CASE 01

ANXIETY
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Summary

Client was 62 years old female. She visited the hospital with the presenting

complaints of anxiety, excessive hand washing, fear of someone broke into her house,

low confidence and disturbed social life, always feel anxious. Clinical interview,

behavioral observation, MSE and Subjective rating of symptoms were done as

informal assessment. In formal assessment, symptom checklist of DSM V and

Obsessive-compulsive inventory (OCI) was used. Case formulation

Indicated that predisposing factor of mother’s history of anxiety and precipitating

factor of husband’s death were significant reasons to exhibit these symptoms. In the

end management plan was proposed in which cognitive behavioral therapy along with

relaxation techniques were used on her to change her thought processes and she also

learned ways to cope with the problematic thoughts in a calming manner.

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Identification data

Name N.K

Age 62

Gender Female

Education Graduation Class

No of siblings 10

Birth order 1st

Occupation house wife

Marital status Married

No. of Children 07

Family system Nuclear

Informants 3rd born

Source and reason of referral

The client was brought by her daughter to the hospital and was referred to

trainee clinical psychologist for psychological assessment and management.

Presenting Complaints Duration

I feel tense or restless most of the time. More then 1 years
I get headaches or stomach discomfort when More then 1 years
I'm stressed.
My heart races sometimes, even when there's
More then 1& a half year
no real reason.
I feel on edge, like something bad might
More then 1 and half years
happen.
I worry about things more than I think I
should.
More then 2 years

I can't stop over thinking things, especially at

night. More then 2 years
I get stuck on 'what if' scenarios and feel
trapped in my thoughts. More then 6 months
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It's hard for me to focus or stay organized. More then 2 years

I avoid certain situations because I feel
nervous about them. More then 1 & a half year
I find it hard to stay calm.
More then 2 years
I get irritated easily with friends or family
More then 1 year
without meaning to.

History of Present Illness

N.K, 62 years old female, graduates, with two kids, belonging to middle

socioeconomic status, presented for management. Her symptoms started slowly; she

was always described as an anxious person and remembers being worried about a lot

of things throughout her life. 10 years ago, following a few life stressors, her anxiety

and intrusive thoughts worsened significantly. She began washing her hands

excessively. She reports she developed an intense fear that someone would break into

the house and it would be her fault because she left something unlocked. She knew

this was “irrational.” Now her symptoms are getting worse, which is why she has

sought treatment. For example, currently she washes her hands until she finishes the

whole soap bar, and her hands are cracked because they are so dry. She expresses

significant distress over these symptoms, as they are taking up more of her time and

robbing her of her confidence, as she is increasingly distracted in house chores and in

family life.

Background Information

Family History

Client’s husband was died 09 years ago at the age of 69. Her mother was alive and 94

years old. She was a housewife and had the history of anxiety. Client’s relationship

with her parents was good. Client had eleven siblings, 4 brothers and 6 sisters.
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Client’s relationship with his siblings was normal. But she reported that after her

husband’s death she started sharing her feelings with the one of her brother. She

didn’t interact much with her other siblings. She belonged to a middle socioeconomic

status. She lived in a nuclear family system. Her Husband was aggressive in nature

and had dominating personality. Authority figure and her husband was very strict

about the discipline and maintenance. Client reported that general home environment

of her house was good. She gets worried about her grandson future she scold her

daughter for this that you are not giving proper time to your son and this will gonna

destroy his future you will be the one who is responsible for all this. Client reported

that she get anxious for little issues like my son did not call me whats wrong is he all

right I feel that he is not sitting in good company and these things makes her condition

worse.

Personal History

Birth and early development history

According to the client, her parents didn’t mention any kind of difficulty during

her mother’s pregnancy and in delivery. She was born in home with the help of

(Daei). Client also didn’t know about her milestones. Client was afraid of darkness in

her childhood.

Educational History

Client done her graduation and according to her, she was an average student in

the class. She reported that in her educational time period she had many friends and

she loved to spend quality time with them.

Marital History

Client was married. At the time of marriage she was 27 years old and her

husband was 31 years old. It was an arrange marriage. Her husband was a doctor.
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According to the client, there was a satisfactory relationship between them. Client had

2 children, 1 sons and 1 daughter. According to the informant, they all had very

satisfactory relationship with their parents and also with each other.

Pre morbid personality

According to informant, client has anxiety issues for very long time but its

intensity was low so she was very friendly and supportive. She had a strong and good

bonding with her siblings and family. She was optimistic about herself and her family

future. Her tolerance towards stress was good. Her decision making abilities were also

good as she was the authority figure of the house after her husband death. Actively

participated in the religious practices.

Social History

According to informant, she didn’t participate in social activities now. As her

condition getting worse, she was most of the time worried about her cleanliness and

therefor also avoid social gathering. She preferred to spent her time at home.

Psychological Assessment

Assessment was carried out at informal level by using following measures.

Informal Assessment

● Clinical interview

● Behavioral observation

● Mental status examination.

● Subjective Rating of Symptoms

Rationale

Informal assessment is conducted to obtain the detailed information regarding the

client’s problem. By obtaining this detailed information we can assess the level of

problematic behavior. By this we know about the frequency and intensity of

problematic behavior. Through this we should know about the client condition that
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gives an overview that client’s orientation regarding time, place and person. We know

about the clothing, voice tone, memory through mental status examination.

Clinical Interview

Clinical interview was used as an informal assessment measure to obtain

information from the client about her illness in detail. Information regarding history,

problematic behavior and presenting complaints was taken from the client and

through observation. Confidentiality and privacy of client’s information was

discussed at the beginning of the interview. The information obtained from clinical

interview was used to proposed management plan according to the needs of the

client’s problems. It helps in getting right to the point of the problematic behavior.

Behavioral Observation

Behavioral observation is a systematic recording of behavior by an observer.

Behavioral observation is characterized by carefully detailed procedure to collect

reliable and valid data about client’s behaviors (Barrios, 1993; Tryon, 1998). clien

twas seems very anxious and continuously tapping her legs and rubbing her hands.

Her voice tone was normal. Sometimes she stares at one object for 10-15 seconds

without blinking her eyes and she continuously cleaning her forehead with her

dupatta.

Mental Status Examination

Domains Status

Appearance Good hygiene, Seasonal dress code and

was sitting in a low posture

Speech Normal volume and pitch

Mood Affect: low facial expressions

Depersonalization and Derealization:

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Absent

Thought Process Delusion: Absent

Obsessive Compulsion Disorder: Present

Perception and Imagery Illusion: Absent

Hallucination: Absent

Cognitive Functioning Memory: Was good which was revealed

through immediate, remote recall of the

events as a faced difficulty recalling

events

Attention and Concentration: was good

Abstract thinking: was good

Orientation about time, place and person

was good

Insight Present

Subjective rating of symptoms

Subjective Ratings were taken to measure the intensity of client’s symptoms.

Table I
Table Showing Symptoms Reported by client on Range of 0-10.
Symptoms Rating by client

Anxiety 10

Hand washing activity 10

Fear of someone break into his house 10

Low confidence 10

Disturbed occupational and social life 10

Fear of loosing her son 10

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Fear of her grandson future 10

Formal Assessment

 Symptom checklist of DSM V (APA, 2013)

 Obsessive-Compulsive Inventory (Foa, et. al, 1988)

 MMSE (Mini-Mental State Examination)

 Human Figure Drawing

Formal Assessment

Symptom checklist of DSM V (APA, 2013)

Obsessive-Compulsive Disorder Present Status

Recurrent and persistent thoughts, urges, or images that are Present

experienced

The individual attempts to ignore or suppress such thoughts, Present

urges, or images.

Repetitive behaviors or mental acts in response to an obsession Present

or according to rules that must be applied rigidly.

The behaviors or mental acts are aimed at preventing or reducing Present

anxiety or distress

If these acts not done if cause distress and anxiety Present

Obsessive-Compulsive Inventory (OCI)

Rationale

The Obsessive-Compulsive Inventory (OCI) was developed to help determine

the severity of Obsessive-Compulsive Disorder (OCD). It consist of 42 items

composing 7 subscales: washing, checking, doubting, ordering, obsessing, hoarding

and mental neutralizing. Each item is rated on a 5 point (0-4) scale of symptom
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distress. Mean scores are calculated for each of 7 subscales and overall mean distress

scores is provided. Each score is presented as a mean out of possible maximum of 4.

lower scores are better. A total score of 42 or more, or a mean score of 2.5 or more in

any of the subscale suggest the presence of OCD.

MMSE (Mini-Mental State Examination)

The client's MMSE score is likely to be within the normal range, indicating no

significant cognitive impairment. However, her responses may reveal some

difficulties with attention and concentration, such as difficulty following instructions

or remembering words. This could be related to her anxiety and obsessive thoughts,

which may be distracting and interfere with her ability to focus. Additionally, her

responses may indicate some difficulty with abstract thinking and problem-solving,

such as struggling to understand complex concepts or generate solutions to problems.

This could be related to her rigid and perfectionistic thinking style, which may limit

her ability to think creatively and flexibly. Overall, the MMSE may provide some

insight into the client's cognitive strengths and weaknesses, which can inform her

treatment plan.

Human Figure Drawing

The client's human figure drawing may reveal a figure with exaggerated or

distorted features, such as oversized hands or a large head, indicating a sense of

anxiety and fear. The figure may be drawn with a rigid or stiff posture, suggesting a

feeling of being "on edge" or constantly alert. The client may have difficulty

drawing facial features, indicating a struggle to express emotions or connect with

others. The figure may be placed in a corner or edge of the page, symbolizing

feelings of vulnerability and a need for control. Overall, the drawing may reflect

the client's obsessive thoughts and compulsive behaviors, such as excessive hand
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washing, as a way to cope with anxiety and fear.

The client's responses to overall tests may reveal a preoccupation with themes

of danger, threat, and vulnerability, indicating a sense of fragmentation and

disintegration, threatening or dangerous, reflecting a sense of fear and anxiety. The

client's responses may be repetitive and lacking in detail, suggesting a sense of

emotional numbness and disconnection. Overall, the tesst may indicate that the client

is struggling with intrusive thoughts and compulsive behaviors as a way to cope with

underlying feelings of anxiety and fear, which is consistent with the diagnosis of

obsessive-compulsive disorder.

Tentative Diagnosis

Generalized Anxiety disorder according to DSM 5.

Differential Diagnosis

Condition Differential Points Key Features

Does not cause
Worries are less pervasive,
significant distress or
Normal Worry more manageable, and related
impairment in
to specific stressors.
functioning.
Anxiety is specific to social
Anxiety occurs only in
situations and fear of
Social Anxiety Disorder anticipation or during
embarrassment or negative
social interactions.
evaluation.
Presence of intrusive thoughts
Anxiety is focused on
Obsessive-Compulsive (obsessions) and repetitive
specific obsessions, not
Disorder behaviors (compulsions) to
generalized.
reduce distress.
Recurrent, unexpected panic
Anxiety focuses on fear
attacks with intense fear and
Panic Disorder of future panic attacks
physical symptoms like
and their implications.
palpitations.
Related to a traumatic event Anxiety is trauma-related
Post-Traumatic Stress
with intrusive memories, and accompanied by
Disorder
avoidance, and hyperarousal. flashbacks or nightmares.
Intense fear of a specific Anxiety occurs only in
Specific Phobia object or situation (e.g., the presence of the
flying, heights). specific phobic stimulus.
Major Depressive Disorder Worry occurs within the Anxiety is often
context of pervasive sadness, secondary to depressive
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Condition Differential Points Key Features

loss of interest, and other symptoms rather than a
depressive symptoms. primary focus.
Resolves upon cessation
Anxiety linked to substance
Substance/Medication- of the substance or
use or withdrawal (e.g.,
Induced Anxiety Disorder treatment of withdrawal
caffeine, stimulants).
symptoms.
Anxiety occurs in response to
Symptoms do not meet
Adjustment Disorder with a specific stressor and
the full criteria for GAD
Anxiety subsides once the stressor is
and are time-limited.
resolved.
Anxiety focuses on physical Preoccupation with
Somatic Symptom Disorder symptoms and their potential somatic complaints rather
medical implications. than generalized worry.
Anxiety due to medical Laboratory findings
Hyperthyroidism conditions like thyroid confirm thyroid
overactivity. dysfunction.

Prognosis of Anxiety

The prognosis of Generalized Anxiety Disorder (GAD) varies based on

several factors, including the severity of symptoms, early intervention, and access to

effective treatment. With appropriate treatment, which often includes cognitive-

behavioral therapy (CBT), medications, or a combination of both, many individuals

experience significant symptom improvement and better quality of life. However,

GAD is a chronic condition, and relapses can occur, particularly during times of

stress. Factors such as comorbid conditions (e.g., depression, substance use disorders)

and a lack of social support may negatively impact the prognosis. Early diagnosis and

a tailored, ongoing treatment plan can greatly enhance long-term outcomes.

Case Formulation

N.K, 62years old Female. Her symptoms started slowly; she was always

described as an anxious person and remembers being worried about a lot of things

throughout her life. 10 years ago, following a few life stressors, her anxiety and
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intrusive thoughts worsened significantly. She began washing her hands excessively.

She reports she developed an intense fear that someone would break into the house

and it would be her fault because she left something unlocked.

In this case, predisposing factors were her mother’s history of anxiety and

father’s dominating personality and after marriage Husband’s dominating personality.

And reported she had mild anxiety issues from the beginning. Precipitating factors

(stressors), were her husband’s death and sudden changes in her life that act as

stressors which makes her condition more worse and she started washing hands until

the soap finished and high level of fear as someone broke into her house. Perpetuating

(maintaining) factors were reduce confidence, distracted at house chores and her

family life also disturb. Protective factor in this case is client had insight all these

thoughts are irrational and she came to seek help through therapy with her son/

daughter.

According to Weingarden and colleagues (2016), if the person had the history

of anxiety, fear and guilt there are more chances of development of OCD in future.

Likewise, genetics and environmental factors also plays important role (Monzani,

[Link], 2014) in this case, client mother had the history of anxiety and his father amd

husband are authoritative in nature. According to Nedeljkovicab, Mouldinga, Kyriosa

and Doron, (2009), as the symptoms of OCD became severe, person feels

uncomfortable to go out in social gathering and preferred to live alone due to this her

confidence and self esteem also became low. As in this case, exact situation occurred

with the client. Client had good insight which was the positive thing and also help in

the treatment prognosis. As according to Jane, [Link] (2001), if the client had insight

that their thoughts are irrational and they want to change it their are more chances of

positive outcome of the management that applied on them.

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Summary of case formulation

Presenting complaints Assessment

 Anxiety  Informal (clinical
 Hand washing interview, behavioral
activity observation, MSE and
Client subjective rating)
 Fear of someone
break into his  Formal (OCI, Symptoms
house checklist of DSM-V)
Perpetuating factors
 Low confidence
 Low confidence  Disturbed
 Disturbed work occupational and
 Disturbed family social life Predisposing factors
and social life  Mother’s history
of anxiety,
Precipitating factors dominating and
aggressive
 Father’s death, personality of
sudden life his father
stressing events
Protective factors
 Good insight
 Seek help
through therapy
Diagnosis
 Generalized Anxiety
disorder.

Management plan

Long Term Goals

1. Reduce the frequency, intensity, and duration of obsessions and compulsions.

2. Reduce time involved with or interference from obsessions and compulsions.

3. Function daily at a consistent level with minimal interference from obsessions and

compulsions.

4. Resolve key life conflicts and the emotional stress that fuels obsessive-compulsive

behavior patterns.

5. Work on self-esteem and social skills to build up confidence.

Short term objectives Therapeutic interventions

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Describe the history and nature History taking, MSE will be taken

of obsessions and compulsions and Rapport building (by showing empathy

openly express thoughts and feelings. and matching and mirror)

Complete psychological tests designed to Symptom checklist of DSM V

assess and track the nature and severity of Obsessive-Compulsive Inventory (OCI)

obsessions and compulsions. Subjective rating of symptoms

Base line chart

Verbalize an accurate understanding of 4 Ps Model will be explained for better

OCD, how it develops, and how it is understanding of problem

maintained.

Learn to implement calming skills to Progressive muscle relaxation and deep

reduce the overall tension and anxiety breathing will be used.

Keep a daily journal of obsessions, Self-monitor obsessions, compulsions,

compulsions, and triggers; record and triggers and record thoughts by

thoughts, feelings, and actions taken. writing it down.

Participate in cognitive behavioral CBT technique of Thought Stopping will

therapy to deal with continuous irrational be used

thought resulting from the stressful Help him to make a survival kit as a

condition coping strategy.

Assist the client in the construction of Imaginal/in vivo exposure therapy will be

hierarchies of feared internal and external used

fear cues.

Help the client accept and openly Acceptance and commitment Therapy

experience obsessive thoughts, images, (ACT) will be used

and impulses without being overly

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impacted by them

Caregivers verbalize an understanding of Psycho-education will be provide to the

the dynamics of client’s problems. caregivers.

Develop and implement a daily Prepare List of the activities to distract

ritual that interrupts the current pattern of Terminate the session

Compulsions.

Summary of Therapeutic Intervention

Different forms of therapeutic interventions were used in order to deal with the

client’s problem. In first session, history and mental status examination was done in

order to get the overview of the client issue along with rapport building which is

important part of therapy as through this client feel safe and trust you with sharing his

personal information. Then psychological assessment was done on him and for giving

him the proper understanding of his issue in the next session 4 Ps model was

discussed with him which gave him the proper manifestation of his problem started

and how its getting worse overtime. In 4th session, as he has suffered with anxiety to

calm him up, PMR and deep breathing would beneficial for him as its help to relax his

muscles. In next session, ask him to keep a daily journal to keep tract of his obsessive

thoughts it helps him to create awareness. In next session, CBT will be used to

thought that stop and help him to make a survival kit as a coping strategy to deal and

distract from that thought. As he mentioned that he has the fear someone enter his

house and it would be his fault asked him to make a hierarchy and then use imagine/in

vivo exposure therapy through this he learned how to control his fear along with

keeping oneself relaxed. In next session, acceptance and commitment therapy will be

used is help the client to accept his obsessive thoughts without being anxious or
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distress over these thoughts. Psycho education will be given to the family as well

because they also have to understand the condition of the client and it will guide them

how to deal with him that will encourage and gave hope to him. In the last session,

with the help of the therapist ask client to prepare a list of things that will help him to

distract these thoughts and terminate the session by asking him to rate his symptoms

and compare the results of pre and post management results.

Post Assessment

Post treatment subjective ratings of the problematic symptoms

Post treatment subjective ratings of the problematic symptoms were obtained on a

10 point rating scale. The client rated the presenting complaints on 0-10 severity

rating scale, “0” mean average severity of symptoms and “10” mean severe. The

subjective ratings of the symptom by client are as following:

Table 1.2

Pre and post assessment rating by mother on problematic symptoms on 0-10 rating

scale

Problematic behaviors Pre-assessment rating Post-assessment rating

Anxiety 10 04

Hand washing activity 10 05

Fear of someone break into his 10 04

house

Low confidence 10 04

Disturbed occupational and 10 04

social life

Session report
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Session 1

In first session I will take the history like bio-data, presenting complaints, family

history, personal history and educational history and applied MSE on her to get the

detailed understanding of the client, try to build rapport with client through this trust

relationship will be build between therapist and client.

Session 2

In session II, I administer test and work on base line chart in which we observed

the behavior of client. With base line observe the frequency intensity and duration of

the behavior.

Session 3

In session III I explained 4 Ps Model, will be helpful for the client for better

understanding of her issue, how the development and maintenance of OCD

highlighting and affecting her life.

Session 4

In next session, I will help her learn to implement calming skills to reduce the

overall tension and anxiety. Progressive muscle relaxation and deep breathing will be

implement on her and instruct her to do it more frequently whenever she feels anxiety

and distress over her obsessions.

Session 5

In this session I will ask her to keep a daily journal of obsessions, compulsions,

and triggers; record thoughts, feelings, as when she self-monitor her obsessions,

compulsions, and triggers it will give her awareness.

Session 6

In session VI, I will apply CBT technique of Thought Stopping, I which I will

relaxed her by doing deep breathing and then ask her to say “STOP” thoughts of her
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obsession after that I will help her to make a survival kit as a coping strategy, in

which with the consensus of the client we make a list of things she would do to

distract her.

Session 7

In next session, I will assist the client in the construction of hierarchies of feared

internal and external fear cues. And then imagine/in vivo exposure therapy will be

applied in order to deal with his fear of someone broke into his house.

Session 8

In this session, I will help the client to accept and openly experience obsessive

thoughts, images, and impulses without being overly impacted by them for this

acceptance and commitment therapy (ACT) will be used.

Session 9

In session IX, psycho-education will be provide to the caregivers this will help

them to get the proper insight of their client issue and because of that they more likely

to act positively with her.

Session 10

In the last session, client prepare list of the activities that help her to distract by

herself. And then I will terminate the sessions by giving recommendation to her and

advised her to come of the follow up at least for once in a week.

Limitation

 As it was a hypothetical case scenario, so limited amount of information was

available.

 In-depth interview and assessment was not possible, which could help in proper

diagnosis and case formulation

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 As no therapeutic intervention was applied in reality so efficacy of the outcome

of these intervention could not be assessed in the particular case scenario.

Recommendations

 Whenever client feel distressed or anxious about any problematic thought she will

have to use relaxing exercise to calm her self down.

 Spent quality time with family and peers in social manner.

 Take healthy diet and drink more water.

 “Stop that thought” activity that was used in the session could be used by the

client herself whenever she thinks of a problematic thought.