1

INTERNSHIP REPORT

Submitted by

ARIBA SADIA

FA19-BPY-019

DEPARTMENT OF HUMANITIES

COMSATS UNIVERSITY,

ISLAMABAD CAMPUS
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Place of Internship

Mega Medical Complex Islamabad

Duration of Internship

12th August to 23rd September, 2022

Supervisor at Internship

Ms. Mahnoor Khan

Clinical Psychologist and Psychotherapist

Supervisor at Department of Humanities

Ma’am Samreen Idress

Professor and CWC In charge

Signature
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Abstract

In my course of the internship, I chose the Mega Medical Complex Hospital which located in

Saddar, Rawalpindi. I started my internship in the second week of August. My supervisor was a

Clinical Psychologist, and her name was Ms. Mahnoor khan. It is basically a hospital with multiple

departments, psychology being one named as the “Healing Hands”: where Ms Mahnoor practiced as

a clinical Psychologist. Five days a week we would initially attend the lecture and then were allowed

to visit the IPDs to visit the patients and provide them supportive psychotherapy. This practice was

aside of the regular lectures and one on one psychological sessions with patients as this was solely

for the other patients in IPDs that were not there for psychological but other fatal health related

issues. Other than after the initial lectures we were allowed to sit with the Clinical Psychologist

during her sessions with the clients.

I opted for Mega Medical Complex because the environment at the hospital was very friendly

and secure. I had least knowledge of clinical setting beforehand, but this gave me so much more

information than I anticipated, and my experience was phenomenal. Although it is not easy to work

and deal with psychotic patients, our supervisor Ms. Mahnoor was very facilitating and cooperative

in this manner. She gave us classes for detailed history taking, and mental state examination before

on-hand experience. Then she also demonstrated to us how detailed case history taking is done, and

how we need to address the basic concepts in history taking and the role of environment and family

in psychological cases.

During the start of my internship, it was difficult to get proper history from patients because

some of them give a fake response and it was difficult to assess which is the true story. Slowly and

gradually with time we learned and started to identify the fake behavior. In addition to that, we got to

know some of them were already prepared for the questions so they would give preferable answers,

which will make them good in front of us.

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Overall, my experience at the centre was very rich, informative, and pleasant. This

experience was eye-opening for me, I learned so many things about how parenting styles, family

negligence, bad company, and peer pressure, lead to such catastrophic conditions and how we can

provide them with a ray of hope to regain their normal lifestyle.

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Case 1

Mixed Anxiety and Depressive Disorder. 309.28 (F43. 23)

ARIBA SADIA

FA19-BPY-019ISB

DEPARTMENT OF HUMANITIES

COMSATS UNIVERISTY ISLAMABAD

MA’AM SAMREEN IDRESS

NOV 7, 2022
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Case Summary

The client M.R was 36-year-old female having average height. She had done Inter and

belonged to an upper-middle-class family. She was reported to the Clinical psychologist with

complaints of low mood, restlessness, insomnia, lack of concentration, somatic complaints, anger

issues, Breathlessness, heart sinking, etc. The client came by herself for her treatment. The client was

referred to the trainee clinical psychologist for psychological assessment, interventions, and

management. Clinical interviewing, behavioural observation, and Mini Mental Status Examination

(MMSE) were used for informal assessment. The formal assessment was done by using the

Diagnostic Statistical Manual DSM-5 and some other projective and non-projective techniques.

Measures of her low moods, restlessness, insomnia, lack of concentration, and somatic complaints

were found under BDI (Beck's Depression Inventory), BAI (Beck Anxiety Inventory) and HFD

(Human Figure Drawing). Based on assessment, the client presented symptoms and behaviour

consistent with the DSM-5 diagnosis of Mixed Anxiety and depression Disorder. CBT-based

treatment was included in the psychologist’s treatment plan, including psycho-education, relaxation

techniques, cognitive restructuring, learning coping skills, and REBT. The client and her family were

educated about the follow-up sessions and positive feedback was obtained from the client and

family. The client has completed 6 sessions up till now and sessions went very smoothly due to her

co-operation.
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Demographics

Name: M.R

Age: 36yr

Gender: Female

Qualification F.A

Occupation: Housewife

Husband's Occupation: Businessman

No. of siblings: 7

Birth order: first born

Marital Status: Married for 15 years

Children: 2 daughters and 1 son

Socioeconomic Status: Upper Middle-Class

Religion: Islam

Informant: Client came herself

Reasons and Source of Referral

The client came herself to Mega medical complex and was referred to a clinical psychologist

for the assessment and management of low mood, restlessness, insomnia, lack of concentration,

somatic complaints, anger issues, shortness of breaths, increase heart rate, et

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Presenting complaints

The client was 36yr old female with average height and low weight. She was dressed up

properly, and a client presented complaints the low mood, restlessness, insomnia, lack of

concentration, somatic complaints, anger issues, Breathlessness, heart sinking, etc.

Table 1

Symptoms and their duration

Duration Symptoms

‫ﭼﮭ ﻣﺎه ﺳﮯ۔‬ ‫ﺑﮩﺖ ﻏﺼہ آﺗﺎ ﮨﮯ۔‬

= ‫ﻧﯿﻨﺪ ﻧﮩﯿﮟ آﺗﯽ۔‬

= ‫روﻧﮯ ﮐﺎ دل ﮐﺮﺗﺎ ﮨﮯ۔‬

= ‫اﯾﺴﺎ ﻟﮕﺘﺎ ﮨﮯ ﮐہ ﺳﺐ ﺧﺘﻢ ﮨﻮ ﮔﯿﺎ ﮨﮯ۔‬

= ‫دل ﺑﻨﺪ ﮨﻮﻧﮯ ﻟﮕﺘﺎ ﮨﮯ۔‬

‫اﯾﮏ ﺳﺎل ﺳﮯ۔‬ ‫ﭼﯿﺰوں ﻣﯿﮟ ﺳﮯ دﻟﭽﺴﭙﯽ ﺧﺘﻢ ﮨﻮﮔﺌﯽ ﮨﮯ۔‬

= ‫ﻋﺠﯿﺐ ﺧﻮاب آﺗﮯ ﮨﯿﮟ۔‬

= ‫ﺟﺴﻢ ﻣﯿﮟ درد ﮨﻮﺗﯽ ﮨﮯ۔‬

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Table 2

Subjective Ratings of Presenting Complaints

Symptoms Rating by Client

Separation from 10/10

home (divorce)

Excessive worries 9/10

about future

Crying spells 9/10

Repeated 9/10

nightmares

Physical Symptoms 8/10

Fear 8/10

anxiety 8/10

Lack of interest 8/10

Shortness of 7/10

breaths

Insomnia 7/10

Background Information
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Personal History

The client's birth was normal as reported by the client and all the milestones were achieved at

the appropriate time. No complications were reported at the time of birth or after birth. Her weight

was normal at the time of birth. She had no physical illness at the time of birth. No neurotic traits

were reported and there was no illness or injury reported during childhood and adulthood. The client

had many friends. After the marriage of her husband, she stopped her routine activities and felt

worthless. She had no drug history.

Family history

The client was a first born and never neglected by her parent. The client was born into an

upper-middle-class family. She has 4 sisters and two brothers; the client is married for 15 years she

has 3 children, it was her love marriage. Her husband ran his own business. The clients belong to a

farmer's family. The client had a strong bond with her siblings but never shared anything with them.

She was married to her cousin. The husband’s attitude toward her illness was very negative, her

husband thought she is pretending because she wants him to leave her second wife.

Family History of physical/psychiatrist illness

There was no psychiatric history in her family. The client had a thyroid problem for which

she was on medications, and she was pregnant as well. The client had no medical or psychiatric

history in her familyy.

Educational History
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The client started school at the age of 4 years. The client reported that she was an average

student till class 12th. She had good relationships with her teachers and peers. In class 10th due to

the company of her friends she was careless regarding her studies and spent most of her time in

leisure activities. The client reported that as her focus was less on studies, and she was involved with

her cousin who is her husband now she got passing marks in 10th class due to which her family

decided to marry her to that cousin. She completed F.A in average marks.

History of Present Illness (onset)

The client's history dated back to a year ago after the second marriage of her husband she was

not able to recover from the loss. The client was worried about her life and her children and what

would happen to them if her husband divorced her. The client was pregnant as well.

Clients verbatim: “My husband and my in-laws betrayed me. His second marriage was without my

consent. All this happened just because of my brother-in-law. My husband is concerned about her

(second wife) he doesn't care about me, whenever I call him to ask when he will come home, her

wife picks the call and abuses me, which is very humiliating for me. I can't bear his behavior because

it was our love marriage too. When he is with me, he promises me a better life but when he leaves

the home, he forgets everything. Now he forgot his children too which is very stressful for me, how

he can do these things. I can't even share this situation with my parents and now it is very unbearable

for me. Now he started shouting at me and he slapped me once. I am afraid to leave him because I

don't want to leave when I think about separation, I feel like dying, I feel suffocated.

I want my happy life back.

I feel it never can happen again, I feel suffocated at home, and I am worried about my life my

children how I will survive without him. When my husband comes home, he never asks me for a

single moment how are you and how is life going even though he knows I am pregnant now I need
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him, I need him like before I asked him if his behavior will remain the same, I can go for abortion,

and he starts shouting at me. Due to his behavior, I can't pay attention to my children, my home, and

myself, I want my romantic life back when we laugh with each other and spend nights talking with

him. My husband always listens to his brother and, he always tried to spoil my marriage life, when I

say something about them (my in-laws) my husband calls me a typical woman, an uneducated

woman, and I am quiet. My mother-in-law isn't supporting me even though she is my sister to my

mother but doesn't care about me.

Everyone takes side of my husband, and no one cares about me. Sometimes I decide to finish myself,

but my children come in front of me and I stop thinking about suicide.”

The client was not much social person and had poor coping skills. In the future, she saw herself as a

failure. She didn’t want to get attach to anyone, because she thought everyone is a cheater like her

husband. The client was referred to the trainee clinical psychologist for assessment and management

of symptoms and I along with another internee assisted the psychologist and observed her during the

sessions.

Premorbid Personality

Before the onset of their illness, she was performing all her duties well. Her sleep was

normal. She was peaceful, kind, and hardworking as she reported. Now she couldn't forget anything

about her destroyed relationship. She was not aggressive before and now she can't control her anger.

She was social and frank with others. Before the onset of the illness, the client was living a healthy

life.

Psychological Assessment
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Informal Assessment

Clinical Interview

Behavioral Observation

Mini Mental Status Examination (MMSE)

Formal Assessment

Human figure drawing (Florence L. Goodenough 1926)

Beck Depression Inventory (Aaron T. Beck 1961)

Beck Anxiety inventory (Beck Anxiety Inventory 1997)

Interpretation of the test Administered

Informal Assessment

Behavioral Observation. The client looked anxious, and she was a bit uncomfortable while

sitting on a chair. She had a panic attack during the history taking and was complaining of body

aches. The client behaved normally otherwise, and she maintained good eye contact.

Mini Mental Status Examination (MMSE). Her appearance was neat and clean. She was in

a neat dress and her hygiene was satisfactory. The client had a proper orientation of space, time, and

direction. The client had a proper insight into her condition. She had suicidal ideation and thoughts

of harming herself. She was in not good condition, but her memory and insight were satisfactory

Formal Assessment
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Human figure drawing. The client's HFD showed rigidity, insecurities, anxiety,

defensiveness, environmental pressure, and lack of psychological warmth in family life. It also

indicated that the client had a guarded personality, not social, and a need for social interaction.

Interpretation of person included that client was aggressive, assertive, and frustrated. She had

voyeuristic guilt, sexual conflicts, and a need for stability.

Beck Depression inventory

score Cut-off Interpretation

28 0- 13 no depression Score indicate moderate

depression

14 – 19 mild

20 – 28 moderate

29 to 63 sever

Beck Anxiety inventory

score Cut-off interpretation

34 0 to 21 mild Scores indicate moderate anxiety

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22 - 35 moderate

36 above severe

Tentative Diagnosis

Mixed Anxiety and Depressive Disorder. 309.28 (F43. 23)

Differential Diagnosis:

Case Formulation

According to the clients’ assessment and her diagnosis, CBT based treatment was used, along

with REBT techniques and other cognitive therapeutic interventions. Cognitive therapy was

developed by Aaron Beck (1970’s) and is a type of psychotherapy. This form of therapy modifies

thought patterns to help change moods and behaviours. The CBT model can be summarized in the

figure below
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The main assumption of the Cognitive School of thought believes that persons thinking,

perception, remembering, learning and attitude towards a stimulus affects their behaviors and so

must be considered. It's based on the idea that negative actions or feelings are the results of current

distorted beliefs or thoughts “Cognitive Distortions”.

According to cognitive psychologists, the cause of cognitive distortions can be the result of,

environmental, biological, and social factors. A therapist helps you identify negative or false

thoughts and replace those thoughts with healthier, more realistic ones i.e., Cognitive restructuring.

In this case, the women had multiple cognitive distortions including:

 Filtering: the woman was focusing on all the negative aspects in her life, including her

conflicts with the husband, his second marriage, lack of family support while ignoring all the

positives including her good physical health, her children, her pregnancy, her capabilities to

live a happy and independent life, her intellect

 Polarized thinking: Either I will have an ideal relationship with my husband, or I’ll be

doomed and dead

 Fallacy of fairness: Assuming that her life should be fair

 Over generalization: generalizing that if her husband has cheated on her, all men are

cheaters. Also, as her in-laws were non supportive, any of the social support she can have

won’t be reliable or trustworthy.

 Control Fallacy: blaming others e.g., “it’s all because of my brother-in-law/it’s all because

of that second woman”

 Catastrophizing: Expecting the worst-case scenario: “If my marriage fails, everything will

fall apart, I will be dead”

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 Fallacy of change: “My husband should change his behavior. My brother-in-law should stop

interfering. My in laws should support me etc.”

First, CBT makes you aware you have these thoughts. Then it teaches you to swap them for more

positive ones. The change in your attitude leads to a change in your behaviour. That can help ease

your depression. "Anxiety and nervousness are rooted in survival, so feeling anxious or fearful is part

of the human experience," explains Ciara Jenkins, a therapist and licensed clinical social worker at

Life on Purpose Counselling & Coaching Services. Every person experiences anxiety from time to

time at varying degrees. Many times, intense anxiety, fear, or panic is caused by how we think about

a certain situation and not necessarily the situation itself."

"Perception accounts for a lot of our experience. Being able to let go of unhealthy thoughts frees

us up to consider other healthier and more factual alternatives, which lead to an improved experience

and less intense uncomfortable emotions," Jenkins adds.

As time goes on, these behaviors start to become repeating patterns. Using CBT, you can

learn to pay attention to those patterns and actively work to change them, along with the feelings tied

to them. Given time, it can help to prevent these behaviors from happening in the future.

"CBT helps individuals identify the links in the chain that lead to worse anxiety and

depression: the thoughts, feelings, behaviors, and physical sensations that are intimately connected to

one another," says Steven Lucero, PhD, MBA, a clPh.D.cal psychologist with Brightside. The key,

he stresses, is that you can take action to disrupt the spiral of avoiding the situation that causes

anxiety. For people with anxiety disorders, negative ways of thinking fuel the negative emotions of

anxiety and fear. The goal of cognitive-behavioral therapy for anxiety is to identify and correct these

negative thoughts and beliefs. The idea is that if you change the way you think, you can change the

way you feel. Thought challenging also known as cognitive restructuring is a process in which you
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challenge the negative thinking patterns that contribute to your anxiety, replacing them with more

positive, realistic thoughts.

Replacing negative thoughts with more realistic ones is easier said than done. Often, negative

thoughts are part of a lifelong pattern of thinking. It takes practice to break the habit.

After seeing her symptoms multiple techniques of CBT were applied for short- and long-term

goals like thought restructuring, cost-benefit analysis, and journal writing for effective treatment.

Treatment and Management Plan

Rational emotive behavior therapy (REBT)

For a client with irrational beliefs, REBT is the best technique. REBT is based on the idea

that how we feel is largely influenced by how we think. As it is clear by the name this form of

therapy encourages the development of rational thinking to facilitate healthy emotional expressions

and behavior. It is a type of therapy introduced by Albert Ellis in the 1950s. It's an approach that

helps you identify irrational beliefs and negative thought patterns that may lead to emotional or

behavioral issues. The activating event of the client's husband's second marriage gave her a shock.

The irrational belief was addressed during the therapeutic session.

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Cognitive-behavioural Therapy

There are the following techniques of CBT that are very effective for the treatment of patients

with traumatic stress.

Journaling and thought records

The client and therapist work together to resolve the client's overthinking issues and record

her daily activities. Express her thoughts on a page of her diary and rule out her negative feelings and

reframe them into healthy activities and share your feelings and experience with your therapist

Cognitive restructuring or reframing

The client and therapist work together to identify the feelings, thoughts, and circumstances of

better client before and after the life of her husband's second marriage. This will help the client and

therapist to better understand client problematic patterns of thought and behaviour and to change

them.

Cost-Benefit Analysis

The client and therapist work together to find client's unhealthy thoughts the benefits to keep

those thoughts and the disadvantages of those thoughts. After practicing this client was fully aware

of her problem and she was really wanting to get rid of her issue which was very helpful during

therapy.

Relaxation and stress reduction techniques. This technique was helpful to deal with the

client's panic attacks whenever she feels she is having an attack try a Deep breathing exercise and try

to change her thoughts and feelings in a healthy positive way.

Activity scheduling and behaviour activation

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This technique was helpful to deal with maintaining the client's daily life routine making

seven pleasure activities which she can perform at her home easily and she engages herself with

them and she will not have spare time for her negative thoughts. During this activity, the client was

very cooperative, and it was done very effectively.

Spitting in the Client Soup Technique

This technique was used by Adler, the main idea is to reject client’s false ideas on the spot to

make them realize her notion is wrong.

When the client said that the world is full of fake people, the client was confronted by saying

you belong to this world as well, how can you think like that. Moreover, your parents and siblings

never betrayed you. The client is made to realize that the betrayal from the husband is just one bad

event int her life. The cognitive distortion of overgeneralization and filtering is being targeting here.

Breathing Relaxation Technique

Jacobson's relaxation technique is a type of therapy that focuses on tightening and relaxing

specific muscle groups in sequence. It's also known as progressive relaxation therapy. By

concentrating on specific areas and tensing and then relaxing them, you can become more aware of

your body and physical sensations. Dr. Edmund Jacobson invented the technique in the 1920s as a

way to help his patients deal with anxiety. Dr. Jacobson felt that relaxing the muscles could relax the

mind as well. The technique involves tightening one muscle group while keeping the rest of the body

relaxed and then releasing the tension. My client had panic Attacks, so I used this technique with her

to deal with her panic attacks I use one of the breathing exercises which Breathing Focus exercise I

gave the instructions to her to close your eyes

“Take a few big, deep breaths.

Imagine that the air is filled with a sense of peace and calm
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Breathe out, While you're doing it, imagine that the air leaves with your stress and tension

As you breathe out, say in your mind, "I breathe out stress and tension"

Session Report

Session 1

 Goals of session

 Rapport building

 Identify her problem

 History taking

In the first session, an observation was done, and rapport was built on the principle of the

motivational interview to enhance the motivation of the patient. A breathing exercise was done

during the session. Thought record was given as a homework

Session 2

 Feedback of the previous session Goals of session

 History taking

 Rule out the symptoms of the client

 Find her triggers

In the second session, the client was asked about the symptoms of her problem, and her

history was taken. The client was a little bit hesitant during the session. Deep breathing and

relaxation techniques were taught to calm and relax the client. In this session thought record and

thought transformation was homework for the client

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Session 3

 Feedback of the previous session Goals of session

 History taking

 Psychometrics done

In the third session. the client came in a happy mood as before she said this week was better than

before, psychoeducation was also given to the client about her social and hygiene problems , and

HFD, BDI, and BAI were applied. Client was asked to make a pleasure activity chart for the next

session

Session 4

 Feedback of the previous session

 Further proceedings

In this session, a subjective rating of the client's behavior was taken. A cost-benefit analysis

was applied during the session. Identify her negative thoughts and starting therapies for her.

Session-5

 Feedback of the previous session

 Further proceedings

In the fifth session, after the test, the client was encouraged and motivated in good words and

appreciated for participation though stopping techniques were used and scheduling the activities
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(prayer, morning walk) so she can overcome the depressed state also advised mindfulness techniques

so she learns how she can focus her attention and stop irrational thoughts.

Session-6

 Feedback of the previous session

 Further Proceedings

In the sixth session, reading material was also given to her about the importance of her religion

and socialization. The client was fully interested throughout the session. Pleasure activities and

distracting activities

throughout the session. Pleasure activities and distracting activities performance task at home was

given to her. Mindfulness techniques were applied as well.

Therapeutic Recommendations

The CBT and REBT techniques that was already being applied to the client that were proven

to be quite helpful in yielding improvements. (Refer to the section above). Further coping skills

could be taught to the client to specifically deal with her situation that she cannot change (e.g., bring

her husband back or change his behaviour). Other CBT techniques can be incorporated, such as

“Playing the script till the end” where the client can be asked to think of the worst case scenario

according to her and then training her to cope with her fear and anxiety and making her realize even

if the worst happens e.g. even if her husband leaves her forever, why and how she will be fine and

what can she do about the situation then to cope. In this way when the client practices such an

exercise in the head multiple times, the client can feel more in control of herself and less afraid and

anxious about the precedented negative event.

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Moreover, ACT specifically could be used as part of the CBT interventions where the focus

could be placed on the lady radical accepting her current circumstances or the ones that may arise in

the future and mindfully coping with them on psychological level. Along with that value assessment,

goal settings and other such helpful ACT interventions can be incorporated.

According to the Association for Contextual Behavioural Science (ACBS), ACT is:

“A unique empirically based psychological intervention that uses acceptance and mindfulness

strategies, together with commitment and behaviour change strategies, to increase psychological

flexibility.”

Prognosis

The prognosis was good as the client had good insight into her problem, and she wanted to

get treated. She was better able to handle stressful situations and was managing her house and

children well. She also started stitching clothes and developed some new hobbies to help her distract

and relax and got indulged in self-care. These improvements were seen during 6 sessions in my

presence. 2 more sessions were to proceed as per the treatment plan, and a few follow up sessions

were also recommended. However, there is no one in her family to support her and take care of her

which might worsen the condition of the patient so a lack of social support might reduce chances of

recovery or increase chances of relapse. On her own, the client was very cooperative and willing to

work towards the treatment.

References

Cherry, K. (2021). Cognitive behavioral therapy. Verywell Mind.

https://www.verywellmind.com/what-iscognitive-behavior-therapy-2795747

Ackerman, C. (2020, January 19). 5 REBT Techniques, Exercises and Worksheets.

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PositivePsychology.com.

https://positivepsychology.com/rebt-techniques-exercises-worksheets/

What is Jacobson’s Relaxation Technique? (2014, December 2). Healthline.

https://www.healthline.com/health/what-is-jacobson-relaxation-technique/

Ruggiero, G. M., Spada, M. M., Caselli, G., & Sassaroli, S. (2018). A Historical and Theoretical

Review of Cognitive Behavioral Therapies: From Structural Self- Knowledge to Functional

Processes. Journal of Rational-Emotive & Cognitive- Behavior Therapy, 36(4), 378–403.

https://doi.org/10.1007/s10942-0180292-8/

How Cognitive Behavioral Therapy Can Treat Your Anxiety. (2021, September 20).

Healthline. https://www.healthline.com/health/anxiety/cbt-for-anxiety#what-it-is/

Ackerman, C. (2017, March). How Does Acceptance And Commitment Therapy (ACT) Work?

PositivePsychology.com. https://positivepsychology.com/act-acceptance-and- commitment-

therapy/
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Annexure of Case 1
27
28
29
 30

Human Figure Drawing (HFD)

Baseline Chart
 ‫‪31‬‬

‫ﮐﺘﻨﯽ دﯾﺮ رﮨﯽ۔‬ ‫ﮐﯿﺴﮯ ﮐﻨﮣﺮول ﮐﯿﺎ۔‬ ‫ﮐﺘﻨﯽ ﺷﺪت رﮨﯽ ۔‬ ‫ﮐﯿﺎ ﺧﯿﺎل ذﮨﻦ ﻣﯿﮟ آﺗﮯ‬ ‫‪ Panic attack‬ﺳﮯ‬

‫ﮨﯿﮟ۔‬ ‫‪.‬ﭘﮩﻠﮯ ﮐﯿﺎ ﮨﻮا ﺗﮭﺎ‬

‫ﭘﮩﻠﮯ ﺳﮯ ﮐﻢ۔‬ ‫ﺟﮕہ ﭼﮭﻮڑ دی۔‬ ‫آدھﺎ ﮔﮭﻨﮣہ۔‬ ‫ﻣﯿﮟ ﻣﺮ ﺟﺎؤں۔‬ ‫ﻣﺎں ﮐﯽ ﯾﺎد آﺗﯽ ﺗﮭﯽ۔‬

‫=‬ ‫ﮔﮭﺮ ﺳﮯ ﺑﺎﮨﺮ ﻧﮑﻞ‬ ‫=‬ ‫اب آﮔﮯ ﮐﯿﺎ ﮨﻮﮔﺎ۔‬ ‫ﭘﺴﯿﻨہ آﺗﺎ ﺗﮭﺎ۔‬

‫ﮔﺌﯽ۔‬

‫ﭘﮩﻠﮯ ﺳﮯ ﮐﻢ۔‬ ‫ﭼﮭﺖ ﭘﺮ ﭼﻠﯽ ﮔﺌﯽ۔‬ ‫=‬ ‫ﻣﯿﮟ ﮐﯿﺴﮯ رﮨﻮں ﮔﯽ۔‬ ‫ﻏﺼہ آﺗﺎ ﺗﮭﺎ۔‬

‫=‬ ‫ﺑﮩﻦ ﮐﻮ ﻓﻮن ﮐﯿﺎ۔‬ ‫ﻣﻨﭧ۔ ‪15‬‬ ‫ﻟﻮگ ﮐﯿﺎ ﮐﮩﯿﮟ ﮔﮯ۔‬ ‫آﻧﮑﮭﻮں ﺳﮯ ﭘﺎﻧﯽ آﺗﺎ‬

‫ﺗﮭﺎ ﺗﮭﺎ۔‬

‫اب ﭘﮩﻠﮯ ﺟﯿﺴﯽ ﻧﮩﯿﮟ۔‬ ‫وﺿﻮ ﮐﯿﺎ۔‬ ‫ﻣﻨﭧ۔‪20‬‬ ‫ﻣﯿﺮی زﻧﺪﮔﯽ ﮐﺎ ﮐﻮﺋﯽ‬ ‫دل ﺑﮭﺎری ﮨﻮﻧﺎ۔‬

‫ﻓﺎﺋﺪه ﻧﮩﯿﮟ۔‬

‫=‬ ‫ﮢﯽ وی آن ﮐﺮ‬ ‫=‬ ‫ﻣﺠﮭ ﺳﮯ ﮐﭽﮭ ﻧﮩﯿﮟ‬ ‫ﮐﭽﮭ ﺑﮭﯽ ﺑﺮداﺷﺖ ﻧﮩﯿﮟ‬

‫ﻟﯿﺎ۔‬ ‫ﮨﻮﺗﺎ۔‬ ‫ﮨﻮﺗﺎ۔‬

 ‫‪32‬‬

‫‪List of Strength and Weakness‬‬

‫ﺧﺎﻣﯿﺎں۔‬ ‫ﺧﻮﺑﯿﺎں۔‬

‫ﻏﺼہ ﭘﺮ ﮐﻨﮣﺮول ﻧﮩﯿﮟ۔‬ ‫ﻣﯿﮟ ﻟﻮﮔﻮں ﺳﮯ ﻣﺤﺒﺖ ﮐﺮﻧﮯ واﻟﯽ ﮨﻮ ﮨﻮں۔‬

‫ﺟﻠﺪی رو ﭘﮍﺗﯽ ﮨﻮں۔‬ ‫ﻟﻮﮔﻮں ﮐﯽ ﻣﺪد™ ﮐﺮﺗﯽ ﮨﻮں۔‬

‫دوﺳﺮوں ﭘﺮ اﻋﺘﺒﺎر ﮐﺮ ﻟﯿﺘﯽ۔‬ ‫اﭘﻨﺎ ﮨﺮ ﮐﺎم ﺧﻮد ﮐﺮﺗﯽ ﮨﻮں۔‬

‫ﻣﯿﺎں ﮐﮯ دھﻮﮐﮯ ﮐﻮ ﺑﺮداﺷﺖ ﮐﺮ ﻟﯿﺎ۔‬ ‫ﮐﻮﺷﺶ ﮐﺮﺗﯽ ﮨﻮں ﮐہ ﺳﭻ ﺑﻮﻟﻮں ۔‬

‫دوﺳﺮوں ﮐﯽ ﺑﺎﺗﻮں ﻣﯿﮟ آ ﺟﺎﺗﯽ ﮨﻮں۔‬ ‫اﭘﻨﮯ ﮐﺎم وﻗﺖ ﭘﺮ ﮐﺮﺗﯽ ﮨﻮں۔‬

‫اب ﯾﻘﯿﻦ ﻧﮩﯿﮟ ﮐﺮﺗﯽ ﮐﺴﯽ ﺑﺎت ﭘﺮ۔‬ ‫ﻣﯿﮟ اﯾﮏ اﭼﮭﯽ اﻧﺴﺎن ﮨﻮں۔‬

‫‪Goals and routine scheduling‬‬

 33

TIME MONDAY TUESDAY WEDNESDA THURSDA FRIDAY SAT SUN

Y Y

6-7 deep translation surah Yaseen deep walk + _ _

of Quran breathing exercise

breathing +

walk

7-8 breakfast _ _ _ _ _ _

prepare

lunch for kid

8-10 session time _ _ _ _ _ _

10-11 namaz+ stitching household spend time family household _

household work with friends time + work

work and kids husband

and kids

12-1 lunch _ _ _ _ _ _

2-3 rest _ _ _ - _ _

3-4 time with _ _ _ _ reading _

kids + surah Faraz o

Rahman Amaal

4-5 outing with book watching tv spend time reading Hadees _

kids reading with husband Faraiz O Reading

Amaal
 34

5-6 preparation _ _ - _ - _

of dinner

6-7 dinner+ _ _ - - - -

namaz

Case 2
 35

299.00 (F84.0) Autism Spectrum Disorder.

ARIBA SADIA

FA19-BPY-019ISB

DEPARTMENT OF HUMANITIES

COMSATS UNIVERISTY ISLAMABAD

MA’AM SAMREEN IDRESS

NOV 7, 2022

Case Summary
 36

XYZ was a 10-year-old boy who was brought by his parents with the complaints of lack of

verbal and non-verbal communication, poor eye contact, self-hitting behavior, sticking specific

routine, and delayed milestones. He was referred to the present trainee clinical psychologist for the

purpose of assessment and management. Informal and formal assessment was done. Informal

assessment included DSM-5 criteria, clinical Interview with parents, behavioral observation. Formal

assessment included Childhood Autism Rating Scale. Because of detailed history and psychological

assessment, he could be concluded that the patient is suffering from autism spectrum disorder with

Intellectual Disability and Behavioral Issues. Management plan was devised based on Behavior

therapy to improve his behaviors.

Demographics

Name: XYZ

Sex: Male
 37

Age: 10

No. of siblings: 1

Birth Order: Last Born

Family system: Joint

Socio-economic status: Middle Class

Religion: Islam

Source of referral:

The child came with his parents to with the complaints of delayed speech, delayed

milestones, language, and social communication deficits, having specific routine, Repetitive or

restrictive behaviors of self-hitting on the left side of his head, and special attachment pattern with

his toy. He came to present trainee clinical psychologist for the assessment and management of his

problems.

Presenting Complaints:

The following complaints were given by the patient’s mother.

‫یہ پچھلے چار سال سے بولتا نہیں ہے صحیح سے۔‬

‫اس سے نظر مال کر بات نہیں ہوتی۔‬

‫اس سے زیادہ دیر تک ایک جگہ نہیں بیٹھا جاتا۔‬

‫اس کو اپنا جو کھلونا اچھا لگ جائے اس سے ہٹتا نہیں ہے۔‬

‫اس کی عمر کے بچے جو کام کر لیتے ہیں اس سے وہ کوئی بھی نہیں ہوتے۔‬

History of Present Illness

 38

The child’s history of present illness can be stretched back to the prenatal stage of pregnancy.

The child’s mother did not take proper care of her nutrition during her pregnancy and underwent a

lot of psychological distress. She had the burden of doing all the household responsibilities on her

shoulders. She would have to pick up her elder daughter and take her upstairs even during pregnancy

which was not good for her and the baby’s health. She gave birth through normal delivery. The child

cried immediately after birth, but he weighed less than 2 pounds. He was breast fed by his mother for

2 days but then he got fever and diagnosed as having jaundice.

After his recovery from jaundice, the child experienced convulsions for which doctors gave

him sleep injections due to which he would sleep for 22 to 23 hours a day. He then recovered from

fits in a few weeks. During this whole time, he was fed though feeding pipe. However, after about a

month the feeding pipe was removed and was then fed orally though bottle.

As he grew up, he was unable to initiate or maintain eye-contact with anyone. He did not

respond or pay attention to anyone calling his name. He would play only with his elder sister.

However, he spent most of his time alone seemingly indulged in himself. He would not utter any

word and would make unintelligible noises whenever his routine was interrupted by others. While

growing up, the child was unable to perform the simplest of tasks. He also experienced difficulties in

hearing for which his parents took him to a doctor who recommended a hearing aid which the child

did not wear in his ear. He would often hit on the left side of his head with a toy. He was completely

unable to take care of his hygiene. He would not interact with strangers and only accepted company

of familiar others such as his mother, father, sister, uncle, and aunt. Whenever he needed to go to

toilet, he would give a slight sign. Other than that, he could not do any task independently. Due to

these issues, he could not be admitted to school. According to his father, he was taken to a doctor due

to these complaints for which the doctor prescribed medications and they were not at all effective.

Personal History:
 39

Perinatal history

The delivery of the child was normal with the labor time of 5 hours. He had first cry but his birth

weight was less than 2 pounds.

Post-natal history

After birth he suffered from jaundice for 2-3 weeks. The doctor told his parents that he had no more

suction power, so food pipe was used for food intake.

Developmental milestones

All the milestones of the child were delayed than normal age. He had specific routine which he

followed as he got up, behaved aggressively, rounded up the whole room, and picked up things and

threw them. He had a red colored toy which was his favorite. He used to keep it by his side even

during sleep. He used to hit the left side of his head with that toy. He did not have developed speech,

but he made noise when someone interfered in his routine. He liked sweets, coca cola, snacks, and

nuggets. He was also attracted towards various colors and keys.

Developmental Milestones Normal Age of Achievement Child’s Age of Achievement

(Seigalman & Rider, 2010)

Head Holding 3 Months 2 years

Sitting 6-8 Months 3 years

Crawling 8-12 Months 2 years

Walking 1-2 Years 3 Years

Speech: Single Word 1.5-2 Years Not yet

 40

Complete Sentence 3.5-4 Years Not yet

Bladder Control 2.5-3.5 Years Not yet

Bowel Control 2.5-3.5 Years Not yet

Dressing without Help 4-4.5 Years Not yet

Taking Bath without Help 3-4 Years Not yet

Family History:

Child lived in a joint family system. He belonged to middle class socioeconomic status.

Child’s father was 43 years old, had studied until M. Phil, and worked as a government officer. He

had polite nature. He had friendly, protective, and caring attitude towards his both children. He had a

concerned attitude toward child’s problems. He was supportive of the child’s condition. He did not

have any psychological illness. However, he was facing high blood pressure problem from past few

months.

Child’s mother was 36 years old, had XYZ, and was a housewife. She also had polite nature

and she had caring attitude towards her children. She was too concerned about the problems of the

child. She did not have any psychological or physical problem.

The parent’s marriage was arranged. They had satisfactory relationship with each other. Both

parents were concerned about their child’s problems and were protective towards his needs.

Child had one elder sister. His sister was 9 years old and was in 3rd class. She had protective

and caring attitude towards the child. She appeared physically and mentally healthy. Their general

home atmosphere was satisfactory. Authoritative figure of family was the father who took all the

important decisions.
 41

Educational History:

The child did not attend any school yet.

History of Psychiatric/Medical Illness:

There was no psychiatric history in his family.

Psychological Assessment

Informal

Behavioural Observation:

It is the informal mode of behavioural assessment used to obtain information in order to

gather specific details about behaviours and document performance. It can be useful for making

judgments by means other than systematic interviews and standardized judgments (Morrison, 2011).

Behavioural observation was conducted in order to gain insight into the child’s disruptive behaviours

and other behaviours indicative of his condition which may prove to be beneficial for assessment

procedure and therefore aid development of management plan too.

Present trainee clinical psychologist conducted thorough individual behavioural observation.

The child was a 10-year-old boy wearing neat and clean clothes. His hair was well- combed. Present

trainee clinical psychologist first tried to build rapport with him by playing with him. In the

beginning, he became restless due to the presence of trainee right away because present trainee

clinical psychologist was not a familiar face for him. But with the passage of time, he became

comfortable with the present trainee clinical psychologist. He had poor eye contact; non- compliant

nature and he also had no capacities of imitation. All the early readiness skills were absent in the

child.
 42

Clinical Interview:

A clinical interview is a conversation between clinician and the patient typically intended to

develop an understanding of the patient’s presenting problems and history to explicate the diagnosis

and develop a therapeutic plan. It is conversation with a purpose that can be structured, semi-

structured, or unstructured. It involves a series of questions to be asked by the clinician designed by

him before the conduction of interview (Huss, 2009).

The child’s parents signed a consent form, and they were assured of the confidentiality of the

information provided. Present trainee clinical psychologist ensured active listening and provision of

unconditional positive regard on her part. She empathized with the child’s parents without letting it

impede her clinical judgment. Semi-structured interview revealed the child’s background

information, relationships with family members, personal information, developmental history,

educational history, and history of present illness. His parents were cooperative and answered in

harmony with each other which ensured the veracity of information provided.

Symptom Checklist according to DSM 5

The checklist based on DSM-V (APA, 2013) criterion of Autism Spectrum Disorder was

administered the child to assess the symptoms of Autism Spectrum Disorder.

Formal

Childhood Autism Rating Scale

 43

Childhood autism rating scale is a formal assessment tool which takes rating of a child’s

behavior characteristics, and abilities against the expected developmental growth of a typical child. It

assesses child’s responses on the 11 areas.

Categories Total Score Interpretation

15 60 Severely autistic

The above table showed that the child falls in severely autistic category. His scores are high

in all areas. His all areas are severely weak as compared to other age fellow’s development.

Human Figure Drawing (HFD)

Human Figure Drawing (Koppitz, 1968) is used to measure the emotional indicators in

children with mental retardation with hyperactivity and without hyperactivity. Human Figure

drawing (HFD) involves the drawing of a whole person by the child on the examiner’s request. The

participant was provided with a pencil and blank sheet of paper and was told to make the best

possible drawing of the whole figure of a man.

The child was unable to draw the picture of man and does not follow the command. He just

draws a circle and irregular lines without attention and interest. These drawing shows the symptoms

of severe autism.

The Childhood Autism Spectrum Test (CAST)

The Childhood Autism Spectrum Test (CAST) is a 39-item, yes or no evaluation aimed at

parents. The questionnaire was developed by ARC (the Autism Research Centre) at the University of

Cambridge, for assessing the severity of autism spectrum symptoms in children. The CAST is used

to screen for autism spectrum disorder.

 44

Total Items Total Score Interpretation

39 25 Lack communication skills

The patient got a score of 25 which is above the cut off score i.e. 15 which indicates that the

child has lack of social and communication skills.

Tentative Diagnosis

Child presents with symptoms and behavior that are consistent with DSM-5 diagnosis of 299.00

(F84.0) Autism Spectrum Disorder.

All his symptoms line up supporting this diagnosis. How he could not speak properly even at

the age of 10, he lacked communication as well as social skills, his addiction to one toy which might

have provided him comfort and now he won’t let go of it shows he has restricted interests, his

disruptive behaviors also support this diagnosis.

Differential Diagnosis

Developmental language disorder (DLD)

Whereas DLD has some similarity to that of this patient’s case like communication and

speech difficulty, still he was not diagnosed with it because his accompanying symptoms of

repetitive behaviors, restricted interest, understanding difficulties and as well as disoriented body

behavior does not support the diagnosis of DLD and so he was diagnosed with Autism not DLD.

Avoidant personality disorder (APD)

 45

Even though APD also talks about the disruption of social cues and communication in an

individual but in our case the patient tends to ignore the social cues and communication whereas in

APD an individual is hypertensive to social cues therefore the patient was diagnosed with autism and

not APD.

Case formulation

The child was 10 years old whose all milestones were delayed. He had no verbal, and non-

verbal communication. His speech is poor except few sounds of aww. He had specific routine which

he followed. He hit himself with his favourite toy on the left side of his head. With the formal and

informal assessment, he was diagnosed with autism spectrum disorder.

Literature reported that Low-birth weight babies are at risk for all sorts of motor and

cognitive delays, and researchers have just added autism to the list. A new study was conducted by

Rochman in 2011 to add autism in that list. He found that premature babies weighing less than 4.5

lbs. at birth are five times more likely than babies born at a normal weight to have an autism

spectrum disorder (ASD). The child’s weight is 2 lb which could be the reason of him having

Autism.

The child was born in winter, and he suffered from jaundice in early infancy this could be

relatable to his present condition. However, researchers also support this reason that children who

had developed jaundice had a risk of developing autism. None of them had been born prematurely

(Norquist, 2010). However, research more relate with the season in which child had born. The results

of this study were that higher autism risk among newborns with jaundice was more markedly noticed

among babies in Denmark born between October and March (from late autumn until late winter/early

spring). They also reveal that the risk was also higher if the mother had already had children.
 46

A study was conducted by autism Speak organization in which they reported that a pregnant

woman's diet could influence prenatal brain development, perhaps in a way that increases autism

risk. The target child’s mother did not take proper care of her diet during her pregnancy. The mother

was also suffering from psychological issues because of socio economic issues and home

environment so these factor also could be the reasons of developing Autism

Treatment and Management plan

According to client condition the following techniques will be used for treatment

Report Building

It’s defined as one’s deliberate approach to make the client feel at ease, particular in the

initial meetings when the trainee is trying to know the client (Taylor, 2008).

Rapport building was done by providing the child motivation, and by providing unconditional

positive regard that would create a non-threatening environment for the child to enhance the efficacy

of the treatment.

Psychoeducation

It is referring to the process of providing education and information to those seeking or

receiving mental health aid, such as people diagnosed with mental health conditions (or life-

threatening/terminal illnesses) and their family members or informants.

Eye-Contact building exercises.

Maintaining appropriate level of eye contact serves an important role in nonverbal

communication as it is already an impaired area in autistic children.

 47

Positive Reinforcement

Reinforcers identified from the child’s mother during clinical interview were snacks and

coke. These reinforcers were provided when the child put his hand on his chest to response his name

with the help of therapist.

Modelling

These procedures generally are combined with other behaviour therapies, such as prompting,

shaping, reinforcement, and behaviour rehearsal, in which child practice performing acceleration

target behaviours and coping skills. Modelling was used with the child to aid socialization learning

of child. Live Modelling was used with the child in which therapist responded his name when he was

called by others. The therapist also modelled how to shake hand in front of the child.

Prognosis

If the following treatment plan is followed with further assistance in the future by the care givers the

child’s autism can be handled and he can learn how to live and function with it for further in his life.
 48

References

Cicchetti, D., &Bukowski, W. (1995).Developmental Processes in Peer Relations and

Psychopathology. Development and Psychopathology, 7(4), 587-589.

https://doi.org/10.1017/s0954579400006726

Comer,R.J.(2006). Abnormal Psychology. (6th edition).USA: Freeman & Company. Craske, M.G.

(2010). Cognitive–behavioral therapy. American Psychological Association.

Matson, J., & Fodstad, J. (2009). The treatment of food selectivity and other feeding problems in

children with autism spectrum disorders. Research In Autism Spectrum Disorders, 3(2), 455

461. https://doi.org/10.1016/j.rasd.2008.09.005

Mesibov, G. B., Schopler, E., Schaffer, B., & Michal, N. (1989). Use of the childhood autism rating

scale with autistic adolescents and adults. Journal of the American Academy of Child &

Adolescent Psychiatry, 28(4), 538-541.

Morrison, K. (2011). What Is a Behavioral Assessment? - Definition, Tools & Example.Retrieved

from http://study.com/academy/lesson/what-is-a-behavioral-assessment- definition-tools

example.html

Papangelo, P., Pinzino, M., Pelagatti, S., Fabbri-Destro, M., & Narzisi, A. (2020). Human Figure

Drawings in Children with Autism Spectrum Disorders: A Possible Window on the Inner or

the Outer World. Brain Sciences, 10(6), 398. https://doi.org/10.3390/brainsci10060398

Rivet, T., & Matson, J. (2011). Review of gender differences in core symptomatology in autism

spectrum disorders. Research In Autism Spectrum Disorders, 5(3), 957-976.

https://doi.org/10.1016/j.rasd.2010.12.003
 49

Case 3

Body Dysmorphic Disorder DSM-5 300.7 (F45)

ARIBA SADIA

FA19-BPY-019ISB

DEPARTMENT OF PSYCHOLOGY

COMSATS UNIVERISTY ISLAMABAD

MA’AM SAMREEN IDRESS

NOV 7, 2022
 50

Case Summary

The client M.R was 22-year-old male having average height and a very thin figure. He is in

his bachelor’s and belongs to an upper-class family. He was referred by his psychiatrist to the

Clinical psychologist with complaints of body dysmorphic disorder, panic attacks, somatic

complaints, self-harm, suicidal ideation and mixed delusions. The client was referred to the trainee

clinical psychologist for psychological assessment, interventions, and management. Clinical

interviewing, behavioural observation, and Mini Mental Status Examination (MMSE) were used for

informal assessment. The formal assessment was done by using the Diagnostic Statistical Manual

DSM-5, Rotter’s Incomplete Sentence Blank (RISB) and Body Dysmorphic Disorder Questionnaire

(BDDQ). Based on assessment, the client presented symptoms and behaviour consistent with the

DSM-5 diagnosis of Body Dysmorphic Disorder with mixed delusions. Psychodynamic and CBT-

based treatment was included in the psychologist’s treatment plan, including psychoeducation, talk

therapy, relaxation techniques, cognitive restructuring, learning coping skills, and ERP. The client

has completed 6 sessions up till now.

 51

Demographics

Name: M.R

Age: 22 years

Gender: Male

Sexuality: Bisexual

Qualification: BS (in continuation)

Occupation: Student

Father's Occupation: Army personnel

Mother’s Occupation: Housewife

No. of siblings: 1

Birth order: youngest

Marital Status: Single

Socioeconomic Status: Upper-Class

Family Structure: nuclear

Religion: Islam

Informant: Client referred by his psychiatrist

 52

Reasons and Source of Referral

The client came himself to Mega medical complex as advised by his psychiatrist and was

referred to a clinical psychologist for the assessment and management of body dysmorphic disorder,

panic attacks, somatic complaints, and mixed delusions.

Presenting complaints

The client was 22yr. old male with average height and low weight. He was normally dressed

and had poor hygiene. The client presented complaints of racing intrusive thoughts, severe body-

related concerns, somatic complaints, self-harm, suicidal ideation and mixed delusions.

Background Information

Personal History

The client's birth was normal as reported by the client and all the milestones were achieved at

the appropriate time. No complications were reported at the time of birth or after birth. His weight

was normal at the time of birth. He had no physical illness at the time of birth. The client once had

chicken pox and influenza in childhood. The client was reported to have neurotic traits since

childhood including bed wetting, nail biting. temper tantrums, teeth grinding and nightmares. The

client’s parents were neglectful, and he reports to be sexually assaulted by a servant(sweeper) at the

age of 8 years. The client had only one friend (male) who accompanied him in multiple sessions. The

client loves to play guitar and owns one and loves music. He has a great interest in rock and metallic

music. The client was religious as a teenager but now he calls himself an agonist. He loves to read

about history and feels like God is unfair due to the injustices prevailing in the world. He had intense

body related concerns since childhood with an over-obsession with his face.
 53

Family history

The client was last born and had one elder brother, he self-reported to be neglected by his

parent. The client was born into an upper class, army family. The client had a strong bond with his

brother. The family environment was abusive, the mother being narcissist and diagnosed with

borderline personality disorder. The father had anger issues. The client reports to have an unstable

family environment and reports that he did not have any emotional connection with any of his family

member except for his brother who he thinks cares for him. He also reports to be a victim of sexual

violence at the age of 8 years by a sweeper who worked at his home.

Family History of physical/psychiatrist illness

The client’s mother was diagnosed with borderline personality disorder with co-morbid

narcissistic personality disorder. The client had been diagnosed with body dysmorphic disorder with

mixed delusions. He was reported to have recurrent panic attacks and suicidal ideation and is on

medications for the past 3 years (Paxil and Alp taken regularly). His elder brother also had some

neurotic traits but no diagnosis. There was no family history of any physical illness.
 54

Educational History

The client started school at the age of 4 years. The client reported that he was an average

student scoring 70 percent marks. He had good relationships with his teachers and peers. He was

currently doing his bachelor’s in psychology, 5th semester.

History of Present Illness

Onset of Illness

The client's history dated back to his teenage years when he went to high school and used to

have severe body related concerns. The client is reported to be obsessed with his face as he feels like

he is ugly. The neurotic traits were present since childhood and worsened with age. The client was

on psychiatric medications, both anti-psychotic and anti-anxiety from past 3 years for his panic

attacks and body dysmorphia along with mixed delusions. His panic attacks reduced with time

(although client had a panic attack during history taking) but body dysmorphia prevailed. The client

was referred by the psychiatrist to the clinical psychologists primarily so that he gets therapy for his

body dysmorphia and delusions, so he learns coping to improve his social and personal life.

Clients verbatim:

The client made such comments during sessions:

“I think I am too awkward and clingy”

“Even if I get out of this, I don’t think I can heal in future or have a family of my own”

“If I was handsome, I would have been happier”

“If I was given a chance to change one thing in my life, I would change my parents”
 55

The client was not a very sociable person and had poor coping skills. In the future, he saw

himself as a failure. On asking him about what things he wanted to change, he repeatedly pointed out

that he wants to change his face and how he looks. He also said that he wants to improve his social

life. The client was referred to the clinical psychologist for assessment and management of

symptoms and I along with another internee assisted the psychologist and observed him during the

sessions.

Premorbid Personality

There is no underlining pre-morbid personality any different from client’s current condition

as the client has been living for a long time with Body Dysmorphia and neurosis. However, the

client’s friend (only friend) reports that he used to be a happy kid back in school till his primary level

of education, used to have many friends and was creative. The client confirms this information and

shows his childhood pictures during the course of the sessions where he was involved in multiple

activities in school, smiling and playing.

Psychological Assessment

Informal Assessment

 Clinical Interview

 Behavioral Observation

 Mini Mental Status Examination (MMSE)

Formal Assessment

 Rotter incomplete Sentence Blanks- RISB (Julian. B.Rotter 1950)

 Body Dysmorphic Disorder Questionnaire (Phillips et al., 1995))

 56

Interpretation of the test Administered

Informal Assessment

Behavioral Observation

The client looked anxious, and he was a bit uncomfortable while sitting on a chair. He had a

panic attack during the history taking and was complaining of body aches. The client had a constant

stare and kept squinting on several occasions. The client seemed very reluctant and hesitant,

especially when talking about his childhood sexual abuse. The clients displayed feelings and

expressions of disgust when he used to talk about his facial appearance and features. He kept biting

his nails on several occasions during the sessions.

Mini Mental Status Examination (MMSE)

The client’s appearance was satisfactory although his hygiene was not very well maintained.

The client had a proper orientation of space, time, and direction. The client had a proper insight into

his condition. He had suicidal ideation and thoughts of harming herself. He was not in a good mental

and emotional state and was quite anxious, but his memory and insight were satisfactory.

Formal Assessment

Rotter incomplete Sentence Blanks- RISB

The Incomplete Sentence Blank is an attempt to standardize the sentence completion method for use

at the college level. Forty stems are given to be completed and then matched with manuals. A scale

value from 0 to 6 is then assigned to the response of the subject.

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Quantitative scoring

Responses Obtained scores

positive

P1 0x2= 0

P2 0x1=0

P3 0x0=0

Total positives 0 (0)

neutral 4x3=12

conflict

C1 6x4=24

C2 11x5=55

C3 7x6=42

Total conflicts 24 (121)

Total 28 (133)

 The total cut-off score that is obtained after the calculation is 133. The total score after

omission of unanswered items.

=40/ (40-12) x 133

=190

 Using this manual for the interpretations of RISB, the cut-off score is 135. If the score is

more than 135 then there is considered maladjusted behaviour patterns but if the score is less

than 135 then the behaviour patterns are adjusted.

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 Here in this case, the cut-off score appears to be 190 which is basically more than 135. So,

these thinking patterns are maladjusted to the environment.

Qualitative analysis

Familial attitudes. Familial attitudes represent the type of attitude the participant had adopted

towards the family and the kind of relationship the participant holds with the family members.

In the statements of RISB, the mother’s attitude toward her children is described in the completion of

sentence 11. In this case, the participant has reported this statement by saying that a mother should

love their children not damage them which indicates that the participant has a poor relationship with

her mother, and it can be scored negative.

The familial attitudes can be represented in the sstatement 17 and 35. The participant reported that as

a child he wanted to know why her mother hated her and her father is trying which represents that he

holds a very poor relationship with her parent. Moving to statement 2 and 4, the participant reported

the feeling of insecurity while being home and staying away from home makes him happy. It depicts

that he has had a bad experience and the environment at home is suffocating for him. Also he feels

unsafe at home (statement 2, 4)

Social and sexual attitudes. The social and sexual attitudes are reflected in ffollowing

statements; 9, 13, 19, 32 and 33. Statement 13 states that his greatest fear is being lonely, so this

shows that she wants to socialize with people but the fear of being judged and being a shy person,

she hesitates in socializing with people. Also, he is annoyed by angry people showing his emotional

sensitivity. (Reported in statement 9). He finds it difficult to understand girls (statement 40)
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General attitudes. The participant seems to reflect a hopeless and devastated attitude

towards life (statements 5, 30, 32, 24) with a representation of being unhappy (statement 3, 15).

Character traits. The client has a lot of conflicts esp. related to family and a difficult social

life. He enjoys music esp. playing guitar. He feels lonely and worthless and has a poor self-esteem.

Summary. The client is overall quite maladjusted, has a negative view towards self, other

people, and the world.

Body Dysmorphic Disorder Questionnaire (BDDQ)

One is likely to have BDD if he/she gave the following answers

 Question 1: Yes, to both parts

 Question 2: Yes, to any of the questions

 Question 3: Answers b or c.

In this case, all the criteria is met indicating BDD.

Please note that the questions contained in the questionnaire are intended to screen for BDD, not

diagnose it; The answers indicated above can suggest that BDD is present but can’t necessarily give

a definitive diagnosis. Thereby, criteria from DSM-V was taken into consideration for proper

diagnosis.

Tentative Diagnosis

According to DSM-V the clients meet the criteria for.

Body Dysmorphic Disorder DSM-5 300.7 (F45)

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Differential Diagnosis:

Case Formulation

Eclectic model

According to the clients’ assessment and his diagnosis, an eclectic approach best applies to

the client primarily combining the psychodynamic and cognitive approach in both understanding the

case and providing treatment recommendations. Eclectic treatment is a strategy that incorporates

numerous theoretical perspectives and methods. It is a versatile and comprehensive approach to

therapy that enables the therapist to use the best techniques to meet the needs of each unique client. It

is also known as integrative therapy or multimodal therapy.

Many therapists sticked to a single type of treatment in the early 20th century. More

therapists have begun to incorporate concepts from several therapeutic perspectives over the past ten

years. Numerous significant advantages to eclectic therapy can be identified:

• Individualized strategy: Because this method of therapy is so flexible, your therapist can create a

treatment strategy that is tailored to your requirements.

• Engagement: Using a variety of strategies may increase patients' sense of interest in and

involvement in the therapeutic process.

• Flexible: You can switch between ways to address one or more requirements because your therapist

can analyze your needs and decide which approaches and techniques they believe will benefit you

the most. For instance, your therapy may address both your fear and your issues with ongoing stress.

Psychodynamic approach:
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A type of psychotherapy known as psychoanalytic treatment is predicated on the notion that

all people are driven by unconscious motivations, including desires that are unconscious, thoughts,

emotions, and memories.   Psychoanalytic therapy, also referred to as psychodynamic psychotherapy,

is based on psychoanalytic theory.

In the late 19th century, the Austrian doctor Sigmund Freud created psychoanalysis.

Psychoanalytic therapists now assist patients in discovering their repressed emotions and memories,

recognizing destructive thought and behavior patterns, and healing from previous trauma. The theory

of psychoanalysis, which Freud developed in the 1890s, gave rise to psychoanalytic therapy.

Among the fundamental notions of psychoanalysis are:

 The "dynamic unconscious," or the collection of thoughts, memories, and feelings that a

person is unaware of, affects everyone's thinking and behaviour. 

 In response to unconscious urges, thoughts, or feelings that would cause them to feel anxious

or ashamed if they surfaced, people build defence mechanisms.

 Denial, damaging thought patterns, repression, and other strategies are all examples of

defence mechanisms. Conflicts between a person's conscious and subconscious ideas are the

cause of mental health issues. The mind frequently tries to come up with a "compromise" for

these conflicting wants and goals.

As the client reports to have a difficult childhood with a dysfunctional family and also sexual

trauma in childhood. Psychotherapy is also relevant to the client to understand and provide treatment

interventions. Talk therapy, free association techniques, transference, dream analysis are of specific

importance in this regard.

Cognitive Approach
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Cognitive therapy was developed by Aaron Beck (1970’s) and is a type of psychotherapy.

This form of therapy modifies thought patterns to help change moods and behaviours. The CBT

model can be summarized in the figure below

The main assumption of the Cognitive School of thought believes that persons thinking,

perception, remembering, learning and attitude towards a stimulus affects their behaviors and so

must be considered. It's based on the idea that negative actions or feelings are the results of current

distorted beliefs or thoughts “Cognitive Distortions”.

According to cognitive psychologists, the cause of cognitive distortions can be the result

of, environmental, biological, and social factors. A therapist helps you identify negative or false

thoughts and replace those thoughts with healthier, more realistic ones i.e., Cognitive restructuring.

In this case, the women had multiple cognitive distortions including:

1. Filtering: the client was focusing on all the negative aspects in his life, including his

perception of his appearance, conflicts with the mother or toxic home environment, his

anxious personality, lack of family support while ignoring all the positives including his good

physical health, his talents including guitar and poetry, his intellect and academic

achievements, his supportive best friend

2. Polarized thinking: Either I will change the way I look, stay away from my mother, become

more sociable, or I’ll be doomed and dead

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3. Fallacy of fairness: Assuming that her life should be fair

4. Over generalization: generalizing that if his trust has been broken in the past, he can trust

nobody ever.

5. Control Fallacy: blaming others e.g., “it’s all because of my parents esp. mother”

6. Catastrophizing: Expecting the worst-case scenario: “If I am not able to change my

appearance or the way I look, I will be a failure”

First, CBT makes you aware you have these thoughts. Then it teaches you to swap them for more

positive ones. The change in your attitude leads to a change in your behaviour. That can help ease

your depression. "Anxiety and nervousness are rooted in survival, so feeling anxious or fearful is part

of the human experience," explains Ciara Jenkins, a therapist and licensed clinical social worker at

Life on Purpose Counselling & Coaching Services. Every person experiences anxiety from time to

time at varying degrees. Many times, intense anxiety, fear, or panic is caused by how we think about

a certain situation and not necessarily the situation itself."

"Perception accounts for a lot of our experience. Being able to let go of unhealthy thoughts frees

us up to consider other healthier and more factual alternatives, which lead to an improved experience

and less intense uncomfortable emotions," Jenkins adds.

As time goes on, these behaviors start to become repeating patterns. Using CBT, you can learn to

pay attention to those patterns and actively work to change them, along with the feelings tied to

them. Given time, it can help to prevent these behaviors from happening in the future.

"CBT helps individuals identify the links in the chain that lead to worse anxiety and depression:

the thoughts, feelings, behaviors, and physical sensations that are intimately connected to one

another," says Steven Lucero, PhD, MBA, a clPh.D.cal psychologist with Brightside. The key, he

stresses, is that you can take action to disrupt the spiral of avoiding the situation that causes anxiety.

For people with anxiety disorders, negative ways of thinking fuel the negative emotions of anxiety
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and fear. The goal of cognitive-behavioral therapy for anxiety is to identify and correct these

negative thoughts and beliefs. The idea is that if you change the way you think, you can change the

way you feel. Thought challenging also known as cognitive restructuring is a process in which you

challenge the negative thinking patterns that contribute to your anxiety, replacing them with more

positive, realistic thoughts. Replacing negative thoughts with more realistic ones is easier said than

done. Often, negative thoughts are part of a lifelong pattern of thinking. It takes practice to break the

habit.

After seeing his symptoms multiple techniques of CBT were applied for short- and long-term goals

like thought restructuring, cost-benefit analysis, and journal writing for effective treatment.

ERP

The primary gold standard for treating obsessive-compulsive and associated disorders is

cognitive-behavioral therapy. Goal of ERP is to stop recurrent behavior like compulsions. As the

obsessive and compulsive pattern related to body dysmorphia is observed in BDD, this therapy has

been widely used for BDD patients quite successfully.

Exposure simply refers to constantly facing or confronting one's worries until the fear

dissipates (called habituation- explained in the treatment section). Refusing to engage in compulsive,

avoidant, or evasive actions is known as response prevention. Let's take the case of an OCD sufferer

who fears germs contaminating their hands. Shaking hands with someone and not washing your

hands after is a common exposure practice (response prevention). A typical exposure exercise for

body dysmorphic disorder (BDD) can involve visiting a crowded shopping mall without wearing any

cosmetics or a hat, but without gazing in any mirrors or reflective surfaces (response prevention).
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Treatment and Management Plan

Psychoanalytical techniques

Talk Therapy (Free association)

While other types of psychotherapy frequently entail targeted, tightly regulated conversations with

specific objectives, psychoanalytic treatment is purposefully more unstructured.

Freud invented the psychoanalytic approach known as free association, which entails encouraging

the patient to speak candidly and spontaneously about whatever is on their mind. This method of

asking open-ended questions is claimed to facilitate the discovery of hidden motivations, concerns,

and fears.

The client here was encouraged to openly talk about his experiences which specifically

helped his childhood traumas to surfaces including the sexual assault and problems with relationship

with his mother.

Cognitive-behavioral Therapy

CBT based treatment was used. Cognitive restructuring techniques were specifically used to

target his cognitive distortions and delusional thoughts, anxiety and appearance related thoughts and

ERP techniques as part of CBT were used to specifically target his body dysmorphia.

Journaling and thought records

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The client and therapist work together to resolve the client's overthinking issues and record

his daily activities. Express his thoughts on a page of his diary and rule out his negative feelings and

reframe them into healthy activities and share your feelings and experience with your therapist

Cognitive restructuring or reframing

The client and therapist work together to identify and then restructure the cognitive

distortions he had (discussed in case formulation). This will help the client and therapist to better

understand the client’s problematic patterns of thought and behavior and to change them.

Cost-Benefit Analysis

The client and therapist work together to find client's unhealthy thoughts the benefits to keep

those thoughts and the disadvantages of those thoughts. After practicing this client was fully aware

of her problem and he was really wanting to get rid of her issue which was very helpful during

therapy.

Relaxation and stress reduction techniques

This technique was helpful to deal with the client's panic attacks whenever he feels he is

having an attack try a Deep breathing exercise and try to change her thoughts and feelings in a

healthy positive way.

Activity scheduling and behavior activation

This technique was helpful to deal with maintaining the client's daily life routine making

seven pleasure activities which he can perform and use as coping for her negative thoughts. During

this activity, the client was very cooperative, and it was done very effectively.
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Breathing Relaxation Technique

Jacobson's relaxation technique is a type of therapy that focuses on tightening and relaxing

specific muscle groups in sequence. It's also known as progressive relaxation therapy. By

concentrating on specific areas and tensing and then relaxing them, you can become more aware of

your body and physical sensations. Dr. Edmund Jacobson invented the technique in the 1920s as a

way to help his patients deal with anxiety. Dr. Jacobson felt that relaxing the muscles could relax the

mind as well. The technique involves tightening one muscle group while keeping the rest of the body

relaxed and then releasing the tension. My client had panic Attacks, so I used this technique with her

to deal with her panic attacks I use one of the breathing exercises which Breathing Focus exercise I

gave the instructions to him to close your eyes

 Take a few big, deep breaths.

 imagine that the air is filled with a sense of peace and calm

 Breathe out, While you're doing it, imagine that the air leaves with your stress and tension

 As you breathe out, say in your mind, "I breathe out stress and tension"

ERP

Exposure Therapy: The effectiveness of exposure therapy relies upon a behavioral principle called

habituation. Habituation is the process by which a person's behavioral and sensory response

diminishes over time, after repeated exposure to a particular stimulus. We all have experienced

habituation. Have you ever jumped into an ice cold swimming pool, only to feel comfortable after a

few minutes? That's habituation at work. Perhaps you have friends who live nearby an airport, busy

highway, or a train station. Have you wondered how they could possibly concentrate or sleep with all

that noise? Your friends may have felt the same way when they first moved in. Now, after living

there for a while, their sensory neurons just stopped reacting to the noise. They will probably tell you
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that they are so accustomed to the noise they no longer even hear it anymore. They've become

habituated to it.

Exposure therapy takes advantage of this principle of habituation. In the context of treatment, it

means allowing repeated exposure to the feared object or situation, so that habituation can occur.

Habituation via exposure is achieved by intentional choice. Overtime, the intensity of exposure is

gradually increased. For instance, people with OCD who fear germ contamination may first touch a

doorknob in the therapist's office. They allow themselves to experience the fear until it subsides, as

habituation takes over. Then, the intensity or difficulty of the exposure is gradually increased. So, the

therapist might take them to a department store. They would practice touching more things, handled

by more people. With the support of the therapist, they would allow themselves to experience the

fear until habituation occurred and the fear subsided. The next level of intensity might be to touch a

doorknob in a public bathroom, etc. A similar process of gradual exposure with increasing intensity

is used with hoarding disorder. First, a person might be asked to throw away one item from a small

box. Next, they might be asked to throw away an entire box, and so on.

Exposure therapy may be conducted using in vivo exposure (meaning real live exposure to the feared

stimulus). Alternatively, it may be conducted using imagination. Regardless of the method,

individuals are encouraged to repeatedly face the anxiety-producing stimulus until habituation

occurs.

Once habituation occurs, the fearful response is diminished and will eventually be extinguished. This

concept is based on the principles of learning theory (specifically, classical conditioning). Research

has demonstrated that individuals learn to become afraid of neutral stimuli (e.g., doorknobs). This

occurs because a paired association forms between a neutral, conditioned stimulus (CS) and fear-

inducing stimuli (UCS). A behavior will be extinguished, (i.e., the fear is eliminated), by reversing

that process. In other words, people can unlearn their fear simply by decoupling the paired
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association between the fear and the neutral stimulus (CS). For example, a person with germ

contamination may have formed a paired association between fear and doorknobs (CS). As a result,

he or she may avoid touching doorknobs directly. Through exposure therapy, the person would

repeatedly touch doorknobs until habituation occurs. Because the doorknobs (CS) no long produce a

fearful response (due to habituation), the association between the doorknob and fear has been

decoupled. As such, the fearful response is gradually eliminated or extinguished. Through repeated

exposure, the person learned something new: Nothing terrible happened as a result of touching the

doorknob.

Response Prevention: Exposure therapy is usually coupled with response prevention. This is also

known as "ritual prevention." This component of treatment is particularly important for people who

have developed ritualized, repetitive behaviors such as compulsions. The compulsive behavior serves

to "undo" or neutralize the anxiety that occurs when faced with an anxiety-provoking situation. Since

compulsive behaviours serve to reduce or eliminate anxiety they are intrinsically rewarding.

Therefore, they are repeated.

Response prevention is based on a principle of learning theory (specifically, operant conditioning).

According to this principle, when a behaviour is no longer rewarded (reinforced) it becomes extinct.

This means the behaviour gradually fades away. For instance, washing hands after contact with a

doorknob serves to "undo," or negate the anxiety that occurs after touching a doorknob. Response

prevention eliminates the rewarding effect of hand washing. As such, compulsive hand washing will

gradually become extinct.

Escape and avoidance behaviours serve the same rewarding function as compulsive rituals. You may

recall that escape and avoidance are protective coping strategies that reduce anxiety in the short-

term. Since anxiety is reduced by avoiding or escaping anxiety-provoking situations, these avoidance

behaviours are rewarded. Since escape and avoidance behaviours are rewarded by the reduction of

anxiety, the avoidance behaviours continue.

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The elimination (extinction) of rewarded behaviours (compulsive rituals, escape, and

avoidance) cannot be achieved unless these behaviours are prevented. Response prevention prevents

these behaviours from being rewarded. Once a behaviour is no longer rewarded, it stops. Response

prevention is a necessary component of behavioural therapy in the treatment of obsessive-

compulsive disorder, body dysmorphic disorder, and hoarding. The combination of exposure to

anxiety-provoking stimuli, along with the prevention of rituals, escape, or avoidance leads to the

most effective treatment response.

It should be evident that exposure and response prevention therapies require the willingness

to tolerate some discomfort until habituation develops. Therapy participants voluntarily choose to

participate in this type of therapy. They are well-prepared in advance of the therapy. At no point is

anyone forced or coerced to participate in the exercises. If it becomes too difficult to complete an

exercise, the process is stopped. Then, the therapist and participant discuss what happened.

Sometimes the therapy participant is ready to try again. At other times, the therapist may switch

approaches and work toward increasing motivation for treatment. The therapy is most effective when

conducted with the therapist guiding the patient during therapy sessions, coupled with follow-up

homework assignments

Therapeutic Recommendations

Dream Analysis

Although multiple psychodynamic techniques were used, due to limited number of sessions

with the client, little attention was given on his patterns of nightmares. He evidently had nightmares

elicited his unconscious conflicts. These nightmares were frequent. The clinical psychologist focused

on other issues that she considered needed more attention and were more alarming. However, as
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these nightmares were recurrent, they must have dealt with as well alongside other psychodynamic

techniques.

ACT

Moreover, ACT could also be used as part of the CBT treatment as ACT can help people with

resistant BDD since it teaches them how to tolerate anxiety-inducing circumstances

Rather than trying to alter, dispute, or come up with alternate interpretations of situations,

ACT places more emphasis on learning to tolerate thoughts and symptoms. The fundamental ideas of

mindfulness, acceptance, and value-based living are all included in this kind of therapy.

• Mindfulness: Improving one's capacity for being in the present and for observing without

passing judgement.

• Acceptance: The capacity to discriminate between suffering and pain as well as the capacity

to put up with and live with discomfort.

• Value-based living: The capacity to live in accordance with your values rather than your

symptoms; embracing life completely now rather than delaying it till your symptoms get better.

Mindfulness

Learning techniques that support accepting thoughts and feelings is part of the mindfulness

component of ACT. When it comes to BDD, you practise accepting ideas like "I have an ugly face"

and emotions like "I am unlovable." This is accomplished by practising several mindfulness

techniques, such going for a silent stroll and merely paying attention to thoughts, feelings, and
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sensations as they arise. You can become aware of the fact that, despite the variety of experiences

you may have, you are never defined by them.

Acceptance

As a result of this fixation, many BDD sufferers endure excruciating anguish. They avoid and

strive to manage unpleasant thoughts when they are struggling. ACT aids people in enduring times of

affliction and difficulty.

It starts by addressing your readiness to go through typical symptoms including unwelcome

thoughts, ideas, and circumstances. The notion that unpleasant internal sensations are not as

destructive as you believe is then introduced.

You will eventually develop more adaptable responses to stressful ideas that lessen misery

and struggle. Instead of changing your thinking about it, ACT focuses on modifying how you react to

triggers like thoughts about your head.

The goal of ACT is to distinguish between a label and a thought. Label: "I am ugly." as

opposed to Thought: "I am thinking that I am unattractive." You can learn the distinction between a

thought and a sense of self. Knowing that we are not our thoughts is crucial for ACT. This procedure

helps to lessen the emotion associated with such ideas.

Value-Based Living

Value-based living is the third element of ACT. Many people with BDD solely prioritise their

appearance. ACT aids in identifying additional values that might act as principles for how to live
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your life. In order to determine what is genuinely important to you, urges and sentiments must be

reduced.

For instance, a person with BDD might appear to place importance on looks, but values-

clarification exercises may show that the person's underlying values are human connection and the

corresponding needs to be loved and valued. This value can be sought therapeutically in methods that

downplay the significance of appearance. An agreement to live life for its values rather than for

symptom relief is a part of this component. This strengthens motivation to have a healthy lifestyle

and helps in continuing therapy.

Prognosis

The prognosis was reasonable in terms of the client having a good insight into his problem.

However, the client was also missing on to psychiatric medications as he was not regular. He also

used to miss sessions especially when not being good in terms with his family and used to have

unstable and fluctuating levels of motivation and will towards the therapy. Added to this was, there

was no one in his family to support him except for his brother. His social support was also minimal

with just one best friend trying to help him, which might worsen the condition of the patient and

reduce the chances of recovery or increase chances of relapse. Although the client learned some

coping techniques, he needed much extensive therapy to improve prognosis.

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References

Cherry, K. (2021). Cognitive behavioral therapy. Verywell Mind.

https://www.verywellmind.com/what-is-cognitive-behavior-therapy-2795747

Ackerman, C. (2020, January 19). 5 REBT Techniques, Exercises and Worksheets.

PositivePsychology.com. https://positivepsychology.com/rebt-techniques-exercises-

worksheets/

What is Jacobson’s Relaxation Technique? (2014, December 2). Healthline.

https://www.healthline.com/health/what-is-jacobson-relaxation-technique/

Ruggiero, G. M., Spada, M. M., Caselli, G., & Sassaroli, S. (2018). A Historical and Theoretical

Review of Cognitive Behavioral Therapies: From Structural Self-Knowledge to Functional

Processes. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 36(4), 378–403.

https://doi.org/10.1007/s10942-018-0292-8/

‌Ackerman, C. (2017, March). How Does Acceptance And Commitment Therapy (ACT)

Work? PositivePsychology.com. https://positivepsychology.com/act-acceptance-and-

commitment-therapy/

Ackerman, C. E. (2017, March ). How Does Acceptance And Commitment Therapy (ACT)

Work? Retrieved from Positive Psychology: https://positivepsychology.com/act

acceptance-and-commitment-therapy/

ACT With CBT for BDD: More Than Alphabet Soup. (2020, June). Retrieved from Anxiety

and Depression Association of America: https://adaa.org/understanding-anxiety/body-

dysmorphic-disorder/treatment/act-with-cbt-for-bdd#:~:text=defect%20in%20appearance.

Treatment,camouflaging%2C%20and%20other%20compulsive%20behaviors

Brohde, S. (2013, December). Validation of the Body Dysmorphic Disorder Questionnaire in

 75

a community sample of Swedish women. Retrieved from Science Direct:

https://www.sciencedirect.com/science/article/abs/pii/S0165178113003946?via%3Dihub

Cherry, K. (2021, January). What Is Psychodynamic Therapy? Retrieved from

Verywellmind: https://www.verywellmind.com/psychodynamic-therapy-definition-uses-

effectiveness-5094933

Exposure and Response Prevention (ERP) Therapy for Obsessive-Compulsive and Related

Disorders. (2015, 5). Retrieved from MentalHealth.net:

https://www.mentalhelp.net/obsessive-compulsive-spectrum/exposure-and-response-

prevention/

Laura Darwot. (2022, April 07). What Is Psychoanalytic Therapy. Retrieved from

Verywellmind: https://www.verywellhealth.com/psychoanalytic-therapy

Lisa Fritcher. (2021, August). What Is Eclectic Therapy? Retrieved from Verywellmind:

https://www.verywellmind.com/eclectic-therapy

‌
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Annexure of Case 3
 77

Mini Mental Status Examination (MMSE)

78
 79

Rotter’s Incomplete Sentence Blank (RISB)

 80

Body Dysmorphic Disorder Questionnaire (BDDQ)