Contents

Introduction ..................................................................................................................................... 3

Diagnostic criteria ....................................................................................................................... 5

Differential Diagnosis ................................................................................................................. 8

Co morbidity ............................................................................................................................... 9

Case 2 ............................................................................................................................................ 10

Duration of session .................................................................................................................... 10

Referral ...................................................................................................................................... 10

Identifying data ......................................................................................................................... 10

Presenting complaints ............................................................................................................... 11

Symptoms .................................................................................................................................. 12

Behavioral observation .............................................................................................................. 13

Personal History ........................................................................................................................ 13

Birth and milestone ................................................................................................................ 14

Childhood history .................................................................................................................. 14

Educational History ............................................................................................................... 14

Work history .......................................................................................................................... 15

Past psychiatry history ........................................................................................................... 15

Medical history/ surgical history ........................................................................................... 15

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 Family History ....................................................................................................................... 15

Relationship with parents ...................................................................................................... 15

Relationship with siblings ..................................................................................................... 16

History of present illness ........................................................................................................... 17

Premorbid personality............................................................................................................ 17

Onset of illness: ..................................................................................................................... 17

Past psychiatric history .......................................................................................................... 18

Informal assessment .................................................................................................................. 18

Formal Assessment ................................................................................................................ 19

Mental Status Examination (MSE) ........................................................................................ 19

House Tree Person (HTP)...................................................................................................... 24

Beck Depression Inventory ................................................................................................... 26

Beck suicide intent scale: ...................................................................................................... 26

Case Formulation ...................................................................................................................... 26

Therapeutic recommendation........................................................................................................ 26

1. Cognitive Behavioural Therapy ......................................................................................... 31

Locate the problem and brainstorm solution: ............................................................................ 32

Psychotherapy ........................................................................................................................... 33

3. Relaxation technique .......................................................................................................... 34

Prognosis ....................................................................................................................................... 34

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 Introduction

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder

characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of

interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians

in the mid-1970s, the term was adopted by the American Psychiatric Association for this

symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical

Manual of Mental Disorders (DSM-III), and has become widely used since. The diagnosis of

major depressive disorder is based on the person's reported experiences, behavior reported by

relatives or friends, and a mental status examination. There is no laboratory test for the

disorder, but testing may be done to rule out physical conditions that can cause similar

symptoms. The most common time of onset is in a person's 20s, with females affected about

twice as often as males. The course of the disorder varies widely, from one episode lasting

months to a lifelong disorder with recurrent major depressive episodes. Those with major

depressive disorder are typically treated with psychotherapy and antidepressant medication.

Medication appears to be effective, but the effect may be significant only in the most severely

depressed. Hospitalization (which may be involuntary) may be necessary in cases with

associated self-neglect or a significant risk of harm to self or 7 others. Electroconvulsive

therapy (ECT) may be considered if other measures are not effective. Major depressive

disorder is believed to be caused by a combination of genetic, environmental, and

psychological factors, with about 40% of the risk being genetic. Risk factors include a family

history of the condition, major life changes, certain medications, chronic health problems,

and substance use disorders. It can negatively affect a person's personal life, work life, or

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education, and cause issues with a person's sleeping habits, eating habits, and general health.

Major depressive disorder affected approximately 163 million people (2% of the world's

population) in 2017. The percentage of people who are affected at one point in their life

varies from 7% in Japan to 21% in France. Lifetime rates are higher in the developed world

(15%) compared to the developing world (11%). The disorder causes the second-most years

lived with disability, after lower back pain.

Major depression significantly affects a person's family and personal relationships, work or

school life, sleeping and eating habits, and general health. A person having a major

depressive episode usually exhibits a low mood, which pervades all aspects of life, and an

inability to experience pleasure in previously enjoyable activities. Depressed people may be

preoccupied with— or ruminate over—thoughts and feelings of worthlessness, inappropriate

guilt orregret, helplessness or hopelessness. Other symptoms of depression include poor

concentration and memory, withdrawal from social situations and activities, reduced sex

drive, irritability, and thoughts of death or suicide. Insomnia is common; in the typical

pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or

oversleeping, can also happen. Some antidepressants may also cause insomnia due to their

stimulating effect. In severe cases, depressed people may have psychotic symptoms. These

symptoms include delusions or, less commonly, hallucinations, usually unpleasant. People

who have had previous episodes with psychotic symptoms are more likely to have them with

future episodes.

A depressed person may report multiple physical symptoms such as fatigue, headaches, or

digestive problems; physical complaints are the most common presenting problem in

developing countries, according to the World Health Organization's criteria for depression.

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Appetite often decreases, resulting in weight loss, although increased appetite and weight

gain occasionally occur. Family and friends may notice agitation or lethargy. Older depressed

people may have cognitive symptoms of recent onset, such as forgetfulness, and a more

noticeable slowing of movements.

Depressed children may often display an irritable rather than a depressed mood; most lose

interest in school and show a steep decline in academic performance. Diagnosis may be

delayed or missed when symptoms are interpreted as "normal moodiness." Elderly people

may not present with classical depressive symptoms. Diagnosis and treatment is further

complicated in that the elderly are often simultaneously treated with a number of other drugs,

and often have other concurrent diseases.

Diagnostic criteria

The individual must be experiencing five or more symptoms during the same 2-week period

and at least one of the symptoms should be either

(1) Depressed mood

(2) Loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,

nearly every day.

3. Significant weight loss when not dieting or weight gain, or decrease or increase in Appetite

nearly every day.

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4. A slowing down of thought and a reduction of physical movement (observable by others,

not merely subjective feelings of restlessness or being slowed down).

5. Fatigue or loss of energy nearly every day.

6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a

Suicide attempt or a specific plan for committing suicide.

To receive a diagnosis of depression, these symptoms must cause the individual clinically

significant distress or impairment in social, occupational, or other important areas of

functioning. The symptoms must also not be a result of substance abuse or another medical

condition.

• Major depressive disorder is associated with high mortality, much of which is

accounted for by suicide. As a result, if you think someone you care about may be

suffering from depression it is important to know the warning signs of suicide and to

take suicidal statements extremely seriously. An active statement by someone with

suicidal ideation might be something like, ―I‘m going to kill myself,‖ but other

passive statements such as, ―I wish I could just go to sleep and never wake up,‖ are

equally worrying. If someone with depression exhibits these verbal markers,

encourage them to consult a mental health professional immediately.

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 • Depressed individuals also present with irritability, brooding, and obsessive

rumination, and report anxiety, phobias, excessive worry over physical health, and

complain of pain.

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the

DSM-5, added two specifies to further classify diagnoses:

• With Mixed Features – This specifies allows for the presence of manic symptoms

as part of the depression diagnosis in patients who do not meet the full criteria for a

manic episode.

• With Anxious Distress – The presence of anxiety in patients may affect prognosis,

treatment options, and the patient‘s response to them. Clinicians will need to assess

whether or not the individual experiencing depression also presents with anxious

distress.

But depression is more than just sadness, and not simply by a measure of degree. The

difference doesn‘t lie in the extent to which a person feels down, but rather in a

combination of factors relating to the duration of these negative feelings, other symptoms,

bodily impact, and the effect upon the individual‘s ability to function in daily life.

Sadness is a normal emotion that everyone will experience at some point in his or her life.

Be it the loss of a job, the end of a relationship, or the death of a loved one, sadness is

usually caused by a specific situation, person, or event. When it comes to depression,

however, no such trigger is needed. A person suffering from depression feels sad or

hopeless about everything. This person may have every reason in the world to be happy

and yet they lose the ability to experience joy or pleasure.

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With sadness, you might feel down in the dumps for a day or two, but you‘re still able to

enjoy simple things like your favorite TV show, food, or spending time with friends. This

isn‘t the case when someone is dealing with depression. Even activities that they once

enjoyed are no longer interesting or pleasurable.

What‘s more, when you experience sadness triggered by a certain something you‘re still

able to sleep as you usually would, remain motivated to do things, and maintain your

desire to eat. Depression, on the other hand, is associated with serious disruption of

normal eating and sleeping patterns, as well as not wanting to get out of bed all day.

Specified

Client has a major depressive disorder with anxious distress:

1. Feeling keyed up or tense.

2. Feeling unusually restless.

3. Difficulty concentrating because of worry.

4. Fear that something awful may happen.

Differential Diagnosis

Manic episodes with irritable mood or mixed episodes. Major depressive episode with

prominent irritable mood may be difficult to distinguish from manic episodes with

irritable mood or from mixed episodes. This distinguish require a careful clinical

evaluation of the presence of manic symptoms.

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Substance/medication- induced depressive or bipolar disorder. This disorder is

distinguish from major depressive by fact that a substance ( e.g. a drug of abuse a

medication , a toxic ) appears to be etiologically related to the mood disturbance for

example depressed mood that occurs only in the context of withdrawal from cocaine

would be diagnosed as cocaine induced depressive disorder.

Co morbidity

Co morbidity is the presence of one more additional disorders co-occurring with a

primary disease or disorder or the effect of such additional disorder or diseases. The

additional disorder may also be a behavioral or mental disorder. The client was observed

with co-occurring with antisocial personality disorder, borderline personality disorder.

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 Case 2

Duration of session

The sessions were conducted from November 16, 2022 to November 20, 2022. Each

session was of 1 hour.

Referral

The client was first diagnosed with depression by her doctor brother. He observed his

attitude from last 8 to 9 months after the death of his father. And then they visited psychologist

in Islamabad for the first time and diagnosed with the depression. And here she started proper

treatment with medications.

Identifying data

Name: A.S

Age: 35 years

Gender: female

Qualification: MA Urdu

Occupation: Housewife

Marital status: Married

No of siblings: 2

Birth Order: 2nd (last born, youngest)

Father alive/ deceased: Deceased

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‫‪Father‘s education:‬‬ ‫‪MA Urdu‬‬

‫‪Mother alive/ deceased:‬‬ ‫‪Living‬‬

‫‪Mother‘s education:‬‬ ‫‪B.Sc.‬‬

‫‪Mother‘s occupation:‬‬ ‫‪Tailor‬‬

‫‪Family structure:‬‬ ‫‪Joint family.‬‬

‫‪Social economic status:‬‬ ‫‪Middle-Class‬‬

‫‪Religion:‬‬ ‫‪Islam‬‬

‫‪Resident:‬‬ ‫‪Rawalpindi‬‬

‫‪Language known:‬‬ ‫‪Urdu, Punjabi, English‬‬

‫‪Informant:‬‬ ‫‪Client, Husband, Mother‬‬

‫‪Presenting complaints‬‬

‫‪By client‬‬

‫مجھےہر وقت سر میں درد رہتا تھا۔کسیسے بات کرنے کا بلکل بھی دل نہیں کرتا رونا بھت زیادہ آتا تھا‬

‫بھوک نہیں لگتی۔کچھ بھی اچھا نہیں لگتا ۔‬

‫صہ آتا ہے۔‬

‫جب گسرے ہوئے واقعات یاد آتے ہیں تو میں خود کو نہیں سنبھال نہیں پاتی۔‬

‫بس دل کرتاہے کہ ہر وقت اپنے کمرے میں اکیلی بیٹھی رھو۔‬

‫دل کرتاہے سب کچھ توڑ دوں۔‬

‫بچوں کے شعراء مجھے سخت چر ہے ۔‬

Client showed inappropriate behavior when arrived for treatment. She was aggressive and is

preoccupied with negative and suicidal thoughts. She was very emotional and hesitant.

Inappropriate behavior, Gestures, and self mutilating are also present in the client. She was

unable to pay attention during session .Client also has social phobia.

Symptoms:

• Low mood

• Fatigue

• Restlessness

• Less interest in daily activities

• Social withdrawal

• Restlessness

• Occasionally breaks household items

• Loss of weight

• Loss of appetite

• Insomnia

• Feeling of worthlessness

• Crying spells

• Suicidal attempts

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Behavioral observation

Session 1

In the first session the client was very shy and don‘t want to share any information and unable to

answered my questions properly. She was totally failed in maintaining eye contact. She was

unable to sit properly and shows continuous movement. She was not in mood to share any

information. Upset in starting later when the rapport was developed the client showed less

intensity in the mentioned specifications and when certain questions were asked on her

information and test description. She showed defensive attitude.

Session 2

The client has showed relatively opened attitude. She shared a lot about her past experiences. but

still on my few questions she just refused to answer such as in laws attitude and brothers after

death of her father.

Session 3

The client was relatively stable. Irritability and agitation was reduced she shared everything

about herself.

Background information

Personal History

Client is 35 years old female. She is the resident of Rawalpindi. She belongs to the

middle-class family. Her father died when she was 17 years old. She has 1 elder sister. She is the

youngest one. She is married for about 10 years and currently living in a joint family with her

husband and in laws.

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Birth and milestone

She was born via spontaneous vaginal delivery (SVD). No complications were reported

during pregnancy. No postnatal complications were seen. She achieved and completed her

milestones at appropriate age.

Childhood history

She had good relationships with her parents and siblings. She used to play and socialize

in her early childhood and early teenage. Later on, she become less social. No traumatic event

happened to her other than the death of his father which was the worst trauma for her as she was

very attached to him. But she gradually composed herself and got over it. She was quiet, slightly

stubborn and get irritated during stress conditions as she was very bad at coping stress. She had

good and pleasant childhood.

Peer relationship

She was social in childhood and teenage but later on she become less social. She had few

friends and she was very concerned about them. She was caring and very friendly. She always

manages time for them, no matter how busy she was. Still she is in contact with them but now

she lost her interests in friendships.

Educational History

She started her school at the age of 4. She was an average student. She failed her F.sc and

repeated her 2nd year 2 times because the trauma of her father's death. Later on, she completed

her B.A. She completed her M.A in Urdu after her marriage.

14
Work history

After her bachelor's degree she worked as a teacher in a local school for about 3 years but

she left her job after her marriage and became a housewife

Past psychiatry history

The client has no specific psychiatry history. But her mother told that she was attached to

her father and her father death is the major trauma for her and for many years she stuck there but

then gradually she returned back to life.

Medical history/ surgical history

Client was suffered from Poly cystic ovaries syndrome (PCOS). Those cysts were turned

into tumours therefore ovaries had to remove. This is the major cause of her infertility. Now, she

is taking medication for her depression, namely Tab Citalopram, Tab Luvox and Tab Alp.

Family History

Client is 35 years old female she is married and living in a joint middle-class family. She

is married for 10 years. Her mother is tailor. Her father died of heart attack in 2001 when client

was 17 years old. Her elder sister is married and she is living in Karachi with her family. She is

married to her cousin (uncle's son). Her husband is a govt teacher. Her mother in law is also

tailor and her father in law is paralyzed. She has 2 sisters in law who are married.

Relationship with parents

Client's mother is alive and she has a good relationship with her mother. Her father is

died 18 years ago. Her mother reported that she was more attached to her father and after her

father's death she used to live according to his rules and regulations. She used her father's field as

a passion. Her mother reported that she was responsible, caring and sensible daughter and she

15
stands firmly besides her family in every hard and tough situation. Her relationship with her

parents was very good.

Relationship with siblings

Client has 1 elder sister who is married and living in Karachi. Client has a good relationship with

her sister. She reported that her sister is her best friend and she used to share everything with her.

Her relationship with her siblings is very good.

Relationship with husband

Her husband mentioned that they married happily. They did love marriage. He reported

that client was very loving, caring and responsible wife. She looks after his family and home

very carefully and devotedly. He further reported that they were living a good healthy life but

after her operation she doesn‘t accept her infertility and things got worse day by day. He

reported:

Relationship with in-laws

Client's mother and father in-law are alive. She has 2 sisters in-laws who are married and

living with their families. After her marriage she had a good family terms with them but from

last 4 years she is having poor family terms with them. Her bad terms are due to her infertility.

Her mother in-law is very strict and conservative so that‘s why she used to taunt client on her

infertility. As client reported that:

Family medical history

Client's father is died of heart attack. Her father in-law is paralyzed. Client has no medical

history.

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Family Psychiatry history

Client's mother had depression and anxiety after the death of her father. But now she is

recovered.

History of present illness

Client was depressed and accused of misbehavior after the death of her father. She spent

most of her time alone in room. She just stays in home refused to attend any gathering or family

events. By passage of time she was unable to adjust in social settings. No hallucinations are

reported. No delusional experiences are reported. Client report that she over think every single

matter and no physical injury has been reported.

Premorbid personality:

She was sensible, responsible and caring person. She was extrovert and very jolly person.

She was slightly stubborn she had no psychological illnesses before. She used to manage

everything perfectly. She was a confident, lively and friendly girl who took interest in socializing

with her friend's circle. She uses to properly concentrate on her work and always tried to make

everyone happy and tried to avoid any kind of conflicts which may make the environment of her

home uncomfortable. According to her husband, she was very optimistic about the future.

Onset of illness:

After her surgery and removal of her ovaries, she became hopeless. She always wanted a

child but now she cannot have her own child. Her husband offered to adopt a baby but she

refused. She became more depressed and her behavior became very problematic. Society and her

in-laws used to blame and taunt her so she lost her worth and started to cry all the time. Rude and

reckless behaviors of her in-laws motivated her to attempt suicide but her husband saved her. So,
17
the main reason of this depression is infertility and environmental pressure. This all started from

2014.

Past psychiatric history

First time visited clinic for migraine but not any satisfactory outcomes have been

received. Then on suggestion of his cousin she visited psychologist in Islamabad.

Informal assessment

An informal assessment is spontaneous. It is a method of evaluation where the instructor

tests participants‘ knowledge using no standard criteria or rubric. This means that there is no

spelled-out evaluation guide. Rather, the instructor simply asks open-ended questions and

observes students‘ performances to determine how much they know.

If informal assessments are not concerned with grading students, then what are they

about? It‘s simple—feedback. Data from these evaluations help the instructor make ongoing

adjustments to create better learning experiences for participants.

Client is 35 years old female. She belongs to a middle-class family. She is the resident of

Rawalpindi. She is married for 10 years and has no child. The client is admitted in Benazir

Bhutto Hospital for about 1 year. She has 2 siblings. The client is the youngest of all. She was

brought here by her husband. The client is experiencing negative thoughts, low mood, low self

esteem and feeling of worthlessness. Client has severe crying spells and she feels muscle fatigue

all the time. She attempted suicide 3 times.

18
 During the sessions client was not taking part in any discussion. She was totally lost in

her own imaginations. The only thing she was discussing is her father death which may be one of

the reasons of depression.

Formal Assessment

It is a type of clinical assessment where the clinician uses standardized tests in a

structured format for the evaluation of the patient. For instance a questionnaire is made with a

number of questions and their possible answer which is used to interview the patient.

The following tests are used to assess the client‘s problems, their intensity and personality

through standards.

 Mental status examination

 House person tree test

 Beck depression inventory

 Beck suicide intent scale

Mental Status Examination (MSE)

The mental status examination was originally modeled after the physical exam: just as the

physical medical exam is designed to review the organ system, the mental exam reviews the

major system of psychiatric functioning. Since its introducing into Americans psychiatric by

Adolf Meyer in 1902, it has become the mainstay of patient evaluation in most psychiatric

settings. Most psychiatrists consider it as essential to their practice as a physical examination in

general medicine.

Appearance, Attitude and Activity

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Appearance

Outlook of patient: Outlook of Patient was proper and decent.

Level of consciousness: The client was attentive and conscious during all sessions.

Apparent age: She seems to be of 17 but originally she was of 21.

Position/ Posture

Session 1: The client was sitting in an uncomfortable position changing her position while

sitting time to time wasn‘t to still and was reporting ache.

Session 2: The client was showing to sit still but un knowingly she was showing instability and

was in an uncomfortable position changing her position time to time, wasn‘t able to sit still and

being on the edge of seat.

Session 3: The client was relatively in a position still body rubbing and uncertainty was

observable. Grooming: Client appearance was organized and proper.

Eye contact:

Session 1: No eye contact by client was observed.

Session 2: Rare eye contact but later in session she maintained approximately proper one.

Session 3: The client maintained approximately proper eye contact.

Attitude:

Session 1: The client was defensive and resistive in her conversation and behavior with a great

intensity. Client was guarded.

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Session 2: The client was open and cooperative. Guarded personality was observed.

Session 3: The client attitude was open but on some areas client showed defensive attitude.

Activity: Voluntary localized movement was shown by client

Tic: Some repeated movement also shown by client.

Involuntary movement: Involuntary movement was not shown by patient.

Compulsion: Compulsion was not shown by patient.

Mood and Affect: Mood: The mood of the client was normal. The client also showed

apprehensive attitude including curiosity.

Affect:

Type of Affects: (Happy, Sad, apprehensive and confused): The clients showed much normal

mood.

Intensity: (Degree): The client showed noticeable moderate degree of effects.

Reactivity: The client showed defensive attitude.

Range of Effects: Clients showed noticeable moderate degree of reactivity.

Appropriateness: The reactivity and affects shown by client were appropriate.

Mobility: (Change of affect / mood shift for reaction): The client showed not a very smooth shift

in mood as her conversation was changing the phase for normal happy or happy to sad events.

Speech and Language

21
Fluency: The speech of the client was slowed.

Comprehension: The client showed an understanding of directions she was given.

Repetition: The client was not repeated any word.

Naming: Nil

Writing: The writing of client was readable.

Reading: Client reported that she was read easily .

Prosody: (Intonation, speech, rate of conversation): Conservation rate was slow and disturbed.

Quality of speech: (Pitch, volume, Articulation): Her was slow, Volume was low.

Thought process, thought content & perception

Thought process

Connectedness: The client showed uncertain shifts in the topics.

Peculiar thought process: No peculiar thoughts were shown by patient. The attention of patient

was distractible.

Thought content

Delusion: NILL

Overvalued ideas: NILL

Obsession: NILL

22
Rumination: ( Repeated thoughts related to ideas.): Ideas related to negative environment the

client is living.

Pre-Occupation: Client is pre - occupied with insomnia.

Suicidal ideation: The client was emphasizing on thought regarding to suicide.

Violent Ideas: NILL

Phobias: The client has social phobia.

Perceptual Abnormalities

Hallucination: NILL

Other perceptual Abnormalities: The client neurocognitive functioning was damage.

Cognition

Orientation: It was distorted.

Attention and concentration: Registration: Client was behaviorally inattentive.

Memory: Long term memory of the client was good but not remembers the things for a short

time. Visuo-constructional Ability: Poor

Executive Functioning: Poor

Insight and Judgment:

Insight: The clients have true insight.

23
Judgment: The bad events affected the client psyche to a very deep extent. The psychological

condition of patient is disturbed.

House Tree Person (HTP)

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 stimulus. This test was

developed by John Buck in1969. 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.

 The house reflects the individual‘s interpersonal relationship.

 The tree reflects the ego development and functioning.

 The person reflects the individual‘s self-perception.

Administration:

 Pencil

 White paper

 Eraser

 And asked to draw a house, tree and male or female figure on paper.

Interpretation: Through HTP following traits are interpreted:

Interpretation of house:

Chimney omitted Lack of warmth in house

Open door Need for warmth

Roof emphasis fantasy

Horizontal emphasis on walls Environmental pressures

24
Window with no panes hostility

Interpretation of tree:

Broken branches Helplessness/ suicidal

Cloud like crown fantasy

Ground line Depression/insecurity

Broad trunk dependency

Dead tree Severe disturbance

Emphasis on bark depression

Interpretation of person:

Undersized arms Inadequacy/guilt

Small head inadequacy

Small eyes introversion

Shrunken legs helplessness

Mitten fingers Repressed aggression

Overall interpretation:

The client has depression, insecurity, rigidity, willingness to engage with others, feeling

of hopelessness, limited ego strength, need of warmth in home, aggression, high need of

achievement.

25
Beck Depression Inventory

Beck‘s depression inventory is a self-rated scale which is widely used to measure level of

depression among people. This test also measures symptoms such as mood, pessimism, sense of

failure, self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying,

irritability and social withdrawal. It is a 21 items questionnaire of multiple choices. It takes 10

minutes to complete this test. It is designed for individuals who are of age 13 or above.

Interpretation: Patient scored 55 on BDI which shows the severe depression.

Beck suicide intent scale:

It is a self-rated scale which is widely used to measure level and severity of suicide

ideations among people. This test also measures symptoms such as mood, pessimism, and

hopelessness, sense of failure, self-dissatisfactions, suicide ideas and social withdrawal. It is 20

item questionnaire of multiple choices each scoring from 0 to 2 points. It takes 10 minutes to

complete this test.

Interpretation: Patient scored 17 on SIS which shows moderate risk of suicide in client.

Tentative diagnosis

According to DSM-V, the client is exhibiting symptoms of 296.23 (F32.2) severe Major

Depressive Disorder according to DSM-V.

Case Formulation

Behaviorist theory

Behaviorism emphasizes the importance of the environment in shaping behavior. The

focus is on observable behavior and the conditions through which individuals' learn behavior,

26
namely classical conditioning, operant conditioning and social learning theory. Therefore

depression is the result of a person's interaction with their environment.

For example, classical conditioning proposes depression is learned through associating certain

stimuli with negative emotional states. Social learning theory states behavior is learned through

observation, imitation and reinforcement.

Operant Conditioning

Operant conditioning states that depression is caused by the removal of positive

reinforcement from the environment (Levisohn, 1974). Certain events, such as losing your job,

induce depression because they reduce positive reinforcement from others (e.g. being around

people who like you).

Depressed people usually become much less socially active. In addition depression can also be

caused through inadvertent reinforcement of depressed behavior by others.

For example, when a loved one is lost, an important source of positive reinforcement has lost as

well. This leads to inactivity. The main source of reinforcement is now the sympathy and

attention of friends and relatives.

However this tends to reinforce maladaptive behavior i.e. weeping, complaining, talking of

suicide. This eventually alienates even close friends leading to even less reinforcement,

increasing social isolation and unhappiness. In other words depression is a vicious cycle in which

the person is driven further and further down.

27
Also if the person lacks social skills or has a very rigid personality structure they may find it

difficult to make the adjustments needed to look for new and alternative sources of reinforcement

(Levisohn, 1974). So they get locked into a negative downward spiral.

Beck's (1967) Theory

One major cognitive theorist is Aaron Beck. He studied people suffering from depression and

found that they appraised events in a negative way.

Beck (1967) identified three mechanisms that he thought were responsible for depression:

1. The cognitive triad (of negative automatic thinking)

2. Negative self schemas

3. Errors in Logic (i.e. faulty information processing)

The cognitive triad is three forms of negative (i.e. helpless and critical) thinking that are typical

of individuals with depression: namely negative thoughts about the self, the world and the future.

These thoughts tended to be automatic in depressed people as they occurred spontaneously.

For example, depressed individuals tend to view themselves as helpless, worthless, and

inadequate. They interpret events in the world in a unrealistically negative and defeatist way, and

they see the world as posing obstacles that can‘t be handled. Finally, they see the future as totally

hopeless because their worthlessness will prevent their situation improving.

As these three components interact, they interfere with normal cognitive processing, leading to

impairments in perception, memory and problem solving with the person becoming obsessed

with negative thoughts.

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Beck believed that depression prone individuals develop a negative self-schema. They possess a

set of beliefs and expectations about themselves that are essentially negative and pessimistic.

Beck claimed that negative schemas may be acquired in childhood as a result of a traumatic

event. Experiences that might contribute to negative schemas include:

 Death of a parent or sibling.

 Parental rejection, criticism, overprotection, neglect or abuse.

 Bullying at school or exclusion from peer group.

However, a negative self-schema predisposes the individual to depression, and therefore

someone who has acquired a cognitive triad will not necessarily develop depression. Some kind

of stressful life event is required to activate this negative schema later in life. Once the negative

schema are activated a number of illogical thoughts or cognitive biases seem to dominate

thinking.

People with negative self schemas become prone to making logical errors in their thinking and

they tend to focus selectively on certain aspects of a situation while ignoring equally relevant

information.

Beck (1967) identified a number of systematic negative bias' in information processing known as

logical errors or faulty thinking. These illogical thought patterns are self-defeating, and can cause

great anxiety or depression for the individual. For example:

1. Arbitrary Inference. Drawing a negative conclusion in the absence of supporting data.

2. Selective Abstraction. Focusing on the worst aspects of any situation.

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 3. Magnification and Minimization. If they have a problem they make it appear bigger

than it is. If they have a solution they make it smaller.

4. Personalization. Negative events are interpreted as their fault.

5. Dichotomous Thinking. Everything is seen as black and white. There is no in between.

Such thoughts exacerbate, and are exacerbated by the cognitive triad. Beck believed these

thoughts or this way of thinking become automatic. When a person‘s stream of automatic

thoughts is very negative you would expect a person to become depressed. Quite often these

negative thoughts will persist even in the face of contrary evidence.

Learned Helplessness

Martin Seligman (1974) proposed a cognitive explanation of depression called learned

helplessness. According to Seligman‘s learned helplessness theory, depression occurs when a

person learns that their attempts to escape negative situations make no difference.

As a consequence they become passive and will endure aversive stimuli or environments even

when escape is possible.

Seligman based his theory on research using dogs.

A dog put into a partitioned cage learns to escape when the floor is electrified. If the dog is

restrained whilst being shocked it eventually stops trying to escape.

Dogs subjected to inescapable electric shocks later failed to escape from shocks even when it

was possible to do so. Moreover, they exhibited some of the symptoms of depression found in

humans (lethargy, sluggishness, passive in the face of stress and appetite loss).

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This led Seligman (1974) to explain depression in humans in terms of learned helplessness,

whereby the individual gives up trying to influence their environment because they have learned

that they are helpless as a consequence of having no control over what happens to them.

Although Seligman‘s account may explain depression to a certain extent, it fails to take into

account cognitions (thoughts). Abramson, Seligman, and Teasdale (1978) consequently

introduced a cognitive version of the theory by reformulating learned helplessness in term of

attribution processes (i.e. how people explain the cause of an event).

The depression attribution style is based on three dimensions, namely locus (whether the cause is

internal - to do with a person themselves, or external - to do with some aspect of the

situation), stability (whether the cause is stable and permanent or unstable and transient)

and global or specific (whether the cause relates to the 'whole' person or just some particular

feature characteristic).

In this new version of the theory, the mere presence of a negative event was not considered

sufficient to produce a helpless or depressive state. Instead, Abramson et al. argued that people

who attribute failure to internal, stable, and global causes are more likely to become depressed

than those who attribute failure to external, unstable and specific causes. This is because the

former attribution style leads people to the conclusion that they are unable to change things for

the better

Therapeutic recommendation

1. Cognitive Behavioural Therapy:

Negative thinking can slow the recovery from depression. When people are depressed, they

view themselves, the world, and their future in a very negative light. These biases can be

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 corrected with cognitive re-structuring techniques, such that negative thoughts can be

replaced can be replaced with more realistic ones. In this technique my client agrees to work

together on pattern of behavior that need to b changed. So, our goal is to recalibrate the part

of brain or cognition that keeping on such a tight hold on happy thoughts. Following 5

techniques I used to recalibrate the negative thoughts.

2. Locate the problem and brainstorm solution:

Journaling and talking with me (therapist) helped her to recognize the main root of depression. I

asked her to write every thought which is bothering her. Once the root is recognized, it can help

counteracting those negative thoughts which are coming from that root. Writing down a list of

things you can do to response a situation can help ease negative or depressive feeling.

A. Write self-statements to counteract negative thoughts:

After locating the root problem of depression, client was asked to think of negative thoughts she

used to damper the positive ones. She used to write a self-statement to counteract each negative

thought. Then, I asked her to remember those statements and repeat those statements back to

herself daily five times a day or whenever she feels depressive outburst. For example, her one

statement was: And her counter statement was:

B. Find new opportunities to think positive thoughts:

As, her husband said that she never comes out of the room because she felt depressive outburst

and she usually started to cry. So, I told her to find and look forward to those things which calm

her. And focus on those things and next time when she entered in my room, she told me 5 things

that soothed her. And in the next session she told me the five things of each room of her house

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that soothed her and now she can go outside her room and interact with her family members and

whenever anyone taunt her, she started to focus on those things in that room which soothes her.

C. Finish each day by visualizing its best part:

I told her to write every best part of the day or the work she did even it that‘s of very small

amount but she has to write and repeat again and again to avoid negative thoughts. And

eventually she felt better.

D. Learn to accept disappointment as a normal part of life:

At the end of these four steps she realized that ups and downs are the part of life and due to our

negative thoughts and response we stuck in that phase and cannot move forward, until and

unless we call ourselves and move out of that phase. Now she started to think that she cannot be

a mother but she can adopt a child and can be a mother of that child.

Psychotherapy

Psychotherapy is also known as talk therapy (catharsis). It is found to be very effective in

treatment of patients with depression. The client expressed her suppressed emotions. It also helps

to develop appropriate coping skills for dealing with everyday life and challenging negative

belief about client‘s self.

3. Family Therapy:

Family therapy is effective intervention in treating people of any age with depression. In this

therapy I guided the family of the client to take care of her. I convinced her mother in law to

accept this disability and try to adopt a child. Furthermore, I explored the roles each family

member plays in the conflict, discovers negative patterns of behavior and identifies each

member‘s strength and weakness. I arranged 10 sessions of client with her family combined and

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that was helpful because both parties agreed and accepted the flaws and look forward to

solutions.

4. Relaxation technique:

We call it the calming breath. Take a long, slow breath in through your nose, first filling your

lower lungs, then your upper lungs. Hold your breath to count of ‗three‘, exhale slowly through

pursed lips, while you relax the muscles in your face, jaw, shoulders and stomach should also be

relaxed. This technique was very effective in my case.

Prognosis

The prognosis of client was positive as the client had full insight and she fully knows her

condition. The proper psychiatric medications and psychotherapy can manage the symptoms,

help the client overcome her condition and led her to live more productive and satisfying life.

The client had greater capacity to recover as she is willing to recover. These would help the

client cope with her condition more effectively.

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