Case Study

Submitted by:

Jaweria Zahid

AU-02-05-13504

Submitted to:

Ms. Sidra Rasool

DEPARTMENT OF PSYCHOLOGY

FAZAIA BILQUIS COLLEGE OF EDUCATION FOR WOMEN

RAWALPINDI
This is certified that the present case study report has been done by Jaweria Zahid, and it is
submitted to Fazaia Bilquis College Education for Women Rawalpindi in partial fulfillment
of the Bachelor’s degree in Psychology.

Instructor: ___________

Head of department: ___________

Principal: ___________

2
3
Table of Contents
CASE 01........................................................................................................................................... 5
1.1 Client’s Particulars ................................................................................................................ 5
1.2 Mode of Referral .................................................................................................................... 5
1.3 Presenting Problems .............................................................................................................. 5
1.4 History of Complaints ............................................................................................................ 5
1.5 Prior Psychiatric History ....................................................................................................... 6
1.6 Medical History...................................................................................................................... 6
1.7 Family History ....................................................................................................................... 6
1.8 Personal History..................................................................................................................... 6
1.10 Behavioral Observations ...................................................................................................... 7
1.11 Tentative Diagnosis .............................................................................................................. 7
1.12 Treatment Plan .................................................................................................................... 7
CASE 02......................................................................................................................................... 13
2.1 Client’s Particulars .............................................................................................................. 13
2.2 Mode of Referral .................................................................................................................. 13
2.3 Presenting problems ............................................................................................................ 13
2.4 History of complaints ........................................................................................................... 14
2.5 Prior Psychiatric History ..................................................................................................... 14
2.8 Personal History................................................................................................................... 14
2.9 Premorbid Personality ......................................................................................................... 15
2.10 Behavioral observations ..................................................................................................... 15
2.11 Tentative diagnosis............................................................................................................. 15
2.12 Treatment plan................................................................................................................... 15

4
CASE 01
1.1 Client’s Particulars
Name: XYZ

Sex: Female

Age: 33 years

Marital status: Married

Children: 2 sons 2 daughters

Qualification: 7th Grade

Occupation: House Wife

Residence: Rawalpindi

Socioeconomic status: Middle Class

Religion: Islam

Siblings: 4 sisters 2 brothers

Birth order: 2nd

Family structure: Nuclear

1.2 Mode of Referral

Self

1.3 Presenting Problems

Ms. XYZ complains that she had the following problems:

• Feel hesitation while talking with others

• Feel difficulty in speaking even in front of close relatives e.g. Husband, sister, mother.

• Can’t tolerate the noises of children

• Anger

• Restlessness

1.4 History of Complaints

Ms. XYZ has been grappling with a series of psychological and behavioral symptoms for the past
three years. Notably, she feels a marked hesitancy and discomfort when communicating, especially in

5
the presence of familiar individuals, a pattern which has led to a decrease in her social engagements
with those known to her. Alongside this, she describes a pronounced intolerance to the sounds of
children, often feeling distressed and opting to distance herself from such environments.
Concurrently, she has been dealing with significant anger issues, manifesting in intense outbursts that
she recognizes as being disproportionate to their causative events. This constellation of symptoms has
progressively intensified, impacting her daily functioning and raising concerns among her close
family and acquaintances.

1.5 Prior Psychiatric History

She had no psychiatric history.

1.6 Medical History

Ms. XYZ has a history of episodic high blood pressure. Apart from these intermittent hypertensive
episodes, she reports no other significant medical concerns or diagnoses. Regular monitoring and
consultations have been advised for her blood pressure, but no other systemic or chronic issues have
been identified in her medical records to date.

1.7 Family History

Ms. XYZ is married with four offspring: two sons and two daughters. She is the second eldest
among her four sisters and two brothers. No significant medical or psychological issues are
noted within her immediate family.

1.8 Personal History

Ms. XYZ, currently in her second marriage, has a complex relational history. She was
previously married, but that union ended in divorce. Beyond the confines of her marital bond,
she has admitted to having an extramarital relationship. Notably, despite recognizing the lack
of reciprocated interest from the man in this relationship, she remains deeply emotionally
attached and professes her love for him.

Three years prior, coinciding with the onset of her reported symptoms, several pivotal
incidents occurred. Firstly, a sum of RS 20,000, entrusted to her by her husband for
safekeeping, went missing from their residence. This event instilled profound feelings of guilt
within her. Around the same time, a gold chain belonging to her sister also vanished under
her care, exacerbating her guilt.

Further delving into events three years ago, it was revealed that she and her husband were
implicated in facilitating the love marriage of their relatives. This involvement resulted in her
being held responsible by family members, casting a shadow of blame upon her. This
incident is significant, as it has had enduring implications for her interpersonal relations,
particularly causing her hesitation when interacting with relatives for fear of further blame.

6
Diagnostic assessments were carried out to gauge the depth of her psychological concerns.
The results from the Beck Anxiety Inventory (BAI) showed a score of 9, suggestive of mild
anxiety. Concurrently, the Beck Depression Inventory (BDI) indicated a score of 8, pointing
to minimal depression. These scores provide a clinical underpinning to her expressed
emotions and behaviors, offering insight into the potential extent and nature of her
psychological state.

1.10 Behavioral Observations

During the initial session with Ms. [Patient's Name], several noteworthy behavioral patterns
emerged. She frequently touched her mouth and fingers, possibly indicative of nervousness or
a self-soothing mechanism. Her demeanor conveyed a sense of low self-esteem, as
manifested through her posture, limited eye contact, and subdued voice. At the
commencement of our interaction, there was a discernible shiver, suggesting initial anxiety or
trepidation about the therapeutic process. As the session progressed, the intensity of these
behaviors seemed to wane slightly, but they remain important markers to consider in
understanding her overall emotional and psychological state.

1.11 Tentative Diagnosis

Adjustment Disorder with Mixed Anxiety and Depressed Mood (DSM-5 309.28).

1.12 Treatment Plan

Progressive Muscle Relaxation Therapy (PMRT):

 Conducted guided sessions to introduce and practice PMRT, aiming for relaxation and
stress reduction.
 Recommended regular practice at home to ensure mastery and ongoing benefit from
the technique.

Activity Chart:

 Introduced a structured activity chart for daily task monitoring and structuring.
 Encouraged consistent logging to gain insights into patterns and triggers of distress.
 Reviewed the chart in subsequent sessions, making necessary adjustments.

Cognitive Behavior Therapy (CBT):

 Identified prevalent negative thought patterns and cognitive distortions.

 Applied cognitive restructuring techniques to challenge and shift unhelpful thoughts
towards more balanced perspectives.

7
  Introduced coping strategies tailored to manage her specific symptoms of anxiety and
depression.

Role Play:

 Engaged in role-playing exercises to simulate and address challenging interpersonal

situations, especially those involving family members.
 Provided constructive feedback and strategies to bolster communication skills and
self-confidence.
 Utilized role play as a therapeutic tool to process feelings of guilt and introduce
effective coping mechanisms.

8
9
10
11
12
CASE 02
2.1 Client’s Particulars
Name: XYZ

Sex: Female

Age: 14 years

Marital status: Unmarried

Qualification: 7th grade

Occupation: Student

Residence: Rawalpindi

Socioeconomic status: Middle class

Religion: Islam

Siblings: 3 sisters 2 brothers

Birth order: 4th

Family structure: Nuclear

2.2 Mode of Referral

Referred by Medical Specialist .

2.3 Presenting problems

Ms. XYZ complains that she had the following problems:

 Persistent silence and limited verbal interactions.

 Acts of physical aggression towards others.
 Frequent use of slang or inappropriate language.
 Memory lapses or forgetfulness.
 Tendency towards absent-mindedness.
 Social withdrawal and isolation.
 Markedly reduced communication with others.
 Pronounced episodes of anger and irritability.
 Complaints of headaches.
 Generalized body aches.
 Profound fear or apprehension towards others.

13
2.4 History of complaints
Over the past 25 days, there has been a notable shift in the behavior and well-being of the
patient. She began to exhibit a marked silence, communicating far less than usual, with her
interactions being limited and often terse. Concurrently, there were instances of physical
aggression directed towards others, a behavior previously uncharacteristic for her. Her
language, too, changed, with her adopting slang and occasionally resorting to inappropriate
vernacular. Memory-related concerns surfaced as she started to forget certain events or tasks,
accompanied by periods of absent-mindedness that were evident in her daily activities.
Additionally, there was a discernible pattern of social withdrawal, where she increasingly
isolated herself from her usual social circles, and her overall communication with peers and
family diminished significantly. This social withdrawal was further compounded by episodes
of pronounced anger and irritability. Physiologically, she reported the onset of recurrent
headaches and general body aches, neither of which had been a concern in her recent medical
history. Perhaps most concerning was her growing apprehension around other people, a
newfound fear that seemed to have developed without an immediately identifiable cause.
This collection of symptoms and behavioral changes has persisted and become more defined
over the aforementioned 25-day period.

2.5 Prior Psychiatric History

Before the onset of the current symptoms, it is important to note that the patient had no
known history of psychiatric issues or interventions. Her mental health record was
unremarkable, with no previous diagnoses, hospitalizations, or treatments related to
psychiatric concerns. This recent manifestation of symptoms over the past 25 days represents
a departure from her established baseline of mental well-being.

2.8 Personal History

The patient is a 14-year-old girl, currently enrolled in the 7th grade. She occupies the fourth
position among a family of five siblings. Prior to the onset of her current symptoms, which
began approximately 25 days ago, she displayed a strong bond and connection with her
family, actively participating in both school and household activities. However, in the recent
span of 25 days, there has been a significant shift in her behavior. She refrained from
attending school and abandoned her usual household chores, indicating a considerable
departure from her routine activities.

Upon deeper exploration, it was discerned that the patient's mother has been grappling with
multiple medical challenges, including conditions such as typhoid and hepatitis, among other

14
health concerns. The stress and worry associated with her mother's deteriorating health have
had a profound impact on the patient. The weight of this tension and anxiety, rooted in her
mother's health predicaments, appears to be the precipitating factor leading to her current
state of mental and emotional distress. It is essential to consider this context while addressing
her symptoms and planning therapeutic interventions.

The House-Tree-Person (HTP) assessment revealed intriguing insights into the patient's
perceptions of her environment, herself, and her relation to the world.

2.6 Medical History

Her assessments were done but she had no medical issues. Her tests were done but the reports
were clear.

2.9 Premorbid Personality

In the period leading up to her recent changes in behavior and mood, the patient's premorbid
history paints a picture of a well-functioning and socially adept individual:

 Demonstrated a well-adjusted and balanced demeanor.

 Engaged in effective and meaningful communication with peers and family.
 Actively participated in household chores, showing a sense of responsibility.
 Was socially adept, mingling comfortably with her immediate environment.
 No previously reported or observed emotional or behavioral issues.
 Stark contrast observed when comparing her previous disposition to her current state.

2.10 Behavioral observations

 Throughout the session, she displayed noticeable hesitation, particularly when
engaging in dialogue or addressing specific topics.
 A significant moment of distress was observed when the suggestion was made for her
mother to exit the room. She reacted with pronounced emotional intensity, crying and
fervently pleading with her mother to remain by her side.
 Over the course of the session, she demonstrated a general sense of lethargy,
characterized by diminished energy and reduced responsiveness to external stimuli.
This sluggish demeanor persisted throughout our interaction.

2.11 Tentative diagnosis

Adjustment Disorder with Mixed Anxiety and Depressed Mood (DSM-5 Code: 309.28).

2.12 Treatment plan

 PMRT (Progressive Muscle Relaxation Technique)

15
 Activity Chart
 Behavior modification

16