ADULT CLINICAL CASE - 2

REASON FOR REFERRAL:

Mr. Y, a 26 years old male Muslim client was referred from Dhaka Medical college
Hospital to ‘Student Counseling and Guidance Center’ TSC, University of Dhaka, for
psychological intervention. Then he was attended by a trainee clinical psychologist in this
center. According to referral agency he had some symptoms like depressed mood,
substance abuse, delusion of persecutory, hypomanic.

DEMOGRAPHIC INFORMATION:

Mr. Y, 26 year’s old unmarried male client. He was 1st child of her parent and had a
younger bother who was 18 years old and a younger sister who was 13. He was from a
middle class family. He was student of BBA (Honors) in the National University. He could
not able to continue his study after 2008 for his problem.

PROBLEM DESCRIPTION:

When Mr. Y came, he mentioned some problems which caused significant suffering and
impairment in his social, occupational and other important areas of functioning. The
presenting problem lists, according to client, is given below-
He had too much guilt feeling for his past activities and about how he was. He had a
relationship which was broken up and he could not adjust with this. He always felt sad
because of low activity level and hypersomnia, also anxious about his future and was
feeling insecure. He did not feel any interest in daily and pleasure activities. He felt fatigue
and weak. He became nervous in social situation. He had fear about exam. He had problem
with recurrent thought of death, being patient with mental illness and. He reported that his
self confidence was very low. Poor concentration and indecisiveness were present. Some
substances like GAJA, alcohol were taken. The last time of taking substances was about 8
month ago from the first session. He also had a problem with smoking.
These problems can be described as behavioral, affective, motivational, cognitive and
physical problems which are given below-

Behavioral:
He mentioned that he had lots of works to do but he was not doing these works, his activity
level was decreased day by day. He had problem with hypersomnia. He had friends but did
not get fun with them. He had adjustment problems with family members. Taking
substances and smoking is another behavioral problem.

Affective:
He always felt sad because of the messy environment, surrounding and situations like
study break, chaotic relationship with his family members, low activity level, etc. He had
guilty feeling about how he was. He had fear about exam and became nervous in social
situation. He was also anxious about his future and was feeling insecure. As a result, he
had feeling of helplessness and hopelessness.

Motivational:
Client did not feel interest to do any thing; he did not get any pleasure from recreational
activities like movie watching, story reading.

Cognitive:
He had problem with recurrent thought of death, being patient with mental illness. He
reported that his self confidence was very low. He did not give attention for a long time in
a matter, so poor concentration was present. He was unable to take decisions. He was
unhappy with his past, he blamed himself for all the misfortune that occurred in his life, he
always criticized his as a failure in every aspect of life, he has nothing to do about his
present and future and he was helpless.

Physical:
He had problem with hypersomina. He also felt fatigue and weak.

FAMILY HISTORY:

The client was born in 1987 through a normal birth process in a nuclear family. His father
was a government service holder and mother was a house wife. There was good relation
between parents. He had a younger brother who was 18 years old, read in 11 and a younger
sister who was 13 years old student of class 8.
Before 2008 there was supportive relation between client and his parent. After passing
H.S.C exam with unsatisfied result and getting humiliated from the relatives of his beloved,
the relation between them become worst. Now client had no good relation with his brother
because his brother always criticized and blamed him as a failure, he wastes money. But
he had a good and support relation with his mother still now.

PERSONAL HISTORY:

Mr. Y was born in Dhaka. The developmental process was normal, there was no
complication. Form his early childhood, he had a supportive family environment. He was
appreciated by his parent for his activities. He started to think he was appreciated and
accepted as good by all like his parents.
When he started to go school, he found that he was not appreciated and accepted as good
by classmates and teachers like his parents. He learnt that, who had a good academic result
and money to expense for friend those classmates get appreciation and acceptance as good.
As a result he tried to do well in academic performance and had a good result. He started
to expanse money for friends. Those activities gave him appreciation and acceptance of
other as a good one.
In his school life, he was fond of passing his time with friends by playing, gossiping etc.
He liked one of his cousins from his school life. Form then he tried to maintain a good
communication and relation with his relatives. Because he thought if the family of his
beloved hared the good appreciation about him from them, it would be helpful for establish
his relationship.
One of his maternal uncles expelled from exam. After that when he attended another exam
he could not able to write in exam scripts and he developed mental illness. From this
experience, an idea of having mental illness by genetically was developed.
He was good in his academic performance before class 11. He always tried to do well in
academic performance. Then he thought that successfulness brought appreciation and
acceptance as good. After passing S.S.C. examination he got admitted to a popular college,
in where he leaded a chaotic life. He had an interest about politics. He wanted to become
popular by political power. He thought that it was a great way which brought great
appreciation and acceptance of all. He thought that it was also helpful to establish his
relationship. As a result, he joined to the political activity. He had lots of friend and passed
his time with them by travelling, gossiping. Even he did some illegal activities such as
hijacking, did not pay the rent of vehicles so on. Later he had guilty feeling for those
activities. In 2007, he had a clash with his friends and they gave threat to him as they will
kill him. Then he started to think others were critical, they were causes of harm. There was
another clash between client and his senior of college and he also gave threat like his
friends. The thought about others were critical, they were causes of harm became strength
for this experience.
When he was college student, he took substance for first time with his uncle. After that he
took these with his friends occasionally. His smoking habit was started from when he was
class 8.

HISTORY OF PRESENT ILLNESS:

In the 2006 he passed H.S.C exam with unsatisfied result and he thought he was failure to
achieve his goal. He thought that he was unaccepted as successful by other. In 2007, his
cosine accepted him as her beloved and he had a relation with her. In 2008 the relationship
was broken up for family pressure. Some of his relatives who gave assurance that they will
help those people facilitated the breaking of relationship by criticized him as bad, criminal
so on. For that his beloved’s family created pressured on her for break up. Then he thought
that if his relative presented him as a good, his relation would be being continuing. His
family was humiliated from the relatives of his beloved. After break up, his close friend
made a relation with that girl. After these experiences he could not trust any one. He
thought everybody was critical and harmful for him. Then he got admitted in BBA in
national university. He took a study break because of adjustment problem with break up.
After a year he started his study. In final exam of 1st year, he could not able to take
preparation for his present problem. He could not able to write single word in examination
scripts for his nervousness. He thought he was mentally ill like his uncle for that he could
not able to write in script and went to Dhaka Medical College for seeking help.

TREATMENT HISTORY:

In 2008, after breaking the relationship, he first developed symptoms of depression. After
failure to write in exam scripts he went to Dhaka Medical College for seeking help. From
end of 2010 he was treated by “Prodep 20 mg” and Epillim choron. Prodep is a selective
serotonin reuptake inhibitor (SSRIs). Prodep operates by restoring the balance of serotonin,
a natural substance in the brain, which helps to improve certain mood problems. In 2011
he was asked to take psychotherapy in ‘Student Counseling and Guidance Center’ TSC,
University of Dhaka, in concurrently.

ASSESSMENT:

Initial assessment was started with client’s demographic information and gradually went
through the symptoms, severity, mood, relevant history, present situation and present
problems in different areas of functions. Whole assessment procedure was done in three
levels, which are:
Subjective assessment:
The main tools of subjective assessment were in-depth clinical interview, observation of
client in the session, activity schedule and thought diary. In-depth clinical interview was
done by the therapist through open- ended and closed questions, empathetic listening, and
active listening. Observation was focused on the attention of client, his appearance, eye
contact, gesture, congruency of mood and speech, instant mood swing in the session.
Thought diary, activity schedule were given to the client as home work.
Objective rating:
Depression scale developed by Md. Zahir Uddin and Dr. Mahmudur Rahman (2005) was
administered to assess the severity level of depression.
Anxiety scale which is developed by Farah Deeba and Dr. Roquia Begum (2004) was also
administered in the session to get objective rating of anxiety.
Subjective mood check:
In this procedure the client was asked to rate her mood as she was considering. He was
asked to rate his mood from 0%-100% where 0% means lowest level of well being and
100% means highest level of well being.
Subjective problem rating:
In this procedure the client was asked to rate his problems as he was considering. He was
asked to rate his problem from 0%-100% where 0% means lowest level and 100% means
highest level.

PROVITIONAL DIAGNOSIS:

According to Diagnostic and Statistical Manual of Mental Disorder-4 (DSM-4), the client
was suffering from Dysthymic disorder.

FORMULATION:

The client’s problem can be formulated on the basis of cognitive model of depression
described by A.T. Beck (1967, 1976). This model suggests that early experience leads
people to form assumptions or schema about themselves and the world. Some assumptions
are rigid, extreme, resistant to change, and hence ‘dysfunctional’. Such assumptions
concern, for example, what people need in order to be happy, and what they must do or be
in order to consider themselves worthwhile. When critical incidents occur, dysfunctional
assumption activates. Once activated, dysfunctional assumptions produce an upsurge of
“negative automatic thoughts”. These may be interpretations of current experiences,
predictions about future events, or recollections of things that have happened in the past.
They, in turn lead on to symptoms of depression.

The client was brought up in a middle class family. He had a supportive environment. From
family, his idea like ‘I and my activities are always good, I am acceptable as good and my
activities bring appreciation for me all the time’ was developed. But when he entered the
school life he found that it is not true. He was not accepted by all and his activities did not
bring appreciation. From here, a schema like ‘I am not good enough’ was developed.
At the same times he found that the classmates who had a good academic result and money
to expense for friend those classmates get good appreciation and acceptance. He leveled
those classmates as successful person. These experiences helped him to develop an
assumption like ‘if I am successful in all my activities, it brings me others’ appreciation
and it helps to create me as good enough.’
He was good in academic performance before HSC. He passed HSC examination with an
unsatisfactory result. He also lost his relationship with his beloved. Then he started to think
‘I am failure’. These were negative automatic thoughts which affected his behavior and
emotion which, in turn, led to the depressive symptoms. The problem of the client can be
presented pictorially according to cognitive model described by A.T. Beck.

Early Experience
Family acceptance as good
 Classmates and other acceptance as not good enough

Core Beliefs
‘I am not good enough’

Assumption

‘If I am successful in all my activities, it brings me others’ appreciation and it helps to

establish me as good enough.’
Critical Incident
Unsatisfactory result
Relationship brake up with beloved

Negative Automatic Thought

“I am failure”
“I am worthless”

Symptoms

Behavioral: Lowered activity, adjustment problems

Motivational: Loss of pleasure and interest
Affective: Sadness, anxiety, guilt, insecurity
Cognitive: Poor concentration, indecisiveness, self-criticism
Somatic: sleep disturbance, fatigue, weakness

TREATMENT GOAL:
The treatment goals were set collaboratively. Overcome the depressed mood, altering
maladaptive beliefs, relapse prevention were Long term goal. Increasing concentration, ,
overcome the problem with indecisiveness, guilty feeling, nervousness, anxiety, improving
low confidence, to alter negative thoughts and beliefs, to increase activities and interest, to
increase self confidence were short term goal.

TREATMENT PLAN:

Goals Treatment
Releasing pent-up emotion ventilation
Increasing awareness about problem Psycho education
Guilty feeling Cognitive restructuring by pie chart
Increasing concentration Graded task assignment
Increasing activities & interest Activity schedule and mastery and
pleasure
Over coming with anxiety and nervousness Breathing relaxation, Graded task
assignment
Over coming with the problem of Pros and cons, Problem-solving method
indecisiveness
Improving self confidence Positive data log
Altering the NATs, assumptions, belief Cognitive restructuring
Relapse prevention Formulating a treatment blueprint

TREATMENT:

As the formulation of the client’s problem can be explained with cognitive model and some
of his problems were due to faulty learning of maladaptive coping pattern, cognitive-
behavior therapy was chosen for intervention.
Ventilation:
Ventilation was used to facilitate sharing and releasing pent-up emotion as pent-up emotion
was helping to maintain the presenting problem.

Pie-chart:
It helps client to see their ideas in graphic form. A pie chart can be used in many ways
according to the individuals need. In the present case it was given to decrease guilt
feeling.

Psycho-education:
Psycho education was provided to explain the interaction between thought, emotion,
behavior and physical reactions. Psycho education about depression was given to make his
understand that it is a common psychiatric problem.

Graded task:
Graded task was given to increase concentration and decrease anxiety. Graded task is the
procedure to break down a task in a convenient part and accomplish them sequentially.
Through accomplishment of small parts a client achieve a sense of success which was
seems not possible to his in past and considered as a huge task.

Positive data log

It was design to increase self confidence by writing positive self statement in a dairy. It was
help for giving sense about he successful in many aspect of his life.

Breathing relaxation:
Pevels and Jhonson (1986) found that relaxation increase the accessibility of positive
memory in the brain. Breathing relaxation training was given to reduce level of anxiety.

Pros and cons:

Pros and cons were designed to take decisions. The client could not take decision about his
readmission. In the case it was used for taking decision about his readmission.

Problem solving:
Problem-solving method was designed to reduce adjustment problem and deal with future
real life problems. Steps in problem solving:

1. Decide which problem(s) to be tackled first

2. Agree goal(s)
3. Work out steps necessary to achieve goal(s)
4. Decide tasks necessary to tackle steps
5. Implementation of decided tasks
6. Review progress at next session, including difficulties that have been encountered
7. Decide next step depending on progress
8. Proceed, as above, to agreed goal(s), or redefine problems and goals
9. Work on further problems if necessary

Activity scheduling and mastery and pleasure:

Activity schedule and mastery and pleasure were given to increase activity level as the lack
of activity was maintaining problem.

Cognitive therapy:
Cognitive therapy was designed as negative automatic thoughts (NAT’s) were maintaining
client’s problem. NATs were replaced by more appropriate alternative adaptive cognitions
through thought challenge which is a cognitive technique. Another cognitive technique was
given to deal with suicidal thought that was distancing technique. It was also in plan to use
distancing technique for replace NATs.

Relapse prevention:
Relapse prevention was also in the treatment plan to help the client to deal with future
possible problems through a treatment blueprint.
Table-1: Scores of depression and anxiety scale in different sessions

Sessions Score on depression scale Score on anxiety scale

1st 102(mild) 67(severe)
2nd 96(minimal) 62(Moderate)
4th 102(mild)
6th 100(minimal)
7th 37(mild)
9th 93(minimal)
11th 79(minimal) 40(mild)
13th 82(minimal) 36(mild)

120

100

80
depression
60 anxiety
40

20

0
1st 2nd 4th 6th 7th 9th 11th 13th

Figure-1: Graphical representation of depression and anxiety scores

Subjective rating of mood was also taken from client. These ratings were as below:

Table-2: Subjective ratings of mood

Sessions Percentage of wellbeing (0-100%)
2nd 40
3rd 40
4th 45
6th 50
7th 65
8th 70
10th 70
11th 65
13th 75
14th 75

Subjective ratings of mood

80
70
60
50
40
30
20
10
0
1st 2nd 4th 5th 6th 7th 8th 10th 11th 13th 14th

Figure-2: Graphical representation of subjective outcomes

Subjective rating of severity of problem is given below-
problem At 1st session At 13th session
Guilty feeling 70% 30%
Problem with concentration 90% 50%
Low activities & interest 70% 30%
Anxiety and nervousness 75% 40%
Problem of indecisiveness 80% 30%
Improving self confidence 70% 30%

Subjective rating of thought is given below

thoughts At 1st session At 13th session

I am failure 70% 20%
I am not good enough 90% 30%
Other are causes harm and 80% 20%
death

CRITICAL DISCUSSION:

The client was referred for depressed mood, substance abuse, delusion of persecutory,
hypomanic. The therapy was designed for treating depression, not for substance abuse,
delusion of persecutory, hypomanic. Referral agency mentioned he had problem with
pressure of speeches and wanted to expense. For that reason the referral agency might
mention the symptoms of hypomanic. But his mother reported that he was like that from
his childhood and it was normal. He wanted to expanse money for activation of a thought
of expanse money was a singe of successful man and he want to be a successful one. He
client wanted to overcome from depression firstly. He reported that he took drugs
occasionally. He did not want to take treatment for that. It was cross checked by his parents
that the last time of substance abused was eight month ago from 1st session of the therapy.
He had no delusion of persecutory. It was a thought about other are causes harm and death
and it had a relevant history. This thought was restructured by thought challenge.

As the client’s symptom was getting reduced to some extent he became motivated. But he
had difficulty in accepting his reality and internalizing therapy (Internalization: The
acceptance of beliefs, values, practices as one’s own.). His family situation and
surrounding was not supportive. So there are a possibility to relapse.
 REFERENCES:

Beck, J. S. (1995). Cognitive therapy: Basic and Beyond. The Guilford Press. New York.

Blackburn, I. and Devison, K. M.(1900, 1995). Cognitive Therapy for Depression and
Anxiety. A practitioner’s guide.

Gelder, M.; Harrison, P. and Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry, 5th
edition. Oxford University Press. New York.

Hawton, K.; Salkovskis, P. M.; Kirk, j. and Clark, D. M. (1989). Cognitive Behavioral
Therapy for Psychiatric Problems. A Practical Guide. Oxford University Press. New York.

Lindsay, S. and Powell, G. (1987). The Handbook of Clinical Adult Psychology, 3 rd

edition.

The Diagnostic and Statistical Manual of Mental Disorder, 4th edition ( DSM-4). The
American Psychiatric Association. Washington. DC.