PSYCHODIAGNOSTIC REPORT

Submitted to: Miss Humaira

Submitted by: Sana Javed

Roll no: 502-20121

Class: Counselling Psychology

Date: 15-06-2023

Department of Psychology Hazara University Mansehra

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TABLE OF CONTENTS

Contents Page No Page No

1 Case History 2

2 Psychodiagnostics report 7

3 Conclusion and recommendation 9

4 Treatment Plane 10

5 Session’s report 12

6 Terminal report 14
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CASE HISTORY SHEET

Name of the Patient: Saiqa Bibi Age: 27 years

Date of birth: July 1995 Appearance: Normal

Religion: Islam Birth order: Third Child

Education: Bachelors

Occupation: Nill

Siblings: 3

Children 1

Marital status Divorced

Family structure: Nuclear

Earning members: 2

Language: Urdu

Intake by: Sana Javed Informant Name: Munazza (Sister)

Presenting problems: (nature of problems, precipating events, patient’s feelings and thoughts

about problems)

Informant reported that she had unsatisfactory relationships with her husband. She was

not happy with her spouse and divorced him. She reported that her ex-husband tried to kill her

many times. She reported that He even tried to poison her food and he was convinced that her

ex-husband hired someone to kill her. She had difficulty falling asleep. She engaged in self-talk,

self-laugh and she also had social anxiety as she felt fearful while communicating with others

History of problem: (duration of present problem, changes in nature, intensity, and / frequency

of problem over time, other past problems of psychological nature, no of attacks)

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It was reported that client’s problem started 3 years ago. He ran off several times from

her home because she thought her husband was going to kill her. Her symptoms appeared and

her condition got worse after her father’s death.

Prior treatment: (detail of treatment sought of presenting problems and from whom; when and

for what duration treatment undergone; nature of treatment methods; name and doses of drugs

taken; ECTs, faith healing, responses to treatments including adverse reaction and side effects)

She was currently taking medication for his symptoms which includes donresp 4 mg,

xtine 12.5 mg, and steric 2 mg.

Medical history:(most recent physical exam; date of results; current medications, health

condition since childhood including details of serious illness/disabilities suffered and surgery

undergone; eating and sleeping habits if remarkable and any change of same; use of stimulants

alcohol, and drugs)

Nil.
Family history: (migration, births, marriages, serious illnesses, deaths, jobs of earning members,

relationship with family members)

The client got married from Dhodial and has 1 child. She is separated from her ex-

husband since 2 years.

She had satisfactory relationships with her siblings but unsatisfactory relationships with

his wife. His wife was ahl-e-hadees and he was ahl-e-sunnah because of which there were

conflicts among them. He did not have any friends and was only close to his mother, but his

mother died a year ago from heart attack. His relationship with his father was also

satisfactory who also died because of a heart attack. He was working at his father’s shop and his

condition got worse after his father’s death.

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School history: (Marks/divisions obtained, school changed, school problems, relationship with

peers and teachers, extracurricular activities)

She was average student and had a limited friends.

Work History: (Nature of job held and remuneration, reasons for job changes, relationship with

juniors, colleagues and bosses)

Client worked as a housewife and didn’t had a job

History of Friendship: (Nature and extent of relationships, recreational activities, degree of

religiosity, sexual history, premarital, marital and extra marital sexual relationships)

The client stated she had limited friends. She is not very social and communal.

Psychosomatic: (Obesity, headaches, painful menstruation, skin disorders, asthma, ulcers,

nausea and vomiting)

Client has obesity, poor appetite and difficulty in falling asleep.

Addictions: (prescribed and non-prescribed medication, narcotics use, smoking, pan/tobacco

chewing, alcohol use, gambling)

No addictions and no use of any medicines etc

Family psychopathology: (Nature, history, and treatment of mental disorders in family

members of patient's family)

Nill

Personality traits: (Schizoid, paranoid, schizotypal, antisocial, borderline, narcissistic,

histrionic, avoidant, dependent, obsessive-compulsive, passive aggressive)

Schizoid, Antisocial, Passive aggressive.

Interview Behavior: (Open, secretive, anxious, relaxed, withdrawn, cooperative, timid,

aggressive, compliant, oppositor)

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Reluctant

Orientation: (person, place, time)

She was not oriented to time and place

Sleep: (Insomnia, nightmares, sleep walking)

Sleep cycle was not normal and she often had nightmares.

Attention: (Concentration, memory)

Her attention, concentration and memory were disturbed.

Perception: (illusion, hallucination, auditory, visual, tactile, somatic and olfactory)

Persecutory delusions and Hallucinations.

Thoughts: (Unusual, content including suspiciousness and delusion, conceptual, disorganization

including losing of association)

Persecutory Delusions

Affect: (Crying spells, depression, guilt feeling, suicidal, excitement, hostility, grandiosity,

blunted affect)

Depression and blunted affect.

Behavior: (Speech, mute, talkative, abusive, restless, assaultive, destructive, excited, motor

retardation)

Se had low mood, and her speech was very low and hesitant

Mannerism and posturing: (unusual gestures, preservative movements)

Rigid pose and showed flat expression.

Diagnosis:
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On the basis of signs and symptoms, assessment, and Diagnostic and Statistical Manual

of Mental Disorders (DSM-V); the client has been diagnosed with 297.1(F22) Delusional

Disorder, Persecution Type.

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PSYCHODIAGNOSTIC REPORT

Name: Saiqa Bibi

Father’s Name: Ahmed Ali

Mother’s name: Remsha

Date of Birth: July 1995

Date of Assessment: 26 November 2022

Examiner: Sana Javed

Identifying Information

Saiqa is 27 years old, divorced Urdu speaking, Muslim Female. She is 3rd born among her

2 brothers and 1 Sister. She belongs to middle socio-economic status family with joint setup and

lives in Attarsheesha, Mansehra. She is educated and unemployed. She got married and has 1

child and She is separated from her Husband since 2 years.

Referral sources and Presenting Complaints

I approached the client for education purpose. Client was chosen on my own

Convenience and further information about her was given by her Sister. Clients presenting

problems include persecutory delusions, auditory hallucination, and social anxiety.

Interview Information

While interviewing Client mother reported that six months ago; when her son was

coming back to home after school, suddenly he was bitten by a dog running from elsewhere. The

dog viciously bite him (client) at his leg and arm, and put him off. Client was hurt and underwent

medical treatment for two months. After recovery, client became phobic of dogs. This unpleasant

encounter with a dog leads him to feel intense fear and anxiety when he thinks about, or sees or
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encounters a dog. In addition, client goes out of his way to avoid dogs. He also experiences

intense fear and panic attack when hearing a dog bark, watching a movie about a dog or going to

a place where a dog might be. Besides, the client also avoids friends and stays indoor because he

worries about meeting a dog. This scary encounter with a dog significantly affected his academic

performance, and social relationships. These terrifying memories can return whenever he thinks

or see a dog and causes significant dread, anxiety, and worry at the thought of being exposed to a

dog.

Psychological Assessment

Psychological assessment had done in two ways:

Informal Assessment

Informal Assessment Informal assessment of client’s problem was carried out through:

1. Interview 2. Behavioral Observation

Formal Assessment

Formal assessment was carried out through administration of standardized tests, which

are as follows:

Mini-Mental State Examination (MMSE). The MMSE was conducted on client. He

scored 17 on MMSE, indicating severe cognitive impairment.

Beck Anxiety Inventory (BAI). The BAI was administered on client. He got 30 scores

on BAL, demonstrating moderate level of anxiety.

Cynophobia Test (CT). The Cynophobia test (CT) was administered to evaluate fear of

dogs. The client scores on Cynophobia test were 34, demonstrating severe level of cynophobia.

Ten-Item Personality Inventory-(TIPI). The Ten-Item Personality Inventory (TIPI)

was administered on client to judge personality traits. The domain score on each personality trait
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are following: Extraversion: 2, Agreeableness: 5, Conscientiousness: 5, Emotional Stability: 3,

and Openness to Experiences: 5. This results indicates client’s personality traits are low on

agreeableness, conscientiousness, and openness to experience; while very low on extraversion,

and emotional stability.

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TREATMENT PLAN

Treatment Plan for overcoming this phobia was to give psychoeducation to the client and

mother and then applying counter conditioning to overcome using a systematic way (Exposure

therapy). This was done in following steps

Psychoeducation to client and mother

Psychoeducation was given to client and his mother about the specific phobia; its reasons,

and consequences. Full information about the nature of problem, current situation of the client

and the causal factors of the problems were specified to the client and his mother as she

supervises client for most of the times.

The client further received psychoeducation on three components of anxiety/ phobia (i.e.,

thoughts, physiological responses, and behavior); how anxiety/ phobia develops and perpetuates

(i.e., genetics, cognitions, safety behaviors, and avoidance), and how systematic desensitization

works to break the cycle of anxiety/ phobia by entering feared situations, confronting feared

objects in a calm state and learning that the situation and specific object is not harmful.

Systematic Desensitization

The systematic desensitization was used to treat client’s specific phobia. In systematic

desensitization, counterconditioning was applied. The feared object was paired with a new

response that was incompatible with anxiety. This new response replaced and blocked the fear

response. The essential task for a therapist conducting systematic desensitization was to expose

client systematically to dog-related stimuli. Based on his attack, client has associated dogs with

fear, but the truth is that for the vast majority of dogs, this is simply an inaccurate expectation.

Unfortunately for client, his avoidance of dogs since the attack has prevented him from having

the opportunity to “unlearn” the association between dogs and fear. Through systematic
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desensitization, therapist gave him exactly that opportunity, and the result of the systematic

exposure to dog-related stimuli was that client’s association between dogs and fear was

unlearned. Systematic desensitization was carried in two steps

Relaxation Trainings

At first, i taught the client deep breathing exercise. Deep breathing Deep breathing was

applied on client to decrease his restlessness, breathlessness, palpitation, and anxiety level. Its

purpose was to calm down the client. He was instructed to slowly and deeply inhale through the

nose; almost for a count of 10, followed by slow and complete exhalation for a similar count.

The therapist also guided client to imagine a peaceful situation during deep breathing. He felt

more relaxed and comfortable after practicing deep breathing. This deep breathing exercise was

also given to client as a home task.

Secondly Muscles Relaxation was conducted on client in order to decrease tension in

various body muscles. Its purpose was to relax the client.

Exposure To Anxiety- Producing Stimuli

Before exposing to anxiety producing stimuli, the client was asked to practice deep

breathing and muscle relaxation exercise. Exposure began at the lowest level and then proceeded

through the hierarchy until the client reached the highest level.
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SESSION REPORT

Name of the Patient: Ahmad Nadeem

Name of the Therapist: Muhammad Fawad Ibrahim

Session Date Summary of session Sig.Supervisor

1 22-12-2022 Client came with his Mother and initial rapport

was built with the client. His initial report and was

taken. His biodata was taken and presenting

problems were discussed thn we discussed about

his problems and about therapeutic process,

privacy and confidentiality and times set for

further sessions.

2 23-12-2022 Clients History of Present illness was taken from

his Mother, His Mother reported reported the

incident that occurred to him. Further his past

psychiatric history, family history, personal

history, friendship – social history and medical

history was taken and mental state was examined.

3 25-12-2022 Client reached on time and psychological tests

were applied to him, completed evaluation and

diagnose illness to the client and therapeutic

technique were planned.

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4 27-12-2022 Psychoeducation was given to client and his

mother about the problem

5 29-12-2022 Systematic desensitization was used to overcome

the phobia of client. He was taught breathing

exercises and relaxation techniques and was asked

to practice this

6 31-12-2022 Client practiced techniques taught and was

motivated before exposure to problem that causes

7 3-1-2023 Client was exposed to problem creating stimuli

8 5-1-2023 Client interacted with problem creating stimuli

and overcame his phobia- fear.

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Terminal Report

Name of the patient: Ms. Saira Khan

1: Date of the interview: 21-12-2022

2: Date of terminal interview: 31-12-2022

3: Total number of sessions: 6 sessions

4: Reason for termination, (planned/withdrawal):

Planned (client become better and no need for session)

5: Condition for discharge:

A. Recover with good insight

B. Be markedly improved

C. Moderately improved

D. Slightly improved

E. Verse improved

7: Areas of improvement:

A. Symptoms mention

B. Adjustment to environment.

C. Physical function

D. Worry and nervousness about things

8: Patient attitude towards therapist at discharge:

A. Friendly
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B. Indifferent

C. Unfriendly

9: Would patient objection. (Yes/No): No

10: Recommendation to the patient at discharge: Need counselling and support

11: Diagnosis at discharge:

At discharge the client has become fully recovered of her problem.