

Res,

235, 239-264.https://doi.org/10.1016/bs.pbr.2017.08.013

Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2014). Abnormal Psychology.

John Wiley & Sons, Hobken

Roberts, S. D., & Bouchard, K. R. (1989). Establishing rapport in rehabilitative audiology.

Journal of the Academy of Rehabilitative Audiology, 22, 67-

73.https://psycnet.apa.org/record/1990-23667-001

Seider, T. (2014), Mental Status Testing. Elsevier Inc.

https://www.sciencedirect.com/science/article/pii/B9780123851574004292

Young, R.C., Biggs, J.T, Ziegler, V.E., Meyer, D.A. (1978). A rating scale for mania:

reliability, validity and sensitivity. Br J Psychiatry, 133:429-435.

 82

Case No. 4
Obsessive Compulsive Disorder
 83

Case Summary
L.H. was a client of 25 years man educated till 10 th class firstborn child among two siblings.

He belonged to a middle-class family. He came to the hospital with complaints of repeated

lining up, checking locks, anxiety, and overthinking. the formal assessment was done for

understanding the problems of the patient Informal assessment included a Clinical interview

Mental status examination, symptom rating, and baseline chart for obsessions Formal

assessment was carried out using the Yale-Brown Obsessive Compulsive Scale (YBOCS)

After the assessment of the patient was diagnosed with Obsessive Compulsive Disorder 3003,

especially with good or fair insight. The therapeutic management comprised of techniques of

CBT as Supportive work, The patient gave appropriate response toward some techniques. A

total of 8 sessions were done. The techniques included rapport building, Psychoeducation,

deep breathing, progressive muscle relaxation, mindfulness exercise, anger management

techniques, and sleep hygiene tips. Through post-assessment as well as the client reported

that she experienced a significant improvement in her symptoms of the client at the

termination of therapy.

Bio Data

Name L.H

Age 25 years
 84

Gender male

Education Matric

Socio-Economic Status middle class

No. of Siblings 2 (2 brothers)

Birth Order first

Marital Status Unmarried

Religion Islam

Reason and Source of Referral

The client was referred to the trainee Clinical Psychologist with the presenting complaints of

repeated checking door locks, lining up, anxiety, overthinking, headache, and extreme anger.

The client was referred to the trainee clinical psychologist for psychological assessment.

Presenting Complaints

According to client

Table 4.1

Duration Presenting Complaints

History of present illness

The client reported that in 2021 his father died because of a heart attack, - dele and

the client were much close with his father. He feel very insecure without his father

and every time he became very sad. The problem started after the death of his father
 85

client was so much upset after this particular incident client usually remained in a low

mood and cried.

In 2022 he felt changes in his thought such as every time he felt the door lock was

open. The client was so much worried but the condition of his control. The client

reported that he was normal but one day he felt a repetitive urge about checking

locks and fixing everything repetitive urges became severe day by day. The client

explained that he started living alone and tried to avoid checking doors. The client

thought about fixing everything related to his father. The client explained that due to

these repetitive urges, his relationship with his family was not healthy and all the

family members started to hate him and always point out with verbal statements like

"he is psycho" extreme These words were felt bad. The client reported that due to

these urges, he felt anger extremely and wants to harm others but the client did not

harm anyone. The client also reported that he cried after-anger emotions because he

can't do anything. But he don’t take any type of treatment.

The client reported that his relationship with his friends was also not healthy due to

these repetitive urges. The client conveyed that he was doing his job but he left his

job due to these repetitive urges. The client reported that he checked the locks 3

times and sometimes he check again and again but he didn't feel satisfaction. The

client reported that he had insights but couldn't get rid of these repetitional problems

and felt stress and anger. He informed me that he felt a severe headache. He started

overthinking every time. The client reported that he was very disturbed because of

his thoughts again and again but his thoughts never changed and he is still stuck in

these urges. The client was interested in treatment so he started to take sessions

properly. He knew that these thoughts were the product of his own mind and were

distressing because he couldn't stop them. The client reported that he always tried
 86

his best to control his feelings and thoughts but all in vain. Because of these

thoughts, he could not concentrate on his daily activities and therefore there was a

significant decline in his daily functioning. Because of these reputational urges, the

client became irritated, distressed, and sad. He felt embarrassed in front of other

people because of his compulsive behavior so he preferred not to

participate in social activities

Family History

The Client belongs to a middle-class family. The client lived in a joined family system. The

client’s father died at the age of 55 years and was educated up to Matriculation. He was a

shopkeeper. He was a humble and caring person. The client was emotionally close to his

father. His relationship with all his children was good. He had heart disease for the last 9

years. His relationship with his wife was not satisfactory due to his illness.

The client's mother was alive. She was 48 years old and she was educated till middle. She

was a housewife, she had a strict and dominating nature, and was the authoritative member of

the family. Although she loved her children and took care of them, she had certain rules in her

life and she didn't let anyone cross them. She was a cleanliness freak and wanted everybody

in the house to maintain cleanliness. She wanted her children to get higher education.

Because of this reason, she was strict about the studies of her children. She did not have a

satisfactory relationship with her husband because he had given her all the responsibility for

their children and other family affairs. She made all the decisions for the family by herself.

She was a bit harsh with her children in the matter of education, but otherwise, she was a

loving and caring mother.

Siblings:

The client had 1 sibling that is one brother

The firstborn was the client himself.

 87

The second born was his 20-year-old brother. He got his education till intermediate. He was

interested in getting higher education. But due to his family's financial problems, his father's

death, and his elder brother's illness he could not continue his studies further. He started

working in his father's shop. He was hard-working. He took all his responsibilities at a very

early age. He had a friendly relationship with the client. He was mentally and physically

healthy.

The client belonged to a middle-class family. His father had a physical illness. The client

lived in a joint family system. They had clashes with his paternal uncle as reported by the

client. The overall home atmosphere was not much satisfactory for the client because of the

client's

illness.

Personal History:

Birth and early development

The client's mother reported that the client's birth was normal. He did not have any prenatal

or postnatal complications regarding his birth. His weight at the time of his birth was normal.

His development was normal. The client's mother fed the client for one and a half years.

The client reached the following milestones within the expected age ranges: sitting without

support, crawling, standing alone, walking alone, eating with a fork, speaking a first word,

and speaking the first sentence. He continued to wet his bed at night when he was asleep till

seven years of age.

He was an active child. No neurotic traits like excessive fears, stammering, sleepwalking,

temper tantrums, nail-biting, and thumb-sucking were reported.

Educational History:

He started his education at the age of 5 years. He joined a Govt. School in his local area. He

was happy to go to school. He had congenial relations with his teachers and friends. He was
 88

an average student in his class. After passing Matric he joined his father’s shop and work with

his

father.

He got his religious education from the Qari in the mosque and completed the recitation of

the Holy Quran under his supervision at the age of 12 years. He reported that he learned

many verses of the Quran easily.

Sexual History
At the age of 15, he achieved puberty. He did not know about certain changes in him in

puberty. When he became aware of it by one of his friends, he was nervous in the beginning

about his pubic hair, the appearance of mustaches on his face. The client reported that he

received sexual information through friends and media. His attitude toward girls was normal

and he liked girls but he did not have any close interaction or relationship with any girl. He

said that he had information about the legality of the nature of man and woman relations in

Islam. He never had any heterosexual or homosexual relations with anyone.

Occupational history:

During the study, he got a job as a computer operator with the help of his friend in a private

company with a monthly income of 7000 RS. Per month. He lost his job due to company loss

and two months' salary was also not given to him. He tried many times to contact the

manager that he needed money but they said the company was at a loss and the owner of the

company closed the office how they could pay. Then he joined his father’s shop.

Premorbid personality:

According to the client, he had a stable life pre-morbidly. He could take care of himself in a

proper way; he could eat well, sleep well and dress well. His judgmental abilities and

problemsolving skills were working at an optimal level. He was able to perform all normal

daily life activities without any difficulty or problem. He had a routine in his life i.e. from
 89

home to study and back to home. The client was a social person. The client had two friends in

school and limited interaction with the rest of their classmates. He had a good relationship

with his friends. The client reported that he was an obedient student and had a satisfactory

relationship with his teachers. He did not like crowded and noisy places and wanted a calm

and peaceful life. He did not have any leadership qualities and was a shy person. He was not

in the habit of talking too much.

He had healthy relations with his family, friends, and others although friends are limited. He

enjoyed playing cricket with his brother. He was a rigid person, He was self-controlled and

had the quality to maintain discipline. He had a positive attitude. He had so much planning in

his life. He reported that his life goal was that he would have a lot of money to support his

family. He was a religious person as he used to offer five-time prayers regularly. He had a

positive attitude towards people in general.

 90

Psychological Assessment:

The psychological assessment was carried out on an informal as well as formal level. The

informal and formal assessment included clinical interview and observation, mental state

examination, symptoms ratings, and Yale-Brown Obsession Compulsion Scale (YBOCS).

Both the informal and formal assessments are discussed one by one as follows: Informal

Psychological Assessment

• Clinical Interview

• Behavioral observation

• Rating of the Client's Symptoms

• Mental Status Examination

Clinical Interview:

In a clinical interview, a detailed and comprehensive history of the present illness was taken

and the family history of the client was also explored in depth. The personal history of the

client involving early childhood, education, socialization, sexual relationships, marriage and

occupation was examined. Precipitating and maintaining causes of the illness were

investigated. Over Predisposing. The functioning of the client and the general atmosphere of

the home were discussed thoroughly in a clinical interview.

Mental Status Examination

Mr. L.H. was a young man of long height and average body weight. He had a thin body

structure. He was neatly dressed up in Jeans and T-Shirt which shows that he had no self-

neglect. He maintained eye contact normally. His facial expression seemed to be tensed and

curious. He appeared to be his reported chronological age which was 23 years. He did not

show any kind of disorganized speech, disorganized behavior, or inappropriate or flat affect.

He seemed to be anxious and curious while talking about his problems. He wanted to be rich

and have a house of dreams. He had guilt feeling because of his thoughts. But he knew these
 91

thoughts were wrong but he couldn't control it. The client had obsessions and compulsions

but psychotic features like hallucinations and delusions were not present in the client.

Subjective Rating of presenting complaints:

The ratings of the symptoms of the client were taken from the client in this case. These

ratings were made out of 10 in increasing order of severity.

Table. 4.2

The client's and the informant's ratings of the symptoms from 0-10 in order of the severity

Symptoms Client’s Rating

The compulsion of taking a bath 9

The compulsion to check locks 8

Ordering things 8

Anger 7

irritable 7
Sleep disturbances 7

Diagnostic Test

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Table 4.3

Raw score Range Category

27 24-31 severe

Quantitative Analysis

The YBOCS score of the client showed that he had a severe presence of OCD.

The client had experienced current obsessions and compulsive acts.

 92

Diagnosis

(F42) Obsessive Compulsive Disorder specifies with good or fair insight

Idiosyncratic Case Conceptualization (well, 1997)

Event

Father’s death

Meta beliefs
I was insecure

Appraisal of
intrusion
I was insecure,
Belief
Without my father I
am useless

Behavioral response
Emotions
Repeated checking
locks Anger

Frustration Anxious

Decrease of sleep Irritated

 93

Case formulation

The client was 25 years old unmarried male. The client came with complaints of an

obsession with compulsions of taking baths, checking and ordering, irritability, restlessness,

inability to concentrate, disturbed sleep, and loss of appetite. These problems had led to a

significant impairment in his daily, social and occupational functioning. The client's

predisposing factors for developing the disorder were his age, socioeconomic status, and

relationships with the family. Clients belonging to a middle socio-economic status markedly

increase the risk of mental disorders.

The client's mother was strict about education but he did not continue his studies because of

his father's illness. The psychoanalytical theory explains obsessions and compulsions are

viewed as similar, resulting from instinctual forces, sexual or aggressive, that are not under

control because of overly harsh toilet training. The person is thus fixed at the anal stage

(Carson, 2001). Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid

toilet-training practices that led to internalized conflicts. Other theorists thought that OCD

was influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as

well as by the attitudes and parenting style of the patient's parents.

The client's mother was a dominating personality in their house. She was harsh with him.

Because of the strict home environment sense of competence was not developed in the client.

Adler (1931) viewed obsessive-compulsive disorder as a result of feelings of incompetence.

He believed that when children are kept from developing a sense of competence by doting or

excessively dominating parents, they develop an inferiority complex and may unconsciously

adopt compulsive rituals in order to carve out a domain in which they exert control and can

feel proficient (Davison

& Neale, 2001).

The client was a student and his present condition was triggered after a stressful event.
 94

According to Kaplan and Sadock (1991) the onset of obsessions and compulsions in about 50

to 70 percent of patients, begins after some stressful event, such as pregnancy, a sexual

problem, or the death of a relative. Cromer, Schmidt, and Murphy (2007) found that

obsessive-compulsive disorder (OCD), like most other psychiatric disorders, is influenced by

life events, both with regard to the onset and course of illness.

The client's symptoms were triggered after his father's death. He also had financial problems.

These were the precipitating factor for the onset of disease. According to Clark, (2004)

Patients with OCD report a significant life event prior to the onset of illness, such as the loss

of a loved one, severe medical illness, and major financial problems. In a more systematic

study of life events, Mckeon, Roa, and Mann (1984) found that patients with OCD

experienced significantly more life events in the 12 months before the onset of the illness.

Preexisting dysfunctional beliefs in personal responsibility, over-importance, control of

thoughts, intolerance of uncertainty, perfectionism, and threat estimation are considered an

underlying vulnerability that may predispose individuals to obsessive-compulsive symptoms.

(Reinecke & Clark, 2004). The client gave importance to his obsessive thoughts and tried to

control them. This led the client to the present condition.

The client faced many problems during his toilet training. His mother had harsh and strict

behavior in this regard. The client might have fixated on the anal stage and might, by reaction

formation, resist the urge to soil and become compulsively neat clean, and orderly. The

client's mother wanted his son to be highly educated and he was also sensitive about the

cleanliness of the house. The client also wanted to meet the expectations of his mother. So,

when he failed his graduation exams, he felt guilty and in order to reduce his tension and guilt

he started performing repetitive behavior of washing hands, cleaning the house, and keeping

things in the right order. An obsessive thought is seen as a defense against the anxiety

produced by an even more unwelcome and unconscious thought. This defensive process

involves displacement and substitution. To defend against this anxiety, the individual
 95

unconsciously displaces this anxiety from the original terrifying thought onto a less

unwelcome substitute. The defense has a powerful internal logic, and the thoughts that are

substituting for the underlying thought are not arbitrary (Cardwell & Flanagan, 2003).

The client was suffering from the symptoms of OCD along with feelings of anxiety and low

mood. Regarding patients with symptoms of OCD, Salkovskis (1997), suggested that the

more they try to suppress these thoughts, the greater their discomfort and inability to stop

them (as cited in Halgin & Whitbourn, 2007).

The client's maintaining factors were his age, distant family relations, sensitive nature, and

reserved personality. These factors would remain a constant barrier between the client and his

prognosis. Unless these factors were worked on and eliminated, the client would be healthy

as these were fairly strong risk factors. Protective factors The client was given medication on

time and had good insight into his problem.

Management plan

The management plan was devised using a cognitive behavioral approach keeping
 96

In consideration of the idiosyncratic needs of the patient.

Short term Goals

• Therapeutic relation was built through active listening to his complaints and

conveying the client’s idea of collaboration in the therapy.

• Supportive work was used to motivate and engage the client in therapeutic work and

maintain the client and therapist relationship

• Psychoeducation was done by educating the client about his disorder and the severity

of the symptoms that the client experience. It helped the client and family members

regarding the client's disorder, its illness, and its causes.

• Deep breathing was used to release the stress and anxiety of the client. The purpose of

this technique is to provide a patient with a safe method of relaxing.

• Progressive muscle relaxation was done with the client by teaching him the PMR

relaxation technique to overcome his anxious and depressed feelings and to make him

relax.

• Activity Schedule was done with the client in order to mobilize and involved the

client in daily routine activities

• Distraction technique The goal of the distraction technique was given to the patient to

change their focus of attention and distract his way from intrusive thoughts.

• A cost-benefit analysis was used to measure the benefits of the decision or taking
action

List of obsessions and compulsions were done to assist the patient to make a more
realistic and accurate interpretation of the significance of their unwanted, intrusive

thoughts.
 97

• The coping statement was taught to enhance self-control against negative thoughts.

Exposure response prevention was used to encourage you to face your fears and let

obsessive thoughts occur without 'putting them right' or 'neutralizing' them with

compulsion.

• Relapse prevention was done to deal with any future symptoms.

• A therapy blueprint was given to the client to find out the learning of the client that,

and what he had learned from therapy.

Long term Goals

• Continuation of short-term goals by encouraging the patient to continue the

techniques she learned during therapy

• To make sure the medicine adherence

• To prevent relapse in the future regular follow-up to be done to check the progress

after the therapy.

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Summary of Therapeutic Intervention

Rapport Build
The aim of the initial sessions was to build trust and support with Mr. L.H. to engage him in

therapy and formulate a therapeutic alliance. The therapist listened to his problems and

history in an empathetic manner without being judged and gave him warmth and

unconditional positive regard. The rapport was developed so that a history of illness can

easily be taken from a patient in order to speculate his current diagnosis and devise an

appropriate management plan.

Psycho educate and normalize obsessions

L.H. was psycho educated about the psychological way of treating the problem. The

precipitating, maintaining, and triggering factors of his illness were explored and he was

educated that these were the signs of psychological problems. His insight was partially

present already therefore, he understood the psychological explanation of his illness quite

well.

Normalization

Normalization was done by telling the patient about common occurrences of obsessions and

compulsions to lower his anxiety level about it. He was told that obsessions also may occur in

normal life and it is only the increase in intensity and frequency of it that leads the path to

obsessive-compulsive disorder. Furthermore, the patient was educated about the treatment

procedure for OCD which is through medication and psychotherapeutic treatment. He also

explained the model of treatment and the efficacy of CBT with OCD. Treatment goals were

set with him and the number, frequency, and duration of sessions, importance of homework

assignments, etc.

Cognitive Distortion

Cognitive distortions were explained to the patient to educate him about different thinking

errors, and to train him to identify these errors so that he can invalidate his intrusive thoughts
 99

and obsessional beliefs. He was also provided with a list of cognitive errors. Examples from

her previous baselines were taken and distortion in his thought process was discussed.

Distortions were identified and labeled in (Leahy, 2003) the final step involved substituting a

rational response for each thought followed by a rating of the beliefs left. The triple-column

technique was then practiced as homework for making the patient capable of identifying

distortions on his own, labeling them, and then reasoning them for getting alternate positive

responses. Initially, he had some difficulty in understanding cognitive errors and identifying

them in his thought process but through various examples from his daily life and continued

cognitive restriction, he was able to reason with his thoughts.

Detached mindfulness

Detached mindfulness was taught to LH to modify his beliefs related to intrusive thoughts.

He had a belief that there is no way to control or let go of intrusive thoughts. He explained

the rationale of detached mindfulness i.e. to not get engaged with the intrusions by

ruminating on them, rather he had to passively let go of the intrusions allowing them to

occupy their own space without engaging with it. The patient was educated that intrusions

themselves are not the problem but the worry about intrusion thoughts is distressing. (Wells

and Matthews, 1997).

Moreover, he was also encouraged to refrain from evaluating whether or not the thoughts is a

fact, it remains thoughts irrespective of their validity. It was first practiced with natural

thoughts i.e. free association task and the step was to practice it with obsessions. The patient

was educated to separate himself from his thoughts. He was also taught to generalize it to

other disturbing thoughts. In 3 sessions he reported that this strategy was helpful for him and

helped him in control over disturbing thoughts which he didn't have earlier.

Exposure and response prevention:

The most widely used and generally accepted behavioral approach to compulsive rituals, was

pioneered in England by Victoria Meyer. In this client exposes himself to situations that elicit
 100

compulsive acts such as checking door locks and then refraining from performing the

accustomed ritual of ordering. The assumption is that the rituals are negatively reinforcing

because it reduces the anxiety that is around by some environmental stimuli or event.

Controlled research suggests that this treatment is at least partially effective for more than

half of patients with OCD, including children and adolescents.

Activity Schedule

An activity schedule is a list of the activities which the Contractor expects to carry out in

completing his obligations under the contract. The total of all the activities and groups is the

Contractor's price for providing the whole of the work. An activity schedule was given to the

client to have a directed set of tasks he can perform during the day and thus distract himself

from distress including thoughts and images (Obsessions).

Evidence for and against

Thought Record (Evidence For And Against) is a cognitive restructuring worksheet that

guides clients through a process of carefully considering the evidence for their automatic

thoughts a process Beck refers to as 'examining and reality testing.

The client was explained that when we have the negative thought we usually dwell on data

that confirm our conclusion. The client was asked to gather evidence that supports his

obsessions and anger. Evidence should be based on data information and the fact that could

not be interpreted. Therapy Blueprint

In the last session, the patient was again psycho-educated about her illness and all the

therapy techniques of the previous sessions were reviewed. The list of skills learned in

therapy was made collaboratively by the patient and the therapist. It was administered and

consisted of a written summary of techniques the client had learned from the therapy about

etiological, maintain factors and the way of overcoming them and preventing future relapse.
 101

Post-treatment Psychological

AssessmentSubjective Post Rating of client

symptom

Table 4.4
Symptoms Client’s Rating

The compulsion of taking a bath 5

The compulsion to check locks 4

Ordering things 4

Anger 3

irritable 3
Sleep disturbances 3

Graphical representation of pre and post-score of subjective rating of symptoms

pre and post ratings

10
9
8
7
6
5
4
3
2
1
0
compusion of compulsion of ordering things anger irritable sleep disturbance
checking locks taking bath

pre ratings post ratings

Post Assessment of Yale-Brown Obsessive Compulsive Scale

Table 4.5
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Raw score Range Category

14 8-15 mild

Graphical representation of pre and post-scores of Yale-Brown Obsessive Compulsive

Scale (Y-BOCS).
YBOCS
30

25
20

15

10

0
pre score post score

Series 1 Series 2

The therapist had total 8 sessions with the client and significant improvement in his

symptoms. Initially report was difficult to build up however gradually as he opened up the

therapist. In the beginning, the emphasis was on relaxation procedures and activity schedules,

Later more sophisticated techniques regarding modifying thinking patterns were adopted and

they were found effective in therapeutic settings. The patient was not reluctant about doing

homework assignments.
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Limitations

• The gap between sessions was long that was 8 to 12 days which influence the

effectiveness of the therapeutic work.

• An interruption-free environment did not exist that created disturbance in taking

sessions with the client.

Suggestions

• The number of sessions should be increased to better improvement of the client.

• The client should continue the medication till the recommendation of the doctor.

• Psychoeducation and family therapy will further help in improving his condition.

Sessions Report Session 1

• Rapport building
• Mental status examination
• Psycho education

Session 2
• Agenda setting
• Brief history taking
• Detailed history taking
• Daily activity chart

Session 3
• Review homework
• Administered of Y-BOCS
• Visual analog

Session 4
• Daily activity chart
• Detached Mindfulness
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Session 5
• Deep breathing
• Review homework

Session 6

• Cognitive Distortion
• Overview the homework

Session 7
• Progressive muscle relaxation
• Therapeutic outcome

Session 8
• Post assessment
• Therapy blueprint
105
 106

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