Case 1 - Generalized Anxiety Disorder

Clinical Internship

Trainee’s Name:

Muhammad Usman Bin Tahir

Supervisor:

Ms. Maria Ahmed

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Psychological Advisory Panel

Rawalpindi

2022
 DECLARATION

I, Muhammad Usman Bin Tahir – Trainee (Intern) Clinical Psychologist at

Psychological Advisory Panel, duration 19 July 2022 – 28 August 2022 hereby declare that

the matter presented in this case report is original work under supervision of Ms. Maria

Ahmed – Clinical Psychologist, Psychological Advisory Panel.

Dated: Signature of Trainee

01-08-2022
 Table of content

Sr No Topics Page No

1 Identifying Information 04

2 Reason & Source of Referral 04

3 Presenting Complaints 05

4 Personal History 05

5 Family History 05

6 Medical & Psychiatric History 06

7 History of Present Illness 06

8 Educational History 06

9 Psychosexual History 06

10 Premorbid Personality 07

11 Behavioral Observation 07

12 Psychological Assessment 07

13 Suspected Problem 07

14 Case Formulation 08

15 Prognosis 09

16 Intervention Plan 09

17 References 11
 Case 1 – Generalized Anxiety Disorder 4

CASE 1 - GENERALIZED ANXIETY DISORDER

Identifying Information:

Name: SA

Gender: Male

Age: 28 years

Religion: Islam

Address: Not Found

Birth Order: N/A

Siblings: Only Child

Education: MSC

Marital Status: Single

Informant: Client’s Father

Date of Referral: 06-02-2009

Reason & Source of Referral:

The patient complained of palpitations, irritation, muscle tightness, and being quickly

worn out when she arrived at the private hospital. For the treatment of her issues, he was

referred to a consultant psychiatrist and a clinical psychology trainee.

 Case 1 – Generalized Anxiety Disorder 5

Presenting Complaints:

‫ا‬DD‫ک جات‬DD‫دی تھ‬DD‫جل‬ 6 ‫ماہ‬

‫ہوں‬

‫ ماہ‬6 ‫ہر وقت الجھن میں رھتا ہوں‬

‫ ماہ‬4 ‫صبح سے سو نہیں سکتا‬

‫ ماہ‬4 ‫مجھے ڈر لگتا ہے میں کسی بھی چیز کو صیح سے نہیں کر سکتا‬

Personal History:

According to the client's mother, her birth was normal. The client did not report any

difficulties during or after pregnancy. All of his developmental milestones were reached at

the proper ages for him. There were no notable illnesses noted during his childhood. When he

first began attending school at age 3, the client was a well-behaved and diligent pupil.

Additionally, he demonstrated enthusiasm in his studies and consistently tried to concentrate

on them, which led to a strong academic record. The client worked for a bank.

When the client was 12 years old, he entered puberty. His initial reaction to these

changes, particularly his physical growth, was a little perplexing, but he eventually grasped

them. The client's religious leaning was acceptable because he regularly attended services and

came from a religious background.

Family History:

Father RK was a graduate and 65 years old. He was courteous and owned his own

electronics firm. He always thought about others and played a role of authoritative figure in

his family. The mother HK was an Intermediate who was 54 years old. She was a respectable
 Case 1 – Generalized Anxiety Disorder 6

housewife. The parents had an excellent relationship and showed constant concern for one

another. His parents only had the client as a child.

The client was one of three people that made up the client's nuclear family. The

residents of the house displayed a good sense of community and care for one another. The

family's head of household was the father.

Medical & Psychiatric History:

The client's family had no history of medical or mental health issues.

Educational History:

No educational history found.

Psychosexual History:

He had a neutral point of view.

Premorbid Personality:

He was naughty and chatty as a child. He enjoyed playing cricket and reading various

children's books. He was really outgoing. He cut himself off from his friends and family as a

result of his anxiousness. He was left alone. He was also unable to carry on with his

coursework.

Behavioral Observation:

No behavioral observation was found.

Psychological Assessment:

Following measures were used as informal assessment.

1. Clinical Interview
 Case 1 – Generalized Anxiety Disorder 7

2. Mental Status Examination

Clinical Interview:

A thorough history of the client's family life, personal life, and history of the current

illness was collected during the clinical interview.

Mental State Examination:

The client was a 28-year-old male. He stood 6 feet 3 inches tall. He had dark hair and

nice features. He was in a good mood and was interested in everything. He had a regular

speech pattern and was cheerful in his interaction. Regarding short- and long-term memory

storage as well as distant recall, memory functions were intact. He had trouble focusing on

anything. Depersonalization and derealization to some extents were noticed. His capacity for

abstract thought was adequate. He had good sense of place, time, and people, as well as good

understanding of his sickness. He wished to recover from his condition.

Diagnosis:

300.02 (F41.1) Generalized Anxiety Disorder.

Case Formulation:

According to DSM-5, generalized anxiety disorder is characterized by excessive

anxiety and worry, occurring more days than not for at least 6 months, about a number of

events or activities. The individual finds it difficult to control the worry. The anxiety and

worry are associated with three (or more) of the following six symptoms. (Association, 2013)

 Restlessness

 Being easily fatigued

 Case 1 – Generalized Anxiety Disorder 8

 Difficulty concentrating or mind going blank

 Irritability

 Muscle tension

 Sleep disturbances

Clinically substantial distress or functional impairment in social, occupational, or

other key areas of functioning are brought on by the anxiety, concern, or physical symptoms.

Because the client got tired easily, generalized anxiety disorder was identified as the client's

condition. He struggled to focus at work. Additionally disrupted was his social life.

Numerous research had backed the psychodynamic perspective's claim that overly

protective parenting frequently causes children to experience significant levels of anxiety. In

this instance, the client's parents were too protective of him, which made him overly sensitive

and worried about his own health.

According to the cognitive approach, generalized anxiety disorder is caused by

fundamentally illogical presumptions. In this instance, the client felt more apprehensive and

had more pessimistic views that if he went outside, he would be in greater risk. According to

metacognitive theory, people start to feel more worried and hold more unfavorable thoughts

about their fears.

Prognosis:

The client's prognosis was favorable because he desired to deal with his issues and

make changes in his life without consulting his family.

Intervention Plan:

The client's intervention strategy was developed using the Cognitive Behavior

Therapy model while taking into account the client's particular needs.
 Case 1 – Generalized Anxiety Disorder 9

Short Term Goals:

 The client received psychoeducation to explain the nature and symptoms of the

anxiety and to assess the impact of the anxiety on his health, social life, and academic

performance.

 The client's family received family counselling to help them learn how to handle the

client's anxiety. The client's family should inspire and encourage him to modify his

unreasonable thinking and social abilities.

 Albert Ellis' Rational Emotive Therapy would help the client comprehend the causes,

consequences, and maintenance of his anxiety. The client experienced less fear,

thanks to this therapy.

 The individual received exposure therapy. The client was encouraged by this therapy

to enter the terrifying social situations and to stay there until his fear passes.

 The client received group therapy to help them deal with anxious situations in a safe

and supportive environment.

 The client received reinforcement from others who had experienced similar obstacles

in order to achieve more fruitful results.

 The client received instruction in assertiveness and social skills so they may practice

trying out new actions.

Long Term Goals:

 Continuation of short-term goals.

 Self-management skills were given to the client to understand his negative and

irrational thoughts and the effected of such thoughts in his life.

Case 1 – Generalized Anxiety Disorder 10

References

Association, A. P. (2013). Diagnostic and Statistical Manual of Mental Disorders DSM - 5 .

United States of America : American Psychiatric Association .