Summary of Case V

The client was 25-year-old lady who has done graduation. She came up with

presenting complaints of pounding heart, sweating, shortness of breath, chest pain,

feeling dizziness, fainted, and fear of dying. She was referred to trainee clinical

psychologist by Allamah Iqbal Memorial Hospital for psychological assessment and

management. Behavioral observation, clinical interview, and mental status

examination, and Visual Analogue Scale make up informal assessment. Severity

Measure for Panic Disorder (SMPD) and DSM-5 Checklist were used for the formal

assessment. Client was diagnosed as having Panic Disorder based on the complaints

that were made. To address the presenting complaints, a proposed management plan

was made such as Rapport building, Psycho-education, Cognitive behavioral therapy,

Aware Therapy, Relaxation techniques (Deep Breathing and PMR).

Identifying Information

Name: S.U

Age: 25 years

Gender: Female

Education: BS Education

Marital status: Married

Family System: Neutral

No. of siblings: 8

Birth Order: 3rd

Informant: Client herself

Total No. of session: 2

Date seen: 05-04-2023

Last date of seen: 12-04-2023

Source and Reason of Referral

The client was referred to trainee clinical psychologist in Allamah Iqbal

Memorial Hospital for the purpose of psychological assessment and management. She

came up with the presenting complaints of pounding heart, sweating, shortness of

breath, chest pain, feeling dizziness, fainted, and fear of dying.

Presenting Complaints
Presenting Complaints and duration as presented by the client.

‫دورانیہ‬ ‫علامات‬

‫تین سال سے‬ ‫گھبراہٹ بہت زیادہ ہوتی ہے‬

‫تین سال سے‬ ‫دل بھاری محسوس ہوتا ہے‬

‫تین سال سے‬ ‫سانس لینے میں دشواری آتی ہے‬

‫تین سال سے‬ ‫ہاتھ پاؤں پھول جاتے ہیں‬

‫تین سال سے‬ ‫ٹھنڈے گرم پسینے آتے ہیں‬

‫دو سال سے‬ ‫بےہوش ہو جاتی ہوں‬

‫دو سال سے‬ ‫مرنے کا خوف رہتا ہے‬

The client S.U was 24 years old came for a therapy session with presenting

complaints of pounding heart, sweating, shortness of breath, chest pain, feeling

dizziness, fainted, and fear of dying. The hygienic condition of client was quite

appropriate. The client was initially hesitant talking about her problems at the start of

session but became comfortable gradually as trainee clinical psychologist established

a good therapeutic relation with client. Client greeted well with the trainee clinical

psychologist. Session was started with open ended questions. She knew the purpose of

coming for therapy session, therefore, session structure was easy to continue and

rapport was also built in an efficient manner. According to behavioral examination,

client was cooperative in her nature, made the proper eye contact while answering,

her voice tone was average. The client reported, she generally feel pounding heart,

sweating, shortness of breath, chest pain, feeling dizziness, fainted, and fear of dying.

Her memory was good. She responded all questions well.

 Client started to present the complaints of her illness with duration; she was

looking much disturbed about her problem. She reported that she got married at the

age of 22 years and she started experiencing sweating, chest pain, shortness of breath,

and also experience fear of dying from her childhood. This constant feeling was

disturbing her daily activities and causing worry day by day.

During the session, client also reported about the mood and behavioral

changing of client. She reported that she remained worried concerning about her panic

attacks. She experience shortness of breath, excessive heart pounding, chest pain etc.

Furthermore, to know more about the client’s mental state, Mental Status

Examination (MSE) was used in which client’s emotional, behavioral, and cognitive

skills were examined. In the first session, it was tried to formulate the case according

to bio-psycho-social model, and by knowing the 4p’s as precipitating, perpetuating,

predisposing and protective factors. In this way, it was easy to proceed the case and to

plan for further sessions, for the betterment of client.

The developmental history of the client’s problem had started after she saw a

serious fight between her parents. Client’s father slapped her mother and client started

facing pounding heart, sweating, shortness of breath, chest pain, feeling dizziness,

fainted, and fear of dying. That’s where client first faced panic attacks. Also, client’s

siblings got died in front of her eyes due to physical abnormalities was another

stressing factor for client’s panic attacks. Client also did not want to married earlier

and wanted to complete her studies first, was also another leading factor of client’s

symptoms. In this way, the client’s problem was started which is now disturbing her

life pattern and daily life.

History of present illness

Client’s problem had started after she saw a serious fight between her parents.

Client’s father slapped her mother and client started developing symptoms of panic

attacks. Also, client’s siblings got died in front of her eyes due to physical

abnormalities was another stressing factor for client’s panic attacks. Client also did

not want to married earlier and wanted to complete her studies first, was also another

leading factor of client’s symptoms. As a result, client started facing psychological

symptoms which are pounding heart, sweating, shortness of breath, chest pain, feeling

dizziness, fainted, and fear of dying. All these symptoms were now disturbing her life

pattern and daily life.

Background Information

Personal History. The client S.U. liked to get up early in the morning. She

was Muslim by birth. She liked to cook food. She also liked to paint as her hobby. She

was a healthy lady. Client had very helping nature. She did not like to make many

friends.

Educational History. The client was 6 years old when she joined school.

Client was an average student in studies. She only had one friend in school. She did

not like to make many friends. In college too, she had only one friend. The client was

now doing BS Education in university.

Family history. The client belongs to a nuclear family system. Client had 8

siblings and she was living art her parents’ house. Client father worked in Dubai at a

workshop. He was 50 years old. He was a healthy person and was financially strong.

The relationship of client with her father was not really satisfactory as he was very
strict. Client’s mother was 47 years old. She was house wife. She had satisfactory

relations with her mother. Client help her mother in daily house chores.

Client had 8 siblings. Client’s birth order was third. The 5 siblings of client

were died due to physical abnormalities, two elder siblings and 3 younger siblings.

The two remaining younger siblings of client, one sister and one brother, were

studying at school. Client had loving and satisfactory relations with her siblings.

Marital History. The client belongs to a nuclear family system. She had one

daughter. Her husband worked in Dubai, she had visited her husband in Dubai but

now she was living at her parents’ house due to her hectic study routine. Client had

loving and satisfactory relations with her husband. Client had not satisfactory

relations with her in laws. Client mother in law was beauty conscious and was

constantly taunt client for not being extra fair, for being short heighted and for not

dressing well like other girls which was also a stressing factor for client.

History of medical and psychiatry illness in family. Client’s siblings died

due to physical abnormalities which was a medical condition. There was no

psychiatry illness in client’s family.

Social history. Client was good person by heart. She had humble and polite

nature. Her social circle was not much big, she had only one friend since her school to

spend a good time with her. She was not a social person. She liked to help poor not

just financially but also by performing their activities which they ask for help from

her.

Psycho-sexual history. The client reached to the puberty at normal age and

her reactions towards physiological changes was normal. She had prior information
about sexual matters. She got information regarding sexual matters from her sister and

mother.

Pre-Morbid Personality According to the client, she was a healthy person

and was fit physically and psychologically before the onset of symptoms. She was

living a normal life with her parents. She had sound sleep and had no worry. She had

enjoyed her life very well with her family.

Psychological Assessment

Psychological assessment is a process of testing that uses a combination of

techniques to help arrive at some hypotheses about a person’s behavior, personality

and capabilities. Psychological assessment is also referred to as psychological testing

or performing a psychological battery on a person (Framingham, 2016). Both formal

and informal psychological assessment procedure was used to assess the client’s

various areas of dysfunction aroused due to symptomatic behavior.

Types of psychological assessment

There are two types of assessment.

 Informal assessment

 Formal assessment

Informal Psychological Assessment

Informal assessment is a way of collecting information about client’s behavior

in normal condition. This is done without establishing test condition such as in the

case of formal assessment. Informal assessment is sometimes referred to as

continuous assessment as it is done over a period of time. Informal assessment

methods are subjective and these methods are often developed treatment specific

assessment needs, they will also normally require less time, money and expertise than

nationally developed techniques (Cardozo & Megdalena, 1978). It includes the

following:

 Clinical Interview

 Behavioral Observation

 Mental Status Examination

 Visual Analogue Scale (VAS)

Clinical Interview. An interview is a conversation which has a purpose or goal

(Bingham & Moore, 1924; Matarazzo, 1965). Clinical Interview is a main tool of

gathering information from client, parents, and other informants (Raynold, 2014).

A clinical interview is a dialogue between psychologist and patient that is

designed to help the psychologist in diagnosis and development of treatment plan for

the patient. Interviews are flexible, relatively inexpensive, highly portable and

perhaps most important, capable of providing the clinician with simultaneous samples

of client’s verbal and nonverbal behavior. The interview was conducted to understand

the nature, severity and etiology of the patient’s problem. The session was started

with open ended questions. She was asked about her present complaints and history of

present illness to know about the duration of the problem along with the predisposing,

precipitating, perpetuating and protective factors. At the time of interview, she was

much worried, later on she starts understanding the interview. Her tone of voice was

normal. Overall, Good rapport was established.

 Behavioral Observation. Behavioral Observation is a systematic way of

recording the observable responses of behavior (Pellering, 2014). Behavioral

observation was done to assess the appearance, posture, speech, verbal, non-verbal

cues and eye contact of the client. Under observation during the session, it was

observed that client was much stressed at start but gets normalized after sometime.

During session, client’s behavior was also observed. The client was 25 years old. She

was wearing neat and clean clothes. She was cooperative. She had made good eye

contact during the session. Her voice tone was average. The client reported she

generally feel pounding heart, sweating, shortness of breath, chest pain, feeling

dizziness, fainted, and fear of dying. Her memory was good. She responded all

questions well.

Mental Status Examination (MSE). The mental status examination is a

structured assessment of the patient’s behavioral and cognitive functioning. It

includes descriptions of the patient’s appearance and general behavior, level of

consciousness and attentiveness, motor and speech activity, mood and affect, thought

and perception, attitude and insight. The specific cognitive functions of alertness,

memory and abstract reasoning are the most clinically relevant (Martin, 1990).

The client was 25 years old. She was very sad and worried. She wore simple but

neat and clean dress. She was talking normally and in a normal voice during the

conversation. Her thought process was good. She had good memory, as she

remembered all the childhood events. Her concentration was normal. Her orientation

of date was satisfactory as when asked what is the date and day today, she replied

well. Her judgment was normal as she answered I will help others when asked her if
you encounter domestic violence on other women, what will you do? The client had

possessed insight about her problem. The good thing is that she wanted to get rid of

all the problems and wanted to go to home and wanted to live a healthy and happy life

Visual Analogue (VAS). A Visual Analogue Scale (VAS) is a measurement

instrument that tries to measure a characteristic or attitude that is believed to range

across a continuum of values and cannot easily be directly measured. It is often used

in epidemiologic and clinical research to measure the intensity or frequency of various

symptoms. For example, the amount of pain that a patient feels ranges across a

continuum from none to an extreme amount of pain. From the patient's perspective,

this spectrum appears continuous ± their pain does not take discrete jumps, as a

categorization of none, mild, moderate and severe would suggest. It was to capture

this idea of an underlying continuum that the VAS was devised (D. Gould et al.,

2001).

Symptomatic behavior as reported by the client herself was rated on 10-point

scale. The purpose was to gain a baseline measure of the client’s behavior to assess

whether her behavior changed or not after counseling and psychological assessment.

Table 1

The following table is showing the self-report measure of the client.

Serial no Symptoms Client rating

1 pounding heart 8

2 sweating 8

3 shortness of breath 9

4 feeling dizziness 9
 5 chest pain 8

6 fainted 7

7 fear of dying 7

Conclusion

The client on visual analogue scale indicates that, she has high disturbing

symptoms like shortness of breath, dizziness, chest pain etc.

Formal Psychological Assessment

Formal assessment methods are considered to be more objective. The FPA is a

new methodology potentially capable of maximizing the advantages of both semi-

structured interviews and self-report questionnaires by overcoming the limitations of

these tools and managing the problems of traditional assessment. The ability to

analyze clinical symptoms is important when evaluating the responses to a

questionnaire. Formal assessment involves the use of tools such as tests,

Questionnaires, checklist and rating scales. The purpose of evaluation is to determine

the client’s personality, problems which impair the client’s normal functioning and

severity of disorder.

The functioning of various areas of personality has been assessed by;

Diagnostic assessment

 Severity Measure for Panic Disorder (SMPD)

Severity Measure for Panic Disorder (SMPD)

The Panic Disorder Severity Scale (PDSS) is a questionnaire developed for

measuring the severity of panic disorder. The clinician-administered PDSS is intended

to assess severity and considered a reliable tool for monitoring of treatment outcome.

Self-report form of the Panic Disorder Severity Scale (PDSS-SR) is used to detect

possible symptoms of panic disorder, and suggest the need for a formal diagnostic

assessment. The PDSS consists of 10 items, each rated on a 5-point scale, which

ranges from 0 to 4. The items assess questions about thoughts, feelings, and behaviors

about panic attacks. The total scores range from 0 to 28. The scores 7 and above

suggest the need for a formal diagnostic assessment

Administration

The client took 5 minutes to complete SMPD. A calm and

comfortable environment was provided for the completion of SMPD.

Behavioral observation

The purpose of applying this test to the client was clarified.

Therefore, the client was relaxed and confident. She was giving the answers

without any delay. She was totally involved in the completion of test. She

remained relax at the end of completion.

Qualitative Analysis

Table 2

Table is showing client’s age, raw scores, ranges of SMPD and results of

client

Age Raw Score Cut of Category

25 21 7 Severe

Qualitative analysis
 The client obtained scores is 21 on “Severity Measure for Panic

Disorder (SMPD)” which fall in severe category and according to DSM-V, it

comes in “Panic Disorder”.

Conclusion

The client got 21 scores on “Severity Measure for Panic Disorder

(SMPD)”, her scores fall on severe category, whose cut of is 7 and above. So

the results show that, the client is suffering from severe level of Panic

Disorder.

Case Formulation

The client S.U was 25 years old. After she saw her parent’s fight, she had

developed some symptoms of panic disorder like pounding heart, sweating, shortness

of breath, chest pain, feeling dizziness, fainted, and fear of dying. The client was

brought for informal assessment which includes Clinical interview, behavioral

observation, Mental Status Examination, and visual analogue; in formal assessment

standardized test was administered.

DSM-5 checklist was used. The client was diagnosed with “Panic Disorder”.

As per mentioned criteria in DSM-V for Panic Disorder is accelerated heart rate,

sweating, shortness of breath, chest pain, feeling dizziness, fainted, and fear of dying.

The formulation was done according to bio-psycho social model. According to

Bio model, the client was 3rd born child as in birth order, the got developed some

symptoms of Panic Disorder because of her parents fight. This causes severe

psychological discomfort to the client. Due to this happening, client became

emotionally disturbed. She became sensitive in nature and got into social withdrawal.
 MSE was applied on her for checking her behavior and intellectual

functioning at the time of her interview. Severity Measure for Panic Disorder (SMPD)

was administered on her to measure the level of panic attacks on the client.

The predisposing factor includes the genetics. Client’s 5 siblings got died due

to physical abnormalities. This was painful for client to see her siblings growing up

and dying in front of client’s eyes. The client had authoritative parents which was also

worrying factor for client to develop symptoms of panic disorder. The client was also

sensitive in nature which was also a leading factor. The Precipitating Factor was the

conflicts between client’s parents. This unstable home environment made client

disturbed. The client mother in law was beauty conscious and was constantly taunt

client for not being extra fair, for being short heighted and for not dressing well like

other girls which was also a stressing factor for client. Also the constant death of

client’s siblings was a stressing factor for client to trigger her panic attacks.

The perpetuating factors of the client disorder taunts from client mother in

law. Client’s mother in law constantly taunted her not being extra fair, for being short

heighted and for not dressing well like other girls which was also a stressing factor for

client. This led her to develop inferiority complex in client as client being constantly

bullied by her mother in law. Another factor which maintains client symptoms was

client’s poor coping style as she did not know how to cope up with situation. Client’s

social withdrawal was also maintain client’s symptoms as client did not like to

socialize. The protective factors include the client’s insight about problem and wanted

to get over of these symptoms. The client mother and husband’s support for client
also protects client’s symptoms. The medication and psychotherapy also make client

to feel better.

The session structures and further proceeding of case was done on the results

of assessment tools, as client get 21 score on “Severity Measure for Panic Disorder

(SMPD)” which is more than normal so she might fall in “Panic Disorder” according

to the concerned criteria of DSM-V. The treatment and management plan were done

in reference to therapeutic treatment as rapport building, psycho education, cognitive

behavior therapy, Aware Therapy, and Relaxation Exercises (deep breathing and

PMR).

Case Formulation Summary

Table

Assessment
Presenting Complaints
 Clinical Interview
 pounding heart
 Behavioral Observation
 sweating  Mental Status
 shortness of breath Examination (MSE)
 chest pain  Visual Analog scale
(VAS)
Client

(S.U)

Predisposing Precipitating Perpetuating Protective

Factors factors Factors Factors
 Genetics  Conflicts of  Taunts from in
 Insight about
 Death of 5 parents laws
 Inferiority problem
siblings due to  Unstable home
complex  Family support
physical environment
 Poor coping  Medication &
abnormalities  In laws are style psychotherapy
 Authoritative beauty conscious  Social
parenting  Death of siblings withdrawal

Diagnosis
 Panic Disorder

Diagnosis
 Client is diagnosed with Panic Disorder with code 300.01 (F41.0), according

to DSM-V.

Short Term Goals

 Rapport building will be used for building the trust of the client on the

therapist.

 Psycho education will be used to educate the client about her psychological

discomfort, its harmful impacts and how she deals with her problem.

 Deep breathing exercise to be used to keep her relaxed under certain

situation, when relaxation could not be used.

 Cognitive Behavioral Therapy (CBT) will be applied to explain the

relationship of negative thoughts with emotional distress and disputing for

counting her irrational beliefs and changing them into rational beliefs.

 Problem solving skills will be taught to client to manage her symptoms.

 Goal settings to be done to enhance her motivation and interest in life

regarding different areas of life.

Long Term Goals

 Follow up sessions to be continued to monitor and assess the patient’s

functioning.

 Achievement of short term goals will be encouraged.

 Encourage the patient to have discuss her problematic issues in future and thus

to sustain her recovery.

 Improve physical functioning due to development of adequate coping

mechanism for reducing symptoms.

  Help the client learn to identify her emotions and express them in healthy,

respectful ways.

 Family therapy session will be arranged to assist the family members increase

their positive support for the client.

Management Plan

The management plan was made according to the current level of the client’s

functioning. Currently she had problems as fatigue, excessive worry, low appetite,

loneliness, crying, restlessness, sleep disturbance.

 Rapport building

 Psycho Education

 Cognitive Behavior Therapy

 Aware Therapy

 Relaxation exercises (Deep Breathing and PMR)

Rapport building. Rapport has been described as “the relative harmony and

smoothness of relation between peoples”. A strong rapport was built as it is a highly

valued part of clinical practice rapport and is often viewed as an exchange of the

pleasantries. It is seen as something to be fostered early in a therapy session so that

the more important therapy goals can be more easily accomplished (Spencer, 2005).

The rational was of the rapport building to develop the trust and self-belief of the

client. Rapport building was necessary for understanding the client’s feelings,

thoughts and problems, as the rapport was developed with the client in the first

session by introducing the client with trainee clinical psychologist, by clarifying the
purpose of session, and assuring her about the privacy and confidentiality of the

problem.

Psycho-Education. Psycho education refers to the education offered to

individuals with a mental health condition and their families to help empower them

and deal with their condition in an optimal way. The Client was psycho-educated in

session about problem and illness. The client was psycho-educated to some extent

about her problem. Psych education is thought to be a fundamental component of all

therapeutic programs, with the aim of assisting client in better understanding (and

adapting to living with) the problem. Client who has a clear understanding of the

difficulties he is dealing with as well as knowledge of his own coping mechanisms,

available resources, and personal areas of strength is frequently better able to deal

with challenges, feel more in control of the problems, and has a greater internal ability

to cope toward mental and emotional well-being.

Cognitive Behavior Therapy. CBT was developed by Aron T. beck in 1960.

Cognitive therapy is a good and time limited therapy. In CBT the negative thoughts

and beliefs of patients are tend to change. This therapy will be applied to client to help

her to overcome her difficulties by identifying and changing dysfunctional changes

and emotional responses. Thought changing and cognitive restructuring is a technique

in CBT. It is process in which you challenge the negative thinking patterns that

contribute to your anxiety, replacing them with more positive, realistic thoughts.

This involves three steps:

  Identifying your negative thoughts, the strategy to ask to ask yourself what

you are thinking, when you started feeling anxious. Your therapist will help

you with this step.

 Challenging your negative thoughts. In second step, your therapist will teach

you how to evaluate your anxiety provoking thoughts.

 Replacing your negative thoughts with realistic thoughts. Once you have

identified the irrational predictions and negative distortions in your anxious

thoughts, you can replace them with new thoughts that are more accurate and

positive.

Aware Therapy. One of the most common maladaptive responses to anxiety

or anxious situations is avoidance. Avoidance is maladaptive because you never learn

how to tolerate the panic attacks to the point that it begins to eventually extinguish

itself. In addition, because avoidance feels good on some level (escaping a negative

feeling) it serves to reinforce the anxiety reaction that you are trying to avoid. The

AWARE model below is adopted from the work by Dr. Aaron Beck and is a tool you

can use to learn to better cope with anxiety about panic. By practicing the AWARE

model you can begin to change your relationship with anxiety and break the cycle of

avoidance that makes your anxiety grow stronger.

 Acknowledge anxiety. Quit fighting it and learn to accept it as an unavoidable

emotion we all experience. Telling yourself “Don’t freak out” only makes it

worse. Instead, try telling yourself “I know my nervous system is working.

This is normal.”
  Watch anxiety. Try not judge as good or bad. Instead, try to rate the intensity

(1-100) over time. Assigning a number helps you recognize gray areas and

that not all anxiety is the same. As the numbers change you will also notice

that there a pattern to your anxiety. The intensity will increase to a peak and

then it will predictably decrease. Learn to realize the emotion is time limited.

 Act through. Don’t let anxiety prevent you from living life. Avoiding it makes

it grow. When the patient is anxious, he or she must continue to do what they

were doing.

 Repeat process. It takes lots of practice to get better at increased acceptance of

your anxiety.

 Expect the best. Each episode is a fresh try. Try to notice even small gains.

Relaxation Exercises. Relaxation techniques are strategies used to reduce

stress and anxiety. One set of skills used to supplement other CBT skills (such as

exposure and cognitive skills) are relaxation skills. Relaxation skills address panic

attacks from the standpoint of the body by reducing muscle tension, slowing down

breathing, and calming the mind. Client was suffering most disturbing psychological

state due to her panic attacks, so relaxation exercises will be necessary for her. The

procedure which will be applied to the client during the session is slow diaphragmatic

breathing and Progressive Muscles Relaxation (PMR). Slow diaphragmatic breathing

is one relaxation skill used in CBT. It is best used as a daily practice, like exercise, or

as a way to get through a tough situation without leaving or making things worse. For

best results, practice slow breathing twice a day for around 10 minutes each time. The

purpose of applying this technique was used to relax the body and calm the mind and

emotions.
 Client will be taught the process of deep breathing. In first session slow

diaphragmatic breathing procedure will be done by these steps. Sit comfortably in a

chair with your feet on the floor. You can lie down if you wish. Fold your hands on

your belly. Breathe in slowly and calmly. Fill up the belly with a normal breath. Try

not to breathe in too heavily. The hands should move up when you breathe in, as if

you are filling up a balloon. Avoid lifting the shoulders as you inhale; rather, breathe

into the stomach. Breathe out slowly to the count of “4.” Try to slow down the rate of

the exhale. After the exhale, hold for 4 seconds before inhaling again. Work to

continue to slow down the pace of the breath. Practice this for about 10 minutes. This

works best if you practice this two times each day for 10 minutes each time. Try to

find a regular time to practice this each day.

Relaxation exercises and deep breathing are two ways to help people to relax

and combat symptoms of anxiety (Manzoni, 2008). PMR (Progressive Muscle

relaxation) is a technique for learning to monitor and control the state of muscular

tension. The rationale of using this technique was to relax the body muscles as client

reported that she had pain in his body (Jacobson, 1938). In the first phase the client

will be told to tense each muscle group step by step before relaxing it. This procedure

will make the client aware of sensation associated with relaxation and will teach her

to differentiate between two sensations, pain and relaxation. This technique benefits

the client physically and psychologically.

Limitations

Limitations are as following:

 Time period for completing the case was very short.

  As there was no psychiatric ward in the hospital, trainee clinical psychologist

had to take session in the OPD with so many people around her.

 Frequent interruptions by people, nurses and doctor checkup made it more

difficult to follow the rhythm.

 Administration of tests was difficult due to continuous interruption by other

patients in ward and paramedical staff.

 No informant was available throughout the assessment. Information from

other family members could not be collected which could helpful in

identifying more.

Recommendations

Following recommendation could be helpful in conducting session successfully.

 Assessment should be carried out in a room or open environment that is free of

distractions.

 Time period for case study should be extended.

 Information should be gathered from the people in close contact of the client.
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Consulting and Clinical Psychology, 61(4), 611.

Jacobson, E. (1938). Progressive Relaxation. Chicago, University of Chicago Press.

Martin, G. & Pear, J. (1992). Behavior modification: What it is and how do it.

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