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Case I

Summary

Ms. ABC, aged 24 years old, came up with the problems of feelings of worthlessness,

emptiness, fatigue, loss of energy and motivation along with other symptoms. The client was

observed, and taken interview. Initially, rapport was build up for sessions. The client was assessed

both formally i.e. Mini Mental State Examination, House Tree Person Test, Hamilton Depression

Rating Scale, Beck Depression Inventory, and informally i.e. observation, interview and mental state

examination. The client was diagnosed with Major Depressive Disorder at severe level. The diagnosis

criteria matched with that of DSM-V. The client was suggested some of the therapeutic techniques to

follow in order to control his psychological ailment, she had an insight of her disorder.
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Case Report

Demographics

Name Ms. ABC

Age 24

Education Graduation

No of Siblings 5

Birth Order 5

Gender Female

Informant Self

Residence Rawalpindi

Family Structure Joint

Socio-economic status Middle class

Main Reasons and source of Referral

The client came up with the presenting complaints of worthlessness, sleep disturbances,

lack of pleasure, emptiness, lack of motivation, lack of energy, loss of weight, restlessness and

irritability from last six months.

Presenting Complaints according to the client

I feel so drained, and lethargic. I have absolutely no energy to do my routine activities. I

just lay down and spend my whole day like this…. I feel like my brain is sleeping because I sleep a

lot. I don’t feel appetite till I get hunger pangs…. I, I, I feel so much pain on my nerves in my head,

I just want to stay still and let the life pass…. I don’t have anything to achieve and I am so dumb and

the most useless person I have ever seen…. I don’t want to do anything for the rest of my life and let
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it be paused…. I don’t find anything interesting…. I wish life just comes to an end and will have

peace….

According to DSM

 Depress Mood

 Markedly Diminish Interest

 Significant weight loss

 Fatigue or loss of energy

 Feelings of worthlessness

 Diminish ability to think or concentrate

 Insomnia or hypersomnia

 Recurrent thoughts of death

Initial observation

The client was tall, healthy and fairly complexioned. She was dressed with shalwar kameez

with dupatta on her shoulders. She was dressed appropriately. Her mood was initially unrecognizable.

She was trying to be very formal initially. She was sitting with a relaxed and lazier posture. Her

energy was below average.

History of Present Illness

Client has severity of symptoms since last six months. Since she got through her university.

She thinks that she got nothing big to achieve now. She has low appetite she eats once in a day.

She reported that she is worry most of the time she fails to concentrate what second person is

saying. She feels that that there is nothing for her in the world everything has become faint she

does not feels happy anymore. She reported that most of the time her body becomes soulless she

gets tired easily. However, there have been no past psychiatric history of the client. But the

symptoms seem to have been intensified within these six months. No prior treatment was taken
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because of no diagnosis at all.

Personal History

Her birth was normal. She achieved her millstones on time. She was obese since childhood.

She passed through all stages of development normally. In academic life, she did her best. She has

recently completed her graduation. There were no childhood stressors then being obese.

Medical History

She has irregular menstrual cycle due to PCOS since she attained puberty for which she

was advised by doctors to reduce weight which she reported to have reduced.

Family History

The patient belongs from middle class family. She is living with her 4 brothers who live in

distorted joint family system in a single house. Her father died when she was 15 years old and

mother also died due to renal failure shortly seven months after her father’s death.

She reported to have a good bond with her father. She regrets not having much time to spend

with him because of his death. She was a bit reluctant to him for expressing her love to him. She

always wanted to but couldn’t express herself to him

She reported to have a very warm relationship with her mother. She reported that till the

time she was alive she didn’t need any best or close friend. Her mother was everything to her. She

was her whole world.

3 out of her 4 brothers are married and have children. She reported to have a formal and

less warming relation with her 3 elder brothers because they are her step-brothers. She reported

that she doesn’t find much warmth in her relation with them. The elder 3 brothers are middle pass

so failed to maintain a good balance in life and relationships. She reported to have witnessed verbal

disputes since her sister-in-laws had issues with her mother but when her mother was on her

deathbed, they took good care of her, to which she is grateful.

The 4th brother is still single and left abroad for higher studies. He is her mentor, guardian
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and friend she reported after her parents’ death. He is a constant source of support and motivation

to her. She loves her the most now.

The distorted family structure and family disputes led to believe that she can live alone and

needs no one. This is the reason behind she have been rejecting proposals which created a state of

frustration for her at home because of pressure from family. She reported that she never wants to

marry anyone.

Educational History

She reported to have an excellent academic record throughout school. She used to remain

among the top three. She passed her matriculation with distinction as well as her intermediate she

had 88%. She wanted to be a doctor but she couldn’t get through MDCAT with just 1.00 aggregate,

she reported. This is the biggest failure she reported she had which doesn’t let her move a head but

she did pretty well in her BS program and passed with Medal.

School History

The client reported to have normal interaction with peers. She also had normal student-

teacher relationship. She reported to have been among the brilliant and most valued students

throughout her academic years. She didn’t reported any misconduct with class fellows, seniors,

juniors and teachers as well.

Occupational History

She worked as an internee at a renowned organization in its HR department. She performed

well. She didn’t show any misconduct with her colleagues, boss and did her job efficiently.
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Sexual history

The client is unmarried and has not indulge in any heterosexual or homosexual activity.

Social History

The client has normal relationships and social interactions. She develops normal ties with

people. She develops an impression of being a happy and jolly person. She reported to be introvert

in her childhood and while with growing years, she learnt how to be socialize. She overall develops

sound relationships but prefers to be alone. She reported to be unbothered with presence or absence

of people.

Premorbid Personality

Before developing illness she was social her interpersonal relationships was good she liked

to visit her relatives and friends. She used to be friendly with everyone. She used to be jocular and

active in her routine. She used to feel so motivated and energetic in herself. She considered herself

of worthy and used to have interests in all activities.

Psychological assessment:

Informal assessment

Observation: Client is 24 years old young lady with tall height and broad shoulders having

bulky body. Her manners were appropriate but she was showing restlessness. Rate and volume of

speech was goodand clear. Subjectivity and objectivity was not stable in mood, she was showing

laziness and fatigue while, speaking.She did not have any delusional problem. Her perceptions

was normal. She don’t have any hallucinations problem. Orientation towards time place and

season was normal.

Clinical Interview: She was spoken in sound and clear tone she was properly maintaining

eyecontact. When she entered in clinic she was bit confused somehow she was looking as mentally

disturbed. When I start asking question she was showing rigidity she was not ready to tell anything

but with the passage of time she started comfortable and willingly she was narrating her story. It

was noted that when she entered in the hospital she was nervous of her surrounding she was feeling

insecurity. She gave relevant answers to all the questions which have been asked.

Mental Status Examination: The client’s appearance was simple. She was wearing simple

shalwar kameez her head was covered with dupatta. She was tall and healthy. The tone of her voice

was clear but speed of speech was bit slow. The client mood was depressed. She seemed hopeless

for the future. She had insight about her disease as referred to it as psychological illness.

Client posture was too relaxed but not calm and composed. There was some agitation in her

behavior. She would press her shoulders complaining pain. She was aware of her surroundings,

day, time and month means her orientation was not lost. During interview, she was answering but

she was not fully involved and she was not focusing. Her concentration was disturbed.

Formal assessment.

Mini Mental State Examination (MMSE): The Mini-Mental State Examination (MMSE) was

first published by Folstein, as a practical method for grading the cognitive state of patients for the clinician study.

The MMSE was designed as a screening test for the purpose of evaluating cognitive impairment. Client had

orientation about her name the placewhere she was aware about time, season, month and hospital

she was admitted. She registered andrecalled a set of unrelated objects with little difficulty. She

was not concentrating properly. She wasable to read, write and copy the designed. She had no

certain cognitive impairment. During the session her memory was fine and impairment wasn’t

reported. (Flostein, 1975)

House-Tree-Person Test: The House-Tree-Person test (HTP) is a projective test designed by

John Buck in 1948, to measure aspects of a person’s personality. The client was seated in

comfortable environment. She was asked to draw a house, a tree and a person on three separate A-

4 sheets.

All the figures drawn are with light, thin and centrally aligned which represents rigidity and

withdrawal of the client. The house represents an individual’s interpersonal life. The house drawn

has thin lines representing weak ego boundaries. The chimney drawn represents sexual concerns.

The smoke represents indecisiveness and extreme tension at home. While, the door and windows

represent social life of the person which are closed in the figure, showing her defensiveness. The

pathway drawn represents that the client wants people to her and develop relation. The curtains on

the window show the withdrawal and evasiveness of the client from home. The emphasized roof

shows her ideation for family life and her fantasy.

The tree reflects ego development and functioning. The tree has cloud foliage representing

confused thinking while the branches drawn are very pointed showing aggressiveness. The

absence of roots show insecurity and instable personality. While, the trunk is broad showing

dependency. The apple drawn on trees represent high need of nurturance. The emphasis on bark

show depression.

The person drawn is a female (same sex). The large had represents regression while the

centrally drawn full face figure show social communication. The long neck represents desire for

the separation of cognitions and drives. The closely tight mouth shows rigidity and non-receptive

nature while the bushy eyebrows show impulsive tendencies. The large open eyes show

suspiciousness. The pointed nose show long represent disapproving attitude towards others. The

clothes drawn show desire for social acceptance while the buttons show affectional deprivation.

The arms crossed show personal problem and defensiveness or rigidity. The omission of feet show

loss of autonomy while omission of hands show antisocial tendencies. The broad shoulder show
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need for autonomy. The emphasis on hair show self-love. The overall image shows desires of the

client to get warmth and affection while showing herself the perfect one. (Groth & Robert, 1998).

Hamilton Depression Rating Scale (HDRS): It is a clinically administered depression scale,

comprising of 17 items measuring depressed mood, feelings of guilt, insomnia, agitation, suicide,

somatic symptoms and insight of the client. Some items are 5-point (0-4) while others are 3 point

(0-2) scale. The score is 23 which show severe depression. (Hamilton, 1960).

Beck Depression Inventory (BDI): The Beck Depression Inventory is a 21 Item self-

reporting questionnaire evaluating the severity of depression in normal and psychiatric

populations. It relied on the theory of negative cognitive distortions as central to depression. Level

of depression was extreme in client since she scored 40. (Beck, 1961)

Tentative Diagnosis

Major Depressive Disorder 296.33 (F 33.2)

Case formulation
In Major Depressive Disorder patient remains depress all the day with significant weight

loss, insomnia and exception of suicidal ideation. Often insomnia or fatigue is the presenting

complaint. Sadness is another feature of MDD. Fatigue and sleep disturbances are present in a high

proportion of cases. Psychomotor disturbances are much less common but are indicative of greater

overall severity, as is the presence of delusional or near delusional guilt. (DSM 5)

Humanistic Perspective: Believe that there are needs that are unique to the human

species. The most important of these is the need for self-actualization (achieving out potential).

The self-actualizing human being has a meaningful life. Anything that blocks our striving to fulfil

this need can be a cause of depression and restlessness. As patient’s self-actualization is

undermined by unhappy relationship with her family and her needs were not fulfilled. Also, the

unaccomplished goals impedes in her way. (Maslow, 1962)

Cognitive Perspective: CBT says that these are intrusive thoughts that can cause depression.

CBT will encourage the sufferer not to ask for reassurance, and see what happens to their irrational

thoughts that leads towards the depression. This makes it seem as if the world really is a dangerous

place, and increases depression. It helps to change your behavior and moods. CBT says that people

with depression thinks differently than the thinking of people who are not depressed. It is their

difference in thinking that cause them to become depressed. The client’s thinking of being

worthless impedes in her way of positive living and happiness. (Beck, 1960)

Behavioral Perspective: This model proposes that depressive disorders can be explained by

the reduce frequency of positively reinforced behaviors that serve to control the person

environment. The origin is not only the absence of reinforces but also the presence of avoidant

behaviors that maintained a very marked pattern of behavioral inhibition. Further it argues that

depression is the cause of interaction with environment For example, classical conditioning

proposes depression is learned through associating certain stimuli with negative emotional states.

Her reaction to proposals show this negative emotional states. (Watson, 1913)

Psychodynamic perspective: This school of thought suggests that childhood traumas led to

frustration in adulthood. So, this is the case with this client as she witnessed traumatic and depressed

family which led her develop insecurity about her future family.(Campell, Kub & Rose, 1996).
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Therapeutic Suggestions

Following are the few suggestions for Miss ABC

Family Therapy: Family therapy is a type of psychological counselling (psychotherapy)

that can help family members improve communication and resolve conflicts. Family therapy is

usually provided by a psychologist, clinical social worker or licensed therapist. These therapists

have graduate or postgraduate degrees and may be credentialed by the American Association for

Marriage and Family Therapy (AAMFT).

Family therapy should be given to the patient’s family. Family therapy is often short term.

It may include all family members or just those able or willing to participate. Family therapy

sessions can teach you skills to deepen family connections and get through stressful times, even

after you're done going to therapy sessions. Family therapy is often short term. It may include all

family members or just those able or willing to participate. Your specific treatment plan will

depend on your family's situation. Family therapy sessions can teach you skills to deepen family

connections and get through stressful times, even after you're done going to therapy sessions.

(Whittaker & Malone, 1953)

Cognitive Behavior Therapy: CBT is a type of talking treatment that focuses on how your

thoughts, beliefs and attitudes affect your feelings and behavior, and teaches you coping skills for

dealing with different problems. It combines cognitive therapy (examining the things you think)
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and behavior therapy (examining the things you do) so I did counsel with the client and tell her

how she can adjust her thoughts and behavior. (Beck, 1960)

Relaxation technique: This is very first recommendation for client is progressive muscular

relaxation because the client has the problem of restlessness and fatigue. This exercise will help

her to reduce her complaints and to relax. The following steps can be used to relieve the pain of

the client. Counseling: Increase level of self-esteem, self-confidence, gave chance to openly share

information about her illness and solve her main problem. (McGuigan, 1989)

Dialectical Behavior Therapy: Dialectical behavior therapy is a type of CBT. Its main

goal is to teach people with depression the skills to cope with stress, regulate emotions, and

improve relationships with others. This type of psychotherapy also incorporates mindfulness

practices from Buddhist traditions and the use of crisis coaching in which an individual can call

the therapist to receive guidance on how to handle difficult situations. As the person practices these

new skills more and more, they will become better at handling these challenging situations on their

own. (Linehen, 1980)

Prognosis

Client has insight about her problem. She shows willingness to solve her problems. The

family support should be available.

Limitations

 The patient was aware of her problem.

 Time was Limited.

 Patient’s family was not cooperative

References

American Psychiatric Association (2013), Diagnostic and statistical manual of mental health

disorders (5th eid,) Washington, DC: Author

Beck, A. T. (1991). Cognitive therapy: A 30-year retrospective. American psychologist, 46(4), 368.

Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck Depression

Inventory: Twenty-five years of evaluation. Clinical psychology review, 8(1), 77-100.

Campbell, J., Kub, J. E., & Rose, L. (1996). Depression in battered women. JAMWA, 51(3), 106-111.

Connors, G. J., DiClemente, C. C., Velasquez, M. M., & Donovan, D. M. (2013). Substance abuse

treatment and the stages of change: Selecting and planning interventions. Guilford Press.

Folstein, M., Folstein, S. E., & McHugh, P. R.(1975). “Mini Mental State”: Practice method for

guiding the cognitive state of patients for the clinician. Journal of psychiatric Research.

Groth-Marnat, G., & Roberts, L. (1998). Human Figure Drawings and House Tree Person

drawings as indicators of self-esteem: A quantitative approach. Journal of Clinical

Psychology, 54(2), 219–222

Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56-62.

Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of dialectical behavior

therapy. American journal of psychotherapy, 69(2), 97-110.

McGuigan, F. J. (1989). Managing internal cognitive and external environmental stresses through

progressive relaxation. In Stress and Tension Control 3 (pp. 3-11). Springer, Boston, MA.

Rakos, R. F. (2013). John B. Watson’s 1913 “behaviorist manifesto”: Setting the stage for

behaviorism’s social action legacy. Revista Mexicana de Análisis de la Conducta, 39(2),

99-118.

Whitaker, Co.A., &Malone, T.P. (1953). The roots of psychotherapy. New York, NY: Blakiston.
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Case II

Summary

Mr. AJ is a child of 6 years. He has been presented with problems like lack of communication

skills along with repetitive as well as restricted behavior. The child has been observed, and has

been assessed formally with Childhood Autism Rating Scale (CARS). His Mental State

Examination was done. He was diagnosed with mild to moderate Autism Spectrum Disorder of

DSM-V. He has been given some treatment suggestions at the end based on his behavioral issues

so that he can modify his behavioral problem.