Internship Report (PSY 619)

Of
Clinical cases
Clinical case studies

Undertaking case:
  Major depressive disorder
 Acute stress disorder
Prepared and Submitted by:
Lubna Parveen
Student id:
Session:
Submission date:

Virtual university of Pakistan

Submitted to:
Department of Management & behavioral sciences

Dedication

First of all I would like to dedicate my all work to Allah almighty who give me the
strength for completing my work and guide me in every step of my life. I am very
thankful to Allah almighty who is given to me the strength in completion of the
report. Secondly I am giving to appreciate to my parents and my family who are
support to me.

Acknowledgement
In the name of Allah who are most merciful and gracious. I am specially thanks to my
parents , my family ,my friends and my all teachers who are support to me in the
completion of my work. I would also like to thanks to Mam Amina Liaqat (supervisor
in BBH), who have given to me the chance to do internship in their hospital. And I am
also thanks to my university teachers who are given us knowledge and guidance in
every step of learning and academic process. Finally, I want to give my especial
thanks to VIRTUAL UNIVERSITY OF PAKISTAN that gave me an opportunity to
get world-class reasonable education at my door step. I will be always thankful to VU
for offering me the chance to achieve my targeted goal. I not only learn about
Psychology but also learn about IT, which is necessary in today’s global village.

Executive summary

This report is basically consist of two clinical cases in which given details about the
patients personal, family and psychological history. Both cases are related to the
neurotic psychological disorder in which one is Major Depressive Disorder and the
second is Acute Stress Disorder.
Case A:

First case is one male case (I.A), he is came to the hospital with the complains of
headache, insomnia, poor appetite, low mood, aggression, worries, restlessness,
stomach problems. All these symptoms are started after 3 months ago, when his son
sold his land without his permission. According to the DSM V, all these symptoms
are related to the Major Depressive Disorder Code 296.xx (F32.x and F33.x)”.

According to his premorbid personality, he has no psychological problems in the past.

He was normal after this incident. He has no hallucination and delusions and also has
good memory. I used to Beck anxiety Inventory (BAI) and depression Anxiety Stress
Scale (DASS) and one personality test HTP. Pharmacological treatments were given
by psychiatrist (Dr. Zona) which are:
Tab: Esgiet 10mg (1+0+0)
Tab: Ozip 5mg (0+0+1)
And psychological treatment I used to Counselling, deep breathing and PMR-RT. I
advised to him sleep hygiene for insomnia and also advised to him take proper diet do
exercise.

Case B:

Case b is a female case came with the complains of headache, insomnia, aggression,
fatigue, flash backs, weeping, low mood, weeping at every time. All these symptoms
are start after her brother death due to accident. Her brother death almost 20 days ago,
when she was came in the hospital. She is very close to her brother and when her
brother died she was under stress after his death. According to the DSM V, she has
suffering from the Acute Stress Disorder code “DSM-5 308.3 (F43.0)”.

After this trauma, she was normal and has good personality and has not any
psychological problems in the past and not in her family. Her mental status normal no
any delusions and hallucination.

For formal assessment I used beck anxiety inventory (BAI).for psychological

treatment I used deep breathing, PMR relaxation therapy, counselling. These
techniques are reduce anxiety and beneficial for my client. I am also advised sleep
hygiene and take proper diet and do exercise morning and evening. And also give
suggestion to manage your time for your family and friends, change attitude and
thoughts.

In the end I wrote case formulation and attached appendences.

Table of Contents
Case A
Background information/ Bio data……………………………………………………
History of present illness …………………………………………………………….
Main reason for referral ……………………………………………………………...
Presenting complaints ……………………………………………………………….
Family history ……………………………………………………………………….
Personal history ……………………………………………………………………..
Premorbid personality ……………………………………………………………….
Previous & presenting psychological problems ……………………………………..
Mental status examination …………………………………………………………...
General information/ intelligence ……………………………………………………
Administration of psychological tests ……………………………………………….
Any other important information ……………………………………………………
Diagnosis & prognosis ……………………………………………………………...
Management and treatment …………………………………………………………
Follow up plans ……………………………………………………………………..
Any suggestions / recommendation …………………………………………………
Case formulation ……………………………………………………………………
Appendances ………………………………………………………………………….

Case B
Background information & Bio data ………………………………………………..
History of present illness ……………………………………………………………
Main reason for referral ……………………………………………………………..
Presenting complains ……………………………………………………………….
Family history ………………………………………………………………………
Personal history …………………………………………………………………….
Premorbid personality ………………………………………………………………
Previous & presenting psychological problems ……………………………………
Mental status examination …………………………………………………………
General information / intelligence …………………………………………………
Administration of psychological tests ……………………………………………..
Any other important information ……………………………………………………
Diagnosis & prognosis ………………………………………………………………
Management ant treatment plans ……………………………………………………
Follow up plans ……………………………………………………………………..
Any suggestion & recommendation ………………………………………………..
Case formulation ……………………………………………………………………
Appendances …………………………………………………………………………
 Case: A
Major depressive
Disorder
Case A

Background information/Bio data:

Name: A.I

Age: 63 years

Gender: Male

Education: Middle

Occupation: Construction

Religion: Islam

Marital status: Married

Children: 1 (son)

Income: Almost 25000(per month)

Informants: Self

Socioeconomic status: Middle

Family: Nuclear

Date of admission: 10 march 2018

Reference: Referred by medical department

Main reason for referral:

The client was referred by a medical specialist after

examining all the results of medical reports, different blood tests.
Client told to the medical doctor that he has headache, feeling
uncomfortable during breathing, fatigue and poor appetite. He

1
suggested to the client to consult a psychiatrist or psychologist for
these problems because according to the test he was normal.

Presenting complaints (client verbatim):

 Mujhe nend nhi aati. mien rat ko sahi se so nhi skta

 Sir mien hr waqt dard mehsoos hota ha
 Bhook nhi lagti
 Rona ata ha lekin ansoo nhi nikalty
 Gussa bht ata ha
 Zindaghi achi nhi lagti
 Koi kam krny ko dil nhi krta
 Jism mien kamzoori mehsoos hoti ha
 Har waqt dil udas rehta ha.ajeeb bechani mehsoos hoti ha
 Agy k soch k mayoosi hoti ha
 Khushhali khatam ho gye ha
 Yeh sub 3 maah se ho rha ha

Brief History of present illness:

According to the patient the problems were started 3 months ago. The
main cause of the problems that his son sold the land without his
permission. When he was knows that the land was sold then he was
worried. He was anger on his son on his act. But he was not
displeasure to his son because he has only one child. He was purchase
this land for making child house in the future at this land. And now the
land was sold so that he was nothing to his hand for his child. And this
thing is very hurted for the client. Patient showing aggression after this
incident. Then the patient worried and feels these problems. Now a
days the client feel low mood whole day and didn’t show interest in his
daily life activities. His behavior also changed after this incident. His
daily life also affected by these problems. Nowadays he seems to be
hopeless. He usually like to be alone and sad. Stomach problem also

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observed. Sleep is very less during these three months. Client is
hopeless in the future. He thought that life is nothing for me. He
doesn’t like his life. He feel weakness in his body. He has headache
most of the time. Client appetite also poor.

After these problems, his relation with his family not seems too good.
His family cooperate him but his own psychological condition
disturbed him. After all his home environment is disturbed due to his
psychological problems.

He became aggressive on normal things. And this thing is disturbed his

wife and his son. They try to avoid as such thing who can be worried to
client. His son obeyed and respect to his father but client did not
happy. He did not know why he show aggression. His wife also take
care of client.

Family History:

 Father

The client father name was S.A. His education was matric and he was
works in a private company as a watchman. He was aggressive but
normal with his family. He has no any medical problem in his life. In
the last stage of life he has depression and end of the life start
hallucination. He was died in 2002.his relation with client was good
because the client is only male in his children.

 Mother:
The client mother also dead. Her name was K.A and she was not
educated. She was housewife. She has no any physical and
psychological problem. She was very loving and caring with her
family especially with client. Because the client was only male in
family so the mother was loved him more. She was also good with her

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husband. She was very religious women and also teach Islamic
knowledge to her children. She was died to

 Siblings:

My client has total 6 siblings, 3 brother and 3 sister. His two brother
was died in their childhood. His birth order is 3 rd. his two sister are
diabetes patient and one is normal. And his brother is also normal. And
their siblings married and well settled in their homes as well. They
have normal which each other and loved and caring which each other.
Client sister loved with their brother.

Martial History:
Spouse
His wife name was I.A. his wife was his cousin and his marriage was
fixed by their parents. She was 62 years old and a house wife. She was
illiterate. She has normal in both physical and psychological health.
Their relationship is good and lived normal.

Children history
He has 3 sons in which two sons was died in their childhood and one is
alive. His sons is 28 years old. His name is J.A. his education is only
matric and he has normal in physical and psychological health. He is
work with his father (client). He work with his father. They do
construction work.

Personal History:

Birth:
The birth of patient was normal without any complications and he was
normal at birth time.

Early development:
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 The history of prenatal, postnatal and infancy stages were all normal.
He developed in a healthy atmosphere.

Physical health/medical health:

He had a good physical health. But now a days he is getting treatment
of depression in Benazir hospital.

Traumatic experience:
The client told that his son sold the land that is the cause of his worries
and these worries becomes into illness.

Any psychological symptoms:

The client did not show any history of psychological problems and
psychological treatment.

Schooling:
He starts his schooling at the age of 5 years. He was normal in the
class. He was passed middle with good marks.

Milestone

Milestone Normal range Achieved age

Cry after birth Immediate Immediate after

after birth birth
Neck holding 2-4 months 2-3 months
Sitting 6-7 months 6 months
Crawling 8-9 months 9 months
Standing 9-10 months 10 months
Walking with 10-12 months 11 months
stand
Walking 12-18 months 13 months
without
support
Babbling 6 months 6 months

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One word 1-2 years 15 months
Two words or 1-2 years/ 2-3 27 months
sentence years
Toilet training 2-3 years 27 months

Adolescence:
The client reached to the age of puberty at age of sixteen.in formation
received by patient.

Sexual Inclination:
The client did not show interest towards the opposite sex because he is
very religious and knows the Islamic knowledge all about it.

Premorbid Personality:

Social Interest:
He was a good companions and a good friendship with others. He has
good relation to others. But now a days he has no interest in others and
not has friends.

Social relationship:
He was good relationship to others before the illness. He has many
friends in his past. He was very confident and had no social fear or
crowd sensitivity. He had a good relationship with his neighbor
friends, school mates and help others. He is very caring person.

Mood:
In the session time his mood was very low. But before his illness his
mood is very good and polite with all the time.

Moral and religious values:

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He has good values. He performed namaz five times daily, and also he
recite holy Quran. He has Islamic point of views and he took stand in
favour of the right. But last few days his fajr prayers missing due to
sleeps problems.

Habits:
He likes books reading. He also like gardening. He likes help other so,
he is help his wife in house chores.

Reaction to stress:
He is mentally strong but nowadays he has anxious in every little
things.

Smoking & Drug history:

The client did not report any forensic history. He never had taken any
drug nor had any police record.

Psychiatry traits & problems:

The client did not report any psychological trait or problem in his past.
His father has depression at his last days of life. But his all other
family member are normal.

Previous & Present Psychological Problems:

His mentally condition was normal 3 months ago. He has good
physical and mentally health before this disorder. He has nothing any
psychological problems in his early life. Before three months he was a
normal person and lives a normal life with his family.
From last three months the patient has developed psychological
symptoms; insomnia (lack of sleep), low mood, fatigue, headache,
poor appetite, hopelessness, aggression. These problems disturbed his
daily life.

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He has no interest in his life and daily activities. He has also worried
about his sleep problems.
Mental status examination:

Sitting posture:
I.A sitting posture is normal and also was sit in relax and calm during
session.
Facial features:
He has normal face as his age. His facial features was clear. His face
color was white. And he has white beard on his chin.
I. Hair color: white
II. Styling and grooming: I.A was a normal person and Islamic so he is in
normal dress and also his dress was simple and clean.

Height: 5 feet 10 inches

Weight: approximately 95 kg
Body shape: normal healthy
Cleanliness/Neatness: he was very neat and clean
Clothing/Dressing: very simple and neatly dressed
Level of eye contact: normal
Eye movement: normal
Degree of friendliness: average
Apparent age: he was looking an old person.

Mannerism: he was very good manners and talked with very nicely
and also told his problems in a normal way.

Mood:
He showed an anxious mood and depressed. He seems to be hopeless
person. He speaks very slightly.

Speech:

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  Form of speech: his speech volume was normal. He gives answer relevantly.
He gives answer with confident.
 Content of speech: the client speech content was appropriate and relevant to
the question. He was talked in normal way and there was no stuttering and
stammering in the speech.

Thoughts:
 Stream of thought: his thoughts was normal no any kind of suicidal thoughts.
 Thought content: the client thought was diverted to negative thoughts and
fears of unexpected events.

Delusions:

Subjectively no delusions was found.

Hallucination:

Auditory: no auditory hallucination was found.

Sensory: no sensory hallucination was found.

Visionary: no visionary hallucination was found.

Orientations:

Time:

Patient is time oriented. He gave all the answer correctly. I had asked
him about date, day and time and he gave the right answer.

Place:

The patient is place oriented. He had knowledge about place and

location.

Person:

He was person oriented because when I asked about his family

members he told correctly.

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Memory:

Long term memory:

His long term memory is good and worked properly. He told me about
his life experience and incident accurately and in proper way. He was
not confused to remember his past life.

Short term memory:

His short term memory also good. He remember yesterday events and
easily recall the names of the family members.

Recent memory:

His recent memory also normal. I asked about some questions and he
answered accurately.

General information:

The client had general information. I asked him different general

knowledge questions and he gave accurate answered. I asked him tell
the difference between snake and rope and he gave the answer
properly.

I asked him to tell the difference between the dog and the goat and he
gave the answer correct.

I asked him what is the capital of our country and he gave the exact
answer.

Insight:

The client was aware of his illness and he knows that he will be cure
after treatment and he will be healthy as such before.

Summary of informal & formal Psychological Assessment:

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 Informal assessment:
Clinical interview and behavioral observation conclude that
client was normal and his physical appearance also normal. The
speech of client was normal. I asked him some questions and he
gave correct answer. During the session his memory was good
and he complete all the task.

 Formal assessment:
I have conduct two types of tests for formal assessment.
Projective test is HTP and objective tests are DASS and BAI.
The formal assessment of the client through following
administered tests.
i.Beck Depression Inventory
ii.Depression Anxiety Stress Scale
iii.House Tree Person

1. Quantitative analysis:

Beck Anxiety inventory

Score Range Category

42 26-63 Severe anxiety

Depression Anxiety Stress Scale (DASS)

Score Rang category

e
D 42 28+ severe
A 32 20+ severe
S 38 34+ severe

2. Qualitative analysis:

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 Beck anxiety inventory (BAI):
The result of the BAI is 42 which falls in the range of 26-32
that is present the severe anxiety. This result shows the anxiety
of the client.
 Depression Anxiety Stress Scale (DASS):
The test was based on 42 questions divided into 3 categories
depression, anxiety and stress holding 14 items for each
category.
The client’s score was all three category were depression
42(range 28+) severe, anxiety 32(range 20+) severe, stress 38
(range 34+) sever.

 House Tree Person:

House tree person is a personality test in which draw a three
pictures. One is person the second is house and the third one is
a person. The main objective of the HTP is to measure the
personality aspects of a person by interpreting drawings and
answers to questions.

House:
House is the symbol of security, status and comfort. I.A draws
house which shows he has not relationship and not sharing
feeling with others. He draws only one door and one window in
house that is represent he wants make relations to others. Walls
doors and boundaries show strength of his ego, doors show his
openness, willingness to interact with others. The roof of the
house presents that he like fantasy world. He did not draw any
path way outside of home its means that he was not social and
not share feelings with others.

Tree:
The drawn by patient was having large trunk which shows
strong ego strength. The tree has no branches in which shows

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 that he has less contact with others. He did not draw roots of
the tree in which shows that he has sense of insecurity.

Person:
Person drawn by patient represent his personality or be figure
of someone’s the person like or hate. He draw a person with
open mouth that is present him is showing verbal aggression.
Open arms presents willingness to engage. He use eraser in
drawings in which presents anxiety and conflict of his
personality. He draw fingers Patel like that is show immaturity.

Any other important information:

No any other information is left behind as far as my concern. I had
tried the all information given in the relevant arear of the case sections.

Diagnosis & Prognosis:

I am used DSM V for the diagnosis.

 Diagnosis:
According to DSM V, my client is suffering through the
problem of Major Depressive Disorder (severe) “Code 296.xx
(F32.x and F33.x)”.

 Prognosis:
My client was highly anxious when I first meet him in first time in the
clinic. He was losses all hopes for his future. But when I counsel him
and give properly treatment then he was seems to be motivated and
hopeful for the future. When I am giving him therapy then he was
normal and seems to be relax and confident. After some 3 session he
seems to be normal. And I hope he will be normal after complete
treatment.

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Management & treatment:
Management plans designed to help the patient to resolve his
problems.
 Pharmacological:
Following medicine given to the client by the psychiatrist.
1. Esglit (escitalopram) (1+0+0)
2. Ozip 5mg ( 0+0+1)

 Psychotherapy:
Psychotherapy interventions have proven to be effective as a major
treatment for various disorders because drugs alone are not enough to
deal with mental disorders so clients know their way of acting toward
the mental state or how to deal with the disorder along with
medication. In this case, the client received a psychological education
and techniques for curing to the illness. Following techniques were
given to clients:
 PMR-TR
 Stress Coping skills
 Sleep hygiene for insomnia
 Deep Breathing
 counselling

Follow up Plans:
The client was given three sessions in which he was given to different
techniques and counselling. Relaxation techniques and deep breathing
are also given for coping to stress and anxiety. Sleep hygiene was also
introduced for insomnia in which told him how to take proper sleep.

Any suggestions & recommendation:

I recommended him daily walk morning and evening. This would be
effective to him in coping stress and anxiety.
I also advised him to take proper diet that would be better for his
physical health and keep healthy his stomach.

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Case formulation:
My client was 63 years old man. His presenting complaints are,
low mood, aggression, hopelessness, fatigue, headache, insomnia, poor
appetite. Psychological test are uses for the diagnosis of the disorder.
In which, his score shows that he has severe major depressive disorder.
I used beck anxiety inventory in which, his score is 42. Score was
shows that he has severe depression. Medicines were also given to
him. Along with medicines other psychotherapies were also used. I
used muscle relaxation technique, stress coping skills, sleep hygiene,
and counselling.
According to the cognitive school of thought, the results of depression
Distorted thoughts and judgments, resulting from misguided beliefs.
Depressed people think differently from ordinary people. Dejected –
Depressed people think about themselves, environment and future
negatively perspective. As a result, they tended to misinterpret the facts
the way. They blame themselves for every misfortune that happens in
their lives life. Negative thinking style makes them feel that the
situation is many worse than it is. According to the cognitive theorist
Dr. Aeron Beck, there are three major misconceptions that dominate
depression people think. First, I am defective. Second, all my
experiences the result in defeats and failure. Third, the future is
useless. These three beliefs are called negative cognitive. When these
beliefs present in the perception of someone, is very likely to take
depression place. These beliefs can also shape a person's focus some
events and ideas. The beck said that people suffer from depression pay
selective attention to aspects of your environment that confirm it what
they already know is your failure to process the information it is also a
feature of depression. These people are paying attention to information
that matches your negative expectations and discards them information
that conflicts with those expectations.

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16
 Case B
Acute Stress
Disorder

Background information/ history:

Bio Data:

Name: S.T

Gender: female

Age: 20 Years

Education: F.A

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Occupation: Nill

Religion: Islam

Marital status: Single

Income: None

Socioeconomic status: Lower

Family: Extended

Date of admission: 12-4-2018

Reference: Referred by emergency

Main Reasons for Referral:

The client comes to the hospital with the complains of sleep

disturbance, difficulty in breathing, and depressed mood in the
emergency. The client was normal before her brother death according
to her mother. The main issues was she spend most of the day alone in
her room and didn’t talked to any other.

Presenting complaints: (mother verbatim)

 20 din pehly isky bhai (mery bety) ki death ho gyi thi us k baad se yeh isi tarh
ha.
 Is k bhai ki (mery bety) mout accident se hwe the. Masjid namaz parhny ja rha
tha gari se accident ho gya bike pe tha. Gari walne takr mari us k bike ko jis se wo
neachy gir gya
 Is ny bhai ko daikha tha jis ki waja se yeh aisi ho gae ha shayad
 Her waqt udas bethi rehti ha

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 Roti rehti ha bhai ko yaad krti rehti ha
 Nend bhi isko sahi nhi ati
 Jism mien bhi is k dard rehta ha
 Gussa bht krti ha bht jaldi gussa a jata ha isy
 Pehly ghar k kam krti thi ab wo bhi nhi krti sara din leti rehti ha
 Sir mien dard bhi rehta ha is k
 Pehly gussa bilkul nhi krti thi ab hr ksi k sath gussy se baat krti ha Mujhe bhi
gussy mien jawab deti ha halan k pehly yeh bht achi tarh mujh se baat krti thi

Client verbatim:

 Mujhe apny gussy pe control nhi rehta

 Mera dil krta ha k main roun
 Pehly main aisi nhi thi jab se bhai ki death hwe ha tab se
mujhe ksi se baat krna acha nhi lgta(weeping)
 Mujhy bhai k chehra nhi bhoolta
 Bhai k chehra meri ankhon k samny rehta hai
 Jab se bahi ki death hwe hai usk bad se mere sath yeh masla
hwa ha. 20 din pehly mery bhai ki death hwe thi

Brief history present illness:

According to client mother, she suffering from stress after her brother
death. Before this incident she was normal but when her brother was
died, she begins to show aggression. Her brother was died from
accident. Her brother death by accident almost 20 days ago and after
this incident she begins to show these symptoms. Because she was
very close to her brother and the other reason is that she has only one
brother who was died.

She is weeping most of the day and night. She has low mood nowadays
and show restlessness most of the time. She remembered her brother
and begins to cry. She has no interest in daily life activities. She is
aggressive and has rude behavior.

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Family history:

 Father:
The client father name was T.M with age of 53 years. His education
middle and work in an electric company but now he is retired. He is
heart patient. But psychologically he is normal and lived normal with
family. He is very humble with his children and wife. He lived in rent
house.

 Mother:
The client’s mother was named A. she was 40 years and an uneducated
women. She was housewife and doing tailoring for house expanses.
She was very loving and caring for her family. She has no any physical
and psychological illness.
She was very strong lady because after her son death she was support
and care to her family and also take care to client. She managed her
home and also taught her children good manners. Nowadays she was
depressed firstly by son’s death and secondly her daughter who was ill
after death of her son.

 Siblings:
The client had 5 sibling in which 1 brother and 4 sister. She had 5 th
birth order among her siblings. First number of her brother who was
died. His age was 29 years when he died and he was also married and
has two children. Second number after brother her elder sister. Her
sister education was middle and also married she was normal. She has
two children. And she lived happily wither her in-laws. Third number
was another sister. She was married and also had 1 daughter and 1 son.
Her age was 25 years. She was also lived in her house with her
husband and her in-laws. She was normal by mentally and physically.
Fourth number is another sister. She was 23 years and her education

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was F.A. she was a teacher and unmarried. She was aggressive but fit
by mentally and physically. The fifth number was client.
S was loved her siblings but her attachment her elder brother rather
than other siblings.
And the last and sixth number was another sister. She was 16 years and
she was study in 10th class. She was normal.
All siblings loved with each other and take care with each other.

Personal history:
Birth:
The client birth history was normal according to her mother. She said
that S was healthy and normal and no facing complications at birth
time.
Early development:
The history of prenatal, postnatal and infancy stages were all normal.
There was no chronic illness (according to her mother).
Physical Health /Medical Health:
She was normal by physically. She was normal by mentally before her
brother death. But nowadays she was psychologically ill by death of
her brother.

Traumatic Experience:
Her brother death has a big disaster for her. She becomes ill by
psychological after her brother death.
Any Psychological Problem:
Acute stress disorder started after death of S elder brother.

Schooling / Educational History:

The client started her schooling at the age of 3.5 years. She goes school
regularly and showed good performance in her school. She was a
brilliant student of her class. Her brother wants to educate more in
future. She was also good in extracurricular activities like debate, quiz

21
competition. She always good marks in every class. Even she got
position in 8th class.

Developmental Milestones:

Milestone Normal Achieved

age age
Cry after Immediatel Immediatel
birth y after birth y after birth
Neck 2-4 months 4 months
holding
Sitting 6-7 months 7 months
Crawling 8-9 months 8.5 months
Standing 9-10 10 months
months
Walk with 10-12 11 months
support months
Walk 12-18 14 months
without months
support
Babbling 6 months 6 months
One word 1-2 years 1 year
saying
Two or 1-3 years 1.5 years
three words
Toilet 2-4 years 3 years
training
Adolescence:
The client started her female biological cycle at the age of 14. All
biological system was normal.no any complications seems in her
biological system.

Sexual inclination:
The client did not interested in opposite sex.

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Premorbid personality:

Social interest:
The client was very friendly and had many friends in her family and in
her school. She likes make friends and she always like Friend
Company. She was very friendly and funny.

Social relationship:

The client was very friendly and helping person. She had good
relations with all other. She likes company of others. She loved her
family friends and other close persons. She enjoyed company of others
and help others.

Her mother told that she was very helping girl in home and family. She
help all family members and also out siders.

Mood:

She had very pleasure mood all the time with smile on her face. She
was very kind hearted and humble. She never fight with other siblings.
But nowadays after illness she had rude behavior with family and
others.

Moral & Religious Values:

The client was very religious. She has very faithful. She offered
prayers daily and recite Quran daily. She like Islam and also followed
Islamic rules and regulation. She also wears scarf according to sharia.

Habits:

The client had interest in cooking and book reading. She also like

Reaction to stress:

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She was very aggressive. She had rude behavior to other. She shout to
others when she didn’t want to talked to others. She was weeping at
any time. Especially when she sees her nieces. She remembered her
brother and start crying.

Smoking & Drug history:

The client did not take any drugs and did not show any forensic
history. She belongs to a very religious family.

Psychiatry traits/ Problems:

The client did not report any psychological problem in past. And not
report any problem in her family.

Previous & Present Psychological Problems:

The client was not any psychological problems in her past. She was
very decent and educated girl. She behave very politely with others.
She was very nice girl in her family (by mother). She was very brilliant
student in her school. But after her brother death, started psychological
problems with her. She has aggression, sleep problems, fatigue, and
low mood all the time. She has depressed behavior and weeping after
remembered her brother. After brother death, she was totally changed.
She shows rude behavior with others, even with her mother. She lost of
interest in daily work. She has lay down on bed most of the time. Or
she was sitting alone all the time.

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Mental Status Examination:

Appearance:

S.T was a 20 years and innocent looking girl. She wears black abaya
and scarf. She has dressed neat and clean. She enter the clinic with her
mother.

Mood:

Her mood was very low and sad. She looking depressed by her face.

Speech:

The client speech volume was low. But she was confident and there
was no stuttering or stammering in the speech. Form of speech was
spontaneous and she responded in sentences. Speech was
comprehensible and understandable.

Thoughts:

The client thoughts was clear and understandable. Firstly client did not
express her feeling but after counselling she express her thoughts and
feelings.

Delusions:

The client did not report any delusions but some time she feels her
brother alive and he comes from door of house.

Hallucinations:

No visual or auditory hallucinations were reported in this case.

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Orientations:

Time:

The client was time oriented. She was aware of the time.

Place:

The client was aware from place. She knows where she came and why.

Person:

The client was person oriented. I am asked about her family members,
she tells accurately whole information.

Memory:

Remote memory:

Of the client was very good and she knew all events taken place in her
past life. She tells her past life events.

Recent past memory:

Of the client was integral.

Recent memory:

Recent memory of the client was good. I asked different question for
checking her recent memory and she answered correct and quickly.

Perception:

 Visual: The client visual perception was right. She did not have any problem
in her vision.
 Perceptual: she was able to hear instructions and answer the questions easily.
Her perception is alright.

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Cognitive assessment:
The client had good general knowledge. I asked different question
about general knowledge and she gives right answers all of these
questions.
The client’s general knowledge was satisfactory.

Insight:
The client did not respond to her illness. She thought that she was not
ill.

Summary of informal & Formal Psychological Assessment:

 Informal Assessment:
Behavioral observation and clinical interview were administered the
illness of the client. In first session when the client was came with her
mother, she was not answered. Her mother told all the symptoms if the
client illness. Her mother told that she has aggressive mood and
weeping all the time. Her sleep was also disturbed after the incident. In
the 2nd session the client was normal and she told her situation in her
own language. Her intellectual level also good. She seems to be
confident and gives response accurately.

 Formal Assessment:
I. Beck Anxiety Inventory

score category
43 Severe anxiety

 House Tree Person(HTP):

House-Tree-Person is a techniques designed for personality

assessment. It gives information about individual sensitivity,
maturity, degree of personality, interaction with environment.

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 House:
House presents the symbol of security, status and comforts. S.T
draw house side of page, its presents feeling of constriction.
Shading presents of client anxiety. House has one door and one
window in which shows client willingness to interact with
others. She draw strong lines in which shows effortful ego. She
gives extra attention to the roof of the house in which show
extra attention to fantasy and ideation. She did not draw any
pathways outside of house that is present she is not social and
did not share feelings with others.

Tree:
Tree drawn by patient was having large trunk which show her
strong ego strength. Her draw wind blowing tree presents
environmental problems or pressure.no roots means feeling of
insecurity. Upward movement of branches shows person might
be ambitious.

Person:
Person drawn by patient presents her personality. She draw
same sex figure show hysteric & manic tendency. She draw
figure mouth closed its show her nonverbal aggression. She
draw arms closed to body its show tension. Arms are thin and
weak shows lack of achievement. Shading presents aggression,
anxiety and conflict in her personality.

Any Other Important Information:

No any other information left of this case. All details are given.

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Diagnosis & Prognosis:

1. Diagnosis:

On the basis of history, complains, behavioral observation and clinical

interview diagnosis made according to DSM V. According to the DSM
V, client is suffering from the Acute Stress Disorder code “DSM-5
308.3 (F43.0)”.

2. Prognosis:
The prognosis was satisfactory. The client wants to cure herself. After
3rd session she becomes normal. She wants to get normal and support
her family.

Management & treatment:

Management plans designed to help the client to resolve her issues and
problems.

 Pharmacological:
The client was prescribed medicines by psychiatrist (Dr. Zona)
After the diagnosis. Medicines for her sleep and her behavior.

 Tab: Paraxyh 20 mg (1+1+0)

 Tab: vitalyz (daily 1 doze)

 Psychotherapy:

Psychotherapy interventions have proven to be effective as primary

treatments for various disorders because drugs alone are not enough to
deal with mental disorders so clients understand how they behave
toward the mental state or how to deal with the disorder along with
treatment and medication. . In this case, the client was given
psychological education and informants were informed so that they
could help him deal with:

 Psycho-education
 Deep breathing
 PMR-RT
 Counselling
 Sleep hygiene

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Follow up Plans:

The client was given four session in which she was guided about
medicine and techniques that can help her in getting normal state.in
session gives her counselling in which told her that she becomes
normal if she wants to improve herself. In techniques also told her
sleep hygiene for insomnia. In session gives her instruction about deep
breathing and PMR-RT.

Any suggestions/ Recommendation:

I have suggested her to exercise 20 mint in morning and evening.

I have also suggested sleep hygiene for insomnia in which tell her that go to
bed at same time every night, and bed is comfortable and environment also
peaceful.

I also suggested take proper diet, which will be beneficial for her health.

I also suggested start study again it will busy you and help in future.

Limitations:

There were limitations of sessions due to unavailability of time.

There were no proper room for counselling and assessment.

Case formulation:

My client was 20 years. She was ill after her brother death. Her
presenting complaints were insomnia, headache, aggression, weeping
most of the day, fatigue, low mood etc. Psychological test was uses for
diagnosis of disorder. I used beck anxiety inventory in which his score
was 43 that was present severe anxiety. According to test and her
history of problems she has acute stress disorder. Medicines and
psychotherapies were also given. I used sleep hygiene for sleep

30
problems, Psycho-education, deep breathing, counselling and PMR-
RT.

According to Beck, problems occur when distorted thought patterns

affect our interpretation of environmental events. In other words, our
behavior is not already determined by what actually happens in the
environment. Instead, our behavior is determined by our thoughts
about what happens. Therefore, the behavior is very influenced by our
perceptions and explanations of the environment. Let's clarify this
important distinction. Suppose someone walks in front of me and steps
on my feet. This can be interpreted as an unwanted act. On the other
hand, it can be interpreted as deliberate and hostile. It is likely that
each explanation provokes a different emotional and behavioral
response.

According to Beck, the way we translate environmental events is a

function of our basic plan. The basic scheme is a central assumption
about oneself, others and the world. These assumptions affect our
feelings and our behavior. Examples of the master plan include: 1) the
world is a dangerous place. 2) I am not loved. 3) I'm not suitable.
Notice how Ellis' contemporary concept of basic beliefs is Beck's
concept of the basic schema. According to the cognitive theory, when
the cognitive distortions are modified and the basic beliefs, the change
of behavior follows naturally. This principle forms the basis of
cognitive therapy methods.

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Appendances

Case A

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Appendences

Case B

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The end

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