CASE CONFERENCE

Psychological Assessment and Management

Akifa Sami
Clinical Psychologist (Trainee)
 Patient Profile
• Patient XYZ
• Age:-20yrs
• Sex:- female
• Marital status:-unmarried
• Education:-student of BA
• Address:- Nankana Sahab,Lahore
Informant
• Name XYZ
• Age 40yrs
• Relationship with pt. :- Mother
• Years living with patient :- 20 yrs (since childhood)
 Presenting Complaints
Complaints Duration Complaints Duration
Headache 8 days Crying Spells 1 month

Muscle Tension 2 weeks Mood irritability 10 days

Lack of
Low Mood 1 month 1 month
Concentration
Body Aches 5 days Fatigue 10 days

Disturbed Sleep 8-10 days Palpitation 1 month

Fatigue 10 days
History of presenting illness
• My pt. with history of major depressive disorder / OCD / FNSD has had an headache
on and off for past 10 years , body aches and muscle stiffness for 1 year and difficulty
in breathing for past 2 days
• She had headache which was unilateral temporoparietal ,1-2 episodes per day,severe
(8/10 in intensity),continuous and ,lasting for Upto 10_15 minutes ,not relieved by
any medication and stopped by itself.It was not associated with photophobia ,
Phonophobia , nausea , vomitting , eye swelling , lacrimation and blurred vision
• Headache was also associated with Body aches and body weakness along with
muscle stiffness
• She also feel difficulty in breathing which was total 3 episodes till now .First episode
was at home ,2nd was on her way to hospital on 26dec,2022 and third episode was on
very next day of admission (27-12-22) and these episodes are gradual in onset
• When these episodes occur , she started pinching her nose and started breathing
from mouth and that relives her SOB
• All her symptoms aggrevated after her BA exam result (4_12_22) in which she
has supply in English
• She has normal sleep , normal apetite
• She didn,t report any guilt ,hopelessness,suicidal ideation at time of admission so
severity of risk is mild
• She has concentration difficulties in studies and house chores
• When inquired further , she had

ideas of reference
Paranoid ideation
low anxious irritable mood with verbal and physical aggression to family
members
Apprehension
Past Psychiatry History
• Her symptoms started in 2012 and then She presented to psychiatrist first time in
2016.Before 2016 , she visited spiritual healers for 2_3 years
• She got admitted to Ali hospital for 2 days in 2018
• 2017 _ 2020 she visited peadrician but no improvement
• 2020_dec 2021. She visited General hospital’ Mental hospital and to some
psychiatrist in faislabad
• She came to mayo hospital in Dec ,2021 in opd .she was on medication with little
improvement in symptoms but on 7 march ,2022 she got admitted to our
department for 1 week and then had DOR on 14 march , 2022
Family psychiatric History
• Not significant
Past Medical And Surgical History
• Not significant
Functioning And Interpersonnel Relationships
Pt has decreased functioning in studies .She couldn’t concentrate on studies
she did not do any house chores before 2020 but she started doing house chores
after 2020.
• She had paranoid ideation againast father and phopho
• She Did not have enough friends
Personal History
• Pt. was delivered via SVD at home , no any Pregnancy complications present
• When inquired about delayed cry , neonatal resuscitation,neonatal asphysxia to
mother , mother did not remember and said she was like normal other children
• She achieved speech , motor and social milestones at appropriate time according
to mother
• No behavioural issues of significant importance as reported by mother
• She had neurotic trait ( thumb sucking started since childhood till 4 years of age )
Family History
• She has 5 sisters and 2 brothers
• She is eldest among them
• All siblings are School going and have better improvements in performance and
carrier as compared to patient
• Both parents are alive and both are cousins
• Mother is house wife and Father is shopkeeper
Educational History

• She started school at 4.5 years of age

• She was average to below average Student .She went to School till 9 th class .After
9th class she started Academy and quit School due to illness
• After matric she Skipped one year and got private admission in FA .she got
supply in FA first year
• After that she got admission in BA but she got supplies in BA 3 rd year and 4th year
English
Marital History
• Unmarried
• Relationalship history/ sexual preferences was inquired but pt was reluctant
when asked and upon repeated iquiry she did not report
Menstrual History
• Menarche _ 13 years of age
• Periods was regular 4/30 days
Premorbid Personality
• She had not good relationship with family besides mother .She was reserved
since childhood impulsive since childhood
• She was not very social . Did not have any friend ( phopho nay mana kea ha Kay
dost ni bnanay)
• Not very religious views
• Predomint mood was depressive
• She used to spend most of her time alone at home and did not tell anyone at
home about her stress and illnes
• She reports of becoming teacher at future (no specific fantacy life)
Socio-economic Status
• She lives in 5 Marla own house
• 10 family members
• Her phopho is unmarried and lives with them
• Only father earner shopkeeper
• Mother reported satisfactory living style
General physical Examination

• Vitally stable
• Other GPE unremarkable
Mental State Examination
• APPEARANCE ,BEHAVIOUR ,ATTITUDE
• Young female of normal built and height
• Walking into room along with mother
• Dressed appropriately acc. To culture and weather
• Sat on chair and well oriented in time place person
• Maintaining eye contact
• Rapport was built easily
• SPEECH
• Normal rate and rythym but decreased volume
• MOOD incongruent
• Subjective theek
• Objective low mood
• THOUGHT DISORDER
• 1) FORM OF THOUGHT
• Loosening of association , flight of ideas , thought block was not present
2)POSSESSION OF THOUGHT
Thought insertion , thought withdrawal and broadcasting of thought was not
present
3) STREAM OF THOUGHT
Pressure and poverty of thoughts was not present
4) CONTENT OF THOUGHT
Reported paranoid ideation but No delusions, obsessions, phobias.
She had no any visual , olfactory , tactile and olfactory hallucinations

INSIGHT :-
Mujay lagta ha masla ni ha bs preshan ho jate Hoon r dawai ki zaroort ni
han
COGNITIVE FUNCTIONS
MEMORY :- She has good short term memory as rat ka khana dal chwal thay
And good long term memory mre school teacher ka nam Shazia ha
• ABSTRACT THINKING :-

similarities as saib r gaind dono gol han

Differences as saib khaya jata ha r gaind say khaila jata ha
MSE at 31dec , 2022
( 5th day of admission)
improvement in symptoms that were reported at the time of admission.
MSE on 3 -01 – 2023
( 8th day of admission)
• Mood: Euthymic
• No formal thought disorder
• No delusions, hallucinations, obsessions
• Improvement in Concentration, and Insight.
Patient 20 years old female, resident of Nankana Sahab,
Formulation
unmarried, Student of B.A, eldest of 8 siblings, having no family
hx of psychiatric illness, with second admission in a psychiatric
facility, now presented to the OPD on 26 December 2022 with
complaints of on and off Headache (10 years) aggravated over
past 20 days, generalized aching and stiffness of the muscles(1
year) aggravated over the past 20 days, and 3 episodes of
shortness of breath over past 02 days. In addition (on exploring)
there was hx of Low, anxious & Irritable mood + verbal and
physical aggression towards family. Patient was diagnosed as a
case of Major depressive disorder, Obsessive compulsive disorder
and Functional neurological symptoms disorder in March 2022.
Patient reported past hx of Paranoid Ideation and Behaviour,
ideas of reference & visual hallucinations, But no current
Psychotic symptoms and MSE was negative for thought echo,
formal thought disorder, Delusions, hallucinations, possession of
thought or delusion of passivity.
• Attendant (Sister) reports Persistent ideas of Reference, paranoid ideation
and Behaviour & Hallucinatory Behaviour, Persistent Tense And Anxious
mood, Excessive sensitivity to correction & Criticism with decline in
educational performance over the past 5 years.In addition, mother and sister
both report persistenly low mood, Tearfulness, social withdrawal, On and off
sleep, appetite & intake disturbances, decreased attention and concentration,
low energy, fatigue, low self esteem , over the past 8 years. .
Prognosis
• Good prognostic factors: Good
compliance with medication and
follow up. Good relationship with
and support of mother. Improvement
in symptoms with medication.
• Bad prognostic factors: presence of
Intellectual impairment, Health belief
model of the family, High expressed
emotions of the family, Delay in
seeking treatment earlier in the
course of illness,
 Scores
 Clinical Interview
Informal Assessment Formal Assessment
• Beck Depression Inventory 28
 Mental Status Examination
• Beck Anxiety Inventory 32
 Dysfunctional Thought Record
• Borderline Personality Disorder Scale 5
• Yale-Brown Obsessive Compulsive Scale 13
• Standard Progressive Matrices <5
percentile
• Rotter's Incomplete Sentence Blank 143
• House-Tree-Person
Formal Assessment

Positive And Negative Syndrome Scale

(PANSS)
Positive Scale

Negative Scale

General Scale
 Diagnosis
Most Likely:

General Anxiety Disorder

Differentials:

Paranoid Personality Traits

Intellectual Impairment
Idiosyncratic Case Conceptualization (Kingdon and Turkington,
1994)
Predisposing Precipitating

Delayed Milestones, Inferiority Low appetite, Disturbed sleep, Death

complex, Asociality, Unstable home of grand father, Exam failure

environment, Domestic violence

Perpetuating Protective

Fever, Negative thoughts Adequate diet, Adequate sleep,

Exercise, Psychotherapy, Family

support
 Management Plan

The management plan was devised using the CBT.

• Rapport Building
• Psychoeducation
• Medical adherence
• Progressive muscle relaxation
• Headache Management
• Breathing Retaining
• Sleep hygiene
• Behavior Therapy
• Contingency Management
• CBT
• ABC Model
• BAP
• Behavioral Experiments
• Symptom induction