CERTIFICATE

It is certified that AQSA MANZOOR (06644) has worked under my supervision. Her

report of “Psychophysiological Cases” has been approved for submission in its present form

as a requirement of BS Applied Psychology 4-year degree program.

ACKNOWLEDMENT

I am grateful to Allah Almighty for the good health and well-being that were

necessary for the opportunity and ability to complete this Psychological Report. I take this

opportunity to express gratitude to Ma’am Meerub who had guided me throughout. I would

like to thank my family for the unceasing support, encouragement and attention.
CASE NO. 1
Case Summary:

The client was 64 years old resident of Rawalpindi. She came with the presenting

complains of aggressive behavior toward others, feeling of restlessness and lack of sleep. She

was under observation of a psychologist at Fauji Foundation Hospital in order to check the

severity of disease and provide particular treatment plan. The results indicate that the client

problem wasn’t genetically inherited as after conversation with her family attendant I came to

know these are the side effects of the her physical illness and her age. She had difficulty with

socializing. The client also reported sleep disturbance. Assessment was done at formal and

informal level to understand the client’s problem and to monitor the progress of therapy.

Informal assessment include clinical interview and behavioral observation while the Formal

assessment included Mini mental status examination (MMSE) Beck Anxiety Inventory

(BAI). Therapeutic recommendation were given that was Rapport, Building, Cognitive

Behavior Therapy, Activity Schedule, and Deep Breathing. Prognosis was favorable because

client was willing for treatment.

Demographics

Name: S.A

Age: 64

Education: Illiterate

Gender: Female

Marital Status: Widow

Occupation: Nil

Dependent Daughter

Residence Adyala Road, Rawalpindi

No. of siblings 6
 No. of issues 3

Family system Nuclear

Religion Islam

Presenting Complaints:

Hadhiya wich dard hota hai

Dil maey ghabrahat hoti hai

Raat kaey waqt hadhiya saun hojati hain

Gussa ata hai

Nend nai aati

Reason for Referral

The client was brought to the hospital by her daughter with reported problems

such as

Aggressive behavior towards other,

Making unusual noises with anything she saw such as by smashing hitting it ,

Irritable mood,

And being violent to others.

Symptoms according to DSM V

Increased energy and activity levels.

Elevated self-esteem or grandiosity.

Decreased need for sleep.

Racing thoughts or a flight of ideas.

Distractibility.

Engaging in risky or pleasurable activities without recognizing the consequences

The mood disturbance is sufficiently severe to cause marked impairment in social or

occupational functioning.
History of Present Illness

Onset of illness

The client mental illness was episodic for past 2 years and her physical illness was

episodic for past 5-6 years. Client was living normal life but five years ago she was

diagnosed with diabetes After she was also diagnosed with high blood pressure problems and

due to her poor economic status, and being left alone after the death of her husband, her

blood pressure once rose, which affected a particular part of her brain. Since then, she

showed abnormal behavior, such as being aggressive towards others and constantly making

noises, like hitting doors or throwing utensils.

Pre-morbid personality

Her behavior towards others was quite good. She was always kind, caring, and a

helpful person. She loved exploring different places since her childhood and was quite active

in most activities. The client had been reported as a friendly, loving, and helping person.

Medical History

The client had not experienced any serious injury in childhood; however, she was

suffering from diabetes and high blood pressure problems for the past five to six years.
Past Psychiatric History

Multiple episodes were reported. She became aggressive suddenly and started

abusing others or hitting them. She had never visited anyone else before for treating her

disease; this was her first time being at the hospital as a client.

Background History

Family History

Both parents were deceased. Psychiatric illness wasn't reported in her parents or any

member of the family. The client had two sisters and three brothers. She got married at the

age of 16 and lived a happy married life, having three daughters.

Personal History

Personal history reported by the client indicated that she lived in Rawalpindi and

belonged to a family with low socioeconomic status. The client had been reported as a

friendly, loving, and helping person.

Educational History

She never got an opportunity to get educated because of the financial issues in her

family and the lack of an education system in her area. Also, her parents fixed her marriage

at a young age, so she was not able to receive an education.

Psychosexual History

She attained her puberty at the age of 15 years. She didn't face any problem in the

delivery case as she was a healthy, eating person who always took care of her diet.

Especially, her husband helped her a lot in checking her diet plan.
Occupational History

She was a housewife throughout her marital life. Then, after the death of her

husband, she started living with her daughter and was totally dependent on her for all her

needs.

Marital History

The client got married at the age of 17 years without her consent; her parents

arranged her marriage with her cousin, who was 10 years older than her. Although her

husband was loving and caring, she lived a happy married life and had three daughters.

Socio economic status

She belonged to a middle-class family. Her husband was the breadwinner of the

family. At the time, she was living with her eldest daughter, who was fulfilling her basic

needs, as, due to her old age, she was not doing any housework.

ASSESSMENT

Assessment was done at formal and informal level to understand the client’s

problem and to monitor the progress of therapy.

INFORMAL ASSESSMENT

Following measures were used as informal assessment.

• Clinical Interview
• Mini Mental State Examination

Clinical Interview

Semi-Structured Clinical Interview was conducted to get description about

her bio data, presenting problems, history of illness, family history, and background

information. It helped in devising a distinctive case formulation and management

plan.
 The Mini Mental State Examination

She was casually dressed. She was avoiding to maintain an eye contact

throughout the session. She didn’t applied any cosmetic. The client appear blank,

perplexed and tensed to answer to the questions. Her speech was slurred, with a

normal rate and volume. When discussing her emotions, she reported feeling anxious,

aggressive and having bones pain. Regarding thought processes, her thought

organization appeared irrelevant, there were flight of ideas. She faced difficulty in

describing her current and back life circumstances. However, she mentioned

occasional difficulty sleeping. Cognitively, she was failed to answer to the calculations

and didn’t remember the date and time. Sometimes she fails to recall significant

life events and details from past. In summary, Her MMSE indicates the

episodes of aggressive behavior and anxious feelings. Her thought processes were not

coherent. However, she reported difficulty sleeping due to numbness and pain in her

bones. Her cognitive functioning was not quite stable.

FORMAL ASSESSMENT

Following scales were used as formal assessment.

• Beck Anxiety Inventory (BAI)

• Mini Mental Status Examination (MMSE)

Beck Anxiety Inventory (BAI)

The BAI was administered to assess the severity of client’s Anxiety.

 Quantitative

Interpretation

Table Showing Subjective Ratings of Client on BAI at Pre-therapy Level

Ranges Anxiety level obtained score

0 to 21 Low anxiety

22 to 25 Moderate anxiety 23

36 and above High anxiety

Qualitative Interpretation

The client scored 23 on BAI, indicating moderate anxiety. The results suggested

that her pain might be contributing to the emotional distress and potentially affecting her

mood and causing anxiety.

Mini Mental Status Examination

Quantitative Interpretation

Table showing score ranges for MMSE

Ranges Cognitive functioning Client’s score

26 – 30 Normal Cognitive functioning

10 - 20 Moderate dementia 17(Moderate dementia)

Less than 9 Cognitive impairment

The client’s score lies between the ranges 10 – 20.

Qualitative Interpretation

The client`s score was 17 out of 30 on MMSE, which indicates moderate cognitive

impairment.

Tentative Diagnosis

296.43(F31.13) Bipolar I Disorder comorbid with Type I Diabetes

Case Formulation

Client was 64 years old who was under observation of a psychologist at Fauji

Foundation Hospital with presenting complaints of having pain and numbness in bones, often

feel aggressive and anxious, and do stupid acts in order to calm her anxiety like hitting things

throwing dishes etc. She belongs to middle class family. The client mental illness was

episodic for past 2 years and her physical illness was episodic for past 5-6 years. Client was

living normal life but five years ago she was diagnosed with diabetes and then after she was

also diagnosed with High B.P problem and due to have a poor economic status and being left

alone after the death of her husband her B.P once rises which effect particular of her brain

since after that she showed abnormal behavior such as she was always being aggressive

towards other was always making noises like she will start hitting doors or throwing utensils.
Her mood was always irritable she always annoy others will tease them or hit them without

any reason. If someone will try to control her she will hit them that’s why most of people are

sacred of approaching to her. Client case was conceptualized according to DSM 5 and she

was diagnosed with 296.43(F31.13) Bipolar I Disorder.

The comorbidity between Type 1 diabetes (T1D) and bipolar disorder is a subject

of interest among researchers due to the notable impact these chronic conditions can have

on an individual's life. Research suggests that individuals with T1D have a heightened risk

of developing mood disorders, including bipolar disorder, when compared to the general

population. This increased risk is thought to be influenced by shared genetic and

environmental factors that may contribute to the development of both T1D and bipolar

disorder. The interplay between these two conditions can complicate the management of

T1D. Bipolar disorder, characterized by mood swings, medication side effects, and

disruptions in daily routines, can hinder adherence to diabetes management plans, potentially

leading to fluctuations in blood sugar control. Consequently, individuals with comorbid T1D

and bipolar disorder may experience poorer health outcomes, facing a higher risk of

diabetes-related complications and a reduced quality of life. Managing the two conditions

together presents additional challenges. Medications used to treat bipolar disorder can affect

blood sugar levels, necessitating vigilant monitoring and potential adjustments to diabetes

medications. Furthermore, the psychosocial aspects of dealing with T1D, combined with the

emotional challenges posed by bipolar disorder, may lead to an increased risk of depression,

anxiety, and an overall reduction in well-being. The coexistence of Type 1 diabetes and

bipolar disorder is a complex and significant medical issue that affects both physical and

mental health. Understanding and addressing this comorbidity require a multidisciplinary

approach involving healthcare professionals specializing in diabetes and mental health.

 The research mentioned focuses on the diagnosis and assessment of bipolar

disorder

(BD) in youth, specifically highlighting the challenges in categorizing cases of

"bipolar not otherwise specified" (NOS). The study underscores disagreements within the
field, particularly regarding the relative importance of elated versus irritable mood in
assessing BD and the boundaries of the bipolar spectrum. While the research primarily
addresses the diagnostic aspects of BD in children and adolescents, it does not explicitly
discuss the relationship between bipolar I disorder and Type 1 diabetes (T1D). However, it's
important to note that individuals may experience comorbid conditions, meaning they have
both bipolar I disorder and T1D, which is relatively common in psychiatry. Managing both
conditions simultaneously can be challenging, as the emotional and psychological
fluctuations associated with bipolar disorder can affect the effective management of diabetes.
Furthermore, medications used to treat bipolar disorder can sometimes have metabolic effects
that could impact blood sugar levels in individuals with T1D, emphasizing the need for a
holistic approach to treatment involving both psychiatric and medical professionals.

The research outlined in this article focuses on the cognitive approach to

explaining mood swings and bipolar disorders, with a particular emphasis on how

individuals interpret changes in their internal states. It delves into the concept that

individuals with bipolar disorders often struggle to control their emotions due to excessive

personal interpretations they assign to their internal states. In essence, their efforts to manage

their emotional states are hindered by these interpretations, which, paradoxically, lead to

more fluctuations in their internal emotional states. This can create a vicious cycle that

sustains or exacerbates the symptoms of bipolar disorder. This research highlights two

categories of ineffective control attempts known as ascent behaviors (increasing activation)

and descent behaviors (decreasing activation). It suggests that specific sets of ideas about

emotions, their management, as well as one's self-perception and relationships with others,

play a significant role in shaping the interpretation of intense personal meaning related to

internal states. The interpretation of changes in internal state is a key explanatory aspect in

the cognitive approach to explaining mood swings and bipolar disorders that is presented in

this article. The concept describes how attempts to control affect are hampered by the

excessive personal interpretations that are assigned to interior states. Exaggerated attempts
to improve or assert control over internal states are prompted by them, which paradoxically

leads to more internal state changes and feeds into a vicious cycle that can maintain or

intensify symptoms. Ascent behaviors (increasing activation) and descent behaviors

(decreasing activation) are two categories for ineffective control attempts. It is proposed that

certain sets of ideas about affect and its management, as well as about the self and

relationships with others, have an impact on assessments of intense personal meaning.

Pertinent literature is reviewed and found to be compatible with such a model. The clinical

implications are discussed and compared to existing interventions.

The client was living a normal life, but five years ago, she was diagnosed with

diabetes. Later, she was also diagnosed with a high blood pressure problem. Due to her poor

economic status and being left alone after the death of her husband, her blood pressure once

rose, affecting a particular area of her brain. Since then, she had been showing abnormal

behavior.

The overall view of the case showed that her health problems were the main reason

for her psychological issues. Additionally, the environment she was living in, with her

daughter, might have often kept her busy with her own life, leading her to spend most of her

time in solitude, which led to tension and anxiety. She needed proper counseling and

therapies, and there was also a need to provide family therapy to her family members.

Therapeutic Recommendations

Client was under observation of a psychologist with presenting complaints of having

pain and numbness in bones, often feel aggressive and anxious, and do stupid acts in order to

calm her anxiety like hitting things throwing dishes etc. She belongs to middle class family.

The client mental illness was episodic for past 2 years and her physical illness was episodic
for past 5-6 years. Bases on these symptoms and after the diagnosis of the disorder following

therapeutic suggestions were given.

Rapport building the patient's general issues were enquired about, and the purpose

of communication was discussed. Building a rapport with the patient was the main objective

of this session in order for her to feel at ease discussing her life events. Both the patient and

the informant participated in the interview, but since the patient was so anxious and restless.

The informant provided the majority of the information. The beginning of the therapeutic

procedure used the information from this interview. The patient's rapport was then

established using listening and empathy skills, which was essential for any subsequent

psychological work.

Cognitive behavior therapy (CBT) it is an individual therapy focused on the

relationship between a person's thoughts, feelings and behaviors. CBT teaches people

to: Identify negative assumptions and thinking patterns, and challenge themselves to

rehearse more adaptive ways of thinking.

Deep breathing involves slow and deep inhalation through the nose, usually to

a count of 10, followed by slow and complete exhalation for a similar count. The process

may be repeated 5 to 10 times, several times a day. Deep breathing exercise was used with

the client, and was advice to repeat it daily to keep the client relax and calm.

Activity charting Activity scheduling is a technique of CBT that is used to maintain

a balance in daily routine. Different activities were planned for the client through activity

schedules. Variety of tasks were introduced in the schedule for setting a daily routine. A

range of activities such as deep breathing, morning walk, progressive muscle relaxation, and

talking with others

 Progressive muscle relaxation in this exercise, the person systematically tenses and

relaxes each of the major muscles group in the body. Tensing and relaxing muscles leave the

muscles in a more relaxed state as compared to their initial state. The PMRT was used and

taught to the client to reduce body pains reported by the client.

Prognosis

Prognosis was favorable because client was willing for treatment.

Limitation

• Time was limited

• Limited consideration of cultural and religious factors that may influence treatment.

Suggestions

• If the client shows willing for further session it will benefit a lot.

• Suggest a plan for ongoing monitoring and follow-up to assess progress and adjust

the treatment plan as necessary.

References

Pompili, M., Ducci, G., Galluzzo, A., Rosso, G., Palumbo, C., & De
Berardis, D. (2021).

The Management of Psychomotor Agitation Associated with

Schizophrenia or

Bipolar Disorder: A Brief Review. International Journal of

Environmental

Research and Public Health, 18(8), 4368. MDPI AG.

 Lewinsohn PM, Seeley JR, Klein DN. Bipolar disorder in adolescents:

epidemiology and suicidal behavior. In: B Geller, MP DelBello eds. Bipolar

Disorder in Childhood and Early Adolescence. New York: Guilford, 2003:

7–24.

Joyce, Emmeline Tai, Sara Gebbia, Piersanti and Mansell, Warren 2017.
What are People's

Experiences of a Novel Cognitive Behavioural Therapy for Bipolar

Disorders? A

Qualitative Investigation with Participants on the TEAMS Trial.

Clinical Psychology & Psychotherapy, Vol. 24, Issue. 3, p. 712.

Case no. 2

Case Summary

The client was 39 years old female. she was brought to the hospital of Fauji

Foundation by her family with presenting complaints of excessive cleanliness, avoid oily

things, spend a lot of time bathing, want to be alone, silent, less talkative, avoid touching

others because of fear of being contaminated by germs from others the presenting complaints

of physical illness were feeling of that something was crawling on her body, body rashes,
unstoppable blinking of eye, loss of appetite, weight loss, fatigue the client's problems were

assessed through formal and informal assessment. The client was unmarried her both parents

were dead she had 7 siblings 4 sisters and 3 brothers. She was on 3rd number in birth order.

The Formal Assessment was done through the administration of the Yale Brown Obsessive

Compulsive Scale (YBOCS) and Mini

Mental Status Examination (MMSE) and Informal Assessment was done through
Client

Interview, and Behavioral Observation. Therapeutic recommendation were given that

was Cognitive Behavior Therapy, Deep Breathing, Systematic Desensitization Therapy,

Family therapy, and Activity schedule. Prognosis was favorable because client was willing

for treatment.

Identifying Data

Name N.B

Gender: Female

Age: 39 years

Marital Status: single

Education: B.A

Father: Dead

Mother: Dead

Siblings: 7 (4 sisters) (3 brothers)

Birth Order: 3rd born

Family Structure: Joint family

Socio economic level: low

Language: Punjabi
 Religion: Islam

Reason for Referral

The client was brought to the hospital by her family with reported problems

such as loss of appetite, sad mood, excessive cleanliness, fear of being contaminated, spend a

lot of time bathing, cleaning, and washing.

Presenting complaints

According to client:

• Apney aap ko rokh nahi pati dil maey har waqt khyal ata hai keh kuch bura hojaye
ga
• Bar bar hath na doun to aisa lagta hai keh mai bemar hojaun gi germs mujh par

attack kar laeyn gaey

• Darwzo kaey dekh kaey aisa lagta hai keh koi achanak saey ajaye ga aur muj par

attack kar laye ga

• Agar mai apne hath na doun na darawze ka lock check karu to mujhey bhut zayada

anxiety hoti bar bar khyal atey kuch bura hojaye ga

According to Referral:

Informant highlight complains regarding

• excessive cleanliness,
• avoid oily things,
• spend a lot of time in bathing,
• less talkative,
• avoid touching others because of fear of being contaminated by germs from others,

 Loss of appetite.
 Symptoms According to DSM-V
• Repetitive behavior
• Time consumption on repetitive behavior was spent more than 1 hour per day
• Recurrent and persistent thoughts
• These symptoms were not attributed to any physiological effects of a substance or

another medical condition

History of present illness

Onset of Illness

The patient's mental illness had been episodic for the past 10 years but got

worse from 4 to 5 months ago. The client's history of the present illness spanned the past ten

years but had worsened from 4 to 5 months ago. The client came to the hospital for the

management of problems such as loss of appetite, a sad mood, excessive cleanliness, fear of

being contaminated, and spending a lot of time bathing, cleaning, and washing.

Pre-morbid Personality

According to the client, she was not social and had no friends, stayed at home

most of the time, had no interests and hobbies. She thought she was less talkative and wanted

to be alone and didn't want to go outside. She was introverted.

Past medical and Psychiatric history

No psychiatric history was reported by the client however, her father was diagnosed

with B.P problem.

Background History
 Personal history

History related to the client's birth and any prenatal or postnatal complications

could not be figured out, as the client did not have any information regarding it. Informants

who knew her childhood or birth history were not present at that time. Personal history

reported by the client was that she lived in Rawalpindi, and her socioeconomic status was

low.

Psychosexual History

She achieved her puberty at 14 years of age. She denies any homosexual or

heterosexual contact.

Academic history

According to the client, she was an average student in school and college, and

after her Bachelors she could not study further and after the death of her parents she had to

suffer both financially and physically.

Family history

The client was the third born, and she had four sisters and three brothers. Her

father and mother were both not alive. She had a good relationship with her parents. Two of

her sisters were married, and one of her brothers had also married. Her relationship with her

siblings was good, and they had a strong bond. For her checkup, her elder sister was helping

her. Her overall home environment was good. She was living in a joint family system but

wanted to be alone most of the time. The client also reported that she didn't talk and didn't sit

with her family members.

ASSESSMENT

Assessment was done at formal and informal level to understand the client’s problem.
 • Informal assessment
• Formal assessment

Informal Assessment

Clinical interview

A clinical interview was conducted with the client, and information regarding

the client’s presenting complaints was noted down. In addition to that, information about the

history of present illness, complete bio data, family history, and personal history was

gathered.

Behavioral Observation

The client was wearing a neat and clean dress, and the overall hygiene

condition of the client was satisfied. She established and maintained eye contact. Her

speech was understandable. During the session, she did not change her posture while sitting.

The client was looking anxious and absent of body gestures. The attitude of the client was

quite cooperative and normal. Her speech was slow. Regarding thought processes, her

thought organization appeared relevant However, and she mentioned occasional difficulty in

sleeping. Cognitively, she was able to answer to the calculations and remember the date and

time.

Formal Assessment

Following scales were used as formal assessment

• Yale-Brown Obsessive-Compulsive Scale (YBOCS)

• Mini Mental Status Examination

Yale-Brown Obsessive-Compulsive Scale (YBOCS)

 The Yale-Brown Obsessive-Compulsive Scale (YBOCS) is a measure of
symptoms

severity. It consists of 10 questions and is scored 0–40 with a higher score equivalent

to worse severity.

Quantitative Interpretation

The interpretation of the Y-BOCS score is as follows:

Ranges Symptoms Severity Obtained score

0 to 7 Mild symptoms

8 to 15 Moderate symptoms

16 to 23 Severe symptoms
24 to 40 Extreme symptoms 30

Qualitative Interpretation

The YBOCS was administered to the client by asking each question present in

scale, and after questioning interpretation was done. The client scored 30 on the Yale brown

OCD test.

Mini Mental Status Examination

Quantitative Interpretation

Table showing score ranges for MMSE

Ranges Cognitive functioning Client’s score

26 – 30 Normal Cognitive functioning 25

 10 - 20 Moderate dementia

Less than 9 Cognitive impairment

The client’s score lies between the ranges 26 – 30.

Qualitative Interpretation

The client`s score was 25 out of 30 on MMSE, which indicates Normal cognitive

functioning.

Tentative Diagnosis

(F42) Obsessive Compulsive Disorder Comorbid with Body Rashes

Case formulation

The client was a 39-year-old female. She was educated and was brought to

the hospital of Fauji Foundation by her family with presenting complaints of excessive

cleanliness, avoidance of oily foods, spending a lot of time bathing, wanting to be alone,

being silent, less talkative, and avoiding touching others due to fear of being contaminated

by germs from others. The presenting complaints of physical illness included a feeling that

something was crawling on her body, body rashes, unstoppable blinking of the eye, loss of

appetite, weight loss, and fatigue. The client's problems were assessed through formal and

informal assessments. The patient's mental illness had been episodic for the past 10 years

but had worsened over the past 4 to 5 months. The client's history of present illness dated

back ten years but had worsened over the past 4 to 5 months. The client had come to the

hospital for the management of problems such as loss of appetite, a sad mood, excessive

cleanliness, fear of being contaminated, spending a lot of time bathing, cleaning, and

washing. The theoretical background of the case highlighted that the client's personality,

presenting problems, and symptoms could be discussed in terms of different theories and

research.
 The Cognitive models suggest that dysfunctional beliefs and inadequate

evaluation underlie unnecessary strategies to manage intrusive phenomena. Such strategies

lead to extreme reactions to specific intrusive thoughts, images, or urges resulting in

obsessive and compulsive symptoms (Clark & Purdon, 1993; de Silva & Rachman, 1998;

Rachman, 1998; Salkovskis, 1985). The Empirical research has indicated that the wide

majority of the population experience intrusions at times and that the difference between

common intrusive thoughts and "obsessions" is in terms of the frequency, intensity, duration,

discomfort, and misinterpretations elicited by the thoughts, rather than in the content of the

intrusions (Rachman & de Silva, 1978; Salkovskis & Harrison, 1984).

Recent cognitive-behavioral research by the Obsessive-Compulsive

Cognitions Working Group (OCCWG, 1997) has focused on six main belief domains that

play a significant role in the development of obsessions from intrusive thoughts: inflated

personal responsibility, over the importance of cognition, beliefs about the importance of

controlling one's thoughts, overestimation of threat, intolerance for uncertainty and

perfectionism. More recently, the OCCWG (Steketee et al., 2003; Taylor, Kyrios,

Thordarson, Steketee, & Frost, 2002) reported not only a high degree of association between

the identified belief domains and OC symptoms but also high intercorrelations between

scales measuring the six domains. Further, examination of the factor structure of a scale

measuring these cognitive domains identified three larger factors

(inflated sense of responsibility/overestimation of threat, perfectionism/intolerance for

uncertainty, and importance/control of thoughts), but, again, these were highly intercorrelated

(OCCWG, 2005). This raises questions about possible higher-order cognitive vulnerabilities

that may account for such high intercorrelations.

Therapeutic Recommendations
 The patient mental illness was episodic for past 10 years but gets worsen

from 4 to 5 months. The client’s history of present illness is from the past ten years but gets

worsen from 4 to 5 months. The client came to the hospital for the management of problems

such as loss of appetite, sad mood, excessive cleanliness, fear of being contaminated, spend

a lot of time bathing, cleaning, and washing. Based on these symptoms and after the

diagnosis of the disorder following therapeutic suggestions were given.

Psycho-education The client was psycho-educated regarding her problems and its

symptomatic presentation was done. She was educated about her illness, its
etiological factors.

Through this technique, the normalizing of the client was easily done.

Deep Breathing Deep breathing involves slow and deep inhalation through

the nose, usually to a count of 10, followed by slow and complete exhalation for a similar

count. The process may be repeated 5 to 10 times, several times a day. The client was taught

the breathing exercise. The purpose of this exercise was to make the client relax when

confronted with any anxious thoughts or stressful situations. The client was instructed to sit

comfortably on a chair with a relaxed body posture, eyes closed, and take a long deep

breath. After that, she was asked to hold her breath for 1 – 2 seconds and then exhale slowly.

This exercise was also practiced during the session and she was advised to repeat it in the

morning, in the daytime, and at night.

Rational Emotive Behavior Therapy (REBT) is a well-established

and widely recognized form of cognitive-behavioral therapy (CBT) developed by

psychologist Albert Ellis in the 1950s. REBT is based on the premise that our thoughts,

emotions, and behaviors are interconnected, and it focuses on identifying and changing

irrational beliefs and thought patterns that lead to emotional and behavioral distress.
 Systematic Desensitization Therapy Systematic desensitization is a

sort of therapy that teaches you how to relax even when you are afraid. Essentially, you'll

discover the abilities and tools you'll need to tackle circumstances that were before

overwhelming. In this therapy the therapist address the patient to identify the specific fear or

phobia that needs to be addressed. They also assess the severity of the anxiety associated

with that fear.

Activity schedule Different activities were planned for the client

through activity schedules. Variety of tasks were introduced in the schedule for setting a

daily routine. A range of activities such as deep breathing, morning walk, progressive muscle

relaxation, and talking with others was added to the activity schedule for management of the

client’s problems.

Sleep hygiene the client reported sleep disturbance so for this problem, sleep

hygiene tips were given to the client and she was told to follow those tips for the betterment

of sleep problems.

Family therapy the client’s family was also involved during the session and

the purpose of this was that the family should understand her problem and she could

communicate effectively.

Prognosis

Prognosis is favorable because client is willing for treatment.

Limitation

• Time was limited

• Extensive cognitive work was difficult with the client because of his

resistant attitude to do homework.

Suggestion
 • If the client shows willing for further session it will benefit a lot.

REFERENCES

Abramowitz, J., Moore, K., Carmin, C., Wiegartz, P., & Purdon, C. (2001). Acute onset of

obsessive-compulsive disorder in males following childbirth. Psychosomatics:

Journal of

Consultation Liaison Psychiatry, 42(5), 429-431.

Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting
interactions.

Thousand Oaks, CA, US: Sage Publications, Inc.

Ainsworth, M., Blehar, M., Waters, E., & Hall, S. (1978). Patterns of attachment:

Assessment in the strange situation and at home. Hillsdale, NJ: Erlbaum.

Ainsworth, M., & Bowlby, J. (1991). An ethological approach to personality

development.

American psychologist, 46(4), 333-341.

 Case No.3

Summary of Case:

The client was 60 years old with the presenting complaints of forgetfulness and lack

of sleep. She was under observation by a psychologist at Fauji Foundation Hospital to check

the severity of the disease and provide a particular treatment plan. The results indicated that

the client's problems weren't genetically inherited, as after conversations with her family

attendant, it was revealed that these were side effects of her physical illness and her age. Due

to the severity of her cardiovascular problem, her psychological issues arose, which affected

her daily life and led to more health and psychological problems. She had difficulty

predominantly in holding onto past memories, even if they were just from a few seconds

ago. She struggled with praying, calculations, and recalling what someone had said to her a

while ago. She also had trouble initiating sleep; sometimes, she didn't sleep for days, which

badly affected her physical health. The Formal

Assessment was done through the administration of the Beck Depression Inventory
(BDI) and

Mini Mental Status Examination (MMSE) and Informal Assessment was done

through Client Interview, and Behavioral Observation. The client's scores indicated a severe

level of depression, and MMSE scores revealed that she had cognitive impairment. For the

treatment of her psychological disturbances, cognitive-behavioral therapies, such as

mindfulness meditation and relaxation training, were used to address her psychological

disorder. Additionally, family therapy and sleep hygiene were advised. She was

recommended to attend therapy sessions on a regular basis for treatment. The prognosis was

favorable because the client was willing to undergo treatment.

Identifying Data
 Name: B.A

Age: 60

Education: Illiterate

Gender: Female

Marital Status: Widow

Occupation: Nil

Dependent/independent Dependent Resident

Resident of Misrial Ring Road

No. of siblings 5

No. of Issues 5

Family system joint family system

Religion Islam

Reason for Referral

Client was not admitted in the hospital she came first time to mental health

department after referred by a doctor from cardiologist department in order to help her to

deal with her daily life problems. She was presented with the complaints of forgetfulness,

lack of sleep.

She was under observation of a psychologist at Fauji Foundation Hospital in order

to check the severity of disease and provide particular treatment plan. Source of

information was herself who was well cooperative in answer to every question.

Presenting Complaints:

• Saab bhool jati hun, namaz partey waqt bhi masla hota hai keh konsi rakat
thi.
• Hath sunn hojata hai
• Daye hath maey drd rehta hai.
• Bhut kaam nend aati hai
• Kisi saey baat karney ka ya kahi janey ka dil nahi karta
 • Ultey hath maey koi chez pakar nahi skhti jo chez pakarti hun wo ghir jati

hai

Symptoms according to DSM 5:

• Depressed mood most of the day

• Markedly diminished interest or pleasure in all
• Insomnia or hypersomnia
• Fatigue or loss of energy
• Diminished ability to think or concentrate

History of Present Illness:

Onset of illness

The client's problem had been episodic for the past 5 years, and her physical illness, a

cardiovascular problem that had resulted in two heart attacks, had been episodic for the past

13-14 years. Due to the severity of her cardiovascular problem, her psychological issues had

arisen, which had affected her daily life and had led to more health and psychological

problems. She had had problems predominantly in being able to hold onto a past memory,

even if it was about a few seconds ago, she had not been able to recall it. She had had

problems with praying, calculations, and remembering what a person had said to her a while

ago. She had had problems initiating sleep; sometimes, she hadn't slept for days, which had

badly affected her physical health.

Pre-morbid personality

According to the client, she was not social and had no friends, stayed at home most

of the time, had no interests and hobbies. She thought she was less talkative and wanted to

be alone and didn't want to go outside. She was introverted as she didn't have a good

memory to hold onto anything.

 Past Medical and Psychiatric History

The client had not experienced any serious injury in childhood; however, she had

been suffering from heart problems for the past five to six years, with multiple episodes

reported. The client's problem had been episodic for the past 5 years. She had never visited

anyone else before for treating her psychological problem; this was her first time being at

this hospital as a client.

Background History

Personal History

Her behavior towards others was quite good; she was always kind, caring, and a

helpful person. She loved exploring different places since her childhood and was quite active

in most activities. The client was reported as a friendly, loving, and helpful person.

However, after she was diagnosed with the disease, she quit doing everything. She had

problems socializing after the onset of her disease, often forgetting what she was talking

about, and having a poor memory for calculations, which resulted in difficulties in

purchasing.

Family History:

Both parents were dead. Psychiatric illness was reported in her father, which

was episodic in nature. She was the only sister and had four brothers. She had three

daughters and two sons, and her husband was not alive. Her husband had passed away

10 years ago, after which she became dependent on her in-laws, who helped her in

fulfilling her basic needs. Two of her daughters and one son were married, and one

daughter and son were currently receiving education.

 Educational History

She never gets an opportunity to get educated because of the financial issues

in her family and lack of education system in her area.

Psychosexual History

She attained her puberty at the age of 15 years. She didn't face any problem in the

delivery case as she was a healthy, eating person who always took care of her diet.

Occupational History

She had been a housewife throughout her marital life. After the death of her husband,

she lived with her daughter and was totally dependent on her for all her needs.

Marital History

The client got married at the age of 20 years to a son of one of her aunts in the

neighborhood. Her husband was loving and caring at the start, but after some years of her

marriage, he sometimes used to abuse her.

Socio economic

She belonged to a middle-class family. Her husband was the breadwinner of the

family. At that time, she was living with her eldest daughter, who was fulfilling all her basic

needs because, due to her old age, she was not doing any housework.

ASSESSMENT

Treatment Assessment was done at formal and informal level to understand the

client’s problem and to monitor the progress of therapy.

• Informal assessment
• Formal assessment
 INFORMAL ASSESSMENT

Following measures were used as informal assessment.

• Clinical Interview
• Behavioral Observation

Clinical Interview

Semi-Structured Clinical Interview was conducted to get description about her Bio

Data, Presenting Problems, History of Illness, Family History, and Background

Information.

It helped in devising a distinctive case formulation and management plan.

Behavioral Observation

She was casually dressed. She was avoiding to maintain an eye contact

throughout the session. She didn’t applied any cosmetic. The client appear blank,

perplexed and tensed to answer to the questions. Her speech was slurred, with a

normal rate and volume. When discussing her emotions, she reported feeling

depressed because of her worst condition there is also signs of aggressive behavior in

her but she didn’t mention throughout the session. Regarding thought processes, her

thought organization appeared irrelevant, there were flight of ideas. She faced

difficulty in describing her current and back life circumstances. However, she

mentioned occasional difficulty sleeping. Cognitively, she was failed to answer to the

calculations and didn’t remember the date and time. She fails to recall significant life

events and details from past. In summary, Her MMSE indicates the episodes of

aggressive behavior and depressed feelings. Her thought processes were not coherent.

However, she reported difficulty sleeping due to numbness and pain in her hand and
unable to do any work because of her left hand she was stressed because of her worst

physical condition. Her cognitive functioning was not stable.

FORMAL ASSESSMENT

Following scales were used as formal assessment.

• BDI (Beck Depression Inventory)

• MMSE (Mini Mental Status Examination)

MMSE (Mini Mental Status Examination)

Quantitative Interpretation

Table showing score ranges for MMSE

Ranges Cognitive functioning Client’s score

26 – 30 Normal Cognitive functioning

10 - 20 Moderate dementia 12(moderate dementia)

Less than 9 Cognitive impairment

The client’s score lies between the ranges 10 – 20.

Qualitative Interpretation

The client`s score was 12 out of 30 on MMSE, which indicates moderate cognitive

impairment. BDI (Beck Depression Inventory)

The BDI consists of 21 questions that assess the presence and severity of depressive

symptoms.
 Quantitative Interpretation

Table showing the score ranges for BDI

Ranges Depression level Client’s score

0-13 Minimal depression

14-19 Mild depression

20-28 Moderate depression

29-63 Severe depression 29(severe depression)

The client`s score lies in the range of 29 – 63, which indicates severe depression.

Qualitative Interpretation

The client scored 29 on BDI out of 63, indicating severe depression. Her score

reflects the severity of her depressive symptoms. The results suggested that her pain might

be contributing to the emotional distress and potentially affecting her mood and causing

depression.

Tentative Diagnosis

296.23[F32.2] (Severe) Major Depressive Disorder Comorbid with Cardiovascular

Disease.
 Case Formulation

The client was 60 years old and she belong to a middle class family. She had 5

siblings and she’s the only sister both of her parents are dead. She was living in joint family

system her husband was not alive she had 3 daughters and 2 sons. The client problem was

episodic for past 5 years and her physical illness that was cardiovascular problem she got

heart attack twice was episodic for past 13-14 years. Due to the severity of her

cardiovascular problem her psychological issues arises which was affecting her daily life

and was leading to more health and psychological problems. She was having problem

predominantly in able to hold a past memory even it is about few seconds ago she was not

able to recall it. She was having problem in praying, in calculations, what a person said to

her a while ago. She was having problem in initiating sleep sometimes she don’t sleep for

days due to which her physical health was affecting badly.

The influence of antidepressant and psychotherapy treatment adherence on

future work leaves for patients with major depressive disorder. The purpose of this study

was to understand the influence of antidepressant and psychotherapy treatment adherence on

future work leaves for patients with major depressive disorder. Patients with a newly

diagnosed major depressive disorder (n = 26,256) were identified in IBM® Watson™

MarketScan® medical and disability claims databases. Antidepressant and psychotherapy

adherence metrics were evaluated in the acute phase of treatment, defined as the 114 days

following the depression diagnosis. Multiple variable Cox proportional hazards regression

models evaluated the influence of antidepressant and/or psychotherapy adherence on future

injury or illness work leaves. The majority of work leaves in the 2-year follow-up period

occurred in the acute phase of treatment (71.2%). Among patients without a work leave in

the acute phase and who received antidepressants and/or psychotherapy

 (n = 19,994), those who were adherent to antidepressant or psychotherapy treatment

in the acute phase had a 16% (HR = 0.84, 95% CI = 0.77–0.91) reduced risk of a future work

leave compared to treatment non-adherent patients. Patients who were non-adherent or

adherent to antidepressant treatment had a 22% (HR = 1.22, 95% CI = 1.11–1.35) and 13%

(HR = 1.13, 95% CI = 1.01–1.27) greater risk of a future work leave, respectively, than

patients not receiving antidepressant treatment. Conversely, patients who were non-adherent

or adherent to psychotherapy treatment had a 9% (HR = 0.91, 95% CI = 0.81–1.02) and 28%

(HR = 0.72, 95% CI = 0.64–0.82) reduced risk of a future work leave, respectively, than

patients not receiving psychotherapy treatment. This analysis suggests that treatment

adherence may reduce the likelihood of a future work leave for patients with newly

diagnosed major depressive disorder. Psychotherapy appears more effective than

antidepressants in reducing the risk of a future work leave.

Over 10% of people may have a depressive disorder at some point in their

lives, placing a significant financial and social strain on healthcare systems and

societies.Nevertheless, rese arch indicates that a sizable portion of patients receive subpar

care.This study sought to assess th e characteristics of depressive disorder patients in Spain,

how these diseases are currently manag ed, and the costs of specialized care.The admission

records of patients who were admitted for a d epressive condition between 2011 and 2016

were included in a retrospective multicenter research that was created using data from a

Spanish claims database.The records found related to 27.963 i ndividuals registered in

specialized care facilities and 306,917 patients who visited primary care facilities.Over the

course of the trial, there was a gradual increase in the number of admissions pe r patient.As

the unemployment rate rose relative to the general population, there was a link with s

ocioeconomic characteristics (OR = 1.41; 95%CI = 1.38-1.43).

 Additionally, severe manifestations of a depressive disorder were linked to

concomitant problem s such hypertension, disturbances of lipoid metabolism, diabetes type

II, other mood disorders, and thyroid issues.In terms of disease management, patients with

severe disorders constituted the majority in settings of specialized care, and the bulk of

admissions were inpatient and urgent. During the study period, more electroconvulsive

therapy and medication therapy were used.

Specialized medical care had an annual cost of €9,654 per patient and an overall cost

of €44,839, 196.An overall reduction in the burden that depressive illnesses place on the

Spanish National H ealthcare System may result from improved diagnostic and treatment

techniques.

Therapeutic Recommendations

The client problem was episodic for past 5 years and her physical illness that was

cardiovascular problem she got heart attack twice was episodic for past 13-14 years. Due to

the severity of her cardiovascular problem her psychological issues arises which was

affecting her daily life and was leading to more health and psychological problems.

Following therapeutic suggestions were given. Following therapeutic suggestions were

given.

Cognitive behavior therapy (CBT) it is an individual therapy focused on the

relationship between a person's thoughts, feelings and behaviors. CBT teaches people to:

Identify negative assumptions and thinking patterns, and challenge themselves to rehearse

more adaptive ways of thinking.

 Deep Breathing Deep breathing is a type of relaxation exercise in which a person

breathes deeply in a slow, repeated manner. Deep breathing involves slow and deep

inhalation through the nose, usually to a count of 10, followed by slow and complete

exhalation for a similar count. The process may be repeated 5 to 10 times, several times a

day. The client was taught the breathing exercise. The purpose of this exercise was to make

the client relax when confronted with any anxious thoughts or stressful situations.

Sleep hygiene Sleep hygiene is defined as behaviors that one can do to help promote

good sleep using behavioral interventions. The client reported sleep disturbance so for this

problem, sleep hygiene tips were given to the client and she was told to follow those tips for

the betterment of sleep problems.

Family therapy Family therapy helps the client with psychological problems to

live better happy life. Family are able to provide powerful support and encouragement, as

well as a vivid setting in which problems based on such distorting effects can be explored

and treated. That is, family can be used at both outer and supportive levels and the deeper

exploratory levels of psychotherapy (Brown & Pedder, 2005) the client’s family was also

involved during the session and the purpose of this was that the family should understand

her problem and she could communicate effectively.

Prognosis

Prognosis was favorable because client was willing for treatment.

Limitations

 Time was limited

 Suggestions

 If the client shows willingness for further sessions it will benefit a lot.

REFERENCES

Gaspar FW, Wizner K, Morrison J, Dewa CS. The influence of antidepressant and

psychotherapy treatment adherence on future work leaves for patients with

major depressive disorder. BMC Psychiatry. 2020 Jun 19;20(1):320. doi:

10.1186/s12888-020-02731-9. PMID: 32560678; PMCID:

PMC7304154.

Darbà J, Marsà A. Characteristics, management and medical costs of patients with

depressive disorders admitted in primary and specialised care centres in

Spain between 2011 and 2016. PLoS One. 2020 Feb 5;15(2):e0228749. doi:

10.1371/journal.pone.0228749. PMID: 32023308; PMCID:

PMC7001952.
ANNEXURES