Midterm Case Report

Ayesha Arshad (362475)

Internship-I

Submitted to:

Dr. Salma Siddiqui

November 13, 2022

Department of Behavioral Sciences

School of social sciences and humanities, NUST

Summary

F.K was a 19 years old unmarried male from a lower middle socioeconomic class family

in south Punjab. He was last born among 4 sisters, all of whom were married. He was a 3rd

semester student of computer science (B.S.) at NUST, currently residing in NUST hostel. Client

presented with low mood, difficulty initiating sleep, irritability, lost interest, difficulty

concentrating, and excessive worry and guilt around his habit of vaping and smoking. Clinically

these symptoms were suggestive of major depressive disorder. Additionally, tobacco

consumption in form of smoking and vaping puts client at risk for comorbidity of tobacco use

disorder. However, the intensity and time period of current symptoms do not the criteria for a

full-blown diagnosis. This report is intended to synthesize the data gathered from the case to

provide clinical presentation of client’s problems keeping in mind the nature and context of these

problems.
Identifying information

Name F.K

Gender Male

Age 19 years

Qualification bachelor’s in computer science

Marital Status Unmarried

Referral and Context

F.K. was a 19 years old unmarried male belonging to a lower middle-class family in

south Punjab. He was a 3rd semester student of computer science (B.S.) at NUST, currently

residing in NUST hostel. He was the youngest among four siblings. Client was approached to

take part in clinical interview for educational purpose. The purpose of this interview was to

complete the writer’s educational requirement for course of Clinical Internship-I. Informed

consent obtained from client is attached in Appendix A.

Presenting complaints

During the interview client reported, that he had been experiencing “low mood and

restlessness along with excessive worry”. “Excessive guilt” around his smoking habit was also

reported by client. He also reported that he had “lost interest” in the routine activities, including

socializing with friends and playing sports which, he used to. He also reported “difficulty

initiating sleep, irritability, difficulty concentrating in academics”. He also reported being

“preoccupied with thoughts” around his future.

History of presenting complaints

 Client’s symptoms reported that his symptoms initiated when he came to NUST

last year, he reported that in beginning he started feeling “distressed” and “isolated” as he

did not have any friends at that time, and he could not manage the “burden” of

academics. He also reported feeling “out of place”. He reported that he would stay in his

room, and he would just go out to take class. He also reported that he coped up with the

stress by avoiding the task as he would scroll on social media for hours while his

assignment would be pending. He reported that After 1st semester he made some friends

at hostel as well as in class. He reported that he started feeling “better”. He was not

feeling low however his academic stress still prevailed. He reported that all of his new

friends used to smoke cigarette and he was the only one who did not therefore he also

started smoking cigarette to “make his place in the group”. He reported that he did not

want to feel being “left out” and he was “scared” that they might “break the friendship”.

Therefore, he also started smoking occasionally. He reported that after few days he

started vaping too as he wanted to try that. During this phase (2nd semester) he also got

“romantically” involved with one of his class fellows. Their relationship lasted for around

6 months, and they broke up in the beginning of 3rd semester almost a month ago. He

reported that he was “upset” because of this and to “cope up” with the stress he increased

his dosage of cigarette. He reported that he stared feeling lonely and he could not think

about anything else. He reported losing interest in activates after this incident.

He reported that during this time period (almost 2 week), he went to a friend’s

apartment on a weekend, and his friends “advised” him take cannabis as it would help

him to “numb” the pain. He reported that he was “sad and upset” and wanted to “get

over” everything so he took half gram of cannabis. He reported that after nearly half an
hour he started experiencing “increased heartbeat, heightened senses, and light

headedness”. Upon father probing he reported that “colors were brighter and more

conspicuous than usual’ he felt “very energetic”, and his overall tactile perception was

heightened as he reported that he could more easily “perceive the feeling of his shorts

rubbing against his legs as he walked”. He also reported being “immersed in daydreams”.

The symptoms lasted for almost a day and stayed at friend’s apartment and only went to

hostel when the effect of cannabis subsided. He reported that the subsequent day when he

talked to his family he felt “extremely guilty and shameful” and felt that he was

“betraying” them behind their backs. He reported that he decided to quit all the “bad

habits” that day. He reported that he did not consume cannabis after that however, he

could not quit smoking and vaping. He reported that he would go few hours without

consuming these things but whenever he goes to his company, he is not able to “resist”.

He reported that his family also came to know about this. They were really “furious” in

the beginning, but client promised them that he would quit these habits. He reported that

he has told them that he does not use any of these things now therefore he feels guilty

about lying to them.

Premorbid Personality

Client reported that he was a “lively and jolly” person before coming to NUST. He

reported being “social and friendly”. He reported that used to actively participate in sports

tournaments. He also reported being “aggressive and quarrelsome”. He would quarrel with his

family when they would ask him to stop going out with friends or refused to give him money.

Personal History

Social History
 Client reported that he used to have a lot of friends since childhood, and he never

encountered difficulty in making friends before coming to NUST. He also reported that his

parents never endorsed his friendships because they considered his friends as bad influence on

him. At NUST he did not have any friends in beginning however he made some friends after

some time, and he reported that now he does not want to lose them because again go back into

that cycle of loneliness.

Academic History

Client reported that he had been a below average student since school and . he did not

like going to school. When he was a child, he would throw tantrums daily before going to

school. And he would also get a handful of scolding from his father sometimes he would even

get beaten by his father. He reported that He had a lot of friends at school, but he wanted to

spend time with his friends who were outside of his school circle. These were the friends of his

colony. He reported that the situation altered in college it was around the same time when his

girlfriend broke up with him and he wanted to rectify his mistake. He reported that he started

studying hard after that and he secured good very good marks in inter. He reported that his was

very happy because of this. After that he got admission in NUST. He reported that he struggled a

lot here. Everything was disparate here. Upon further inquiry he reported that there was way too

much independence here and he was scared that he would get lost. He also reported that the

relative grading was a source of stressor for him, and he had difficulty competing with others. He

reported that he passed previous semesters with a lot of struggles and in his current semester he

is scared that he will fail as he had not studied anything for exams yet. He attributed his struggle

to his bad habits and his low mood.

Sexual history
 Client was in his early adulthood. He reported he had been in romantic relationship twice.

He has been emotionally attached to a girl before coming to Islamabad too. It was the first

romantic relationship experience in his life. He reported that she lived in his colony. They were

also enrolled in same academy. As reported by client She was very pretty, and client was

extremely in love with her. He reported that initially she was reluctant to be in a relationship but

eventually she became also equally involved in the relationship. Client reported that she broke

up with him because he was very possessive, and he would always invade in her personal space.

She felt could not even breathe in peace these were the perceptions of his that girl as reported by

client however client also agreed with these complaints. Client reported that he was sad and

guilty after the breakup, and he realized his mistakes. He reported that his friends helped him a

lot during that phase.

Client’s second relationship was with one of his class fellows and this relationship ended

almost after a semester. Client reported that both of them were happy and satisfied with the

relationship, but the girl got engaged to her cousin and therefore broke up with him. Client

reported that he felt extremely dejected and lost after that. he just wanted to get over the feelings

because they were too much handle therefore, he got indulged in bad habits to avoid those

feelings.

Health and Medical History

The client reported to have no major illness since his childhood. He was healthy in his

childhood. Even now he only had some seasonal flu or fever.

No major psychological history was reported in his family. The client’s father was a client of

hypertension. The client reported no accidents and head injuries.

Family history
 Client reported that his father was a driver, with an aggressive temperament. Client

reported that he was very religious, and he was strict with all of the family, and they were scared

to talk to him. He also reported that he was never able to form an emotional bond with him as he

never approved of his habits (hanging out with friends, relationships with opposite gender,

ignorance of namaz, carelessness in studies, bad company). He reported that his father

extremely critical of whatever he does and never approves of anything. He reported that his

relationship further deteriorated with him when he came to know about his habit of smoking and

vaping. Client reported that he has not talk to his father for almost three months. Client’s mother

was a housewife. Client reported that she has a friendly nature, she is a quiet and calm person,

and they share a congenial relationship. He reported that she is the most important person in the

world for him. She has supported him the most. She has always motivated him to do better. He

also reported that she tries to save him from his father. She also used to give him money behind

his father’s back.

Mental status examination

The client was well kempt on the interview day. His appearance seemed to be consistent

with his reported age. He was a well-mannered and his personal hygiene was maintained. His

gait seemed to be lazy. He did not make eye contact. Although he seemed to be much

cooperative, attentive, interested in session. He was seemed to be vigilant and listening actively.

His orientation of time and place was accurate. His speech was slurred, and tone was soft. The

quality of speech was emotional. Client’s mood was appropriate with his affect; he was in

dysthymic mood. His thoughts were logical, goal directed, appropriate, and relevant with the

situation. It seemed that he was vigilant to provide correct answers. He would apologize if he did
not know any answer. He had a fair insight about his problem and seemed to be motivated to

“change” himself. He was able to make the link between his increased smoking and the problems

in different domains of his life.

Summary and conclusion

F.K was a 19 years old unmarried male from a lower middle socioeconomic class family

in south Punjab. He was last born among 4 sisters, all of whom were married. He was a 3rd

semester student of computer science (B.S.) at NUST, currently residing in NUST hostel. Client

presented with low mood, difficulty initiating sleep, irritability, lost interest, difficulty

concentrating, and excessive worry and guilt around his habit of vaping and smoking. Client’s

history and MSE revealed several factors which can be attributed to his presenting complaints i.e

social, familial, personal. Avoidant coping strategies were noted

Diagnostic Formulation

The presenting complaints of the client are suggestive of 296.22 (F32.1) Major

Depressive Disorder indicated by

 Depressed mood

 Loss of interest

 Disturbed sleep

 Difficulty concentrating

 Fatigue

 These symptoms appear to have caused significant impairment in the client’s daily

functioning i.e., social, familial, and academic.

Keeping all of the above-mentioned symptoms in view and the duration (since past two months),

the provisional diagnosis can be major depressive disorder.

Additionally, tobacco consumption in form of smoking and vaping puts client at risk for

comorbidity of 305.1 (Z72.0) tobacco use disorder. However, the intensity and time period of

current symptoms do not the criteria for a full-blown diagnosis.

Differential Diagnosis

Client could be assessed for adjustment disorder as he has had a shift of environment

which could act as a stressor (moved to hostel). However, client had adjusted there after his first

semester. He reported that he started feeling better after 1st semester as he had made new friends.

therefore, adjustment disorder was ruled out.

Persistent depressive disorder was ruled out as client had been experiencing the

symptoms for almost a month and the previous episodes (when he came to hostel) was also less

than two years old i.e., occurred one year ago.

Anxiety and related disorders can also be accessed as client reported excessive worry and

restlessness. However, client’s symptoms seem to be attributed to the tobacco consumption as he

has experienced these symptoms after consumption or withdrawal.

The client was assessed for manic episode with irritable mood or mixed episodes as she

had reported “irritated mood”. However, he denied any history of elevated mood, inflated self-

esteem, decreased need for sleep, more talkative than usual or any of the related symptoms.

Therefore, Bipolar Affective disorder was ruled out.

 Client was assessed for obsessive-compulsive disorder as he reported being preoccupied

with thoughts and they were causing significant distress. However, these thoughts did not appear

to be intrusive, they seemed to be a manifestation of rumination. The thoughts were mood

congruent, as he had those thoughts mostly when he was “sad”. Therefore, OCD was ruled out.

Case conceptualization

F.K was a 19 years old unmarried male from a lower middle socioeconomic class family

in south Punjab presented with complaints of restlessness, low mood, difficulty initiating sleep,

irritability, lost interest, difficulty concentrating, preoccupation with thoughts and excessive

worry and guilt around his habit of vaping and smoking. These symptoms were suggestive of

major depressive disorder. These difficulties seemed to be arising from harsh behavior of his

father as it seemed to be a source of distress for client moreover, there was a pattern of

inconsistent parenting i.e., harsh behavior of father and dismissive parenting from mother which

may be made client vulnerable in handling problems and uncertainties. Excessive criticism also

seemed to inculcate doubts about his self-efficacy and seemed to lower his self-esteem. It also

seemed that client was trying to find the warmth and affection in hi friends and relationships

which he desired from his family as indicated by excessive compliance with friends. Client also

seemed to adopt an aggressive temperament which appeared to be another predisposing factor

for him. Company of friends who were seemed to be a bad influence for him also seemed to be a

contributor as he learned to follow his peer and adopted the coping strategies suggested by them.

As a result, when challenges arose for him in the form of relocation, breakup, academic stress he

was exasperated, and he found this constraining to deal with.

A series of behavior and cognitive strategies further seemed to exacerbate the problems.

He either choose to avoid these problems or choose maladaptive strategies i.e., cannabis
consumption to deal with them. Client had a number of responsibilities that he was unable to

manage effectively, at the same time has held expectation that he needs to succeed in these

domains. When he struggled in any of these areas, he would withdraw from the behavior entirely

(e.g., extensive social media usage, avoiding doing assignments). This avoidance appeared to

serve as negative reinforcement as it temporarily relieved pressure to perform in these domains.

This avoidance served as short-term effective solution for the problems and exacerbated the

symptoms in longer run. As the midterm exams drew close, client’s overall distress alleviated.

This served to nurture the low self-efficacy belief which further discouraged her from engaging

in these activities. Company of friends who smoked also seemed to maintain the symptoms as

client found it difficult to refuse them, and the idea of breaking ties seemed to be related to

rejection sensitivity this was also corroborated to his behavior during the interview as he seemed

to be vigilant about giving the right answer. Client’s fair insight about his problem and

determination to quit smoking and vaping can be protective factors for him

Treatment Formulation

Treatment plan can be formulated based upon the following factors:

 Psychiatric treatment seeking for his addiction of smoking and vaping.

 Restoring his self-esteem by making him realize via motivational interviewing and

rationalizing and shifting his attention to his strengths.

 Emotion regulation strategies to manage emotions and processing of break up, social

skills to make friends who will have good influence, problem solving strategies including

distress management.

 Resumption of recreational activities i.e., sports to form healthy coping strategies.

 Cognitive behavioral therapy can be adopted as well with the underlying idea to change

the thought patterns that are disturbing the client’s life. This might happen through

identifying the underlying automatic thought thoughts and beliefs from which they

originate (which might be belief of incompetency or abandonment)