PSYCHOLOGICAL ASSESSMENT REPORT

Name: Ms. Kafia Nasreen

Father’s Name: Mr. Muhammad Akbar
Date of Birth: 17th February 2000
Assessment Dates: 15th March 2022- 20th April 2022
Assessed By: Arooba Sania
Case No: 03
IDENTIFYING INFORMATION

Ms. Kafia is a 21 years old female. Her education is Fsc pre-engineering, currently she is
doing BBA. She has 2 brothers. She belongs to low middle socioeconomic status and Urdu-
speaking Muslim family. Her father has a private job and her mother is house a wife.

REFERRAL SOURCE AND PRESENTING COMPLAINTS

Client was not referred by any source she approached for therapy by herself. Her
presenting complaints as reported by her include fear and anxiety of speaking in front of people
and performing in front of others and being observed by others along with that she has a fear of
being negatively evaluated and possible scrutiny by others, such social situations provoke fear
and anxiety in client and cause heavy breathing and increased heart rate along with other anxiety
symptoms.

INTERVIEW INFORMATION

According to client, she always had fear of being observed and speaking publically as she
always avoided it, but this problem gradually increased when she got herself into university
where it was mandatory to give presentations in every semester. Client’s birth was normal and
did not had any developmental delay, her physical health was good since childhood and she was
loved by her family in her lifetime.

As for schooling client state that she was a good student but she was shy to speak in front
of everyone and never participated in anything in which she had to go on stage and make herself
prominent. She had a fair number of friends in school and she enjoyed her school life.

In adolescence when she started going to college, she had the same issue and she never
availed any apportunity which associated with speaking in front of class or a crowd.
 In early adulthood when she went to university she was not able to avoid speaking in
front of everyone anymore, as she had to give presentations in front of class every semester, this
is when she started having increased symptoms of social phobia, whenever she have to give a
presentation, her heartbeat and breathing get faster and she gets extremely nervous when she has
to present in-front of everyone. This issue affects her ability to deliver the content she had
prepared which eventually affect her evaluation and sessional scores. After repeated attempts of
trying she eventually decided not to give presentations and now she lose her marks every
semester due to social phobia.

BEHAVIOR DURING TESTING SESSIONS

Client appeared relaxed and corporative during the testing sessions. She was eager to
know about the test results. She enjoyed doing HFD and RISB, she took quite enough time
during HFD and drew the figure very slowly and carefully. The length of TAT made her feel
exhausted and irritated in the end. She carefully marked all the answers on SPM sheet after some
brainstorming on each of the questions.

TEST ADMINISTERED

Solloson Drawing Coordination Test (SDCT)

Standard Progressive Matrices (SPM)
Human Figure Drawing (HFD)
Thematic Apperception Test (TAT)
Rotter’s Incomplete Sentence Blank (RISB)
Social Phobia Inventory (SPIN)
PSYCHOLOGICAL EVALUATION

Solloson drawing coordination test (SDCT), a neuropsychological screening test indicates

that Ms. Kafia’s eye-hand coordination is intact.

Standard Progressive Matrices (SPM), a test of abstract reasoning (it is one aspect of
intelligence) which indicates that Ms. Kafia’s intellectual capacities fall within above average
range.

Human Figure Drawing Test (HFD), a projective test, indicates that the Ms. Kafia has
difficulty in reaching out toward people as indicated by short arms in client figure. She also has
difficulty making contact with people as indicated by big hands in clients figure. In addition a
Projective test Thematic Apperception Test (TAT) indicated that client has poor self-concept.
Client’s significant needs are passivity, sentience, approval, and elation. Client’s significant
presses are lack(confidence) and dissatisfaction from physical surrounding. To deals with
conflicts she used defense mechanisms of isolation and splitting. Client stories indicate lack of
self-confidence and scrutinizing environment. Projective analysis of test Rotter’s Incomplete
Sentence Blank (RISB) further reveals that test Ms. Kafia is not well adjusted in her environment
she scored 138 which was above the cutoff score. Most of the statements indicated school
difficulties and anxiousness and fear of scrutiny from others.

The scores on the Social phobia inventory (SPIN) indicated severe level social phobia.
Overall analysis reveals that client has social anxiety disorder. The retesting of SPIN indicated
that client scores moved from severe to moderate.

TENTATIVE DIAGNOSIS

300.23(F40.10): Social Anxiety Disorder (Social Phobia) performance only.

PROGNOSIS:

Chances of recovery are maximum due to high motivation and enthusiasm of client along
with good insight of the problem.

CASE FORMULATION

Predisposing factors: there are no predisposing factors, Ms. Kafia has anxious personality and
her mother also has anxiety issues.

Precipitating factors: moving to a new city for higher studies and she was bound to give
presentations in university which triggered high anxiety in client.

Perpetuating factors: failure to perform and give successful presentations every time, and lack
of support from teachers and classmates.

CONCLUSION

Ms. Kafia is a 21 years old female studying BBA 8th semester. She has good relations
with her family and has a healthy childhood. Her issues include fear and anxiety of speaking in
front of people and performing in front of others and being observed by others along with that
she has a fear of being negatively evaluated and possible scrutiny by others. Tests administered
are SDCT, HFD, SPM, TAT, RISB and SPIN. Test results indicate high level social anxiety.
Overall analysis reveals that client has social anxiety disorder performance only. Her changes of
recovery are good due to high motivation and good insight of problem.
RECOMMENDATION:

 Psycho-education of client and awareness about the tentative diagnosis and treatment
plans to be applied.
 Deep-breathing and muscle relaxation exercise to help client calm her nerves.
 Replacement of negative thoughts with positive ones through consistent practice and
thought keeping journal or by replacing negative statements like “what if I forget the
content” that create self-doubt from positive ones like “what if I am great at this”.
 Imagination of worst case scenario so that when client will know that the outcome is not
that bad it will help her calm her nerves.
 Rather than a 30-minute presentation, client was taught to think of it in five-minute
chunks. When you’re on stage, just focus on getting through each five-minute part, and
before you know it, the presentation will be done.
 Practice of correct body language for public speaking that induce confidence like
hunching shoulders and open up chest etc.
 Exercising regularly as it boost endorphins and promote good mood and confidence.

NOTE: This report is only for clinical and therapeutic purpose

Supervisor Examiner
Case No 01 Client’s Name Ms. Kafia Nasreen Age 21 Gender Female

Symptoms Fear of public speaking, anxiety and fear of embarrassment and scrutiny from others.

Diagnosis 300.23(F40.10): Social Anxiety Disorder (Social Phobia) performance only

Target Symptoms  Anxiousness about public performance

 Fear of negative evaluation
Treatment approach  Cognitive Behavioral therapy

Frequency of sessions 2 per week Proposed number of 15-20

required sessions to achieve goals

Major  Reduce social anxiety of client, induce performance confidence

Treatment Goals  Replacement of negative thoughts with positive ones

 Reduce fear of scrutiny from others

Number Expected Time

Interim Treatment To achieve

Goals for target 1. Establish working relationship with the client. 2

Symptoms 2. Rapport building with client 2

3. Performing initial testing on client 2

4. Discussing the test results and possible diagnosis 1

5. Deciding treatment goals with mutual consent. Teaching 2

initial deep breathing and muscle relaxation exercises and
giving homework assignment of performing these exercises
daily

6. Practice of replacing negative thoughts before inclusion in a 2

social setting or giving presentation.

7. Imagination of worst case scenario through systematic 1

desensitization technique.
 8. Helping practice in front of imaginary audience. And 1
practice of correcting posture for public speaking.

9. Visualization of positive outcomes before participation in 1

public speaking. And dividing presentation content in 5
minutes chunks.

 Establishment of working relationship

Initial Phase  Rapport building

 Initial testing

 Goal setting
Middle Phase  Muscle relaxation and deep breathing exercises

 Cognitive behavioral therapy and fulfillment of decided goals through

replacement of negative thoughts with positive ones through consistent
practice and thought keeping journal or by replacing negative
statements and by resurfacing past successes.

 Practice of correcting body language for public speaking that induce

confidence like hunching shoulders and open up chest etc

 Continuous monitoring of chunk presentation technique and practicing

the visualization of positive outcomes through frequent trials

Evaluation of the progress of therapeutic work and success of overall

treatment to a moderate extent.
Termination Phase

Therapist name: Date: ______________________

____________________________

Approved by _____________________________