Case I

Identifying Information

Name: B. A

Age: 31

Gender: Male

Education: Matric not

clear

Marital status: Married

Family System: Joint

No. of siblings: Six

Birth Order: last one

Informant: Client himself and family

Total No. of session: 1

Date seen: 25-02-2022

Last date of seen: 28-02-2021

Source and Reason of Referral

The client was referred to trainee clinical psychologist in Umeed-nuh Clinical for the purpose of

psychological assessment and management. He came with the symptoms of shivering, low

blood pressure , fast heartbeat, loneliness, restlessness, .

Presenting Complaints

Presenting Complaints and duration as presented by the client.

‫دورانیہ‬ ‫عالمات‬

‫بہت ز یادہ اکیال لگتا ہے‬

6 ‫ ما ہ سے‬3

‫ماہس‬

‫ آتی‬P‫نیند نہیں‬

‫ ماہ سے‬6

‫ ماہ سے‬1 ‫بھوک نہیں لگتی‬

‫اکیال پن محسوس ہوتا ہے‬

‫ماہ سے‬6

‫تھکاوٹ رہتی ہے‬

‫ ماہ سے‬3 ‫پٹھوں میں کھچاؤ محسوس ہوتا‬

‫ہے‬

‫ماہ سے‬

The client B. A . was 31 years old came for a addiction and depression treatment a with

presenting complaints of, low blood pressure, fatigue, headache, shivering and trembling of the

hands loneliness, repetitive thoughts of the event, low mood, negative emotions etc. The client

family was also with him, who was much conscious about his mental health and they are also

worried about the psychological disturbance of B. A . The hygienic condition of client was neat
and clean, appropriate. The client was little bit nervous at the beginning of session, but after

establishing a good therapeutic relation with trainee clinical psychologist, he gradually became

relaxed and feel comfortable sharing his thoughts with the psychologist. At start he gave a good

response to the greetings. Session was started with open ended questions. He was aware of the

purpose of coming for counseling session therefore session structure was easy to continue, the

client was calm and relax and rapport was also built in a good manner. According to behavioral

examination client was cooperative in his nature do not made the proper eye contact while

answering, his voice tone was average, his Hands were shivering and he had some lines on fore-

head The client reported he generally feel breathing problem, feelings of anxiousness, trembling

of hands, low blood pressure and fast heart beat and he was worries about his son’s future. He

remembered each and every thing and his memory was quite good . He responded well to all

questions. Client started to present the complaints of his illness with duration; he was looking

much disturbed about his problem, and he want to recover from it and he came to the clinic

because he wants to recover He reported that he didn’t not have good relations terms with his

elder brother and mother and his family is against his thoughts he said that he wants to have a

separate room for kids but his family is not agree with him and he started taking drugs after his

breakup.

Client B. A reported that he had faced a lot of problems in his teenage, he did not complete his

matric because of his family pressure and after his forced marriage he started taking chars.

During the session, client’s family also reported about the mood and behavioral changing of

client after his breakup and conflict with his brother. His family reported that he remained

silent all the time, and do not talk about his problems with anyone and he only share good bond

with his father and sister’s , feel alone.

The developmental history of the client’s problem had started when he went to another country

by an illegal way and after his breakup he started taking drugs But after some time he came back

to Pakistan and then he got married and his marriage was a forced marriage and he did not want

to get married. In this way clients problem were started but client was aware of his

psychological problems and he wants to get rid of these drugs and he want to go back to a

normal life because he was a worry about his son future and he has motivation.

History of present illness

When the client was 16 years old he had conflicts with his family and when client was underage

he had physical relationship with someone and he had breakup and after that he started taking

weed drugs on regular basis which becomes the reason of his addiction and depression and after

that he came to Pakistan and then he got married and his marriage was a forced marriage after

his marriage he started taking chars and had conflict with his wife. The client reported some

complains that he was not able to sleep properly and had fatigue. Heart beat, shivering and

trembling of hand when he takes chars and had Low blood pressure.

Background Information

Personal History. The client was a religious mind person and sometimes he get up early

in the morning and offer prayers and recite Quran after prayer. He was Muslim by birth and

born in a religious family. . Client has introvert personality and he don’t talk with someone first

and didn’t get frank easily. He likes kids and he likes to spend time with kids he also love his

son and he want to recover because of his son. He was healthy child and start walking at the age

of 1and half year. He don’t like to spend his time with his family but he likes to spend his time

with his friends and friends are most important for him.

.
 Educational History. The client B. A started going to school at the age of 5. He was an

intelligent student but don’t focus much on studies and he oftened mixing the school and went

away from the school and spend time with his friends. He was a good student at 9th class and

performed well in exams and achieved a great percentage but not able to complete his education

due to his family conflicts and his family wanted him to do a business and he was not able to

complete his education. The client was feeling guilty because he was not able to continue his

education and left the school at the age of 16.

Family history.

The client belongs to a joint family system, where he was living with his brother’s and

sister’s and parents. Clients birth order was last one and his 3 brothers and 2 sisters were younger

to him. Father of the client was a nice man and he gave azan in the Mosque and he was a

religious man. He is such a kind and humble man and the client has good relation with his father.

The client’s mother was a 59 years old lady and she holds all the control of the family and client

don’t have good and friendly relationships with his mother and clients mother was a house wife.

The client reported unsatisfied and bad relation terms with his mother.

He had 5 siblings, 3 brother and 2 sisters. As they are younger to him so he didn’t have

good relationships with his 1st elder brother since childhood because his elder brother imposed

rules on him.. Client is married and his marriage is a forced marriage and he was not happy with

his marriage life and client has one kid who was 2 years old boy and client has a good

relationship with his child. Client did not reported any family illness problems but he was

suffering from Depression and addiction due to some of his personal conflicts with family

members and also because of his breakup.

History of psychiatry and psychiatry illness in family:

The client told that there was no psychiatry illness in their family, but his mother has sugar

problem and father may has some issues of blood pressure. But the client may feels severe

depression due to his addiction of taking drugs in excessive amounts because he was forced to

do arrange marriage. He had bad habit of taking drugs again and again. He feels so helpless and

sad due to this bad habit. He takes tension that when he will leave all the bad habits and

become a good man.

Social history:

The client was very polite and had humble nature. He was replying all questions which were

asked by him. He takes less interest in people and takes time to get frank with others. He has

very small friend circle and don’t spend too much time with them. He likes to spend time alone

and likes to play with kids or spending time with them. He wants to do good things for his child

and he is worried for his bright future.

Psychosexual history:

At the age of 15, the client reached to the puberty. He knew about all psychosexual matters.

Before the age of 18, he had some physical relation with a girl. He knew all these things before

the age of maturity which lead him towards the wrong path and he did some wrong things which

are not acceptable in Islam. He had become addicted to drugs due to this and destroyed his

mental health day by day. His past and some sexual relations are the main cause of his

depression and drugs addiction.

Pre morbid personality

According to the client, before the habit of taking drugs he was mentally or physically good. He

didn’t feel any weakness in his body. He was able to do his task at his own. But after drug

addiction, he feels severe depression, headache, body shivering. He doesn’t feel good or relax or
now he is totally fed up from his life and don’t want to make new friends due to his bad habits

of drugs. He just want to get rid of his bad habit and want to do work so he can make his child a

good person.

Psychological assessment

Psychological assessment is a process of testing that uses a combination of techniques to help

arrive at some hypotheses about a person’s behavior, personality and capabilities. Psychological

assessment is also referred to as psychological testing or performing a psychological battery on a

person (Framingham, 2016). Both formal and informal psychological assessment procedure was

used to assess the client’s various areas of dysfunction aroused due to symptomatic behavior.

Types of psychological assessment

There are two types of assessment.

 Informal assessment

 Formal assessment

Informal Psychological Assessment

Informal assessment is a way of collecting information about client’s behavior in normal

condition. This is done without establishing test condition such as in the case of formal

assessment. Informal assessment is sometimes referred to as continuous assessment as it is done

over a period of time. Informal assessment methods are subjective and these methods are often

developed treatment specific assessment needs, they will also normally require less time, money

and expertise than nationally developed techniques (Cardozo & Megdalena, 1978). It includes

the following:

 Clinical Interview

 Behavioral Observation
 Mental Status Examination

Clinical Interview. An interview is a conversation which has a purpose or goal (Bingham &

Moore, 1924; Matarazzo, 1965). Clinical Interview is a main tool of gathering information from

client, parents, and other informants (Raynold 2014). A clinical interview is a dialogue between

psychologist and patient, that is designed to help the psychologist in diagnosis and development

of treatment plan for the patient (Natalie Boyd). Interviews are flexible, relatively inexpensive,

highly portable and perhaps most important, capable of providing the clinician with

simultaneous samples of client’s verbal and nonverbal behavior. The interview was conducted to

understand the nature, severity and etiology of the patient’s problem. He was asked about his

present complaints and history of present illness to know about the duration of the problem along

with the predisposing, precipitating and maintaining factors. At the time of interview, he was

confused later on he starts understanding the interview. His tone of voice was slow and no

pressure of speech. Overall, Good rapport was established.

Behavioral Observation. Behavioral Observation is a systematic way of recording the

observable responses of behavior (Pellering, 2014). Behavioral observation was done to assess

the appearance, posture, speech, verbal, non-verbal cues and eye contact of the client. Under

observation during the session it was observed that, client was confused at start but gets

normalized after sometime, During session client’s behavior was also observed. The client was

31years old and his height was 5ft. He was wearing neat and clean clothes. He was cooperative

and friendly. He had made weak eye contact during the session. His voice tone was average. The

client reported he generally feel, trembling of hands, , shivering, low blood pressure , fast

heartbeat, loneliness, restlessness.

His memory was quite fair. He responded all questions well.

Mental Status Examination (MSE). The mental status examination is a structured assessment

of the patient’s behavioral and cognitive functioning. It includes descriptions of the patient’s

appearance and general behavior, level of consciousness and attentiveness, motor and speech

activity, mood and affect, thought and perception, attitude and insight. The specific cognitive

functions of alertness, memory and abstract reasoning are the most clinically relevant (Martin,

1990 as cited in Walker, Hall, & Hurst, 1990).

The client was 31 years old. He was very sad and anxious. He wore simple but neat and clean

dress. He was talking normally and in a normal voice during the conversation. His thought

process was not so good. The client’s abstract thinking was not good. He seemed to have intact

remote memory as he reported events of his early childhood. The client’s recent past memory

was not so good. His concentration was neither good nor bad because when asked him to count

backward he count very few. His orientation of person was not satisfactory as when asked his

doctor’s name he replied he did not know. His judgment was normal as he answered I will help

others when asked him if you encounter an accident on the roadside, what will you do? The

client possessed insight about his problem. The good thing is that he wanted to get rid of all the

problems and wanted to live a healthy and happy life.

Formal Psychological Assessment

Formal assessment methods are considered to be more objective. The FPA is a new methodology

potentially capable of maximizing the advantages of both semi- structured interviews and self-

report questionnaires by overcoming the limitations of these tools and managing the problems of

traditional assessment. The ability to analyze clinical symptoms is important when evaluating the

responses to a questionnaire. Formal assessment involves the use of tools such as tests,

Questionnaires, checklist and rating scales. The purpose of evaluation is to determine the client’s
personality, problems which impair the client’s normal functioning and severity of disorder. The

functioning of various areas of personality has been assessed by;

Diagnostic assessment

 Depression Anxiety Stress Scale (DASS)

Depression Anxiety Stress Scale (DASS)

The Depression Anxiety Stress Scale (DASS) is a widely used instrument developed

byLovibond and Lovibond (1995b) to measure anxiety, depression, and stress. The DASS was

constructed not merely as another set of scales to measure conventionally defined emotional

states, but to further the process of defining, understanding, and measuring the ubiquitous and

clinically significant emotional states usually described as depression, anxiety and stress. The

DASS should thus meet the requirements of both researchers and scientist-professional

clinicians.

Each of the three DASS scales contains 14 items, divided into subscales of 2-5 items with

similar content. The Depression scale assesses dysphoria, hopelessness, devaluation of life, self-

deprecation, lack of interest/involvement, anhedonia, and inertia. The Anxiety scale assesses

autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of

anxious affect. The Stress scale is sensitive to levels of chronic non-specific arousal. It assesses

difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and

impatient. Subjects are asked to use 4-point severity/frequency scales to rate the extent to which

they have experienced each state over the past week. Scores for Depression, Anxiety and Stress

are calculated by summing the scores for the relevant items.

Administration
The client took 14 minutes to complete DASS. A calm and comfortable environment was

provided for the completion of DASS

Behavioral observation

The purpose of applying this test to the client was clarified. Therefore,

The client was relax and confident. He was giving the answers without any delay. He was very

confident. He was totally involved in the completion of test. He remained relax at the end of

completion.

Quantitative analysis

Table 1

Following scores are showing the results of DASS applied on client.

Depression (D) Anxiety (A) Stress (S)

Ranges Score Ranges Score Ranges Score

Normal (0—9) (0—7) (0—14)

Mild (10—13) (8—9) (15—18)

Moderate (14—20) (10—14) 13 (19—25)

Severe (21—27) 25 (15—19) (26—33) 27

Extremely 28+ 20+ 34+

severe

Qualitative analysis

The client obtained 25 score on depression scale which fall in severe category. Client obtained

13 score on anxiety scale which fall in moderate category. Client obtained 27 score on stress

scale which fall in severe category.

Conclusion
The client got 25 scores on depression scale. According to scale, his scores fall on severe

category, whose range is 21-27. So the results show that, the client is suffering from severe

depression.

The client got 13 scores on anxiety scale. According to scale, his scores fall on moderate

category, whose range is 10-14. So the results show that, the client is suffering from moderate

anxiety.

The client got 27 scores on stress scale. According to scale, his scores fall on severe category,

whose range is 26-33. So the results show that, the client is suffering from severe stress.