Case No.

1
(Major Depressive Disorder)
 CASE 1
Bio Data
Name S.K
Father Name A.K
Age 21 years
Gender Male
Education B.A
Religion Islam
Birth Order 1st
Siblings 4
Parents Alive
Father Occupation Jobless
Mother Occupation Housewife
Social Economic Status Lower middle class
Address Faisalabad
Examiner F.N

Reason and Source of Referral

The client was hospitalized after having unbearable distress because of the
symptoms he suffering from.

Presenting Complaints

According to Client:

 Feeling hopeless and worthless for the past few months.

 Unable to enjoy activities he previously liked.
 Frequent thoughts of ending his "useless" life.
 Disturbed sleep patterns and excessive overthinking.

According to Informant:

The client’s close family members observed his withdrawal from family gatherings
and lack of interest in daily activities. Increased irritability and sadness have been
noticed.
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History of Present Illness

S.K. has been experiencing worsening symptoms of depression and obsessive

thoughts for the past 2-3 months. The symptoms include a lack of interest in
previously enjoyed activities, feelings of worthlessness, disturbed sleep, and suicidal
ideation. These issues intensified after his failure to be commissioned as a second
lieutenant in the army following his 12th-grade education. This failure significantly
affected his self-esteem and led to persistent rumination and obsessive thoughts about
his thin body shape and curly hair, which have been ongoing since the 8th grade.

S.K. was admitted to the hospital due to the severity of his symptoms from the
previous 9 days. He was prescribed Olanzapine, Sertraline, and other supportive
medications, which have shown some positive effects.

Developmental History

He achieved developmental milestones on time. As a child, he was sensitive

and cautious, often comparing himself to others. During adolescence, he developed
obsessive thoughts about academics and body dysmorphia. These issues worsened
when he failed to achieve his goal of joining the army.

Personal History

S.K. comes from a financially dependent and religiously conservative

household. Despite academic struggles and limited social interactions, he has shown
resilience by continuing his education and supporting himself through teaching.
However, his preoccupation with body image and failure to meet personal goals has
severely impacted his self-esteem.

Family History

S.K. has a supportive but financially constrained family. His uncles provide
financial assistance, while his father focuses on religious activities. There is no history
of mental illness in the family, but the family’s dependency and societal pressures
have influenced S.K.’s mental health.
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Educational History

He received a scholarship to study at an army cantonment school, where he

consistently performed above average despite facing obsessive thoughts and academic
pressure. He is now pursuing a B.A. privately.

Social History

The patient maintains limited social interactions, preferring a few trusted

individuals. He avoids social gatherings due to his cautious nature and past
experiences with bullying. His relationships with family members remain positive and
supportive.

Occupational History

S.K. works as a teacher at a small school in his village, which provides him
with modest financial independence. His job gives him a sense of purpose, but his
mental health challenges affect his performance.

History of Drug Use/Abuse

S.K. has no history of drug use or substance abuse.

Premorbid Personality

S.K. was described as a sensitive, cautious, and hardworking individual. He

maintained good relationships with his family and community but often compared
himself negatively to others.

Mental Status Examination

• Thoughts

The patient presents depressive thoughts regarding his future, academic

performance, and body image. These thoughts have been persistent and distressing for
him, contributing to feelings of worthlessness and anxiety. He expresses concerns
about his abilities and achievements, often dwelling on negative outcomes and self-
critical thoughts.

• Level of Consciousness
 5

He appears fully conscious and aware of his surroundings. He is responsive

and engaged during the assessment, despite the burden of his depressive thoughts.

• Memory

S.K. demonstrates intact memory functions, recalling past events and

providing coherent responses to questions about his personal history and recent
experiences.

• Orientation

S.K. is oriented to person, place, and time, accurately identifying himself, his
current location, and the present date.

• Mood

S.K.'s mood fluctuates between sadness and anxiety, particularly when

discussing his academic and personal challenges. He appears despondent at times but
is responsive to supportive interventions.

• Affect

S.K.'s affect is congruent with his mood, displaying signs of sadness and
anxiety during the assessment. However, he is able to maintain appropriate emotional
expression and engagement in conversation.

• Dress/ Hygiene

The patient presents with a well-groomed appearance and appropriate dress.

His hygiene appears to be well-maintained, suggesting a level of self-care despite his
emotional struggles.

• Speech

His speech is normal in rate, volume, and articulation. He communicates

effectively and coherently, expressing his thoughts and feelings with clarity.

• Insight

He demonstrates insight into his mental health struggles and acknowledges the
need for professional help. He recognizes the impact of his depressive thoughts and
 6

mood disturbances on his daily functioning and is open to receiving support and
guidance.

• Behavior

S.K.'s behavior is cooperative throughout the assessment, actively

participating in the conversation and following instructions as needed.

Psychological Assessment

1. Human Figure Drawing (HFD)

 Repressed sex drives (Hair given much attention)

 Instability and impulsivity (Poor integration and Asymmetry, slanting
figure)
 Sensual needs (Hair shaded)
 Anxiety over sexual needs possibly (Hair emphasis with heavy
shading)
 Feeling of anxiety or inferiority over body functions (Head clearly
indicated)
 Egocentricity, Regression (No pupils)
 Uninhibitedness (Brushy eyebrows)
 Passive or oral aggression (Mouth heavy line)
 Sexual Preoccupation (Trunk not closed at bottom)
 Depression, sense of withdrawal and poor self-image (Tiny Figure)
 Fear of attack and Tension related to sexual activity (Pressed legs)

2. DASS 21 (Depression Anxiety Stress Scale)

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Table 1

DASS 21 Quantitative Interpretation

Scale Score Severity

Depression 20 Moderate

Anxiety 16 Moderate

Stress 32 Severe

Qualitative Interpretation

Depression Score of 32 falls into the "Extremely Severe" range, indicating a very high
level of depressive symptoms. Anxiety Score of 22 falls into the "Extremely Severe"
range, indicating a very high level of anxiety symptoms. Stress Score of 24 falls into
the "Moderate" range, indicating a significant but not extreme level of stress
symptoms.

These scores suggest the individual is experiencing severe levels of depression and
anxiety, along with a moderate level of stress.

3. Yale Brown Obsessive Compulsive Scale

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) Y-BOCS is applied to check the
severity of obsession and compulsion of preoccupation with body related insecurities
especially thin curly hairs and thin body shape which distressed the client sometimes
ago.
Table 2
YBOCS quantitative Analysis

Score Severity
 8

22 Moderate

Qualitative Analysis
The client, S.K., with a Y-BOCS score of 22, demonstrates a moderate level of
obsessive-compulsive symptoms. His obsessions primarily revolve around intrusive
and distressing thoughts about his body image, including concerns about his thin body
shape and curly hair. These intrusive thoughts significantly impact his ability to
concentrate on academic and personal responsibilities, causing considerable
emotional distress. Additionally, he engages in compulsive behaviors, such as
excessive grooming or seeking reassurance, in an attempt to manage his distress.
Despite the severity of his symptoms, S.K. shows partial insight, as he recognizes
these thoughts and behaviors as excessive or irrational at times, which creates further
frustration and self-critical feelings.

Case Formulation

S.K., a 22-year-old B.A. student navigates a complex mental health journey shaped by
his upbringing, societal pressures, and significant life experiences. His struggles are
exacerbated by factors relating to his family background, academic pressures, and
personal setbacks, all of which have shaped his psychological landscape.

Predisposing Factors

 Upbringing in a conservative household: Instilled cautiousness and

sensitivity, contributing to emotional reactivity to stressors.

 Socio-economic background: Raised in a lower-middle-class family with

limited financial resources, which contributed to feelings of insecurity.

 Academic experiences: Attended an army cantonment school, leading to

heightened concerns about body image and academic performance.
 9

 Family role: As the eldest sibling in a large family, S.K. likely experienced
early responsibilities, which may have impacted his sense of identity and
autonomy.

Precipitating Factors

 Failure to join the army: The failure to fulfill his aspiration to become a
commissioned officer shattered his self-esteem and intensified pre-existing
insecurities.

 Academic pressure and social comparison: The pressures from academic

life and negative self-comparisons, especially after the failed military
aspiration, triggered a spiral of negative self-reflection and rumination.

Perpetuating Factors

 Negative self-reflection and rumination: These cognitive patterns continue

to reinforce feelings of hopelessness, worthlessness, and inadequacy.

 Limited social support: Despite family ties, S.K. lacks wider social networks,
leading to isolation and a sense of helplessness.

 Financial dependency: This factor exacerbates his autonomy struggles and

feelings of helplessness, as S.K. feels trapped in his circumstances.

 Internalized societal expectations: Societal pressures contribute to a cycle of

self-doubt and feelings of failure, deepening his psychological distress.

Protective Factors

 Strong family bonds: His close relationship with his family provides
emotional support and a sense of belonging, offering hope in times of distress.

 Academic achievements: S.K. has demonstrated intellectual capacity and

resilience through his academic performance, which serves as a foundation for
future growth.

 Employment as a teacher: This role reflects his determination and capability,

offering an opportunity for personal growth and an external source of
validation.
 10

 Resilience and determination: Despite his challenges, S.K. has shown

resilience in managing academic and personal setbacks, suggesting a potential
for growth and recovery.

Provisional Diagnosis

Major Depressive Disorder (296.20)

Management Plan

Objectives Short Term Goals Interventions

 11

 To reduce obsessive  Decrease  Cognitive

thoughts and feelings
frequency and Behavioral
of inadequacy.
intensity of Therapy (CBT):
obsessive thoughts -Cognitive
 To enhance self- related to body Restructuring
esteem and build a
image and - Thought
more realistic self-
concept. academic Stopping
performance. Techniques
 Enhance Self-  Exposure and
 To improve coping
Esteem and Self- Response
strategies and reduce
rumination. Concept Prevention (ERP)
 Improve Coping  Psychoeducation
Skills and Manage  Social Skills
 To strengthen social Rumination Training
support and autonomy
in decision-making.  Increase Social  Mindfulness and
Support and Relaxation
Strengthen Techniques
 To promote a sense of Autonomy
hope and future
growth.  Promote Hope and
Future Growth

Prognosis

The prognosis for S.K is cautiously optimistic, contingent upon several

factors. His response to psychiatric treatment and therapy, along with the support of
his family and social network, will be pivotal. If he demonstrates improvement and
 12

engages actively in his recovery, there's potential for significant progress in managing
his mental health challenges.

Sessions

Sessions 1 to 4

The first session focused on building rapport and establishing a trusting

relationship with S.K. The therapist began by explaining the therapeutic process,
emphasizing confidentiality and a non-judgmental approach. S.K. shared his personal
history, including his family background and key life experiences, such as his
academic journey and his aspiration to join the army. The therapist actively listened,
validating S.K.'s emotions and ensuring he felt heard. S.K. expressed concerns about
obsessive thoughts, body image issues, and feelings of inadequacy after not being able
to join the army. The session also included a discussion on his strengths, like his
academic success and his role as a teacher, which were identified as crucial assets in
his healing journey. The therapist administered standardized assessments, such as the
DASS-21, to assess S.K.'s levels of anxiety, depression, and stress. This session
provided a foundational understanding of his mental health concerns and helped
establish a supportive therapeutic environment.

The second session continued building the therapeutic relationship, further

exploring S.K.'s background and mental health concerns. The therapist revisited the
topics from the previous session, ensuring S.K. felt comfortable and supported. The
conversation deepened into S.K.'s upbringing in a conservative household, his
academic life, and societal pressures, which were contributing to his mental health
struggles. The therapist introduced the concept of cognitive distortions, particularly
negative self-comparisons and rumination, and explained how these thought patterns
were affecting his well-being. Psychoeducation on Cognitive Behavioral Therapy
(CBT) was provided, emphasizing the link between thoughts, emotions, and
behaviors. S.K. was introduced to the thought record technique, which would allow
him to track and challenge his negative thoughts between sessions. The session also
explored his social support system, particularly his family, and the potential for
expanding this network..

The third session focused on intervention, specifically cognitive restructuring

and exposure techniques. S.K. began by reviewing his thought record, and the
 13

therapist helped him identify recurring negative thoughts related to his self-esteem
and the failure to join the army. Together, they worked on challenging these thoughts
by examining evidence for and against them, fostering more balanced and realistic
alternatives. The therapist also discussed how S.K.'s perfectionism was contributing to
his feelings of inadequacy and taught strategies for setting more realistic standards.
Additionally, graduated exposure was introduced to help S.K. face situations that
trigger anxiety and obsessive thoughts. Starting with less challenging situations, the
therapist guided S.K. through exposure exercises aimed at reducing his distress.
Mindfulness techniques, including deep breathing and grounding exercises, were
introduced to help S.K. manage intrusive thoughts and anxiety.

The fourth session shifted focus toward enhancing S.K.'s social support
network and developing adaptive coping strategies. The session began with a review
of S.K.'s homework, where he reflected on his use of the thought record and
mindfulness practices. The therapist acknowledged his successes and discussed any
challenges he faced in applying these tools. The conversation then turned to the
importance of expanding S.K.'s social support system. While his family was a strong
support, the therapist encouraged him to explore opportunities to connect with peers
or engage in community-based groups, such as academic or social clubs, to alleviate
feelings of isolation

Recommendation

 Encourage S.K. to continue using the thought record to track and challenge
negative thoughts, particularly those related to self-worth and failure.
 Introduce a daily mindfulness practice, such as deep breathing or guided
imagery, to help manage anxiety and intrusive thoughts.
 Explore additional social support networks outside of family, including joining
academic groups, clubs, or community organizations to reduce isolation.
 Work on building financial independence and autonomy by exploring part-
time job opportunities or other means of self-sufficiency.
 Encourage S.K. to set small, achievable goals related to his academic and
personal life, helping him gradually rebuild his self-esteem and confidence.
 Recommend practicing self-compassion exercises, focusing on acceptance of
imperfections and embracing personal strengths.
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 Utilize exposure techniques in a graduated manner to help S.K. face anxiety-

provoking situations and reduce avoidance behaviors.
 Suggest engaging in regular physical activity or hobbies that promote
relaxation and well-being, such as walking, yoga, or creative pursuits.
 15

Case No. 2
(Schizophrenia)
 CASE 2
Bio Data
Name M.S
Father Name M.N
Age 42 years
Gender Male
Education Matric
Religion Islam
Birth Order 2nd
Siblings 5
Parents Father Deceased
Father Occupation Businessman
Mother Occupation Housewife
Social Economic Status Middle class
Address Faisalabad
Examiner W.K

Reason and Source of Referral

The client was admitted to the hospital after a recent episode.

Presenting Complaints

According to Client

The client, M.S., states that he hears his father's voice communicating with
him and believes his father's soul is guiding him. He reports feeling distressed and
unable to work at his shop due to these experiences.

According to Informant

According to the informant, M.S. has been experiencing auditory

hallucinations, delusions involving his deceased father, social withdrawal, and
difficulty managing daily responsibilities, including running his shop. These
symptoms have persisted for the past 6-7 years.
 17

History of Present Illness

M.S. began experiencing these symptoms approximately 6-7 years ago

following the death of his father. He reported hearing voices, which he believes are
his father's soul communicating with him. These auditory hallucinations, coupled with
delusions, have caused significant distress and impairments in his daily functioning.
Over time, he has become increasingly withdrawn, unable to manage his shop, which
is now rented out to sustain the family's financial needs. His condition has
progressively worsened, with persistent symptoms interfering with his personal,
social, and occupational life.

Developmental History

The patient achieved all his milestones at appropriate time without any
specific complications.

Personal History
M.S. is a 42-year-old married man with two children, a 12-year-old daughter,
and a 10-year old son. He had been running a small shop in Faisalabad with his father
until his father’s death, which triggered the onset of his psychotic symptoms.

Family History
His father, M.N., was the owner of the family shop, and M.S. worked
alongside him from an early age. After his father's death, M.S. developed
schizophrenia, which has had a profound impact on his family life. M.S. is married
with two children, and his wife has become the primary caregiver as M.S. struggles
with his mental health. The family's financial situation has become precarious, as they
now rely on the rental income from the shop to meet their basic needs. There is no
known history of mental illness in M.S.’s immediate family, but the stress of dealing
with his illness has affected the entire household.
Educational History

M.S. completed his education up to the 10th grade. His educational journey
was straightforward, with no significant challenges reported during his school years.
After completing matriculation, M.S. began working full-time at his father’s shop,
where he gained practical business experience.
 18

Social History
M.S.'s social interactions have become increasingly limited since the onset of
his schizophrenia. Prior to his illness, M.S. had an active social life, interacting with
customers and fellow shopkeepers in the bazaar. However, the hallucinations and
delusions have led to significant social withdrawal. M.S. now spends most of his time
at home, avoiding contact with people outside of his immediate family.
Occupational History
M.S. was actively involved in running his family’s shop in Faisalabad, which
was the main source of income for the household. He took over the responsibilities of
the shop after completing his education and worked there until his father’s death.
However, the onset of schizophrenia and the resulting hallucinations and delusions
made it impossible for M.S. to continue working.
Psychosexual History
Not significant

History of Drug Use/Abuse

M.S. has not reported any history of drug use or abuse. His symptoms are
attributed to the onset of schizophrenia following the death of his father, and there is
no indication of substance-related issues contributing to his condition.

Premorbid personality
M.S. was described as a calm, responsible, and hard-working individual before
the onset of his illness. He managed his small shop efficiently and provided for his
family. He was socially active, maintained good relationships with family and
community members, and was considered reliable and grounded. There were no
notable behavioral or psychological concerns prior to the onset of his symptoms.
Mental Status Examination

General Appearance:
M.S. appeared disheveled, with poor grooming and hygiene. He was dressed in untidy
clothing inappropriate for the weather.
 19

Behavior:
He displayed psychomotor retardation, with slow movements and limited engagement
during the session. His eye contact was intermittent and poorly sustained.

Speech:
Speech was low in volume, with a slow rate and occasional pauses. The tone was
monotonous, and responses were brief but relevant to direct questions.

Mood and Affect:

Mood appeared low and dysphoric. Affect was blunted, with limited expression of
emotions throughout the session.

Thought Process:
Thought processes were disorganized, with loose associations. He frequently jumped
from one topic to another, making it difficult to follow his train of thought.

Thought Content:
Delusions of reference and persecution were evident, as M.S. expressed beliefs about
people plotting against him and his father's soul communicating with him. No suicidal
or homicidal ideations were reported.

Perception:
Auditory hallucinations were reported, with M.S. hearing voices he attributed to his
late father, which he described as commanding and distressing.

Cognition:
M.S. was alert but exhibited significant impairment in concentration and attention.
Memory for recent and remote events appeared intact, though insight into his
condition was limited.

Insight and Judgment:

Insight was poor, as M.S. did not fully recognize his condition as an illness and
attributed his experiences to supernatural causes. Judgment was impaired, as
evidenced by his inability to manage daily responsibilities and interactions.

Orientation:
M.S. was oriented to person, place, and time.
 20

Psychological Assessment

1. Human Figure Drawing (HFD)

• Brief Psychiatric Rating Scale (BPRS)
• Disorganization and Confusion (Incomplete figure)
• Psychic Distress (Uneven lines and lack of symmetry)
• Distorted Perception of Self (Exaggerated ears)
• Delusional Fixation (Strongly outlined eyes)
• Emotional Vulnerability (Slumped posture)
• Isolation and Detachment (No arms)
• Disconnection from Reality (Disconnected body parts)
• Helplessness and Fear (Small figure)
• Lack of Control (Jagged and uneven lines)
• Deep-Seated Anxiety (Shaded areas on the figure)

2. Brief Psychiatric Rating Scale (BPRS) Results

Table 1
BPRS severity level and score ranges

Severity Mild Moderate Severe Extreme

Level
Score range 18-31 32-52 53-70 71+
Score 58

Qualitative Interpretation

M.S.'s score of 58 on the Brief Psychiatric Rating Scale (BPRS) falls within
the "Severe" category, which indicates significant psychiatric impairment. This
severity level reflects intense symptoms, including persistent auditory hallucinations,
fixed delusions, and disorganized thinking, all of which have greatly impacted his
daily functioning. Patients in the severe range often experience substantial distress
and disability, necessitating comprehensive psychiatric intervention. The presence of
 21

such high levels of psychotic symptoms, as indicated by M.S.'s score, underscores the
need for ongoing, intensive treatment to manage his condition and improve his quality
of life.

Case Formulation

Predisposing Factors:

• Family History: No significant psychiatric history in the family.

• Personality: M.S. has a generally introverted and dependent personality style,
possibly contributing to his difficulty in coping with stressors.
• Life Events: The death of his father 6-7 years ago, which acted as a major
stressor, appears to have precipitated the onset of his symptoms.
Precipitating Factors:

• The Death of Father: This traumatic event triggered the onset of his psychotic
symptoms, including auditory hallucinations and delusions, marking a sharp
decline in M.S.'s mental health.
• Emotional Distress: His grief, combined with an inability to process the loss of
his father, seems to have contributed to his psychosis, where he believes his
father's soul is communicating with him.
Perpetuating Factors:

• Poor Insight: M.S. lacks insight into his condition and attributes his
hallucinations and delusions to his deceased father’s communication. This
makes it difficult for him to seek proper treatment or acknowledge the severity
of his illness.
• Limited Social Support: Although M.S. lives with his wife and children, the
isolation and strained relationships, exacerbated by his delusions, perpetuate
his symptoms and reduce his ability to cope effectively.
• Functional Impairment: His inability to return to work and manage day-to-day
responsibilities further entrenches his condition.
 22

Protective Factors:

• Family Support: Despite the strain, M.S. has a support system in the form of
his wife and children, which can be leveraged to assist in his recovery.
• Marital Stability: Although his psychosis affects his interactions, his long-term
marriage could provide a stable foundation for therapy and social support.

Provisional Diagnosis

Schizophrenia (295.90) with predominant auditory hallucinations

Management Plan

Objectives Short Term Goals Interventions

• Reduce the • Antipsychotic
severity of Medications (e.g.,
 To reduce the severity
psychotic Risperidone,
of psychotic symptoms
symptoms Olanzapine) to target
(hallucinations and
(hallucinations psychotic symptoms.
delusions).
and delusions).
• Medication
 To improve insight into
• Improve insight Monitoring to assess
the illness and encourage
into illness and effectiveness, side
engagement in treatment.
encourage effects, and make
treatment adjustments.
 To restore functional
adherence.
abilities and improve
quality of life.
• Cognitive-Behavioral
• Restore functional Therapy for Psychosis
 To enhance social
abilities and
support and improve improve social • Psychoeducation
functioning. about schizophrenia
communication within the
and the role of
family. • Enhance social medication.
support and
improve family • Motivational
dynamics. Interviewing (MI

• Supportive
Counseling
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Prognosis

With appropriate antipsychotic medication, therapy, and family support, M.S.

has a fair prognosis for symptom management and improving social functioning.
Long-term recovery will depend on adherence to treatment and ongoing support.

Sessions

Sessions 1 to 4

The first session with M.S. focused on a comprehensive assessment and

detailed history taking. The session explored M.S.’s background, including his
familial responsibilities, his experience running a small shop in Faisalabad, and the
onset of his psychotic symptoms following his father's death. M.S. described the
distress caused by persistent auditory hallucinations, which he believes are connected
to his father’s spirit. During the session, 65 rapport-building was emphasized to create
a safe and supportive environment for M.S. to express his concerns. The initial
assessment also covered the impact of his symptoms on his daily life and
relationships, laying the foundation for future therapeutic work.

The second session focused on psychoeducation about schizophrenia, helping

M.S. better understand his condition. The session included explanations about the
nature of auditory hallucinations, delusions, and the role of stress in exacerbating
psychotic symptoms. M.S. was educated on the importance of consistent medication
adherence and the role of antipsychotics in managing his symptoms. He expressed
concerns about the long-term use of medication, which were addressed with
information on balancing side effects and benefits. The session also introduced
grounding techniques to help M.S. manage his distress when experiencing
hallucinations, offering practical tools to begin regaining a sense of control.

Building on the previous session, the third session concentrated on further

psychoeducation and the introduction of therapeutic strategies to manage psychotic
symptoms. Cognitive behavioral techniques were introduced, including reality-testing
exercises to help M.S. differentiate between hallucinations and reality. The session
 24

also focused on stress management techniques, such as deep breathing and

progressive muscle relaxation, to reduce anxiety and prevent symptom exacerbation.
M.S. expressed a growing sense of relief as he began to see a path toward managing
his symptoms. Together, we developed a structured daily routine to help him establish
consistency and reduce stressors, setting the stage for continued progress in therapy.

Recommendation

• Ensure consistent use of prescribed antipsychotic medications to manage

symptoms and prevent relapse.
• : Engage in Cognitive Behavioral Therapy (CBT) or other therapeutic
modalities to help with cognitive restructuring and stress management.
• Encourage family support and involvement in treatment to improve
understanding and reduce stigma around mental illness.
• Connect with support groups or community resources for individuals with
schizophrenia to reduce isolation.
• Introduce relaxation techniques and stress-reduction strategies to help cope
with triggers.
• Gradually increase social activities to improve social skills and reduce
isolation.
• Regular follow-up with mental health professionals to assess progress and
adjust treatment as needed.
• Develop a crisis intervention plan in case of worsening symptoms or
potential relapse.
• Explore vocational or skill-building opportunities to enhance
independence and self-esteem.
 25

Case No. 3

(Substance Use Disorder)

 CASE 3
Bio Data
Name I.S
Father Name S.S
Age 25 years
Gender Female
Education F.A
Religion Islam
Birth Order 3rd
Siblings 5 (3M, 2F)
Parents Mom is alive
Father Occupation Farmer
Mother Occupation Housewife
Social Economic Status Middle class
Address Manawala, FSD
Examiner W.K

Reason and Source of Referral

The client was referred to the hospital after a recent overdose episode.

Presenting Complaints

According to the Client

The patient was recently admitted to the hospital 2 days ago, following an exacerbation of
her ongoing symptoms. She has been struggling with low mood, disturbed sleep, low
appetite, body aches, and fatigue for the past 3.5 to 4 years. However, in the last few weeks,
her symptoms worsened significantly, leading to increased emotional distress and physical
discomfort. The patient reports feeling overwhelmed by these symptoms, which have
become more intense and debilitating.

According to the Informant (Her Elder sister)

According to the patient's elder sister, the patient’s condition significantly worsened
in the days leading up to her hospitalization. The sister explained that, on the day
before her admission, the patient injected herself with a total of 17 doses of Diazepam
 27

and Kinz, likely in an attempt to manage her distress. Despite this, her symptoms,
including low mood, disturbed sleep, low appetite, body aches, and fatigue, continued
to intensify. The patient's sister expressed concern that the combination of escalating
symptoms and the self-administered doses of medication contributed to her decision
to seek hospitalization two days ago for further care and assessment.

History of Present Illness

The Patient was in usual state of health 4 years back when her father died and she
developed the above symptoms of low mood, decreased sleep and appetite, body
aches and fatigue. A medical professional initially prescribed nalbuphine and
diazepam for her body aches and sleep issues, but she later developed a
dependency and began self-injecting with increasing dosages. One day before
her hospital admission, she injected 17 doses of the medication and lost
consciousness.

Developmental History

The patient had completed her developmental milestone normally. She doesn’t
have any history of developmental delays.
Personal History

I.S. is a 25-year-old female from a middle-class family in Manawala,

Faisalabad. She is the third-born of five siblings and grew up in a family where her
father, a farmer, passed away four years ago, leaving her mother, a housewife, as the
primary caregiver. I.S. completed her F.A. and identifies as a practicing Muslim. Her
struggles began after the loss of her father, which led to significant emotional distress,
including persistent low mood, grief, and stress. These challenges eventually
contributed to her developing a dependency on prescribed medications, which
worsened over time. Despite her difficulties, I.S. maintains some familial connections
but feels isolated emotionally, particularly due to her substance misuse.

Family History

I.S. comes from a middle-class family in Manawala, Faisalabad. She is the

third-born among five siblings. Her father, a farmer, passed away four years ago,
which significantly impacted the family dynamics. Her mother, a housewife, is the
primary caregiver. Notably, her elder brother experienced similar symptoms of low
 28

mood, stress, and substance misuse following their father's death. However, unlike
I.S., he sought timely treatment and successfully recovered, highlighting the
importance of early intervention in addressing emotional distress and substance
dependency.

Educational History

I.S. was an average student throughout her academic journey, successfully

completing her F.A. She maintained normal relationships with her teachers and peers,
demonstrating no significant behavioral concerns in the school setting. However, her
social circle was limited to a few friends, and these relationships were generally not
long-lasting. Despite her academic and social challenges, there were no notable
incidents of conflict or disciplinary actions during her education.

Social History

I.S. grew up in a middle-class family and has limited social interactions. While
she maintains occasional contact with her family, her substance use has led to feelings
of emotional and social isolation. Her friendships have been few and short-lived, and
she tends to avoid forming deep or lasting connections. She reports spending most of
her time at home and has minimal engagement in social or community activities.

Occupational History

After completing her F.A., I.S. began working as a nurse at a local private
hospital, where she has been employed for the past five years. Despite receiving a
minimal salary, she has maintained stable employment without any significant issues.
I.S. reports having normal working relationships with her colleagues and supervisors
and has faced no conflicts or challenges in her professional environment.

History of Drug Use/Abuse

I.S.’s substance use began four years ago when she started injecting diazepam
and nalbuphine (Kinz) to manage persistent body aches, sadness, and emotional
distress following her father’s death. Initially, the medications were prescribed by a
medical professional and provided temporary relief. Over time, however, she
developed a dependency and began increasing the dosage on her own. Her misuse
escalated significantly, leading to addiction. Two days prior to her hospital admission,
I.S. injected 17 doses in a single day, resulting in unconsciousness and necessitating
urgent medical intervention.
 29

Psychosexual History

I.S. reports a normal sexual history without any concerns or complications.

Her menstrual cycle is regular, and she has experienced no significant premenstrual or
gynecological issues.
 30

Premorbid personality

I.S. appears to have had a relatively stable premorbid personality. She was an
average student with normal relationships with teachers and peers, although her
friendships were few and not long-lasting, indicating a somewhat reserved social
style. She maintained normal working relationships in her role as a nurse, showing
responsibility and adaptability in her professional environment. Despite these
strengths, I.S. exhibited limited social engagement and emotional dependence on her
family, particularly after her father’s death. This reliance, combined with her
difficulty forming lasting relationships, may suggest traits of emotional vulnerability
and a tendency to internalize stress, which likely contributed to her coping through
substance use.

Mental Status Examination

Appearance: I.S. appeared her stated age, dressed in simple, clean clothing. She
maintained appropriate hygiene and grooming during the interview.

Behavior: She was cooperative and calm throughout the session. There were no signs
of agitation or psychomotor abnormalities.

Speech: Her speech was slow and low in tone, with a reduced rate of speech. There
were no signs of pressure or unusual speech patterns.

Mood: I.S. reported feeling "low" and expressed sadness about the recent loss of her
father and her struggles with substance misuse.

Affect: Her affect was congruent with her reported mood, appearing flat and
restricted. She seemed emotionally subdued.

Thought Process: Her thought process was coherent and logical, though somewhat
slow. There were no signs of flight of ideas or tangential thinking.

Thought Content: No delusions, hallucinations, or suicidal ideation were noted

during the interview. She expressed regret about her substance misuse and
acknowledged the impact it has had on her life.
 31

Perception: There were no signs of perceptual disturbances (e.g., hallucinations or

illusions).

Cognition: I.S. was oriented to time, place, and person. Her memory appeared intact
for both recent and remote events. She demonstrated adequate attention and
concentration during the session.

Insight: I.S. showed partial insight into her situation, recognizing her substance
dependency and its negative effects on her life. She expressed a willingness to seek
treatment.

Physical Assessment

I.S. appeared lethargic during the examination, displaying signs of fatigue and
minimal attention to grooming. Vital signs were within normal limits, and there were
no significant abnormalities in her neurological or cardiovascular systems. The
respiratory examination revealed clear breath sounds bilaterally, with no signs of
wheezing or crackles. Examination of the skin showed multiple injection marks,
primarily on the arms, consistent with her history of substance use, but no signs of
infection or abscesses at the injection sites. Her abdominal examination was
unremarkable, with no tenderness or palpable masses. Musculoskeletal evaluation
revealed no deformities, and she demonstrated a normal range of motion. Overall,
there were no acute withdrawal symptoms or physical complications observed during
the assessment.

Psychological Assessment

Based on her history, clinical interview and physical appearance the following
assessment tools were applied.

1. Human Figure Drawing (HFD)

 Low self-esteem or emotional indifference (Short Hair)
 Overthinking or an intellectual focus at the expense of physical or emotional
well-being (Large Head, Proportionally)
 Desire to appear happy or socially acceptable, potentially masking feelings of
insecurity or emotional distress (Entreating Face)
 32

 Impulsivity or difficulty in managing emotions and connecting thoughts to

actions (No/Minimal Neck)
 Emotional constraint, defensiveness, or feeling restricted in personal life
(Rectangular Body)
 Difficulty reaching out to others, feelings of helplessness, or lack of
confidence in handling challenges (Rigid Arms with Minimal Detail)
 Instability, insecurity, or a lack of emotional grounding (Thin, Straight Legs)
 Feelings of being ungrounded or lacking direction (Simplistic Feet)
 Need for control, balance, or order to manage inner emotional conflicts
(Symmetry)
 Low energy, hesitance, or emotional withdrawal (Light Line Pressure)

Drug Abuse Screening Test (DAST-10)

Score Severity
7 Significant Drug Use Problem

Qualitative Analysis

DAST-10 was administered, and the client’s score was 7, which indicates a
significant problem with substance misuse. A score of 6 or higher suggests the
presence of moderate to severe substance use issues, including dependency and
negative consequences in various areas of life, such as social, emotional, and physical
well-being. This score aligns with I.S.'s history of escalating drug use, including her
increased reliance on nalbuphine (Kinz) and diazepam, which has led to addiction and
severe health consequences, such as the overdose that resulted in unconsciousness.
The test results highlight the need for focused intervention to address her substance
dependency and its impact on her daily functioning and mental health.

Depression Anxiety Stress Scale (DASS-21)

Scale Score Severity

Depression 48 Extreme
Anxiety 30 Moderate
Stress 36 Moderate
 33

Qualitative Interpretation of DASS-21

The DASS-21 results show significant psychological distress in I.S.'s case:

 The depression score of 48 falls within the extreme range, reflecting severe
symptoms of depression, such as pervasive sadness, low energy, loss of
interest, and hopelessness. This is consistent with her emotional struggles after
her father's death and her ongoing substance misuse.
 The anxiety score of 30 falls in the moderate range, suggesting noticeable
anxiety, which may stem from her emotional turmoil, dependency on
substances, and general distress about her life situation.
 The stress score of 36 also places I.S. in the moderate range, indicating that
she is experiencing significant stress, likely amplified by her substance use,
grief, and difficulties coping with her circumstances.

Case Formulation

I.S., a 25-year-old female from a middle-class family in Manawala, Faisalabad, has a

history of significant emotional attachment to her father, who was her primary source
of support and stability.

Predisposing Factors

 Emotional Attachment to Father: I.S. had a strong emotional attachment to

her father, who was a primary source of support and stability in her life. The
loss of this important figure significantly impacted her psychological
resilience.
 Limited Coping Skills: I.S. had limited coping strategies to manage
emotional distress, which made her vulnerable to developing maladaptive
coping mechanisms, such as substance misuse.
 34

 Emotional Dependence: Her emotional dependence on her father and limited

social support contributed to her vulnerability to emotional distress and
substance misuse.
 Low Emotional Regulation: Prior to her father’s death, she may have lacked
the tools to regulate her emotions effectively, which exacerbated her response
to stressors after his passing.

Precipitating Factors

 Death of Father: The sudden loss of her father was a major psychological
stressor, triggering emotional distress such as grief, sadness, and a profound
sense of loss.
 Job Stress: Her job as a nurse in a private hospital with minimal pay added
financial strain, further exacerbating her emotional distress.
 Initial Prescription of Medication: Nalbuphine and diazepam were initially
prescribed to manage physical and emotional symptoms following her father’s
death, which led to a pattern of misuse and dependency.

Perpetuating Factors

 Substance Dependency: I.S. developed a dependency on nalbuphine and

diazepam, increasing her reliance on these substances over time, which
contributed to a vicious cycle of misuse and emotional withdrawal.
 Social Isolation: Her substance misuse led to emotional withdrawal and
isolation from social support, making it difficult to recover.
 Unresolved Grief: The grief over the loss of her father remains unresolved,
continuing to affect her emotional well-being.
 Lack of Coping Mechanisms: Continued lack of healthy coping mechanisms
to deal with her emotions keeps her trapped in the cycle of dependency.

Protective Factors

 Resilience and Employment: I.S. has shown resilience by maintaining her

job as a nurse for eight years despite the emotional and psychological
challenges, suggesting a sense of responsibility and work ethic.
 35

 Willingness to Seek Treatment: I.S. is open to seeking treatment and

acknowledging her substance misuse, which is a critical step toward recovery.
 Family Support: Although impacted by her emotional withdrawal, her family
remains a potential source of support in her recovery journey.
 Religious Faith: Her faith may offer a foundation for psychological resilience
and motivation, providing her with a sense of purpose and hope for recovery.

Diagnosis

Substance Use Disorder, Severe (Opioids - Nalbuphine, Benzodiazepines - Diazepam)

F11.20 (Opioid Use Disorder, Severe)
F13.20 (Sedative, Hypnotic, or Anxiolytic Use Disorder, Severe)

Management Plan

Objectives Short Term Goals Interventions

 Achieve abstinence  Stabilize the patient  Medical Interventions
from opioids medically and
(nalbuphine) and address withdrawal  Psychoeducation
sedatives (diazepam). symptoms.
Psychotherapies like:

 Address physical and  Educate the patient

 CBT
psychological about the harmful
 Motivational
withdrawal symptoms. effects of substance
Interviewing
use.
 Relapse Prevention
 Enhance coping
Therapy
mechanisms to prevent  Establish
 Family Therapy
relapse. motivation for
recovery through
 Lifestyle
 Improve social psychoeducation
Interventions
functioning and counseling.
(mindfulness,
relaxation exercises)
 36

 Involve the family  Social and Vocational

supporting the Rehabilitation
patient.  Support Groups

Prognosis

The patient's motivation for recovery, recent hospitalization, and family involvement
are positive prognostic indicators. Comprehensive treatment, including medically
supervised detoxification, medication-assisted treatment (MAT) for opioid use, and
gradual tapering for sedative dependence, alongside psychotherapy (e.g., CBT and
relapse prevention strategies), can improve outcomes. Co-occurring psychosocial
factors, such as isolation and emotional distress, must also be addressed to reduce
relapse risks.

Sessions

Sessions 1 to 4 26 Sept- 07 Oct

2024

The focus of the first session was to establish rapport and gather a detailed history of
the patient’s substance use, triggers, and psychosocial context. The patient shared her
escalating reliance on opioids and sedatives following her father’s death, highlighting
emotional distress and social withdrawal. Empathy and a supportive approach were
used to help her feel comfortable and engaged in the therapeutic process.

In the second session, standardized tools such as the Addiction Severity Index (ASI),
Beck Depression Inventory-II (BDI-II), and Drug Abuse Screening Test (DAST-10)
were used to evaluate the severity of substance use and emotional distress. The
 37

session also included psychoeducation about the effects of opioids and sedatives on
the brain and body, helping the patient gain insight into her condition.

The third session involved using Motivational Interviewing (MI) techniques to

explore the patient’s ambivalence about quitting substances and strengthen her
motivation for change. Coping strategies, such as grounding exercises, deep
breathing, and urge-surfing, were introduced to manage cravings and emotional
distress. The patient actively engaged in practicing these techniques and expressed a
sense of empowerment.

The final session emphasized relapse prevention by identifying triggers and creating a
personalized plan to manage high-risk situations. Strategies like the three-step urge
management plan (delay, distract, decide) were taught. The importance of family
involvement was discussed, and the patient agreed to include her family in future
counseling sessions to enhance her recovery support system.

These sessions laid a solid foundation for continued recovery by addressing both
psychological and social aspects of her substance use disorders.

Limitation and Recommendation

 Maintain Long-Term Abstinence from Opioids and Sedatives

 I recommend strong Rapport building.
 Streamline Sessions should be conducted.
 Utilize all Available Resources in the hospital
 Family Active engagement is recommended
 Psychoeducation related to the core element “ Shame”
 Long term Planning for Continuity of Care
 Develop and Strengthen Healthy Coping Mechanisms
 Reintegrate the Patient into a Functional and Fulfilling Lifestyle
 38

Case No. 4

(Obsessive Compulsive Disorder)

 39

CASE 4

Bio Data

Name S.A

Father Name A.L

Age 47 years

Gender Female

Education Matriculation

Religion Islam

Birth Order 3rd

Siblings 4 (2F,2M)

Parents Deceased

Husband Occupation Gov. Employee

Mother Occupation Housewife

Social Economic Status Middle Class

Address Rawalpindi
 40

Examiner F.N

Reason and Source of Referral

The client was referred to the hospital due to her unbearable condition.

Presenting Complaints

According to Client

She has a severe fear of contamination, especially regarding washrooms, hair combs, and
sinks. She feels overwhelmed by a constant need to maintain cleanliness and order, which has
caused significant distress in her life. Her obsession with cleanliness has increasingly strained
her relationships, particularly with her husband. This tension eventually escalated into a
physical altercation during an argument.

According to Informant (Her Sister in-law)

The patient’s sister-in-law shared that the patient often spends hours in the washroom,
seemingly driven by her compulsions. She also noted that the patient avoids touching hair
combs due to a strong association with contamination, and this avoidance has become a
significant part of her daily routine.

History of Present Illness

The patient reports a four-year history of considerable distress stemming from

obsessive-compulsive symptoms, primarily characterized by an intense fear of contamination.
These symptoms are particularly associated with washrooms, hair combs, and sinks. She
 41

experiences severe anxiety and distress when touching these objects or when they are not
arranged in a specific manner.

Developmental History

The patient had completed her developmental milestone normally. She doesn’t have
any history of developmental delays.

Personal History

The patient is 47-year-old housewife from Rawalpindi, has been married for 20 years and is a
mother of three. She comes from a middle-class family and has dedicated her life to
managing household duties and caring for her family.

Family History

She belongs to a middle-class family in Rawalpindi and has been married for two decades.
She lives with her husband, the family’s primary earner, and their three children. While there
is no known history of mental illness or substance abuse in her immediate family, recent
conflicts with her husband have intensified her distress and worsened her symptoms.

Educational History

She completed her matriculation before marriage. She was an average student who
maintained cordial relationships with her teachers and peers, though she was generally
reserved. She regularly attended school and completed her education without any major
disruptions.

Social History

In her earlier years, she was sociable and maintained strong connections with her peers and
community. She participated in social gatherings and enjoyed spending time with family and
friends. However, since developing obsessive-compulsive symptoms, she has become
increasingly withdrawn. She now avoids social activities, limiting herself to household tasks.
 42

This isolation has strained her relationships, especially with her husband, leading to feelings
of loneliness and emotional distress.

Occupational History

She has been a full-time housewife for the past 20 years, focusing on household management
and family care. She has no history of formal employment outside the home. However, her
obsessive-compulsive symptoms, particularly her fear of contamination and compulsive
cleaning habits, have significantly disrupted her daily routines and responsibilities.

History of Drug Use/Abuse

She does not have a history of drug abuse or misuse. Despite the emotional and psychological
challenges caused by her symptoms, she has not turned to substance use as a coping
mechanism.

Psychosexual History

Her marital life has been strained for the past two years. She has been unable to engage in
intimacy despite her husband’s efforts, which she believes has contributed to recent marital
conflicts. Her difficulty with intimacy stems from fears of uncleanliness associated with the
process and the overwhelming need for extensive cleaning afterward.
 43

Premorbid personality

She has always described herself as detail-oriented and conscientious. From a young
age, she displayed a strong preference for maintaining order and cleanliness, often striving
for perfection in her surroundings. While these traits were prominent, she remained active
and balanced multiple activities, showcasing her structured and diligent nature. Her
inclination toward obsessive behaviors, particularly regarding cleanliness, has been a
longstanding feature of her personality.

Mental Status Examination

Appearance: Safia appeared her stated age and was dressed in simple, clean clothing. She
exhibited appropriate hygiene and grooming throughout the session

Behavior: Safia was cooperative and calm throughout the session. She occasionally exhibited
signs of restlessness, such as fidgeting or adjusting her clothing, which seemed to stem from
discomfort related to her obsessive thoughts. There were no signs of psychomotor agitation.

Speech: Her speech was slow, with a reduced tone and rate. Safia often paused before
speaking, reflecting her carefulness in choosing her words, particularly when discussing her
obsessive concerns. There were no signs of pressured speech or unusual speech patterns.

Mood: Safia reported feeling "low”. She described feeling overwhelmed by her compulsive
need to maintain order and cleanliness.

Affect: Her affect was restricted and flat, consistent with her reported mood.

Thought Process: Safia’s thought process was coherent, but it was marked by rigidity and
repetitiveness. Her thoughts were predominantly centered on cleanliness and contamination,
and she had difficulty shifting her focus away from these themes.

Thought Content: Safia denied any delusions or hallucinations. However, she reported
persistent obsessive thoughts about contamination, particularly regarding objects such as
combs and sinks.

Perception: There were no perceptual disturbances, such as hallucinations or illusions.

 44

Cognition: Safia was oriented to time, place, and person. Her memory appeared intact, both
for recent and remote events..

Insight: Safia demonstrated insight into her situation. She recognized that her obsessive-
compulsive thoughts and behaviors were negatively impacting her life, especially in terms of
her emotional well-being and relationships.

Psychological Assessment

Psychological Assessment was done keeping in view her symptoms, and initial clinical
interview.

1. Human Figure Drawing (HFD)

 The drawing suggests a return to earlier developmental stages, possibly due to
stress or emotional discomfort.
 The patient's feminine identity is influenced by narcissistic tendencies, seeking
external validation and striving for perfection.
 The drawing reflects a strong aversion to perceived flaws or imperfections,
aligning with her perfectionistic traits.
 Safia demonstrates emotional reliance on others, seeking support from her
environment.
 There is a struggle with feelings of helplessness when expectations, either her
own or others’, are not met.

2. Depression Anxiety Stress Scale (DASS-21)

Table 1 DASS-21

Scale Score Severity

Depression 20 Moderate

Anxiety 16 Moderate

Stress 32 Severe
 45

Qualitative Interpretation
Her DASS-21 scores indicate significant emotional distress. Her severe stress reflects
the overwhelming impact of her obsessive-compulsive symptoms and life difficulties. The
moderate depression (score: 20) points to feelings of sadness, hopelessness, and energy
depletion, likely linked to the toll her OCD and interpersonal conflicts have on her well-
being. Additionally, the moderate anxiety (score: 16) suggests persistent worries and fears,
particularly around contamination and perfectionism, which intensify her distress and
emotional instability. These results highlight the complex interplay of stress, depression, and
anxiety in Safia’s condition.
3. Yale-Brown Obsessive Compulsive Scale

Score Severity

30 Moderate to Severe

Qualitative Interpretation
Her Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 30 indicates
moderate to severe obsessive-compulsive symptoms. This score reflects a significant level of
distress related to her obsessions and compulsions, particularly concerning contamination and
the need for perfection. The severity of her symptoms suggests that they are impacting her
daily functioning, leading to significant emotional distress and interference in personal and
social life. Safia’s compulsive behaviors and obsessive thoughts are likely causing
considerable anxiety and frustration.
 46

Case Formulation
The patient is a 47-year-old woman, experiences significant distress due to obsessive-
compulsive symptoms. She struggles with intrusive thoughts about contamination, especially
related to items like combs, sinks, and other household objects, leading to repetitive cleaning
rituals. These behaviors have caused emotional strain and marital discord, ultimately
resulting in her hospitalization.
Predisposing Factors
 Family Environment: Raised in a strict household where cleanliness and order were
emphasized, Safia developed perfectionistic tendencies early in life.
 Perfectionism and Control: A childhood shaped by perfectionism instilled a lasting
need for control over her environment, which now manifests as obsessive-compulsive
behaviors.
 Marital Role and Self-Sacrifice: Safia’s commitment to serving her husband’s
family for over 15 years fostered a sense of duty and self-worth tied to others’
approval, leaving her needs unmet.
 Transition to Independent Living: Living independently over the last 4-5 years
heightened her sense of responsibility for maintaining order, amplifying her anxiety
about control and cleanliness.
Precipitating Factors
 Interpersonal Conflict: Increasing marital conflicts, stemming from Safia’s
symptoms, have intensified her emotional distress and compulsive behaviors.
 Emotional Vulnerability: Dependence on others for validation and suppression of
personal needs have left Safia emotionally fragile, making her more susceptible to
stress.
Perpetuating Factors
 Compulsive Rituals: Repetitive cleaning provides temporary anxiety relief but
reinforces obsessive thoughts, perpetuating the cycle of OCD.
 Emotional Dependence: Reliance on her spouse for emotional validation creates
feelings of helplessness and isolation, exacerbating her distress.
 Avoidance of Triggers: Avoiding perceived contaminants prevents Safia from
addressing and overcoming her irrational fears, sustaining her symptoms.
 Partial Insight: Although Safia recognizes her behaviors as irrational, her incomplete
understanding may limit her engagement in fully addressing her symptoms.
 47

Protective Factors
 Family Support: Safia’s long-term relationship with her supportive spouse can
facilitate her recovery journey.
 Insight and Motivation: Her acknowledgment of her condition and willingness to
seek treatment demonstrate readiness for change.
 Independent Living: Managing her own household gives Safia some control, which
can be leveraged to challenge her compulsions in therapy.
 Resilience: Safia has shown adaptability and strength in handling responsibilities,
such as managing her family and household, which can support her recovery.

Provisional diagnosis

Obsessive-Compulsive Disorder (OCD), Contamination Subtype (F42.1)

 48

Management Plan

Objectives Short Term Goals Interventions

 Reduction in  Decrease frequency  Cognitive

Obsessive and intensity of Behavioral
Symptoms obsessive thoughts Therapy (CBT):
related to Cognitive
contamination. restructuring to
challenge
 Reduction in  Begin exposure to irrational thoughts
Compulsive feared situations about
Behaviors (e.g., touching contamination.
contaminated
items).  Exposure and
Response
 Reduce time spent Prevention
on compulsive (ERP): Gradual
rituals (e.g., exposure to
washing, cleaning). contamination
 Improved triggers while
Emotional  Improve emotional preventing the
Regulation regulation in compulsive
response to stress. response (e.g.,
washing,
cleaning).

 Emotion
 Challenge Regulation Skills:
 Management of perfectionistic Teach techniques
Perfectionism standards related to such as
cleanliness and mindfulness,
order. relaxation
exercises, and
grounding
 Improved  Teach coping techniques to
Coping strategies for manage stress.
Mechanisms managing anxiety
related to  CBT
contamination  Deep breathing,
fears. PMR etc.
 49

Prognosis

The prognosis for the patient will depend on her willingness and ability to confront her
perfectionistic tendencies, reduce emotional dependency, and actively engage in therapy
targeting the anxiety driving her compulsions

Sessions

Sessions 1 to 4 01-12 Nov 2024

The primary goal was to build rapport and establish a therapeutic alliance with Safia.
During the session, Safia shared her background and concerns regarding contamination fears,
compulsive cleaning, and emotional distress related to her obsessive thoughts. The therapist
provided an overview of the treatment approach, which included cognitive-behavioral
therapy (CBT) and exposure and response prevention (ERP).

Second Session: Further assessment tools were administered, including the DASS-21
and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). These assessments revealed
significant emotional distress, particularly related to obsessive thoughts and anxiety. The
therapist provided psychoeducation about OCD, explaining the relationship between
obsessive thoughts and compulsive behaviors and emphasizing that the compulsions only
provide temporary relief. Safia was encouraged to engage more openly in the treatment
process.

Third Session: The intervention focused on cognitive restructuring. The therapist

worked with Safia to identify and challenge distorted thoughts, particularly perfectionistic
thinking and catastrophic predictions about contamination. Safia was taught to recognize
these distorted thoughts and begin testing their validity. Practical exercises, such as writing
down obsessive thoughts and questioning their accuracy, were incorporated into the session,
and Safia was encouraged to track these thoughts between sessions.
 50

Fourth Session: Exposure and response prevention (ERP) was introduced as a key
technique for managing OCD. The therapist explained ERP’s principle—gradually exposing
Safia to feared situations while preventing compulsive responses. Together, they developed a
hierarchy of feared situations, starting with less anxiety-provoking scenarios and gradually
progressing to more distressing ones. Safia was encouraged to practice ERP tasks at home
and was supported in managing any anxiety that arose during exposures.

Recommendation

 Build strong rapport and therapeutic alliance

 Reduce obsessional thoughts and compulsions
 Improve emotional regulation
 Address perfectionism
 Develop healthy coping mechanisms
 Involve husband in the treatment process
 51

Case No. 5

(Generalized Anxiety Disorder)

 52

CASE 5
Bio Data
Name K.T
Father Name M.T
Age 23
Gender Female
Education BS
Religion Islam
Birth Order First
Siblings 5
Parents Both Alive
Father Occupation Businessman
Mother Occupation Housewife
Social Economic Status Middle
Address Faisalabad
Examiner F.N

Reason and Source of Referral

The client was referred to the hospital after a recent distress episode

Presenting Complaints

Presenting Complaints (According To Client)

The client reported that is suffering from Overthinking, Difficulty concentrating on

studies, Restlessness and Muscle tension. She reported that:

‫مجھے ہر وقت پریشانی ہوتی ہے۔‬

‫میں بہت زیادہ سوچتی رہتی ہوں۔‬

 53

‫پٹھوں میں کھچاو محسوس ہوتا ہے۔‬

According to her Attendant

Her informant reported that she is having excessive anxiety, which has been persistent
for about 1.5 years, described her anxiety as pervasive, affecting various aspects of her life,
including academic performance and daily activities.

History of present Illness

K.T’s current struggles with anxiety began approximately 1.5 years ago, following a
significant academic setback during her 9th-grade year, where she failed two subjects. This
event marked a turning point in her mental health, leading to persistent symptoms of
generalized anxiety, including excessive worry, difficulty concentrating, restlessness, muscle
tension, sleep disturbances, fatigue, and feelings of worthlessness. These symptoms have
progressively worsened, impacting her academic performance and daily functioning.

Developmental History

The patient had completed her developmental milestone normally. She doesn’t have
any history of developmental delays.

Personal History

K.T was raised as the eldest of five siblings in a middle-class family. Her childhood
was marked by emotional distance, particularly from her father, which fostered a sense of
insecurity and isolation. Despite this, she had no significant developmental delays or prior
psychiatric issues. K.T’s relationships with her family members have been strained, with
limited emotional support and understanding from her parents.

Family History

She belongs to a middle class family. Her parents and siblings have no psychological
history. She has 2 younger brothers, and two younger sisters. Her both parents were alive.
Relation of K.T with parents and siblings was not quite normal, because of her worries her
family attitude changes in cold attitude.

Educational History
 54

She was very intelligent and position holder student till 8th grade in school. She was
loved by all her teachers, her relationship with teachers and class fellows was friendly but in
9th grade board examination she failed in two subjects which was quite shocking for her.
After that incident her morale got down and she started overthinking and getting anxious all
time. All memoires of past educational levels were unforgettable for her either good ones or
bad ones.

Social History

She had less friends but she don’t share family issues with them.

Occupational History

K.T is currently a full-time student pursuing her BS degree and has not engaged in
any formal occupation or employment. Her primary focus has been on her education, which
has been significantly impacted by her anxiety symptoms.

History of Drug Use/Abuse

There was no history of drug use

Psychosexual History

She denies any severe pain (dysmenorrhea) or other gynecological issues. There is no
history of hormonal treatments or medical conditions affecting her menstrual health.

Premorbid personality

K.T describes herself as a conscientious, responsible, and goal-oriented individual

prior to the onset of her current difficulties. She was known for being academically driven
and highly motivated, often taking pride in her achievements. Socially, she was somewhat
reserved but maintained cordial relationships with her peers and teachers. K.T was
emotionally sensitive and tended to internalize criticism, which occasionally led to self-
doubt. Despite these tendencies, she managed her responsibilities effectively and was
perceived as a dependable and high-functioning individual within her family and academic
circles.

Mental Status Examination

Appearance and Hygiene: K.T presented as a neat and well-groomed individual,

maintaining proper hygiene.
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Behavior: she appeared hesitant and less engaged in social conversation, showing
reluctance while responding.

Speech: Her speech rate and volume were low, with an adequate response rate.
Occasionally, she gave short pauses while recounting events.

Mood and Affect: Her mood was anxious, and she became emotionally disturbed when
discussing her family's cold attitude and her academic failures. She started weeping
during the session.

Thoughts: Obsessional

Delusions: Absent

Memory: Memory for recent events and immediate recall was adequate.

Orientation: She was oriented to time, place, and person.

Insight: Fair insight was present.

Psychological Assessment

Assessment was done keeping in view her initial interview and symptoms. Following
tests were conducted:

 Cross Cutting Measures level-1

 Level 2 anxiety
 Beck Anxiety inventory (BAI)

Cross Cutting Measures Level 1

Domains Name Obtained Score Level of Severity

I. Depression 4 Moderate
II. Anger 3 Moderate
III. Mania 0 None
IV. Anxiety 8 Severe
V. Somatic Symptoms 1 Slight
VI. Suicidal Ideation 0 None
VII. Psychosis 0 None
VIII. Sleep Problems 3 Moderate
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IX. Memory 4 Severe

X. Repetitive thoughts 0 None
and behavior
XI. Dissociation 0 None
XII. Personality 0 None
Functioning
XIII. Substance Use 0 None

Interpretation of cross cutting level 1:

Adult version of cross cutting assesses 13 psychiatric domains, each item represents
about the frequency of actions or experiences in past 2 weeks, each item scored on 4 point
Likert scale (0= never to 4=severe/nearly every day).

Client scored severely high on Anxiety, and moderate on anger, personality, suicidal
ideation, sleep problem, memory and repetitive thoughts or behaviors. The client is more
severe on Anxiety with the highest score so she was further assessed by level 2 for detailed
and reliable prognosis.

Level 2 Anxiety

Sr.No Item Score

1 I felt fearful 4
2 I felt anxious. 5
3 I felt worried. 4
4 I found it hard to focus on anything other than my anxiety. 4
5 I felt nervous 4
6 I felt uneasy. 4
7 I felt tense. 4
Interpretation of cross cutting level 2:

Level 2 of Anxiety was applied to know further details; she scored 29 points on level
2 of Anxiety. The T scores are 71.5 which indicate severe level of Anxiety.

Beck Anxiety Inventory (BAI)

The BAI consists of twenty-one questions about how the subject has been feeling in
the last week, expressed as common symptoms of anxiety (such as numbness and tingling,
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sweating not due to heat, and fear of the worst happening). It is designed for an age range of
17–80 years old. Each question has the same set of four possible answer choices, which are
arranged in columns and are answered by marking the appropriate one with a cross

Sr. No Statement Rating (0-3)

1 Numbness or tingling 2
2 Feeling hot 1
3 Wobbliness in legs 2
4 Unable to relax 3
5 Fear of worst happening 3
6 Dizzy or lightheaded 1
7 Heart pounding or racing 1
8 Unsteady 1
9 Terrified 3
10 Nervous 3
11 Feeling of chocking 3
12 Hands trembling 2
13 Shaky 3
14 Fear of losing control 2
15 Difficulty breathing 2
16 Fear of dying 2
17 Scared 1
18 Indigestion or discomfort in abdomen 1
19 Faint 1
20 Face flushed 2
21 Sweating (not due to heat) 3
Total Score = 42

Qualitative Interpretation

According to the result the client seems to have “severe level” of anxiety.
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Case Formulation

K.T, a 23-year-old BS student, presents with symptoms consistent with Generalized

Anxiety Disorder (GAD), characterized by severe anxiety, difficulty concentrating, and
pervasive worry. These symptoms are significantly affecting her daily functioning and
academic performance.

Predisposing Factors

 Previous history of academic excellence

 Supportive yet emotionally distant family environment

Precipitating Factors

 Academic failures and subsequent decline in self-esteem

 Familial discord, particularly with her father

Perpetuating Factors

 Strained family relationships

 Lack of emotional support from her family, especially her father

 Non-supportive home environment contributing to ongoing anxiety

Protective Factors

 Some support from her mother, providing a slight buffer against anxiety

Provisional Diagnosis

Generalized anxiety disorder (F41.1)

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Management Plan

Objective Short Term Goals Interventions

 Reduce symptoms of 1. Decrease overall  Cognitive Behavioral
anxiety and anxiety levels within Therapy (CBT
restlessness 4 weeks  Acceptance and
 Improve 2. Increase Commitment Therapy
concentration and concentration and (ACT)
academic reduce academic  Stress Management
performance impairment within 6 Training
 Enhance emotional weeks  Psychoeducation
regulation and coping 3. Build a positive  Family Therapy
mechanisms understanding of her  Academic Support
 Strengthen familial anxiety and its
relationships and triggers
communication 4. Enhance coping
skills and emotional
regulation in daily
life

Prognosis

Prognosis of client was guarded. There is a chance of improvement if the proper

sessions were taken on time.

Sessions

Sessions 1 to 4

In the first two sessions, the aim was to make the client actively participate. The
complete history of his symptoms and all other relevant history were taken. She was
cooperative and told everything that was asked. She was assured about the confidentiality of
information that she shared with therapist. Good rapport was build up with the client in first
two sessions and client was psycho-educated about her problems and gave a proper
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knowledge of the disorder. Deep breathing was practiced with the client to stay calm as she
was crying due to her issues. Clinical interview was also conducted in these sessions.

In 3rd and 4th session psychological assessment was conducted for the client on the
bases of her symptoms. Cross cutting measures level-1 and Level 2 anxiety scales was
implemented on the client. Lastly Beck anxiety inventory was applied which confirmed that
the client is suffering from generalized anxiety disorder. During these sessions deep breathing
was practiced to overcome the stress and anxiety of the client

Recommendation

 Engage in regular mindfulness and relaxation practices

 Set realistic academic and personal goals to reduce the pressure and enhance
motivation.
 Establish a daily routine that includes dedicated study time, breaks, and self-care
activities.
 Build a support network outside of the family, such as friends or peer groups
 Communicate openly with her mother about her feelings and needs to strengthen
emotional support at home.