CASE REPORT 1

“PERSISTENT DEPRESSIVE DISORDER”

 SUMMARY
The client was 37 years old lady with normal complexion. She had average height and appropriate

weight with age. She belongs to middle class family and was married. She lived in a nuclear family

system and was mot very social. Her problem started 8 years ago and she took treatment in known

hospital in Jhelum. As client reported that she was not feeling better after treatment and from past 2

3months her illness got severe. She came with the complaints of severe headache, depressed mood, low

self-esteem, hopelessness, crying spells, worthless, irritability and lack of interest. Information obtained

from the client herself. Psychological assessment included Clinical Interview, Mental Status

Examination, Subjective Ratings, and Dysfunctional Thought Record, beck depression inventory

(BDI), beck anxiety inventory (BAI) and house tree person. In house tree person client show

defensiveness, lack of psychological warmth, not social, confused thinking, emotional instability and

withdrawal tendencies. In BAI client scored 36 which was significantly high from cut off 8 indicates

that she had severe anxiety and severe depression. In BDI client scored 38 which was significantly high

from cut off 14 indicates that she had severe depression .Client diagnosed with persistent depressive

disorder (dysthymia) with co-morbid anxiety. A management plan consisted of Cognitive Behavior

Therapy, supportive therapy and couple therapy. These therapies were implemented on the client in

order to help her in dealing with her problems. Total 12 sessions were conducted with the client. At the

end of the intervention, client reported 80% improvement in her condition and daily functioning.
DEMOGRAPHICS

Name Ms IQJ

Gender Female

Age 37 years

Education Matric

Religion Islam

Number of siblings 10 (5 sisters & 5 brothers)

Birth order 3rd

Marital status Married

No. Of Children 3 (2 sons & 1 daughter)

Occupation Housewife

Father (alive/dead) Alive

Mother (alive/dead) Alive

Socioeconomic structure Middle Class

Family system Nuclear Family System

Monthly Income Around 40,000

Residence Jhelum

Reason of referral Depressive Symptoms

Source of referral Client Herself

Informant Herself

No. Of sessions conducted 12 sessions for 30-45 minutes

Diagnosis Persistent depressive disorder with co-morbid Anxiety

REASON AND SOURCE OF REFERRAL
The client was referred by her husband. The patient was referred by the psychiatry department
Fauji Foundation Hospital with the complaints of excessive problems in her daily life due to her
headache, depressed mood, fatigue, hopelessness, irritability, muscles tension, her husband‟s attitude,
and worse home atmosphere. Then the supervisor referred to us for assessment, intervention and
management purposes.

PRESENTING COMPLAINTS

Duration: She had severe headache from past 8 years and she was taken medications. Her depressive
symptoms include hopelessness, helplessness, sad, fatigue, loss of interest appeared from last 3-4 years.

SYMPTOMS ACCORDING TO DSM-V

 Depressed Mood
 Loss of Interest
 Fatigue
 Low Self-Esteem
 Irritability
 Hopelessness & Sadness
 Sadness
 Sleep Disturbance
 Difficulty in Concentration
 FAMILY HISTORY

In the past, when her father was in army he had strict home environment. The authority figure was her

father. The client family system was authoritative where all decisions are mostly taken by her father.

The client belonged to a middle class family. She lived in a nuclear. Before marriage, she lived in a

town with her parents. After marriage, she moved towards Jhelum with her husband but her in laws were

in Karachi. She reported about her worse home environment. The client and her husband had daily basis

arguments on regular basis which made the home environment unsatisfactory.

Relationship with Mother

Client‟s mother was an old lady, simple by nature. She was a housewife and loved her home

and children. She shared her issues and problems with her. She was more attached with her mother. As,

her mother lived in town with her eldest brother. The client has healthy relationship with her mother.

Relationship with Father

Client‟s father studied up to F.A and was an army retired person. Now he worked in a factory.

He was nice and calm person by nature. He was caring and loving towards her children. The client has

good relationship with her father.

Relationship with Siblings

 Client had 9 siblings 1st born and 2nd born was her brothers who are married and had children.

The client has good relationship with her brothers but not much with her brothers. She respected

both of them.
  4th born and 5th born was her sisters and her 4th born sister was also married. Her sister lived

near to her house. She was very close to her sister. She visited her sister‟s house once in week

or after two weeks.

 6th born was her brother and also married. She had congenial relationship with her

brother because he always listened to her. Her brother often visited her house to meet her.

 7th born was brother of client. She shared congenial relationship with her brother. Her

brother listened to her but sometime he refused to listen her.

 8th born and 9th born was twin sisters of client. She was closely attached with her. She used

to share almost all of her problems with client and always sought for her opinion from her.

 10th born was her brother who was younger from all. She loved her brother and her brother was

attached with her.

Client loved his sisters so much and always tried to give them respect and support. She giver respect and

love to her elder brothers.

HISTORY OF PHYSICAL AND PSYCHIATRIC ILLNESS IN FAMILY

There was no history of any psychiatric illness in the family. But there was history of diabetes

in her family and her father was also diabetic patient and taking medicines.

PERSONAL HISTORY

PRE-NATAL HISTORY

No birth complications were reported. Mother‟s physical and psychological health was

satisfactory without any psychological, social and financial stressor.

PERINATAL HISTORY
 According to the client, at the time of birth she was a healthy baby girl and born in hospital with

normal delivery. New born‟s weight, breathing and appearance was normal. No peri-natal complications

had been encountered. Child was completely normal and fully functioning. At the time of birth, she was

healthy and weight was 7 pounds.

POSTNATAL HISTORY

She achieved all the developmental milestones at appropriate age. She reported no severe injuries

during his childhood. The client had a shy nature from her childhood. She didn‟t consider himself to be

a naughty child. She started to sit at the age of 5th months. She started to walk at the age of 9thmonths.

She started to speak at the age of 2.5th years of age. Her independent eating food and toilet training was

also in normal age. She got admission in school when she was four year of age. Her grades in school

were good.

EDUCATIONAL HISTORY

Client took admission in a local school when she was four years old. Client reported that in the

school there was not much competition and standard of education was low. She was an average in her

class and obtained average marks in her subjects. She was an obedient student and had good relationship

with her teachers. She did not take participation in extracurricular activities. She was shy and not

friendly. She had few friends and faced difficulty in making friends and interacting others. She remained

quiet in class most of the time and she also used to avoid going out with her friends. She took education

till matric.

SEXUAL AND MARITAL HISTORY

 The client achieved puberty at the age of 14 and she coped with physical changes very well. Her

mother told her about the changes of the body. The client reported no heterogeneous and homogenous

sexual experience. The client was not engaged nor had any sort of romantic relationship before her

marriage. There was no record of sexual abuse. She was married at the age of 23. It was an arrange

marriage and her husband was not her relative. The client‟s husband was 42 years old. Initially, she had

good relationship with her husband. After birth of her 3rd daughter, she had complaint of headache after

delivery. She was taking medicines for her illness. She had quarrels with her husband often on daily

basis and she was upset and depressed all day. Her husband was not allowed her to go anywhere even to

her sister‟s house without her permission.

CHILDREN

She had three children, 2 sons and 1 daughter. She conceived her after six months of her

marriage. She gave birth to a son through normal delivery after 9 months. She conceived her second

baby after one and half year, which was also a boy through normal delivery. The client gave birth to a

daughter after 1 year through cesarean. She faced some complications during delivery. Her elder son

was of 13 years old and other one is 11 years old. Her daughter was last born she was almost 9 years

old. She had good and healthy relation with her children but sometime she behave so rude and scold

them even they did not make any mistake. Her daughter was more close to her.

PREMORBID PERSONALITY HISTORY

Before the onset of the illness, client was happy person. She was introvert and not had many

friends as reported by her. She has good relationship with her parents and her siblings. Since childhood,

she was not very social and friendly by nature. She has small circle of friends in her school life. The

client had calm temperament and a reserved personality. She was caring and loving towards her child.
She told that she could easily be worried when faced stressful situations. She used to meet her relatives

with an open heart. She had no specific interests and hobbies. However she used to perform her all

house chores. In the times of stress, client reported that she lacked courage. She reported that she is not

a good decision maker and lacked problem solving ability. She had low mood most of the time because

of her headache before the illness as well.

RELIGIOUS INCLINATIONS

The client used to offer five time prayers and recite Holy Quran since childhood. She had strong

faith and firm belief in religion. During her illness, she sometime missed her prayers because of

fatigue, body weakness and her low mood.

HISTORY OF PRESENT ILLNESS

The client informed that, initially she had headache after the birth of her younger daughter. She

consulted to her gynecologist about her condition and her doctor gave her pain killers to reduce her

headache. She told that she feel better after taking medicines but not full recovery. After that, client also

had presenting complaint of low mood, lack of interest, hopelessness and sleep disturbance. Client

reported that she was facing this issue from 8 years and she was on medication for her illness. From last

3-4 years her headache got severed and she was facing symptoms of depression. Then, her psychiatrist

referred her to the psychologist for assessment and intervention purpose. The client reported that she do

not want to talk to anyone. During her illness, client became expected again but her illness not allowed

gave birth. She reported that she had severe headache and body ache along with depressive she could

not bear her pain. At last, they both decided to abort this baby. After the abortion, she had feeling of

guilt like she was not doing right with baby. She did sin and her symptoms got severed. Later on, her

doctor counsel her and motivated her that she did not do wrong she did this because of her health issues

and
illness. She felt worthless and hopeless; she also assumed that her husband and in laws were irritated

from her.

She told that her husband has paranoid personality he did not allowed her wife to go anywhere

without him or his permission. He even not allowed his children to play outside. She was experiencing

low mood, fatigue, restlessness, hopelessness, loss of interest and poor concentration. She told that she

always has a lot of thoughts in her mind about her illness and her husband. Her thoughts badly affect

her social and personal life. Client reported that her husband and her in laws thought that she lied and

pretend that she had headache but she in reality she did not had any issue. She was upset from her

husband‟s attitude. She linked her reason with family pressure and stigmatization. She reported that she

used to have problem in concentration and used to stutter while talking and also used to feel that she

does not have words to explain what she wants to say. She also used to experience physiological

changes like nausea, increase heart rate, and high blood pressure. Her social and personal life was

disturbed badly due to her illness.

As client reported that, she was taking medicines and treatment from known hospital. But she

was not feeling better after that. From last 5 6 months she was facing severe problems due to illness. She

was irritated from her husband and her children as she told that she was easily annoyed and aggressive

because of noise. This time she face lack of appetite, sleep disturbance, crying spells even on minor

thing, irritability, depressed, sad, hopeless about her future, helpless and worthless that her husband not

love her and he was fed up from her. She has negative thoughts all the day or most of days. She stopped

to interact with anyone because of her depressed mood. Before that she was normal and happy personal

but social. His husband was on duty and spent most of the time on duty. If she compliant that he did not

spent time with him he scolded him and leaves her. Even, she told him that she has severe pain but her

husband did not take her serious. He used to say that she was lying and pretended to be for his attention.
In past few months, she had severe headache, sleep disturbance, hopelessness, lack of interest,

worthlessness and depressed mood. Although she took medicine for her symptoms but her medicines did

not work effectively. She did not recover from medicines.

PROVISIONAL HYPOTHESIS

1. It might be because of uncooperative and supportive behavior of her husband.

2. It may be the restricted and authoritative behavior of her husband is one reason of her illness.

3. Lack of communication between husband and wife creates conflicts among them.

PRELIMINARY INVESTIGATION (Psychological Investigation)

Psychological assessment was based on detailed clinical case history taking interview, detailed

mental status examination and behavioral observations. Furthermore, rating of the patient on 10 point

rating scale where taken on both pre and post treatment level on target problem areas. Formal

psychometric assessments were done with the patient, as and when required in the case.

PSYCHOLOGICAL ASSESSMENT

Psychological assessment of the client was carried out in order to gather information regarding her

background, nature of symptoms, their causes and maintaining factors in order to diagnose and manage

the illness.

The assessment was done on two levels.

1. Informal Assessment

2. Formal Assessment

INFORMAL ASSESSMENT
 1. Clinical Interview

2. Subjective Rating of Symptoms

3. Mental Status Examination

4. Dysfunctional Thought Record

CLINICAL INTERVIEW

Clinical interview is used to collect detailed information about the client‟s problems, lifestyles,

and relationships, educational and personal history. (Comer, 2001)

By taking clinical interview the working diagnosis can be refine in persistent depressive

disorder. It was also taken to examine influences of biological, psychological, cultural, familial and

social factors of the client‟s life. Clinical interview was conducted to gather information about the

family history, birth history of the client, academic history, sexual history and marital history of the

client. Client was assured of keeping shared information confidential.

SUBJECTIVE RATING OF SYMPTOMS

On 0-10 scale, subjective rating was taken by the client regarding the problematic areas presented by

him.

0 = no problem, 5 = average problem, 10 = severe problem

Problematic Areas Rating by the client

Depressed mood 9

Loss of interest 8

Sleep disturbance 8
 Difficulty in concentration 9

Sadness 10

Irritability 8

Hopelessness 9

Low self-esteem 9

Helplessness and worthless 10

Fatigue 10

MENTAL STATUS EXAMINATION

Mental status examination was done in order to understand the presentation of the client‟s

symptoms and to conceptualize his disorder for diagnostic purposes (Semple, D. & Smith,R., 2009).

The client was 37 years old lady. She had average height and weight. She wore culturally

appropriate clothes and her clothing was tidy. She seemed depressed and low mood most of the time she

did not maintain eye contact. The subject‟s personal hygiene was maintained. She was slow and

resistant while giving information. She was attentive and concentrating during session.

Her attitude was observed as defensive. She expressed restricted range of feelings. Her observed

level of conscious can possibly be described as: drowsy, lethargic and confused. She talked hesitantly.

Her tone of voice was weak and rate of speech was slow. Her mood was low, both objectively and

subjectively. The client‟s thought content was related to her future. She wishes to improve her

condition. But she was not motivated to maintain good relations with relatives.
 Delusions and hallucinations were not present. Client was well-oriented about the time, day,

date, place and person. The client was trying to remain attentive and concentrated, but felt dizzy and

depressed. Her thoughts were coherent, logical and relevant.

Client had fair insight as she was both intellectually and emotionally aware of his problem and

its possible causes. Her short term memory and long term memory was intact. The client was aware of

her condition but reported fear of going mad in case of not being able to overcome her negative thought

patterns.

DYSFUNCTIONAL THOUGHT RECORD

Dysfunctional thought record is a technique in which negative automatic thoughts are being

assessed on daily basis with their emotional and behavioral consequences. Dysfunctional thought

record was filled by the client in order to know about his negative automatic thoughts according to

situations.

Functional analysis of DTR, according to client,

 Client was having anxious and depressive thoughts almost all the day time especially when she

was alone and had conflict with her husband.

 Client‟s negative automatic thoughts were having the theme of apprehensions about

future, hopelessness, low self-esteem and self-blame.

 Core beliefs were “I am failure and my husband was fed up from me. I am not a good wife.

Moreover, I am not a good relation maker and decision maker.

 Emotional/behavior consequences were depressed mood, lack of interest, hopelessness, self-

blame, feelings of worthless, overthinking and crying spells.

FORMAL ASSESSMENT
 1. Beck Depression Inventory (BDI)

2. Beck Anxiety Inventory (BAI)

3. House Tree Person (HTP)

4. Mini Mental Status Examination (MMSE)

BECK DEPRESSION INVENTORY (BDI)

Beck Depression Inventory (BDI) II is a 21-item, self-report rating inventory that measures

symptoms of depression. BDI was administered on the client to determine level of depression. The BDI

contains 21 items on a 4-point scale from 0 (symptom absent) to 3 (severe symptoms). Scoring is

achieved by adding the highest ratings for all 21 items. The minimum score is 0 and maximum score is

63. Higher scores indicate greater symptom severity. In non-clinical populations, scores above 20

indicate depression. In those diagnosed with depression, scores of 0– 13 indicate minimal depression,

14–19 (mild depression), 20–28 (moderate depression) and 29– 63 (severe depression). The

questionnaire is commonly self-administered and it takes 5–10 minutes (Jackson-Koku, 2016).

QUANTITATIVE ANALYSIS

Raw score Cut off score Level of depression

38 14 Severe depression

QUALITATIVE ANALYSIS

The client scored 38 raw score in BDI which was significant from cut off score 14. The result

shows that client has severe level of depression with feelings of hopelessness, fatigue, depressed and

lack of interest.
BECK ANXIETY INVENTORY (BAI)

Beck Anxiety Inventory (BAI) is a 21 item, self-report rating inventory that measures the

symptoms and level of anxiety. BAI was administered on the client to determine the level of anxiety on

client. The BAI contains 21 items on a 4-point scale from 0 (symptom absent) to 3 (severe symptoms).

Scoring is achieved by adding the highest ratings for all 21 items. The minimum score is 0 and

maximum score is 63. Higher scores indicate greater symptom severity. In non-clinical populations,

scores above 15 indicate anxiety. In those diagnosed with anxiety, scores of 0– 7 indicate (minimal

anxiety), 8–15 (mild anxiety), 16–25 (moderate anxiety) and 26– 63 (severe Anxiety). The questionnaire

is commonly self-administered and it takes 5–10 minutes (Jackson-Koku, 2016).

QUANTITATIVE ANALYSIS

Raw score Cut off score Level of anxiety

36 8 Severe anxiety

QUALITATIVE ANALYSIS

The raw score of client in BAI was 36 which was significant from cut off score 14. The result

shows that client has severe level of anxiety with feelings of excessive worry, overthinking, restlessness,

muscles pain and agitation.

MINI MENTAL STATUS EXAMINATION (MMSE)

The Mini-Mental State Exam (MMSE) is an interviewer- administered 30- item screening

examination to assess cognitive status and to track cognitive impairment or recovery over time.

Although the MMSE is typically used to screen for mental impairment in older adults, the test can be
administered to individuals who are 18-85 years or older, with some normative data available for

children as young as 10 years of age.

QUANTITATIVE ANALYSIS

Raw score Cut off score Level of cognitive impairment

23 24 Mild Cognitive impairment

QUALITATIVE ANALYSIS

The client scored 23 on MMSE which lies in mild cognitive impairment. The score less than 24

were considered as cognitive impairment in individual.

HOUSE TREE PERSON (HTP)

The House-Tree-Person (HTP) technique, developed by Buck (1948) and Hammer (1958), is one

of the most widely used projective tests for children and adults. It can be used with individuals aged 3

years and older and is almost entirely unstructured; the respondent is simply instructed to make a

freehand drawing of a house, a tree, and a person. Analysis of the HTP is a two-phased process. In phase

one testing is nonverbal and almost entirely unstructured; the medium of expression is the freehand,

pencil drawings of a house, tree, and person (Buck, 1966). The second phase is verbal, apperceptive, and

more formally structured. In it, the subject is given the opportunity to describe, define, and interpret his

or her drawn objects and their respective environment and to respond to various open-ended questions

(Gordon & Barnard, 2011).

The client drew a normal size of house. Client has drawn no window which shows withdrawal.

Missing chimney suggest passivity and lack of psychological warmth in person‟s home life. The client
drew a house first, which indicates she is concerned with bodily needs. The house‟s door is closed

which shows her guarded personality and defensiveness.

The subject drew a spring tree that shows to be impressed by others but also reported that it‟s

dead which indicates that there is sever disturbance, defensiveness, powerlessness or other influence of

environment. Absence of branches shows that he has little contact with people. She is hesitant to be

social. The small trunk and absence of bark suggest that the subject has limited ego strength. Narrow

base shows loss of control.

The subject drew large head of the person, which shows there are some brain intellectual

problems with the client. The client has overemphasized the nose which depicts some sexual fears and

difficulties. Emphasis on finger shows aggression tendencies in the subject; more than five fingers show

dependency and helplessness. Eyes dot with pressure and unenclosed show ideas of reference and

paranoia. Eyebrows show immaturity. Hair indicates feminine identification and obsessive compulsive

mechanisms. Missing neck show immaturity, lack of impulse control. He has omitted abdominal area

which indicates severe deterioration and some psychotic tendencies. She drew claw-like feet of the

person which shows overt aggression and paranoia. Thin legs show dependency and insecurity.
TENTATIVE DIAGNOSIS

“Persistent Depressive Disorder (Dysthymia) 300.4 (F34.1) comorbid with

Anxiety”

Persistent Depressive Disorder

Diagnostic Criteria

A. Depressed mood for most of the day, for many days than not, as indicated by

either subjective account or observation by others, for at least 2 years.

B. Presence, while depressed, of two or more of the following:

1. Poor appetite or over eating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self esteem

5. Poor concentration or difficulty in making decisions

6. Feeling of hopelessness

C. During the 2 year period, the individual has never been without the symptoms in

c4riteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode, and criteria have

never been met for cyclothymic disorder.

 CASE FORMULATION

The client was 47 years old lady with normal complexion. She had average height and weight.

She was dressed up cultural appropriately clothes. Her presenting factors are depressed mood

low self-esteem, fatigue, irritability, sleep disturbance, hopelessness, sadness and lack of interest

in her daily tasks.

According to DSM 5 client met the criteria of persistent depressive disorder. The

diagnosis was also confirmed through informal assessment by taking Clinical interview, MSE

and formal assessment by applying Mini Mental Status Exam, Beck depression inventory, beck

anxiety inventory and house tree person. Persistent depressive disorder involves the criteria of

depressed mood, lack of interest, fatigue, poor concentration, psychomotor agitation, sleep

disturbance, weight loss or gain without diet, feelings of hopelessness, feelings of worthlessness

and irritability. These complaints are presenting for more than two years than we diagnosed

them Persistent depressive disorder. Anxiety is a normal reaction to stress and can be beneficial

in some situations. It can alert us to dangers and help us prepare and pay attention. Anxiety

disorders differ from normal feelings of nervousness or anxiousness and involve excessive fear

or anxiety. (American Psychiatric Association, 2013)

According to cognitive view depressed individual focus on depressing information

because they are likely to process it and send it on storage in long term memory just like the

subject seems to be depressed because she had focused her attention to isolation.

Since 1967 one of the most influential theories of depression has been that of Aaron Beck who

developed his own cognitive theory of depression. Beck hypothesized that the cognitive

symptoms of depression often precede and cause the affective or mood symptoms. There are
underlying dysfunctional beliefs known as depress genic schemas which are rigid, extreme and

counterproductive. Such a person with dysfunctional belief would develop negative thoughts.

These dysfunctional beliefs are not sufficient to make someone depressed; instead, he maintained

that these need to be activated by the occurrence of some form of stress (e.g., perceiving social

rejection or feeling like a failure. Beck gave a model of negative cognitive triad that includes

three themes. 1) Negative thoughts about the self; 2) negative thoughts about one‟s experiences

and the surrounding world; and 3) negative thoughts about one‟s future (Clark, Beck, & Alford,

1999).

The subject‟s problem seems to be relating with psychodynamic theory in which Freud

hypothesized the withdrawal of affection, just as in this case the subject seems unsatisfied with

her childhood memories. She had no friends which caused her to indulge in state of depression.

Freud and Abraham (1927), both hypothesized that due to the loss of loved one people regress

to the oral stage of development (when the infant cannot distinguish self from others) and

interjects or incorporates the lost person, feeling all the same feelings towards the self as toward

the lost person. These feelings were thought to indulge anger and hostility because Freud

believed that we unconsciously hold negative feelings toward those we love, in part because of

their power over us. This is what led to the psychodynamic idea that „depression is anger turned

inward‟.

Freud hypothesized that depression could also occur in response to imagined or symbolic losses

(Freud, 1917).

Depression is mainly a learned phenomenon, related to negative interactions between the

individual and his or her environment (e.g., low rate of reinforcement or unsatisfactory social

relations). These interactions are influenced by cognitions, behaviors and emotions. An excess of
avoidance behaviors and the lack of positive reinforcement or the loss of efficiency of positive

reinforcements (Costello, 1972).

A person with depression initially receives a lot of attention from his social environment

(family, friend), and behaviors such as crying, complaints or expressions of guilt are reinforced.

When these depressive behaviors increase, the relationship with the child becomes aversive, and

the people who used to accompany the child avoid being with him, which contributes to

aggravating his depression (Lewinsohn, 1974). Low reinforcement rates can be explained by

maternal rejection and lower parental support, by a lower rate of reinforcement offered to their

children by mothers of depressed children, or by low social competence (Cole and Rehm, 1986).

PROGNOSIS

1. Patient‟s prognosis is favorable as:

2. Client was so cooperative.

3. The client was motivated to resolve her issues.

4. Client was 37 years old lady and aware of her illness.

 MANAGEMENT PLAN

Management plan was designed to help the client in order to resolve her problem and return

back to her normal functioning. Several therapies and techniques can be used for those who

suffered with Persistent Depressive Disorder such as;

 Rapport Building

 Psycho-Education Of Family

 Relaxation Therapy

 Deep Breathing

 Baseline Charts

 Progressive Muscular Relaxation Training

 Activity Scheduling

 Guided Imaginary

 Cognitive Behavioral Therapy

 Cognitive Restructuring

 List Of Strengths And Weaknesses Technique

 Mastery And Pleasure Chart

 ABC Formulation And Disputing

 Homework Assignment

 Double Column Chart

 Interpersonal Therapy

 Couple Therapy

 Triple Column Chart

 Time Management
  Cost Benefit Analysis Technique

 Coping Statements Practice

 Self-Esteem Building Exercise

 Family Therapy

 Mindfulness

SHORT TERM GOALS

 Supportive work was done with the client by showing empathy and active listening of

problem in order to make him comfortable in sharing information and further showing

compliance towards therapy.

 Rapport building is a key factor which makes supportive psychotherapy effective. So

rapport was built with the client in order to make him easy and feel free during

sessions.

 Psycho education was carried out to give orientation to the client around the nature of

illness and the relapsing factors.

 Catharsis was done with the client to resolve the intensity of the problem and to give her

chance to express her feelings.

 Guided imaginary relaxation technique was used to make her more comfortable and

relax and also to reduce her negative thoughts and anxiety.

 ABC model was taught to the client in order to link the situational triggers and

their emotional and behavioral consequences.

 Time management technique was used to manage her time and avoid her

depressive thoughts and asked her to communicate people in her surroundings.

 Activity Schedule was given to re-energize the client and offer significant help in

overcoming anxiety.
 Deep breathing was taught to the client to prevent further muscle/tissue tightening.

 List of Strengths and weaknesses technique was done to increase his level of self- esteem.

 Double column was taught to the client to make her enable to identify and change

her negative thoughts into positive to encounter her depressive thoughts.

 Mindfulness techniques were used with the client in order to make him more focused

towards present moment and to separate herself from the cobweb or negative

automatic thoughts.

 Mastery and pleasure chart was given to the client to encounter her anxious mood &

help her gain a sense of achievement and pleasure though activities.

 Couple therapy was used to sort out the conflicts and enhance interpersonal relationships

among husband and wife.

 Triple column was taught to the client to counter her anxiety and depression on

cognitive level more effectively.

 Coping statement was given to deal with her depressive thoughts by replacing her

NATs related to hopelessness and low mood into positive one.

 Self-esteem building ensures was taught to the client to increase her self-esteem.

 Progressive Muscular Relaxation Training was used for relaxation.

 Steps for better problem solving were taught to the client for improving his problem

solving ability and self-confidence.

LONG TERM GOALS

 Continuation of short term goals will be done to maintain improvement and

enhance progress made by the client.

  Couple therapy, CBT, interpersonal therapy, Cognitive restructuring and family therapy

will be applied.

 Assertiveness skill training was in process with the client for effective communication.

 Follow up sessions will be conducted with the client

THERAPEUTIC OUTCOME

Problematic Areas Pre Assessment Post Assessment

Depressed mood 9 2

Loss of interest 8 3

Sleep disturbance 8 2

Difficulty in concentration 9 1

Sadness 10 0

Irritability 8 3

Hopelessness 9 2

Low self-esteem 9 1

Helplessness and worthless 10 1

Fatigue 10 3

Therapeutic outcome was assessed to check the efficacy of the treatment by taking subjective

ratings of the client‟s problems at the post assessment level.

Beck Anxiety Inventory (BAI)

Raw Score Cutoff Score Level Of Anxiety

13 8 Mild

Beck Depression Inventory (BDI)

Raw Score Cutoff Score Level Of Depression

18 14 Mild

SUMMARY OF THERAPEUTIC INTERVENTIONS

SUPPORTIVE PSYCHOTHERAPY

Supportive psychotherapy was the first and foremost management therapy which started

very early in the intervention since first session. In this therapy supportive work was done with

the client through different ways. Firstly, the client was provided the opportunity of empathetic

listening which helped in her catharsis and ventilation of pent-up feelings and emotions. Through

active listening the client was provided unconditioned positive regard, which helped in

developing trustworthy relations with the client needed for the effective progress of the therapy.

RAPPORT BUILDING

Rapport was built easily but the client took time to open up and great deal of

information. Reassurance was provided to the client throughout the intervention on different

levels especially in maintaining confidentiality of the client's related information and cure from

her illness and also while conducting the assertiveness training and self-esteem building

exercise.

PSYCHOEDUCATION
 It is the presentation of systematic, structured, didactic information on illness and its

treatment. It aims on providing the information about causes, symptoms, and 60 progressions of

illness and it reflects mind body conceptualization of the problem (Power & Freeman, 2007).

Client was psychoeducated about his illness, possible causal factors, problems he may face if

condition persists and possible treatment option. She was told for normalization purpose that

many people suffer from the disorder with even worse conditions and she was not alone. Client

was curious about theory and treatment options of the disorder. She also insisted in knowing the

altered brain functioning. She was interested in the treatment.

DEEP BREATHING

Deep breathing was taught to the client to induce relaxation and using it as a coping

strategy against distress and stressful situations. It was also taught as a meditation technique to

increase the concentration and focusing ability of the client so that she could concentrate and

focus her attention on this while going through stress. The client was told to practice this

exercise as many times as she could during the day. It was taught to her in the initial session

and was used by the client throughout the intervention. It was also used to induce relaxation in

the client and to cope up with the stress produced or faced at any time.

COGNITIVE BEHAVIORAL THERAPY

Cognitive behavioral therapy (CBT) is a form of psychotherapy that focuses on

modifying dysfunctional emotions, behaviors, and thoughts by interrogating and uprooting

negative or irrational beliefs. Considered a "solutions-oriented" form of talk therapy, CBT rests

on the idea that thoughts and perceptions influence behavior. CBT aims to identify harmful

thoughts, assess whether they are an accurate depiction of reality, and, if they are not, employ
strategies to challenge and overcome them. CBT focuses on challenging and changing unhelpful

cognitive distortions e.g. thoughts, beliefs, and attitudes and behaviors, improving emotional

regulation, and the development of personal coping strategies that target solving current

problems.

TIME MANAGEMENT

Time management is the process of planning and controlling how much time to spend on

specific activities. Good time management enables an individual to complete more in a shorter

period of time, lowers stress, and leads to career success. Client was asked to spend her time in

positive and healthy activities like spent time with her children and neighbors. Client told that

after the implementation of this technique she feel so relax and optimistic. She told that she did

not spent much of her time on negative thoughts that she did before.

PROGRESSIVE MUSCLE RELAXATION TECHNIQUES

Progressive muscle relaxation (PMR) is a relaxation technique. It involves tensing and

then relaxing your muscles, one by one. This helps you release physical tension, which may ease

stress and anxiety. Research has shown that PMR offers a range of benefits, including pain relief

and better sleep. This technique was taught to the client to resolve her sleep issues and her body

aches. Also taught her head exercise which beneficial for her headache and reduce her

symptoms. The client was about the benefits of PMR that progressive muscle relaxation is a

method that helps relieve that tension.

COUPLE THERAPY
 Couples therapy is a particular form of counseling and involves a couple meeting with

the psychologist, social worker or other type of mental health professional for counseling to

address the dysfunction in their marriage. In this case, wife told that her husband was not

cooperative. So, couple therapy was initiated to resolve their conflicts and issue and enhance

their interpersonal communication.

SELF-ESTEEM BUILDING EXERCISE

Different self-esteem building exercise was taught to the client as client had a very low

self-esteem. Extensive work had been carried out in this regards the client. The client was told to

write her 10 strengths and 10 weaknesses and then an imagery exercise was carried out in which

she had to instruct to improve the quality and pattern of her sleep. For this purpose she various

self-esteem building exercises was taught to the client as the replace the weakness with her

strength.

DOUBLE COLUMN AND TRIPLE COLUMN CHART

Double column and then triple column was carried out regarding the negative

dysfunctional thoughts and the client was to change them in positive one by giving rational

responses. These exercises helped the client in cognitive storming and enable her to raise her

self-esteem by bringing modification in self-defeating and other's defeating behaviors. These two

techniques were very helpful for the client.

FAMILY THERAPY

Family therapy is a type of psychological counseling (psychotherapy) that can help

family members improve communication and resolve conflicts. Family therapy is often short
term. It may include all family members or just those able or willing to participate. Your

specific treatment plan will depend on your family's situation. Family therapy sessions can teach

you skills to deepen family connections and get through stressful times, even after you're done

going to therapy sessions. Her family was asked to support her and motivated her to come from

this situation. Her family was psychoeducated about her illness, nature and intensity of illness

along with treatment.

ABC FORMULATION AND DISPUTING

Cognitive restructuring was further continued on more intensive level. To uproot the

cause of her illness she was taught to ABC formulation, the purpose of which was to break the

cycle of adversities, which was increasing her distress and maintaining her symptoms. She was

educated around the REBT'S basic step of ABC model while focusing on B-C connection

irrational and rational beliefs and functional and dysfunctional emotions. She seemed to

comprehend ABC model well and after that disputing was carried out related lower irrational

beliefs

COSTS AND BENEFITS ANALYSIS

Many people view worry as a form of problem solving, preparation, or protection against

possible calamities. However many don‟t serve the function of preparation, motivation or

problem solving. Client‟s underlying theory of worry was explored by evaluating the costs and

benefits of worrying.

GUIDED IMAGERY RELAXATION TECHNIQUE

 Guided imagery is a form of psychotherapy is a mind-body intervention by which a

trained practitioner or teacher helps a participant or patient to evoke and generate mental

images that simulate or re-create the sensory perception of sights, smells, movements, and

images associated with touch as well as imaginative or mental content that the participant or

patient experiences as defying conventional sensory categories, and that may precipitate

strong emotions or feelings in the absence of the stimuli to which correlating sensory

receptors are receptive. Those who use guided imagery for stress relief may also imagine a wise

'guide' with them, answering their questions and asking them questions that they must

ponder in order to get to a better place in their lives.

MINDFULNESS

Mindfulness is a form of self-awareness training adapted from Buddhist mindfulness

meditation. It has been adapted for use in treatment of psychological disorders, especially

preventing relapse and for assisting with mood regulation. It has been described as a state of

being in the present, accepting things for what they are, i.e. non-judgmentally. Client was asked

to practice mindfulness in her daily activities. She was asked to practice mindful walking,

mindful eating, cooking and mindful bathing.

MASTERY AND PLEASURE CHART

Mastery and pleasure chart was introduced in the initial session after the client was put on

activity schedule. It was taught to the client to enable her to resume the interest and pleasure in

activities by focusing on the greater sense of accomplishment and pleasure on a day-to-day life.

The purpose was to reduce the low morale, passivity, lack of gratification, feelings of

worthlessness etc.
 After this technique the client reported to feel the lost sense of pleasure in the activities as

it was focused on doing the thing in the best possible way through which the feeling of

achievement come and the client's feeling of inadequacy decreased and finally, she was able to

overcome on her feelings of worthlessness and started feeling pleasure in daily activities.

COPING STATEMENTS

Coping statements were also given to the client in the intervention program to overcome

her depressive thoughts. Through these statements, told her about how to cope up with negative

thoughts and situations. There were the statements written on 1 or 3 white paper with prominent

black marker related to the areas such as thoughts replacing hopelessness worthlessness, sad

mood, optimistic view about the future, self-esteem enhancing statements, statements to

overcome the illness etc.

APPENDIX OF CASE
REPORT
 CASE REPORT 2

“SEVERE BIPOLAR I DISORDER CURRENT

MANIC EPISODE WITH PSYCHOTIC

FEATURES”
 SUMMARY

Client was 20 years old boy with average height and weight. He had a fair complexion, with dark

brown eyes and black hair. He was dressed properly. The client belonged to a middle

socioeconomic status. He lived in a nuclear family system. He was continuously talking and had

pressured speech. he came with his parents with the presenting complaints of decreased appetite

and need for sleep, pressure to keep talking including flight of ideas, aggressive behavior, labile

mood, having grandiose, persecutory and referential delusions. He was referred to present trainee

clinical psychologist for assessment and management of his symptoms. Client was assessed

informally through clinical interview, subjective ratings of the problem and mental status

examination and behavioural observation. In formal Young Mania Rating Scale (YMRS), Beck

Depression Inventory (BDI) and Positive and Negative Syndrome Scale (PANSS) were used.

The client constantly thought of his previous failure. The client‟s mother informed that, after

quitting college the client became disturbed and started to cry a lot. He became distant from his

parents; his outdoor activities decreased and would remain in his room all day. His mother

informed that his appetite decreased and he seemed fatigued all the time. He always used to

listen 2 specific scholars and he considered himself as prophet of Allah in other he had

grandiose delusions. Total 12 sessions were conducted with client of average time 30 to 40

minutes. the management plan was consisted of Cognitive Behavior Therapy, Supportive

therapy, baseline charts for delusion, mood monitoring and coping statements.
DEMOGRAPHICS

Name Mr. G.H

Gender Male

Age 20 Years

Education Matric

Religion Islam

Number of Siblings 1 Brother

Birth Order Last

Marital Status Unmarried

Work Status Student

Father (Alive/Dead) Alive

Mother (Alive/Dead) Alive

Socioeconomic Structure Middle Class

Family System Nuclear

Monthly Income Around 1 Lac

Residence Chakwal

Reason Of Referral Bipolar Symptoms With Psychotic Features

Source Of Referral Client‟s Parents

Informant Client‟s Parents And Client Himself

No. Of Sessions Conducted 12 Sessions For 30-45 Minutes

Diagnosis Bipolar I Disorder With Psychotic Features

REASON AND SOURCE OF REFERRAL

The client‟s father was referred his son to Hospital. The client came to the OPD with his

parents with the presenting complaints of decreased appetite and need for sleep, pressure to

keep talking including flight of ideas, aggressive behavior, labile mood, having grandiose,

persecutory and referential delusions. He was referred to present trainee clinical psychologist

for assessment and management of his symptoms.

PRESENTING COMPLAINTS

DURATION: 6-8 months

SYMPTOMS ACCORDING TO DSM-V

1. Decreased Appetite

2. Insomnia

3. Inflated self-esteem

4. Pressure to Keep Talking

5. Flight of Idea

6. Distractibility

7. Aggressive Behavior
 8. Labile Mood

9. Depressed Mood

10. Having Grandiose, Persecutory and Referential Delusions

FAMILY HISTORY

The client belonged to a middle socioeconomic status. He lived in a nuclear family system. The

family system was egalitarian where everybody gave their opinions in making a decision.

Before the client‟s illness the general home environment was peaceful but after illness the client

and his mother had daily arguments on regular basis which made the home environment

unsatisfactory. RELATIONSHIP WITH FATHER

The client‟s father was 51 years old. He was educated till Matric. He was retired Lans

Naik from Army. He was disciplined and had a strict temperament. The client shared congenial

relationship with father.

RELATIONSHIP WITH MOTHER

The client‟s mother was 49 years old. She was illiterate and was a housewife. She had a

calm temperament but after the client‟s illness she used to get irritated easily on client‟s

behavior. The client‟s parents had an arranged marriage and were relatives. The client shared

congenial relationship with mother.

RELATIONSHIP WITH SIBLINGS

The client had 1 elder brother. He was 24 years old and achieved education till Matric.

After passing Matric Exams, he went to Sharjah, UAE and worked there as a labourer. They both

shared congenial relationship.

HISTORY OF PSYCHIATRIC ILLNESS IN THE FAMILY

The client‟s maternal uncle was a diagnosed patient of depression.

PERSONAL HISTORY

BIRTH AND EARLY CHILDHOOD

The client‟s mother informed that he was born through a normal delivery. He had no

post natal and pre natal complications. The client had achieved all his developmental milestones

at appropriate time. He had no severe injuries during his childhood. The client had a calm

temperament in his childhood. His independent eating food and toilet training was also in normal

age. He got admission in school when he was five year of age. His grades in school were good.

EDUCATIONAL HISTORY

The client‟s mother informed that he started to go to the school at the age of 5 years.

Throughout his academic years he obtained above average grades and was considered a bright

student. He had congenial relationship with his peers and teachers. He did Matric in Computer

Sciences and passed it with an A grade. After passing Matric, he changed his school as that

school was only till 10th class. He got admission in a new private college and made new friends.

He had satisfactory relationship with his classmates and teachers.

SEXUAL HISTORY

The client achieved puberty at the age of 16 and he coped with physical changes very

well. His father told him about the changes of the body. There was no record of homogenous or

heterogeneous relationship.

PRE-MORBID PERSONALITY

Before the onset of illness the client had calm nature. He used to talk less unlike after the

onset of illness. He had few close friends till matric with which he used to play cricket. After
taking admission in Intermediate his outdoor activities changed like wandering in city with his

new friends. He had good problem solving and decision making skills as it was indicated through

the fact his parents used to take his opinion before making any decision before the onset of

illness.

RELIGIOUS INCLINATION

On a scale of 0-10, the client rated himself 8 point on religiosity. He believed in religion

and prayed regularly. He followed all necessary religious obligations.

HISTORY OF PRESENT ILLNESS

The client informed that, he passed Matric, in 2017, and accomplished good result so his

paternal uncle and his son became jealous. As the paternal uncle son was not good in studies and

was working in fields. After taking admission in [Link]. his friends gave him cigarettes to smoke

which he sometimes smoked and sometimes rejected their offer. With the passage of time, they

tried to settle him with a girl but the client declined it fiercely. Even so, he had declined this

offer; his friends would message any girl with his number and tried to coerce him to talk to her

but he had always refused. The client started to bunk classes and smoke cigarettes, occasionally.

the client had final board exams of Intermediate part 1, before the start of first exam his friends

made him to smoke a cigarette. During the paper he developed a severe headache and he left his

paper in the middle of it. He also didn‟t give the remaining of papers, as the client reported, he

was angry on himself and others.

The client‟s mother informed that, after quitting college the client became disturbed and

started to cry a lot. He became distant from his parents; his outdoor activities decreased and

would remain in his room all day. His mother informed that his appetite decreased and he

seemed fatigued all the time. He started to wake up late in the morning even though he was
going to bed early. After few weeks, the client started to go to his paternal grandmother, who

was living with his Uncle. There his Uncle introduced him to watching videos of 2 religious

scholars. The client started to listen to them and was inspired by them.

After watching these videos the client, gradually, started to become better and started to

feel relaxed. His appetite became normal and his irritated behavior and crying spells decreased.

In 2019, the client‟s father admitted him in Pakistan Air force Academy which was a boarding

school. The client informed that, he was motivated to study and did a lot of hard work in

studying. He started to remain awake late at nights and would study. Along with this, he was

also listening to the recordings of the same two religious scholars as they made him feel better.

The client wasn‟t satisfied with his performance in studies. Even though, the head of the PAF

academy acknowledged his hard working and was satisfied with his progress. The client

constantly thought of his previous failure. In July 2019, the client‟s father informed that, after 3

weeks of living in the academy, as reported by the head, the client started to talk a lot, he wasn‟t

sleeping.

After showing these symptoms, the client‟s father was called the very next day and was

asked to take him back home. His father took him to a hospital in Chakwal for the treatment. He

took medications from that hospital for 1 week but did not feel better so his father took him to

another hospital. From the second hospital he took medications for two weeks but did not

recover his symptoms. His father took him to two more hospitals from where he took

medications for 2-3 weeks each but still he didn‟t get any better. His father reported that, his

symptoms escalated.

After visiting the fourth hospital and not getting the satisfied improvement, the client‟s

father was referred by his friend to the Fauji Foundation Hospital. When the client came to
Hospital, he was hyperactive, was talking loudly and excessively and grandiose and

persecutory delusions could be easily observed.

PROVISIONAL HYPOTHESIS

1. It might be because of his failure in previous examination.

2. It may be because he overcomes his depression through manic phase.

3. It might be he had grandiose delusions to uplift his low self-esteem and low self-confidence.

4. It may be because patient did not have coping skills and he avoid environmental stressors and

depressive tendencies.

PRELIMINARY INVESTIGATION (Psychological Investigation)

Psychological assessment was based on detailed clinical case history taking interview,

detailed mental status examination and behavioural observations. Furthermore, rating of the

patient on 10 point rating scale where taken on both pre and post treatment level on target

problem areas. Formal psychometric assessments were done with the patient, as and when

required in the case.

PSYCHOLOGICAL ASSESSMENT

Psychological assessment of the client was carried out in order to gather information regarding

her background, nature of symptoms, their causes and maintaining factors in order to diagnose

and manage the illness.

The assessment was done on two levels.

3. Informal Assessment

4. Formal Assessment
INFORMAL ASSESSMENT

The following informal assessment was done with the patient.

Informal assessment consisted of the following procedures.

 Clinical Interview

 Mental Status Examination (MSE)

 Subjective rating of presenting complaints

 Baseline Chart of Delusion

 Mood Monitoring Chart

CLINICAL INTERVIEW

“A clinical interview is a dialogue between psychologist and patient that is designed to

help the psychologist diagnosed and plan treatment for the patient” (Comer, 2015). Through the

clinical interview the working diagnosis can be refine in Bipolar I Disorder with mood-

congruent psychotic features. Moreover, in the course of gathering a psychiatric history, the

client‟s self- perception, perception of his experiences and perspectives on his problems, and

goals of treatment were evaluated.

In the presented case, clinical interview was conducted with the client and his mother in

the psychiatry ward of Hospital. As it was conducted in a hospital setting there were few noises

which may have hinder the communication between the therapist and the client. The first sitting

was held in the psychologist room, the client was talking continuously that he was prophet and

came to bring the people on the right path. He would recite several Quranic verses in the middle

of conversation. He also showed his concern that the Prime Minister of Pakistan was after him to

kill him to stop him from spreading the truth along with this people from India are also trying to

kill him.
MENTAL STATUS EXAMINATION

“The mental status examination reviews the major systems of psychiatric functioning

(appearance, cognitive function, insight, etc.)” (Marnat, 2003). Client was 20 years old boy with

average height and weight. He had a fair complexion, with dark brown eyes and black hair. He

was dressed properly. He was continuously talking and had pressured speech. The speech did not

consist of relevant answers. He was not properly maintaining the eye-contact with the therapist.

He was well oriented with the place but not with city, time and person but had no insight of why

he was in the hospital. He had flat effect on his face. Delusions were reported by the client‟s

parents as well as they were observed in the first session. No hallucinations were present. No

obsessions and compulsions were reported. His long term along with short term memory was

intact. His attention and concentration was judged through seven digit spans and upon asking this

question he never gave answer to it and started to repeat his previous statements.

SUBJECTIVE RATING OF PRESENTING COMPLAINTS

Subjective ratings of presenting complaints are psychometric measuring instruments

designed to document the characteristics of illness-related symptom severity in individual

patients and use this to achieve a rapid classification of symptom severity and illness control

(Klimek et al., 2017). The following table shows the Pre-treatment ratings for the problematic

areas:

0 = no problem, 5 = average problem, 10 = severe problem

Problematic Areas Family’s Rating (0-10)

Hyperactivity 10

Labile mood 9

Lack of sleep 8
 Grandiose delusions 8

Excessive talk 9

Persecutory delusions 8

Flight of ideas 7

Referential delusions 8

Anger 7

According to the family members the client‟s most significant problems were sleep

disturbance, talkativeness, high energy, labile mood, and delusions.

BASELINE CHART OF DELUSION

Areas Functional Analysis

Triggers Heard voices from outside the window.

Food came from ward kitchen.

Thoughts Mirza people are trying to harm me.

The food wasn‟t halal.

Want to PM of Pakistan and serve Muslims

Coping Behaviours Read Quranic Verses.

Didn‟t eat food.

FORMAL ASSESSMENT

The following psychological tools were used.

1. Mini Mental Status Examination (MMSE)

2. Young Mania Rating Scale (YMRS)

3. Positive and Negative Syndrome Scale (PANSS)

 4. Beck Depression Inventory II (BDI)

MINI MENTAL STATUS EXAMINATION (MMSE)

The Mini-Mental State Exam (MMSE) is an interviewer- administered 30- item screening

examination to assess cognitive status and to track cognitive impairment or recovery over time.

Although the MMSE is typically used to screen for mental impairment in older adults, the test

can be administered to individuals who are 18-85 years or older, with some normative data

available for children as young as 10 years of age.

QUANTITATIVE ANALYSIS

Raw score Cut off score Level of cognitive impairment

18 24 Moderate Cognitive impairment

QUALITATIVE ANALYSIS

The client scored 18 on MMSE which lies in moderate cognitive impairment. The score

less than 24 were considered as cognitive impairment in individual.

YOUNG MANIA RATING SCALE (YMRS)

The Young Mania Rating Scale (YMRS) is a clinical interview scale to assess the

severity of manic states. The Young Mania Rating Scale (YMRS) is a clinical interview scale to

assess the severity of manic states. The items have five defined grades of severity. Four items

are double weighted (irritability, speech, thought content and disruptive/aggressive behavior).

Inter- rater reliability reported by the authors was adequate for total score (0.93) and for

individual items ranged from 0.67 to 0.95. They presented validation using concurrent global

ratings and ratings with other mania rating scales. The YMRS total score ranges from 0 to 60

where higher
scores indicate more severe mania, thus, a negative change (or decrease) from baseline indicates

a reduction (or improvement) in manic symptoms. Total score ≤12 indicates remission (0-

10=minimal symptoms; 11-15=mild mania, 16-19=moderate mania, 20 above =severe mania)

(Young, Biggs, Ziegler, & Meyer, 1978).

QUANTITATIVE ANALYSIS

Raw score Cut off score Level of Mania

35 11 Severe mania

Qualitative analysis

The client obtained total score of 41 in YMRS that comes under severe manic mania

category. He scored high in item no 2, 4, 5, 6, 7, 8 and 11 which shows increased motor activity,

sleep problems, irritability, speech problems(rate and amount), language problems (thought

disorder), content (delusions), and lack of insight, respectively.

POSITIVE AND NEGATIVE SYNDROME SCALE (PANSS)

The Positive and Negative Syndrome Scale (PANSS) is based on findings that

schizophrenia comprises at least two distinct syndromes the positive syndrome, consisting of

productive symptoms; and the negative syndrome, consisting of deficit features. It is useful when

developing treatment plans because we can focus on the type of symptoms the patient is

experiencing. The PANSS is also helpful when studying the effects of medication (e.g., in

clinical drug trials) because it allows us to determine which type of symptoms are being affected

(Leucht, 2005). The key areas measured by it were Positive Scale, Negative Scale, General

Psychopathology Scale, and Supplemental Aggression Risk Profile. PANSS was used to

evaluate the patient‟s symptom severity and to gather information about the type of symptom

manifestation. The results of PANSS are as follows

Variables Raw Scores T Scores

Positive Scale 30 66

Negative Scale 21 49

General Scale 47 58

Anergia 12 55

Thought Disturbance 24 75

Activation 9 60

Paranoid 9 55

Depression 15 61

Client‟s scores on PANSS indicate that positive and negative symptoms are both above

average as well as paranoia and activation is also above average.

BECK DEPRESSION INVENTORY (BDI)

Beck Depression Inventory (BDI) II is a 21-item, self-report rating inventory that

measures symptoms of depression. BDI was administered on the client to determine level of

depression. The BDI contains 21 items on a 4-point scale from 0 (symptom absent) to 3 (severe

symptoms). Scoring is achieved by adding the highest ratings for all 21 items. The minimum

score is 0 and maximum score is 63. Higher scores indicate greater symptom severity. In non-

clinical populations, scores above 20 indicate depression. In those diagnosed with depression,

scores of 0– 13 indicate minimal depression, 14–19 (mild depression), 20–28 (moderate

depression) and 29– 63 (severe depression). The questionnaire is commonly self-administered

and it takes 5–10 minutes (Jackson-Koku, 2016).

QUANTITATIVE ANALYSIS
Raw score Cut off score Level of depression

37 14 Severe depression

QUALITATIVE ANALYSIS

The client scored 38 raw score in BDI which was significant from cut off score 14. The

result shows that client has severe level of depression with feelings of fatigue, depressed and lack

of interest.

TENTATIVE DIAGNOSIS

“Severe Bipolar I Disorder current or most recent episode manic with mood-

congruent psychotic features 296.44 (F31.2)”

Bipolar I Disorder Current Episode Manic With Psychotic Features

A. During the period of mood disturbance & increased energy or activity, three or more

of the following symptoms(four if the mood is only irritable)are present to a

significant degree & represent a noticeable change from usual behavior:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility reported or observed

B. Presence of grandiose delusions, referential delusions and persecutory delusions.

C. Presence of thoughts disturbance

CASE FORMULATION
The client was 20 years old boy with average height and weight. He had a fair complexion, with

dark brown eyes and black hair. He was dressed properly. He came with the presenting

complaints of decreased appetite and need for sleep, pressure to keep talking including flight of

ideas, aggressive behavior, labile mood, having grandiose, persecutory and referential delusions.

According to DSM-5, the client met the criteria of Severe Bipolar I Disorder current or

most recent episode manic with mood-congruent psychotic features. The diagnosis was also

confirmed through informal assessment by taking history, MSE, DTR, Mood Monitoring Chart

and formal assessment by applying YMRS, PANSS and BDI-II. Client was having decrease in

appetite and need for sleep, pressured to keep talking including flight of ideas, had aggressive

behavior, and was having grandiose, persecutory and referential delusions.

Bipolar 1 Disorder involves criteria for a manic episode which may have been preceded

by and may be followed by manic or major depressive episodes. Symptoms of mania involves

grandiosity, decrease need for sleep, talkativeness, flight of ideas, distractibility, increase in goal-

directed activity and excessive involvement in activities that have high potential for painful

consequences whereas Major Depressive Disorder involves symptoms of sadness, insomnia,

poor appetite, suicidal ideation, irritable mood, fatigue and indecisiveness (APA, 2013).

The client had a depressive episode when he displayed symptoms of crying spells,

irritable mood, hypersomnia and loss of energy after quitting college. Whereas, the client came

with manic symptoms to the present therapist such as, decrease need for sleep, excessive

talking, flight of ideas and was having delusional content.

Theory given by Susan Nolen-Hoeksema (1991), known as rumination theory indicates

that specific way to thinking called rumination may increase the risk of depression. Rumination

is a tendency to repeatedly dwell on sad experiences and thoughts, or to chew on material again
and again. The client had ruminations regarding his failure and the behavior of his friends

towards him. So there is likelihood that one of the major causes of client‟s illness is his

ruminations.

Delusional guilt, due to severe depression, underlies the belief that punishment is

deserved and imminent, but this is mixed with intense fear for survival. Just as psychotic

depression can lead to guilt-induced paranoia, manic grandiosity readily proceeds to paranoia.

Mania can lead to grandiose delusions of ownership of possessions of exaggerated value that

others want. The fear for survival, ie, paranoid delusions, develops and escalates as grandiose,

manic patients begin to believe that others are willing to inflict harm to gain their possessions

for themselves (Lake, 2008). During the time of depression, the client experienced guilt of doing

wrong things with his friends. When he started to see videos of the religious scholars he started

to believe that he was messiah (grandiosity) came to save people from the sins. Which in turn,

generated fear in him, that people are after him to stop him from the right path.

Bipolar affective disorder patients often show cognitive deficits that are similar to those

found in schizophrenia patients. Theory of mind (the ability to understand others‟ mental states

such believes, emotions and intentions) is compromised in currently ill schizophrenia patients.

Impaired performance on theory of mind was found for both bipolar-depressed and bipolar-

manic patients, even when memory was controlled for (Kerr, Dunbar, & Bentall, 2003). The

client‟s symptoms of persecutory delusions and thoughts about that people are doing black

magic on him may be because of this cognitive deficiency in which he is giving his

interpretations to people‟s actions.

PROGNOSIS

1. The prognosis of the patient was to be guarded

2. Clear stressors present at the time of onset

3. Family is supportive

4. Client is co-operative

5. He is now hopeful and want to become a normal person.

6. He was able to understand that the delusions are untrue, unreal.

 MANAGEMENT PLAN

Management plan was designed to help the client in order to resolve his problem and return

back to his normal functioning. Several therapies and techniques can be used for those who

suffered with Schizophrenia such as;

 Rapport building

 Psycho-education

 Family Counseling

 Deep Breathing and PMR

 Behaviour Management

 Social Skills training

 Medication Adherence Therapy

 Cognitive Behaviour Therapy

 Cost benefit analysis

 Contingency management

 Systematic desensitization for delusion

 Verbal Challenging Technique

 Double column chart

 Coping strategies enhancement

 Activity Scheduling

 Cognitive Restructuring

 Therapy Blueprint

SHORT TERM GOALS

 Supportive work was done to develop rapport and trustworthy relationship with the

patient and to enhance his motivation for the treatment.

 Psycho-education of the patient and family was done regarding the nature, etiological and
 maintaining factors of illness and to develop realistic goals and expectations.

 Medicine adherence was ensured by educating the patient and her mother regarding

its importance for the treatment.

 Mood monitoring worksheet was used for self-awareness, early signs of mood episode and to

help him to take steps to prevent full blown episodes of mania and depression.

 Case conceptualization was done to increase the patient‟s understanding about his illness.

 Deep breathing was taught in order to help him feel comfortable and relaxed.

 Progressive Muscle Relaxation exercise was taught to him with the rationale of

conditioning to improve the quality of sleep.

 Activity schedule was made to structure his routine so that he will be able to use his

time effectively, especially during manic state.

 Sleep hygiene techniques were given in order to improve his sleep quality such as not

eating food with high sugar quantity, elimination of caffeinated and carbonated drinks and

walk at night time.

 Thought feeling connection was explained to teach to him about the supremacy of thoughts.

 Reality testing was done to help him to differentiate self-generated stimuli (e.g.,

thoughts, imagery, and feelings) from external stimuli (i.e., perceptions) and assign

appropriate meaning to experiences.

 Verbal challenging technique of evidence for and against would be used to challenge

and modify delusional beliefs and hallucinatory experiences of the client.

 Cost benefit analysis technique will be used on client.

 Systematic desensitization will be used for delusion.

 Family counseling would be done to educate client's family as to how families can have a
 significant impact on their relative's maintenance of illness and its recovery.

 Relapse Prevention plan was used to prevent relapse in future.

 Therapeutic blueprint would be provided to the client that would include the summary of

what the client has learned in the therapeutic process and how will he apply the learned

strategies to handle future obstacles.

LONG TERM GOALS

 Continuation of short-term goals, by encouraging the patient to continue the

techniques he learned during therapy.

 Problem solving technique should be taught in order to enable the client to deal with

his life stressor in a better way and to decrease the vulnerability towards relapse due to

stressors.

 Self-Management techniques should be taught to help manage bipolar symptoms.

 Regular follow-up to be done to check the progress after the therapy.

THERAPEUTIC OUTCOME

Therapeutic outcome was assessed to check the efficacy of the treatment by taking subjective

ratings of the client‟s problems at the post assessment level.

Problematic Areas Family’s Rating (0-10) Family’s Rating (0-10)

Hyperactivity 10 5

Labile mood 9 4

Lack of sleep 8 3

Grandiose delusions 8 4

Excessive talk 9 4
 Persecutory delusions 8 5

Flight of ideas 7 3

Referential delusions 8 4

Anger 7 3

CRITICAL EVALUATION

The hospitalization of the client made the therapy effective. However, one time when the

client had an excess to the religious video in ward created hindrance in treating him more

effectively as his grandiose delusion became stronger after watching one. To improve the

desirable healthy behaviours, differential reinforcement was introduced and administered which

is the implementation of reinforcing only the appropriate response (Smith, [Link], 2003).

SUMMARY OF THERAPEUTIC INTERVENTIONS

SUPPORTIVE PSYCHOTHERAPY

Supportive psychotherapy was the first and foremost management therapy which started

very early in the intervention since first session. In this therapy supportive work was done with

the client through different ways. Firstly, the client was provided the opportunity of empathetic

listening which helped in her catharsis and ventilation of pent-up feelings and emotions. Through

active listening the client was provided unconditioned positive regard, which helped in

developing trustworthy relations with the client needed for the effective progress of the therapy.

COGNITIVE RESTRUCTURING

Cognitive restructuring, or reframing, is used throughout the relapse prevention treatment

process to assist clients in modifying their attributions for and perceptions of the relapse process.
In particular, cognitive restructuring is a critical component of interventions to lessen the

abstinence violation effect (Marlatt& Gordon‟s, 2005).

RAPPORT BUILDING

Rapport was built easily but the client took time to open up and great deal of

information. Reassurance was provided to the client throughout the intervention on different

levels especially in maintaining confidentiality of the client's related information and cure from

her illness and also while conducting the assertiveness training and self-esteem building

exercise.

PSYCHOEDUCATION

It is the presentation of systematic, structured, didactic information on illness and its

treatment. It aims on providing the information about causes, symptoms, and 60 progressions of

illness and it reflects mind body conceptualization of the problem (Power & Freeman, 2007).

Client was psychoeducated about his illness, possible causal factors, problems he may face if

condition persists and possible treatment option. She was told for normalization purpose that

many people suffer from the disorder with even worse conditions and she was not alone. Client

was curious about theory and treatment options of the disorder. She also insisted in knowing the

altered brain functioning. She was interested in the treatment.

FAMILY COUNSELLING

Family counselling brings together members of a family to work through situational or

relationship issues (Rowlson, 2019). The parents of the client were informed about the disorder,

the client was facing. They were informed, about the nature, symptoms and causes of the

disorder and how to deal effectively with it. They were enlightened, about the importance of
medication adherence and if faced with any difficulty regarding medications, who they should

contact.

PROGRESSIVE MUSCLE RELAXATION

The aim of relaxation techniques is to achieve physical and mental relaxation. They are

meant to reduce physical tension and interrupt the thought processes that are affecting sleep.

Studies show that people who have learned relaxation techniques sleep a bit longer at night

(Vancampfort, Correll, Scheewe, Probst, Knapen, & De Hert, 2013). In progressive muscle

relaxation exercises, particular muscles are tensed up and are kept tensed for about 5 seconds and

then are relaxed slowly. 16 body muscles are tensed up and relaxed for his purpose.

INDIVIDUAL COUNSELLING

Individual counseling is a key to addiction recovery. The role of this counselor is not only

to counsel the patient on chemical dependency issues, but also work with the client to create an

individualized treatment plan, and coordinate all care with other substance abuse recovery

professionals.

DEEP BREATHING

The client was informed that when we become anxious our breathing rate often changes,

resulting in a range of other physical sensations. Slowing down our breathing can help to

control physical sensations quickly and therefore help us to feel more comfortable.

ACTIVITY SCHEDULE

Daily activity schedule was chalked out with the consent of the client in the initial

sessions of the intervention program. The aim was to structure his daily routine in a productive

and more effective way. Activities were daily take bath for twice or thrice. Physical exercises
were added in the schedule but he is over aged so he can‟t, which improved his blood

circulation and sleep eventually, relaxation exercise was also included in the schedule to

practice daily.

MEDICATION ADHERENCE THERAPY

It was used in the intervention in initial phases but during the middle and last phase of

intervention it was again emphasized and practiced as the client and her in laws especially

fiancé need to be educated about the role of medicines in the disorder, when they take the

medicines and how to take the medicine. They were also educated around the medication

adherence and change in the medicines.

SELF-ESTEEM BUILDING EXERCISE

Different self-esteem building exercise was taught to the client as client had a very low

self-esteem. Extensive work had been carried out in this regards the client. The client was told to

write her 10 strengths and 10 weaknesses and then an imagery exercise was carried out in which

she had to instruct to improve the quality and pattern of her sleep.

COPING STATEMENTS

Coping statements were used as cognitive breakers and were given to the client on 3 by 5

sizes of colored flash cards. The purpose was to enable client to deal with his thoughts related to

craving confidently and to overcome his problem of addiction with positive affirmations which

motivated him whenever he faced difficulty in leaving or abstaining himself from their delusions.

COGNITIVE BEHAVIORAL THERAPY

Cognitive-behavioural therapy treatment (Rothbaum, Meadows, Resick, & Foy, 2000) is

tailored to the individual patient‟s needs in order to place an emphasis on the thoughts that lead

to their use and then making behavioural changes to the reaction that they have to these

thoughts. CBT is based on the belief that thoughts cause behaviours, and these thoughts

determine the way

in which people perceive, interpret, and assign meaning to the environment. Thus, by

changing our thought process, maladaptive behaviours can be changed even if our

environment does not change.

THERAPY BLUEPRINT

The revision of all the activities learnt during the course of therapy was carried out in order to

guide client about continuation of the activities for each symptoms, when experiencing them in
future.
References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.).

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and negative syndrome scale

(PANSS) for schizophrenia. Schizophrenia Bulletin, 13 (2), 261–76.

Kerr, N., Dunbar, R. I., & Bentall, R. P. (2003). Theory of mind deficits in bipolar affective

disorder. Journal of Affective Disorders, 73(3), 253-259.

Lake, C. R. (2008). Hypothesis: Grandiosity and Guilt Cause Paranoia; Paranoid Schizophrenia

is a Psychotic Mood Disorder; a Review, Schizophrenia Bulletin, 34 (6), 1151-

1162. [Link]

Marwah, S. (2019). Practical tips for 22 –Mental and behavioural disorders. Shubham Vihar,

Bilaspur: Chhattisgarh.

Vancampfort, D., Correll, C. U., Scheewe, T. W., Probst, M., De Herdt, A., Knapen, J., & De

Hert, M. (2013). Progressive muscle relaxation in persons with schizophrenia: a

systematic review of randomized controlled trials. Clinical rehabilitation, 27(4), 291-

298.

Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978. A rating scale for mania:

reliability, validity and sensitivity. British Journal of Psychiatry, 133, 429-435.

APPENDIX OF CASE
REPORT