Clinical Internship Report

Name of Intern:
Anika Hassan

Student ID:
(BC190411552)

Session:
Spring 2023

Submission Date:
18/07/2023

DEPARTMENT OF PSYCHOLOGY,
VIRTUAL UNIVERSITY OF PAKISTAN

i
 Dedication

I would like to dedicate my work to my beloved parents, Shahid and Amna Hassan, for

always believing in me and never doubting my capabilities. It is their endless love and

support that has led me to achieve what I have so far and has given me the courage to

chase after my dreams. They have always been and always will be the biggest inspiration

in my life. I would like to express my deep feelings of gratitude to Mom and Dad for

being the greatest role models I could have ever wished for, for always giving me more

than I deserve, and for showing me the true meaning of never giving up and that anything

is possible if I truly believe and put my mind to it. I am deeply grateful for the

appreciation for the importance of education and experience they have instilled in me,

and for all the sacrifices and efforts they have put into providing me with high-quality

education, and always finding time to answer my countless questions. I would not have

been able to get through my student life without their never-ending love and

encouragement. It is my parents who have given me the confidence to realize my

potential and to never doubt myself. Every achievement I have accomplished has been

because of them and for that, I am truly thankful. I could never have done this without

them.

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 Acknowledgment

Firstly, I would like to thank God for helping me from the beginning to the end of my

internship experience and my overall educational journey. I would not have been able to

accomplish these goals without Allah, the most gracious and most merciful, keeping an

eye on me and leading me toward reaching my goals.

I am truly grateful to my course instructor, Ms. Maria Zaheer, for helping me

tremendously in every step of my internship by providing me with the advice I needed

and always answering my questions. She was always there to clear up any confusions that

I had, and I am grateful from the bottom of my heart for all her support and guidance.

I would like to extend my deepest gratitude to Prof. Dr. Hamid Hassan, Chief Executive

Officer, for accepting me as an intern at the Gulab Devi Hospital’s Department of Mental

Health.

I would like to express my heartfelt appreciation to my internship supervisor, Ms.

Amama Faiz, Clinical Psychologist, for all her efforts in providing me with proper

advice, training, and experience, and equipping me with the skills to deal with a vast

range of patients. She is an amazing psychologist, and I am truly grateful for all the

knowledge and training she has provided me with during my internship. Because of this, I

am really looking forward to pursuing a career as a clinical psychologist.

I would also like to give a warm thanks to all the staff, including all the psychiatrists,

psychologists, nurses, office staff, and guards, for making me feel welcome and

providing me with a safe and loving environment to carry out my training.

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And last but not least, I would like to give my warmest and deepest thank you to my

family. To my parents Amna Hassan and Shahid Hassan, for always supporting me and

showering me with unconditional love, for the time they took out to take me to the

hospital for my internship, and for never backing down on helping me whenever I needed

it. Their never-ending belief in me is the reason I strive to do my best. Thank you to my

parents for being the most amazing role models I could ever ask for, and for showing me

the importance of education and experience. They have and always will be the biggest

inspiration in my life, seeing them succeed makes me want to succeed too. Their love and

encouragement have been my fuel during my educational journey. Thanks to them for

always believing in me and always making me feel worth their time. I will never take

them for granted, and will never forget their love and support during this journey. I could

not have done this without them.

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 Executive Summary

As a 4th year student of BSc. Psychology at the Virtual University of Pakistan, it was an

obligation for me to carry out my clinical psychology training at a proper organization

under the supervision of a working clinical psychologist. I was accepted to do my

internship at Gulab Devi Hospital’s Department of Mental Health, under the supervision

of Clinical Psychologist, Dr. Amama Faiz.

Though I was provided the opportunity to deal with several patients suffering from

different conditions, this report portrays in depth the 2 main cases taken during the 6

weeks of the internship. The procedure for the two cases started with developing a

rapport with the clients to make them feel comfortable to open up about their history.

Once the history was taken, the clients underwent therapy as per their conditions.

Each client was given up to 3 hrs of therapy every day for the 6 weeks of the internship,

in which they were allowed to freely communicate their feelings without interruption,

and given therapy, namely CBT and progressive muscular therapy. This report also sheds

light on the assessments carried out on the clients including personality tests, and other

assessments as deemed necessary. It is important to note that the assessments were only

applied once they were approved by my clinical psychologist supervisor. After all the

needed assessments were taken, the patient’s diagnosis was made after a discussion with

the clinical psychologist.

This report is divided into two main sections. The first section is for case 1, which

includes subsections starting with their history and background and ending with the

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diagnosis as per APA DSM-5 along with appendices providing pictures of the taken

assessments. The second section is for case 2 and follows the same layout as for case 1.

Overall, this report tries to put together the overall outlook on the 2 patients’ mental

health conditions along with the diagnosis of the conditions.

vi
Letter of Undertaking
(Scanned Copy)

vii
Internship Completion Certificate
(Scanned Copy)

viii
 Table of Contents
Topic Page number
Dedication ii
Acknowledgment iii-iv
Executive Summary v-vi
Letter of Undertaking vii
Internship Completion Certificate viii
(Case 1)

Topic Page number

Background Information / History 1-2

Main Reason For Referral 2

Presenting Complaint 2-4

History of Present Illness 4-6

Family History 6-8

Personal History 8-9

Marital History 9

Occupational History 9

Pre-Morbid Personality 9-10

Assessment 10-18

Mental Status Examination 18-20

Summary of Formal and Informal 20

Psychological Assessment

Diagnosis 20
Prognosis 21
Management and Treatment 21

Case Formulation 21-23

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Appendances 24-42

(Case 2)

Topic Page number

Background Information / History 43-44

Main Reason For Referral 44

Presenting Complaint 44-45

History of Present Illness 45-47

Family History 47-48

Personal History 48

Marital History 49

Occupational History 49

Pre-Morbid Personality 50

Assessment 50-60

Mental Status Examination 60-62

Summary of Informal and Formal 63

Psychological Assessment
Diagnosis 64
Prognosis 64
Management and Treatment 64
Case Formulation 64-65
Appendances 66-76

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 (Case 1)
Background Information / History
Initials F.S.

Age 22

Gender Female

Hospital Gulab Devi Hospital’s Department of

Mental Health

Date of Admission 17th of May, 2023

Education Level FSc.

School/College Punjab Daanish School located in Harnoli

Mor, Mianwali

Number of Siblings 5

Birth Order 4

Marital Status Unmarried

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 Occupation No occupation (was a student before

hospital admission)

Religion Muslim

Social Class Lower-Middle

Informant The client herself

Chaperone Mother

Main Reasons for Referral

The main reasons for her referral include insomnia, loss of interest in activities she once

enjoyed, continuous depressive thoughts, fits and seizures, constant headaches, weakness,

and suicidal thoughts. She was referred to the trainee clinical psychologist by the Clinical

Psychologist for psychological assessment and management of the problem.

Presenting Complaints

As reported by the client, she had:

Presenting Complaint Duration (in weeks/months/years)

I had severe constant headaches since I 3 months ago

experienced an electric shock from a

socket.

I can’t even comb my hair anymore. 2 weeks

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Touching my head makes it hurt badly. I

want to hit it on the wall.

For 20 days, I haven’t slept properly. I 20 days

only get 1 to 2 hours of sleep per day.

Everyone says I look tired. I can’t even

sleep with sleeping pills.

I want to cry all the time. I cannot think 3 years

of anything positive because it makes

my headache worse. These days I do cry

a lot.

When I am sitting on the bed, or on a 2 years

chair, I start to shake a lot. Then, I woke

up on the floor. My head hurts even

more because I keep falling and hitting

my head on the floor.

I think about killing myself a lot. I’ve 3 years

tried to do it, but I only made cuts on

myself with sharp things.

I’ve lost interest in all my hobbies. 3 years

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 Whenever I write or draw, I start getting

a headache

History of Present Illness

The client’s first symptoms started to show 3 years after her father’s death, he passed

away in the year 2017. She was emotionally very attached to her father from a very

young age and experienced a few nightmares for a couple of days after his passing, but

initially was able to get a grip on herself and accepted that no person lives forever. The

client has always been an introvert, even before her current condition. Her parents got

along just fine, and she had a loving relationship with all her siblings. At school, she

studied hard and wanted to become a doctor as per her father’s wishes, but she was

unable to get into a medical college. Along with this, she witnessed several of her family

and friends passing away after her father, this brought back a lot of memories she had

with her dad. Being unable to fulfill her father’s dream after his passing, and the

sorrowful events that constantly reminded her of her father’s death, she started showing

symptoms of depression. The symptoms were that she would cry alone in her room for

hours, severe headaches, had suicidal thoughts and attempts, stopped carrying out her

hobbies, and felt extra guilty for not being able to pursue a medical career. She also

completely lost her ability to sleep normally (maximum 1 to 2 hours of sleep a day).

Her relationship with her boyfriend of six years has also been on-and-off, sometimes

leaving her confused if they had gone through a breakup or were still together. Her

boyfriend would show her that he cared, then he would say something hurtful about

4
breaking up with her and go no contact for a while, then he would re-appear again. This

caused a lot of stress on the client’s thoughts. Thinking about this made her headache

worse. She felt like banging it against the wall. Her sleeplessness was consistent because

she indulged herself in these thoughts.

A year into developing these depressive symptoms (which were getting worse by the

day), she started to get seizures, in which she would start to tremble and then fall to the

ground unconscious. It got so bad to the point where she could no longer walk and had to

crawl on the floor to get around. Around this same time, she started to suffer from

symptoms of dissociative amnesia, where she would forget the names of her siblings or

what she was thinking or about to say. CT scans and MRI scans were taken, but the

results were clear.

Her seizures started to become less occurring, but 2 months ago she claimed to have

experienced a minor electric shock from a socket. After this, her headache doubled. She

started experiencing fits and seizures even more than before to the point where she would

be lying unconscious on the floor for anywhere up to 30 minutes, and to avoid these

constant falls, she started sleeping on the floor instead of the bed.

Predisposing factors include her introverted personality which acted as a contributor to

her condition as she would prefer to not share her emotions with anyone. This would

have caused a build-up of emotions, which eventually became too much to handle. Her

lack of control of her emotions, i.e., she lets anger take over her and allows herself to

start taking out this anger verbally on anyone near her. This often ends up with her

having a fit or headache. Another predisposing factor includes her easily-trusting

5
personality. She says she has a tendency to easily trust others, this would predispose her

to get hurt easily if someone breaks her trust.

Precipitating factors include the death of her father and the fact that she was unable to

fulfill her deceased father’s wishes for her to become a doctor, the deaths of other people

in her family and friends reminding her of the death of her father, and the every-now-and-

then breakup with her boyfriend whom she’s very fond of.

Maintaining factors include her habit of ruminating about past events, and reluctance to

think about the future. She is also reluctant in thinking positively. Whenever asked to

think positively, she says she gets a severe headache. She also intentionally indulges in

occupying herself with negative thoughts. This overthinking in a pessimistic way

prevents her from getting to sleep. Constantly thinking about negative events causes her

to get severe headaches and causes her a lot of stress, thus resulting in a seizure attack.

She’s impulsive when it comes to her anger, so she doesn’t second-think her actions

when angry. This usually ends up in her experiencing terrible headaches, suicidal

thoughts, and severe seizures.

Family History

F.S.’s father passed away naturally in the year 2017. His educational level was

Metric/10th-grade education and his occupation wasn’t specified by the client as she

didn’t want to talk much about her father. He did not seem to suffer from any physical

health problems, nor was he a smoker or drinker. He didn’t suffer from any psychiatric

problems either. According to the patient, he had a loving personality and was easy to get

6
along with. He was also very concerned with keeping his family happy and safe,

especially his daughters. He put a lot of emphasis on how much he wanted her to become

a doctor and since F.S. loved him so much, she was willing to leave her wish to study arts

and instead go for the medical field, which she was unable to do. The nature of the

relationship with the patient was very warm, friendly, and caring. The patient was more

attached to her father than to her mother. Her father was also very loving towards his

wife (the patient’s mom). They got along very well.

The patient’s mother is alive and well. He only studied until middle school. She is a

housewife and never pursued any other job. Her mother’s physical and mental health are

both good. She has a quiet personality, especially around strangers. She is extra caring

and protective towards the patient. This is something the patient hates as she really gives

importance to her personal space and freedom due to her introverted personality. Her

relationship with her husband was friendly and loving. They were very supportive of each

other.

She has 5 siblings, so they are 6 kids in total. She has 2 brothers and 3 sisters. The

client’s birth order is 4. Her siblings and she herself have no physical complications. Her

siblings are all mentally healthy. She has a friendly relationship with all her siblings,

though she does get angry at her older brother for repeating the same statement to her

over and over again which is “You’ll get better”. She also got angry with her younger

sister once, because her sister joked that she wasn’t missing her, but she went back to

normal with her after a day.

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Overall, the family seemed close-knitted in terms of friendliness and compatibility. They

were and the remaining members still are very supportive of each other. No medical or

mental problems are present in the patient’s family members’ history.

Personal History

The patient was born without any complications and the pregnancy was normal. The

mother claims that she had no complications during pregnancy or after giving birth to

F.S.

The patient had normal development and achieved every milestone at the appropriate

time for a female child. She started crawling when she was a couple of months old (the

mother couldn’t recall when the patient started crawling), started using words, and started

walking around the age of one.

Prior to her mental disturbance, she never suffered from any major physical health

problem and her medical history is that of a healthy individual.

Some of the traumatic experiences she went through include the passing away of her

father, which she still thinks about a lot, and being bullied by her boarding school’s

hostel staff members, whom she hates even today. She wasn’t able to fulfill her father’s

will for her to get into medical school, and this fact traumatizes her whenever she thinks

about it.

She studied until FSC, which she completed at Punjab Daanish School located in Harnoli

Mor, Mianwali. She stayed in the school’s hostel for seven years (from class 6 to 12). She

8
was often bullied by the hostel’s staff, which is the reason she hates them even today.

Thinking about the hostel staff brings about severe headaches and anger in her. She really

liked her teachers as well as her classmates. Talking about her classmates makes her

smile. She claims to have been a really good student, especially in Maths. She loved

literature classes but hated Urdu classes. She loves to study and gain knowledge, and now

she wants to pursue psychology, literature, and art. She was never bullied by her

classmates and got along with them very well.

The client reached the stage of puberty at the age of 12, and this stage was not

uncomfortable for her. She had cramps during her menstruation cycle, but other than that

she had no troubles during this time. She is heterosexual in terms of sexuality.

Marital History

The client is unmarried.

Occupational History

The client has never pursued a formal job.

Premorbid Personality

Before the onset of her mental disturbances, she was and still is an introvert. She never

liked to associate herself with many people and preferred time to herself or spending time

with those she was really close to. Her social relationships were quite friendly, and

9
 whomever she associated herself with, she kept close, like her boyfriend. She had a stable

mood before the onset of the mental conditions. She would get upset every now and then,

but she still had control over her emotions. She is Muslim and believes that everything

that belongs to God will return to Him, even people will ultimately return to him, but she

doesn’t consider herself extremely religious. The moral values she keeps close to her

heart are no lying, and never cheating on your partner. She had a normal routine and a

habit of spending time with herself. Her reaction to stress was to isolate herself from the

outside world. She was never a smoker or drug abuser.

Assessment

 Informal Assessment:

Baseline Chart
Day
Time/Date/

Antecedent

Consequences
Triggering

Frequency

Duration

Intensity
Thought
Belief/
event/

2020 Father’s She Nightmares of a Once a day, All night Severe

death in misses her black figure standing before long

2017, father very at the foot of the bed bedtime

following much but waving at her, as

subsequent believes well as hearing her

deaths in that father’s voice when

the family nobody trying to sleep,

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 lives constant crying at

forever night, wanting to

commit suicide

April Got a minor The client Severe headache that Every day continuous Severe

(3 months electric believes is constant; wants to onwards

ago) shock from that the bang her head

an open current against the wall and

socket went up windows

her head

18/05/2023 Her The client Constant crying at Once a day 3-4 hours Severe

boyfriend believes night alone; tried to

said he that she’s cut herself using a

wants to a burden sharpener blade;

break up and not experienced fits

with her worth

anyone’s

love;

suicidal

thoughts

20/05/2023 Brother The client A fit of anger; Once during 30 minutes Severe

kept asking doesn’t verbally aggressive the day

how she felt believe towards her brother;

and kept she’s okay hitting her head

saying that and against the wall

11
 things will doesn’t behind the bed;

get better want poked herself with

soon. anyone to sharp pins

try to

convince

her

otherwise.

Every day Memories She Suicidal attempts; Every night All night Severe

before of her father believes constant crying

bedtime replaying in that she during the night; loss

(approx. the client’s can’t go of appetite;

9:00 P.M.) mind on living sleeplessness

without

him.

20/05/2023 Tried to do She Headache; dizziness Often 15-20 Moderate

some doesn’t minutes

painting feel like

which she doing it

used to love anymore

No specific Can’t stop She Sleeplessness; Everyday Constant Severe

time was thinking wishes she constant headache;

mentioned about the was able seizure; crying for

by the client past to fulfill several hours; loss of

her appetite; suicidal

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 father’s thoughts and

dream of attempts

her

becoming

a doctor

23/05/2023 Argument She Threw a tantrum of Once every Approx. Severe

with her doesn’t anger; felt dizzy; felt few days 1 hour

mother and believe her body tremble,

the nurses she can then fell unconscious

control her (seizure); a severe

anger. She headache

wants to

be

independe

nt of her

family

Every night Stressed Constant Dizziness; severe Every night Constant (as Severe

from the because of negative headache long as she’s

time of her not being thoughts awake)

father’s able to sleep about the

death past

26/05/2023 Forgot the She Long episodes of All day Most of the Severe

sisters’ believes crying; severe day

names that she’s

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 never headache

going to

get better

No specific Can’t get She Severe headache; Every day Most of the Severe

time rid of wishes she lack of sleep; crying; day

specified stressful could fits of anger;

thoughts change her seizures

past; she

believes

she’ll get

better

once she

goes

home.

26/06/2023 The She is Crying often at the Once-twice a All day Severe

paternal disappoint thought; seizures; day

grandmothe ed in her trembling of the

r said that grandmoth body; dizziness

the client er; when trying to walk;

belongs in a She feels constant headache

mental as if she is

hospital and no longer

shouldn’t be worth

14
 allowed to being

come home. loved; she

She also wants to

told the be

client that independe

she never nt as soon

wants to see as possible

her face

again

Informal Assessments, other than the baseline chart, were also carried out:

1. Activity chart:

- (The client was provided with a schedule of activities to be done from

the time to wake up until bedtime.)

- The client was cooperative in trying her best to do all the activities

given to her on time.

2. Sleep Hygiene Chart:

- ( this chart was made to ensure that the sleep time of the client

improved with the passing of time)

- Though the client rated all her sleep experiences as not good, her

sleep improved from 1-2 hours of sleep to 4-6 hours of sleep a night.

3. Chart for Timings and Durations of Seizure Occurrence:

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 - (this chart was given to record the thought before and after the fit, as

well as the duration of the fit)

- The client experienced episodes of seizures whenever she was

overthinking about her past or any other stressful thought.

4. Subjective rating of how well she slept:

- (the client was asked to record her time of sleeping, and time of

waking, and to rate the comfort of her sleep)

- Even though her sleep timing improved a lot, she rated all her sleep

as not good.

 Formal Assessment:

1. Montgomery and Asberg (MADRS) Depression Rating Scale:

- This scale was used with the purpose of diagnostic assessment of the

client’s condition.

- The client obtained a score of 35, which falls under the category of

severe depression.

2. Conversion Disorder Questionnaire:

- This questionnaire was used with the purpose of diagnostic

assessment of the client’s condition.

- According to the results obtained, the client falls positive in the

conversion disorder category

- As answered in the questionnaire, her first ever episode was 2 years

ago.

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 - The symptoms or signs present at the time of diagnosis, as ticked off

in the questionnaire are pseudoseizure, motor weakness (in the legs

area), abnormal gait (limping), pain (severe headaches), fatigue,

anaesthesia, abnormal speech, dizziness, trembling, and lack of sleep.

3. Eysenck Personality Inventory ( long and short scale):

- This questionnaire was used to determine the levels of extroversion

and neuroticism in the client.

- The client scored high in the categories of introversion, neuroticism

and lie.

4. Rotter’s Incomplete Sentence Blank – College Form:

- This projective psychological test was used to determine the degree of conflict

the client is facing.

- The client’s answers mostly fell under the category of C3, i.e. most serious level

of conflict

- The client obtained a score of 163, which is much higher than the cut-off score

of 135-140 of the RISB scale. This indicates a high degree of conflict and

maladjustment.

5. HTP test:

- This test was applied to determine the internal thoughts of the client.

- The house: sees her house as a cage; no freedom

- The tree: the tree trunk represents inner strength. She says the tree

represents her helplessness, and that she needs her family’s support.

The tree crown was drawn very large in size, thus representing a lot

17
 of space in thoughts. No branches were drawn, thus indicating a lack

of connection with people.

- The person: In her drawing, the person represents herself. She drew

herself reading a sad book and sitting under the tree (which she said

represents her helplessness). She believes she is helpless without her

family’s help, and that her family will help her achieve her freedom.

She prefers isolation from her family.

- Other details: she drew a footpath leading from her house to the tree.

She says that the path leads to her helplessness and that she can only

change this path with her family’s permission. She also drew 3 flower

pots on the right side of the footpath. She states that the flower pots

represent her freedom. The path is diverting from the freedom

destination. She says it’s impossible for her to reach the state of

freedom, and thus prefers loneliness.

Mental Status Examination:

 Appearance: The client sits in a slouched position with her shoulders hunched.

Her facial expression is usually sad, even her smile seems sad and lasts for only a

few seconds. She has dark brown hair, wavy in texture, and is always tied back in

a low bun. She always partially covers her hair with a dupatta. Her clothes are

usually somewhat fancy, though she prefers to wear plain clothes (her mom

makes her wear clothes with embellishments). Her height is around 4’9, and her

18
 weight is around 45 kg. She has a slender body, not many curves. She makes little

to no eye contact. She is friendly with the ones she’s comfortable with and has

manners (hates anyone who doesn’t have manners). Her volume of speech is low

and the rate of speech is slow. She doesn’t stammer, in fact, the words come out

clear and collected, but just at a very slow pace.

 Mood and Affect: Her mood is usually very down, and she’s just desperate to be

alone again. She doesn’t like talking too much or answering too many questions.

She’s usually gloomy and smiles only when she talks about her classmates or

some past memory from her ‘good’ days.

 Thoughts: Her stream of thought is very pessimistic and she thinks of only

negative things that have happened or are happening to her. She doesn’t want to

even try to think about the future and the opportunities it may hold.

 Delusions: She has no delusions

 Hallucinations: She has no hallucinations

 Orientation: She is well aware of the time, the place she’s been and is currently

present at, who she is, and what her name is.

 Memory: Suffers from short-term memory loss as she forgets quite recent events

and thoughts, even though she can remember things that happened a while or even

a long time ago. She suffers from dissociative amnesia, as she forgets her family

members’ names often.

 General Information Intelligence: She can easily answer general knowledge

questions

19
  Insight: Her insight towards her problem is negative, as she doesn’t think she’ll

improve in terms of her depression. Though she believes it is easier for her to fix

her sleep.

Summary of Informal and Formal Psychological Assessment:

The patient has a very pessimistic point of view, has an introverted personality, and

suffers from major depression.

On the Eysenck Personality Questionnaire, she scored high on introversion, neuroticism,

and lie.

The answers the client gave on the Rotter’s Incomplete Sentence Blank show highly

depressive thoughts and a preference for isolation and freedom.

The MADRS scale results showed severe depression, with a score of 35.

Most of her answers on the HTP test also express depressive thoughts along with the

longing for independence from her family.

Diagnosis:

According to DSM-V, the client is diagnosed with:

1) F33.2: Major depressive disorder, recurrent, severe without psychotic features

2) 300.11 Conversion disorder (functional neurological symptom disorder)

- (F44.5) with attacks or seizures

Prognosis

20
F.S. has shown satisfactory recovery from the therapy and treatments provided to her.

This can be seen in her being able to accept and speak more openly about her father’s

death. The recovery can also be seen in her being able to walk without help and she also

is able to smile a little while remembering something nice. Though she still experiences

seizures and headaches, her sleep has improved considerably, from 1-2 hours of sleep,

now to 4-6 hours of sleep.

Management and Treatment

 Psychotherapy Conducted With Client:

1. CBT

2. Relaxation Therapy (deep breathing exercises, and progressive muscular therapy)

3. Creative therapy (asked to draw whatever makes her feel good)

Case Formulation

The psychodynamic school of thought supports this case. The psychoanalytic theory

proposes that individuals develop depression when they direct their repressed anger

inwards due to the loss of a loved one during childhood, being rejected by a loved one,

introjection of love object loss, or not being able to attain certain goals that have been set

by the person. Individuals with high levels of interpersonal dependency tend to become

more prone to developing depression as they rely on others for approval. Since the anger

21
is directed inwards, the individual becomes a victim of low self-esteem and re-lives the

loss or rejection if triggered by similar circumstances in the future. Sigmund Freud, the

founder of the psychodynamic school of thought, suggested that when exaggerated

feelings of guilt and shame are internalized they can manifest depression.

Client F.S. shows all of the conditions mentioned above as proposed by the

psychoanalytic theory. Her father, whom she was very attached to, passed away when she

was still in grade 11. In the following years, several of her family and friends passed

away which triggered her to re-experience the moment her father died. Since she has an

introverted personality, she preferred to cry alone and indulge herself in the memories

without sharing her thoughts with anyone. Her father wanted her to become a doctor,

therefore she set that as a goal, which she was unable to attain after his passing. She

never stopped feeling guilty about not being able to fulfill her father’s wishes. She

internalized these feelings of anger and guilt, thus becoming a victim of self-blame. This

made her develop low self-esteem and prevented her from wanting to think about a better

future for herself, subsequently leading to her developing MDD. She also claims to be

easily trusting, so when her boyfriend, whom she’s very fond of, broke her trust, she

suffered greatly from low self-esteem and feelings of not being worthy of love. These

feelings developed because instead of letting out her anger on her boyfriend, she

internalized these feelings of anger, thus enhancing her condition of depression.

The psychoanalytical theory also proposes that the somatic symptoms of conversion

disorder are a type of defense mechanism to defend the individual against the unwanted

negative feelings the emotional conflicts would cause the person, i.e., these emotional

22
conflicts are repressed by the individual into their unconscious mind. These are then

converted into the symptoms of conversion disorder.

Client F.S. repressed her anger inwards, which made her vulnerable to negative emotions

and beliefs against herself. Her defense mechanism would come into play when she

would stress herself with negative thoughts and memories. This can be seen in her case,

as whenever she would indulge in negative thoughts or overstress on a triggering topic,

she would experience fits or seizures. So, her emotional conflict was converted into

somatic symptoms, thus leading her to develop conversion disorder.

23
 Appendices

- Rotter’s Incomplete Sentence Blank:

24
25
- MASDR Scale:

26
27
28
29
30
- Conversion Disorder Questionnaire:

31
32
- HTP Test:

33
34
35
36
- Art Therapy:

37
- Eysenck Personality Questionnaire:

38
39
40
41
42
43
 (Case 2)
Background Information / History
Initials N.K.

Age 35

Gender Female

Hospital Gulab Devi Hospital’s Department of

Mental Health

Date of Admission 3rd of May, 2023

Education Level B.A.

Number of Siblings 2

Birth Order 2

Marital Status Married

Children 3 kids of her own

2 step-kids (from husband’s first

marriage)

Occupation Middle School teacher (before getting

44
 married)

Religion Muslim

Social Class Middle

Informant Cousin (female)

Chaperone Cousin (female)

Main Reasons for Referral

The main reasons for the referral of the client include fear of looking old, fear of looking

at her reflection, belief that she has hollows under her eyes, and can’t look at the elderly

or anyone with skin problems as she believes she has the same problem as them. She was

referred to the trainee clinical psychologist by the Clinical Psychologist for psychological

assessment and management of the problem.

Presenting Complaints
As reported by the client and translated by her cousin, she had,
Presenting complaints Duration

I can’t look into the mirror without feeling 2 years

scared

I see old people and feel scared, I feel like 2 years

I am becoming old by looking at them and

like my skin looks older, I have wrinkles,

45
 and hollows under my eyes.

My head is never stops hurting. It feels 2 years

like someone is holding my head tightly

and it is numb. I can’t stop thinking about

the hollows under my eyes.

I tried to commit suicide by overdosing on 2 months ago

pills before admission to the hospital

I’m afraid of getting old 2 years

I feel like banging my head on the wall 2 years

and other hard surfaces. I also feel like

crying loudly every day.

History of Present Illness

The client’s first symptoms started to surface around 2 years ago. This was after her

arranged marriage to her now husband who has 2 kids from his previous marriage with

his first wife who’s no longer with him. The client wasn’t willing to get married to him

because of her interest in someone else, but her family convinced her in doing so. She

stopped her job as a teacher after she got married. She was and still is neglected by her

husband. In her childhood, her dad was abusive (her mother passed away because of

46
sorrow and abuse), and when she got married her husband was neglectful of her presence.

Her husband made her go through 3 abortions because he believed that she wouldn’t give

time to his step-kids if she had too many of her own. This developed the belief in her that

all men are bad. At home, she was the one who tended to her husband’s needs as well as

to her step-kids’, and in-laws’ needs but was still considered worthless by them. Thinking

that maybe if she lost some weight (she weighed around 60kg at the time) and had a

prettier skin tone, her husband might give her some attention. So, she bought weight

losing syrup and cream for her skin. Ever since then, she started to believe that her skin

was sagging, that she looked old, and that the medicine and cream made her get hollows

under her eyes, thus making her look ugly. Her husband and in-laws also told her that her

skin looked older after using the medicine and cream. She believed this so much to the

point that she couldn’t look in the mirror at herself nor could she look at old people

anymore. Whenever she sees someone with a skin problem or aging skin, she starts to

think that she has the same problem, even though that is not the case. It is important to

note that she has an anxious temperament, which made her more prone to deeply

believing the comments made by others in her family about her appearance. It also

predisposed her to develop anxiety.

Predisposing factors for her condition include her anxious temperament, childhood abuse,

and the early death of her mother.

Precipitating factors for her condition include not marrying the person she loved, constant

neglect of her presence by her husband, buying that medicine and cream which she

believes still affects her today and constantly being told by her in-laws and husband that

the medicine and cream affected her skin negatively.

47
Maintaining factors include her low self-esteem, stubbornness in terms of changing the

way she thinks and feels, and her perception of her illness being the result of the cream

and medicine she took earlier.

Family History

She grew up in a toxic home environment. Her father passed away from a natural death.

He didn’t have a job and was very abusive towards his wife and daughters as well. He

didn’t suffer from any mental disorder or physical problem. He didn’t have any medical

problems either. N.K. describes her father to have been a cold-hearted individual. He

physically abused the patient’s mother in front of the kids and showed absolutely no

remorse or guilt of any sort. He would even hurt both daughters, i.e. the patient and her

sister.

Her mother also passed away. She died from a heart attack and suffered from sexual and

mental abuse from her husband. She suffered from depression and stress in her lifetime.

She had a loving relationship with the patient, though she wasn’t able to give enough

time to her kids because of her abusive husband.

She has one sister and one brother (deceased). She is the second child of her parents and

has a pretty good relationship with her remaining sibling. She also had a good

relationship with her brother.

The overall family history was full of toxicity and abuse because of the father who had a

lot of toxic masculinity which he used on his wife and daughters. She grew up in a toxic

environment and witnessed her mom get beaten by her dad. Now she fears the touch of

48
men, even if it’s a friendly gesture, thanks to the tyrant–like image, her father has

implanted in her mind about men since her father was the only man she grew up around.

Personal History

Her mother gave birth to her in a normal manner without complications before and after

the pregnancy.

She had a normal development despite the toxic family environment. She started talking

and walking around the age of 1-year-old.

She suffers from obesity and swelling (especially after taking sleeping pills called ‘Alp’

and anti-depressants), but other than that her physical health is fine (even though her

husband has made her go through 3 abortions).

She has gone through the traumatic experience of neglect just like her mother did by her

husband. She was made to do all the chores of the house and to take care of her step-

children, and even then she didn’t get attention from her husband.

She is heterosexual in terms of sexuality but believes that all men are inherently bad.

Marital History

49
Her spouse is alive and well but is extremely toxic in personality. Her relationship with

her husband is terrible. She says she feels like a stranger to him, but due to societal

pressures and for the sake of her kids, she’s staying with him. He is 50 years old and has

no medical or psychological problems reported. She doesn’t even sleep in the same bed

as him. Her husband doesn’t beat her like her father did her mother, but he doesn’t pay

attention to her either. According to the patient, her husband spends all day watching the

news. He doesn’t sleep with her, has made her go through 3 abortions, and doesn’t give

attention to her kids either.

She has 3 children of her own and 2 step-kids from her husband’s previous marriage.

Her own daughter is aged 12, her sons are aged 6 and 4 respectively. She loves her

children very much and the relationship between them is really good. They seem to love

her back also and are desperate for her to come home to them.

Occupational History

The client was a middle school private teacher prior to getting married. She started

working right after she completed her B.A. degree. She enjoyed her job and work

environment. She loves kids, therefore she really had fun teaching them. She also got

along with her colleagues very well. She had to leave her job once she got married to her

present husband.

Premorbid Personality

50
 She used to be a very social person who loved to tend to guests, especially her in-laws.

But she always had an anxious temperament and her mood would always be in a swing

from good to bad. She is a very strong believer in God and is Muslim. She believes that

God will listen to her prayers and cure her of this mental disturbance. The moral value

she believes in is that all humans should be treated with respect, regardless of the

differences between them.

Assessment
 Informal Assessment:
Baseline Chart
Day
Time/Date/

Consequences
Antecedent

Triggering

Frequency

Duration

Intensity
Thought
Belief/
event/

From Physical She believes - Fears men Every All night, Severe

childhood and mental she’s helpless - Sadness night until she falls

(time or abuse from under a - Anxious asleep

date not the father man’s abuse. temperament

specified) Believes all - Loss of

up until the men are bad. control over

death of her emotions

father - Wants to cry

loudly all the

time

51
 - Suicidal

thoughts

2006 Her ex- She believes - Wants to cry Most Approx. 2-3 Moderate

lover she’s not all the time nights hours before

moved worth being loudly sleeping

abroad and loved. Misses - Indulges in

lost contact him very ruminating

with her for much about past

a while lover

- Leads to

sleeplessness

2007 Forced to She believes - Crying Sometime Approx.15 – Moderate

leave her that she - Anger s ( once 30

job as a should be - Feeling of every minutes

teacher after allowed to hopelessness week or 2

marriage to work. She - Feeling weeks)

a widower thinks her life helpless

would have

been better if

she was still

doing her job

as a teacher

2007 – Neglect and She thinks - Wants to cry Everyday Constant Severe

present lack of she’s too

52
 attention ugly to be and scream

from her loved. - Numbness of

husband Believes all head

men are bad, - Laziness

but she’ll - Low self-

stay with him esteem

for the sake - Throbbing

of her headache

children

Date or time Her Her thoughts - Anger Once or A few Low

not husband at the time - Helplessness twice minutes

specified made her go were that she - Low self- every 2 (when she

through 3 hates her esteem weeks thinks of it)

abortions husband very - feeling guilty

much, but she

should stay

quiet and be

submissive to

her husband.

2021-2022 Started Eating made - Excessive Often All evening Moderate

binge her feel good, gain of

eating; her but inside she weight

family knew it was - Made

53
 made fun of damaging her movement

her weight health harder for her

- Laziness

- Lack of

motivation to

carry out

daily

activities

2021 Took an She believes - Fears looking Everyday Constant Severe

unnamed the woman at herself in

syrup and lied to her the mirror

face cream and gave her - Constantly

that a things that thinks about

woman made her her image

claimed look old and - Severe

would help damaged the headache

her lose under-eye - Wanting to

weight and area. She scream and

make her regrets taking cry

skin the syrup and - Suicidal

beautiful cream. thoughts

2021- Everyone She believed - Headache Everyday Constant Severe

54
present around her that everyone that is never-

kept telling thought she ending

her that her became - Constant

skin started uglier and negative

to sag after looked older. thoughts

using the about her

syrup and image

face cream - Suicidal

thoughts

2021- Stopped She didn’t - Laziness Everyday Constant Severe

present doing feel like - Low self-

household doing esteem

chores, or anything. Her - Family thinks

any activity thoughts she’s useless

by herself, were that she and a burden

thus gaining just feels lazy - Excessive

considerabl and too tired weight gain

e weight to move.

2021- Looking at She believes - Fears Everyday Constant Severe

present the elderly she has the becoming old

and people skin - Can’t interact

with skin condition she or even look

problems sees in at the elderly

55
 others. She - She panics

also fears when she

growing old. sees someone

with a skin

condition

- Starts

repeatedly

thinking and

saying that

she has the

same

problem with

her skin and

that she has

hollows

under her

eyes

2021- Looking in She believes Everyday Constant Severe

present the mirror she has

scares her wrinkled skin

and hollows

under her

eyes. She

56
 doesn’t want

to look at

herself.

2021- Lost the She believes - Restlessness Every All night Severe

present ability to she can’t during the night until she

sleep sleep without night takes the pills

enough and taking - Tiredness

on time sleeping pills. during the

day

- Tries

overdosing

on sleeping

pills

- Doesn’t sleep

without the

pills

2021- Constant She believes - Fears looking Everyday Constant Severe

present thoughts she looks old. at her

about She wants reflection

having these - Fears old

sagging thoughts to people

skin and go away. She - Constant

hollows says she’s negative

57
 under her lost all her thoughts that

eyes. willpower to won’t go

get better. away leading

to a severe

headache and

numbness of

head

- Wants to

scream and

cry

Informal Assessments, other than the baseline chart, were also carried out:

1. Activity chart

- (The client was provided with a schedule of activities to be done from

the time to wake up until bedtime.)

- The client carried out all the activities given to her with the

encouragement of her cousin who has been by her side at the hospital

to attend to her if needed.

2. Sleep Hygiene Chart

- ( this chart was made to ensure that the sleep time of the client

improved with the passing of time)

58
 - She carried out all the activities given to her as part of her sleep

hygiene and was mostly able to go to bed on time.

3. Least to most list of fears:

- (this allowed the client to rate her fears from what she feared the

most to what she feared the least)

- She feared animals and insects the least, and she feared elderly

people, people with skin problems, mirrors, and cameras the most.

 Formal Assessment:

1. Body Dysmorphic Disorder Questionnaire (BDDQ):

- This diagnostic assessment was applied to the patient to determine

the presence of her condition.

- According to the answers given, the client is worried all the time

about their looks and wishes she could worry less about it. The body

areas she doesn’t like include her under eyes and stomach area. The

concerns mentioned are interfering with her life, daily activities, and

relationships. She spends more than 3 hours on average a day

thinking about how she looks.

2. Beck Anxiety Inventory (BAI):

- This inventory was used to determine the presence of anxiety in the

patient.

- The client obtained a score of 42. This falls under the category of

potentially concerning levels of anxiety.

59
3. Perceived Stress Scale:

- This scale was applied to determine the level of stress the client is

facing.

- The client obtained a score of 34. This falls under the category of

high perceived stress.

4. Eysenck Personality Questionnaire:

- This scale was used to determine the levels of extroversion and

neuroticism present in the client.

- The client scored high on the categories of neuroticism and lie.

5. HTP test

- This projective test was applied to determine the internal thoughts of

the client.

- The tree: she placed a lot of emphasis on the tree and drew it with

many branches. This shows connectedness with others. She drew her

tree-trunk bent and drew lines to show that it was cut. She said she

cut it after marriage. Since the tree crown represents inner strength,

her inner strength and confidence have been lost after her marriage to

her present husband. The tree crown has been drawn crowded with

leaves. She said the leaves are her life before marriage. This shows

her excessive thinking about her past before her marriage.

- The house: She drew the house with a lot of attention and said she

liked the house very much.

60
 - The person: She says that the person is a 50-year-old man who

represents her husband. She says, that in the picture the man is happy.

Her husband’s lack of interest in her and her kids has made her lose

confidence in herself.

Mental Status Examination

 Appearance: Always sitting slouched and shoulders hunched with her chest

inwards. Her hair color is dark brown and is rough to look at in texture. She used

to like taking care of her appearance, but she no longer feels like it. She always

has a dupatta covering her head lightly, She is around 5’4 in height and she

weighs at 90 kg. She has a square body shape and is very curvy (mostly because

of being overweight). She seems well put together in terms of neatness, only

because it’s one of her tasks to do things herself (like self-grooming, making the

bed, etc.). She looks at the person she’s talking to, but if she starts getting anxious

she tends to slowly look somewhere else. She is quite friendly and easily opens up

to others (as long as they don’t have any skin problems). She is 35 years old and

also looks like she’s in her 30’s. She has manners and knows how to behave in

front of others.

 Speech (form and content): Her speech is clear and she doesn’t stutter while

speaking. But, she tends to speak really fast, especially when stressed out. When

she’s in an anxious mood, the content of her communication is about how she has

hollows under her eyes, and how she will never be okay. She also keeps talking

about losing her willpower (according to the HTP test, she lost her strength and

61
 willpower after her marriage). She talks about how she doesn’t fear things like

snakes and lizards, but she’s terrified of old people. People with skin problems

and her reflection, because she believes that she has the same skin

disease/problems as those people and that if she looks at her reflection, she

believes she will see hollow under her eyes.

 Mood and Affect: She is usually very anxious. She gets upset talking about skin

complications and old people. When she’s upset, she cries a lot and says she

wants to bang her head against things. She also says she wants to commit suicide

but doesn’t because of her kids.

 Thoughts: One minute she says she’s getting better, and the next minute she says

there is no hope for her to stop thinking about these cognitive distortions. But the

good thing is that she does believe that her negative thoughts are just cognitive

distortion and aren’t true. Her stream of thought is usually that she has skin

problems, fears getting old, and that her thoughts control her instead of her

controlling the thoughts.

 Delusions: She has the delusion that there was a woman who provided her cream

and medicine to spoil her face. She keeps saying that ever since she got the cream

and took the medicine, her skin started to sag and she began to get hollows under

her eyes (even though her skin is completely clear and wrinkle-free, also she has

no hollows under her eyes)

 Hallucinations: She says she hears the voice of a man, who sounds like her ex-

lover, telling her to take her own life.

62
  Orientation: She is well aware of her surroundings, time, place, and person. She

knows where she is and at what time she did certain activities as well as the

current time. She also knows who she is as she seems very fond of her name (she

kept writing her name on the HTP test).

 Memory: She has a really good remote, recent past, and recent memory.

 General Information Intelligence: She is able to answer general information

questions (keeping in mind where she’s from and her background)

 Insight: She says her thoughts control her and that she is a slave of her own

thoughts. She knows that her thoughts are cognitive distortions, but she says that

even though she knows this, her brain doesn’t accept it. She believes she feels this

way due to some chemical imbalances in her brain. She also believes that she

won’t be able to sleep without taking Alp (0.5mg) pills. She believes she can’t

control her situation and that she needs some physical treatment like some kind of

shock through a machine or more medicine.

Summary of Informal and Formal Psychological Assessments:

The client has an anxious temperament which has led her to develop anxiety. She also

suffers from BDD (Body Dysmorphic Disorder). She has very low self-esteem along with

63
high perceived stress. She also has a cognitive distortion that her skin is sagging and has

hollows under her eyes.

On her Eysenck Personality Scale, she scored high in the categories of neuroticism and

lie.

On the Beck Anxiety Inventory Scale (BAI), she scored 42, which falls into the category

of potentially concerning levels of anxiety

On the Perceived Stress Scale (PSS), she scored 34, which falls under the category of

high perceived stress.

The HTP test shows how much she values her home. The interpretation also shows that

she emotionally and mentally broke down after her marriage to her now husband.

Her fear of looking at her reflection, her fear of old people, and her belief she has the skin

conditions she sees in others, though her skin is completely clear, concludes her suffering

from BDD.

Diagnosis

- 300.7 (F45.22) BDD (Body Dysmorphic Disorder)

Prognosis

N.K.’s recovery is satisfactory. The progress made in her recovery can be seen in her

ability to now carry out most of her chores herself, such as making herself tea or combing

64
her hair. She is also able to move around more than before. She now accepts the fact that

having hollows under her eyes and sagging skin are just thoughts, i.e., she can

differentiate between her cognitive distortion and reality. She is also able to apply lipstick

while looking at herself in the mirror.

Management and Treatment

 Psychotherapy Conducted With the Client:

1. CBT

2. Breathing exercises and Progressive muscular exercises (relaxation

therapy)

 Behavioral Therapy Conducted With the Client:

- Exposure therapy (to mirrors and old people)

Case Formulation

The Psychodynamic approach and the Cognitive Behavioral models both support this

case.

According to the psychoanalytic theory, when sexual or emotional conflict, feelings of

inferiority, or perception of poor self-image are displaced in the unconscious mind of the

individual, then body dysmorphic disorder (BDD) tends to develop.

As per the cognitive behavioral models, when an individual perceives a defect in any

part/s of their body and then pays excessive attention to that perceived defect, then they

65
tend to develop BDD. Another influence is when they misinterpret the comments of

others around them as a response to the individual’s body image or perceived defect.

When these perceptions of defect are reinforced, the individual develops BDD.

The client N.K. fulfills the above conditions in the following way. In her toxic marriage,

she experienced sexual abuse and verbal abuse from her husband, who forced her to go

through 3 abortions and made her feel not beautiful enough. He would constantly neglect

her presence. So, N.K. embedded in her unconscious mind that she isn’t that beautiful

leading to low self-esteem and BDD. Also, when she used a treatment to lose weight and

get better skin, her husband and in-laws would constantly tell her that she got worse, and

that she looks older and has hollow under her eyes. She had an anxious temperament

from childhood under the custody of her abusive father, this led her to having anxiety,

making her more prone to believe what others told her. This reinforced her belief that she

had skin problems. Another reinforcement she gives herself is the repetitive statement she

keeps making that she has hollows under her eyes and looks older, thus leading her to

develop BDD.

Appendices

- Plan for Patient:

66
- Body Dysmorphic Disorder Questionnaire (BDD):

67
- HTP Test:

68
69
70
71
- Eysenck Personality Test (Short Scale):

72
73
- BAI Scale:

74
75
- PSS Scale:

76
77
END OF REPORT

78