hareem

ADULT CASE REPORTS
Submitted by
Hareem Marwat
SAP ID
51501
Submitted to
Umer Fyyaz
MS Clinical Psychology
Session (2023-2024)
Declaration
I Hareem Marwat SAP ID 51501 student of MS clinical psychology session 2023-2024 hereby
declare that the material printed in this case report is my own work and has not been submitted or
will be printed or published, fully or partially in any university research institute etc, by me in
Pakistan or abroad.
Supervisor signature Signature

Acknowledgment
Apart from the efforts of myself, the success of any project depends largely on the encouragement
and guidelines of many others. I take this opportunity to express my gratitude to the people who
have been instrumental in the successful completion of this project. I would like to show my
greatest appreciation to Sir Umer Fyyaz I can’t say thank you enough his tremendous support and
help. I feel motivated and encouraged every time I attend her meeting. Without his encouragement
and guidance this project would not have materialized. The guidance and support received from
all the member who contributed and who are contributing to this project, was viral for the success
of project. I am grateful for their constant support and help.

CASE REPORT NO 1
1. Case summary
Biodata
2. Preliminary investigation
Informal assessement
Formal assessement
3. Diagnosis
4. Management plan
5. References
6. Appendix – B
CASE REPORT NO 2
1. Case summary
Biodata
Formal assessement
3. Diagnosis
4. Management plan
5. References
6. Appendix – B
CASE REPORT NO 3
1. Case summary
Biodata
Formal assessement
3. Diagnosis
4. Management plan
5. References
6. Appendix – B
CASE REPORT NO 4
1. Case summary
Biodata
Formal assessement
3. Diagnosis
4. Management plan
5. References
6. Appendix – B
Case no 1:
Major Depressive Disorder.
Case summary
The client was 24 years old male, client belongs to a nuclear family system have both
parents. She had 2 brother and 1 sister. She is doing job .Reports from the client, showed
that she hadsome marked problem regarding her behavior.Different assessments tools were
used Mini-Mental State Examination (MMSE), Beck Depression Inventory (BDI), Beck
Anxiety Inventory, House Tree Person (HTP) all these were done on the client. She was
taken to CDA Hospital Islamabad for treatment.
1. Bio Data
Names S.K
Age 24 years
Date of birth 22-06-1997
Siblings 1 sister 2 brother
Birth order 3RD
Socio- economic status Average family
Religion Islam
Dependent/ Independent Independent

Reason and source of referral:
S.K was a 24 years old female and she was referred by a friend to CDA Hospital Islamabad.
Presenting complaints (verbatims):
‫میں بہت تنہا محسوس کرتا ہوں‬
‫میرا جسم کانپنے لگتا ہے‬
‫مجھے نیند کے مسائل ہیں‬
‫مجھے بے چینی ہے‬
History of illness:
• Feeling of worthlessness
• Guilt
• Slowing of thoughts
• Anxiety
• Irritability
• Sleep disburbance
• Loss of appetite
• Shivering
• Suicidal ideations.
Background information
The patient belongs to the average middle class family. she has four siblings. She is 3rd among
them. She has two brothers and one sister. The patient father is government officer. Her father is
a man of principle he had maintained balance between everything between his family and office
life. Her mother is a house wife. She has a very polite personality. General home atmosphere is
normal and well managed.
Personal history
The birth of the client was normal without any complication. Client childhood was normal too as
per by client. She is not married and has a desire to marry a person of her own choice. She was in
a relationship for 5 years.because of some family issues there are complications in getting
married due to this she is going through rapid change in mood and constant state of worry which
is affecting her daily life.
Educational history
She went to school at the age of 3 years.she was a very active in her childhood and was always
curious to learn something new in school and make new friends.She had done her graduation in
BS IR and currently doing job in a well reputed company as a assistant teacher with handsome
salary.
Pre-morbid personality
The mood before the onset of her illness was normal she enjoyed the company of family as well
as the friends. She was lively and active to explore new things.but after being in persistent state
of worry and mood disorders she has no desire to participate in daily life normal activities.
Preliminary Investigation:
Assessment has been done by following ways.
• Informal
• Formal
Informal assessment:
Clinical interview:
Client was asked about her relation with family, friends. Client was cooperative and extrovert.
she talked about her personal life and what problems are faced by her in past years. All the
information provided by client was same as provided by clients mother.her behavior was
observed by behavioral observation.
Behavioral observation:
The client was informally assessed by the interview as well as behavioral observation. According
to the information provide by her and through observation it was clear that the client is a
pessimist ambivert. She was very cooperative during sessions.

Formal assessment:
Client was assessed through following test:
• Minnental State Examination MMSE
• Beck Depression Inventory (BDI)
• Beck Anxiety Inventory (BAI)
• House Tree Person (HTP)
Mental status examination
Quantitative Analysis
Maximum Score Patient’s Score
Total Score: 30 30
Qualitative Analysis
Result of mental state examination revealed that client was attentive alert and cooperative. Eye
contact was maintained properly. The patient was debonair and neatly dressed. Her score was 30
which shows that there is no cognitive impairment.
Beck Depression Inventory (BDI):
Score Sum Range Levels of Depression
35 31-40 Severe depression
BDI Score is 35 which shows severe depression.
Beck Anxiety Inventory (BAI):
Score Sum Range Severity Range
46 36 – Above Potentially concerning level
of anxiety
BAI Score is 46 which shows potentially concerning level of anxiety.
House Tree Person (HTP):
Client HTP interpretation is not social which means client is not very social person and has less
social interaction with others and environment. Overt behavior which means client thinks that
everything she does are always observed by others. Sexual identification which can also refer
towards client gender or sexual needs. Conflict which refer to disagreement of client towards
different situations or people around her. Aggression which relates to hostile or violent behavior.
Anxiety which refer to some sort of fear or guilt about the future.
Case Formulation:
The client was 24 year old girl with the presenting complaints of depressed mood, lack of
socialization, restlessness, loss of energy, fatigue, loss of pleasure, hopelessness, loss of appetite,
disturbed sleep. The client was assessed through multiple assessment tools which indicate that
most important maintaining factor of the patient’s case. A study was conducted on higher rate of
depression between males and females The prevalence of major depression is higher in women
than in men.(Ford DE, Erlinger TP,2004).Although differences in socioeconomic factors,
including abuse, education and income, may impact the higher rate of depression in women,this
editorial focuses on biological contributors that are experimentally tractable can help to
understand how and why depression is more prevalent in women and lead to better treatments
(Rai D, Zitko P, Jones K, Lynch J, Araya R ,2013).
Women displayed more sensitivity to interpersonal relationships, whereas men displayed more
sensitivity to external career and goal-oriented factors. Women also experience specific forms of
depression-related illness, including premenstrual disorder, postpartum depression and

postmenopausal depression and anxiety, that are associated with changes in ovarian hormones
and could contribute to the increased prevalence in women.(Kendler KS, Gardner CO, 2014).
Bio psycho social model:
Biological factors Psychological factors Social factors
Anxiety Poor interpersonal
Stress relationships
Poor coping skills Stressful environment at
Suicidal ideation home
Diagnosis:
296.23 (F32.2) Major Depressive Disorder. severe features.With anxious distress
Prognosis
As the clients score lies in severity she need constant care and treatment and her family is very
supportive toward her and he is also willing to get better and want counseling so he can get out
of this illness and live a normal life.
Management plan
Cognitive behavioral therapy (CBT)
Relaxation methods
Cognitive behavior therapy was used with client the first step which was taken with client was
Cognitive restructuring or reframing asked client to make negative things in a positive way like
leaving your good friends in past because of drugs use can be changed into going out again
facing them socializing again. This work as exposure therapy for the client to as facing anxieties
and fear.while overcome the fear of being judged again for negative aspects can be changed into
positive way of living.
Progressive muscle relaxation therapy
Muscle relaxation therapy was used throughout with client to make client more relaxed and
active during the sessions and to give positive environment. Deep breathing process was also
introduced to the client to face anxious situation which can cause anxieties.
Summary of Sessions:
Session No. 1
In first session main focus was on rapport building with the client and then intake form were
filled from the information provided by the client himself furthermore, to discuss about different
issues of the client, and take clinical interview. The client was asked basic information about his
past and present life.
Session No. 2
During second session more detailed information was gathered through history taking form. In
which multiple factors was gathered which may the reason of his drug abuse and anxiety related
to withdrawal symptoms.
Session No. 3
In third session client talked more openely about its previous life while taking educational,
friendship and sexual history and problem faced by client during all these times.
Session No. 4
In this session tests were applied on the client. Started with beck depression inventory, beck
anxiety inventory to check which is more relatable to the client distressful situation.
Session No. 5
In this session client was administered by few more test batteries such as drug abuse screening
test to see if client still do any drugs by any chance but denied in clinical interview after that
mini-mental state examination was done to check client orientation about its environment.
Session No. 6
In this client was provided with paper pencil as instructions to draw house, tree, person on the
paper for personality assessment of the client.while client was drawing HTP client was observed
closely later on asked few questions which were related to the drawing. And client answered
them nicely.
Session No. 7
From the previous session, it was diagnosed that client has major depressive disorder the
therapies which I used with the client were cognitive behavior therapy such as Cognitive
restructuring or reframing asked client to make negative things in a positive way like leaving
your good friends because of drugs can be changed into going out again facing them socializing
again. This work as exposure therapy for the client to as facing anxieties and fear.
Session No. 8
Client was provided with muscle relaxation therapy which help client to overcome situation and
feel more lively and relaxed while making new decision in life.due to good progress in client
health client was terminated from the hospital.
References:
1. Ford DE, Erlinger TP. Depression and C-reactive protein in US adults: data from the
Third National Health and Nutrition Examination Survey. Arch Intern Med. 2004.
2. Kendler KS, Gardner CO. Sex differences in the pathways to major depression: a study of
opposite-sex twin pairs. Am J Psychiatry. 2014
3. Rai D, Zitko P, Jones K, et al. Country- and individual-level socioeconomic determinants
of depression: multilevel cross-national comparison. Br J Psychiatry. 2013

Case no 2:
Generalized Anxiety Disorder
1 Case summary
The client was 26 years old male, client belongs to a nuclear family system have both
parents. He had 3 brother and 1 sister. He is doing job .Reports from the client, showed
that she hadsome marked problem regarding her behavior.Different assessments tools
were used Mini-Mental State Examination (MMSE), Beck Anxiety Inventory (BAI),
Beck Anxiety Inventory (BAI), Drug Abuse Screening Test (DAST-10), House Tree
Person (HTP) all these were done on the client. She was taken to CDA Hospital
Islamabad for treatment.
2 Bio Data
Names S.S
Age 26 years
Birth order 2nd
Religion Islam
Independent/ Dependent Independent

S.S was a 26 years old male and he was referred by a psychiatrist to CDA Hospital Islamabad.
‫انتباہ میں اضافہ‬
‫بلندی محسوس کرنا‬
‫بے ترتیب دل کی دھڑکن‬
‫اعلی جسم کا درجہ حرارت‬
،‫بھوک میں کمی‬
‫نیند نہ آنا‬
‫تحریک‬
‫بے چینی‬
The patient belongs to the high socio-economic status family. he has four siblings. he is 2nd
among them. he has three brothers and one sister. The patient father belongs to political party.
His father is strick and rigid man. His mother is a house wife. She has a very polite and loving
personality. General home atmosphere is normal and well managed.
Personal history
The birth of the client was normal without any complication. Client childhood was normal too as
per by client. he is not married and has no desire to marry soon. he was in a relationship for 1
years. As by client he and his partner were in sexual relationship they use to do drugs together
before breakup they use too do cocaine but after the breakup client stopped using cocaine which
cause withdrawal symptoms which is causing issue in his daily life.
Educational history
He went to school at the age of 3 years.he was a very active in his childhood and was always
curious to learn something new in school and but he was introvert doesnot make new friends.he
had done his graduation in BS IR and currently doing job in a well reputed company as a
manager with handsome salary.
The mood before the onset of his illness was normal he enjoyed the company of family as well as
the friends. he was lively and active to explore new things.but after drugs withdrawal symptoms
he is in persistent state of worry and mood disorders he has no desire to participate in daily life
normal activities.such as interacting with friends and going out with family.
• Informal
• Formal
Clinical interview:
Client was asked about his relation with family, friends. Client was shy and introvert.he talked
about his personal life and what problems are faced by him past these years. All the information
provided by client was same as provided by clients family.other then this his behavior was
to the information provide by her and through observation it was clear that the client is a
introvert person. She was very cooperative during sessions. Client was well dressed and cleaned
up and active.
Formal assessment:
• Mini-Mental State Examination (MMSE)
• Beck Anxiety Inventory (BAI)

• Drug Abuse Screening Test (DAST-10)
Mini-Mental State Examination
Total Score: 30 30
Result of mental state examination revealed that client was attentive alert and cooperative
throughout the sessions. Eye contact was maintained properly. The patient was neatly dressed.
his score was 30 which shows that there is no cognitive impairment.
11 11-16 Mild mood disturbance
BDI Score is 11 which shows Mild Mood Disturbance.
Beck Anxiety Inventory (BAI):
Score Sum Range Severity Range
47 36 - Above Potentially concerning level
of anxiety
BAI Score is 47 which shows potentially concerning level of anxiety.
Drug Abuse Screening Test (DAST-10):
Score DAST Severity Range
3 3-5 Harmful
DAST - 10 Score is 3 which shows harmful.

Client HTP interpretation means Conflict which refer to disagreement of client towards different
situations or people around him. The client is not social which means client is not very social
person and has less social interaction with others and environment. Aggression which relates to
hostile or violent behavior. Anxiety which refer to some sort of fear or guilt about the future.
Sexual identification which can also refer towards client gender or sexual needs.lack of
confidence which refers to not being socially active.
Case Formulation:
The client was 26 year old boy with the presenting complaints of increased alertness, feeling
high, irregular heartbeat, high body temperature, reduced appetite, insomnia, agitation,
anxiety.These drug-related changes to brain stress and reward systems have been associated with
enhanced emotional and behavioral sensitivity to stress during protracted withdrawal including
increased reports of irritability, restlessness, depressed mood, anxiety, and high cravings.
(Kampman, Alterman, Volpicelli, 2001).
Despite young adult males displaying increased physiological, stress-related activity compared to
females.subjective anxiety following exposure to personalized, individually calibrated stress,
drug-cue, and neutral imagery. (Fox HC, Garcia M, Kemp K, Milivojevic V, Kreek MJ, Sinha R.
2006).this report clearly shows that’s substance induced anxiety is more common in male.
As per by my client when he left drugs he start experiencing withdrawal symptoms which makes
him restless, loss of appetite, high irratibility, anxiety such as social anxiety which made him
interact less with his social environment family and friends.
Anxiety Poor interpersonal
Stress relationships
Insomnia Breakup with girlfriend
History of drug abuse
Aggression
Diagnosis:
300.02 (F41.1) Generalized Anxiety Disorder
Prognosis
As the clients score he need constant care and treatment and her family is very supportive toward
her and he is also willing to get better and want counseling so he can get out of this illness and
live a normal life.Client has high chances for recovery because client had insight about his
problem and he was motivated to get proper treatment.

Management plan
Session No. 1
Session No. 2
Session No. 3
Session No. 4
In this session tests were applied on the client. Started with beck depression inventory, beck
anxiety inventory to check which is more relatable to the client distressful situation.
Session No. 5
In this session client was administered by few more test batteries such as drug abuse screening
test to see if client still do any drugs by any chance but denied in clinical interview after that
mini-mental state examination was done to check client orientation about its environment.
Session No. 6
them nicely.
Session No. 7
From the previous session, it was diagnosed that client has generalized anxiety disorder the
therapies which I used with the client were cognitive behavior therapy such as Cognitive
restructuring or reframing asked client to make negative things in a positive way like leaving
your good friends because of drugs can be changed into going out again facing them socializing
again. This work as exposure therapy for the client to as facing anxieties and fear.
Session No. 8
References:
• Fox HC, Garcia M, Kemp K, Milivojevic V, Kreek MJ, Sinha R. Gender differences in
cardiovascular and corticoadrenal response to stress and drug cues in cocaine dependent
individuals. Psychopharmacology (Berl) 2006;185:348–57.
• Kampman KM, Alterman AI, Volpicelli JR, et al. Cocaine withdrawal symptoms and
initial urine toxicology results predict treatment attrition in outpatient cocaine
dependence treatment. Psychol Addict Behav. 2001;15:52–9
Case no 3:
Delusional Disorder
Case Summary
A.K was 38 years old, not educated. She had 2 siblings, 2 sisters. She was married but later on got
divorced. After that he lost her father too.From the past few years, she has been experiencing lack
of interest, disturbed social functioning, depressed mood, hallucinations, illusions, aggressive
behavior, irritability and anger.Different assessments tools were used Mini-Mental State
Examination (MMSE), Beck Depression Inventory (BDI), Positive and Negative Syndrome Scale
(PANSS), House Tree Person (HTP) all these were done on the client. She was taken to CDA
Hospital Islamabad for treatment.
1. Bio Data
Names A.K
Age 38 years
Siblings 2 sister
Birth order 2nd
Religion Islam
Independent/ Dependent Dependent
A.K was a 38 years old female and she was referred by her family doctor to CDA Hospital. Due
to her psychiatric symptoms.

‫میں اپنے والد کی آواز سن سکتا ہوں‬
‫میں اپنے والد کو دیکھ سکتا ہوں‬
‫میں رات کو سو نہیں سکتا‬
History of Present Illness
• Depressed mood
• Hallucinations
• Illusions
• Aggressive behavior
• Irritability
• Lack of interest
The patient belongs to the middle class family. she has two siblings. she is 1st among them. she
has two sisters. The patient father was a government officer. Her father was loving and
supportive man and she was very close to her father. Her mother is a house wife. She has strick
but caring personality. General home atmosphere is normal and well managed.
Personal history
The birth of the client was normal without any complications. Client childhood was normal too.
But later on had asthma issues.She had a lot of friends but later on she socialize less with her
friends. She was married to the person she loved but later on she got divorced. Her father could
not bear this pain and had heart attack after few months later after that she’s in the state of
paranoia and facing hallucinations. According to client mother she use to tell her that her father
is alive and at night she can talk to him. Because of such abnormal behavior her family took her
to psychiatrist for consultation who then forwarded her case to hospital.
Educational history
She went to school at the age of early years. she was a very talktive in her childhood and was
always curious to learn something new in school and but she was extrovert and alway make new
friends.she had done her graduation in Masters in economics and then got married to person she
was currently dating for few years they were classmates in same university.
Sexual history
She got married to person she loved few months were very good and sexual relation between
both husband and wife were good. But after sometime husband stops talking interest in her and
she had trust issues with him because she noticed some unusual details that her husband was
involved in someone else other than her.she confronted him but he denied.she cameback to her
parents home after few months he divorced her.
The mood before the onset of her illness was normal she use to enjoy her life to fullest with her
friends and family.she was lively and active to explore new things.but after her divorce and
sudden death of her father made her traumatized and she lost her connection with social
environment. she starts to live alone locked up in her room stay hungry for days and quit going
out or any social interaction with others after few month she starts telling her mother that she can
talk to her father at night and he’s alive. she was experiencing auditory and visual hallucinations.
• Informal
• Formal
Clinical interview:
Client was asked about her relation with family, friends. Client was cooperative and extrovert.
she talked about her personal life and what problems are faced by her in past years. All the
information provided by client was same as provided by clients mother.her behavior was

to the information provide by her mother and through observation it was clear that the client is a
extrovert person. he was not very cooperative during sessions. Client was not well dressed and
cleaned up.
Formal assessment:
• The Positive and Negative Syndrome Scale (PANSS)
Total Score: 30 28
throughout the sessions. Eye contact was not maintained properly. The patient was not neatly
dressed. Her score was 21 which shows that there is No cognitive impairment.
25 21-30 Moderate depression
BDI Score is 25 which shows Moderate depression
The Positive and Negative Syndrome Scale (PANSS)
Scales Score Range Scored
Positive scale 7 - 49 18
Negative scale 7 - 49 20
General Psychopathology 16 - 112 40
scale
Panss overall 30 - 210 78
PANSS overall score is 78 which means Mild symptoms.
Client HTP interpretation is feeling of anxiety and insecurity which means she have anxieties
and insecurities regarding others or situation. Sexual concerns which can be related to sexual
orientation and desires of client. Depression, poor interpersonal relationships with others.
Suspiouse towards the situations. Withdrawal from reality which mean no connect with real
world. Psychotic, Paranoid, auditory hallucinations which refers to delusions.
Case Formulation:
The client was 38 year old female with delusional disorder content of the primary delusion:
persecutory, jealous, erotomanic, somatic, grandiose, mixed and unspecified. (Kendler,
Schizophr Bull. 2017) these all primary delusion are subtyped categorized which can give further
information about the condition of client current state of symptoms.the origins of delusional
beliefs, whether in men or women, continue to baffle clinicians (Connors, Halligan, 2020)
so that psychological assistance cannot easily be directed at the putative source of whatever
cognitive distortions exist. These same difficulties perplex the families of patients. The
seemingly unprovoked emergence of implausible beliefs in their relative bewilders them, and
they are at a loss as to how best to respond. (Rose, Mallinson , Gerson, 2006)
The client should be provided by the insight of her problem and should be well aware of what
issues client is going through which therapies will help them to do better. In schizophrenia,
women are prescribed clozapine or long-acting antipsychotics less frequently than men, but these
drugs are not often used for delusion disorder.Again, in the context of schizophrenia, women are
more likely than men to be prescribed an antidepressant, mood stabilizer, anxiolytic and sedative
along with their antipsychotic (Sommer, Tiihonen, van Mourik, Tanskanen, Taipale, 2020) .
Because of estrogen effects on the enzymes that metabolize olanzapine and clozapine,
premenopausal women need lower doses than men at least for these two drugs. (Seeman, 2020).
These are medication which can be proceed along with other therapies for making client
condition stable.
Family reactions are important to a patient’s recovery from psychotic illness. where one family
member was experiencing a psychosis for the first time. Some family responses, such as
withdrawal, guilt, fear, and a stigmatization of mental illness, led to the avoidance of engaging
mental health services in the treatment of their ill family member. Although patients with
delusional disorder are older than those with first episode psychosis, the influence of family
response on help-seeking is probably similar in the two conditions. (Wainwright, Glentworth,
Haddock, Bentley, Lobban, 2015)
Asthma Hallucination Poor interpersonal
Depressed mood relationships
Illusions Divorced
Aggressive behavior
Irritability
Lack of interest
Diagnosis:
297.1 (F22) Delusional Disorder.Unspecified type
Prognosis
Management plan
Relaxation methods

introduced to the client which can help to relax during hard times when client is having hurdle
with thinking process.
Session No. 1
Session No. 2
Session No. 3
Session No. 4
In this session tests were applied on the client. Started with beck depression inventory, to check
which is more relatable to the client distressful situation.
Session No. 5
In this session client was administered by few more test batteries such as mini-mental state
examination was done to check client orientation about its environment. Positive and Negative
Syndrome Scale which indicate positive symptoms and negative symptoms and also
psychopathology symptoms of the patient.
Session No. 6
them nicely.
Session No. 7
From the previous session, it was diagnosed that client has delusional disorder. therapies which
used with the client were giving insight of the problem and doing psychotherapy. cognitive
behavior therapy such as Cognitive restructuring or reframing asked client to make negative
things in a positive way like leaving your good friends because of drugs can be changed into
going out again facing them socializing again. This work as exposure therapy for the client to as
facing anxieties and fear.
Session No. 8
Reference:
1. Connor M.H., Halligan P.W. Delusions and theories of belief. Conscious. Cogn.
2020;81:102935. doi: 10.1016/j.concog.2020.102935.
2. Rose L., Mallinson R.K., Gerson L.D. Mastery, burden, and areas of concern among
family caregivers of mentally ill persons. Arch. Psychiatr. Nurs. 2006;20:41–51. doi:
10.1016/j.apnu.2005.08.009
3 Sommer I.E., Tilhonen J., van Mourik A., Tanskanen A., Taipale H. The clinical course
of schizophrenia in women and men—A nation-wide cohort study. Npj Schizophr.
2020;6:12. doi: 10.1038/s41537-020-0102-z
4 Seeman M.V. Men and women respond differently to antipsychotic drugs.
Neuropharmacology. 2020;163:107631. doi: 10.1016/j.neuropharm.2019.05.008.
5 Wainwright L.D., Glentworth D., Haddock G., Bentley R., Lobban F. What do relatives
experience when supporting someone in early psychosis? Psychol. Psychother.
2015;88:105–119. doi: 10.1111/papt.12024
6 Kendler K.S. The clinical features of paranoia in the 20th century and their representation
in diagnostic criteria from DSM-III through DSM-5. Schizophr. Bull. 2017;43:332–343.
doi: 10.1093/schbul/sbw161
Case 4:
Schizophrenia. First episode, currently in acute episode.
Case Summary
A.A was 40 years old, not educated. He had 2 siblings, 1 sister and 1 brothers. He was not married
but always wanted to get married. From the past few years, as told by family He has been
experiencing lack of interest, hallucinations, disorganized speech, abnormal psychomotor
behavior, and negative symptoms . He attempted suicide 3 times. Different assessments tools were
used Mini-Mental State Examination (MMSE), Beck Depression Inventory (BDI), Positive and
Negative Syndrome Scale (PANSS), House Tree Person (HTP) all these were done on the client.
She was taken to CDA Hospital Islamabad for treatment.

1. Bio Data
Names A.A
Age 40 years
Birth order 1st
Religion Islam
Independent/ Dependent Independent
A.A was a 40 years old male and he was referred by a psychiatrist to CDA hospital Islamabad.
‫کمرے میں گھٹن محسوس ہوتی ہے‬
‫آنکھ کھلتی ہے تو خود کو کمرے میں بند پاتا ہوں‬
‫اپنے ہاتھوں پر کٹ لگایا ہوتا ہے‬
History of illness:
• lack of interest
• Disturbed social functioning,
• Depressed mood
• Hallucinations
• Illusions
• Aggressive behavior
• Irritability
• Stubbornness
• Anger
The patient belongs to the high socio-economic status family. he has two siblings. he is 1st
among them. he has one brother and one sister. The patient father is a businessman. His father is
loving and supportive man. His mother is a interior designer. She has a very polite and loving
personality. General home atmosphere is normal and well managed.
Personal history
The birth of the client was not normal it was by C-section and during time of birth he lost his
breath but was saved. Client childhood was normal too as per by friends. He was not married and
has desire to get married. He was in a relationship in past for 10 years. As by client family he and
his partner were in sexual relationship they use to live together but after breakup that girl got
married to someone else and moved out of Pakistan.before recovering from this trauma he lost
his best friend in an car accident.After that client starts to isolate his self and starts living alone
with no connection with outside world or family.on night his family found him locked in room
after several tries they opened the door found him laying on ground with a cutted wrist after that
family took him to hospital and later on consulted a psychiatrist.
Educational history
He went to school at the age of early years. He was a very shy in his childhood and was always
curious to learn something new in school and but he was introvert doesnot make new friends.he
had done his graduation in Masters in english literature and went to abroad for job for 5 years but
came back due to his nature of being introvert and couldn’t adjust in such open environment and
start doing job here.
The mood before the onset of his illness was normal he use to stay with his girl friend and
hangout with his best friend..he use to meet his family during this time period. He was lively and
active to explore new things.but after his breakup and death of his only best friend he stats to live
alone and quit going out or any social interaction with others after few month he starts
complying about his friend is alive and he can see him and talk to him. He was experiencing
auditory and visual hallucinations.
• Informal
• Formal
Clinical interview:
Client was asked about his relation with family, friends. Client was shy and introvert.he talked
about his personal life and what problems are faced by him past these years. All the information
provided by client was same as provided by clients family.other then this his behavior was
to the information provide by his parents and through observation it was clear that the client is a
introvert person. he was not very cooperative during sessions. Client was not well dressed and
cleaned up.
Formal assessment:

• The Positive and Negative Syndrome Scale (PANSS)
Total Score: 30 21
throughout the sessions. Eye contact was not maintained properly. The patient was not neatly
dressed. His score was 21 which shows that there is Mild cognitive impairment.
45 Over 40 Extreme depression
BDI Score is 45 which shows Extreme Depression.
Positive and Negative Syndrome Scale (PANSS)
Scales Score Range Scored
Positive scale 7 - 49 23
Negative scale 7 - 49 30
General Psychopathology 16 - 112 72
scale
Panss overall 30 - 210 125
PANSS overall score is 125 which means moderate symptoms.
House Tree Person (HTP)
Client HTP interpretation is Psychotic, Paranoid, auditory hallucinations which refers to
delusions. He has feeling of anxiety and insecurity which means he has anxieties and
insecurities regarding others or situation. Conflict over interpersonal relations means no social
relations with family or friends. Withdrawal from reality which mean no connect with real world.
Sexual concerns which can be related to sexual orientation and desires of client. Depression,
poor interpersonal relationships with others.

Case Formulation:
The client age is 40 years suffering from schizophrenia hallucinations, aggression, illusion,
anger. Several studies have found gender differences in negative symptoms, showing that in
males, they were more severe. (Riecher-Rössler, Häfner, 2000). Galderisi et al. found that men
scored higher in disorganization and negative symptoms. (Galderisi S, Bucci P, Üçok A,
Peuskens, 2012) In a large sample of patients with psychosis, Morgan et al. identified a higher
prevalence of depressive symptoms and lower prevalence of negative symptoms in women.
(Morgan, Castle, Jablensky, 2008) Higher prevalence of depressive and anxiety symptoms in
women had been found in previous studies. (Walker, Bettes, Kain, Harvey, 1985)
There are many new way of therapies and treatment methods for the person with schizophrenia
Current treatments of schizophrenia have significant limitations. Firstly, they are efficient for
only about half of patients enabling them independent life (Stroup, Lieberman ,Swartz, McEvoy,
2000). Secondly, they ameliorate mainly positive symptoms (e.g., hallucinations and thought
disorders which are the core of the disease) but negative (e.g., flat affect and social withdrawal)
and cognitive (e.g., learning and attention disorders) symptoms remain untreated. (Carbon,
Correll, 2014). Thirdly, they involve severe neurological and metabolic side effects and may lead
to sexual dysfunction or agranulocytosis (clozapine). (De Berardis, Rapini, Olivieri, Di Nicola,
Tomasetti, Valchera, Fornaro, Di Fabio, Perna, Di Nicola, Serafini, Carano, Pompili, Vellante,
Orsolini, Martinotti, Di Giannantonio, 2018).

c-section Hallucinations Poor interpersonal
Disorganized speech, relationships
Abnormal psychomotor Breakup with girlfriend
behavior Death of best friend
Negative symptoms
Diagnosis:
295.90 (F20.9) Schizophrenia. First episode, currently in acute episode.
Prognosis
Management plan
Relaxation methods
Management plan
Relaxation methods
Session No. 1
Session No. 2
Session No. 3
Session No. 4
In this session tests were applied on the client. Started with beck depression inventory, to check
which is more relatable to the client distressful situation.
Session No. 5
In this session client was administered by few more test batteries such asmini-mental state
examination was done to check client orientation about its environment. Positive and Negative
Syndrome Scale which indicate positive symptoms and negative symptoms and also
psychopathology symptoms of the patient.
Session No. 6
them nicely.
Session No. 7
From the previous session, it was diagnosed that client has schizophrenia the therapies which I
used with the client were cognitive behavior therapy such as Cognitive restructuring or reframing
asked client to make negative things in a positive way like leaving your good friends because of
drugs can be changed into going out again facing them socializing again. This work as exposure
therapy for the client to as facing anxieties and fear.
Session No. 8
References:
1. Galderisi S, Bucci P, Uçok A, Peuskens J. No gender differences in social outcome in
patients suffering from schizophrenia. European Psychiatry.
2. Riecher-Rössler A, Häfner H. Gender aspects in schizophrenia: bridging the border
between social and biological psychiatry. Acta Psychiatrica Scandinavica. 2000;102(407):58–
62.
3. Morgan VA, Castle DJ, Jablensky AV. Do women express and experience psychosis
differently from men? Epidemiological evidence from the Australian National Study of
Low Prevalence (Psychotic) Disorders. Australian and New Zealand Journal of
Psychiatry. 2008;
4. Walker E, Bettes BA, Kain EL, Harvey P. Relationship of gender and marital status with
symptomatology in psychotic patients. Journal of Abnormal Psychology. 1985;94(1):42
5. Stroup T.S., Lieberman J.A., Swartz M.S., McEvoy J.P. Comparative effectiveness of
antipsychotic drugs in schizophrenia. Dialogues Clin. Neurosci. 2000;2:373–379.

6. Carbon M., Correll C.U. Thinking and acting beyond the positive: The role of the
cognitive and negative symptoms in schizophrenia. CNS Spectr. 2014;19(Suppl. 1):35–
53. doi: 10.1017/S1092852914000601.
7. De Berardis D., Rapini G., Olivieri L., Di Nicola D., Tomasetti C., Valchera A., Fornaro
M., Di Fabio F., Perna G., Di Nicola M., et al. Safety of antipsychotics for the treatment
of schizophrenia: A focus on the adverse effects of clozapine. Ther. Adv. Drug
Saf. 2018;9:237–256. doi: 10.1177/2042098618756261.

hareem

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

hareem

Uploaded by

Copyright:

Available Formats

ADULT CASE REPORTS

Supervisor signature Signature

of project. I am grateful for their constant support and help.

Major Depressive Disorder.

taken to CDA Hospital Islamabad for treatment.

Date of birth 22-06-1997

Siblings 1 sister 2 brother

Birth order 3RD

Socio- economic status Average family

Dependent/ Independent Independent

Presenting complaints (verbatims):

‫میں بہت تنہا محسوس کرتا ہوں‬

‫میرا جسم کانپنے لگتا ہے‬

‫مجھے نیند کے مسائل ہیں‬

‫مجھے بے چینی ہے‬

normal and well managed.

is affecting her daily life.

Assessment has been done by following ways.

observed by behavioral observation.

pessimist ambivert. She was very cooperative during sessions.

Client was assessed through following test:

• Minnental State Examination MMSE

• Beck Depression Inventory (BDI)

• Beck Anxiety Inventory (BAI)

• House Tree Person (HTP)

Mental status examination

Maximum Score Patient’s Score

which shows that there is no cognitive impairment.

Beck Depression Inventory (BDI):

35 31-40 Severe depression

BDI Score is 35 which shows severe depression.

Beck Anxiety Inventory (BAI):

Score Sum Range Severity Range

46 36 – Above Potentially concerning level

BAI Score is 46 which shows potentially concerning level of anxiety.

House Tree Person (HTP):

than in men.(Ford DE, Erlinger TP,2004).Although differences in socioeconomic factors,

(Rai D, Zitko P, Jones K, Lynch J, Araya R ,2013).

depression-related illness, including premenstrual disorder, postpartum depression and

Bio psycho social model:

Biological factors Psychological factors Social factors

Anxiety Poor interpersonal

Poor coping skills Stressful environment at

Suicidal ideation home

296.23 (F32.2) Major Depressive Disorder. severe features.With anxious distress

of this illness and live a normal life.

Cognitive behavioral therapy (CBT)

positive way of living.

Progressive muscle relaxation therapy

past and present life.

health client was terminated from the hospital.

opposite-sex twin pairs. Am J Psychiatry. 2014

3. Rai D, Zitko P, Jones K, et al. Country- and individual-level socioeconomic determinants

of depression: multilevel cross-national comparison. Br J Psychiatry. 2013

Generalized Anxiety Disorder

Islamabad for treatment.

Date of birth 21-11-1995

Siblings 1 sister 3 brother

Birth order 2nd

Socio- economic status Average family

Independent/ Dependent Independent

Reason and source of referral:

Presenting complaints (verbatims):

‫انتباہ میں اضافہ‬