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Clinical Case Report – I (Neurotic)

Sana Al Sehar

28511

Ms Nabeela Raza

Clinical Internship & Report Writing

Riphah International University , Islamabad

(GGC)
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Case Summary

Ms A.A was 45 years old female. She came to the CDA Hospital with the presenting

complaints of Excessive worry and thoughts about something worse could happen,

Difficulty concentrating, Accelerating heart beating, Shivering and Sweating when

feeling worried, and experiencing Sadness and Irritability, Restlessness, Muscles

tension, and Sleep disturbance. The assessment was done through Informal and

Formal Assessment measures such as Clinical Interview, Mental State Examination,

Beck Anxiety Inventory (BAI), Manifest Anxiety Scale (MAS), Rotter Incomplete

Sentences blank (RISB) Along with (HTP & DAP). The client was diagnosed with

Generalized Anxiety Disorder 300.02 (F41.1) according to DSM-5. The management

plan was devised on the basis of her symptoms. Cognitive Restructuring (CBT),

Relaxation technique, lifestyle changes, Family Therapy and thought Record through

(ACT) were with different Sessions. The outcome of therapy was positive. 56% of

symptoms improved after the continuation of therapeutic sessions.

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DEMOGRAPHICS

Name : A.A

Gender : Female

Age : 45 Years

Education : Primary

Occupation : House Wife

Birth Order : 1st Born

Marital Status : Married

Spouse Education : Matriculation

Spouse Occupation : Private Job

Family Setup : Nuclear

No. Of Children : 05 ( 04 Son , 01 Daughter )

Father Education : Matriculation

Father Occupation : Teacher

Mother Education : Primary

Mother Occupation : House Wife (Not Alive)

City : Islamabad

Informant : Spouse
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Introduction

Reason & Source Of Referral

A.A was brought to the CDA hospital by her husband on 10th of July 2023 for psychological

Assessment due to her behavioral and psychological problems.

Observations

The client was dressed up properly and sitting comfortably. She maintain her eye contact and

not hesitate but look anxious. Her voice was clear and easy to understand.

Presenting Complaints

Table 1

Frequency intensity and duration of presenting complaints

Complaints Frequency Intensity Duration

Chir chira pan Everyday 9/10 2 weeks
hota ha

Sar bhari hota Frequently 8/10 1 week

hy

Thakawat Frequently 6/10 2 weeks

mehsos krna

Jism ma drd Frequently 7/10 1 week

Neand nhi atti Everyday 9/10 2 weeks

Hr wqt preshani Everyday 7/10 1 week

rehti ha

Dil khabrata ha Frequently 6/10 2 weeks

Paseena any Frequently 6/10 1 week

lgta hy

Kam krny ko dil Frequently 7/10 1 week

nae krta
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The client came to the hospital with the following compalints : Chir chira pan hota ha hr wqt

gusa ata ha, koi kam krny ko dil nae chahta hr wqt sar ma drd jism ma drd bht

thakawat mehsos hoti ha, raat ko neand nae ati 2 ghnty pehly uth jati hon phir soya

nae jata, dil khabrata ha paseeny any lgty hain

History of Present illness

Table 2

Frequency intensity and duration of history of present illness

Complaints Frequency Intensity Duration

Irritability Everyday 9/10 6 months

Headache Frequently 8/10 3 months

Easily Fatigued Frequently 6/10 3 months

Body pain Frequently 7/10 3 months

Sleeplessness Everyday 9/10 6 months

Excessive Everyday 7/10 3 months

Worry
Rapid heart rate Frequently 6/10 2 months

Sweating Frequently 6/10 2 months

The patient is 45 years old female, the client is having irritable mood, unable to concentrate

on things, having headache and lack of concentration. Clients complain of body pain,

sleep disturbance, restlessness and being easily fatigued without any work. Client

having sleep issues, get up before 2 hours of awakening time than unable to sleep.

The client also feels rapid heart rate. The client is suffering from these symptoms

from last 6 months, The onset of illness started when her daughter turned 26, she

remained worried about her marriage as she got no suitable proposal for her. She

couldn’t share her worry with others. She started overthinking about her daughter’s

future. Due to this situation, the client started remaining stressed and worried. She felt
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fatigued most of the day and had difficulty in concentrating on her daily chores, also

she is unable to sleep well.

Background Information

Birth and Early Childhood

Ms A.A was born with normal delivery and she achieved her developmental milestones at

appropriate time. Client reported the she was very healthy, social and active in her childhood

as her parents have very good interpersonal relation.

Family History

A.A is belong to middle class family. She had two brothers and one sister. She is eldest among all.

Her father is alive and mother was died. Her father is retired teacher. She has very good

relation with her father and siblings.

Occupational History

According to Client she is a house wife so there is no occupational history of the client

Marital History

The client was 45 years old married female. She got married at the age of 18 and now has 04 son and

01 daughter . It was an arranged marriage. She is very happy and satisfy with his married life.

Sexual History

Client has very good and satisfactory relationship with her husband.

Social History

She was very social and active person before and after marriage.

Drug History

The drug history of client is insignificant.

Forensic History

There is no forensic and criminal history reported by client.

Medical History
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She has no past medical and surgical history.

Psychiatric History

According to client , there is no past psychiatric history is present and the family history of

psychiatric illness is also not present.

Pre-Morbid Personality

Before the onset of the illness, the client was a healthy person. She was very caring and loving. She

had good relationships with father and siblings. She was happy in her life without any

tension. Her marital life was also very good. She had a good appetite before the onset of the

illness.

Assessment

Informal Assessment

For the Assessment of personality and intellectual functioning the following measures were used ;

Case history interview method and mental status examination

Case History Interview

Informal assessment was carried out by semi-structured interview and behavioral observation.

Informal clinical interview was done and asked different questions regarding his education,

family, occupation, forensic history, medical history, drug history, marital status and answers

were recorded.

Mental Status Examination

The client was dressed casually according to weather, hygiene is partially maintained. She was

sitting comfortably. The client-maintained eye contact throughout the session, she was not
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hesitant while giving information about her life. She was very cooperative but during the

whole session, she looked anxious.

Formal Assessment

Formal assessment was carried out by Beck anxiety inventory BAI, Taylor manifest anxiety scale

MAS, Rotter incomplete sentences blank RISB Along with HTP & DAP.

Beck Anxiety Inventory BAI (Urdu Version)

The Beck Anxiety Inventory (BAI) was created by Arron T. Beck in 1988.. It consist of 21 item

questions, multiple choice self report inventory that is used for measuring the severity of

anxiety in adolescents and adults of age 17 and older. It takes 5 to 10 minutes to complete it.

BAI scores are classified as minimal anxiety (0 to 7), mild anxiety (8 to 15), moderate

anxiety (16 to 25), and severe anxiety (30 to 63).

Quantitative Analysis

Table 3

Raw score, range and severity of BAI

Raw Score Range Severity

39 0-63 Severe Anxiety

Qualitative Analysis
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The questionnaire was administered to the client and she took 5 minutes to to complete the

assessment. She scored 39 out of 63 which indicates that the client is suffering from severe

anxiety.

Manifest Anxiety Scale (MAS)

The Taylor Manifest Anxiety Scale is a test of anxiety as a personality trait. It was developed by

Janet Taylor in 1953 to identify the subjects who would be useful in the study of anxiety

disorders. The test is for adults but in 1956 a children form was developed. Items

1,2,3,6,9,11,14,16,23,25,30 and 38 are reversed score. There is one total scale with each item

worth 1.scores can range from 0 to 38 with higher scores indicating more severe anxiety.

Quantitative Analysis

Table 4

Raw score, range and severity of MAS.

Raw Score Range Severity

32 0-63 Moderate Anxiety

Qualitative Analysis

The client scored 32 on MAS, which indicates that the client is suffering from a moderate level of

anxiety. Based on the response of the client on 1st item, it is concluded that client is having

psychological complaints. She is having a lack of confidence as indicated by her response on

item no 3. She is in a state of confusion as indicated by her response on item no 5. She has

impaired concentration as indicated by her performance on item no 6. She is involved in

overthinking and hyper-vigilance as indicated by her response on item no 7. She has low self-

esteem as indicated by her response on item no 12. Based on the response of patient on item
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no 14, the patient is facing disturbance in sleep-wake cycle. Based on the response of the

patient on item no 34, it is concluded that she has a feeling of restlessness.

Her overall performance on MAS indicated the presence of moderate level of anxiety.

Rotter Incomplete Sentence Blank (RISB)

The Rotter Incomplete Sentence Blank (RISB) is a projective psychological test developed by Julian

B. Rotter. It comes in three forms (for different age group) and comprises 40 incomplete

sentences usually only 1-2 words long, such as “I regret….” And “mostly girls” As with other

sentence completion tests, the subject is asked to complete the test. Scores can range from 0

to 240 (40 items times 6); practically, they range from around 70 to 200 with scores of 110 to

150 being most common. A cutting score of 135 on the ISB would correctly identify adjusted

cases and the maladjusted cases.

Quantitative Analysis

Table 5

Raw score, range and severity of RISB

Raw Score Range Severity

110 200 Positive/Stressed

Qualitative Analysis

Client score 110 on RISB test which indicates client is adjusted in her environment. The client is

having positive attitude towards family. However, some of her responses on statements in

RISB indicate that she is stressed about her daughter and her marriage such as in item

9,13,21,26,28,29,37 and 39.

Draw-A-Person Test (DAP)

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The first Draw-A-Person test was created by Florence Goodenough in 1926 to initially assess

intelligence & maturity level in children through a non verbal task: drawing a person. The

Draw-A-Person Test (DAP) is a projective psychological test that is used to assess a person’s

personality, emotional functioning, and self-concept. The test is administered by a trained

psychologist who asks the test subject to draw a person. The test administrator then scores the

drawing based on a variety of criteria, the size and placement of the figure, the use of lines and

shading, the facial expression, the omission of body parts, position of the body parts, dress or

clothing, QSS (Quantitative Scoring System) this system analyzes fourteen different aspects of

drawing (such as specific body parts and clothing). Goodenough’s original scale had 46 scoring

items for each drawing with 5 bonus items for drwaing in profile. Harris’s scale had 73 items

for male figures and 71 for female figures. Most recent version used 64 scoring items for each

drawing.

Quantitative Analysis

Table 6

Raw score, range and severity of DAP.

Raw Score Range Severity

16 46 Mildly Impaired

Standard Scores are 75

Percentile Rank is 05

Age equivalent = 7-3

Grade equivalent = 2-2

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Qualitative Analysis

The client was also assessed by DAP, Her inferiority feelings and low self-esteem are shown by

drawing the person at the bottom of the page. Lines have many sharp edges which indicates

aggression. Animate/ cartoon like figure shows feelings of inadequacy and rejection. Small

eyes indicate self-absorption tendency. Emphasis on ears indicates that she is sensitive to

criticism. Omission of neck implies conflict between control and expression of emotion.

Qualitative description of the IQ level, according to the scores of the client , the IQ level is 75 i-e; raw

score of the client are 75 that indicates “mildly impaired”.

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House-Tree -Person Projective Drawing Test (HTP)

The HTP test was developed by early clinical psychologist John Buck in 1948. Buck further updated

the HTP test with psychologist Emanuel Hammer in 1969. Projective test for individuals aged

3 years and older. HTP test Takes on average 150 minutes to complete.

Qualitative Analysis

House: The drawing of house includes strong lines which shows problems of anxiety and need to

reinforce boundaries. Doors are closed that indicate guarded personality and defensiveness.

Small windows and doors indicate that the client might be shy, withdrawn suspicious or even

hostile. Little attention on roof that indicate avoidance of over-powering and frightening

fantasies. No pathways shows that client is not very social and not share feelings with others.

Tree: The drawing of tree shows lacking details which indicate withdrawal, cloud foliage tree that

shows confused thinking and not a social person. No roots of tree indicate instable

personality and sense of insecurity. Small trunk shows limited ego strength, knots like leaves

shows that part of the ego is twisted in an issue.

Person: Active same sex figure was drawn by the client that shows restlessness, changing in details

of drawing was observed that shows defense against spontaneous reactions. Use of eraser was

observed to indicate anxiety, indecision, and self-dissatisfaction. Little person indicated

feelings of inferiority complex; inaccuracy of proportion indicates pathology. A small head is

drawn that shows inadequacy, feet omitted that shows discouragement. Finger omitted that

shows guilt, drooping shoulders indicate feelings of guilt. Ear absence shows that the client is

not able to bear criticism. Shading in the drawings shows problems of anxiety.
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Case Formulation - 5P’s

Case formulation using the "5 P's" approach can provide a comprehensive understanding of the

factors contributing to an individual's difficulties. In the context of the stress surrounding

daughter's marriage, here's how the 5 P's (Presenting problem, Predisposing factors,

Precipitating factors, Perpetuating factors, and Protective factors) might be applied:

Presenting Problem: The presenting problem is generalized anxiety disorder (GAD) symptoms that

have emerged or worsened following the stress of your daughter's marriage. This may include

excessive worry, restlessness, difficulty concentrating, irritability, muscle tension, and sleep

disturbances.
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Predisposing Factors: Predisposing factors are pre-existing vulnerabilities that make an individual

more susceptible to developing GAD. Examples might include a family history of anxiety

disorders, a personal tendency toward perfectionism or high levels of anxiety, or genetic

factors that influence the regulation of stress hormones or neurotransmitters.

Precipitating Factors: Precipitating factors are specific events or stressors that trigger the onset or

exacerbation of GAD symptoms. In this case, the stress surrounding your daughter's

marriage, such as concerns about her well-being, expectations, family dynamics, or cultural

factors related to marriage, may have acted as precipitating factors.

Perpetuating Factors: Perpetuating factors are ongoing processes that maintain or worsen GAD

symptoms over time. These factors may include negative thought patterns, cognitive biases

(e.g., catastrophizing), avoidance behaviors, ineffective coping strategies, strained family

relationships, or difficulties in communicating or expressing emotions within the family.

Protective Factors: Protective factors are strengths or resources that can help individuals cope with

stress and mitigate the impact of GAD. Examples might include a supportive network of

friends or family members, access to professional help or therapy, effective coping skills,

healthy lifestyle habits, and resilience in facing challenges

Diagnosis & Plan

Tentative Diagnosis

Differential diagnosis, specifiers etc. as mentioned in DSM 5.

Generalized Anxiety Disorder (GAD), 300.02 (F41.1).

Prognosis
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The prognosis of the present client seems to be highly favorable because her problem was not severe,

and she has good insight about her problem. Moreover, the client was motivated for the

recovery, and she also has family support.

Recommendations

Cognitive Behavioral Therapy (CBT)

This form of therapy focuses on identifying and changing negative thought patterns and behaviors

associated with anxiety. CBT helps individuals develop coping strategies, challenge irrational

thoughts, and gradually face anxiety-inducing situations through exposure therapy.

i. cognitive restructuring.

Identification of negative thoughts is the first step with client than gradually drag to the way to

overcome these thoughts and enable him to reframe those thoughts and so they are positive

and productive for client.

ii. Journaling and thought records.

I asked the client to list negative thoughts that occurred to you between sessions, as well as positive

thoughts you can choose instead and keep track of the new thoughts and new behaviors you

put into practice since the last session.

Medication

Certain medications may be prescribed to manage GAD symptoms, that can help alleviate anxiety

symptoms. Medication should always be prescribed and monitored.

Relaxation Techniques
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Learning relaxation techniques can help reduce anxiety levels. Techniques such as deep breathing

exercises, progressive muscle relaxation, mindfulness meditation, and guided imagery can

promote a sense of calm and relaxation.

Lifestyle Changes

Incorporating healthy lifestyle habits can have a positive impact on anxiety levels. Regular exercise,

a balanced diet, adequate sleep, and minimizing the use of stimulants like caffeine and

nicotine can contribute to overall well-being and reduce anxiety symptoms.

Stress Management

Developing effective stress management techniques is important for individuals with GAD. This

may involve prioritizing self-care, setting realistic goals, practicing time management, and

engaging in activities that promote relaxation and enjoyment.

Family Therapy

With the help of this therapy, it will be helpful to know about client’s emotions and help to identify

the severity of these expressed emotions and provide guidance to her family members that

how to control and manage the client, so they can help her overcome the problems. Family

should be taught to provide her with love and attention.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) is another present- and problem-focused talk therapy

used to treat used with client to treat. Although like CBT, ACT is used to reduce the struggle

to control anxious thoughts or uncomfortable sensations and increase involvement in

meaningful activities that align with chosen life values because ACT may produce symptom

improvement in client.
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Management Plan

The client was 45 years old female. She belonged to a middle-class family. She was first born child

of her family. Her father is a retired teacher. Her relationship with her father is good. She was

a responsible person since her childhood. The onset of illness occurred when her daughter

turned 26 and she was unable to find a suitable proposal for her so she could not share her

worry with anyone. Due to this, she started overthinking a lot about the future of her daughter

which results in excessive worry most of the time. The client was unable to sleep properly,

and she is suffering from headache, irritation, and lack of concentration in daily chores.

People with anxiety disorders often report believing that bad things are likely to happen. People who

think they lack control over their environment appear to be at greater risk for a broad range of

anxiety disorders than people who do not have such beliefs. For example, people with anxiety

disorders report experiencing little sense of control over their surroundings (Mineka &

Zinbarg, 1998). The same happens in the present case as the client had feelings of

hopelessness consequently, she developed fears about the future.

The socio-cultural perspective theories assert that GAD arises when people are in poor social

situations, ones that may even be hazardous. This perspective asserts that people are more

likely to develop GAD in stressful situations. Thus, when a person encounters highly

threatening and stressful situations, they develop anxiety, fatigue, and disturbance in sleep

which leads to GAD. This correlates with the present case, the most threatening and stressful

situation for the client is her daughter’s marriage that is causing tension and anxiety. From a

Behavioral perspective, anxiety is learned from the environment, rather than inherited or

unconscious. Anxiety is regarded as having been classically conditioned to the external

stimuli, although the range of conditioned stimuli is broader; when people are confronted

with painful and stressful stimuli, they have no control and anxiety prevails. This proves true
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in the present case, the client is worried about her daughter marriage so, when she was not

able to avoid stressful stimuli, she eventually got anxious and developed Generalized anxiety

disorder.

Biopsychosocial Model

The biopsychosocial model is a framework that considers multiple factors contributing to the

development and maintenance of mental health conditions, including generalized anxiety

disorder (GAD). In the context of the stress surrounding daughter's marriage,

Biological Factors: Biological factors can influence the development of GAD. Genetic

predispositions, imbalances in neurotransmitters (such as serotonin or GABA), and hormonal

factors may contribute to an individual's susceptibility to anxiety disorders. Additionally,

certain medical conditions or medications can also affect anxiety levels.

Psychological Factors: Psychological factors play a crucial role in GAD. Stressful life events, such

as the marriage of a loved one, can trigger or exacerbate anxiety symptoms. Negative thought

patterns, excessive worry, perfectionism, low self-esteem, and a history of trauma or abuse

are psychological factors that may contribute to GAD. Cognitive biases, such as

catastrophizing or overgeneralizing, can also maintain anxiety symptoms.

Social Factors: Social factors, including family dynamics and relationships, can impact GAD. The

stress surrounding daughter's marriage may involve various social pressures and expectations.

Difficulties in communication, conflict within the family, or a lack of support can contribute

to anxiety. Cultural or societal factors may also play a role in shaping perceptions of marriage

and associated stressors.

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It's important to recognize that the biopsychosocial model considers interactions between these

factors. For example, biological vulnerabilities may increase the likelihood of experiencing

anxiety symptoms, while psychosocial stressors can trigger or exacerbate them.

Understanding these factors can guide treatment approaches, which may include a

combination of therapy, medication, stress management techniques, and social support to

address the multifaceted nature of GAD.

By considering the 5 P's, we can develop a more comprehensive understanding of the individual's

unique circumstances, contributing factors, and potential treatment interventions. This

understanding can guide the selection of appropriate therapeutic approaches, such as cognitive-

behavioral therapy (CBT), stress management techniques, and communication skills training,

to address the specific needs and challenges related to GAD in the context of stress about

daughter's marriage as mentioned in the present case.

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References

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

(5th edition) Washington.

Barlow, D. & Durand, V. (2011). Abnormal Psychology: An integrative approach. Nelson

Education.

Buck, J. N. (1966). The house-tree-person technique: Revised manual. Western Psychological

Services. Taylor, J. A. (19530. A personality scale of manifest anxiety. The journal of abnormal

and social psychology, 48 (2), 285.

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