1

Bio Data

Name S.N

Father Name M.F

Age 46 years

Gender Female

Siblings 3 sisters and 1 brother

Birth order 1st

Marital status Divorced

Children 3 daughters

Education M.A Economics

Religion Islam

Occupation Teacher

Source of Referral

The client was referred for the academic purpose.

Presenting complaints reported by client

Table 1

Duration Symptoms
1 year ‫میراکسیچیزمیںدلنہیںلگتا‬
1 year ‫نیندنہیں آتیہے‬
9 months ‫تھکاوٹہوجاتیہے‬
1 year ‫مجھےغصہبہتزیادہآتاہے‬
1 year ‫بھوکنہیںلگتیہے‬
1 year ‫میںبالکلخاموشہوجاتیہوں‬
5 months ‫مجھےرونابہتزیادہ آ تاہے۔ کبھیکبھارمیرادل کرتا ہےکہمیںمرجاؤں۔‬
9 months ‫میںکسیچیزکیطرفتوجہنہیںدےپاتیہوں‬
 3

History of Present Illness

The client’s main complaint was the symptoms of depression, anxiety and excessive
distress that again started about one and half months ago with daily depressed mood, decrease
of interest in everyday activities, irritability, and trouble sleeping at night, lack of energy and
lack of concentration due to excessive worry. With the passage of time the symptoms just get
worse. The attendant of the patient reported that when she was in jail about 4 years ago for
two months, she faced many tortures and abuse. After her bail from the jail she lost her sense
of recognizing. She even did not recognize her any family member. After her return from
lockups she admitted in DHQ Hospital for the treatment of depression and had 8 ECT done
during this admission after which she improved. She did not complete her medication
properly. Now she is at home.
Background Information:
Family History
Client was divorced and has three daughters. She has 4 siblings. Her parents are alive.
She still lives in husband’s house because her husband lives in abroad that’s why she lives
with her daughters. Client lives in a joint family system. The general home atmosphere is
non-supportive and non-cooperative. Client reported that at first her relationship with her
husband was very good but when he started following her sister in Law and began to suspect
her, their relationship became disturbed. When their quarrels escalated, he divorced her 2
years ago. Their separation had a profound effect on their daughters. Now her daughters are
also very stubborn and not respect and care her. The client also reported that her parents does
not support her and no siblings support her.
Personal History
Birth and Early Development
According to the client’s sister, she was born at home, with a normal delivery. Her
sister reported no complications at the time of birth. Client achieved all the developmental
milestones at the appropriate age. No neurotic traits were reported by the sister.
Educational History
The client started her schooling at 5 years of age. She was an average student who
used to spend time playing and studying at home. She completed her M.A Economics with
good grades. She was not much talkative and was always reluctant to participate in
extracurricular activities. He had good relationship with her class fellows. She had only one
close friends.
4
 5

Occupational History
She is doing a job as a teacher in Shiblee College Faisalabad. She is satisfied with her
job.
Sexual History
According to her sister client reached puberty at the age of 14 years.
Pre-morbid Personality
Client reported that during her childhood he used to play with her friends and siblings.
She had friendly behaviour with her siblings and few childhood friends. The client said that
her relationship with her grandmother was very strong. She was strongly attached with her
grandmother more then parent and when his grandmother died and then his family members
stopped fulfilling her wishes. Due to which she was very anxious since childhood.
History of Psychiatric Illness in Family
Non-significant
Psychological Assessment
Informal Assessment
Behavioural observation

The behaviour of my client was nervous. She became irritated easily. She was
weeping easily. She was co-operative. She answered to my questions properly. Her mood was
low. She wears was neat and clean clothes. Her eye contact was poor to some extent.

 Mental status Examination (MSE)

Appearance: Client was 46 years old female. She was wearing weather appropriate dress.
Her hair were not well combed.

Behaviour: She was not maintaining proper eye contact, and her behaviourwas cooperative
during the interview.

Talk & Mood: Her speech was normal but her mood was low and depressed.

Thoughts: She was little bit disturbed due to her mental condition and negative thought
process. She responded the question with restlessness.

Orientation: Client was well oriented about herself, time and the place. She properly
answered the questions asked to check her general awareness and general knowledge.

Insight: She had proper insight about her illness and she gave all the relevant information in
a very good manner.
 6

Perception: Her short term and long-term memory was intact.

 Psychological testing
1. Solloson Drawing Coordination Test (SDCT)
2. Depression Anxiety Stress Scale ( DASS)
3. Rotter’s Incomplete Sentence Blank (RISB)
4. Human Figure Drawing (HFD)
5. Thematic Apperception Test (TAT)

Results:

1. Solloson Drawing Coordination Test (SDCT)

Qualitative analysis:
Client score 99.4 on SDCT which indicate that client’s eye and hand coordination
seems to be intact.

2. Depression Anxiety Stress Scale ( DASS)

The client’s score on stress items is 32 which is severe level, score on anxiety items is
24 which is extremely severe level and the score on the depression items is 42 which is fall in
extremely severe category.

3. Rotter’s Incomplete Sentence Blank (RISB)

The client scores of 174shows that the person seems to be mal adjusted.
Qualitative analysis
The RISB measured the different aspect of her personality such as,
• Familial attitude.
• Social and sexual attitude.
• General attitude.
• Character traits.
Familial attitude
The statement no.4 shows client negative attitude towards her home. She remains
upset when she is at home. Statement no.11 shows her attitude towards her mother is positive.
She considers her mother a great blessing in her life. Statement no. 35 shows that she has
positive attitude towards her father. Statement no.39 shows her biggest tension is her present
life.
Social and sexual attitude
 7

My client also has negative experience towards other people. Statement no.7, 9 and
10, 19 clears that she thinks that other people are selfish. She thinks that other people are not
good. They don’t interfere in their life. Statement no. 29 and 30 indicates that she hate her
husband and worried about the future of her daughters. Statement no. 40 indicates that other
women’s always failed to please their husbands. Statement no. 26 she reported that marriage
is a big promise.
General attitude
Statement no. 1 and 2 indicates that she likes to spend her time alone. And also
recalled the memories of her parent’s home. Statement no. 8 indicates when there were no
worries in her life. Statement 27 indicates she is better when she does any work with
attention.
Character traits
Statement no.32 indicates she was well but not now. And 37 indicates that she is
failure. Statement no. 12 indicates that she felt her life remains short. Statement 5 shows that
she regrets about her relationship. Statement no 24 and 25 indicates that she is pessimist
about future and she needs a person who better understand her.
4. Human Figure Drawing (HFD)
Crossed eyes:
It shows hostility, rebellion, anger and does not view world in the same manner as
other.
Teeth:
It indicates that she is overtly aggressive, and also shows emotional disturbance,
sadistic tendencies and hysteric.
Long arms:
It shows she is overtly aggressive and strive for love and affection.
Legs pressed together:

It shows she has psychosomatic complaints and rigidity.

Monster or grotesque figure:

It shows hostility, intense feeling of inadequacy and very poor self-concept.

Thematic Apperception Test (TAT):

The client seems to have the need of Autonomy, Succorance, Passivity Affiliation,
and Sex. The client seems to have the presses of Claustrum, Aggression, Dominance,
 8

Rejection , Loss and Lack. She seems to have the conflict between Approval and Disapproval
and Helpless Vs Help. The inner state of my client seems to be Dejection. She wants love,
support and affection.
 9

Summary of Case Formulation

Presenting complaints:
Depressed mood, insomnia, lose interest, lack of energy and
fatigue, aggressive behavior, low appetite, crying spells, lack of
concentration

Adult Precipitating factors:

Predisposing factors:
Female S.N 46 Divorce and her insecurities
Strict and conservative
about her daughters future.
environment

Perpetuating/Maintaining factors:
Her daughters ignore her and her
parents do not support her

Protective factors:
Her sister’s support

Assessment:
1. Slosson Drawing Coordination Test (SDCT)
2. Depression Anxiety Stress Scale ( DASS)
3. Rotter’s Incomplete Sentence Blank ( RISB)
4. Human Figure Drawing (HFD)
5. Thematic Apperception Test (TAT)

Diagnosis
Major Depressive Disorder
 10

 Diagnosis According to DSM-5

According to the DSM-V all the symptoms of the client lied in the criteria of Major
Depressive Disorder, 296.32(F33.1) Recurrent episodes (Moderate).
Differential Diagnosis:
The primary difference between the diagnoses of a Major Depressive Episode and Generalized
Anxiety Disorder is that a person who experiences depression usually describe their mood as sad, hopeless,
feeling “down in the dumps” or “blah” while a person who struggles with Generalized Anxiety Disorder
reports feeling constantly worried and having a hard time controlling the worry. The physical symptoms of
depression and anxiety can also help us differentiate between the diagnoses.
 11

Treatment Plan

Case No 04 Client’s Sana Nasir Age 46 Gender Female

Name

Symptoms Depressed mood, insomnia, lose interest, lack of energy and fatigue, aggressive
behavior, low appetite, crying spells, lack of concentration

Diagnosis Major Depressive Disorder, 296.32(F33.1)

Recurrent episodes (Moderate)

Target  Depressed mood

Symptoms  Insomnia
 Lose interest
 Aggressive behavior
Treatment  Cognitive Behavior Therapy ( Cognitive restructuring)
approach

Frequency 1 per Proposed 6-7

of sessions week number of
required sessions to
achieve
goals

 Psychoeducate the client family

Major  Identifying Cognitive Errors
Treatment
 Daily Activity Scheduling
Goals
 Focusing on the Positive

 Productive and Unproductive Worries

 Self-reinforcement
Number Expected Time
Interim To achieve
Treatment
1. Establish working 2
Goals for relationship with the client.
target
2. Muscle relaxation 3
Symptoms
3: Deep breathing
3

4. Find underlying cognitive 2/3

errors

5.Emotional regulation 2/3

10

Initial Phase  Establish working relationship

 12

 Ensure confidentiality and empathy

 Took initial history

Middle  Applied Progressive muscle relaxation technique

Phase  Gave Psycho-education
 Presented ABC Model to client
 Identify cognitive errors
 Explained productive and unproductive thinking
 Applied Cognitive restructuring (from CBT)
Termination  Evaluate the progress of therapeutic work
Phase
 Analyze the satisfaction of client

 Analyze the recovery of client

 Check the dependency level

 Ensure the termination 2 session before terminating the client

 Decrease the session gradually

 Ask for feedback and reviews.

 13

Session Report
Session I
In the initial session rapport building was not done. But after sometime I talked to her
and relaxed her, and told her that she will be fine soon. She understood me and relaxed for
sometime.
Session II
In the second session rapport building was done. The initial history was completed.
The Progressive muscle relaxation technique was also taught to the client. She was
cooperative. Her appearance was kempt. But her mood was low and depressed. Negative
thoughts still present.
Session III
The positive statement was given and as well as Progressive muscle relaxation
technique was given again and also taught Deep breathing. She also done her activity chart.
Her sister reported that her appetite also improved and her sleep was also improved. 16 PMR
was also done in this session. And in this session Psycho-Education given to her daughters
because they misbehave with their mother and don’t understand her mental condition.
Session IV
In the fourth session client reported by herself that now she feels much better and her
muscle stiffness decrease by did the Deep breathing exercise and 16 PMR. Today ABA
model represented to client in which the cognitive pathway that led to the negative or positive
outcomes on the bases of our own personal evaluation of the situation.
Session V
Client was explained the difference between productive and unproductive worries,
that sometimes person use to think and worry excessively about the things which are not even
happening to her and the person makes the situation worse by only focusing on bad things.
The cognitive behavioural therapy was also done on the client. The main purpose of use CBT
on the client was to aware her to better understanding of her problems.
Session VI
Client was asked to focus more on the positive things and blessings in his life, and
avoid the disturbing thoughts as much as possible. Negative assessment of one’s own life
lead to the depression and stress, and can reduce the individual’s ability to cope with stressful
events of life.
 14

Post-Management Assessment
Pre and Post Assessment of Symptom Severity

Pre and Post Assessment of self reported

symptom severity
post assessment Pre assessment
50
80
symtom 7 60
70
symptom 6 70
75
symptom 5 60
80
symptom 4 65
75
symptom 3 50
65
symptom 2 70
80
symptom 1 60
75