Case 7

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Case no 7

History

Mr. Irshad Ahmad is outdoor patient who referred for psychological assessment. He is 22
years old. He did i.com and now he is doing BBA. His birth order is first. He came with
complaints hopelessness, lack of pleasure in all activities, guilt feelings, loneliness, and disturbed
sleep, lack of confidence, inferiority, and attempted suicide. Several psychological assessments
like clinical interview (SDCT) (HFD emotional) (SPM) (BDI) (BAI) (TAT) were ministered and
that tests indicated that client has major depressive disorder with severe psychotic features. For
medical treatment psychotropic medication is recommended to social skill training to survive in
society, rational emotive behavior therapy to change his thoughts according to reality, and
behavioral therapy for behavior modification.
Bio data

Name Muhamad Irshad

Age 22 years

Sex Male

Education BBA

Occupation Teacher

Socioeconomic status Middle

Date of assessment 25 December2016


Identification Factors

Client I.S is an unmarried male of 22 years old. His religion is Islam. He belongs to a
poor family. He lives in FSD. He did Fsc and now he is doing BBA and also a home tutor. He is
only child of his parents. His father has died. His mother is alive and a housewife.

Reason for referral

I.S was a outdoor patient in Ahmed Clinic. He came there alone with some psychological
issues. Now he is taking Psychiatry treatment from psychiatry department of District Head
Quarter (DHQ) Faisalabad. For the reason of major depressive episode.

Main Reasons for Referral

1. Hopelessness
2. Lack of confidence
3. Lack of interest
4. Disturbed sleep
5. Guilt feelings
6. Isolation
7. Irritability
8. Repetitive thoughts

Presenting complaints

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Family history

My client I.S is an unmarried male of 22 years old. His birth order is first. His father has
died while his mother is alive. He lives in FSD. His behavior was relaxed and cooperative during
assessment. He reported that he was admitted in school at the age of 6 years. He also reported
that he was an average student and he has no friend. He reported that he was an child when his
father died. His mother got second marriage and but due to some clashes his second father left
them.

Siblings:

He is only child of his parents.

Personal History

He was an active boy in his childhood. His nature was cooperating. He like to live with
his mother. He like to play foot ball in his childhood age with his friends. He got all milestones
successfully. He had good memories regarding his childhood. He was a cooperative child in his
school his mental abilities was not so much good according to him self. He don’t like his
teachers.

In his adolescence as mentioned earlier he was an active boy. The client’s complained
reported by him that he has useless and wrong thoughts about Mohemmed S.A.W.W and these
thoughts dominate himself and he becomes disappoint. He reported that he couldn’t sleep very
well and having no interest in daily life activities. He reported that when he saw an animal he
gives similarities that animal with PBUH ( NaauzbillAh) too many dirty thoughts about
Mohammed S.A.W.W.

He reported that it seems he cannot do anything. He reported he avoids social circle and
like to live alone. He reported that wrong or dirty thoughts of his mind make him anxious and
then he started to apologize to Allah but I felt that I couldn’t get excuse from Allah.He reported
that he has tried to attempt suicide two times but escape.
He reported that I have this problem from five or six years. He further reported that I am
suffering bad thinking about Hazrat Muhammad SAW in my mind when I was in 9 th class and I
tried to ignore these bad thinking but I could not. He reported that he had a habit to wash hand
again and again but he started to play cricket and his attention diverted from this act.He reported
that he played cricket two or three months and started net surfing.He reported that there is a
website on internet with the name of Pepper Unity. Muslims and Hindus abused each other and
also do vulgar chat. He reported that Muslims condemned Hindus Gods and Hindus also
disrespect of last Prophet Mohammed S.A.W.W.

Premorbid Personality

Avoidance becomes a part of personality due to serious emotional problem. Data


collected from the results of tests and interview shows that he was very cooperative person.

Previous and present psychological problem

He is admitted in DHQ hospital for the 1 st time to cure his symptoms. Such as Hopelessness,
Lack of confidence, Lack of interest ,Disturbed sleep, Guilt feelings, Isolation, Irritability,
Repetitive thoughts.

Mental state examination

General Behavior:

He wears t.shirt with jeans . He had appropriate eye contact and cooperative and open
attitude. His level of consciousness was alert. The rate of his speech and rhythm tone was low.
The volume was also low.

Mood:

He had a normal mood.

Thought:

His thinking for future was normal and hopeful. His thinking was control.

Delusions:
There is no delusion like symptoms.

Perception:

There was no complaint of hallucination and illusion. His perception was not good. His cognition
was not intact.

Orientation:

His insight was present. He has awareness relevant to time, place and person.

Memory:

His long term memory is good and he has awareness regarding his short term memory.

Administration of psychological tests:

1. Human Figure Drawing……………………………………………… (HFD)


2. Thematic Appreciation Test………………………………………….. (TAT)
3. Slosson Drawing Coordination Test…………………………………... (SDT)
4. Standard Progressive Metrics …………………………………………..(SPM)
5. Rotter Incomplete Sentence Blank…………………………………….. (RISB)
6. Back Depression Inventory…………………………………………….. (BDI)
7. Beck Anxiety Inventory ………………………………………………….(BAI)
8. Minnesota Multiphasic Personality Inventory ...........................................(MMPI)

Human Figure Drawing (HFD)

Introduction:

Developed originally by Florence Good enough in 1926, this test was first known as the
Good enough Draw-a-Man test. It is detailed in her book titled Measurement of Intelligence by
Drawings. Dr. Dale B. Harris later revised and extended the test and it is now known as the Good
enough–Harris Drawing Test. The drawing figures are widely managed as an ideal instrument for
self-expression. HFD test (Human Figure Drawing) is an abbreviated test which was developed
with the aim to evaluate various psychological states, especially assessing the psychic status
including psychiatric illness and personality state. Thus, the reliance on the drawings must be
proven that it has no bias due to cognitive differences between subjects. In the present study it is
demonstrated that drawing tests are influenced, to a certain extent, by the subject’s cognitive
style.

Qualitative Analysis:

The client’s drawing reveals his anxiety, fearfulness, guilt feelings over voyeuristic
tendencies, with the vague perception of the world, emotional immaturity, egocentricity,
dependency, lack of discrimination, and depression, insecurity, feeling of inadequacy,
stubbornness, and negativism, poor coordination and impulsiveness, physical awkwardness,
physical inadequacy or a confusion of lateral dominance.

Thematic Appreciation Test (TAT)

Introduction:

The TAT was developed during the 1930s by the American psychologist Henry A.
Murray and lay psychoanalyst Christiana D. Morgan at the Harvard Clinic at Harvard University.
The Thematic Apperception Test (TAT) is a projective psychological test. Proponents of the
technique assert that subjects' responses, in the narratives they make up about ambiguous
pictures of people, reveal their underlying motives, concerns, and the way they see the social
world. Historically, the test has been among the most widely researched, taught, and used of such
techniques.

Qualitative Analysis:

The client’s stories on TAT reveals that he has needs, sentience, achievement,
acquisition, indecisiveness, cognizance, construction, affiliation, sex, recognition, passivity,
abasement, autonomy (resistance) superego, exposition, he also show the press of example
(good influence)
Slosson Drawing Coordination Test (SDCT)

Introduction:

Purpose Designed to identify individuals with brain dysfunction or perceptual disorders


involving hand eye coordination. Population Children and Adults Scores Raw scores,
Accuracy Score Time (10-15) minute Author Richard L. Slosson Publisher Slosson
Educational Publications Description The Slosson Drawing Coordination Test (SDCT) is a
supplement to the Slosson Intelligence Test (SIT). It can be given individually or in groups.

Quantitative analysis

Neurological screening test and this test gives eye hand coordination.

Errors Accuracy Age


17 53% 22 years
Cut off score is 85%.

Qualitative Analysis:

The client score on SDCT is 53% which shows that eye- hand coordination does not
seem to be intact.

Standard Progressive Metrics (SPM)

Introduction:

The SPM is a group or individually administered test that nonverbally


assesses intelligence in children and adults through abstract reasoning tasks. Appropriate for ages
8-65, the SPM consists of 60 problems (five sets of 12), all of which involve completing a
pattern or figure with a part missing by choosing the correct missing piece from among six
alternatives. Patterns are arranged in order of increasing difficulty. The test is untimed but
generally takes 15-45 minutes and results in a raw score which is then converted to a percentile
ranking. The SPM is considered an "average"-level test for the general population.
Qualitative Analysis:

On standard progressive matrices (SPM) the clients got 19 scores, 5 th percentile which
lies in grade V that shows the client is “intellectually defective”.

Quantitative Analysis: - SPM

NO A KEY NO B KEY NO C KEY NO D KEY NO E KEY


1 + 4 1 + 2 1 - 8 1 - 3 1 - 7
2 + 5 2 - 6 2 - 2 2 - 4 2 - 6
3 + 1 3 - 1 3 - 3 3 - 3 3 - 8
4 + 2 4 - 2 4 - 8 4 - 7 4 + 2
5 + 6 5 - 1 5 - 7 5 - 8 5 - 1
6 + 3 6 - 3 6 - 4 6 - 6 6 - 6
7 + 6 7 - 5 7 - 5 7 + 5 7 - 1
8 - 2 8 + 6 8 - 1 8 - 4 8 - 6
9 + 1 9 + 4 9 _ 6 9 - 1 9 - 3
10 + 3 10 - 3 10 + 6 10 _ 3 10 + 3
11 + 5 11 + 4 11 + 1 11 - 5 11 _ 5
12 - 5 12 + 5 12 - 2 12 - 6 12 _ 4
9 5 2 1 2

The person score is the total number of responses correctly solved is 19

Discrepancy Score: -

Discrepancy score 96320

Person score 95212

Discrepancy 0 1 -1 -1 2

Scoring
Raw score 19
Percentile 5%
Grade V (intellectually defective)
Discrepancy 0 1 -1 -1 2
Time 40minuts

Rotter Incomplete Sentence Blank (RISB)

Introduction:

The Rotter Incomplete Sentence Blank is a projective psychological test developed by


Julian Rotter and Janet E. Rafferty in 1950. It comes in three forms i.e. school form, college
form, adult form for different age groups, and comprises 40 incomplete sentences which the S’s
has to complete as soon as possible but the usual time taken is around 20 minutes, the responses
are usually only 1-2 words long such as "I regret ..." "Mostly girls...". the test can be
administered both individually and in a group setting. It doesn’t have long set of instructions and
can be easily worked out on a greater population.

Quantitative analysis

Types of No. of responses Value Total responses


responses
C3 0 6 6
C2 8 5 40
C1 9 4 36
N 2 3 6
P1 7 2 14
P2 8 1 8
P3 4 0 0
Total score=110
The results indicated that the grand score is 110 and the cut score of this test is 135, thus the
subject seems to be well-adjusted.

Qualitative analyses

Familial attitudes:

There is no indication of any maladjustment regarding family attitudes. As, he expresses positive
attitudes towards both her mother and father (item 11 and 35). He has good relationships with
both his parents. He also good behavior with parents and with other family member. Item 4 and
26 shows his conflict and positive response towards his home and marriage, “Home. . I feel
obsessions” and “Marriage. . . I like marriage”

Social & sexual orientation:

His social attitudes shows that he has positive and neutral responses toward people because of
their optimistic nature as indicated in item 2, 8, 10, 19, 29. He also shows some conflict and
responses regarding people (item 9, 25). Item 40 indicated positive responses toward sexual
attitudes. Most women--------“Women’s are beauty”

General attitudes:
General attitudes indicates some experience regarding his decision of studies and he seems
extrovert as he likes to stay with friend, spend time with friend and like extracurricular activities
as sports, he also like dancing etc. (item 2,16,38) “sports. . . I like sports very much”. Generally
he has whished attitudes and like to spend time with parents. (item 1, 34.) ; and regarding
studies conflict response is indicated in that items (5, 33) positive response about life in these
items.(12, 27 ) I am best-----When I feel peace. and positive and conflicted responses in that
items (14, 23, 24) such as My mind-----“was ok”.

Character trait:

Subject shows her activities in having a conflicted and negative connection with people. He
wants his self to be involve of bad deeds and sometimes seems happy & sad (item 13, 18, 20, 21)
in item 29 “painful for me “when I rid away from my thoughts”.

Back Depression Inventory (BDI)

Introduction:

The Beck Depression Inventory (BDI, BDI-1A, BDI-II), created by Aaron T. Beck, is a
21-question multiple-choice self-report inventory, one of the most widely used psychometric
tests for measuring the severity of depression. Its development marked a shift among mental
health professionals, who had until then, viewed depression from a psychodynamic perspective,
instead of it being rooted in the patient's own thoughts. he Beck Depression Inventory (BDI) is a
21-item, self-report rating inventory that measures characteristic attitudes and symptoms of
depression (Beck, et al., 1961). The BDI has been developed in different forms, including several
computerized forms, a card form.

Quantitative Analysis

Scores Range Category


33 29-63 Sever
Urdu (version)

Qualitative Analysis
On the Beck Depression inventory (BDI) the client’s got 33 scores which indicate that he
has severe level of Depression.

Beck Anxiety Inventory (BAI)

Introduction:

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other colleagues, is a
21-question multiple-choice self-report inventory that is used for measuring the severity of
anxiety in children and adults. The questions used in this measure ask about common symptoms
of anxiety that the subject has had during the past week (including the day you take it) (such as
numbness and tingling, sweating not due to heat, and fear of the worst happening). It is designed
for individuals who are of 17 years of age or older and takes 5 to 10 minutes to complete. Several
studies have found the Beck Anxiety Inventory to be an accurate measure of anxiety symptoms
in children and adults.

Quantitative Analysis

Scores Range Category


25 17-29 Moderate
Urdu (version)

Qualitative Analysis

(BAI) on the Beck Anxiety Inventory ( BAI) client’s got 25 scores which indicates that he has
moderate level of anxiety.

Psychological Evaluation:

The client’s drawing reveals his anxiety, fearfulness, guilt feelings over voyeuristic
tendencies, with the vague perception of the world, emotional immaturity, egocentricity,
dependency, lack of discrimination, and depression, insecurity, feeling of inadequacy,
stubbornness, and negativism, poor coordination and impulsiveness, physical awkwardness,
physical inadequacy or a confusion of lateral dominance.
The client’s stories on TAT reveals that he has needs, sentience, achievement,
acquisition, indecisiveness, cognizance, construction, affiliation, sex, recognition, passivity,
abasement, autonomy (resistance) superego, exposition, he also show the press of example
(good influence).

The client score on SDCT is 53% which shows that eye- hand coordination does not
seem to be intact.

On standard progressive matrices (SPM) the clients got 19 scores, 5 th percentile which
lies in grade V that shows the client is “intellectually defective”.

The results indicated that the grand score is 110 and the cut score of this test is 135, thus the
subject seems to be well-adjusted.

On the Beck Depression inventory (BDI) the client’s got 33 scores which indicate that he
has severe level of Depression.

(BAI) on the Beck Anxiety Inventory ( BAI) client’s got 25 scores which indicates that he has
moderate level of anxiety.

Diagnosis

The client is suffering from major depressive episode with severe psychotic feature.

Code: 296.24

Criteria:

A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
(Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation.)

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (Note: In
children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down)

. 6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)


nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by


subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational,


or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another


medical condition.

Note: Criteria A-C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understandable
or considered appropriate to the loss, the presence of a major depressive episode in addition
to the normal response to a significant loss should also be carefully considered. This decision
inevitably requires the exercise of clinical judgment based on the individual’s history and the
cultural norms for the expression of distress in the contest of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified
and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance induced or are attributable to the physiological effects of another medical
condition.

Prognosis

At the early stages of his prognosis was poor because he was not interested to talk with
the internee psychologist. After some therapy session his condition improved and psycho
education worked well with his through the use of family therapy and relaxation her prognosis
seems better.

Management and Treatment:

Along with pharmacological treatment, the client is being treated with psychological
intervention. According to the current picture of the client there are two management plans for
her.

Short term management plan

This is immediate management plan, in which daily activity chart, relaxation training and
Psych education was use with the client.

Psych education
Psycho education was given to the client in the form of informational care. She thought
that she has suffering both psychological or physical problem. Information was given to the
client about her disorder and current condition. She got insight about her problem and be
motivated to get over her condition.

Daily activity chart

Daily activity chart was maintained for her. It based on the routine activities like daily
bathing, teeth brushing, walking, exercising, offering prayers, maintaining diet, sleep etc. Which
become disturb of the client. By using this chart her routine was regularized and she felt better
then earlier.

Relaxation training

The client show some psychosomatic complaints such as headache, back ache, and legs
pain or the psychiatrist conform that their is no physical cause of this pain. So relaxation training
was taught to the client to relax her muscles and to get rid of all these pain. She learn to de
breathing daily along with her morning walk.

Long term management plan

In this management plan efforts were mad to make her well- adjusted in her later life. It
includes Supportive therapy, Family therapy and Social skill training .

Supportive therapy

Treatment designed to improve, reinforce, or sustain a patient's physiological well-being


or psychological self-esteem and self-reliance.

Social skill training

As the client is in depressed state of mind which is closely related to interpersonal


difficulties, behavioral treatment focus on helping client to improve social interaction. Work was
done to enhance the self esteem and motivational level of the client.

Family therapy
Family therapy is very important for the depressed patient. After her discharged from the
hospital she has live with her family. The following family counseling done with client family.

1. Education and information was provided to the client family related to depression.
Because the depression is mostly tied interpersonal problems.
2. It was suggested to family improve their communication and attention to reduce stress on
her.
3. Internee therapist informed the client or therapist regarding to the side effect of
medication that can accord so that the client could not discontinued the medicine.
4. Work was done on expressed emotions that the client should not be blamed for her
illness.

Recommendations :

 Supportive therapy is used to provide support and help to resolve the interpersonal
conflict which she faces in family, and try to develop the confidence in the client.
 Assertive training is applied to make her assertive and confident.
 Interpersonal psychotherapy is used to help the client to cope with personal and social
aspects and improve the social functioning.
 Cognitive therapy is used to change her adaptive belief system, and encourage the client
to attempt specific “experiment” in real life to help challenge the faulty assumptions.
 Cognitive restructuring is applied to reconstruct her thoughts.
 Family counseling is recommended to improve the family environment and
communication skills among all family members.
 Relaxation technique is use to relax the body when feels the fatigue and low energy
 Deep breathing in the time of stress and improve the depressed mood and feel
comfortable.
 Referred to psychotherapist and psychiatry.

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