File No: A 798688 Date 22nd October 2013

Seen the patient referred to me by Dr. Frank for brief relaxation exercise and assessment.
Together we go through relaxation exercise to help her come down from state of being anxious.
After that we agree to have assessment on 23.10.2013 at 2:30pm.

23.10.2013

ID: ZG, 22 years, female, married with no child, university student, Muslim, first time to attend in
psychiatry, living with his husband in Tabata

CC: “I was to come in hospital for sleeping problem, now I was brought for the problem of being
anxious”.

PI: She reported her condition of being anxious started when she was in form IV to V. With that
condition she experience changes such as headache, and pain on her hair roots. However she
reported since her childhood she was anxious but not that much as now. Currently she is afraid
of going to hospital, being injected, and standing in front of people. She reported to have bad
thoughts when she heard people talking about their problem. She will be disturbed as if she is
the one having those problems. Asked what she experienced in her body when she is anxious,
she reported her heart beat fast, sweating, nausea a lot of days, stomach ache, dizziness, and
sometime having difficulties in breathing and trembling. She added that she felt her legs to be
lighter like piece of paper (numbness). However she said eating apples has helped to decrease
her sweating. Emotionally she reported to experience intense fear, worry, anger, and sadness.
Moreover most of time she is having thought of losing control, fear of dying, and ask herself if
she is sick or not. What she does to cope with that situation, she reported not to go to hospital,
avoid areas with a lot of voices, crowd such as parties. She added that the day before yesterday
she was forced to go for communion party; she felt intense fear, headache, and leave early. She
is afraid to travel and last time to travel was in 2007 where she travelled to Arusha. She swear
not to travel by a car may be a train. She also reported to hate news bulletin. She reported
before coming to hospital she had difficulties in sleeping where she stayed awake for long time
with the reason of having a lot of thoughts during the night.

She is current on medication which helped her to sleep well. She eat small amount of food, and
has decreased energy and sexual desire for some time. She is not cooking, cleaning her house,
not washing dishes or clothes since July 2012. She likes fashion, still enjoying but not that much.
She exercises by playing music alone at her room but nowadays she did not do that. She
reported to have thoughts to harm herself on March 2013; she was in pain not being in college
and thought to insert a knife on her body. She reported to hear a door opened and closed and
step like a person is walking without seen anyone in 2011. She suspected that some students
are following her life since she has stopped going to college. She reported some colleagues
suspect she is pregnant and other thought she has an abortion.

PH: It is her first episode

MH: Do not want to hear about blood pressure. She reported to have ulcers hence she do not use
pepper or lemon. Last month she checked her blood level, and result shows it was okay.
1
SH: She denies using any substance

FH: She is the 3rd born among 6 children. Her father is accountant, mother business woman and
house wife. 1st born is a male, single, studied at Sudan University. 2nd born is female, married
with 2 children, form III leaver, leaves with her husband and children in Dar. 4th born is a male,
form V in Azania secondary school. 5th born is a female, student form II at Loyola secondary
school. 6th born is a female, student standard IV. She related well with the 1st born. She denies
history of mental illness within a family.

PH: She was normally delivered at Aghakhan hospital. Her mother reported she is an introvert
person. On her 6 year of age she experience condition as asthma, chest problem, and not eating
well. She was admitted for 1 week at Aghankhan. They found that her chest problem was due to
be allergic to kerosene. In 2001 family shifted to Sinza where there was no kerosene around like
in the former house hence the condition of asthma disappeared. Her father was very strict not
letting her and siblings to play outside. She was worried person since her father was threatening
them. She started her primary education when she was 7 years of age at Bunge primary school
and completed standard VII. She joined form one at Alpha secondary school in 2002. School was
not registered hence she shifted to Perfect secondary school in 2003 repeat form one. She
reported the school was not good hence shifted to Green Acress in 2004 form II. She reported at
that school they beat students a lot hence shifter to Sinza tower in form IV. She passed and
joins St. Mary for form V education. She reported to be lonely and weak. She finished form six
and join Tumaini University in Dar for bachelor in Mass communication year I to II. She attains
her puberty when she was in standard VII. She had her first boyfriend in college who she
decided to leave him since she was older than him. She met her husband on the facebook,
though he also told her he knew her before. They get married on June 2013. He is a flight
operator at airport.

MSE:
Appearance Well kept Perception Uneventful
Behaviour Anxiousness Insight & judgment Fair
Cooperation Cooperative Cognitive functioning Good
Speech Slow rate, clear Orientation Time, place, people
Thoughts (C & P) Fear oriented Memory Intact
Affect Anxious Attention & concentration Good
Mood Anxious Reading and writing Good

DX: [DSM IV TR] Anxiety Disorders

Provision Panic Disorder with Agoraphobia
Differential Generalised Anxiety

31.10.2013

FM: Together with the patient we use CBT formulation model to have a shared understanding of her
illness.

2
 Situation
When I was at home, with my mother in law, in June 2013 I received the news my sister has
died and she was sick

Thoughts & Images

I will die in that way too; she was taken to hospital still she died

Body / Physical Sensation Moods / Emotions

Trembling, headache, sweating, Sadness (100%)
heart beat fats, difficulty in Fear (90%)
breathing, feeling hot

Behaviour
Reading religious books, avoiding going to hospital, staying alone,

After developing a shared understanding I provide psycho education and insight orientation for
panic attack and agoraphobia. After that we agreed to have six sessions of CBT to start with for
panic disorder with agoraphobia including this one. Agreed on the first assignment, thought
record I after providing rationale for CBT.TCA 14.11.2013

14.11.2013
Seen the patient. She reported to feel better, she can now stay home alone, and she was able to
start doing small works like cleaning their house, washing clothes, cooking and other house
chores. On the other hand she reported to experience stress due to marriage problem. During
the night she took the phone of her husband and passing various messages. He saw
conversation between her husband and woman in neighbourhood. She was unable to sleep. She
called her mother in-law who promises her to talk about that in the morning. Asking husband he
denies having affair and told her she consulted that woman for getting contact of the person
who will come to repair their toilet. She coped by keeping herself busy, crying to help her come
down from anger which she was experiencing. In the morning mother in law discuss with her
and her son apologise though he did not admit. She believes God will take good care of her from
anything.

1. Skill deficit – problem solving skills 4.

2. Going back to college 5.
3. Marriage challenges /stressors 6.
Long Term Goal: recover from anxiety disorder – panic with agoraphobia

3
 Date Review of Previous Goal(s) / Plan Assignment
(Session) Session & Progress Objective(s) / Agreement
14.11.2013 Report to feel better, Share CBT Pass through Thought
2nd session start to perform home formulation on formulation record II
among 6 cores, and can stay the thoughts, Identify area to dealing
sessions home alone emotions, with her condition
Current stressor couple avoidance & (cognition) “I am going
relation Proceed with other safety to die”
treatment CBT session II behaviours

21.11.2013 Report to experience Developed Together we analyse Thought III

attack on her way to shared her situation; Thoughts
hospital after seen her understanding “he might think I am
primary school mate using panic crazy by being here; I
formulation thought I will die”.
Emotion she was very
anxious 80% worry
90%. Behaviour avoid
eyes contact, want to
run, and she cry

Continue with Review relaxation

CBT session on techniques and
coping with panic breathing exercised
Introducing distraction
where she has to focus
on what is going on
outside rather than
what is going inside her
body

Cognitive restructuring
thought record II

*After therapy she was

able to face him and
even ask for the phone
number without being
told to do so
28.11.2013 Reported to feel more Changing We pass through Symptoms
better, no panic attack negative thinking thought record III on checklist for
was reported for the habits the main thought capturing
past one week Able to develop misinterpretat
alternative balance ion
thought “with that

4
 thought I am still alive
though we all face
death in our life but no
one knows when”
12.12.2013 Reported she is doing Continue with Dealing with Agreed to
fine, no panic attack, changing misinterpretation from welcome her
but a lot of stress negative thinking her assignment husband on
coming out of marriage. the next
session
18.12.2013 Seen the patient Assessing role From assessment we Continue with
together with the confusion, discover they have CBT session
husband interpersonal unresolved arguments, for the patient
disputes and misunderstanding,
deficits unreasonable
expectation and
communication
problems. Plan to have
couple therapy in the
future
23.01.2013