CASE REPORTS

Table of contents

Case report 1

Case report 2

Case report 3

Case report 4
Case Report 1
Identifying data

Name initial NA

Gender Man

Age 30

Education Intermediate

Marital status Single

Patient Drug addict

Source and Reason for Referral

Referred by psychiatrist

Presenting Complaints

Table 1

Presenting Complaints according to the client

Intensity/ Complaints

Duration

18 years 60% Stealing habit

9 year 70% Drug addiction

3 years 80% Low mood

 3 years 90% self dislike

20 years 90% Poor problem solving

20 years 70% Poor decision making

20 years 60% Discrimination by parents

20 year 70% Attention seeker

20 years 50% Passive communication

Behavioural Observation

The client was an educated heighted man with average weight. His personal hygiene was good

and was wearing neat and tidy clothes. He appears active, energetic, and was in good mood. He

was maintaining good eye contact. His sitting posture was much relaxed. The client seems quiet

motivated to seek treatment.

Developmental History of the problem

WR was having the problem from 18 years.

Personal history.

Birth Order 2nd

Childhood Client don’t have satisfactory relations with his father, According to the client in

his childhood there is not a single day or event to remember in which he experienced the sense of

security, warmth, love and attention from his father.

Actually client’s father was the only earner of his family, he has the burden of 7 people including

him that is why he was unable to attend his Family.

Educational History

Client’s schooling was of a government school. He was a good student, and always got good

grades. He likes reading and exploring different books. His education was till intermediate, he

was unable to continue his studies because the family cannot afford the further expenditures. The

client’s relationship with his teachers, fellows and friends were good, and he uses to respect

everyone. He had never gone through any kind of adjustment difficulties as he was a social

person, and was good in making adjustment

Pre-morbid personality

He had a healthy premorbid personality.

Marital history

He is not married.

Occupational history

The client has a long occupational history. He had worked in up to 15 organizations. The

posts on which he worked were accountant, cashier, receptionist, computer operator, data

enterer, and assistant web developer. The reason for several job shifts was that he was caught

several times when performing the theft. Several times he was hired on warning, but he

continued the same act, that is why he was fired from several organizations, and some were left

by him by choice as the pay was too low and work load was great.
History of family psychiatry/medical illness

There is a family history of psychiatry and medical illness as client’s elder brother is also a

substance abuse, his mother is hypertensive and is sugar patient while his father has hepatitis - C

Assessment

The assessment was carried out in different dimensions. Following is the list of

assessment techniques which were carried out with the client.

• Behavioural Observation

• Clinical Interview

• Mental Status Examination

• Subjective Ratings

Behavioural observation

The client was a person of inferiority complex and was disheartened too. But he gave

answers frequently also he wanted to change himself. Client was wearing clean clothes.

He was not distracted, he focused on every detail of the session.

Clinical interview

It is a face to face interaction in which clinician asks questions of clients’ problems, their

responses and reactions. Clinician collects the detailed information about the person’s problem,

feelings, life styles, relationships and other personal history. Clinical interview was conducted

with the client to get detailed information about his family, personal and the history of
psychiatric problem. The client had proper insight about his problem, and he was motivated to

seek treatment. During the complete interview session the client was very complaint, and was

attentive.

Mental status examination

The client was much compliant, and was maintaining a good eye contact. He seems to be much

cooperative, attentive, interested in session. He was vigilant and alert, and was actively listening.

His orientation was good as he responded accurately when asked about the place, season, year,

date, month, time and city. His rate of speech was normal, and tone was soft. The quality of

speech was emotional. Client’s mood was appropriate with his affect. He was in good mood and

was energetic. His thought process was logical, goal directed, appropriate, and was relevant with

the situation. His thought content involves the messages to self about the “right” and “wrong”.

He had a proper insight about his problem and was motivated to seek treatment

Subjective rating.

Table 2

Patient’s Symptoms and their Ratings by the Client

Symptoms Ratings(0/10)

Stealing habit 10

Carving of drugs 4
 Sadness 9

Worthlessness 10

Self dislike 10

Passivity 10

Muscle pain 9

Case formulation

Precipitating factor

Is refer to a specific event or trigger to the onset of the current problem. In this case client's bad

relationship with his family and girlfriend trigger his problem.

Perpetuating factors

They are those that maintain the problem once its established. He was continuously staying away

from his family and home it maintained his problem.

Protective factors

These are strengths of the person to reduce the severity of problem and promote healthy and

adaptive behaviour. In WR's case his psychiatrist helped him to make him aware of his problem.

Suspected problem

According to DSM-5 the client was suspected to be Drug Addiction.

Intervention Plan and Management

Intervention plan was designed to help the client to resolve problem he is facing and to aid the

natural process of adjustment, to develop a positive self-concept and to save him, and to learn to

interact with others.

Therapies that will be applied

i. By using supportive therapy build a level of trust with the client and create a supportive

environment that will facilitate the client to share his problems.

ii. Psycho educates the client about the harmful effects of the substance use.

iii. Asking the relevant questions to probe the underlying factors of her problems.

iv. Explore experiences from the client’s early life that contributes to develop the problem.

v. Active listening, positive reinforcement, reassurance and unconditional acceptance to facilitate

his sharing and catharsis.

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th
edition, Washington DC: American Psychiatric Association; 2013.
Case Report 2
Identifying data

Name initials NA

Gender Girl

Age 20

Education BS Biotechnology

Marital status Single

No of sessions Two

Patient Anxiety

Source and Reason for Referral A doctor referred her

Presenting Complaints

Table 1

Presenting Complaints according to the client

(0-10)Intensity Complaints

10-9 Fear of interaction with people

8-10 Sleep difficulties

6-10 Less apatite

 6-10 Tiredness

8-10 Discomfort

7-10 Headache

Behavioral Observation

Her behaviour was normal at the beginning, but when I started questioning her she got

confused. Her behaviour was not so well at start she didn’t answered me clearly but slowly

slowly she opened up. Her sitting style was telling she was confused and was afraid too.

Her hands were shivering slowly slowly. She tried to communicate but she was hesitated.

Developmental History of the Problem

Her anxiety began at the age of 15. She used to be stressed out because of her studies.

Her parents pressurised her for high marks and she was so anxious about that.

Personal history

Birth Order Single child

Childhood Her childhood was normal. She got normal development her social background

was strong as well. She got good schooling.

Educational History She was good in her primary and higher education. Her behaviour was

good with her classmates as well as with her teachers

Vocational History She is a student.

Pre-morbid personality
 According to patient she was doing fine.

Sexual history.

Her menstrual period started in class 8 and her age was 13.

When she had her periods she got nervous and started crying as she was unaware of it. Her

mother guided.

Marital history

She is not married still single

Educational history

She studied in oxford school and was a position holder her matric was done from here

She joined Allama Iqbal College for further studies. In college her performance and grades were

affected because of her anxiety.

Her relationship with her teachers and class mates was normal she often hesitate while

interacting with them as her anxiety made her antisocial person.

Occupational history

She is a student.

History of family psychiatry/medical illness

None of her family member had any mental illness. Her father was a patient of diabetes

Assessment
 The assessment was carried out in different dimensions. Following is the list of

assessment techniques which were carried out with the client.

• Behavioral Observation

• Clinical Interview

• Mental Status Examination

• Subjective Ratings

• Back anxiety inventory

Behavioural observation

Client was very nervous at the beginning, as she was an antisocial person she didn’t

shared her problem openly with me. Her way of sitting and talking were telling how nervous she

was. She was not making eye contact at start, as she was avoiding the questions.

Slowly slowly she became comfortable and started talking openly and shared her problems

directly. Her behaviour was not rude she wanted to change herself and get rid of anxiety. She

was cooperative as she conducted the sessions sincerely.

Clinical interview

A clinical interview is a conversation between a clinician and a client that is intended to

develop a diagnosis. It is a "conversation with a purpose" that can be structured, semi-structured,

or unstructured. Emphasis is placed on open-ended questions with the focus being on the patient

and not the clinician. Clinical interviews are used with other measures and methods to diagnose
the patient. There are many different types of clinical interviews: diagnostic, termination,

orientation, selection, intake, case history, and mental status exams are all examples

To diagnose the problem of my client, I conducted clinical interview. The questioning

session started and she was allowed to give answers freely. Through this interview her anxiety

was diagnosed. She was having severe anxiety and that was the reason behind her fear, antisocial

personality and odd behaviour towards people. Open ended questions were asked from her. She

was answering questions but the way she was talking showed her nervousness and anxiousness.

During the whole interview she eye contacted very less.

Mental status examination

Her looks were fine because she was nervous she walked slowly. She tried to talk

normally but because of her nervousness she was not making strong eye contact. Her hands were

shivering while talking, it was easily seen that she is trying to look normal but she couldn't.

Her speech was not organized as well, because she was anxious she repeated her words.

She was not telling unnecessary details, when I asked her current time and what is the weather

outside she got nervous and couldn't tell me. As her current mood was not so good she answered

every question I asked but nervously. According to her, study pressure was the cause of her

anxiety and antisocial behaviour.

Subjective rating.

Subjective rating scales are widely used in almost every aspect of ergonomics research

and practice for the assessment of workload, fatigue, usability, annoyance and comfort, and
lesser known qualities such as urgency and presence of any behavior. In subjective rating based

on any rating that a person gives that is based on their subjective reaction or opinion, their

feelings, desires, priorities. The subjective rating used to assess the client current level of

functioning and rating the client symptoms which helpful to managed the client behavior need to

be managed.

Table 2

Patient’s Symptoms and their Ratings by the Client

Symptoms Ratings (0-10)

Workload 7-10

Fear 8-10

Discomfort 7-10

Sleep difficulties 8-10

Less appetite 7-10

Case formulation

Presenting problems

These are concerns that clients find difficult to manage. In this case my client was having

difficulties in managing her fear because of anxiety.

Precipitating factor

Is refer to a specific event or trigger to the onset of the current problem. In this case the pressure

of grades acted as a precipitating factor which triggered the symptoms of anxiety in her.

Perpetuating factors

These are those that maintain the problem once its established. Fear of bad grades, interaction

with people acted as perpetuating factor.

Protective factors

These are strengths of the person to reduce the severity of problem and promote healthy and

adaptive behaviour. In this case support of her friend acted as a protective factor.

Suspected problem

According to DSM-5 (American Psychological Association, 2013) the client was suspected to be

with social anxiety.

Intervention Plan and Management

BT was applied to the client

Exposure therapy will be used with client

As she was antisocial person, In exposure therapy we started by giving her imaginal view. After

that side by side also worked on her unconscious fears, as she always felt like she is drowning in

the water or she is locked in a cupboard or in a dark room and no one is there to help her.

At start imaginal exposure of people made her afraid and she started shivering badly. But slowly

slowly she tried to control herself.

Cognitive Behavioural Therapy

Cognitive-behavioural therapy for adult anxiety disorders is very effective and widely accepted

by the most researchers. So this therapy will be used explained to the patient the mechanism of

anxiety formation and maintenance and the fact that this must be understood in terms of the

vicious circle that negative thoughts produce which, in turn, produces an anxious state that

generates negative thoughts also explained to her that the external events do not produce the

negative affective states and that these are produced by her attitude towards the external events

and that she can modify the negative emotions by changing this negative attitude.

informed the patient that psychotherapy aims to help the patient become

aware of the anxiety that represents a side of her existence which is linked to the vulnerability of

each human being and to find in herself the resources to live, to achieve her goals, and to

properly develop her latent capabilities.

 Case Report 3

Identifying data

Name initials NA

Gender Girl

Age 8

Education She is in 5 class

Marital status Single

No of sessions Two

Patient Autism

Source and Reason for Referral Referred by her teacher

Presenting Complaints

Table 1

Presenting Complaints according to the client

(0-10)Intensity Complaints
 7-10 Less of appetite

6-10 Feel unsafe

7-10 Lack of interest in environment

7-10 Lack of sleep

Behavioural Observation

Client was really nervous. She was not answering the questions as she was the patient of autism,

she was not making any eye contact.

It was difficult for her to focus on something. In second session she gave answer of a few

questions but still she was not making any eye contact at all. By engaging her in different

activities, it became possible to get answers.

Developmental History of the problem.

AL presented with a 4-year history of impairments in all aspects of the autistic triad: social

interaction, imagination, and social communication.

Personal history.

Birth Order second

Childhood AL was born five weeks pre-term weighing 4 lbs and 9 oz. She spent four weeks in

a neonatal unit to gain sufficient weight. She had a childhood developmental delay and learning

disabilities.
Educational History She is in 5 class. Her interaction with her classmates was poor. Also her

teacher noticed a lack in the drive to explore environments and ability to ‘parallel play, a

developmental concept whereby infants begin to play alongside each other.

Vocational History Student

Pre-morbid personality.

She had a premorbid personality of being introvert.

Marital history.

She is not married.

Educational history.

She is studying in a higher education school which is a private school.

Occupational history.

She is a student

History of family psychiatry/medical illness.

There was no family history of mental or physical illness.

Assessment

The assessment was carried out in different dimensions. Following is the list of

assessment techniques which were carried out with the client.

• Behavioural Observation
• Clinical Interview

• Mental Status Examination

• Subjective Ratings

• Autism rating scale

Behavioural observation.

As the client seems shy she was really nervous at beginning. She was having difficulty in

concentrating and maintaining on seat behavior. She was a kid so it was becoming difficult for

her to give answer of each question being asked. She had difficulty in maintaining attention.

Also she was a bit afraid at the beginning of the session.

Clinical interview.

To diagnose the problem of client, Clinical interview was conducted. The questioning

session started and she was allowed to give answers freely. Through this interview her autism

was clearly diagnosed. She was experiencing it from 4 years AL’s parents reported a sleep

latency problem as well.

AL had poor interpersonal relationships, driven by poor verbal and non-verbal comprehension.

Her expressive language was vague, her sentences were long enough and had the right grammar

and syntax. But the words she chose did not quite communicate her meaning so it was hard to

decoding the message

Mental status examination

 Mental state examination conducted upon hospital revealed that, Autism spectrum

disorder is a developmental neurological disorder characterized by a typical development in

social interaction in communication. It was hard to deal her, she tended to monopolise the taking,

worked hard to steer it toward one of her favourite subjects and did not appear to listening when

it was the other person’s turn to talk. He had trouble with focus and attention, she was quite

distractible.

She had two favourite subjects and didn’t really talk much about anything else.

Case formulation

Presenting problems

In this case client was having problem of focusing, she was unable to concentrate, and also she

had no interest in anything except her three favourite subjects. She was having difficulty in

maintaining thoughts.

Precipitating factor

Refer to a specific event or trigger to the onset of the current problem. In this case her problem

of distraction was precipitating factor.

Perpetuating factors

These factors are those that maintain the problem once its established. She was unable to focus

on anything as well as her disorganized thoughts maintained the problem.

Protective factors
These are strengths of the person to reduce the severity of problem and promote healthy and

adaptive behaviour. In AL's case her mother wanted her to be like a normal kid and behave like

them, to take interest in things like normal kids do.

Suspected problem

According to DSM-5 the client was suspected to be Autistic.

Proposed Intervention Plan and Management

Therapy that should applied

Occupational Therapy

Behavioural Therapy

Cognitive Therapy
Case Report 4
Identifying data

Name initials NA

Gender Male

Age 25

Education Graduate

Marital status Single

No of sessions Two

Patient Schizophrenia

Source and Reason for Referral Referred by his mother

Presenting Complaints

Table 1

Presenting Complaints according to the client

(0-10)Intensity Complaints

10-9 Hearing voices

8-10 Loss of appetite

9-10 feel unsafe

 7-10 delusions

7-10 difficulty in sleep

Behavioural Observation

Client was talking normally but it was clearly seen that he was not answering openly. He did

least eye contact, his way of sitting was not so comfy. Few times he repeated his answers and he

was a bit confused as well.

At the beginning he wasn’t comfortable but slowly slowly he started sharing his problems easily.

He shared his past experiences too.

Developmental History of the Problem

His schizophrenia began from the past 10 months. He felt unsafe in his house and thought

that people are trying to harm him. He had delusions too.

Personal history.

Birth Order first child from sibling

Childhood His childhood was normal. He got normal development his social background was

strong as well. He got good schooling.

Educational History He was good in his primary and higher education. His behaviour was not

so good with his classmates his personality was a bit aggressive.

Vocational History Job holder

Pre-morbid personality.

He had a premorbid personality of being introvert.

Marital history.

He is not married.

Educational history.

He studied in Bacon House School and was an average student his matric was done from

here

He joined Punjab College for further studies. In college his performance and grades were

average too, same as in school.

His relationship with his classmates was not so friendly he had few friends not more.

Occupational history.

He is a job holder

History of family psychiatry/medical illness.

There was no family history of mental or physical illness.

Assessment
 The assessment was carried out in different dimensions. Following is the list of

assessment techniques which were carried out with the client.

• Behavioral Observation

• Clinical Interview

• Mental Status Examination

• Subjective Ratings

Behavioral observation.

As the client was introvert he was hesitated at beginning. He was having difficulty in

concentrating and maintaining train of thoughts. His emotions were disturbed, because he

believed his symptoms were spiritual as well as he repeated the answers of few questions.

He was not showing any expression. He was afraid of his lost of control and he was avoiding the

questions too.

Clinical interview.

To diagnose the problem of my client, I conducted clinical interview. The questioning

session started and he was allowed to give answers freely. Through this interview his

schizophrenia was diagnosed. He was experiencing hallucinations and delusions. Open ended

questions were asked from him.

As he believed that his emotions were spiritual he was saying that spirits are controlling him. He

said he is fine, but his family members are trying to harm him. He was avoiding eye contact and

he was trying to avoid questions.

Mental status examination.

Mental state examination conducted upon hospital admission revealed that the patient

was emaciated and appeared informally dressed. He exhibited apprehensive behaviour, fatuous

laughter, and hesitancy. His mood was depressed and affect constricted. The patient experienced

auditory hallucinations. He complained of hearing voices and engaged in third person

conversations involving both a man and a woman. The patient also complained that he heard

people talking about him and insulting him, some of whom he knew. He was therefore

suspicious and felt uneasy.

Subjective rating.

Table 2

Patient’s Symptoms and their Ratings by the Client

Symptoms Ratings (010)

Lost of appetite 7-10

 Delusions 8-10

Discomfort 7-10

Sleep difficulties 8-10

Hallucinations 7-1

Disorganized thoughts 7-10

Case formulation

Presenting problems

In this case client was having delusions, hallucination, he was afraid of being harmed, his

thoughts were disorganized and he was having sleeping difficulty.

Precipitating factor

Are refer to a specific event or trigger to the onset of the current problem. In this case job

pressure and separation from her finance trigger him.

Perpetuating factors

Are those that maintain the problem once its established. Constant fear that his family will harm

him as well as delusions and hallucinations maintained his problem.

Protective factors
Those are strengths of the person to reduce the severity of problem and promote healthy and

adaptive behaviour. In this case the client himself wanted not to became severe schizophrenic

patient and his family helped him as well.

Suspected problem

According to DSM-5 the client was suspected to be Schizophrenic

Intervention Plan and Management

The client had not taken prescription medications in the past six months prior to being seen

at the hospital since he had not been diagnosed with any mental illness previously. He had no

known allergies, and he did not smoke or use recreational drugs. The patient demonstrated

suspected adherence concerns since he had poor insight and repeated several times that there was

nothing wrong with him.

Therapy that will apply

Medication

Occupational Therapy

Behavioural therapy