5 Cases Report

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Case I
Identifying Information
Name: U.A
Age: 33 years
Gender: Male
Education: Middle pass
Marital status: Married
Family System: Joint
No. of siblings: 3
Birth Order: 3
Informant: Client himself and brother
Total No. of session: 1
Date seen: 8-03 - 2022
Source and Reason of Referral
The client was referred to trainee clinical psychologist in Umeed- Nuh clinic
for the purpose of psychological assessment and management. He came with the
symptoms of shivering, hand and legs shaking, loss of energy, suicidal thoughts, low
appetite, loneliness, restlessness, sleep disturbance and digestive issue.

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Presenting Complaints
Presenting Complaints and duration as presented by the client. ‫دورانیہ‬
‫عال مات‬
‫ ماہ سے‬5 ‫تی‬CC‫تی رہ‬CC‫بہت ساری سوچیں میرے دماغ میں چل‬
‫ہیں‬
‫ ماہ سے‬6 ‫مجھے بھوک بالکل بھی نہیں لگتی دن میں کچھ‬
‫بھی کھائے بغیر رہ لیتا ہو‬
‫ ماہ سے‬5 ‫حیح سے سو نہیں پاتا مجھے نیند نہیں آتی‬CCCCCC‫ص‬
‫رات کو‬
‫ ماہ سے‬4 ‫ئلے چل رہے ہیں جس‬CC‫ارے مس‬CC‫گھر میں بہت س‬
‫کی وجہ سے میں پریشان رہتا ہوں‬
‫ماہ سے‬4 ‫بے چینی ہوتی ہے‬
‫ ماہ سے‬4 ‫اکیالپن محسوس ہوتا ہے‬
‫ ماہ سے‬5 ‫تھکاوٹ رہتی ہے‬
The client was 33 years old came for a therapy session with presenting
complaints of excessive worry, sleep disturbance, restlessness, hand and legs shaking
low appetite, loneliness, digestive problems, suicidal thoughts, low mood, negative
emotions etc. The client brother was also with him, who was much worry about his
health and somehow worried about the psychological disturbance of S. A. The
hygienic condition of client was quite good and appropriate. The client was not
hesitant at the beginning of session, and after establishing good therapeutic relation
with trainee clinical psychologist, he gradually became relaxed and comfort. At start
his response to the greetings. Session was started with open ended questions. He
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knew the purpose of coming for therapy session therefore session structure was easy
to continue and rapport was also built in an efficient and good manner.
According to behavioral observations client was so cooperative in his nature,
made the proper eye contact and his tone was not so high and he listen loudly. The
client reported he generally feel dryness in mouth, shaking and trembling of hands
and legs, excessive tension about his business, worry about future and anxious about
his wife that she has some relation with his brother. His memory was quite good. He
answered to all the questions. Client started to present the complaints of his illness
with duration; he was looking much disturbed about his problem, because of his silent
mood and pauses while during presenting the issues. He reported that his mother died
6 months ago because of high blood pressure and sugar level, and said that he didn’t
have good relationship with his father, brother and wife. He reported that his marriage
was a forced marriage and he didn’t want to get married.
During the session, client’s brother also reported about the mood and
behavioral changing of client due to the addiction and due to the death of his mother.
He reported that he didn’t speak and remained silent most of the time and always
worry about his business and his brother reported that the client has trust issues with
his wife and the clients thought that his wife has affair with his elder brother. She
reported that he remained silent all the time, worried about family members, feel
alone. Furthermore, to know more about the client’s mental state‫۔‬
Mental Status Examination (MSE) was used in which client’s emotional,
behavioral, cognitive skills were examined. In the first session it was tried to
formulate the case according to bio-psycho-social model, and which give us the basic
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information about the client problems. 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 he engaged
in business and he was worry about his business and about his marital life. He had
good bonding with his children and he had 3 children. He had good binding with his
mother and after the death of his mother he feel so lonely and sad. His development
history was started when he started to take drugs. He didn’t had good relationship
with his wife and he don’t want to leave with his wife. He had conflict with his elder
brother.
He was aware of the purpose of coming for counseling session therefore
session structure was easy to continue, the client was calm and relax and rapport was
also built in a good manner. According to behavioral examination client was
cooperative in his nature do made the proper eye contact while answering, his voice
tone was average, his Hands and legs were trembling. The client reported he generally
feel breathing problem, feelings of anxiousness, shaking of hands, and dryness of
mouth. He remembered each and every thing and his memory was quite good. He
responded well to all questions.
Client started to present the complaints of his illness with duration; he was
looking much disturbed about his problem, and he want to recover from it and he
came to the clinic because he wants to recover He reported that he didn’t not have
good relations terms with his elder brother and wife and father. He started taking
drugs after his forced marriage and business.

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Client U.A reported that he had faced a lot of problems in his teenage, he did
not complete his matric because of his interest in business. During the session, client’s
family also reported about the mood and behavioral changing of client. .
History of present illness
When the client was 14 years old he left his education and started his own
business and after sometime he was so busy with his business and always worry about
his business and when client was 28 years old he got married and his marriage was a
forced marriage and he had no interest in his wife but after 3 years of marriage he had
trust issues with his wife and he thought that his wife had physical relationship with
his brother and he had conflict with his brother and father. At the young age he started
taking the doses of bhang which trigger his emotions and become the reason of his
problem. He said that he feel anxious, tension about business, shaking of hands and
legs.
Background Information
Personal History. The client U.A Was sued to get up early in the morning for
having breakfast on time He liked to read books and he liked to invent new this and
According to the client he invented small fan and he liked to work in market and do
more investments. . The client liked to eat home food, and to the client was born
normal. He was a healthy child. He started walking at the age of 1 year and started
speaking at the age of 2 year. He was Muslim by birth. He born in a Muslim family
and likes to offer prayers and read Quran. He was good in studies and but left school
at the age of 14 and he did not complete his education and started his business
because he had interest in money and he was a master mind by nature.

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Educational History. He started going to school at the age of 4. He was a
good student and do his homework at time. He was an intelligent student and always
got 2 or 3 position in his class and he gave proper time to his study. He got 2nd
position in 7th grade and he stopped his education at the age of 14 when he was in 8th
grade he studied in a Ideal School Lahore. He left his study because he wants to
become a rich person and he was greedy.
Family history. The client belongs to a joint family system, where he was
living with his 2 brothers and one cousin, parents and. Client’s birth order was last
one , and his 2 brothers were elder to him Father of the client was 60 years old. He
was a nice man and a worker in a factory. He didn’t interfere in the matters of his
children. He is a nice man but client didn’t have good relationship with his father. The
client’s mother was a 55 years old lady, who died 6 months ago and client had good
relationships with her mother and he discuss his problems with his mother but after
her death he felt so lonely. .
He had 2 siblings 2 brother. As they are elder to him and he didn’t had good
relation with his elder brother and he said that he hate his brother and had major
issues with his brother. Client was a married man and his marriage was a force
marriage and he had not good relationship with his wife and he had 3 kids and he love
his kids and likes to spend time with his kids.
History of psychiatry illness in family. There was no psychiatry illness in
family, whereas, client reported that sugar problem is common in their family, as his
mother died because of it. His father is also suffering from blood pressure and sugar
issues. . This condition or all behavioral changes of client started at the age of 14
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when he left his studies and started taking his bhang and then at 28 he got married and
his marriage was a force marriage.
Social History. Client was good person. He had anger issues and introvert
personality why he had a bad relation with everyone. His social circle was not much
big and at school time he had friends but now he was so busy in his business that he
didn’t have enough time to spend time with his friends but at Sunday he spend his
time with his friends and then he drunk bhang almost 75 grams. His social circle is
small and he did not like to got mingle with others and spend his time lonely
Psycho-Sexual History. The client reached to the puberty at the age of 14
years and his reactions towards physiological changes was normal. He had prior
information about sexual matters. He had information about sexual matters from his
friends or movies and he also had a physical relationship with someone at his teenage
and now he didn’t have good sexual relationships with his wife.
Pre-Morbid Personality. According to the client he was a healthy person and
he didn’t have any psychological symptoms. He enjoys his normal life and spends
time with his family and friends.
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

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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. It includes the following:
 Clinical Interview
 Behavioral Observation
 Mental Status Examination
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
(Natalie Boyd). 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. He was asked about his
present complaints and history of present illness to know about the duration of the
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problem along with the predisposing, precipitating and maintaining factors. At the
time of interview, he was confused later on he starts understanding the interview. His
tone of voice was slow and no pressure of speech. 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 confused at start but gets normalized after sometime; during
session client’s behavior was also observed. The client was 33 years old and his
height was 5ft. He was wearing neat and clean clothes. He was cooperative and
friendly. He had made good eye contact during the session. His voice tone was high.
The client reported he generally feel, trembling of hands, , shivering, low blood
pressure , fast heartbeat, inappropriate guilt and hopelessness. His memory was good.
He responded all questions very 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 as cited
in Walker, Hall, & Hurst, 1990).
The client was 33 years old. He was very sad and anxious. He wore simple but
neat and clean dress. He was talking normally and in a normal voice during the
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conversation. His thought process was not so good. The client’s abstract thinking was
good. He seemed to have intact remote memory as he reported events of his early
childhood. The client’s recent past memory was good. His concentration was good
because when asked him to count backward he count very well. His orientation of
person was not satisfactory as when asked his doctor’s name he replied he did not
know. His judgment was normal as he answered I will help others when asked him if
you encounter an accident on the roadside, what will you do? The client possessed
insight about his problem. The good thing is that he wanted to get rid of all the
problems and wanted to continue his business.
memory and abstract reasoning are the most clinically relevant‫۔‬
not good. He seemed to have intact remote memory as he reported events of his early
childhood. The client’s recent past memory was not so good. His concentration was
neither good nor bad because when asked him to count backward he count very few.
His orientation of person was not satisfactory as when asked his doctor’s name he
replied he did not know. His judgment was normal as he answered I will help others
when asked him if you encounter an accident on the roadside, what will you do? The
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client possessed insight about his problem. The good thing is that he wanted to get rid
of all the problems and wanted to live a healthy and happy life.
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
 Beck Anxiety Inventory
Personality assessment
 House Tree Person
Beck Anxiety Inventory.
The Beck Anxiety Inventory (BAI) consists of 21 items with a Likert
scale ranging from 0 to 3 and raw scores ranging from 0 to 63. It was developed in
1988 and a revised manual was published in 1993 with some changes in scoring. The
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). The BAI correlates highly with the
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BDI-II indicating that although the BAI may provide useful clinical information, it is
not specific and can’t be used diagnostically.
Administration
The client took 11 minutes to complete BAI. A calm and comfortable
environment was provided for the completion of BAI.
Behavioral observation
The purpose of applying this test to the client was clarified. Therefore, the
client was relax and confident. He was giving the answers without any delay. He was
very confident. He was totally involved in the completion of test. He remained relax
at the end of completion.
Quantitative analysis
Table 1
Following scores are showing the results of BAI applied on client.
Ranges Score Result
Minimal (0—7 )
Mild (8—15 )
Moderate (16—29 )
Severe (30—63) 34 Severe anxiety
Qualitative analysis
The client obtained 34 score on anxiety scale which fall in severe category.
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Conclusion
The client got 34 scores on anxiety inventory. According to this inventory, his
scores fall on severe category, whose range is 30— 63. So the results show that, the
client is suffering from severe anxiety.
House, Tree, Person
The house-tree-person test (HTP) is a projective personality test, a type of
exam in which the test taker responds to or provides ambiguous, abstract, or
unstructured stimuli (often in the form of pictures or drawings). In the HTP, the test
taker is asked to draw houses, trees, and persons, and these drawings provide a
measure of self-perceptions and attitudes. As with other projective tests, it has flexible
and subjective administration and interpretation.
The primary purpose of the HTP is to measure aspects of a person’s
personality through interpretation of drawings and responses to questions. It is also
sometimes used as part of an assessment of brain damage or overall neurological
functioning. The HTP was developed in 1948 by Buck, and later updated in 1969 by
Buck and Hammer. Tests requiring human figure drawings were already being
utilized as projective personality tests. Buck believed that drawings of houses and
trees could also provide relevant information about the functioning of an individual’s
personality.
Administration
The client was given with a pencil and a eraser, the client was completely
guided. The client draws the drawing in 30 mints.

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Behavioral Observation
client was relaxed and confident. He was giving the answers without any delay. He
was very confident. He was totally involved in the completion of the test. He
remained too relaxed at the end of completion.
House shows sense of belongingness, nurturance and stability and the part of
self that is concerned with the body, House also indicates the client mother. The
interpretation of the client house, the client has big aims in his life, the client pays
extra to fantasies his life, but the client needs protection of somebody. The client
shows positivity. The client is distant from people due to his past. But the client has
insight willingness to accept new people and new environment.
The interpretation of the client tree, the client has less interaction with others.
According to the figure drawn, the client has a very little contact with others
especially regarding personal issues. He is influenced by the environment and tends to
avoid direct confrontation. Having anxiety with rigid and compulsive personality. He
is insecure, aggressive and has no feeling of being grounded. His ego strength and
sense of self is strong.
Person is more direct represent of self. The client is grandiosity and has
intellectual ego. The client indicates the desire to avoid perceiving the world. The
client has a denial phase of needs and has passive aggressive tendencies.
Case Formulation
The client A.M was 33 years old. After the death of his mother and doubt on
his brother that he had physical relation with his wife had developed some symptoms
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of Generalized Anxiety Disorder with prominent symptoms. Sadness, sleep
disturbance, restlessness, self-defeating, muscle tension, difficulty concentration,
headache, fast heartbeat, depressed, worry most of the time, suicidal thoughts, heart
attack thoughts. The client was brought for informal assessment which includes
Clinical interview, behavioral observation, and visual analogue; in formal assessment
standardized tests are administered.
DSM-5 checklist was used. The client was diagnosed with “Generalized
Anxiety Disorder”. As per mentioned criteria in DSM-V for GAD are restlessness,
excessive worries, muscle tension, sleep and eating problems etc. Different techniques
including Behavioral Techniques, Social Skill Training, Cognitive Behavior Therapy,
Rational Emotive Therapy was also used.
The formulation was done according to bio-psycho social model. According to
Bio model, the client was third born child as in birth order, the mother of client got
died 6 months ago due to high blood pressure and physical relation of his wife with
his brother which causes severe psychological discomfort to the client. Due to this
happening client became very silent, emotionally disturbed because he had a strong
bonding of love and attachment with his brother, but due to this he had become
sensitive in nature.
MSE was applied on him for checking his behavior and intellectual
functioning at the Time of his interview. Two other test were administered on him
were HTP to measure his personality and other test was that administered on him was
BAI, it was used to measure the level of anxiety in the client. The assessment of
personality tests revealed that he is insecure depressed and have withdrawal and
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feelings of loneliness and difficulties of interpersonal and physical environment, and
problem in concentrating on studies.
The predisposing factor is not discovered as his parents had no disorder. The
disorder is not inherited to him. People with GAD have abnormalities in the way their
brain unconsciously controls emotions. Psychological problems are often caused by
dysfunctional ways symptoms of GAD. It is thought that maladaptive assumptions
cause GAD. (Peggy A Thoits et al, 1987).
The Precipitating Factor was the client remained frustrated and unhappy due
to his father illness and death of brother. He always thinks “what will happen in
future, if his father also get die”. .(Oltsmann et al; 2003).
The perpetuating factors of the client disorder were ignorance for treatment, taboo’s
fear. As client’s brother reported that it may consider bad in our family to visit the
psychologists for any mental illness, we all believe on medical treatment only.
Environmental factor such as stressful life event appear to play an equal role in
determining the risk of anxiety disorder. ( Christoffer Johansen, Isabelle Deltour,
Kirsten Frederiksen,2013).
The session structures and further proceeding of case was done on the results
of Assessment tools, as client get score 34 on Beck Anxiety Inventory which falls in
severe category so he might fall in GAD according to the concerned criteria of DSM
V.
The treatment and management plan was done in reference to therapeutic
treatment as rapport building, psycho education, cognitive behavior therapy, cognitive
restructuring, deep breathing and Progressive

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Case Formulation Summary Table
Presenting Complaints: Assessment:
 Restlessness  Clinical Interviews

 Muscle fatigue  Behavioral
observation
 Excessive woriness
Client  Mental Status
 Low appetite
Examination (MSE)
 Loneliness
(U.A)  Beck Anxiety
 Restlessness
Inventory (BAI)
 Sleep disturbance.
Predisposing Precipitating Perpetuating Protective

Factors Factors Factors Factors
 Birth  Relationship  His own  Parents
Order problems thoughts of  Insight
 Genetics worthlessness about
. problem
Diagnosis
Generalized Anxiety
disorder (GAD)
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Diagnosis
Client is diagnosed with Generalized Anxiety disorder (GAD) with code
300.02 (F41.1) according to DSM-V.
Short Term Goals
 To educate the client about his psychological discomfort, its harmful impacts and
how he deals with his problem, psycho education will be used to educate a client
in a manner able or authentic way.
 To keep him relax under certain situation, when relaxation could not be used, we
may use deep breathing process so that he will be able to feel relax or comfortable
in distress situations
 ABC model we will be used which will help the client to understand the
relationship of irrational beliefs with emotional distress and converting negative
thoughts into positive ones and disputing to be used for counting his irrational
beliefs and changing them into rational beliefs.
 To teach the patient for his emotional outlet in appropriate manner, we will use
anxiety management techniques
 Relaxation exercise to be used to help him to overcome his muscle tension, to
decrease his anxiety level and exercise will help him not to think about negative
thoughts and he will feel relax after doing relaxation exercise
 To enhance his motivation and interest in life regarding different areas of life, it is
necessary to set goals, which may help a client to stay motivated and calm in
distress or critical conditions or situations.

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Long Term Goals
 To monitor and assess the patient’s functioning, sessions will be continued to
make his functioning properly.
 Cognitive restructuring to change client’s way of thinking.
 Encourage the patient to discuss about his problematic issues in future and thus to
sustain his recovery.
 For development of adequate coping mechanism for stress management, there is
need to improve physical functioning which may help the client to feel better
rather than before.
Proposed Management Plan
The management plan is made according to the current level or situations of
the client’s functioning. He was facing problems such as excessive worry,
restlessness, trembling, sleep disturbance etc.
 Psycho Education
 Rapport building
 Cognitive Behavior Therapy
 Relaxation exercises
 Sleep Hygiene
 Stress management skills training
Rapport building. Rapport has been described as “the relative harmony and
smoothness of relation between peoples”. It is a highly valued part of clinical practice,
It is seen as something to be done earlier in a therapy session so that the more
important therapy goals can be done or accomplished easily. The rational was of the
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rapport building to develop the trust and self-belief of the client so that in a comfort
zone he will be able to discuss or share his problems easily. Rapport building was
important to understand the client’s feelings, thoughts, behavior and problems, as the
rapport was developed with the client in the first session by introducing the client
with trainee clinical psychologist which helps him to discuss his problems more easily
by clarifying the purpose of session, and assuring him about the privacy that it will
not be discuss with anyone.
Psycho-Education. It may refers to the education which offered to
individuals with a mental health condition and their families to help empower
them ,to take care of the client and deal with their condition in an optimal or manner
able way. The Client will be psycho-educated in session about problem and illness.
Psycho education to the client will be given according to the cognitive behavioral
model of Generalized Anxiety Disorder (GAD). Individuals with generalized anxiety
disorder (GAD) report excessive worry which is difficult for them to control and
experience as distressing. Other common symptoms include restlessness, physical
arousal, trembling, difficulty concentrating, muscle tension, and poor sleep. The
Cognitive Behavioral Model of Generalized Anxiety Disorder (GAD) presented here
describes four factors which are thought to be important in the maintenance of GAD.
It has seen that the clients with anxiety, they mostly complaints about their thoughts,
fears and emotions associated with the particular event, so in therapy session if we
teach them the basic ABC-model of cognitive behavior therapy proposed by Albert
Ellis. It is that our emotions and behaviors are not directly determined by life events
or traumas which are being happening in the client’s life, but rather by the way these
events are cognitively processed and evaluated

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Cognitive Behavior Therapy. CBT was developed by Aron T. beck in 1960.
Cognitive behavioral therapy is a short-term therapy technique that can. Help people
find new ways to behave by changing their thought patterns. Engaging with CBT can
help people reduce stress, cope with complicated relationships, deal with grief, and
face many other common life challenges. Cognitive therapy is a good and time
limited therapy. In CBT the negative thoughts and beliefs of patients are changed into
positive ones. It is also called talk therapy. This therapy helps the patient to overcome
his difficulties by identifying and changing dysfunctional changes and emotional
responses. CBT is based on the concept that our thoughts, feelings, physical
sensations and actions are interconnected, and that negative thoughts and feelings can
trap you in a vicious cycle. CBT aims to help you deal with overwhelming problems
in a more positive way by breaking them down into smaller parts. 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 or collaborating your negative thoughts, to ask to ask yourself
what you are thinking and how you are feeling, when you started feeling
anxious. The therapist will help you regarding to your problems or disorder
 Challenging your negative thoughts. In the next step, your therapist will teach
you that how you can cope up with your anxiety and stress level or will listen
to your problem carefully which will help you to feel relax.
 After this step, your negative thoughts will be replaced with realistic thoughts.
Once you have identified the irrational predictions or negativity in your

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anxious thoughts, you can replace them with new thoughts that are more
positive and may leads them towards positivity or relaxation.
Relaxation Techniques. 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 anxiety
from the standpoint of the body by reducing muscle tension, improves energy, lower
blood pressure ,improves digestion ,slowing down breathing, and calming the mind.
Client was suffering from most disturbing psychological state due to his anxiety so
relaxation exercises were necessary for him.
The procedure which will be applied to the client during the session will be equal
deep breathing and Progressive Muscles Relaxation (PMR).Equal deep breathing is
one relaxation skill used in CBT. It is best used as a way to get through a tough
situation without leaving or making things worse and to get relax. For best results,
client will be asked to practice equal deep breathing thrice a day for around 8 to 10
minutes each time.
The purpose of applying this technique is used to relax the body, to improve
digestion, worry to calm the mind and emotions. Client will be taught the process of
equal deep breathing. In first session equal deep breathing procedure will done by
these steps. Sit comfortably on the floor or in a chair. Breathe in through your nose.
As you do it, count to five. Breathe out through your nose to the count of five. Repeat
several times. Practice this for about 10 minutes. This works best if you practice this
three times each day for 10 minutes each time. Try to find a regular time to practice
this each day.

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Relaxation exercises and deep breathing are two ways to help people to relax and
combat symptoms of anxiety. 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 he had pain in his
body. 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 him to differentiate between two sensations, pain and
relaxation. This technique benefits the client physically and psychologically.
Building self-esteem. People with anxiety disorder often have low self-
esteem. Feeling worthless can make the anxiety worse in many ways. It can trigger a
passive style of interacting with others and foster a fear of being judged harshly. Low
self-esteem may also be related to the impact of the anxiety disorder on your life.
These problems may include: Isolation, feelings of shame and guilt, depressed mood
and difficulties in functioning at school work or in social situations
Stress Management skills. As client reported earlier that he feel alone, have
trust issues, excessive worry and also feel stressed sometimes Firstly its reason was
identified that he had no source of catharsis, In social skills training session client
will be taught to manage the stress by following some simple tricks, as to change his
daily routine and ways of living. So he should find any source of catharsis which
make him feel relaxed and at ease. Which will be helpful to his body and mind too it
may be any kind of activities as reciting the Holy Quran, sports, yoga, cycling,
exercises, sharing with right person, or something art or music etc. . To be physically
fit and healthy client should adopt the good and healthy eating patterns as add salads,
24
meat and green vegetables and fresh juices in food, more take at least 8 glass of water
in a day.
Limitations
Limitations are as following:
 Time management was difficult for me because of work load.
 The process of getting permission from the University management was also a
bit difficult task.
 I was nervous, hesitant and a bit uncomfortable while taking the case history.
 As I am an intern so it was bit difficult to take permission from the hospital
authorities.
 Due to COVID-19 situations it was bit difficult to take permission from the
hospital authorities, in reference of SOPS and others, for dealing with clinical
patients.
 As it was a private clinical setup for drug addict patients so the concerned
authorities were much conscious to give their clients to the students.
 Administration of tests was difficult because I was doing it for the very first
time
 No informant was available throughout the assessment. Information from the
family members wasn’t obtained so it could be more helpful in identifying
more information.
Recommendations
Following recommendation could be helpful in conducting session successfully.

25
 Assessment should be carried out in an open environment which 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.
 Hospital authorities or the concerned authority of any clinical setups should
cooperate with the new interns so that they can perform and learn well by
practical exposure.
 There should be proper guidance from the universities while issuance of
permission letter.
26
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: Author.
Beck, A.T. (1961). Introduction to cognitive behavior therapy. Retrieved from:
research gate
Diagnostic, A. P. A. (2013). Statistical manual of mental disorders, (DSM-5)
Washington. DC: Author.
https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/
tools/beck-depression
Diagnostic, A. P. A. (2013). statistical manual of mental disorders,(DSM-5)
Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized
anxiety
disorder: A preliminary test of a conceptual model. Behaviour
Research and Therapy, 36(2), 215-226.
Jay, R., & Cohen, S. (2010). Psychological Testing and Assessment.
Jacobson, E. (1938). Progressive Relaxation. Chicago, University of Chicago Press.
NJ: Prentice-Hall
27
Case II
Name: H.R
Age: 37
Gender: Male
Education: Matric fail
Marital status: Married
Family System: Joint
No. of siblings: Six
Birth Order: last one
Informant: Client himself and family
Date seen: 25-02-2022
The client was referred to trainee clinical psychologist in Umeed-Nuh Clinical
for the purpose of psychological assessment and management. He came with the
symptoms of shivering, low blood pressure, fast heartbeat, inappropriate guilt and
hopelessness.
28
Presenting Complaints and duration as presented by the client.
‫دوران ی ہ‬ ‫ع المات‬
‫ہت‬ ‫ت‬
‫ماہ سے‬5 ‫ے‬
‫بہت ھکاوٹ ر ی ہ‬
‫ ماہ سے‬6 ‫ ہیں‬C‫ہاتھ کانپتے‬
‫ ماہ سے‬6 ‫دل میں کھینچ پڑتی ہے‬
‫ ماہ سے‬2 ‫ نہیں آتی‬C‫نیند‬
‫ماہ سے‬3 ‫بے چینی ہوتی ہے‬
‫ ماہ سے‬2 ‫اکیالپن محسوس ہوتا ہے‬
The client H.R was 37 years old came for an addiction and depression
treatment a with presenting complaints of, low blood pressure, fatigue, headache,
shivering and trembling of the hands, hopelessness, inappropriate guilt, repetitive
thoughts of the event, low mood, negative emotions etc. The client family was also
with him, who was much conscious about his mental health and they are also worried
about the psychological disturbance of H.R. The hygienic condition of client was neat
and clean, appropriate.
The client was little bit nervous at the beginning of session, but after
establishing a good therapeutic relation with trainee clinical psychologist, he
gradually became relaxed and feel comfortable sharing his thoughts with the
psychologist. At start he gave a good response to the greetings. Session was started
with open ended questions. He was aware of the purpose of coming for counseling
session therefore session structure was easy to continue, the client was calm and relax
and rapport was also built in a good manner. According to behavioral examination
29
client was cooperative in nature do not made the proper eye contact while answering,
his voice tone was average. His Hands were shivering and he had some lines on fore-
head.
The client reported that he generally feel breathing problem, feelings of
anxiousness, trembling of hands, low blood pressure and fast heart beat and he was
worries about his son’s future. He remembered little thing and his memory was
average. He responded well to all questions. Client started to present the complaints
of his illness with duration; he was looking much disturbed about his problem, and he
want to recover from it and he came to the clinic because he wants to recover He
reported that he didn’t not have good relations with his elder brother and mother and
his family is against his thoughts. He said that he wants to have a separate room for
kids but his family is not agree with him and he started taking drugs after his breakup
which leads him to depression.
Client H.R reported that he had faced a lot of problems in his teenage, He did
not complete his matric because of his family pressure and after his forced marriage
he started taking weed drugs.
His family reported that he remained silent all the time, and do not talk about
his problems with anyone and he only share good bond with his father and sister’s.
The developmental history of the client’s problem had started, when he went to
another country by an illegal way and after his breakup he started taking drugs. But
after some time he came back to Pakistan and then he got married and his marriage
was a forced marriage and he did not want to get married. In this way clients problem
were started but client was aware of his psychological problems and he wants to get
30
rid of these drugs and he want to go back to a normal life because he was a worry
about his son.
When the client was 17 years old he had conflicts with his family and when
client was underage he had physical relationship with someone and he had breakup
and after that he started taking weed drugs on regular basis which becomes the reason
of his addiction and depression and after that he came to Pakistan and then he got
married and his marriage was a forced marriage after his marriage he started taking
chars and had conflict with his wife. The client reported some complains that he was
not able to sleep properly and had fatigue. Heartbeat, shivering and trembling of hand
when he takes chars and had Low blood pressure.
Personal History. The client was a religious mind person and sometimes he
get up early in the morning and offer prayers and recite Quran after prayer. He was
Muslim by birth and born in a religious family. Client has introvert personality and he
doesn’t talk with someone first and didn’t get frank easily. He likes kids and he likes
to spend time with kids he also love his son and he want to recover because of his
son. He was healthy child and start walking at the age of 1and half year. He didn’t
like to spend his time with his family but he likes to spend his time with his friends
and friends are most important for him.
Educational History. The client H.R started going to school at the age of 6.
He was an intelligent student but didn’t focus much on studies and he oftener mixing
the school and went away from the school and spend time with his friends. He was a
good student at 9th class and performed well in exams and achieved a great percentage
31
but not able to complete his education due to his family conflicts and his family
wanted him to do a business and he was not able to complete his education. The client
was feeling guilty because he was not able to continue his education and left the
school at the age of 16.
living with his brother’s and sister’s and parents. Client’s birth order was last one and
his 3 brothers and 2 sisters were younger to him. Father of the client was a nice man
and he gave azan in the Mosque and he was a religious man. He is such a kind and
humble man and the client has good relation with his father. The client’s mother was
a 59 years old lady and she holds all the control of the family and client don’t have
good and friendly relationships with his mother and client’s mother was a house wife.
The client reported unsatisfied and bad relation terms with his mother.
He had 5 siblings, 3 brother and 2 sisters. As they are younger to him so he
didn’t have good relationships with his 1st elder brother since childhood because his
elder brother imposed rules on him.. Client is married and his marriage is a forced
marriage and he was not happy with his marriage life and client has one kid who was
2 years old boy and client has a good relationship with his child. Client did not report
any family illness problems but he was suffering from Depression and addiction due
to some of his personal conflicts with family members and also because of his
breakup.
History of psychiatry illness in family. There’s no psychiatric illness in her
family because client didn’t report any kind of psychological symptoms in his family.
And his informant also didn’t discuss any kind of psychiatric illness in his family.
32
Social history. The client was very polite and had humble nature. He was
replying all questions which were asked by him. He takes less interest in people and
takes time to get frank with others. He has very small friend circle and don’t spend
too much time with them. He likes to spend time alone and likes to play with kids or
spending time with them. He wants to do good things for his child and he is worried
for his bright future.
Psychosexual history. At the age of 15, the client reached to the puberty. He
knew about all psychosexual matters. Before the age of 18, he had some physical
relation with a girl. He knew all these things before the age of maturity which lead
him towards the wrong path and he did some wrong things which are not acceptable
in Islam. He had become addicted to drugs due to this and destroyed his mental health
day by day. His past and some sexual relations are the main cause of his depression
and drugs addiction.
Pre morbid personality. According to the client, before the habit of taking
drugs he was mentally or physically good. He didn’t feel any weakness in his body.
He was able to do his task at his own. But after drug addiction, he feels severe
depression, headache, body shivering. He just wants change himself and want to do
work so he can make his child a good person.
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

33
and informal psychological assessment procedure was used to assess the client’s
various areas of dysfunction aroused due to symptomatic behavior.
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. It includes the following:
Clinical Interview. An interview is a conversation which has a purpose or
goal Clinical Interview is a main tool of gathering information from client, parents,
and other informants. 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 (Natalie Boyd). 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
34
interview was conducted to understand the nature, severity and etiology of the
patient’s problem. He was asked about his present complaints and history of present
illness to know about the duration of the problem along with the predisposing,
precipitating and maintaining factors. At the time of interview, he was confused later
on he starts understanding the interview. His tone of voice was slow and no pressure
of speech. Overall, Good rapport was established.
Behavioral Observation. Behavioral Observation is a systematic way of
recording the observable responses of behavior. 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 confused
at start but gets normalized after sometime; during session client’s behavior was also
observed. The client was 37years old and his height was 5ft. He was wearing neat and
clean clothes. He was cooperative and friendly. He had made weak eye contact during
the session. His voice tone was average. The client reported he generally feel,
trembling of hands, , shivering, low blood pressure , fast heartbeat, inappropriate guilt
and hopelessness. His memory was quite fair. He responded all questions well.
memory and abstract reasoning are the most clinically relevant.
35
not good. He seemed to have intact remote memory as he reported events of his early
childhood. The client’s recent past memory was not so good. His concentration was
neither good nor bad because when asked him to count backward he count very few.
His orientation of person was not satisfactory as when asked his doctor’s name he
replied he did not know.
His judgment was normal as he answered I will help others when asked him if
you encounter an accident on the roadside, what will you do? The client possessed
insight about his problem. The good thing is that he wanted to get rid of all the
problems and wanted to live a healthy and happy life.
by;
 Beck Depression Inventory (BDI)
Personality Test
36
 House Tree Person (HTP)
Beck Depression Inventory (BDI)
The Beck Depression Inventory (BDI) is a 21-item, self-rated scale that
evaluates key symptoms of depression including mood, pessimism, sense of failure,
self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas,
crying, irritability, social withdrawal, indecisiveness, body image change, work
difficulty, insomnia, fatigability, loss of appetite, weight loss, somatic preoccupation,
and loss of libido (Beck & Steer, 1993; Beck, Steer & Garbing, 1988).
Administration:
Client was given 15 minutes to complete the BAI. A calm and comfortable was
provided to the client so that she will not feel discomfort to complete BAL. Each item
is rated on a 4-point scale ranging from 0 to 3. The maximum total score is 63.
Special attention must be paid to the correct scoring of the Changes in Sleeping
Pattern (Item 16) and Changes in Appetite (Item 18) items.
Behavioral observation:
client was relax and confident. She was giving the answers without any delay. She
was very confident. She was totally involved in the completion of test. She remained
relax at the end of completion.
Quantitative analysis:
Table 2
Table is showing the items, cut-off score, obtained score and category of disorder.
Ranges Items Obtained Range Category
scores
37
Minimal 0-13
Mild 14-19
Moderate 21 30 20-28 Moderate
Depression
Severe 35-63
The client obtained scores is 30 on manifest depression scale which fall in
moderate depression category and according to DSM-V it’s come in Major depressive
disorder.
Conclusion
The client got 30 scores on BDI. According to scale, his scores fall on
moderate category, whose range is 16-38. So the results show that, the client is
suffering from Moderate Depression.
House, Tree, Person

38
personality.
Administration
guided. The client draw the drawings in 30 mints.
show positivity. The client is distant from people due to his past. But the client has
39
is insecure, aggressive and have no feeling of being grounded. His ego strength and
Case formulation:
The client H.R who is 37 year old referred to trainee psychologist with
complains of low blood pressure, fast heartbeat, and sleep less. He is also addicted to
drug due to some family or personal issues. He was sent to abroad forceful by his
family at the age of 17. He is totally unknown that how to survive in another country
without family. He start’s using drugs like’s weeds, chars. When he came back to
Pakistan his family forced married him with his cousin. He miss-behave with her all
the time. The client wants to change himself because now he is having one child. He
wants to change himself for his child. He is referred to Umeed-e- Nuh clinic for
treatment. The client is Muslim by birth. He loves to read Islamic books. He prays 5
times a day. The history I collect by the client shows that he is having conflicts with
his family. His relationship with his elder brother is not good. His father also ordered
him. Because he is the last child of his family. He feels that nobody care about him.
The client behaviour shows that he is not happy in his joint family. He is introvert
because he don’t easily frank with someone. He said that he believe in friendship bit
the age he leave the school and not even contact with my friends. He is a drug using
Client. The client doesn’t even talk about his future.

40
DSM-5 checklist was used. The client was diagnosed with “Major Depressive
Disorder”. As per mentioned criteria in DSM-V for Depressive disorders are
hopelessness, muscle tension, sleep and eating problems etc.
Bio model, the client was last born child as in birth order, client had conflict with his
elder brother, relationship issues, and forced marriage. Due to this happening client
became very silent and emotionally disturbed.
functioning at the time of his interview. One other test was administered on him was
BDI to measure the depression, anxiety and stress level. House tree person (HTP)
personality test was also administered to check the personality of the client which
revealed that he is insecure depressed and have withdrawal and feelings of guilt and
hopelessness.
The predisposing factor is not discovered as his parents had no disorder. The
disorder is not inherited to him. People with depression have abnormalities in the way
their brain unconsciously controls emotions. Psychological problems are often caused
by dysfunctional ways symptoms of depression. )Kirsten Frederiksen,2013).
The precipitating factors are the places where the client used to go when he
was in relationship. His medical illness was act like his perpetuating factor and his
thoughts of worthlessness. He always thinks “what will happen in future, if my child
also started to take drugs”. .(Oltsmann et al; 2003).
The perpetuating factors of the client disorder were ignorance for treatment,
taboo’s fear. Environmental factor such as stressful life event appear to play an equal
41
role in determining the risk of depressive disorder.) Christoffer Johansen, Isabelle
Deltour, Kirsten Frederiksen, 2013).
of assessment tools, as client get score 25 on depression Scale which fall in severe
category so he might fall in depression according to the concerned criteria of DSM-V.
Similarly client scored 13 on anxiety scale which fall in moderate category so he
might fall in moderate anxiety according to the concerned criteria of DSM-V.
Similarly client scored 27 on stress scale which fall in severe category so he might fall
in severe stress according to the concerned criteria of DSM V.
treatment as rapport building, psycho education, cognitive behavior therapy, cognitive
restructuring, deep breathing and Progressive Muscle Relaxation (PMR).

42
 depressed mood  Clinical Interviews

 hypersomnia  Behavioral
observation
 Fatigue/ loss of
Client energy  Mental Status
Examination (MSE)
 Guilt feelings
(H.R)  House Tree Person
 feelings of
(HTP)
worthlessness
 Beck Depression
 low concentration
Scale (BDI)
and suicidal
thoughts
Predisposing Precipitating Perpetuating Protective

Factors Factors Factors Factors
 Birth  Relationship  His own  Parents
Order thoughts of  Insight
Problems
 Genetics worthlessnes about
s. problem
Diagnosis
Major Depressive Disorder
(DSM-5)
43
Diagnosis
Client might be diagnosed with Major Depressive Disorder with code F32 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 his problem. .
 Deep breathing exercise to be used to keep him relaxes under certain situations
and conditions.
 Mastery and Pleasure chart will be used to know about the disturbance level of
the client.
 Relaxation exercises will be used which help client to sleep properly
 Goal settings to be done to enhance his 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.
• Mastery and pleasure chart will be used continuously.
• Encourage the patient to have discuss his problematic issues in future and
thus to sustain his recovery.
• Improve physical functioning due to development of adequate coping
mechanism for stress management.

44
• Family therapy session will be arranged to assist the family member’s
increase their positive support for the client and it help to resolve the
conflicts.
Proposed Management plan
The management plan was made according to the current level of the client’s
functioning. Currently he had problems as shivering, low blood pressure, fast
heartbeat, inappropriate guilt and hopelessness.
 Behavioral Activation
smoothness of relation between peoples”. It is a highly valued part of clinical practice
rapport 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 him
about the privacy and confidentiality of the problem.
Psycho Education. Psycho education refers to the education that is given to
individuals with a mental health condition and their families to help empower them
45
and deal with their condition in an optimal way. In session the client will be psycho
educated about the issue and illness. For an effective treatment it is needed to psycho
educate the client to some extent .This will gradually reduce client's stress by
developing acceptance of the problem .Psycho education to this client was given
according to the cognitive behavioral model of Major Depressive Disorder (MDD)
Individuals with major depressive disorder report sleep problems, fatigue,
feelings of worthlessness and guilt which affect their normal life. Other common
symptoms include restlessness, weight loss, loss in appetite and indecisiveness. So on
the basis of these symptoms it is important to teach them the basic ABC-model of
cognitive behavior therapy (CBT) proposed by Albert Ellis. The basic idea behind the
ABC model is that “external events (A) do not cause emotions (C), but beliefs (B)
and, in particular, irrational beliefs (IB) do” (
Another way to think about it is that “our emotions and behaviors (C:
Consequences) are not directly determined by life events (A: Activating Events), but
rather by the way these events are cognitively processed and evaluated.
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 helps the patient to overcome
his 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:
46
 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.
The ABC model is a technique used in cognitive behavioral therapy (CBT), a form
of psychotherapy that helps individuals reshape their negative thoughts and feelings in
a positive way. CBT trains individuals to be more aware of how their thoughts and
feelings affect their behavior, and the ABC model is used in this restructuring to help
patients develop healthier responses.
Behavioral activation. Behavioral activation is designed to increase our contact
with positively rewarding activities. Approach to mental health that involves someone
using behaviors to influence their emotional state. It is often a part of cognitive
behavioral therapy (CBT), but it can also be a standalone treatment particularly when
we notice ourselves feeling anxious or depressed, we should work on an activity. This
teaches us that our behavior can affect our mood and according to our mood we may
act in the situations. We may feel better or happy when we do activities which help us
to stay connected to others.
Client helps us to increase engagement in adaptive activities, decreases
engagement in those activities that maintain depression or increase the risk of

47
depression. It solves problems that limit access to reward or that maintain or increase
aversive control. Behavioral activation helps us understand how behaviors influence
emotions, just like cognitive work helps us understand the connection between
thoughts and emotions.
Limitations
 Time period for completing the case was very short.
 As it was a private hospital setup for psychotic patients so the concerned
authorities were much conscious to give their clients to trainee clinical
psychologist, two to three days were just spent to clarify the purpose of case
reports and all.
 Administration of tests was difficult due to continuous interruption by other
peoples in ward and paramedical staff.
 Only one informant was available throughout the assessment. Information
from other family members could not be collected which could helpful in
identifying more.
Recommendations
 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. ∙
Hospital authorities or the concerned authority of any clinical setups should

48
cooperate with the trainee clinical psychologists so that they can perform and
learn well by practical exposure.
 There should be proper guidance from the universities while issuance of
permission letter. Hospital authority should cooperate with proper guidelines
about the premises use, and session’s basics.

49
References
Alexander, S. P., Fabbro, D., Kelly, E., Marrion, N. V., Peters, J. A., Faccenda, E.,&
Davies, J. A. (2017). The concise guide to PHARMACOLOGY 2017/18: Enzymes.
British journal of pharmacology, 174, S272-S359.
https://www.psycom.net/depression-definition-dsm-5-diagnostic-criteria/
50
Case III
Name: M.B
Age: 33
Gender: Male
Education: Intermediate passed
Marital status: Unmarried
Family System: Separate
No. of siblings: Five
Birth Order: Last one
Informant: Client and his family
Date seen: 18-03-2022
The client was referred to Umeed-e-nuh Clinical due to his family choices
for the purpose of psychological assessment, diagnosis and management. He came
with the symptoms of shivering, high blood pressure, sadness, loneliness, rapid
heartbeat, restlessness, exhaustion, dizziness.

51
‫دورانیہ‬ -‫عال مات‬
‫ ماہ سے‬6 - ‫چ ڑچ ڑا پ ن رہ ت ا ہ ۓ‬
‫ ماہ سے‬6 -‫سردرد رھتا ہے‬
‫ ماہ سے‬11 .‫ایک خیال بار بار آتا ہے۔‬
‫ ماہ سے‬6 -‫کسی کام میں دل نہیں لگتا‬
‫ماہ سے‬2 ‫غصہ بہت آتا ہے۔‬
The client M.B was 33 years old who came for the treatment of severe Stress
and came with the presenting complaints of high blood pressure, fatigue, headache,
shivering and trembling of the legs, dizziness, and loneliness, repetitive thoughts of
the taking drugs or restlessness. He feels craving for drugs all the day because drugs
make him feel happy. The client’s family was also worried about him that when he
will leave his bad habit of taking drugs, they were much conscious about his mental
health, future and marriage of M.B.
The client’s father and mother had died and after their death he became too
much addictive to drugs, before the death of his parents, he took drugs in less amount
but after their death he started taking drugs in excessive amount to keep his self-calm
and relax. The hygienic condition of client was neat and clean but he doesn’t like to
share his personal information with anyone. The client was little bit nervous at the
beginning of session, but after establishing a good therapeutic relation with trainee
clinical psychologist, he became little bit relaxed, he was introvert and didn’t tell too
much about his past personal information.

52
I started session with open ended questions. He came here by the reference of
his sisters and brothers. The client was not so cooperative in nature and he did not
made the proper eye contact while answering, his voice tone was low, his hands were
shivering and he was replying very slowly, it seemed that he does not want to share
anything which were being asked by him. The client told me that he often feel
breathing problem, feelings of anxiousness, trembling of hands, high blood pressure,
loneliness, anger issues and rapid heartbeat and he was worried about his marriage
He has no good relationship with his friends or brothers but somehow he has
good relationships with his sisters. He talks to everyone angrily and doesn’t like if
anyone interferes in his matters. Client started to present the complaints of his illness
with duration; he was looking much disturbed about his problem, he want to get rid of
his problem that’s why he came to the clinic because he wants to leaves his bad habit.
In the past, he had relationship with his girlfriend and she left her and the client
started taking drugs due to his breakup.
The client M.B reported that he had faced a lot of problems in his teenage, he
did not complete his studies because of his family pressure and their family forced
him to start business. The developmental history of the client’s problem started when
he went to another country by the reference of his friend and after his breakup he
started taking drugs and he doesn’t like to do any business and just likes to takes
drugs all the time. In this way, client’s problem started but now he wants to get rid of
taking drugs and he wants to spend a normal or good life or to get married as soon as
possible.

53
When the client was 15 years old he had conflicts with his family and at the
age of 18 he had relationship with his girlfriend, who left him and after that he started
taking weed drugs on regular basis which leads him to drug addiction and after
coming back to Pakistan, he started taking drugs in an excessive amount. At first
time, he took drugs with his friends, he tried it as a fashion but now he is too much
addicted that it’s very difficult for him to leave it. The client reported some complains
that he is not able to sleep properly and feels fatigue, restlessness and unhealthy
sleeping habits.
Personal History. The client was a religious minded person and sometimes he
gets up early in the morning and offer prayers and recite Quran after prayer. He was
Muslim by birth and born in a religious family. The client was introvert and he
doesn’t like to talk with anyone at first time and doesn’t get frank easily. He likes
only drugs and doesn’t like to spend his time with anyone. Even though, his friends
had also left him due to his habit of taking drugs. He is just fed up from his life and
wants to get married.
Educational History. The client M.B went to school at the age of 4. He was
an intelligent student but he left his studies due to his family pressure. He was a good
student at 8th class and performed well in exams and got highest percentage but not
able to complete his education due to his family conflicts, his family wanted that he
should start his own business and he was not able to continue his studies after
intermediate.
Family history. The client belongs to a separate family system, after his
parent’s death he lived with his sister whom with she has good relationships. He often
54
took money from his sister for taking the drugs. The clients was the youngest one in
his family and the father of the client was a nice and religious man. He had no good
relations with his family. The client’s mother was a 70 years old, and has sugar and
blood pressure problems and she had all the control of the family. The client reported
unsatisfied and bad relation terms with his mother. He hates his family because they
don’t prefer the choices of client, he also told that he did not have good relationships
with his t elder brother since childhood because his elder brother imposed rules on
him and he was suffering from stress and addiction due to some of his personal
conflicts with family members and also because of his breakup.
History of psychiatry and illness in family. The client told that there was
no psychiatry illness in their family, but his mother had sugar problem and blood
pressure and father may have some issues of hepatitis. But the client may feel stress
due to addiction of drugs and marriage issues. He feels so helpless and sad. He takes
tension that when he will leave all the bad habits and become a good man.
Social history. The client was very polite and had introvert nature. He was
replying slowly to the questions which were asked by him. He takes less interest in
people and takes time to get frank with others. He had very small friend circle, which
also ignores him nowadays. He likes to spend time alone. The client feels no interest
in anyone, likes to stay alone and to takes drugs.
Psychosexual history. At the age of 15, the client reached to the puberty. He
knew about all psychosexual matters. But he had not any physical relationship with
anyone but he had relationship on the call with his girlfriend. He had become addicted
to drugs due to his breakup and conflicts with brother and destroyed his mental health
55
day by day. His past and some bad relations are the main cause of his stress and drugs
addiction.
Pre morbid personality. According to the client, before the habit of taking
drugs he was mentally or physically good. He didn’t feel any weakness in his body.
He was able to do his task at his own. But after drug addiction, he feels stress,
headache, body shivering or restlessness. He doesn’t feel good or relax or now he is
totally fed up from his life and don’t want to make new friends due to his bad habits
of drugs.
“A psychological assessment is gathering information to evaluate a person’s
behavior, character, strengths, and needs for the purpose of diagnosing, setting goals,
and recommending treatment,” explains Wendy Pitts, LCSW-C, a clinical social
worker in Maryland. “While tests can be used as a part of gathering information for
an assessment, the tests themselves are not the assessment.
• Informal assessment
• Formal assessment
Informal assessment of individuals with stress involves the collection of
information about the individual, interpreting that information and applying it in a
systematic manner, the purpose of which is to better understand the individual’s
abilities. Although the overall goals of informal and formal assessment are similar,
56
they differ in the use of the information collected, the manner in which the
information is collected, and the type of information collected.
The specific purpose of informal assessment is usually to use the information
collected in order to set goals, identify intervention strategies, and measure
intervention outcomes. In formal assessments, information is collected through the
use of standardized, norm-referenced tests, whereas in informal assessment,
information is based on careful observation of behaviors by the examiner.
It includes the following:
Clinical Interview. A clinical interview is a tool that helps physicians,
psychologists, and researchers make an accurate diagnosis of a variety of mental
illnesses, such as stress. Clinical Interview is a main tool of gathering information
from client, parents, and other informants. 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. At the time of interview, he was confused later on he starts
understanding the interview. His tone of voice was slow and no pressure of speech.
57
Behavioral observation is one of several measurement approaches available
to investigators engaged in quantitative behavioral research. It is often the method of
choice when nonverbal organisms are studied (or nonverbal behavior generally);
when more natural, spontaneous, real-world behavior is of interest; and when
processes and not outcomes are the focus (e.g., questions of contingency). Compared
with other approaches, it is often labor-intensive and time-consuming.
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 confused at start but gets
normalized after sometime; during session client’s behavior was also observed. The
client was 33 years old and his height was 5ft. He was wearing neat and clean clothes.
He had made not so good eye contact during the session. His voice tone was low. The
client reported he generally feels trembling of hands, shivering, low blood pressure ,
fast heartbeat, inappropriate guilt and hopelessness. He was replying very slowly to
the questions which were asked by him.
Mental Status Examination (MSE). Mental status examination (MSE) is
an important diagnostic tool in both neurological and psychiatric practice. MSE is
used to describe a patient’s mental state and behaviors, both quantitatively and
qualitatively, at a specific point in time. The main components of an MSE are
appearance and behavior, mood and affect, speech, Thought process and content,
perceptual disturbances, sensorium and cognition, and insight and judgment.
The clinician conducting an MSE collects data by observing the interviewed
individual’s behavior and asking specific questions. The findings of the MSE
summarize the results of a psychiatric examination on a comprehensive, cross-

58
sectional level. When integrated with the interviewee’s biographical information and
psychiatric history, MSE findings form the basis for diagnostic and therapeutic
decisions. A thorough MSE also provides essential information for establishing a
diagnosis according to DSM-5 criteria.
When conducting the MSE or interpreting MSE findings, it is important to
consider the cultural background of both the clinician conducting the MSE and the
interview because behavioral patterns vary significantly across cultures (e.g., nodding
your head as a sign of approval in some countries might signify disagreement in
others). The client was 33 years old. He was very sad and anxious. He was talking
normally and in a normal voice during the conversation. His thought process was not
so good.
He did not share too much about his past information or traumas. He seemed
to have intact remote memory as he reported events of his early childhood. The
orientation of person was not satisfactory as when asked his doctor’s name he replied
he did not know. Then, I asked him the days of week, he replied but did not tell the
correct order of days of week. But, the good thing is that he wanted to get rid of all
the problems and wants to become a good person in his life.

59
by;
 Depression Stress Scale (DASS)
 House Tree Person
Depression Anxiety Stress Scale (DASS)
The Depression Anxiety Stress Scale (DASS) is a widely used instrument
developed by Lovibond and Lovibond (1995b) to measure Stress, depression, and
stress. The DASS was constructed not merely as another set of scales to measure
conventionally defined emotional states, but to further the process of defining,
understanding, and measuring the ubiquitous and clinically significant emotional
states usually described as depression, and stress. The DASS should thus meet the
requirements of both researchers and scientist-professional clinicians.
Each of the three DASS scales contains 14 items, divided into subscales of 2-5
60
items with similar content. The Depression scale assesses dysphoria, hopelessness,
devaluation of life, self-deprecation, and lack of interest/involvement, anhedonia, and
inertia. The Stress scale assesses autonomic arousal, skeletal muscle effects,
situational Stress, and subjective experience of anxious affect. The Stress scale is
sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing,
nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.
Subjects are asked to use 4-point severity/frequency scales to rate the extent to which
they have experienced each state over the past week. Scores for Depression, Stress
and anxiety are calculated by summing the scores for the relevant items.
Administration
The client took 14 minutes to complete DASS. A calm and comfortable
environment was provided for the completion of DASS

61
Table 1
Following scores are showing the results of DASS applied on client.
Depression (D) Stress (A) Stress (S)
Ranges Score Ranges Score Ranges Score
Normal (0—9) (0—7) (0—14)
Mild (10—13) (8—9) (15—18)
Moderate (14—20) (10—14) 22 (19—25)
Severe (21—27) 29 (15—19) (26—33) 36
Extremely 28+ 20+ 34+
severe
The client obtained 29 score on depression scale which fall in extremely
severe category. Client obtained 22 score on Stress scale which fall in extremely
severe category. Client obtained 36 score on stress scale which also fall in extremely
severe category.
Conclusion
The client got 29 scores on depression scale. According to scale, his scores fall
on extremely severe category, whose range is 28+. So the results show that, the client
is suffering from extremely severe depression.
The client got 22 scores on Stress scale. According to scale, his scores fall on
extremely severe category, whose range is 20+. So the results show that, the client is
suffering from extremely severe Stress.

62
The client got 36 scores on stress scale. According to scale, his scores
fall on extremely severe category, whose range is 34+. So the results show that, the
client is suffering from extremely severe stress.
House, Tree, Person
personality.
Administration
guided. The client draws the drawings in 30 mints.
63
avoid direct confrontation. Having Stress with rigid and compulsive personality. He is
insecure, aggressive and have no feeling of being grounded. His ego strength and
Person is more direct represent of self. The client is grandiosity and has intellectual
ego. The client indicates the desire to avoid perceiving the world. The client has a
denial phase of needs and has passive aggressive tendencies.
Case formulation
The client M.B was 33 years old. After his parents death or breakup , he had
developed some symptoms of stress i.e.: loneliness , sleep disturbance, restlessness,
self-defeating, muscle tension, difficulty concentration, headache, rapid heartbeat,
depressed, worry most of the time, suicidal thoughts, . The client was brought for
64
informal assessment which includes clinical interview, behavioral observation; in
formal assessment standardized tests are administered.
DSM-5 checklist was used. The client was diagnosed with “stress”. As criteria
is mentioned in DSM-V for stress are restlessness, excessive worries, muscle tension,
sleep and eating problems etc. Different techniques including Behavioral Techniques,
decision making, cognitive Behavior Therapy, activity schedule, time management
was also used.
Bio model, the client was last child as in birth order, he had conflicts with the
youngest brother, he was emotionally disturbed because he had a strong bonding of
love and attachment with his girlfriend and she left him, but due to this he had
become sensitive in nature and became addicted to drugs.
functioning at the time of his interview. Two other test were administered on him
were DASS to measure the level of adjustment and stress and other test was that
administered on him was HTP. The assessment of the tests revealed that he is
insecure, depressed, feel stress and have feelings of loneliness and difficulties of
interpersonal and physical environment, and problem in concentrating on studies.
People with stress have abnormalities in the way, their brain unconsciously controls
emotions.
The Precipitating Factor was, the client remained frustrated and unhappy due
to his parent’s death and breakup. Most of the people face stressful events such as
extreme physical injuries, illness or death fear rejection. He was very tired from his
life and had bad relationships with his friends and brothers. Early parental death is
65
one of the most stressful childhood life events and may influence subsequent
psychological health. We investigated the association between early parental loss and
risk of hospitalization for an affective disorder in adulthood. ( Christoffer Johansen,
Isabelle Deltour, Kirsten Frederiksen,2013).
The perpetuating factor was unstable home environment, dependence on
brother or single marital status. The group members at higher risk of disturbance
perceive less control over their lives, these perceptions neither singly nor jointly with
event exposure, explain gender or marital status differences in psychological distress
or in vulnerability to negative events in general. In light of these findings, the utilities
of a “common stress” and a “unique stress” approach for explaining status differences
in symptoms are contrasted. (Peggy A Thoits et al, 1987).
The protective factor was psychotherapy and family support. Using practice or
psychotherapy, the practitioner can help the client to assess issues or problems,
understand their concerns, develop a range of possible solutions and implement
strategies. (Stephen Palmer et al, 2007). The treatment and management plan was
done in reference to therapeutic treatment as rapport building, psycho education,
cognitive behavior therapy, decision making, and time management. He might fall in
stress according to concerned criteria of DSM-V.

66

 Shivering  Clinical Interviews
 High blood  Behavioral
pressure observation
 Sadness  Mental Status
Client  Loneliness Examination (MSE)
 Rapid heartbeat  Depression anxiety
(M.B)  Restlessness stress scale (DASS)
 Exhaustion  House Tree person
Predisposing Precipitating Perpetuating Protective Factors

Factors Factors Factors  Family
 By Birth  Parents  Negative support
death coping style  Physiotherapy
 Family
history  Unemploy  Unstable  Medication
ment home
environment
 Single
marital status
 Dependent on
brother
Diagnosis
Stress disorder
(DSM-5)
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Diagnosis:
Client might be diagnosed with stress with code Z73. 3 according to DSM-V
Short Term Goals
 To educate the client about his psychological discomfort, its harmful impacts and
how he deals with his problem, psycho education will be used to educate a client
in a manner able or authentic way
 To keep him relax under certain situation , we may use deep breathing process so
that he will be able to feel relax or comfortable in distress situations
 To teach the patient for his emotional outlet in appropriate manner, we will use
stress management techniques
 Relaxation exercise to be used to help him to overcome his muscle tension, to
decrease his stress level and exercise will help him not to think about negative
thoughts and he will feel relax after doing relaxation exercise
 To enhance his motivation and interest in life regarding different areas of life, it is
necessary to set goals, which may help a client to stay motivated and calm in
distress or critical conditions or situations
Long Term Goals
make his functioning properly
 Cognitive restructuring to change client’s way of thinking.
 Encourage the patient to discuss about his problematic issues in future and thus to
sustain his recovery.

68
 For development of adequate coping mechanism for stress management, there is
need to improve physical functioning which may help the client to feel better
rather than before
Restlessness, trembling, sleep disturbance etc.
 Time management
 Deep breathing
 Decisions making
smoothness of relation between peoples”. It is a highly valued part of clinical practice,
important therapy goals can be done or accomplished easily. Build rapport when you
develop mutual trust, friendship and affinity with someone. Building rapport can be
incredibly beneficial to your career – it helps you to establish good interpersonal
relationships the rational was of the rapport building to develop the trust and self-
belief of the client so that in a comfort zone he will be able to discuss or share his
problems easily.
Rapport building was important to understand the client’s feelings, thoughts,
behavior and problems, as the rapport was developed with the client in the first
69
session by introducing the client with trainee clinical psychologist which helps him to
discuss his problems more easily by clarifying the purpose of session, and assuring
him about the privacy that it will not be discuss with anyone.
Psycho-Education. It may refers to the education which offered to
individuals with a mental health condition and their families to help empower
them ,to take care of the client and deal with their condition in an optimal or manner
able way. The Client will be psycho-educated in session about problem and illness.
Psycho education to the client will be given to the client. Psychoeducation helps
patients improve their self-esteem, develop skills and strategies to control their mental
well-being provides them with emotional support and teaches them problem-solving
skills. Other common symptoms include restlessness, physical arousal, trembling,
difficulty concentrating, muscle tension, and poor sleep. Psychoeducation is
increasingly used following trauma. The term covers the provision of information
about the nature of stress, posttraumatic and other symptoms, and what to do about
them. The provision of Psychoeducation can also occur before possible exposure to
stressful situations or, alternatively, after exposure. The intention of both is to
ameliorate or mitigate the effects of exposure to extreme situations. Educational
information can be imparted in a number of ways and can also form part of what has
been termed psychological first aid. (Neil Greenberg, Mark Earn Shaw, John Shapley,
Jamie Hacker Hughes, 2008)
Cognitive Behavior Therapy. Cognitive behavioral therapy is a short-term
therapy technique. It can people find new ways to behave by changing their thought
patterns. Engaging with CBT can help people reduce stress, cope with complicated
relationships, deal with grief, and face many other common life challenges. Cognitive
70
therapy is a good and time limited therapy. Over the past 50 years, cognitive-
behavioral therapies (CBT) have become effective mainstream psychosocial
treatments for many emotional and behavioral problems.
Behavior therapy approaches were first developed in the 1950s when
experimentally based principles of behavior were applied to the modification of
maladaptive human behavior (e.g , Wolpe, 1958; Eysenck, 1966). In the 1970s,
cognitive processes were also recognized as an important domain of psychological
distress (Bandura, 1969). As a result, cognitive therapy techniques were developed
and eventually integrated with behavioral approaches to form cognitive-behavioral
treatments for a variety of psychological disorders.
In CBT the negative thoughts and beliefs of patients are changed into positive ones. It
is also called talk therapy. This therapy helps the patient to overcome his difficulties
by identifying and changing dysfunctional changes and emotional responses.
CBT is based on the concept that our thoughts, feelings, physical sensations
and actions are interconnected, and that negative thoughts and feelings can trap you in
a vicious cycle. CBT aims to help you deal with overwhelming problems in a more
positive way by breaking them down into smaller parts. It is process in which you
challenge the negative thinking patterns that contribute to your anxiety, replacing
them with more positive, realistic thoughts.
 Identifying or collaborating your negative thoughts, to ask to ask yourself what
you are thinking and how you are feeling, when you started feeling stress . The
therapist will help you regarding to your problems or disorder

71
 Challenging your negative thoughts. In the next step, your therapist will teach you
that how you can cope up with your stress level or will listen to your problem
carefully which will help you to feel relax.
Once you have identified the irrational predictions or negativity in your stressful
thoughts, you can replace them with new thoughts that are more positive and may
leads them towards positivity or relaxation.
Relaxation Technique. 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 stress
from the standpoint of the body by reducing muscle tension, improves energy, lower
blood pressure ,improves digestion ,slowing down breathing, and calming the mind.
Client was suffering from most disturbing psychological state due to his stress
so relaxation exercises were necessary for him. The efficacy of meditation-relaxation
techniques has been widely researched in the laboratory, but their effectiveness for
management of stress in organizational settings is still relatively unexplored. The
present study compared relaxation and control conditions as part of a program of
stress-reduction. (Patricia Carrington, Gilbeart H Collings Jr, Herbert Benson, Harry
Robinson, 1980)The procedure which will be applied to the client during the session
will be equal deep breathing and Progressive Muscles Relaxation (PMR).
Equal deep breathing is one relaxation skill used in CBT. It is best used as a
way to get through a tough situation without leaving or making things worse and to
get relax. For best results, client will be asked to practice equal deep breathing thrice a
day for around 8 to 10 minutes each time. The purpose of applying this technique is
72
used to relax the body, to improve digestion, worry to calm the mind and emotions.
Client will be taught the process of equal deep breathing. In first session equal
deep breathing procedure will done by these steps. Sit comfortably on the floor or in a
chair. Breathe in through your nose. As you do it, count to five. Breathe out through
your nose to the count of five. Repeat several times. Practice this for about 10
minutes. This works best if you practice these three times each day for 10 minutes
each time. Try to find a regular time to practice this each day.
Relaxation exercises and deep breathing These are two ways to help people
to relax and combat symptoms of stress, a relaxing technique called deep breathing
(stress Intervention Functional IFA) is capable to improve the mood and to reduce the
levels of stress(Luana Bertolo, Fulvia Fischer, 2017). 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 he 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 him to differentiate between two sensations, pain and
relaxation. This technique benefits the client physically and psychologically.
Decision Making. Many decisions must be made under stress, and many
decision situations elicit stress responses themselves. Thus, stress and decision
making are intricately connected, not only on the behavioral level, but also on the
neural level, i.e., the brain regions that underlie intact decision making are regions
that are sensitive to stress-induced changes. Stress affects decisions under various
degrees of uncertainty. Stress alters underlying decision-making mechanisms. If stress

73
confers and advantage or disadvantage depends on the specific situation. Cortisol
responses are closely related to the decisions
Time management. Time management is the process of organizing and
planning how to divide your time between different activities. Get it right, and you'll
end up working smarter, not harder, to get more done in less time – even when time is
tight and pressures are high. The highest achievers manage their time exceptionally
well. And by using Mind Tools' time-management resources, you too can make the
most of your time – starting right now!
There are some Time Management Tips that we give to client was Prioritize your to-
do list, Break large tasks into manageable chunks, Set time limits, Note your
distractions, Evaluate how you're spending your time and Know when to say “NO”
Sleep Hygiene. Obtaining healthy sleep is important for both physical
and mental health, improving productivity and overall quality of life. Everyone, from
children to older adults, can benefit from better sleep, and sleep hygiene can play a
key part in achieving that goal. Research has demonstrated that forming good habits is
a central part of health1. Crafting sustainable and beneficial routines makes healthy
behaviors feel almost automatic, creating an ongoing process of positive
reinforcement. On the flip side, bad habits can become engrained even as they cause
negative consequences. Thankfully, humans have an impressive ability2 to make our
habits serve our long-term interests. Building an environment and set of routines that
promote our goals can really pay off.
Sleep hygiene encompasses both environment and habits, and it can pave the
way for higher-quality sleep and better overall health.

74
Some sleep hygiene tips that we will use to reduce the stress of client was: Maintain a
regular sleep routine،Avoid daytime naps. Don't stay in bed awake for more than 5-10
minutes, Don't watch TV, use the computer, or read in bed, Drink caffeinated drinks
with caution, Avoid inappropriate substances that interfere with sleep, Clean fresh air
and Have a quiet, comfortable bedroom.
Limitations
• Time management was difficult for me because of work load.
• The process of getting permission from the University management was also a bit
difficult task.
• I was nervous, hesitant and a bit uncomfortable while taking the case history
• Also I am an intern so it was bit difficult to take permission from the hospital
authorities
• It was bit difficult to take permission from the hospital authorities, in reference of
SOPS and others, for dealing with clinical patients.
• As it was a private clinical setup for drug addict patients so the concerned
• Administration of tests was difficult because I was doing it for the very first time
• No informant was available throughout the assessment. Information from the
family members wasn’t obtained so it could be more helpful in identifying more
information.
Recommendations

75
• Assessment should be carried out in an open environment which 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.
• Hospital authorities or the concerned authority of any clinical setups should
cooperate with the new interns so that they can perform and learn well by practical
exposure.
• There should be proper guidance from the universities while issuance of
permission letter.
76
References
Appel, C.W., Johansen, C., Deltour, I., Frederickson, K., Hjalgrim, H., Dalton, S.O.,
Dencker, A., Dige, J., Bøge, P., Rix, B.A. and Dyregrov, A., 2013. Early parental
death and risk of hospitalization for affective disorder in adulthood. Epidemiology,
pp.608-615.
Carrington, P., Collings Jr, G. H., Benson, H., Robinson, H., Wood, L. W., Lehrer, P.
M., ... & Cole, J. W. (1980). The use of meditation--relaxation techniques for the
management of stress in a working population, 1980 Journal of occupational
medicine.: official publication of the Industrial Medical Association
CBT, B. P. O. (2002). Brief cognitive-behavioral therapy: Definition and scientific
foundations. Handbook of brief cognitive behaviour therapy.
Beck, A.T. (1961). Introduction to cognitive behavior therapy. Retrieved from:
research gate
77
Case IV
Identifying information:
Name: B.P
Age: 35 years
Gender: Male
Education: Middle pass
Family System: Nuclear
No. of siblings: Five
Birth Order: 1st
Informant: Client himself and mother
Date seen: 19-3-2022
The client was referred to trainee clinical psychologist in DHQ for the purpose
of psychological assessment and management. He came with the symptoms of,
unwanted and persistent thoughts, anger issues, and repetitive mental acts, fear of
contamination, needing things orderly and restlessness.

78
‫عال مات‬ ‫دورانیہ‬
‫ ماہ سے‬6 ‫مزاج میں تیزی بہت ہے ۔‬
‫ ماہ سے‬11 .‫ایک بات بار بار دہراتا ہوں‬
‫ ماہ سے‬1 .‫ایک خیال بار بار آتا ہے۔‬
‫ ماہ سے‬6 ‫کبھی کبھی نیند کا مسئلہ ہوتا ہے۔‬
‫ماہ سے‬2 .‫غصہ بہت آتا ہے۔‬
‫ماہ سے‬4 .‫ہاتھ محسوس ہو تا ہے کہ گندے ہے۔‬
The client B.P was 35 years old came for a therapy session with presenting
complaints of unwanted and persistent thoughts, anger issues, and repetitive mental
acts, fear of contamination, needing things orderly and restlessness. The client mother
was also with him, who was much conscious about his son, and somehow worried
about the psychological disturbance of B.P the hygienic condition of client was quite
appropriate. The client was some hesitant at the beginning of session, but after
establishing a good therapeutic relation with trainee clinical psychologist, he
gradually became relaxed and comfortable. At start he did not response to the
greetings.
Session was started with open ended questions. He 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

79
client was cooperative in his nature, made the proper eye contact while answering, his
voice tone was average. The client reported he generally feel angry, have unwanted
thoughts, feelings of being contaminated and restlessness. His memory was not fair.
He didn't respond at few questions.
looking much disturbed about his problem. He reported that his elder brothers are
abroad so in this case his responsibilities to run the house and fear of being alone had
increased. These things are disturbing him and his anger issue is increasing day by
day. Client B.P reported he often takes chars.
During the session, client’s mother also reported about the mood and
behavioral changing of client at home. She reported that he wanted to have things in
order, feel angry and have unwanted thoughts. He also repeats things again and again.
Furthermore, to know more about the client’s mental state, Mental Status Examination
(MSE) was used in which client’s emotional, behavioral, 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 precede the case and to
plan for further sessions, for the betterment of client.
The developmental history of the client’s problem had started after he worked
as a labor in a garbage waste company and due to his unstable home
environment .After that he developed fear of being contaminated due to which he
wash his hands and take bath again and again. He generalized the situation with this
statement that “If I will not take care of my cleanliness, I’ll get angry and will not be
able to perform other tasks without being mentally disturbed”. It was the triggering or
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precipitating factor of the client’s illness. In this way the client’s problem was started
which is now disturbing his life pattern and schedules.
When the client was 20 years old he started taking Chars due to his unstable
home environment. Both his younger brothers are abroad .As a result he was alone to
run the house in an efficient manner. He worked as a labor in a garbage waste
company due to which he has developed fear of being contaminated. Moreover both
his parents have relationship issues. Therefore he often became much stressed and
angry. These reasons make him ill. He is mentally disturbed now. His appetite and
sleep was also disturbed with excessive thinking and restlessness.
Personal History. The client B.P. used to get up early in the morning for
reciting The Holy Quran and to offer his prayers. After that he used to take breakfast
on time .He liked to watch movies, morning shows and talk shows on TV. The client
liked to eat heathy food mostly, fruits, vegetables and dry fruits etc. The client was
born normal. He used to play cricket. He was a healthy child. He started walking and
speaking at the age of two years He was Muslim and was good in study. He liked to
spend time with friends and family. He has good relations with his siblings.
good student but now he is not studying. After his brothers went abroad he could not
able to continue his study normally, because of responsibilities of taking care of his
father, and mother. He did his Middle from a nearby school in his street, and to
become Hafiz e Quran he went to the nearby Madrassa. He wanted to continue his
studies but unfortunately he was unable to do so.

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Family history. The client belongs to a nuclear family system, where he was
living with his mother and father. Client’s birth order was first, and his 3 sisters were
younger to him and 2 brothers. Father of the client was 60 years old. He was a nice
man and a work in a Mosque. He didn’t interfere in the matters of his children. He is
such a kind, and humble man. The client’s mother was 55 years old lady, who was a
supportive woman but due to her illness she often become angry. She was uneducated
She was typical and overprotective mother and wife. The client reported good
and satisfactory relationship with his mother as she always supported in the ups and
down of his life. Both parents of the client have OCD disorder. He had 5 siblings, 3
sisters and two brothers. His 3 sisters are married and settled in their lives and two
brothers are unmarried. Client had good relations with his family. He has family
history of Obsessive-Compulsive Disorder and he takes drugs.
History of psychiatry illness in family. There was a psychiatry illness in
family, whereas, client reported that Obsessive Compulsive disorder common in their
family. His father is also suffering from Obsessive-Compulsive disorder and with
high blood pressure.
Social history. Client was good person by heart. He had humble and polite
nature that’s why he had a good relation with everyone. His social circle was so small
and client has introvert personality and financially condition of his family is good.
Psycho-sexual history. The client reached to the puberty at the age of 16
information about sexual matters. He got information regarding sexual matters from
his friends and movies.

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Pre-Morbid Personality. According to the client he was a healthy person and
was fit physically and psychologically before the onset of symptoms. He was living a
very happy life with his parent’s. At the age of 14 he started taking drugs and then he
went to Dubai and when he returned to a Pakistan he takes drugs and have repetitive
tasks and unwanted thoughts
an assessment, the tests themselves are not the assessment.”
Types of psychological Assessment
Informal assessment of individuals with obsessive compulsive disorder
involves the collection of information about the individual, interpreting that
information and applying it in a systematic manner, the purpose of which is to better
understand the individual’s abilities. Although the overall goals of informal and
formal assessment are similar, they differ in the use of the information collected, the
manner in which the information is collected, and the type of information collected.
The specific purpose of informal assessment is usually to use the information
collected in order to set goals, identify intervention strategies, and measure

83
intervention outcomes. In formal assessments, information is collected through the
use of standardized, norm-referenced tests, whereas in informal assessment,
information is based on careful observation of behaviors by the examiner. (Shulman,
2007)
illnesses, such as obsessive-compulsive disorder (OCD). Clinical Interview is a main
tool of gathering information from client, parents, and other informants. 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. He was asked about his present complaints and history of
present illness to know about the duration of the problem along with the predisposing,
precipitating and maintaining factors. At the time of interview, he was cooperative
and understanding the interview. His tone of average and was slow and no pressure of
speech. Overall, Good rapport was established.

84
Behavioral Observation. Behavioral observation is one of several
measurement approaches available to investigators engaged in quantitative behavioral
research. It is often the method of choice when nonverbal organisms are studied (or
nonverbal behavior generally); when more natural, spontaneous, real-world behavior
is of interest; and when processes and not outcomes are the focus (e.g., questions of
contingency). Compared with other approaches, it is often labor-intensive and time-
consuming. 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 little bit
confused at start but gets normalized after sometime; during session client’s behavior
was also observed. The client was 35 years old and his height was 6ft. He was
wearing neat and clean clothes. He was cooperative and good in nature. He had made
good eye contact during the session. His voice tone was normal and slow. The client
reported he generally have sleep disturbance, repeat things again and again, constant
thoughts, feelings of being contaminated and shaking if hands His memory was quite
fair. He responded all questions well.
Mental Status Examination (MSE). Mental status examination (MSE) is an
important diagnostic tool in both neurological and psychiatric practice. MSE is used
to describe a patient’s mental state and behaviors, both quantitatively and
perceptual disturbances, sensorium and cognition, and insight and judgment. The
clinician conducting an MSE collects data by observing the interviewed individual’s
behavior and asking specific questions.

85
The findings of the MSE summarize the results of a psychiatric examination
on a comprehensive, cross-sectional level. When integrated with the interviewee’s
biographical information and psychiatric history, MSE findings form the basis for
diagnostic and therapeutic decisions. A thorough MSE also provides essential
information for establishing a diagnosis according to DSM-5 criteria.(Sim, 1995)
interviewee because behavioral patterns vary significantly across cultures (e.g.,
nodding your head as a sign of approval in some countries might signify disagreement
in others). The client was 35 years old. He was anxious and worry about the future. .
He wore simple but neat and good clothes. He was talking normally and in a Average
voice during the conversation. His thought process was good.
The client’s abstract thinking was good. He seemed to have intact remote
memory as he reported events of his early childhood. The client’s recent past memory
was good. His concentration was good because when asked him to count backward he
count very well. His orientation of person was not satisfactory as when asked his
doctor’s name he replied he did not know. His judgment was normal as he answered I
will help others when asked him if you encounter an accident on the roadside, what
will you do? The client possessed insight about his problem. The good thing is that he
wanted to get rid of all the problems and wanted to continue his business of welding
and wants ti get married and go to Dubai. .
Formal assessment methods are considered to be more objective. A Formal
Assessment, as used in psychology, combines a process of interviewing a subject or

86
client and using appropriate test instruments and written assessments to identify the
issues involved in the case and to arrive at an appropriate diagnosis.
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;
 Yale – Brown Obsessive Compulsive Scale
Personality Test
 House Tree Person Test
Yale–Brown Obsessive Compulsive Scale (Y-BOCS)
The Yale Brown Obsessive-Compulsive Scale (Goodman et al., 1989a,b) is
regarded as the “gold standard” in the measurement of obsessive-compulsive disorder
(OCD) symptom severity and treatment response (Steketee, 1994; Moritz et al.,
2002). It is a semi-structured interview that consists of 10 core items, 5 measuring
time, interference, distress, resistance and control of obsessions (items: 1–5), and 5
identical items measuring compulsions (items: 6–10). The items are rated from 0 (no
symptoms) to 4 (severe symptoms), and yield a global severity score (range 0–40). In
addition, Goodman et al. (1989a)have suggested six investigational items (insight,
avoidance, indecisiveness, pathological responsibility, pathological slowness, and
pathological doubting).
In contrast to the rest of the scale, the resistance items (items: 4, 9) have
demonstrated problematic psychometric properties and lower correlations to the Y-
BOCS total scores (Goodman et al., 1989b; Woody et al., 1995). These findings have
87
led to the suggestion of deleting the resistance items from the scale (Woody et al.,
1995). The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) is a test to rate the
severity of obsessive–compulsive disorder (OCD) symptoms.
Administration
The client took 12 minutes to complete Y-(BOCS). A calm and comfortable
environment was provided for the completion of Y- (BOCS).

88
Table 2
Table is showing client’s age, raw scores, ranges of OCD and results of client.
Age Raw score Range Result
0-15(Mild)
35 20 16-23 (moderate) Moderate OCD
24-31(severe)
32-40 (Extreme)
The client obtained scores is 20 on Yale – Brown Obsessive scale which fall
in moderate OCD category and according to DSM-V it’s come in Obsessive
compulsive disorder (OCD).
Conclusion
The client got 20 scores on Yale – Brown Obsessive scale. According to scale,
his scores fall on moderate category, whose range is16-23. So the results show that,
the client is suffering from moderate OCD.
House Tree Person (HTP)
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and subjective administration and interpretation. (Buck, 1996)
personality.
Administration
guided. The clients draw the drawings in 30 mints.
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is insecure, aggressive and have no feeling of being grounded. His ego strength and
Case Formulation
The client B.P. was 35 years old. After he worked as a labor in garbage waste
company and due to unstable home environment he had developed some symptoms of
Obsessive Compulsive Disorder with prominent symptoms of unwanted and
persistent thoughts, anger issues, and repetitive mental acts, fear of contamination,
needing things orderly and restlessness. The client was brought for informal
assessment which includes Clinical interview and behavioral observation in formal
assessment standardized tests are administered.
DSM-5 checklist was used. The client was diagnosed with “Obsessive
Compulsive Disorder”. As per mentioned criteria in DSM-V for OCD are repetitive
thoughts e.g checking, hand washing, ordering) or mental acts (counting, repeating
words) fear of being contaminated and sleep problems etc. Different techniques
including Behavioral Techniques, Cognitive Behavior Therapy and ERP.

91
Bio model, the client was 1st born child as in birth order, the elder brothers of client
went abroad , his parents are old so in this case his responsibilities to run the house
and fear of being contaminated due to working in a garbage waste company has
increased. These things are disturbing him and his anger issues are increasing day by
day which causes severe psychological discomfort to the client. Due to this
happening client became extremely disturbed and angry. He used to think a lot and
repeat various activities.
functioning at the time of his interview. Two other test were administered on him
were HTP to measure the different aspects of clients personality other test was that
administered on him was YBOCS to rate the severity of Obsessive compulsive
disorder in the client. The assessment of personality tests revealed that he is insecure
depressed and have withdrawal and feelings of loneliness and difficulties of
interpersonal and physical environment, and problem in concentrating on studies.
The predisposing factor is client’s family history and his genetics as both his
parents had obsessive compulsive disorder. So the disorder is inherited to him.
Obsessive compulsive disorder (OCD) is a common psychiatric disorder that can have
disabling effects on both adults and children. Twin, family, segregation, and linkage
studies have demonstrated that OCD is familial, that the familiarity is due in part to
genetic factors and there are regions of the genome which very likely harbor
susceptibility loci for OCD.(Pauls at al; 2008)
The Precipitating Factor was the client work he done as a labor in a garbage
waste company and his unstable home environment .He remained frustrated,
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extremely angry and unhappy due to his parents behavior as they both are patients of
OCD. He always thinks “what will happen in future, his anger will get under control
or not”. Such as adverse perinatal events, psychological trauma and neurological
trauma may modify the expression of risk genes and, hence, trigger the manifestation
of obsessive–compulsive behaviors. ( Pauls et al; 2014)
The perpetuating factors of the client disorder were ignorance for treatment,
taboo’s fear and Poor coping style. As client’s mother reported that it may consider
bad in our family to visit the psychologists for any mental illness, we all believe on
medical treatment only. A hypothesis was tested that individuals with elevated levels
of obsessive-compulsive personality traits exhibit a compromised ability to tolerate
uncertainty. This hypothesis was tested by examining attentional coping style in the
face of an ego-threatening event. (Oltsmann et al; 2003).
of assessment tools, as client get score 20 score on Yale- Scale which is moderate so
he might fall in OCD according to the concerned criteria of DSM-V. Similarly House
Tree Person Test indicated that client has an introvert personality and has less
interaction with others.
treatment as rapport building, psycho education, cognitive behavior therapy, Exposure
and Response Prevention Therapy, deep breathing and Progressive Muscle Relaxation
(PMR).
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Assessment:
Presenting Complaints:
 Clinical Interviews
 Muscle fatigue
 Behavioral
 Restlessness observation
Client  Low appetite  Mental Status
Examination (MSE)
(B.P)  Loneliness  House Tree Person
 Excessive worries (HTP)
 Yale–Brown
 Sleep disturbance Obsessive
Compulsive Scale
(Y-BOCS)
Predisposing Precipitating Factors Perpetuating Protective Factors

Factors  Worked as labor Factors  Insight about the
 Genetics in garbage work  Poor coping problem
 Family  Unstable home style  Family and
history environment  Taboo’s financial support
fear
Diagnosis
Obsessive- Compulsive
Disorder
(DSM-5)
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Diagnosis
Client might be diagnosed with Obsessive-Compulsive disorder (OCD) with
code F42.9 according to DSM-V.
Short Term Goals
 To educate the client about his psychological discomfort, its harmful impacts
and ways to deal with his problem, psycho education will be used to educate a
client in a manner able or authentic way.
 To reduce his obsessive thoughts, we may use deep breathing exercises so that
he will be able to feel relax or comfortable in distress situations.
 To teach clients how to change their thoughts and how to focus on different
things with the help of some techniques.
 To teach the patient how to control his aggressive behavior with the help of
relaxation techniques.
 Relaxation exercise to be used to help him to overcome his muscle tension
 To enhance his motivation and interest in life regarding different areas of life,
it is necessary to set goals, which may help a client to stay motivated and calm
in distress or critical conditions or situations.
Long Term Goals
 Cognitive restructuring to change client’s way of thinking and Behaviour
 Encourage the patient to share his problems and thoughts with his family or
seek psychological help.

95
 For development of adequate coping mechanisms for thoughts and repetition
of behavior management, there is a need to improve physical functioning
which may help the client to feel better rather than before.
Restlessness, trembling, sleep disturbance etc.
 Exposure and response prevention therapy
 Sleep Hygiene
 Stress management skills training
smoothness of relation between peoples”. It is a highly valued part of clinical practice.
important therapy goals can be done or accomplished easily. The rationale was the
rapport was developed with the client in the first session by introducing the client with
trainee clinical psychologist which helps him to discuss his problems more easily by
96
clarifying the purpose of session, and assuring him about the privacy that it will not be
discuss with anyone.
Psycho-Education. It may refer to the education which is offered to
individuals with a mental health problem and their families to help empower them, to
take care of the client and deal with their condition in an optimal or manner-able way.
The Client will be psycho-educated in sessions about problems and illness. Psycho
education to the client will be given according to the cognitive behavioral Obsessive-
Compulsive Disorder (OCD). Individuals with Obsessive-Compulsive Disorder report
excessive thoughts, repetition of behavior which is difficult for them to control and
experience as distressing. Cognitive behavior therapy proposed by Albert Ellis.
It is that our emotions and behaviors are not directly determined by life events
or traumas which are happening in the client’s life, but rather by the way these events
are cognitively processed and evaluated. Exposure therapy will be used which helps
the client to expose his thoughts and to control his unwanted thoughts and to pay
attention to things.
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 helps the patient to overcome
the 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:
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 Identifying your negative thoughts, the strategy 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.
Exposure and response prevention therapy. Exposure with Response
Prevention (ERP) is an evidence-based treatment. It involves intentionally exposing
yourself to distressing thoughts, images, items, or situations that make you anxious in
a planned and intentional way. The goal is to expose you to the obsessions and
conditions -inducing experience, while preventing your typical response, including
avoidance behaviors and compulsions. This process allows you to learn something
different, rather than reinforce your existing fears. ERP can be helpful for individuals
with diagnoses of Obsessive-Compulsive, and other anxiety-related disorders.
When you decide to engage in ERP treatment, you will work with your
therapist to assess your obsessions and compulsions, set goals, and create an exposure
list. Your therapist will also make sure you understand the cycle of obsessions and
how ERP works. You will always be in the driver’s seat, choosing which topics to
focus on, and at a pace that feels manageable for you. A core component of ERP is
practice in between sessions, and we will help support you in doing so in a way that
feels challenging, but not overwhelming. The ultimate goal of ERP is that you will be
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able to engage in valued activities in your life, without compulsions or anxiety getting
in the way.
Relaxation Techniques: Relaxation exercises are strategies used to reduce
tension, anger and other issues. One set of skills used to supplement other CBT skills
(such as exposure and cognitive skills) are relaxation skills. Relaxation skills address
obsessive thoughts and behavior from the standpoint of the body by reducing
recurrent behavior, improves sleep disturbances, improve anger issues and calming
the mind. Client was suffering from most disturbing psychological state due to his
overthinking and thoughts. So relaxation exercises were necessary for him.
The procedure which will be applied to the client during the session will be
equal deep breathing and Progressive Muscles Relaxation (PMR).Equal deep
breathing is one relaxation skill used in CBT. It is best used as a way to get through a
tough situation without leaving or making things worse and to get relax. For best
results, client will be asked to practice equal deep breathing thrice a day for around 6
to 10 minutes each time. The purpose of applying this technique is used to relax the
body, to improve sleep disturbance, to reduce guilt and negative feelings and to calm
the mind and emotions.
Client will be taught the process of equal deep breathing. In first session
equal deep breathing procedure will done by these steps. Sit comfortably on the floor
or in a chair. Breathe in through your nose. As you do it, count to five. Breathe out
through your nose to the count of five. Repeat several times. Practice this for about 10
minutes. This works best if you practice this three times each day for 10 minutes each
time. Try to find a regular time to practice this each day.

99
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 he had pain in his body (Jacobson, 1935). 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 him
to differentiate between two sensations, pain and relaxation. This technique benefits
the client physically and psychologically.
Sleep Hygiene. As it was reported by the client in the earlier mentioned
symptoms that he had sleep difficulties and according to him his sleep patterns are
disturbed and he is unable to have a good and proper quality of sleep due to this
psychological discomfort, unwanted and persistent thoughts, anger issues, repetitive
mental acts, fear of contamination, needing things orderly and restlessness. Excessive
worry about his mother, business and future marriage So it was identified that client
was suffering from insomnia, which was need to manage And the first step for this is
the activity scheduling, so that he can perform all his work there is a proper time for
sleeping.
A plan will be given to the client for good quality of sleep as, no chars or glass
smoking more than once or at night, coffee after 4 pm, no driving after 9 pm, go on
bed when you need to sleep, exercise or deep breathing during the day, keep yourself
busy indifferent activities, wakeup early, relaxation exercises on daily basis, soothing
music, glass of milk, healthy and nutritious food, read books and offer prayers and
read Quran on daily basis.

100
Limitations
 It was difficult for me to manage because of the workload. .
 The process of getting permission from the University management was also a
bit of a difficult task.
 I was afraid and nervous at the starting of the session
 As I am an intern so it was a bit difficult for me to take permission from
Hospital authorities. .
 Due to the strict environment of the hospital it was bit difficult to take
permission from the hospital authorities, in
 As it was a private clinical setup for drug addict patients so the concerned
authorities were much conscious to give their clients to the students
 Administration of tests was difficult because I was doing it for the very first
time
 Interruption by paramedical staff was also a problem.
 No informant was available throughout the assessment. Information from the
family members wasn’t obtained so it could be more helpful in identifying
more information.
Recommendations
 Following recommendations could be helpful in conducting sessions
successfully.
 Assessment should be carried out in an good environment in which there is no
distractions
 Time period for session should be extended

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 Information should be gathered from the people in close contact with the
client.
 There should be proper guidance from the universities while issuing a
permission letter.
 There should be a proper room where a trainee can take sessions.

102
References
Pauls, D. L., Abramovitch, A., Rauch, S. L., & Geller, D. A. (2014).
Obsessive–compulsive disorder: an integrative genetic and neurobiological
perspective. Nature Reviews Neuroscience, 15(6), 410-424.
Gallagher, N. G., South, S. C., & Oltmanns, T. F. (2003). Attentional coping
style in obsessive-compulsive personality disorder: a test of the intolerance of
uncertainty hypothesis. Personality and Individual Differences, 34(1), 41-57.
Pauls, D. L. (2010). The genetics of obsessive-compulsive disorder: a review.
Dialogues in clinical neuroscience, 12(2), 149.
Shulman American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., Text Rev.). Washington, DC: Author.
Groth-Marnat, Gary. Handbook of Psychological Assessment. 3rd edition. New York:
John Wiley and Sons, 1997.
Sims, A. G. (1995). Symptoms in the mind: an introduction to descriptive
psychopathology. Philadelphia: W.B. Saunders. ISBN 0-7020-1788-4.
Buck, J. N. (1966). The house-tree-person technique: Revised manual. Western
Psychological Services.
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Case V
Name: M.A
Age: 27 years
Gender: Male
Education: Intermediate
Family System: Joined
No. of siblings Four
Birth Order: 2nd
Informant: Client himself and brother
Date seen: 19-03-2022
The client was referred to trainee clinical psychologist in DHQ for the
purpose of psychological assessment and management. He came with the symptoms
of sweating, shaking, accelerated heart rate, chest pain, fear of losing control, feeling
dizzy and heat sensations.

104
‫دوران ی ہ‬ ‫عال مات‬
1 ‫ما ہ سے‬ ‫سینے میں درد رہتا ہے ۔‬
2 ‫ما ہ سے‬ ‫دل کی دھڑ کن تیز رہتی ہے‬
1 ‫ما ہ سے‬ ‫پسینہہ أ تا ہے‬
3 ‫ما ہ سے‬ ‫ کا ڈر رہتا ہے‬C‫حواس کھو دینے‬
2 ‫ما ہ سے‬ ‫گر می کا احساس ہو تا ہے‬
4 ‫ما ہ سے‬ ‫جسم میں کپکپا ہٹ ہوتی ہے‬
The client M.A was 27 years old came for a therapy session with presenting
complaints of sweating, shaking, accelerated heart rate, chest pain, feeling dizzy and
heat sensations, etc. The client brother was also with him, who was much conscious
about his brother, and somehow worried about the psychological disturbance of M.A.
The hygienic condition of client was not appropriate. The client was some hesitant at
the beginning of session, but after establishing a good therapeutic relation with trainee
clinical psychologist, he gradually became relaxed and comfort. At start, he did not
response to the greetings. Session was started with open ended questions. He 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 wasn’t cooperative in his nature,
made the poor eye contact while answering, his voice tone was low, The client
reported he generally feel chest pain, sweating, accelerated heart rate, fear of losing
control, feeling dizzy ,heat sensations and shaking .He responded to some questions.
105
looking much disturbed about his problem, because of his silent mood and pauses
while during presenting the issues. He reported that his mother died 6 months ago
because of sudden heart attack, after her death his father became ill as suffering from
hepatitis, in this case his responsibilities to run the house and fear of losing his father
have increased. These things are disturbing his daily schedules and causing
disturbance day by day. Client M.A reported that he had faced a lot of problems after
the death of his mother and father’s illness, as not finding a proper job, incomplete
studies etc.
During the session, client’s brother also reported about the mood and
behavioral changing of client after the death of his mother, she reported that he
remained silent all the time, get panic attacks, feel dizzy , feel alone and have chest
pain. Furthermore, to know more about the client’s mental state,
Mental Status Examination (MSE) was used in which client’s emotional,
behavioral, 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 the
sudden death of his mother. He was so upset because he had good bonding with his
mother but after the sudden death he became silent and in excessive grief phase due to
which he get panic attacks. But after some months when his father became ill, he fell
into more worriness and generalized the situation with this statement that “if my
father got died because of his illness, I’ll also get alone and will not be able to manage
106
the life”. It was the triggering or precipitating factor of the client’s illness. In this
way the client’s problem was started which is now disturbing his life pattern and
schedules.
When the client was 27 years old his mother died suddenly with a severe Heart
attack, and after sometime his father became ill. As a result he was alone to run the
house in an efficient manner. His father was not strong financially. Client faces a lot
of problems after the death of his mother and father’s illness. He had great fear of
losing his father due to which he get panic and often get panic attacks. He became
much stressed. His appetite and routine was also disturbed with excessive tension.
Personal History. The client M.A was used to get up late in the morning for
having breakfast. He liked to watch morning shows, talk shows on TV, and to play
cricket. The client liked to eat sweet dishes mostly, as bakery products etc., and to the
client was born normal. He was a weak child. He started walking and speaking at the
age of two year. He was Muslim by birth, was average in study. He liked to spend
time alone. He was very active in riding cycle.
good student, now he was also studying. But after his mother death and father’s
illness he could not able to continue his study normally, because of some financial
issues and responsibilities of taking care of his father, sisters and brothers. He did his
Matric from Government school, completed intermediate with good marks from Govt.
College, now was studying B.A in an academy but had left. He wanted to get rid of
this problem, so that he can continue his study further.

107
living with his 2 sisters, parents and brother. Client’s birth order was second, and his 2
sisters were younger to him. Father of the client was 65 years old. He was a nice man
and a worker in a factory. He didn’t interfere in the matters of his children. He is such
a kind, and humble man. The client’s mother A. M was a 53 years old lady, who was
very lovely and supportive woman. She was uneducated up to. She was submissive by
nature. She was typical and responsible mother and wife. The client reported
congenial and satisfactory relations with his mother as she always supported in the
ups and down of his life and now his mother has died
He had 3 siblings, 2 sisters and 1 brother. As they are younger to him these all
are studying in a govt. school in different grades Client had good relations with his
family. Due to his mother m and his father became illness. As a result of it he became
much worried and have panic attacks and developed Panic disorder Client also
reported the medical illness in family that in his family the heart problems are
common as his mother died because of it and father is also suffering from it.
History of psychiatry illness in family. There was no psychiatry illness in
family, whereas, client reported that cardiac problem is common in their family, as his
mother died because of it, now father is also suffering from heart problem. This
condition or all behavioral changes of client started at the age of twenty two when his
mother got died.
Social history‫ ۔‬Client was good person by heart. He had humble and polite
nature that’s why he had a good relation with everyone. His social circle was not
much big but enough to spend a good time with them He liked to help poor not just
financially but also by performing their activities which they ask for help from him.
108
Psycho-sexual history. The client reached to the puberty at the age of 15
information about sexual matters. He got information regarding sexual matters from
his friends and movies.
Pre-Morbid Personality According to the client he was a healthy person and
was fit physically and psychologically before the onset of symptoms. He was living a
very happy life with his parent’s before the death of his mother, and illness of his
father. He had sound sleep and had no worry. He had enjoyed his life very well with
his friends.
an assessment, the tests themselves are not the assessment.”
Informal assessment of individuals with autism panic attacks involve the
collection of information about the individual, interpreting that information and
applying it in a systematic manner, the purpose of which is to better understand the
individual’s abilities. Although the overall goals of informal and formal assessment
109
are similar, they differ in the use of the information collected, the manner in which the
information is collected, and the type of information collected. The specific purpose
of informal assessment is usually to use the information collected in order to set goals,
identify intervention strategies, and measure intervention outcomes. In formal
assessments, information is collected through the use of standardized, norm-
referenced tests, whereas in informal assessment, information is based on careful
observation of behaviors by the examiner. (Shulman, 2007
illnesses, such as panic attacks. Clinical Interview is a main tool of gathering
information from client, parents, and other informants. 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. He was asked about his present complaints and history of
present illness to know about the duration of the problem along with the predisposing,
precipitating and maintaining factors. At the time of interview, he was cooperative

110
and understanding the interview. His tone of average and was slow and no pressure of
speech.
Behavioral Observation. Behavioral observation is one of several
measurement approaches available to investigators engaged in quantitative behavioral
research. It is often the method of choice when nonverbal organisms are studied (or
nonverbal behavior generally); when more natural, spontaneous, real-world behavior
is of interest; and when processes and not outcomes are the focus (e.g., question of
contingency). Compared with other approaches, it is often labor-intensive and time-
consuming. 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 little bit confused at start but gets
normalized after sometime,
According to behavioral examination client wasn’t cooperative in his nature,
made the poor eye contact while answering, his voice tone was low, The client
reported he generally feel chest pain, sweating, accelerated heart rate, fear of losing
control, feeling dizzy ,heat sensations and shaking .He responded to some questions.
Mental Status Examination (MSE). Mental status examination (MSE) is an
important diagnostic tool in both neurological and psychiatric practice. MSE is used
to describe a patient’s mental state and behaviors, both quantitatively and
perceptual disturbances, sensorium and cognition, and insight and judgment. The
clinician conducting an MSE collects data by observing the interviewed individual’s
behavior and asking specific questions. The findings of the MSE summarize the
111
results of a psychiatric examination on a comprehensive, cross-sectional level. When
integrated with the interviewee’s biographical information and psychiatric history,
MSE findings form the basis for diagnostic and therapeutic decisions. A thorough
MSE also provides essential information for establishing a diagnosis according to
DSM-5 criteria.(Sim, 1995
interviewee because behavioral patterns vary significantly across cultures (e.g.,
nodding your head as a sign of approval in some countries might signify disagreement
in others)
The client was 27 old. He was anxious and worry about the future. . He wore
simple but neat and good clothes. He was talking normally and in an Average voice
during the conversation. His thought process was good
The client’s abstract thinking was good. He seemed to have intact remote
memory as he reported events of his early childhood. The client’s recent past memory
was good. His concentration was good because when asked him to count backward he
count very well. His orientation of person was not satisfactory as when asked his
doctor’s name he replied he did not know. His judgment was normal as he answered I
will help others when asked him if you encounter an accident on the roadside, what
will you do? The client possessed insight about his problem.
Formal assessment methods are considered to be more objective. A Formal
Assessment, as used in psychology, combines a process of interviewing a subject or

112
client and using appropriate test instruments and written assessments to identify the
issues involved in the case and to arrive at an appropriate diagnosis
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;
 Beck Depression Inventory
 Panic Disorder Severity Scale
 House tree person (HTP)
Beck Depression Inventory
Introduction. The Beck Depression Inventory (BDI) is a 21-item self-
reporting questionnaire for evaluating the severity of depression in normal and
psychiatric populations. Developed by Beck et al. in 1961, it relied on the theory of
negative cognitive distortions as central to depression. It underwent revisions in 1978:
the BDI-IA and 1996 and the BDI-II, both copyrighted. The BDI-II does not rely on
any particular theory of depression and the questionnaire has been translated into
several languages. A shorter version of the questionnaire, the BDI Fast Screen for
Medical Patients (BDI-FS), is available for primary care use. That version contains
seven self-reported items each corresponding to a major depressive symptom in the
preceding 2 weeks.
The questionnaire was developed from clinical observations of attitudes and
symptoms occurring frequently in depressed psychiatric patients and infrequently in

113
non-depressed psychiatric patients. Twenty-one items were consolidated from those
observations and ranked 0–3 for severity. The questionnaire is commonly self-
administered although initially designed to be administered by trained interviewers.
Self-administration takes 5–10min. The recall period for the BDI-II is 2 weeks for
(major depressive symptoms) as operationalized in the fourth edition of Diagnostic
and Statistical Manual (DSM-IV)
Procedure
Familiarize yourself with the Beck Depression Inventory. There is a lot of
information online about the administration and scoring of the Beck Depression
Inventory. It’s a good idea to do some online research before you begin. Here is some
valuable information about the inventory It is a 21 item self-report inventory. It is
used to evaluate depression in both clinical and non-clinical patients. It was
developed to be administered on adolescents and adults, so it can be used by anyone
13 and above. It uses a rating tool where each item is rated on a four point scale from
0-3.0 means you are experiencing no symptoms, while 3 means you are experiencing
a severe form of the symptoms.
Administration
The client took 15 minutes to complete BDI. A calm and comfortable
environment was provided for the completion of BDI.

114
Table 1
The following table is showing the self-report measure of the client.
RANGE Score Result
Minimal (0—7 )
Mild (8—15 )
Severe
Moderate (16—29 ) Depression

38
Severe (30—63)
The client obtained 38 score on depression scale which fall in severe category.
Conclusion
The client got 38 scores on depression inventory. According to this inventory,
his scores fall on severe category, whose range is 30—63. So the results show that,
the client is suffering from severe depression.
Personality Test
House Tree Person. The house-tree-person test (HTP) is a projective
personality test, a type of exam in which the test taker responds to or provides
ambiguous, abstract, or unstructured stimuli (often in the form of pictures or

115
drawings). In the HTP, the test taker is asked to draw houses, trees, and persons, and
these drawings provide a measure of self-perceptions and attitudes. As with other
projective tests, it has flexible and subjective administration and interpretation. (Buck,
1996)
personality.
Administration
guided. The client draws the drawings in 30 mints.
116
avoid direct confrontation. He is insecure, aggressive and have no feeling of being
grounded. His ego strength and sense of self is strong.
Panic Disorder Severity Scale (PDSS)
The Panic Disorder Severity Scale (PDSS) is a self-report scale that measures
the severity of panic attacks and panic disorder symptoms. It is appropriate for use
with adolescents (13+) and adults.
The scale is a useful way of assessing overall panic disorder severity at
baseline, and it provides a profile of severity of the different panic disorder symptoms.
It is a good monitoring tool because it is brief and sensitive to change, and can be
used to track symptoms over time.
The scale consists of seven items, each rated on a 5-point scale. The items
assess panic frequency, distress during panic, panic-focused anticipatory anxiety,
phobic avoidance of situations, phobic avoidance of physical sensations, impairment
in work functioning, and impairment in social functioning.
Administration
117
The client took 15 minutes to complete PDSS a calm and comfortable
environment was provided for the completion of PDSS.

118
Table 2
The following table is showing the self-report measure of the client.
Serial no Items Client rating
1 Felt moments of sudden terror 3

fear or flight, sometimes out the
blue
Felt anxious, worried, or nervous

about having more panic attacks.
2 2
Had thoughts of losing controls,

dying, going crazy or other bad
3 3
things, happening because of panic
attacks
Felt a racing heart, sweating, trouble

breathing, faint, or shaky 3
4
Felt tense muscle, felt on edge or

5 restless or had trouble relaxing or 3
trouble shaking
Avoided or did not approach or
enter situations in which panic
6 2
attacks might occur.
Left situation early, or participated

7 only minimally because of panic 2
attacks.
Spent a lot of time preparing for,
8 or procasting about situations in 2
which panic attacks might occur.
Distracted myself to avoid thinking
9 about panic attacks 2
10 Needed help to cope with panic 1

attacks.
119
Table 3
Table is showing client’s age, raw scores, ranges of PDSS and results of client.
Age Raw score Range Result
0-10=minimal
11-20 mild
27 26 21-30 moderate Moderate
31 – 40 severe
Qualitative Analysis
It shows that the clients have these symptoms sweating, shaking, accelerated
heart rate, chest pain, feeling dizzy and heat sensations. The clients total score is
26which lies between the range 21-30 indicating that he bas symptoms of panic
disorder which are at moderate level and according to DSM-V depicting that he is
falling under panic disorder.
Conclusions
The client was administered with Panic Disorder Severity Scale. He scored
26 on it in the range of 21-30 indicating that client has a moderate level of panic
disorder
120
Case formulation
The client was 27 years old, his mother had died due to heart attack and due
to unstable home environment and financial issues he has problems and symptoms
such as sweating, shaking, accelerated heart rate, chest pain, feeling dizzy and heat
sensations .The client was brought for informal assessment which includes Clinical
interview and behavioral observation in formal assessment standardized tests are
administered. DSM-5 checklist was used.
The client was diagnosed with “Panic Disorder”. As per mentioned criteria in
DSM-V for Panic Disorder Sweating, shaking, accelerated heart rate, chest pain,
feeling dizzy and heat sensations Different techniques including Behavioral
Techniques, Cognitive Behavior Therapy and ERP. The formulation was done
according to bio-psycho social model. According to Bio model, the client was 2nd
born child as in birth order, the elder brother of client lives with him, his mother had
died and father has some heart problem and he was in depression due to the sudden
death of his mother.
The financial burden of the family also disturbing him and due to the sudden
death of his mother he got panic attacks and worry about his family. MSE was
applied on him for checking his behavior and intellectual functioning at the time of
his interview. Three other test were administered on him were HTP to measure the
different aspects of clients personality other test was that administered on him was
BDI and PDSS to rate the severity of Panic and depression in the client. The
assessment of personality tests revealed that he is insecure depressed and have
withdrawal and feelings of loneliness and difficulties of interpersonal and physical
environment, and problem in concentrating on studies. The predisposing factor is

121
clients’ family history and his genetics and sensitive in nature so the disorder is due
to the death of his mother to him. We review the genetic epidemiology of PD as well
as recent molecular genetic studies of the disorder, and conclude with a discussion of
promising strategies that attempt to uncover specific genetic loci involved in the
etiology of PD.
The Precipitating Factor was the client’s mother death and unstable home
environment after the death of his mother. He remains in seating worry and heart
sensation. We have found that patients’ feelings that their panic symptoms “come out
of the blue,” an idea that is underscored in DSM-IV (p. 397), are related to their lack
of conscious awareness of the meaningful stressors and ensuing reactions that led to
panic. Many studies suggest that acute stressors, described in the literature as “life
events,” occur just prior to panic onset.
The perpetuating factors of the client disorder were Illness of his father and
depression and poor copying style. As client’s brother reported that it may consider
bad in our family to visit the psychologists for any mental illness, we all believe on
medical treatment only. Structured diagnostic interviews were obtained from 770
parents of participants in a school-based risk factor study for adolescent panic.
Parent-reported risk factors assessed included characteristics of the child (negative
affect, childhood chronic illness, and childhood loss) as well as characteristics of the
parent (parental panic disorder or agoraphobia [PDA], parental major depression, and
parental chronic illness). (Peggy A Thoits et al, 1987).
of assessment tools, as client get score 34 score on BDI And Moderate Levels of
PANIC score on PDSS - Scale which is moderate so he might fall in Panic Disorder
122
according to the concerned criteria of DSM-V. Similarly House Tree Person Test
indicated that client has an introvert personality and has less interaction with others.
treatment as rapport building, psycho education, cognitive behavior therapy, graded
exposure therapy, deep breathing and Progressive Muscle Relaxation (PMR).

123
Assessment:
Presenting Complaints:
 Clinical Interviews
 Sweating
 Behavioral
 Shaking observation
Client  Accelerated heart  Mental Status
Examination (MSE)
(M.A) rate  House Tree Person
 Chest Pain (HTP)
 Beck depression
 Feeling dizzy
inventory
 Heat sensation  Panic disorder
severity scale
Predisposing Precipitating Factors Perpetuating Protective Factors

Factors  Mother death Factors  Insight about the
 Genetics  Unstable home  Illness of problem
 Sensitive environment his father  Family and
in nature  depression financial support
 Birth order
Diagnosis
Panic Disorder (DSM-V)
124
Diagnosis
Client might be diagnosed with panic disorder with code F41 according to
DSM-V.
Short Term Goals
 To educate the client about his psychological discomfort, its harmful impacts
and ways to deal with his problem, psycho education will be used to educate a
client in a manner able or authentic way.
 To reduce his panic thoughts or actions, we may use ERP, so that he will be
able to feel relax or comfortable in his situations.
 To teach clients how to change their thoughts and how to focus on different
things with the help of some techniques.
 To teach the patient how to control his panic behavior with the help of deep
breathing or medication
 To enhance his motivation and interest in life regarding different areas of life,
it is necessary to set goals, which may help a client to stay motivated and calm
in distress or critical conditions or situations.
Long Term Goals
 Cognitive restructuring to change client’s way of thinking and Behavior
 Encourage the patient to share his problems and thoughts with his family or
seek psychological help.

125
 For development of adequate coping mechanisms for thoughts, there is a need
to improve physical functioning which may help the client to feel better rather
than before.
the client’s functioning. He was facing problems such as dizziness, chest pain,
sweating, and fear of losing control or heat sensation
 Exposure and response prevention therapy
 Deep breathing
smoothness of relation between peoples”. It is a highly valued part of clinical practice.
important therapy goals can be done or accomplished easily. The rationale was the
rapport was developed with the client in the first session by introducing the client with
trainee clinical psychologist which helps him to discuss his problems more easily by
clarifying the purpose of session, and assuring him about the privacy that it will not be
discuss with anyone.

126
Psycho Education. It may refers to the education which offered to
individuals with a mental health condition and their families to help empower them ,to
take care of the client and deal with their condition in an optimal or manner able way.
The Client will be psycho-educated in session about problem and illness. Psycho
education to the client will be given to the client, Psych education helps patients
improve their self-esteem, develop skills and strategies to control their mental well-
being provides them with emotional support and teaches them problem-solving skills.
Other common symptoms include accelerated rapid heartbeat, sweating, trembling,
difficulty concentrating, fear of losing control, and poor sleep.
Psychoeducation is increasingly used following trauma. The term covers the
provision of information about the nature of panic attacks, posttraumatic and other
symptoms, and what to do about them. The provision of Psychoeducation can also
occur before possible exposure to panic situations or, alternatively, after exposure.
The intention of both is to ameliorate or mitigate the effects of exposure to extreme
situations. Educational information can be imparted in a number of ways and can also
form part of what has been termed psychological first aid. (Neil Greenberg, Mark
Earn Shaw, John Shapley, Jamie Hacker Hughes, 2008)
Cognitive Behavior Therapy. Cognitive behavioral therapy is a short-term
therapy technique. It can people find new ways to behave by changing their thought
patterns. Engaging with CBT can help people reduce stress, cope with complicated
relationships, deal with grief, and face many other common life challenges. Cognitive
therapy is a good and time limited therapy. Over the past 50 years, cognitive-
behavioral therapies (CBT) have become effective mainstream psychosocial
treatments for many emotional and behavioral problems.

127
Behavior therapy approaches were first developed in the 1950s when
experimentally based principles of behavior were applied to the modification of
maladaptive human behavior (e.g , Wolpe, 1958; Eysenck, 1966). In the 1970s,
cognitive processes were also recognized as an important domain (Bandura, 1969). As
a result, cognitive therapy techniques were developed and eventually integrated with
behavioral approaches to form cognitive-behavioral treatments for a variety of
psychological disorders.
Clark's (1986) cognitive theory of panic disorder proposes that individuals
who experience recurrent panic attacks do so because they have an enduring tendency
to misinterpret benign bodily sensations as indications of an immediately impending
physical or mental catastrophe. The expanded model identifies the critical
mechanisms of panic which include: catastrophic misinterpretation of bodily
sensations (which lead to a feeling of anxiety and exacerbation of bodily symptoms)
and safety-seeking behaviors (which prevent disconfirmation of threat beliefs).
In CBT the negative thoughts and beliefs of patients are changed into positive
ones. It is also called talk therapy. This therapy helps the patient to overcome his
difficulties by identifying and changing dysfunctional changes and emotional
responses. CBT is based on the concept that our thoughts, feelings, physical
sensations and actions are interconnected, and that negative thoughts and feelings can
trap you in a vicious cycle. CBT aims to help you deal with overwhelming problems
in a more positive way by breaking them down into smaller parts. It is process in
which you challenge the negative thinking patterns that contribute to your anxiety,
replacing them with more positive, realistic thoughts.

128
 Identifying or collaborating your negative thoughts, to ask to ask yourself what
you are thinking and how you are feeling, when you started feeling panic . The
therapist will help you regarding to your problems or disorder
 Challenging your negative thoughts. In the next step, your therapist will teach you
that how you can cope up with your panic situation or will listen to your problem
carefully which will help you to feel relax.
Once you have identified the irrational predictions or negativity in your panic
thoughts, you can replace them with new thoughts that are more positive and may
leads them towards positivity or relaxation.
Exposure and response prevention therapy (ERP). Exposure with Response
Prevention (ERP) is an evidence-based treatment. It involves intentionally exposing
yourself to distressing thoughts, images, items, or situations that make you anxious in
a planned and intentional way. The goal is to expose you to the anxiety-inducing
experience, while preventing your typical response, including avoidance behaviors
and compulsions. This process allows you to learn something different, rather than
reinforce your existing fears. ERP can be helpful for individuals with diagnoses of
Panic Disorder, and other anxiety-related disorders.
When you decide to engage in ERP treatment, you will work with your
therapist to assess your anxiety and panic attacks, set goals, and create an exposure
list. Your therapist will also make sure you understand the cycle of panic attacks and
how ERP works. You will always be in the driver’s seat, choosing which topics to
focus on, and at a pace that feels manageable for you. A core component of ERP is
practice in between sessions, and we will help support you in doing so in a way that
129
feels challenging, but not overwhelming. The ultimate goal of ERP is that you will be
able to engage in valued activities in your life, without compulsions or anxiety getting
in the way.
Relaxation Technique. Relaxation techniques are strategies, 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, improves energy improves digestion, slowing down
breathing, and calming the mind. Client was suffering from most disturbing
psychological state due to his panic attacks so relaxation exercises were necessary for
him. The efficacy of meditation-relaxation techniques has been widely researched in
the laboratory, but their effectiveness for management of panic attacks in
organizational settings is still relatively unexplored.
The present study compared relaxation and control conditions as part of a
program of panic attacks reduction. (Patricia Carrington, Gilbeart H Collings Jr,
Herbert Benson, Harry Robinson, 1980)The procedure which will be applied to the
client during the session will be ERP. It is best used as a way to get through a tough
situation without leaving or making things worse and to get relax.
The purpose of applying this technique is used to relax the body, involves
intentionally exposing yourself to distressing thoughts, images, items, or situations
that make you anxious in a planned and intentional way, worry to calm the mind and
emotions. Client will be taught the process of equal deep breathing. In first session
equal deep breathing procedure will done by these steps. Sit comfortably on the floor
or in a chair. Breathe in through your nose. As you do it, count to five. Breathe out
through your nose to the count of five. Repeat several times. Practice this for about 10
130
minutes. This works best if you practice these three times each day for 10 minutes
each time. Try to find a regular time to practice this each day.
Relaxation exercises and Deep breathing These are two ways to help
people to relax and combat symptoms of stress, a relaxing technique called deep
breathing (stress Intervention Functional IFA) is capable to improve the mood and to
reduce the levels of stress(Luana Bertolo, Fulvia Fischer, 2017). 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 he 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 him to differentiate between two sensations, pain and relaxation. This technique
benefits the client physically and psychologically.
Limitations
• Time management was difficult for me because of work load.
• The process of getting permission from the University management was also a bit
difficult task.
• I was nervous, hesitant and a bit uncomfortable while taking the case history
• Also I am an intern so it was bit difficult to take permission from the hospital
authorities
• As it was a private clinical setup for drug addict patients so the concerned
• Administration of tests was difficult because I was doing it for the very first time
131
• No informant was available throughout the assessment. Information from the
family members wasn’t obtained so it could be more helpful in identifying more
information.
Recommendations
• Assessment should be carried out in an open environment which 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.
• Practice stress management and relaxation techniques
• Hospital authorities or the concerned authority of any clinical setups should
cooperate with the new interns so that they can perform and learn well by practical
exposure.
132
References
Clark D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy,
CBT, B. P. O. (2002). Brief cognitive-behavioral therapy: Definition and scientific
foundations. Handbook of brief cognitive behaviour therapy.
Palmer, S. (2007). : A model suitable for coaching, counselling, psychotherapy. The
Coaching Psychologist,
Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW, Gorman
JM, Papp LA. Multicenter collaborative Panic Disorder Severity Scale. American
Journal of Psychiatry 1997; 154:1571-1575
Shulman American Psychiatric Association. (2000). Diagnostic and statistical manual
of mental disorders (4th ed., Text Rev.). Washington, DC: Author.
Groth-Marnat, Gary. Handbook of Psychological Assessment. 3rd edition. New York:
John Wiley and Sons, 1997.
Sims, A. G. (1995). Symptoms in the mind: an introduction to descriptive
psychopathology. Philadelphia: W.B. Saunders. ISBN 0-7020-1788-4.
Buck, J. N. (1966). The house-tree-person technique: Revised manual. Western
Psychological Services.

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1

Education: Middle pass

Marital status: Married

Family System: Joint

Informant: Client himself and brother

Total No. of session: 1

Date seen: 8-03 - 2022

Source and Reason of Referral

appetite, loneliness, restlessness, sleep disturbance and digestive issue.

Presenting Complaints and duration as presented by the client. ‫دورانیہ‬

‫بھی کھائے بغیر رہ لیتا ہو‬

‫ ماہ سے‬5 ‫حیح سے سو نہیں پاتا مجھے نیند نہیں آتی‬CCCCCC‫ص‬

‫ ماہ سے‬4 ‫ئلے چل رہے ہیں جس‬CC‫ارے مس‬CC‫گھر میں بہت س‬

‫کی وجہ سے میں پریشان رہتا ہوں‬

‫ماہ سے‬4 ‫بے چینی ہوتی ہے‬

‫ ماہ سے‬4 ‫اکیالپن محسوس ہوتا ہے‬

‫ ماہ سے‬5 ‫تھکاوٹ رہتی ہے‬

health and somehow worried about the psychological disturbance of S. A. The

According to behavioral observations client was so cooperative in his nature,

was a forced marriage and he didn’t want to get married.

alone. Furthermore, to know more about the client’s mental state‫۔‬

Mental Status Examination (MSE) was used in which client’s emotional,

to plan for further sessions, for the betterment of client.

He was aware of the purpose of coming for counseling session therefore

also built in a good manner. According to behavioral examination client was

feel breathing problem, feelings of anxiousness, shaking of hands, and dryness of

responded well to all questions.

drugs after his forced marriage and business.

History of present illness

because he had interest in money and he was a master mind by nature.

Educational History. He started going to school at the age of 4. He was a

become a rich person and he was greedy.

her death he felt so lonely. .

his kids and likes to spend time with his kids.

History of psychiatry illness in family. There was no psychiatry illness in

his marriage was a force marriage.

Psycho-Sexual History. The client reached to the puberty at the age of 14

Pre-Morbid Personality. According to the client he was a healthy person and

time with his family and friends.

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

various areas of dysfunction aroused due to symptomatic behavior.

Types of psychological assessment

There are two types of assessment.

Informal Psychological Assessment

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

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

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

nationally developed techniques. It includes the following:

 Mental Status Examination

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

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

Behavioral Observation. Behavioral Observation is a systematic way of

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

He responded all questions very well.

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

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