CASE

PRESENTATION
Yudhajit Roychowdhury
2037426
Client Details
◦ Age- 22

◦ Gender- Female

◦ Education- BTech in chemical engineering

◦ Occupation- Customer service employee at an MNC

◦ Languages known- Tamil and English

◦ Socioeconomic status- Affluent middle class

◦ Informant- Self
Presenting complaints
◦ Unhappy with self.

◦ Self doubts and guilt feelings because of a belief of personal inadequacy and dependence on people.

◦ Submissive attitudes and behaviours in order to avoid hurting people, leading to increased feelings of guilt at the inability to
confront others.

◦ Feeling of lack of independence.

◦ Feeling of helplessness

◦ The symptoms have persisted for a prolonged period of time and were exacerbated by a breakup six months prior to therapy,
i.e. early 2021.
History of Presenting Illness
◦ Onset- Gradual, insidious onset.

◦ Precipitating factors- Poor family dynamics characterised by parental conflicts, loss of friends during the final year of
graduation, breakup.

◦ Course of illness- Chronic course. The client reported never feeling any different for a long time.

◦ Associated disturbances- Disturbances in mood, memory, and attention.

Personal History
◦ Birth and early development- The client was born full-term through vaginal delivery. She accomplished the developmental
milestones successfully within time.

◦ Physical illness- The client suffered from tuberculosis as a child.

◦ Past psychiatric history- The client does not have a history of a psychiatric illness.

◦ Educational history- The client reported good educational performance with no serious academic difficulties.

◦ Occupational history- The client is currently employed. This is her first job.

◦ Sleep and appetite- Fluctuating pattern and quality of sleep, switching between restorative and non-restorative; fluctuating
appetite.

◦ Use of substances- None

Premorbid Personality
◦ Attitude towards others- The client reported being an introverted and shy person who often finds it difficult to start a
conversation with strangers in social situations. She also reported having few friends.

◦ Attitude towards self- The client reported being self-critical towards herself since childhood. This has only increased in
frequency now.

◦ Mood- The client reported experiencing a much wider range of mood states previously.

◦ Leisure activities- The client has a repertoire of leisure activities, including watching shows on Netflix, playing the piano, and
spending time with and taking care of her sister. These activities still persist, albeit in much reduced form.
Family history
◦ Family dynamics characterised by parental conflicts which is exacerbated by the presence of paternal grandmother, leading to
a form of triangulation.

◦ The client’s mother and paternal aunt’s wife left home when she was 8-years-old, although they returned later.

◦ The client’s elder sister has a diagnosis of bipolar disorder and is currently on medications.

◦ The client and her sister have frequent conflicts with her father.

◦ The client characterised her home environment as being “extremely restrictive” which does not allow for much freedom.
Family Genogram
Mental Status Examination
◦ Appearance- The client had a generally straight posture and was dressed and groomed according to the situation.

◦ Behaviour- The client maintained eye contact throughout the interview. There were no signs of tics, mannerisms, or abnormal
psychomotor activity.

◦ Attitude- The client displayed a cooperative and open attitude toward the therapist.

◦ Consciousness- The client was adequately conscious during he examination, being attentive to the questions being asked.

◦ Orientation- The client was adequately oriented to space and time.

◦ Speech- The client spoke in a fluent, and descriptive manner, with appropriate rate and volume.
Mental Status Examination
◦ Mood- The client appeared to be in a low mood.

◦ Thought- The client’s thought process was linear and goal-directed. No abnormalities in thought content and thought process
was noticed.

◦ Suicidality and homicidality- Absent.

◦ Insight and judgement- The client's personal and social judgement was found to be appropriate. She could only identify few
problems but was not much aware of the reasons- level IV.

◦ Attention- There were some delay with reverse digit span and spelling backwards.

◦ Memory- The client had better performance on recent and remote memory than immediate memory.

◦ Intellect- Vocabulary and abstraction abilities were found to be intact.

PSYCHODIAGNOSTIC
FORMULATION
Type-based Aetiological Factors
◦ Biological factors- History of mental illness in family (sibling has bipolar disorder).

◦ Psychological factors- Shyness, submissiveness, and lack of assertiveness.

◦ Sociological factors- The client had broken up with her partner not long before approaching therapy. The relationship was
abusive. Furthermore, at the same time, she had a fallout with her classmates and friends. Her family environment is hostile,
characterised by frequent conflicts between her parents, her mother and paternal grandmother, and her sister and her father.
She also shares a hostile relationship with her father.
Time-based Aetiological Factors
◦ Predisposing factors- History of mental illness in family (sibling has bipolar disorder).

◦ Precipitating factors- The breakup with her boyfriend and the subsequent fallout of the relationship had a profound impact
on the client.

◦ Perpetuating factors- The stress at her new job and the ongoing conflict within family.

◦ Protective factors- The client shares a good relation with her elder sister. She also has certain hobbies which she pursues.
Assessment and Diagnosis
◦ The client was assessed on the Patient Health Questionnaire which returned a score of 26, indicating moderate depression.

◦ The diagnosis is of recurrent depressive disorder with moderate episode (F33.1).

◦ Differential diagnosis- dysthymia, bipolar disorder, anxiety disorder

CBT FORMULATION
TREATMENT
Treatment Phases
◦ Assertiveness training

◦ Behavioural activation

◦ Challenging negative thoughts

◦ Exploring core beliefs and assumptions

◦ Relapse prevention