Clinical cases report writing May 14, 2022

Submitted by: hajra shereen

Reg no: 21111149
Submitted to: Ma’am Sana mukhtar
Clinical cases report writing May 14, 2022

MAJOR DEPRESSION DIORDER

Summary

The client was 50 years old woman. She belongs to a middle class family. She has

one son and five daughters. Her son went to Dubai for job. She was very attached

to him in his absence she began to remain depressed and isolate from other family

members. After psychological assessment she was diagnosed with major depressive

disorder her symptoms includes lack of pleasure, poor appetite, poor sleep, negative

thoughts, and worthlessness.

Demographic Data

Name: Mr.Z

Gender: Female

Age: 50Years

Marital status: widow

Area of education: Rawat

Education: Uneducated

Siblings: 8

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Birth order: 2nd

Socioeconomic status: Middle class

Reason for Referral

Client was brought by her father to the Islamic international medical hospital

railway hospital for the checkup of somatic complains but the doctors refer her to

the psychiatrist because she doesn’t have any evidence for somatic complains.

Presenting Complaints

According to client:

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The Client has been suffering from the following complaints for last 1 year.

Table 1

Shows presenting complaints according to the Client:

Presenting complaint Duration

Disturbed sleep during whole night 2 months

Decreased appetite 6 months

Low mood 1 year

Fatigue 4 months

Muscular pain 3 months

Lack of happiness 6 months

Negative thoughts about self, future and world 1 year

Family History:

Client is fifty years old woman. She has eight siblings in her family including her.

She was happily married and lived a happy life. There is no medical or psychiatric

history of the family.

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Personal History:

Clients belongs to a middle class family. She is very attached with his son. She is

having good relationship with her family.

Onset of Illness:

The above symptoms manifested in client about 8 months ago. When his son went

to Dubai for job she used to remain isolated and depressed as she was very attached

his son. Gradually her symptoms increased in intensity and she lost interest in

household activities and difficulty in memory. Specially memory problems occur

during when she offer prayer and she forgets what she was reciting. According to

her she feels very happy better when his son comes to Pakistan.

TEST ADMINISTERD

Assessment of the client was made both informally and formally.

Informal Assessment:

Informal assessment was made through interview and behavioral observation.

Interview and behavioral observation. Interview was last from 40 minutes to on

hour.

Formal Assessment:

Formal assessment includes following test administration:

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Human Figure Drawing (HFD)

Beck Depression Inventory (BDI)

BEHAVIORAL OBSERVATION

The patient was very sad in low mood. She was well-kept wearing clean clothes.

She was sitting on the chair comfortably. She was co-operative and eye contact was

poor. Her short term and long term memory was little unstable.

PSYCHLOGICAL INTERPRETATION

Quantitative Interpretation: (BDI)

Obtained Marks Cut Of Score Interpretation

scores indicate severe

31 0-13 no depression depression

14-19 Mild

20-28 Moderate

29-63 Sever

Quantitative Interpretation: (HFD)

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HFD gives and obvious representation of the client. The omission of some facial

features and parts shows Impulsivity, social withdrawal and poor eye contact.

Narrow stanched legs and heavy line quality shows rigidity.

DAIGNOSIS

Diagnostic is made according to DSM-V the client is diagnosed with major

depression disorder. After formal and informal assessment, diagnostic criteria were

checked from DSM-5. As formal and informal assessment showed symptoms of

major depressive disorder, it was checked from

DSM-5 criteria. The symptoms have been diagnosed as major depressive disorder

according to

DSM-5.

Diagnostic criteria Symptoms present in client Status of symptoms

Depressed mood most of the Depressed most the time

day, nearly every day with low mood.

reported subjectively or

observed. Markedly
Client did not want to involve
diminished interest or

pleasure in all, or almost all,

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Clinical cases report writing May 14, 2022

activities most of the day,in any activity almost every

nearly every day. day.

Significant weight loss Client’s appetite was

when not dieting or weight decreased noticeably.

gain, or decrease or

increase in appetite nearly

Poor sleep quality
every day. Insomnia or

Hypersomnia nearly every

day. Fatigue and low energy level

Fatigue or loss of energymost of the days

nearly every day.

Prognosis:

Client’s problem was reported timely which is a major factor in treatment.

Antidepressants were prescribed by the psychiatrist towards which client showed

good compliance. Both client and her husband had good insight of the issues she

was facing and husband was very motivated to bring her for further sessions. All

these factors indicate good prognosis.

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Management plan:

Management plan was devised on the basis of client’s symptoms and their severity

level. It consisted of the following therapeutic interventions:

• Rapport building

• Psycho education

• Social skill training

• Counselling

• Relation of her thoughts with Islam

• CBT

• Behavior therapy

• Progressive muscle relaxation

• Key words

• Smiling

• Listening to Tilawat of Surah Al-Rehman

• Cognitive behavior therapy

▪ Activity schedule

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▪ Introspection

▪ Thought reconstruction

Goals:

1. Short term goals:

⚫ completing exposure to all avoided situations;

⚫ engaging in one pleasurable activity daily; acquiring assertion skills.

2. Long term goals:

⚫ eliminating all depressive symptoms

⚫ engaging in all previously avoided activities.

CASE 2

Summary

Client belongs to a middle class family. Her father is a government servant.

After matric she decided to hifz Quran. She got admission in madrassa and

was happy with her decision. The patient one day coming from madrassa

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Clinical cases report writing May 14, 2022

next morning she started behaving strangely and became very aggressive.

Her family did not understand what happened to her they tried to know but

she was very aggressive and did not talk to anyone. Now she is under

psychiatric treatment from one year.

Demographic Data

Name: Mr. x

Gender: Female

Age: 27 Years

Marital status: Unmarried

Area of education: Rawalpindi

Education: Matric

Siblings: 5

Socioeconomic status: Middle class

REFFERRAL SOURCE

The patient was referred by her parents for psychiatric assessment .

According to client:

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Symptoms:

• Low mood

• Distractibility

• Auditory hallucinations

• Visual hallucination

• Memory loss

• Poor concentration

• Difficulty in expressing thoughts

• Slow thinking

• Disorganized thinking

INTERVIEW INORMATION

Family History:

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Clinical cases report writing May 14, 2022

Patient family consist of 5 siblings. Her father is very co-operative and supportive

with her daughter. She is not having good relationship with her mother as she is

having with her father.

There is no past medical or psychiatric history.

Personal History:

Client is 27 years old woman. She is unmarried. She got education till matric then

she used to in Madrassa to Hifz the holy Quran. She is having one brother and one

sister and her birth order is second.

Onset of illness:

According to the client was very jolly and lively before the manifestation of above

symptoms. She was used to do all the household work happily she was very good in

her studies. She desired to hifz the Holy Quran and she was doing it very happily.

On the whole she was very active and was able to manage and cope up with

problems. The client has joined the madrassa to hifz the Holy Quran. One day in the

evening she came back from Madrassa and did not talk to any one and she slept. In

the morning when she got up she suddenly behaving inappropriately and

aggressively. She started to saying that “chikala” is standing in front of her and he

is forcing me to behave in inappropriate way. She says that all the humans

specifically all men are chikala. According to her father she used to smile or behave

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aggressively and when they ask why she smiling she says that chikala asked her to

smile. But the strange thing is that does not talk to her verbally when she sees the

chikala she used to talk to him by producing the words just in her lips not

pronouncing the words. According to her father she has auditory and visual

hallucinations.

TEST ADMINISTERED

Assessment of the client was made both informally and formally.

Informal assessment:

Informal assessment was made through interview and behavioral observation.

Interview was last from 45 minutes to on hour.

Formal Assessment:

Human figure drawing (HFD)

Positive and Negative symptom scale (PANS)

Beck depression inventory (BDI)

BEHAVIORAL OBSERVATION

The patient was very inactive and lazy She was wearing clean clothes. She was very

restless and was unable to maintain eye contact. She has no contact with reality as

she doesn’t know about time, place or date.

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PSYCOLOGICAL INTERPRETATION

Quantitative Interpretation:(PANS)

Obtained cut off Interpenetration

124 70 Schizophrenia present

Quantitative Interpretation:(HFD)

She draw the figure on the top of the pages and it was very small sized figure which

shows insecurity, avoidance and social withdrawal. Emphasis on ears shows

hallucinations. The overall analysis of the figure indicates that patient has poor eye

contact, immaturity, hopelessness, regression, loss of autonomy and sexual

concerns.

Quantitative Interpretation:(BDI)

Obtained Marks Cut Of Score Interpretation

33 0-13 no depression Scores indicate severe

14-1`9 Mild depression

20-28 Moderate

29-63 Sever

DIAGNOSIS

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The client is diagnosed with schizophrenia with the comorbidity of depression.

TREATMENT PLAN

Treatment involves antidepressant and anti-psychotic medicines.

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APENDIX #1

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Appendix # 2

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