BIO DATA

Name A.S

Father Name M.S

Age 23 years

Sex Male

Birth Order 3rd

Education Primary

Profession welder

Marital Status Single

Informant The client’s brother

Reason of Referral

He was showing symptom of low mood, isolation, suicidal attempts, poor appetite and sleep etc

from post 4 to 5 months. So his family first brought him to private hospital of ryk but it laid no

positive effects on him. Then his family brought him to the hospital for proper diagnosis and

treatment.

Presenting Complaints

Loss of sleep

Loss of appetite

Severe headache

Loss of interest in pleasure

Depressed mood

Thoughts of death
History of Current Illness

According to the patient who seemed reliable, patient was alright. his symptoms started after the

marriage of his brother when his friend insisted him to use drug. Unfortunately he did so. The

patient told, he loved he loved his cousin and wanted to marry her. They were engaged and soon

they were going to married. His friends who were jealous with his marriage offered him drugs

and insisted to use these drugs. He used drugs secretly for some time. But when his family

members and relatives came to know about his drug use, her fiancée’s father refuse to marry his

daughter with him. He became more disheart and started excessive smoking. His brother beat

him a lot due to drinking alcohol. Then, he went to Karachi and worked there as a welder. After

3 months, he came back from Karachi. After that, he showed the symptoms of aggression, body

aches, restlessness, decreased in sleep and appetite, laughing at people quarreling with his

parents, self talking with moon and stars. He believed that people wanted to harm him and kill

him. He started considering himself as the superior and powerful man and started to believe that

people feel jealousy to him. Due to these symptoms, his family members took him to the

Hospital and then, he referred to psychiatry ward for proper diagnosis and treatment.

Family History

He lived in a nuclear family system. The atmosphere of his home was good. He was very much

attached to his father. His father had polite attitude towards his family. A big financial crisis

dropped his father’s health due to which he had to quit his studies and became depressed.

They were 2 brothers and 1 sister. His birth order was 3 rd. All siblings had friendly relationship

with one another.

He was normally born. There were no complications during his birth. He was a healthy child.

Milestones of his development (e.g. crawling, walk, speech, etc) were achieved at appropriate

times of age. He was an active child during his childhood.

He was a brilliant student. He studied till matriculation. But he had to quit his studies due to

financial crisis. He was non-addict. He had good social relationships. His hobbies were martial

arts and cricket. He had normal views for religion and moral values. He was very much attached

to with his father. He had never been suffered from any psychiatric and significant medical

illness before. He also had never been involved in any crime. He was single. He never had been

involved in any love affair or sexual activity. He never had masturbated himself.

Family Psychiatric History and History of Medical Illness

None is his family ever had any psychiatric illness. All were healthy and mentally fit. He had

never been suffered from any significant medical illness in any age. He had good physiques and

health.

Assessment

Informal assessment

Formal Assessment

Informal assessment

Mental Status Examination

He was in good hygiene. First, he hesitated to cooperate but then he was comfortable of it. He

was maintaining good eye- contact. He was smiling during interview, and was not totally bored.

His sitting posture was relaxed. He was responsive and cooperative. He was answering all the

questions being asked to him. His tone was low and was difficult to understand. His talk was
relevant over all. He said that he was not comfortable physically. He said he was depressed. His

mood was low and he was depressed. Her thought processes were coherent,and goal directed.

Delusions, hallucination and illusion were not observed. I asked him what the time now is. He

said its 10 o’clock in the noon. I asked him what you think about this place. He said this place is

better than mental hospital. I asked tell me something about yourself. He said my name is S.A

and I am 23 years old. I am a patient of depression. He was attentive throughout the interview

and his concentration was not diverted due to surround days throughout the interview. I asked

him to tell me backward and forward subtraction series of 7. He told accurately. I asked what

you ate in lunch yesterday. He said I ate rice. This answer was right. I asked what the name of

your school was. He answered accurately that it was Govt. High School Sadiq Abad. I asked

about the name of Pakistan team captain she said Misbah ul haq. I asked him tell me the

difference between snake and rope. She answered that snake can bite but rope can’t. He was

aware of his mental illness and told that “my father’s financial crisis changed my life”. He also

told that “I am taking medicines regularly but those medicines also have side-effects like

lethargy dizziness and laziness”.

Formal assessment

Formal assessment of the client was done by using following psychological tests.

1. Beck depression inventory (BDI)

Beck Depression Inventory (BDI)

Dr. Aaron T. Beck introduced Depression inventory in 1961. It is revised in 1971 and 1996. It is

a 21 question multiple choice self-report inventory that is one of the most widely used

instruments for measuring the severity of depression. The questionnaire is composed of items

relating to depression symptoms such as hopelessness and irritability, cognitions such as guilt or
feelings of being punished, as well as physical symptoms such as fatigue and weight loss. Its

standard cutoffscores are as under:-

___________________________________________________________________________

Sr # Level of Depression Score

___________________________________________________________________________

1 These ups and downs are considered normal 1-10

2 Mild mood disturbance 11-16

3 Borderline clinical depression 17-24

4 Moderate depression 21-30

5 Severe depression 31-40

6 Extreme depression above 40

Qualitative Analysis

Patient score is 34 on BDI, which indicates severe depression.

Diagnosis

Major Depressive Disorder