CASE REPORTS
Table of contents
Case report 1
Case report 2
Case report 3
Case report 4
Case Report 1
Identifying data
Name initial NA
Gender Man
Age 30
Education Intermediate
Marital status Single
Patient Drug addict
Source and Reason for Referral
Referred by psychiatrist
Presenting Complaints
Table 1
Presenting Complaints according to the client
Intensity/ Complaints
Duration
18 years 60% Stealing habit
9 year 70% Drug addiction
3 years 80% Low mood
3 years 90% self dislike
20 years 90% Poor problem solving
20 years 70% Poor decision making
20 years 60% Discrimination by parents
20 year 70% Attention seeker
20 years 50% Passive communication
Behavioural Observation
The client was an educated heighted man with average weight. His personal hygiene was good
and was wearing neat and tidy clothes. He appears active, energetic, and was in good mood. He
was maintaining good eye contact. His sitting posture was much relaxed. The client seems quiet
motivated to seek treatment.
Developmental History of the problem
WR was having the problem from 18 years.
Personal history.
Birth Order 2nd
Childhood Client don’t have satisfactory relations with his father, According to the client in
his childhood there is not a single day or event to remember in which he experienced the sense of
security, warmth, love and attention from his father.
Actually client’s father was the only earner of his family, he has the burden of 7 people including
him that is why he was unable to attend his Family.
Educational History
Client’s schooling was of a government school. He was a good student, and always got good
grades. He likes reading and exploring different books. His education was till intermediate, he
was unable to continue his studies because the family cannot afford the further expenditures. The
client’s relationship with his teachers, fellows and friends were good, and he uses to respect
everyone. He had never gone through any kind of adjustment difficulties as he was a social
person, and was good in making adjustment
Pre-morbid personality
He had a healthy premorbid personality.
Marital history
He is not married.
Occupational history
The client has a long occupational history. He had worked in up to 15 organizations. The
posts on which he worked were accountant, cashier, receptionist, computer operator, data
enterer, and assistant web developer. The reason for several job shifts was that he was caught
several times when performing the theft. Several times he was hired on warning, but he
continued the same act, that is why he was fired from several organizations, and some were left
by him by choice as the pay was too low and work load was great.
History of family psychiatry/medical illness
There is a family history of psychiatry and medical illness as client’s elder brother is also a
substance abuse, his mother is hypertensive and is sugar patient while his father has hepatitis - C
Assessment
The assessment was carried out in different dimensions. Following is the list of
assessment techniques which were carried out with the client.
• Behavioural Observation
• Clinical Interview
• Mental Status Examination
• Subjective Ratings
Behavioural observation
The client was a person of inferiority complex and was disheartened too. But he gave
answers frequently also he wanted to change himself. Client was wearing clean clothes.
He was not distracted, he focused on every detail of the session.
Clinical interview
It is a face to face interaction in which clinician asks questions of clients’ problems, their
responses and reactions. Clinician collects the detailed information about the person’s problem,
feelings, life styles, relationships and other personal history. Clinical interview was conducted
with the client to get detailed information about his family, personal and the history of
psychiatric problem. The client had proper insight about his problem, and he was motivated to
seek treatment. During the complete interview session the client was very complaint, and was
attentive.
Mental status examination
The client was much compliant, and was maintaining a good eye contact. He seems to be much
cooperative, attentive, interested in session. He was vigilant and alert, and was actively listening.
His orientation was good as he responded accurately when asked about the place, season, year,
date, month, time and city. His rate of speech was normal, and tone was soft. The quality of
speech was emotional. Client’s mood was appropriate with his affect. He was in good mood and
was energetic. His thought process was logical, goal directed, appropriate, and was relevant with
the situation. His thought content involves the messages to self about the “right” and “wrong”.
He had a proper insight about his problem and was motivated to seek treatment
Subjective rating.
Table 2
Patient’s Symptoms and their Ratings by the Client
Symptoms Ratings(0/10)
Stealing habit 10
Carving of drugs 4
Sadness 9
Worthlessness 10
Self dislike 10
Passivity 10
Muscle pain 9
Case formulation
Precipitating factor
Is refer to a specific event or trigger to the onset of the current problem. In this case client's bad
relationship with his family and girlfriend trigger his problem.
Perpetuating factors
They are those that maintain the problem once its established. He was continuously staying away
from his family and home it maintained his problem.
Protective factors
These are strengths of the person to reduce the severity of problem and promote healthy and
adaptive behaviour. In WR's case his psychiatrist helped him to make him aware of his problem.
Suspected problem
According to DSM-5 the client was suspected to be Drug Addiction.
Intervention Plan and Management
Intervention plan was designed to help the client to resolve problem he is facing and to aid the
natural process of adjustment, to develop a positive self-concept and to save him, and to learn to
interact with others.
Therapies that will be applied
i. By using supportive therapy build a level of trust with the client and create a supportive
environment that will facilitate the client to share his problems.
ii. Psycho educates the client about the harmful effects of the substance use.
iii. Asking the relevant questions to probe the underlying factors of her problems.
iv. Explore experiences from the client’s early life that contributes to develop the problem.
v. Active listening, positive reinforcement, reassurance and unconditional acceptance to facilitate
his sharing and catharsis.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th
edition, Washington DC: American Psychiatric Association; 2013.
Case Report 2
Identifying data
Name initials NA
Gender Girl
Age 20
Education BS Biotechnology
Marital status Single
No of sessions Two
Patient Anxiety
Source and Reason for Referral A doctor referred her
Presenting Complaints
Table 1
Presenting Complaints according to the client
(0-10)Intensity Complaints
10-9 Fear of interaction with people
8-10 Sleep difficulties
6-10 Less apatite
6-10 Tiredness
8-10 Discomfort
7-10 Headache
Behavioral Observation
Her behaviour was normal at the beginning, but when I started questioning her she got
confused. Her behaviour was not so well at start she didn’t answered me clearly but slowly
slowly she opened up. Her sitting style was telling she was confused and was afraid too.
Her hands were shivering slowly slowly. She tried to communicate but she was hesitated.
Developmental History of the Problem
Her anxiety began at the age of 15. She used to be stressed out because of her studies.
Her parents pressurised her for high marks and she was so anxious about that.
Personal history
Birth Order Single child
Childhood Her childhood was normal. She got normal development her social background
was strong as well. She got good schooling.
Educational History She was good in her primary and higher education. Her behaviour was
good with her classmates as well as with her teachers
Vocational History She is a student.
Pre-morbid personality
According to patient she was doing fine.
Sexual history.
Her menstrual period started in class 8 and her age was 13.
When she had her periods she got nervous and started crying as she was unaware of it. Her
mother guided.
Marital history
She is not married still single
Educational history
She studied in oxford school and was a position holder her matric was done from here
She joined Allama Iqbal College for further studies. In college her performance and grades were
affected because of her anxiety.
Her relationship with her teachers and class mates was normal she often hesitate while
interacting with them as her anxiety made her antisocial person.
Occupational history
She is a student.
History of family psychiatry/medical illness
None of her family member had any mental illness. Her father was a patient of diabetes
Assessment
The assessment was carried out in different dimensions. Following is the list of
assessment techniques which were carried out with the client.
• Behavioral Observation
• Clinical Interview
• Mental Status Examination
• Subjective Ratings
• Back anxiety inventory
Behavioural observation
Client was very nervous at the beginning, as she was an antisocial person she didn’t
shared her problem openly with me. Her way of sitting and talking were telling how nervous she
was. She was not making eye contact at start, as she was avoiding the questions.
Slowly slowly she became comfortable and started talking openly and shared her problems
directly. Her behaviour was not rude she wanted to change herself and get rid of anxiety. She
was cooperative as she conducted the sessions sincerely.
Clinical interview
A clinical interview is a conversation between a clinician and a client that is intended to
develop a diagnosis. It is a "conversation with a purpose" that can be structured, semi-structured,
or unstructured. Emphasis is placed on open-ended questions with the focus being on the patient
and not the clinician. Clinical interviews are used with other measures and methods to diagnose
the patient. There are many different types of clinical interviews: diagnostic, termination,
orientation, selection, intake, case history, and mental status exams are all examples
To diagnose the problem of my client, I conducted clinical interview. The questioning
session started and she was allowed to give answers freely. Through this interview her anxiety
was diagnosed. She was having severe anxiety and that was the reason behind her fear, antisocial
personality and odd behaviour towards people. Open ended questions were asked from her. She
was answering questions but the way she was talking showed her nervousness and anxiousness.
During the whole interview she eye contacted very less.
Mental status examination
Her looks were fine because she was nervous she walked slowly. She tried to talk
normally but because of her nervousness she was not making strong eye contact. Her hands were
shivering while talking, it was easily seen that she is trying to look normal but she couldn't.
Her speech was not organized as well, because she was anxious she repeated her words.
She was not telling unnecessary details, when I asked her current time and what is the weather
outside she got nervous and couldn't tell me. As her current mood was not so good she answered
every question I asked but nervously. According to her, study pressure was the cause of her
anxiety and antisocial behaviour.
Subjective rating.
Subjective rating scales are widely used in almost every aspect of ergonomics research
and practice for the assessment of workload, fatigue, usability, annoyance and comfort, and
lesser known qualities such as urgency and presence of any behavior. In subjective rating based
on any rating that a person gives that is based on their subjective reaction or opinion, their
feelings, desires, priorities. The subjective rating used to assess the client current level of
functioning and rating the client symptoms which helpful to managed the client behavior need to
be managed.
Table 2
Patient’s Symptoms and their Ratings by the Client
Symptoms Ratings (0-10)
Workload 7-10
Fear 8-10
Discomfort 7-10
Sleep difficulties 8-10
Less appetite 7-10
Case formulation
Presenting problems
These are concerns that clients find difficult to manage. In this case my client was having
difficulties in managing her fear because of anxiety.
Precipitating factor
Is refer to a specific event or trigger to the onset of the current problem. In this case the pressure
of grades acted as a precipitating factor which triggered the symptoms of anxiety in her.
Perpetuating factors
These are those that maintain the problem once its established. Fear of bad grades, interaction
with people acted as perpetuating factor.
Protective factors
These are strengths of the person to reduce the severity of problem and promote healthy and
adaptive behaviour. In this case support of her friend acted as a protective factor.
Suspected problem
According to DSM-5 (American Psychological Association, 2013) the client was suspected to be
with social anxiety.
Intervention Plan and Management
BT was applied to the client
Exposure therapy will be used with client
As she was antisocial person, In exposure therapy we started by giving her imaginal view. After
that side by side also worked on her unconscious fears, as she always felt like she is drowning in
the water or she is locked in a cupboard or in a dark room and no one is there to help her.
At start imaginal exposure of people made her afraid and she started shivering badly. But slowly
slowly she tried to control herself.
Cognitive Behavioural Therapy
Cognitive-behavioural therapy for adult anxiety disorders is very effective and widely accepted
by the most researchers. So this therapy will be used explained to the patient the mechanism of
anxiety formation and maintenance and the fact that this must be understood in terms of the
vicious circle that negative thoughts produce which, in turn, produces an anxious state that
generates negative thoughts also explained to her that the external events do not produce the
negative affective states and that these are produced by her attitude towards the external events
and that she can modify the negative emotions by changing this negative attitude.
informed the patient that psychotherapy aims to help the patient become
aware of the anxiety that represents a side of her existence which is linked to the vulnerability of
each human being and to find in herself the resources to live, to achieve her goals, and to
properly develop her latent capabilities.
Case Report 3
Identifying data
Name initials NA
Gender Girl
Age 8
Education She is in 5 class
Marital status Single
No of sessions Two
Patient Autism
Source and Reason for Referral Referred by her teacher
Presenting Complaints
Table 1
Presenting Complaints according to the client
(0-10)Intensity Complaints
7-10 Less of appetite
6-10 Feel unsafe
7-10 Lack of interest in environment
7-10 Lack of sleep
Behavioural Observation
Client was really nervous. She was not answering the questions as she was the patient of autism,
she was not making any eye contact.
It was difficult for her to focus on something. In second session she gave answer of a few
questions but still she was not making any eye contact at all. By engaging her in different
activities, it became possible to get answers.
Developmental History of the problem.
AL presented with a 4-year history of impairments in all aspects of the autistic triad: social
interaction, imagination, and social communication.
Personal history.
Birth Order second
Childhood AL was born five weeks pre-term weighing 4 lbs and 9 oz. She spent four weeks in
a neonatal unit to gain sufficient weight. She had a childhood developmental delay and learning
disabilities.
Educational History She is in 5 class. Her interaction with her classmates was poor. Also her
teacher noticed a lack in the drive to explore environments and ability to ‘parallel play, a
developmental concept whereby infants begin to play alongside each other.
Vocational History Student
Pre-morbid personality.
She had a premorbid personality of being introvert.
Marital history.
She is not married.
Educational history.
She is studying in a higher education school which is a private school.
Occupational history.
She is a student
History of family psychiatry/medical illness.
There was no family history of mental or physical illness.
Assessment
The assessment was carried out in different dimensions. Following is the list of
assessment techniques which were carried out with the client.
• Behavioural Observation
• Clinical Interview
• Mental Status Examination
• Subjective Ratings
• Autism rating scale
Behavioural observation.
As the client seems shy she was really nervous at beginning. She was having difficulty in
concentrating and maintaining on seat behavior. She was a kid so it was becoming difficult for
her to give answer of each question being asked. She had difficulty in maintaining attention.
Also she was a bit afraid at the beginning of the session.
Clinical interview.
To diagnose the problem of client, Clinical interview was conducted. The questioning
session started and she was allowed to give answers freely. Through this interview her autism
was clearly diagnosed. She was experiencing it from 4 years AL’s parents reported a sleep
latency problem as well.
AL had poor interpersonal relationships, driven by poor verbal and non-verbal comprehension.
Her expressive language was vague, her sentences were long enough and had the right grammar
and syntax. But the words she chose did not quite communicate her meaning so it was hard to
decoding the message
Mental status examination
Mental state examination conducted upon hospital revealed that, Autism spectrum
disorder is a developmental neurological disorder characterized by a typical development in
social interaction in communication. It was hard to deal her, she tended to monopolise the taking,
worked hard to steer it toward one of her favourite subjects and did not appear to listening when
it was the other person’s turn to talk. He had trouble with focus and attention, she was quite
distractible.
She had two favourite subjects and didn’t really talk much about anything else.
Case formulation
Presenting problems
In this case client was having problem of focusing, she was unable to concentrate, and also she
had no interest in anything except her three favourite subjects. She was having difficulty in
maintaining thoughts.
Precipitating factor
Refer to a specific event or trigger to the onset of the current problem. In this case her problem
of distraction was precipitating factor.
Perpetuating factors
These factors are those that maintain the problem once its established. She was unable to focus
on anything as well as her disorganized thoughts maintained the problem.
Protective factors
These are strengths of the person to reduce the severity of problem and promote healthy and
adaptive behaviour. In AL's case her mother wanted her to be like a normal kid and behave like
them, to take interest in things like normal kids do.
Suspected problem
According to DSM-5 the client was suspected to be Autistic.
Proposed Intervention Plan and Management
Therapy that should applied
Occupational Therapy
Behavioural Therapy
Cognitive Therapy
Case Report 4
Identifying data
Name initials NA
Gender Male
Age 25
Education Graduate
Marital status Single
No of sessions Two
Patient Schizophrenia
Source and Reason for Referral Referred by his mother
Presenting Complaints
Table 1
Presenting Complaints according to the client
(0-10)Intensity Complaints
10-9 Hearing voices
8-10 Loss of appetite
9-10 feel unsafe
7-10 delusions
7-10 difficulty in sleep
Behavioural Observation
Client was talking normally but it was clearly seen that he was not answering openly. He did
least eye contact, his way of sitting was not so comfy. Few times he repeated his answers and he
was a bit confused as well.
At the beginning he wasn’t comfortable but slowly slowly he started sharing his problems easily.
He shared his past experiences too.
Developmental History of the Problem
His schizophrenia began from the past 10 months. He felt unsafe in his house and thought
that people are trying to harm him. He had delusions too.
Personal history.
Birth Order first child from sibling
Childhood His childhood was normal. He got normal development his social background was
strong as well. He got good schooling.
Educational History He was good in his primary and higher education. His behaviour was not
so good with his classmates his personality was a bit aggressive.
Vocational History Job holder
Pre-morbid personality.
He had a premorbid personality of being introvert.
Marital history.
He is not married.
Educational history.
He studied in Bacon House School and was an average student his matric was done from
here
He joined Punjab College for further studies. In college his performance and grades were
average too, same as in school.
His relationship with his classmates was not so friendly he had few friends not more.
Occupational history.
He is a job holder
History of family psychiatry/medical illness.
There was no family history of mental or physical illness.
Assessment
The assessment was carried out in different dimensions. Following is the list of
assessment techniques which were carried out with the client.
• Behavioral Observation
• Clinical Interview
• Mental Status Examination
• Subjective Ratings
Behavioral observation.
As the client was introvert he was hesitated at beginning. He was having difficulty in
concentrating and maintaining train of thoughts. His emotions were disturbed, because he
believed his symptoms were spiritual as well as he repeated the answers of few questions.
He was not showing any expression. He was afraid of his lost of control and he was avoiding the
questions too.
Clinical interview.
To diagnose the problem of my client, I conducted clinical interview. The questioning
session started and he was allowed to give answers freely. Through this interview his
schizophrenia was diagnosed. He was experiencing hallucinations and delusions. Open ended
questions were asked from him.
As he believed that his emotions were spiritual he was saying that spirits are controlling him. He
said he is fine, but his family members are trying to harm him. He was avoiding eye contact and
he was trying to avoid questions.
Mental status examination.
Mental state examination conducted upon hospital admission revealed that the patient
was emaciated and appeared informally dressed. He exhibited apprehensive behaviour, fatuous
laughter, and hesitancy. His mood was depressed and affect constricted. The patient experienced
auditory hallucinations. He complained of hearing voices and engaged in third person
conversations involving both a man and a woman. The patient also complained that he heard
people talking about him and insulting him, some of whom he knew. He was therefore
suspicious and felt uneasy.
Subjective rating.
Table 2
Patient’s Symptoms and their Ratings by the Client
Symptoms Ratings (010)
Lost of appetite 7-10
Delusions 8-10
Discomfort 7-10
Sleep difficulties 8-10
Hallucinations 7-1
Disorganized thoughts 7-10
Case formulation
Presenting problems
In this case client was having delusions, hallucination, he was afraid of being harmed, his
thoughts were disorganized and he was having sleeping difficulty.
Precipitating factor
Are refer to a specific event or trigger to the onset of the current problem. In this case job
pressure and separation from her finance trigger him.
Perpetuating factors
Are those that maintain the problem once its established. Constant fear that his family will harm
him as well as delusions and hallucinations maintained his problem.
Protective factors
Those are strengths of the person to reduce the severity of problem and promote healthy and
adaptive behaviour. In this case the client himself wanted not to became severe schizophrenic
patient and his family helped him as well.
Suspected problem
According to DSM-5 the client was suspected to be Schizophrenic
Intervention Plan and Management
The client had not taken prescription medications in the past six months prior to being seen
at the hospital since he had not been diagnosed with any mental illness previously. He had no
known allergies, and he did not smoke or use recreational drugs. The patient demonstrated
suspected adherence concerns since he had poor insight and repeated several times that there was
nothing wrong with him.
Therapy that will apply
Medication
Occupational Therapy
Behavioural therapy
