Case Report: 01
Submitted to: Ma’am Zartasha
Submitted by: Laiba Ishaq
Department: Psychology
Semester: 7 th
Roll no: 35
Table of content:
Demographics of the client
Source of referral
History Of complaints
Chief Complaints
Past Medical History
Family History
School and Educational History
Job History
History Of friendship
Personal History
Degree of religiosity
Sleep
Attention
Psychosexual History
Psychosomatic History
Family Psychopathology
Personality Traits
Mental State Examination
Beck Depression Inventory
Beck anxiety Inventory
Human Figure Drawing
Rotter Incomplete Sentence Blank
Social Interaction Anxiety Scale
Tentative Diagnosis
Treatment Plan
Prognosis
Demographics of the Client:
Name: XYZ
Age: 20 years
Gender: Female
Marital Status: Single not engaged
Socioeconomic Status: High
Birth Order: 1st
Number of siblings: 2 ( brothers)
Education: BS psychology
Father status: Alive
Mother status: Alive
Father occupation: Property Dealer
Mother Occupation: House wife
Address: Village Bagra , Haripur
Religion: Islam
Cast: Pathan
Source of Referral:
The client was approached by therapist for educational purpose.
History of Complaints:
According to client she is an introvert person and not actively involved in family gatherings. She
suffered from depression since 2 years when she refused to engage her cousin. After refusal she
had to face hate of everyone in her family even her parents and she became very depressed,
she used to sleep a lot and would wake up only for eating and spend rest of her time in room
and sleeping. The client reported that she had attempted suicide before taking admission in BS,
the reason was that she was very depressed and disappointed. She felt that there was no
purpose in living anymore; she had become very hopeless. That’s why she found an excuse and
took 10 sleeping pills. Then she vomited and was taken to the hospital, where she admitted for
one day. Miss XYZ reported that after all this, her family members scolded her a lot and her
father told her that it would have been better if she had never been born than to be the kind of
daughter she was, he wished she had died at birth. She also reported that her parents used to
punish her in darkness when she was suffering from urinary incontinence.
Chief Complaints:
Fear of darkness
Overthinking
Oversleeping
Introvert
Excessive Worry
Restlessness
Fatigue
Difficulty Concentrating
Sleep Disturbances
Irritability
Past Medical History:
According to client when she was in 3rd grade she suffered from urinary incontinence which
occurs due to urinary tract infection but she recovers after 2 years due to medications.
Family History:
According to client her parents are alive and healthy. Her father is property dealer and her
mother is house wife. She have 2 siblings (brothers) and is 1st among her siblings. Her 1st
brother in grade 6 and 2nd brother in grade 1 In fundamental Sciences Academy. According to
client her parents’ relationship with one another is not like normal couples. Her father seemed
dominating and this made the client unhappy and sad.
School and Educational History:
Client reported that she started to going to school at the age of 4 years and got her primary
education from Fundamental Sciences Academy Bagra Haripur. She reported that she was an
average student from the very start of her schooling. Client also reported that if she wouldn’t
have good results her father punished her in darkness in closed room.
Job History:
Nill
History Of friendship:
Client reported that she had only one close friend but her friend betray her and now client have
no close friends.
Personal History:
Client is 19 years old single female and student of BS psychology in Govt. Girls Degree College.
Currently she is busy in preparation of her mid-term exams.
Degree of Religiosity:
Good religious inclination
Orientation:
Well oriented to time, place and person.
Sleep:
Disturbed
Attention:
Disturbed
Psychosexual History:
Her menstrual cycle started at the age of 15 years, when she was in 9th class. She did not
report any disturbance in menstrual cycle.
Psychosomatic History:
She had urinary incontinence but she recovered in 2 years due to medications.
Family Psychopathology:
No history of mental illness was reported to be present in family.
Personality Traits:
Client seemed to be dependent, anxious, fearful and emotionally dysregulated.
Mental State Examination:
Appearance: Client was younger, wearing neat and clean uniform and shoes and good hygiene.
Mood: The client mood was normal.
Behavior: She show avoidance in some queries, emotional responses, anxious and having lack
of confidence. When talking about past her hands are began to shake.
Talk: When client talk about past her voice started to shake and her tone was normal.
Perception: The client do not report any delusion and hallucinations.
Personality Traits: Client was anxious, depressed and have emotional sensitivity.
Mannerism: During interview she remained seated in the same position and did not move
much. However she described everything and started explaining herself, during which she
began to cry.
Orientation: Well oriented to time, place and person.
Memory: The client memory is good.
Concentration: The client concentration is good.
Insight: The client has partial insight about her problems.
Informal Assessment:
Following methods were used for informal assessment of client problem:
1. Interview
2. Behavioral Observation which was done by MSE
Formal Assessment:
BDI: Beck Depression Inventory
BAI: Beck Anxiety Inventory
RISB: Rotter Incomplete Sentence Blank
HFD: Human Figure Drawing
SIAS: Social Interaction Anxiety Scale
BAI:
Introduction:
The Beck Anxiety Inventory (BAI) was developed by Dr. Aaron T. Beck and his colleagues 1990. It
is a self-report questionnaire designed to measure the severity of anxiety in adults and
adolescents. The BAI consists of 21 items, each reflecting common symptoms of anxiety.
The client score on this test was 37 indicate severe anxiety.
BDI:
Introduction:
The Beck Depression Inventory (BDI) was developed by Dr. Aaron T. Beck and his colleagues in
1961. It is a widely used self-report tool designed to assess the severity of depression in
individuals. The inventory consists of 21 items that reflect various symptoms of depression.
The client score on this test was 33 which indicate severe depression.
HFD:
Introduction:
The Human Figure Drawing Test was proposed by Goodenough in 1926 and further developed
by Harris in 1963. It is a projective psychological test used primarily to assess a child's
intellectual and emotional development.
The following emotional symptoms indicators were found in HFD drawn by client.
Sensuality,regression,feeling of anxiety and inferiority, mental
retardation,immaturity,refinement,primitive aggression,fear,self-
indulgence,repression,sexual conflict,depression,repressed aggression and insecurity.
SIAS:
Introduction:
The Social Interaction Anxiety Scale (SIAS) was developed by Mattick and Clarke in 1990. It is
designed to measure anxiety specifically related to social interactions. The Social Interaction
Anxiety Scale (SIAS) consists of 20 items. Respondents rate their level of anxiety in various
social interaction scenarios, which helps to assess the severity of their social interaction anxiety.
The client score 48 on this test which indicates the severe level of social interaction
anxiety.
RISB:
Introduction:
The Rotter Incomplete Sentences Blank (RISB) was developed by Julian B. Rotter in 1950. It is a
projective psychological test designed to assess a person's thoughts, feelings, and attitudes. The
test consists of a series of 40 incomplete sentences that respondents are asked to finish,
allowing them to express their inner thoughts and emotions in a spontaneous manner.
Quantitative Scoring:
Client Score: 119 maladjusted
Clinically research values: 112
Maximum scoring: 40*6 =240
Minimum Scoring: 40*0=0
Cut off Score: 240/2=120
Cut off score= Difference between adjusted and maladjusted person.
The client score on this test is 119 which indicate that the client is maladjusted.
Qualitative Scoring:
Familial Responses:
In statement 11: A mother -------always follow her husband.
Client show negative feelings towards her mother that her mother never understand her
and always follow her father.
In statement 17: When I was child -----------my parents brutally punish me.
The client negative feelings towards her parents that they treated her harshly in her
childhood.
In statement 35: My father ----------love me a little.
The client expressed negative attitude towards her father that her father do not love much
more as he love his sons.
Social and Sexual Responses:
In statement 10: People--------hate me.
The client show negative attitude towards people that everyone in this world hate her.
In statement 19: Other people---------always talk about me.
Client shows negative attitude towards others because she has not good experience with
her closed one.
In statement 2: The happiest time-------when I met him.
Client shows strong positive emotion to a specific person that she loves a lot.
• In statement 40: Most girls --------I don’t know.
Client shows humility and avoidance to generalization.
In statement 7: Boys------loved one (Ammar).
Client shows some feelings of attraction, likeness and positive attitude toward someone
special.
General Responses:
In statement 3: I want to know --------about my future.
The client show curiosity and desire for information about personal future.
In statement 9: What annoys me--------lie.
Client shows prioritizations of personal values and integrity.
In statement 15: I cannot ----------fly.
The client shows humility.
In statement 39: My greatest worry is--------can I become successful in future.
Client shows concern for future outcomes and worry about personal success.
In statement 26: Marriage-------you may have a good friend.
Client shows positive attitude towards marriage and want a sincere friend.
In statement 40: Most girls --------I don’t know.
Client shows humility and avoidance to generalization.
Character Responses:
In statement 1: I like -----------my imaginary world.
The client shows interest in fantasies and focus on imaginations.
In statement 12: I feel -------sick.
Client shows expression of weakness.
In statement 20: I suffer ------ all the time.
Client shows discomfort and recognition of internal state.
In statement 27: I am best when --------I draw something.
Client shows positive attitude about her drawing skills.
In statement 34: I wish -------I can fly.
The client shows her world of imagination and fantasies.
In statement 37: I ------- want to become independent.
Client shows her concern about her success in future.
Tentative Diagnosis:
Treatment Plan:
Systematic Desensitization
Deep Breathing
Prognosis:
Since client is motivated and educated, having insight into her problem, so her prognosis
seems to be good.
