Demographic data:

Name ZI

Age 34

Gender Male

Education Primary

Religion Islam

Occupation Teller Master

No of Siblings 03

Birth Order 1st

Marital Status Married

Children 3

Socioeconomic Status Middle Class

Family Structure Joint

Resident Arif Wala

Referral Source Self

Assessment Place Dewan Mind Care Hospital Burewala

Reason of Referral

The clients come to the psychiatry ward of Dewan Mind Care Hospital with himself with
complaints of sleep disturbance, swings of mood, and aggressive behavior.

Presenting complaints:

According to the Client:

The following complaints have been reported by the client.

Firstly, they have trouble sleeping and suffer from insomnia. Secondly, they lack the motivation
to engage in any activities or tasks. Thirdly, they frequently have thoughts of dying, which are
bothersome. Lastly, they have a decreased appetite and find that they don't feel as hungry as they
used to. The client has been experiencing these complaints for the past year and a half.

History of Presenting Complaints

The client came to the psychiatry ward with complaints of sleep disturbance, swings of mood
aggressive behavior, etc. he was facing these symptoms severely for 6 months. He got sleep
problems 1.5 years ago due to work overload He was accounted to have slept just often with the
use of medicine. He becomes irritated and aggressive even in normal conversations with his
children. He encountered a physical head injury during learning sewing work. He has also had a
problem with aches past 1.5 years. He has not a good relationship with his family. Children don’t
obey him. He also worried about their children’s studies. His relationship with his wife is also
not good.

Psychological assessment:

The client’s informal assessment was done through:

Clinical interview:

During the clinical interview, I conducted a thorough assessment with ZI, a 34-year-old married
male who presented with complaints of insomnia, mood swings, and aggressive behavior. I
established a rapport with ZI, creating a safe and non-judgmental space for him to share his
experiences. He reported a persistent difficulty in falling asleep for the past 1.5 years due to work
overload and mentioned feeling a lack of interest in activities. He expressed irritability and
aggression towards his children, even in normal conversations. He disclosed strained
relationships within his joint family, particularly with his wife, and concerns about his children's
studies. Additionally, He mentioned experiencing chronic physical aches and a history of a head
injury during sewing work. The interview revealed symptoms of depression, including a
persistent depressed mood, loss of interest, changes in appetite, thoughts of death, and impaired
sleep. The onset of these symptoms was associated with work-related stress and strained family
dynamics. Considering the severity of symptoms and their impact on ZI's daily functioning, a
diagnosis of Major Depressive Disorder (MDD) was appropriate.

Mental status examination (mse):

During the mental status examination, the client appeared neat and tidy in his white clothes. He
displayed restless speech, with a slightly low pitch towards the end of the interview. The client
exhibited a worried and low mood as we progressed, along with pessimistic thoughts about the
present and future. His memory appeared intact, and he maintained good eye contact. He
reported sleep disturbances for the past 1.5 years.

Formal assessment:

Scale:
A psychometric scale was applied on the client to screen out the possibility of potential
disorders, following is the psychometric scale applied with the client.

Beck Depression Inventory

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures
characteristic attitudes and symptoms of depression (Beck, et al., 1961). The BDI takes
approximately 10 minutes to complete, although clients require a fifth – sixth grade reading level
to adequately understand the questions (Groth-Marnat, 1990)

Table 7: BDI scoring

Score Range Severity Index

1-10 These ups and downs are considered normal

11-16 Mild mood disturbance

17-20 Borderline clinical depression

21-30 Moderate Depression

31-40 Severe Depression

40-above Extreme Depression

The client’s score on the Beck depression Inventory was 41 (severe).

Depressive Anxiety Stress Scale (DASS 21):

The DASS-21 is a well-established instrument for measuring depression, anxiety, and stress.

Table 1 depicts results of DASS-21.
Qualitative analysis:

DASS 21 indicated stress score 5 which is very mild level. The scoring of stress in the scale for
level lies in 5-10. The Anxiety score was 10 which are in moderate condition. Anxiety’s
periphery of scores for moderate condition is between10-15. Score for Depression was 33 which
also show severe condition of depression in patient. The Satisfaction with Life Scale (SWL)
indicated score of 25.It indicate that she is satisfied with her life. It is very alarming.

Quantitative Analysis:

Table1
DASS 21 scores of the patient

DASS-21

Stress score 5

Anxiety score 10

Depression score 33

Diagnosis:

Major Depressive Disorder DSM-5 296.20-296.36

Prognosis:

Engaging in psychotherapy, making lifestyle changes, and considering medication can

significantly improve client symptoms. The support of his family and adherence to the treatment
plan will be important for his long-term prognosis and overall well-being.

Case formulation:

ZI, a 34-year-old married male, presents with complaints of insomnia, mood swings, and
aggressive behavior. These symptoms have been severe for the past 6 months, with sleep
disturbances experienced for the last 1.5 years due to work overload. The client exhibits
irritability and aggression even during normal conversations with his children. He has a strained
relationship with his family, especially his wife, and worries about his children's studies. The
client's history includes a physical head injury and chronic physical aches. He belongs to a joint
family and carries significant financial responsibilities as the eldest son. Based on the client's
symptoms, including depressed mood, loss of interest, decreased appetite, thoughts of death, and
sleep disturbances, along with a severe score on the Beck Depression Inventory and DASS the
diagnosis of Major Depressive Disorder (MDD) is appropriate. The symptoms meet the criteria
outlined in the DSM-5, indicating the presence of depressive episodes for at least two weeks,
significantly impacting daily functioning. The client's symptoms are not better explained by any
other medical condition or substance use. The case formulation emphasizes the interaction
between environmental stressors, family dynamics, and the client's depressive symptoms. The
client's significant financial responsibilities and strained relationships contribute to his depressive
symptoms. A comprehensive management plan is recommended, including lifestyle changes
such as physical exercise, talking therapies like psychotherapy to address underlying issues, and
the consideration of antidepressant medication to alleviate depressive symptoms.
Management plan:

 Lifestyle changing (physical exercise etc.)

 Talking therapies (psychotherapy)
 Antidepressants

Short-term goal: Improve sleep quality, stabilize mood, and reduce aggressive behavior.

Long-term goal: Enhance coping skills, improve family relationships, and achieve remission
from Major Depressive Disorder.