Psycho – Diagnostic Report

Bio Data
Name A.H
Father name H.R
Gender M
Age 25
Education Intermediate
Marital status single
Dates of assessments 10,11,12,13,14,15 Feb 2021
Hypothetical Case no. 4

Identifying Information
Client is 25 years old single male. His birth order is 1st.. he has 2 siblings one elder brother and
one younger sister. He belongs to middle class family. Both parents of the client are alive father
of the client is a teacher and his mother is a house wife.
Referral source
Hypothetically case was developed for the treatment plan
Presenting complaints

Interview information
Client’s problem started in childhood when he was in 6th grade. Whenever he asked questions in

the class his hands start sweating, blood rushed to his neck and face and he feel difficulty in

breathing. His legs start shaking when he stands gradually it got even worse. During childhood

he suffered due to family problems that had left him with some disturbing memories of domestic
violence. Whenever his friends introduce him to somebody new he feels anxious. Client suffered

from depression two years ago for which he took drugs. He also received CBT which did not

prove to be beneficial for him. His social relationships and friends decreased due to his problem.

client’s parents often tried to engage him in social talk and take him to social gatherings but he

feels anxious while talking to other people. He became nervous and feel anxious while in social

gathering. His social relation with his peers during his school life were not good and he had

shyness in his behavior and he feel shy while interacting with his classmates and friends.

Test administered
Beck Anxiety Inventory (BAI)
Behavior during sessions
Client’s walk was slow. His appearance was good and he was wearing shalwar kameez. Client
was interested to talk and share his information regarding his problem.
Psychological evaluation
Client’s BAI score is 21 which shows that client is suffering from moderate social anxiety.
Tentative diagnosis
300.23(F40.10) Social Anxiety Disorder, severe
Prognosis
Client’s prognosis was good. He was willing to change his behavior and has insight regarding his
problem and was willing to overcome his shy behavior among people and friends.
Management plan
Client name A.H
Age 25
Presenting complaints Feel shyness while interacting others
Become nervous while asking question in
class
Become nervous while socializing with
others
Target symptoms Make client to socialize with people
around him
Make client relax by using progressive
muscle relaxation
 Test administered Beck Anxiety Inventory (BAI)
Diagnosis 300.23(F40.10) Social Anxiety Disorder
Goals of Therapy Short term goals:
Build rapport with client
Make client feel relax and calm

Long term goals:

Deep breathing
Progressive muscle relaxation (PMR)
Mindfulness (J.k Zinn,1979)
Engage client in follow up sessions
Make client socialize with people around
him and with his classmates. Make client
extraverted and social.
Main therapy Exposure Therapy
phases Initial Phase
Session 1-4
Rapport building
History taking
Test administered

Session 5 -10
Deep breathing (write et al,1993)
Psychoeducation(Wells,1996)
Psychoeducate the client about his
problem
Progressive muscle relaxation (Edmund
Jacobson,1920)

Session 11- 12
Client was recommended for follow up
sessions
Client was provided guidance about
termination phase

Individual sessions
Session 1
Target Rapport Building
Interview with client

Therapeutic intervention Active listening (Roger,1942)

Unconditional positive regard
Genuineness
Outcomes Rapport among therapist and client was
developed

Session 2

Target Test Administration

Outcomes Beck Anxiety Inventory Test (BAI) was
administered.
Client’s score on beck anxiety inventory test was
30 which shows that client is suffering from
moderate social anxiety

Session 3
Target Psychoeducation (wells,1996)
Psychoeducate client about problem and
treatment of problem.
Outcomes Client became aware of his problem’s nature and
came to know how to manage his problem
accurately

Appendices
Case Conceptualization
According to behavioral school of thought the behavior of client is unhealthy as he feels shy

while interacting in social gatherings and people around him. He feels shy and become anxious

while asking question in class. According to behavioral perspective environment shapes behavior

of an individual.

Case Formulation
 The Precipitating factor
The Predisposing Factor
A.H Whenever he asks question in
Domestic Violence
class
When he interacts with someone
new he become anxious

The Presenting complaints The Protecting

Perpetuating Factors Client become nervous while Factors
Shyness of client asking question in class Supportive Friends
while interacting Feel Shy while interacting with
others others

Prognosis
Psychological Diagnosis The prognosis of client was
Test good and he was willing to
300.23(F40.10) Social change
Beck Anxiety Anxiety Disorder
Inventory (BAI)