CLINICAL INTERNSHIP REPORT

AT

THE HEALTH CARE REHABLITATION CENTER

MULTAN

Muhammad Usama Jamshaid

BS-19-50
BS Applied Psychology

Session 2019- 2022

DEPARTMENT OF APPLIED PSYCHOLOGY

BAHAUDDIN ZAKARIYA UNIVERSITY MULTAN

 CLINICAL INTERNSHIP REPORT

AT

THE HEALTH CARE REHABLITATION CENTER

ALI GENERAL HOSPITAL, MULTAN

Muhammad Usama Jamshaid

BS-19-50

BS Applied Psychology

APPROVED BY

Supervisor
 Acknowledgment
First and foremost, I am grateful to Allah Almighty that He has provided me with this
opportunity to seek knowledge and the potential to materialize my endeavors. Without His will, I
would not have been able to accomplish my goals and make the best use of His blessings. Then I
would like to thank Our Prophet Hazrat Muhammad ‫ صلى هللا عليه وسلم‬who was a beacon of light,
knowledge and guidance for us all.

I feel obliged to my supervisor Dr. Irum Batool for galvanizing me and enabling me to permit
my best efforts. Her exemplary counsel capacitated and facilitated me in my task. I am also
thankful to my family for the unconditional support and faith in me.

Muhammad Usama Jamshaid

Dedicated to All the hardworking self-empowered students who are trying their best to

make a difference in this world.

And My teachers; without whose efforts I would not be here.

INTRODUCTION TO HOSPITAL
CASE:01

Aggression
Identifying Information:

Name: D.J

Age: 15

Gender: Male

Education: Middle Occupation Student

Marital status: Single

Residence: Mumtazabad

City: Multan

Source of referral:
Client is referred by the family.

Presenting complaints:

‫لوگ بات نہیں سمجھتے۔‬

‫جب کوئ میری بات نہیں سنتا تو مجھے بہت غصہ آتا ہے۔ یہ بس اپنی منواتے ہیں‬

،‫میری نہیں سنتے۔‬

‫پھر مجھے بہت برا لگتا ہے اور دل کرتا ہے کچھ کر دوں۔‬

Family history:
The parents of my client are deceased. His mother passed away when he was 7 years old and his
father passed away when he was 11 years old. They are 6 siblings and my client’s birth order is
5. My client had a very close relationship with his father. He isn’t close to his siblings. The
family system is nuclear and the eldest sisters are authoritative figures of family. The home
atmosphere in childhood was upsetting as there were constant arguments and fights but now the
atmosphere is comparatively much better.
Past psychiatrist history:
Nil

Medical history:
Nil

Personal history:
My client was born through normal delivery. The health of client and mother was better. He is
currently a student of 9th class and is academically doing well. He is not a fan of school but his
attitude towards teachers is good. He wants to be an army officer or doctor. He was really close
with his father and after the death of his father, he has developed aggression issues and he
doesn’t get attached to anyone else. He had childhood habits of bed wetting and nail biting. He
experienced loneliness as a child. He had no fears in childhood but he received a shock; death of
his parents. He is not much religious. He sleeps well and doesn’t dream often.

Premorbid and Postmorbid personality:

My client was a normal kid before the onset of problem. Now the client is very aggressive and
has habits of shouting in case of even minor inconveniences. He has also tried to light important
documents on fire. He stays secluded in events and tries to avoid them altogether. Doesn’t make
much friends and doesn’t turn to anyone for emotional support or even to share the problems.

PSYCHOLOGICAL ASSESSMENT
1. Informal assessment

2. Formal assessment

Informal assessment:
 Behavioural observation
 Mental status
 Rating scale

Behavioural observation:
He was very awkward and hesitant in opening up. Didn’t talk openly and avoided eye contact.
He was constantly shaking his leg and tearing off a rubber. His behavior was rather guarded.

Mental Status Examination (MSE):

Motor behaviour: normal
Mood: flat

Speech: hesitant

Attitude: awkward

Thoughts: paranoid

Obsession/compulsions: leg shaking

Delusions and Hallucinations: none

Appetite: normal

Orientation (time, place): intact

Memory: intact

Attention and concentration: adequate

General appearance:

He was decent and well-mannered. He was well dressed.

Formal Assessment:
1. Buss and perry aggression questionnaire. Client scored 18 for aggression and 23 for hostility
which is above the normal range. The rest scores were normal.

2. On DASS-21 scale, the client scored 14 for stress (normal), 4 for anxiety (normal) and 16 for
depression (moderate).

Diagnosis:
Depression with hostile attitude/aggression. This diagnosis was affirmed by applying appropriate
scales. The trauma that my client faced in his childhood is a clear indicator for his depression.
CASE:02
ANXIETY
Identifying Information:
Name: Muneer

Age: 38

Gender: Male

Education: Primary Occupation Barber

Marital status: Married

Residence: Dolat gate

City: Multan

Source of referral:
Client is self-referred.

Presenting complaints:

‫بہن کی یاد آتی ہے۔‬

‫ماں کا نہیں پتہ۔ ماں کی جگہ صرف بہن کا ہی پتہ ہے۔‬

‫بہت پریشان ہو جاتا ہوں۔ بہن کا سوچ کر دل بھر آتا ہے‬

‫اور آنکھیں نم ہو جاتی ہیں۔‬

Family history:
My client’s mother is alive but father passed away when he was 11 years old. His eldest sister
also passed away a year ago. Currently he is married and has 5 kids; 2 daughters and 3 sons. One
daughter is married and the other children are studying. All kids are Hafiz-e-Quran. The family
is joint and he is the authoritative figure of his family. The home atmosphere is good.

Past psychiatrist history:

Nil

Medical history:
My client has had a recurring problem of hernia. He has had 7-8 surgeries for it.

Personal history:
My client was born through normal delivery. The health of client and mother was better. He has
completed education till primary. Due to the death of his father, he had to provide for his family
at such a young age, and thus had to quit studying. His eldest sister was really supportive in this
regard and had helped client manage the responsibilities of family. He was really close to his
sister and after losing her, he feels her absence. He is married and has 5 kids. His relationship
with his spouse is cooperative and understanding.

Premorbid and Postmorbid personality:

My client was friendly and extroverted. He is trying to maintain a positive attitude towards life.
But he misses his sister who passed away a year before. He still talks about her sister and gets
teary-eyed. It is difficult for my client to make decisions on his own now because he was
habitual of taking his sister’s advice. He often doubts his decisions too whether what he is doing
is right nor not.

PSYCHOLOGICAL ASSESSMENT
1. Informal assessment

2. Formal assessment

Informal assessment:
 Behavioural observation
 Mental status
 Rating scale.

Behavioural observation:
He remained cooperative throughout the sessions. He was well dressed. He got emotional while
talking about his elder sister and cried.

Mental Status Examination (MSE):

Motor behaviour: normal

Mood: normal

Speech: coherent

Attitude: Normal

Thoughts: Religious

Obsession/compulsions: none

Delusions and Hallucinations: none

Appetite: normal

Orientation (time, place): intact

Memory: intact

Attention and concentration: Good

Insight: adequate

General appearance:

He was decent and well-mannered. He was nervous and it could be seen through the movement
of his hands.

Formal Assessment:
• On DASS-21, he scored 10 for stress (normal), 18 for anxiety (severe), and 10 for depression
(moderate).

• On BAI my client scored 26.

Diagnosis:
My client has severe anxiety and a moderate level of depression which was confirmed by
applying DASS-21 and BAI. The fidget and nervous behavior could be clearly seen and it further
assures the diagnosis.
 CASE:03
OBSESSIVE COMPULSIVE DISORDER
Identifying Information:
Name: Majida

Gender: Female

Age: 32 Years

Religion: Islam

Marital Status: Married

Education: F.A

Occupation House Wife

Residence: Bhakkar

City: Multan

Source of referral:
Friend and patient herself.
PRESENTING COMPLAINTS:

‫بار بار ایک ایک چیز کو صاف کرتی ہوں۔ منہ ہاتھ دھوتی رہتی ہوں۔‬

‫ذہن میں ہر وقت پریشانی اور وسوسے آتے رہتے ہیں۔‬

‫چھوٹی چھوٹی باتوں پر پریشان ہو جاتی ہوں۔‬

HISTORY OF PRESENT ILLNESS:

She was facing some Psychiatry problem since last 11 years. This problem was started when her
husband beat her. Her husband beat her on her head and pushed her toward in the fire. At this
time, the 8 years of her marriage was passed. After beating her husband the problem get raised.
She was spitting again and again if do not spitting then she had pain in her head. She was lining
on earth even her nail were injured her, washing hand and mouth all the day.

PAST PSYCHIATRIC HISTORY:

Patient has face these severe problem four times in 3 years she admitted in AlRahma, Hospital
for 3 days but cant recover, she visited our facility for about one week. She used medicine but as
she stopped taking the symptoms started again. She was admitted in hospital again due to
recurrence of her symptoms.

FAMILY HISTORY:
Her father died at age of 70, when she was 10 years old, His name was Allah Ditta. His
relationship was good with his family. Patient’s mother name is Zeno, she was also very lovely
with her children. She has 1 brother and 2 sisters. Her home environment is not so good because
her brother is not caring of her mother and sisters. Her younger sister took divorce of her
husband. Patient belongs to a poor family. No major mental and physical illness is present in the
family members.

PERSONAL HISTORY:
Her birth was normal. Her parents welcomed her warmly. Her infancy period was healthy and
childhood was also healthy, she used to play all the time with her friends. Menstruation cycle
was started in the age of fourteen years old. She didn’t want to study and go to school she was
very naughty girl. She has bad feelings about boys and didn’t fall in love with any boy.

PRE-MORBID PERSONALITY:
She has been a socially active girl. She also used to play Gulli Danda with her village fellows.
She used to practice fasts and offers prayers but off and on. The patient used to take care of her
personal hygiene. She also used to respect her parents and was not aggressive towards them and
was also very lovely and caring toward her children.

PSYCHOLOGICAL ASSESSMENT
1. Informal assessment

2. Formal assessment

Informal assessment:
 Behavioural observation
 Mental status
 Rating scale

Behavioral Observation:
The client was very thin middle aged female. She was very cooperative and given all
information boldly. She has also good eye contact.

Mental Status Examination (MSE):

General Appearance: not proper well dress

Mood: normal

Speech: fast and fluently

Attitude: Normal

Thoughts: Religious

Obsession/compulsions: none

Delusions and Hallucinations: Suicidal thougths

Appetite: normal

Orientation (time, place): intact

Memory: intact

Attention and concentration: Good

Insight: quite good

FORMAL ASSESSMENT:
Client's raw score is 27 that is above the cut off score of BDI which is 10. This indicates that she
has moderate depression, the qualitative analysis of her raw score shows her low mood,
hopelessness, anger and fits which significantly interferes with our daily life.

Patient's raw score is 35 that is above the cut off score 16 hence the patient has extreme OCD.
The score indicates her depression, excessive nail filing and excessive cleaning. These symptoms
thus interfere with his daily life activities.

DIAGNOSIS:
She along with mild to severe depression OCD.

CASE:04
 Substance Abuse Disorder

Identifying Information:
Name: Sohail

Gender: Male

Age: 50 Years

Religion: Islam

Marital Status: Divorced

Education: Graduate

Occupation Factory operator

Residence: Multan

City: Multan

Source of referral:
Client was referred by his brother.

Presenting complaints:
‫میں ہیرویئن کا عادی ہوں۔ میں نے اپنی جوانی میں دوستوں‬

‫کے ساتھ شروع کی تھی کیونکہ اسے تب فیشن سمجھا جاتا تھا۔‬

Family history:
My client’s parents have passed away. He belongs to a wealthy family. His father owned a lot of
land and property that he inherited. He has 5 siblings and his birth order is 1. He had an
understanding and supportive relationship with his parents. He is divorced and he lives his
brother. His brother is also well educated and well settled. My client is really close with his
brother. The home atmosphere as a child was really good and it is also good now.

Past psychiatrist history:

Admitted to rehabilitation center 6 times.

Medical history:
My client has suffered weight loss due to his addiction problem.

Personal history:
My client was born via normal delivery. The health of mother and child was well and there were
no complications afterwards. As a child, my client was really jolly and had lots of friends from
all social groups. He had a habit of walking on his knees instead of his feet in childhood. He
loves to play cricket. He had good grades as a student and had positive attitude towards school
too. He was liked by teachers too. He has done graduation along with other diplomas. He is
currently working as an operator in a factory because he likes to work with diligent and
hardworking people. My client was married for a short period of time, he has no kids and he still
considers himself unmarried even though he is divorced. The reason of his divorce was that he
didn’t want to take responsibility of someone else and ruin their life when according to him he
can’t even take his own responsibility.

Premorbid personality:
My client was very social and active but now due to his addiction problem, he remains secluded.

PSYCHOLOGICAL ASSESSMENT
1. Informal assessment
2. Formal assessment

Informal assessment:
 Behavioural observation
 Mental status
 Rating scale.

Behavioural observation:
He remained cooperative throughout the sessions. He was well dressed.

Mental Status Examination (MSE):

Motor behaviour: normal

Mood: normal

Speech: coherent

Attitude: Normal

Thoughts: normal

Obsession/compulsions: none

Delusions and Hallucinations: none

Appetite: normal

Orientation (time, place): intact

Memory: intact

Attention and concentration: Good

Insight: adequate

General appearance:

He was decent and well-mannered. His mood was appropriate. Her attitude was open &
cooperative.

Formal Assessment:
On DAST, he scored 14.

Diagnosis:
My client has substance abuse problem.

CASE:05

Clinical Depression
Identifying Information:
Name: Fatima

Gender: Female

Age: 21 Years

Religion: Islam

Marital Status: Single

Education: Graduated

Occupation: Student

Residence: Mumtazabad

City: Multan

Source of referral:
Client is referred by self.

Presenting complaints:
‫سر میں درد رہتا ہے ہر وقت پریشان رہتی ہوں۔‬

I feel meaning less and useless. I feel like I'm wasting my life
Family history:
My client’s mother has passed away. She has a good relation with her father. They are 3 siblings
and her birth order is 3. Her relationship with her siblings is not close. The home environment as
a child was very good and the home atmosphere now is also good.

Past psychiatrist history:

Nil

Medical history:
My client is diabetic.

Personal history:
My client was born through C-section. The health of client and mother was better. She used to
sleep with her grandma in her childhood. As a kid, she was quiet and got irritated by loud noises.
She also didn’t experience happiness as other kids. She was scared of the dark. The death of her
grandmother was a huge shock for her in her childhood. As a student, she has good grades and
she liked to attend school and was adored by teachers too. She is religious. She experiences
sadness and depression sometimes during morning and sometimes during evening.

Premorbid and Postmorbid personality:

My client was a jolly and lively person before the onset of her problem but now she feels
detached from her previous self and feels sad for most of the time. She also questions her self-
worth and she is exhausted all the time.

PSYCHOLOGICAL ASSESSMENT
1. Informal assessment

2. Formal assessment

Informal assessment:
 Behavioural observation
 Mental status
 Rating scale
Behavioural observation:
She was avoiding eye contact while answering my questions.

Mental Status Examination (MSE):

Motor behaviour: normal

Mood: normal

Speech: coherent

Attitude: Normal

Thoughts: normal

Obsession/compulsions: none

Delusions and Hallucinations: none

Appetite: normal

Orientation (time, place): intact

Memory: intact

Attention and concentration: Good

Insight: Fair

General appearance:

My client was well dressed. Her way of talking reflected that she belongs to a well-educated
family.

Formal Assessment:
On BDI, my client scored 42.

Diagnosis:
My client has major depressive disorder. Her personal history gives strong indicators of
depression. Furthermore, the BDI score confirms this.