Portfolio Reports
Bio-data
Name: H.N
Age: 27
Gender: male
Religion: Islam
Marital Status: Unmarried
Siblings: 1 sister, 3 brothers
Education: Intermediate
Occupation: Mobile and Computer repairing shop
Reason for referral
The client was referred for psychological assessment and management of his
disorder to fountain house.
Presenting complaints
Symptoms Duration
Neend nahi ati 5 to 6 years
Meray abbu meray asli baap nahi hain 6 years
Meray maa baap mujhy nuqsan 6 years
pohanchana chahtay hain
Meray abbu ny meri dadi ko mara hai 6years
Main aik scientist hun, American mujhy 6 years
dhoond rahay hain
History of present illness
The client was referred with the presenting complaints of sleeplessness,
grandiosity and persecutory delusions.
As reported by the client, his mother used to hit during his toilet training time
and he got afraid at that time. His father also used to hit on his mistakes when he was
a child. He used to run to his grandmother when his parents were angry with him. He
reported he had a great relation with his grandmother.
7 years ago, his grandmother died. He said he did not cried when his
grandmother died as he had belief she must be living at a better place. But this
incident made him depressed and he wanted to finish himself. He also had thought
that his father must killed his grandmother as he did not took her to hospital on time.
His grandmother’s death lead him to these symptoms of delusions that his father and
mother are his enemy and his father is not his real father. This also led towards the
grandiosity that he has a special intelligence, for this reason his parents wanted to
harm him or wanted to take financial advantage of him.
Background Information
Family History
The patient was living in a joint family system with his parents, brothers, and
sister in law (bhabhi). He had conflicts with his parents as he thought them as his
enemy. The delusional thoughts were also related to his parents specifically to his
father. He also complaint an FIR against his father 2 years ago, as he had a fake
currency note and he thought his father gave him that note to made him feel
embarrass. He had good relation with his sister but he said he don’t like his brother in
law.
Personal History
He was the youngest child of his family. According to client, his mother used
to hit him during his toilet training time. His father also hit him once when a rubber
was stuck in his ear. He had childhood memories with his grandparents.
Educational History
He reported he was a good student in school but when he was in college he
started taking more interest in mobile and computer repairing and he left the studies.
Occupational History
Client reported he had a shop of mobile repairing. Now he wanted to open
another shop but due to his symptoms he was unable to work.
Past Medical history
Client had an operation of his kidney as he had kidney stone, reported by his
father.
Past Psychiatric history
Client reported no past psychiatric history.
Pre-morbid personality
Client was a happy person before his illness. He enjoyed a healthy relation
with his parents as well. He also send his parents on Umrah on his own expense.
Overall he had a functional social and occupational life before these symptoms
Preliminary Investigations
Clinical Interview
Mental State Examination
Behavioral observations
PTSD Checklist
PANSS
Diagnosis
After this assessment, client was diagnosed presecutory and grandiose type
delusional disorder.
Proposed Management plan
Psycho-education
Rapport building
Sleep hygiene
Progressive Muscles Relaxation
Journaling
Evidence for and against thoughts
Bio-data
Name: T.H
Age: 36 years
Gender: male
Religion: Islam
Marital Status: Unmarried
Education: Masters (English and Islamiyat)
Siblings: 4 brothers, 3 sisters
Reason for referral
The client was referred for psychological assessment and management of his
disorder to fountain house.
Presenting complaints
Symptoms Duration
Sadness More than 5 years
Excessive worry about cleanliness 10 years
Repetitive hand washing 10 years
Repetitive behavior of face washing 10 years
Body rashes 10 years
History of present illness
The client was referred to fountain house with presenting complaints of
excessive worry, repetitive behaviors like washing hand, washing face and taking bath.
He reported he kept on thinking about keeping himself clean almost all day. He used
to wash his hands 10 to 15 times a day, took bath twice a day. The patient also had
rashes on his body due to excessive cleaning.
According to the patient, his father was an authoritative parent who used to hit
his mother when she did not obey her and he also hit the client for not doing any
work/job. There was a family history of diabetes and high blood pressure as well.
He had a good quality of life before the separation of his family. He was
living in a joint family with his uncle then due to family issues between his father and
uncle they started living separately and he started having these symptoms.
Background Information
Family History
He was living in a joint family system. The patient’s father and mother were
alive. There was a age difference of 10 years between his parents. His father had
diabetes and his mother was a patient of high blood pressure. His father was an
authoritative and dominant person who used to hit his mother as well. He had four
brothers and 3 sisters and patient had good relation with his siblings. He had likeliness
towards his extended family (uncle’s family).
Personal History
He was the youngest child of his family. According to patient, he had a good
childhood. He was a happy child. He liked to keep himself clean even in childhood.
He said his father was very concerned about cleanliness. So, he also had thoughts that
uncleanliness leads towards serious illness.
Educational History
He did masters in English and Islamiyat. He reported he was a good student.
Occupational History
The patient was a jobless person. His father had a factory on sharing basis
with his uncle. He worked there for sometime.
Past Medical history
Patient had no medical history.
Past Psychiatric history
Patient reported no past psychiatric history.
Pre-morbid personality
Client was a happy person before his illness. He enjoyed a healthy relation
with his parents as well. He liked to spend time with his cousins. He was working
with his father before his illness. He was also an active person. The symptoms
affected his social, occupational life.
Preliminary Investigations
Clinical Interview
Mental State Examination
Behavioral observations
Yale Brown Obsessive Compulsive Scale
Diagnosis
After this assessment, client was diagnosed Obsessive Compulsive Disorder
with absent insight.
Proposed Management plan
Psycho-education
Rapport building
Self hygiene
Progressive Muscles Relaxation
Systematic Desensitization
Exposure Therapy
Token Economy
Bio-data
Name: N.L
Age: 30 years
Gender: female
Religion: Islam
Marital Status: Unmarried
Education: Matriculation
Siblings: 2 sisters, 1 brother
Reason for referral
The client was referred for psychological assessment and management of his
disorder to fountain house.
Presenting complaints
Symptoms Duration
Headache 2.5 years
Feeling of loneliness 2.5 years
Feeling of sadness 2.5 years
Lack of interest in daily activities 2.5 years
Suicidal attempt 2.5 years ago
History of present illness
The patient was admitted in fountain house due to presenting complaints of
excessive sadness, feeling of loneliness, lack of interest in daily activities and suicidal
attempt.
She reported that 17 years ago, her father died in a road accident. After which
her family faced severe financial crisis. Her mother’s brother was the only financial
support till her brother started earning. It took six months to her to get stable after the
death of her father.
She had a great bonding with her mother and siblings. Her one sister got
married and 5 years ago, her other sister died and she started feeling lonely and
depressed. After sometime her brother also got married. She reported that she had
conflicts with her brother’s wife and once after an argument with her, she attempted
suicide.
Background Information
Family History
The patient was living in a joint family system with her mother and brother’s
family. She belongs to a lower middle class family. She had a great relation with her
mother. Her father died 17 years ago in a road accident. She had a good relation with
her father and he was the only bread earner of family.
The patient had two sisters and one brother. One sister was married and had
six children. Other sister died five years ago whose death lead her towards these
symptoms. Although she had good relation with her brother but have had conflicts
with her brother’s wife
Personal History
She was the youngest child of the family. She reported that she had a good
childhood. Her parents love her the most. During adolescence, she used to get
aggressive when someone tease her. At the age of 16, her menstruation cycle started.
She said, she have had irregular periods and irritable moods during her adolescence.
Educational History
She did matriculation with good grades. But she had to left her study for house
hold responsibilities.
Occupational History
The patient had no occupation.
Past Medical history
Patient had no medical history.
Past Psychiatric history
Patient reported no past psychiatric history.
Pre-morbid personality
She had a healthy relation with her family. The patient had extrovert
personality and she liked to socialize with her friends before these symptoms. She
also had interest in cricket. Her interpersonal relation were affected due her illness.
Moreover, her interest in daily activities and the things she liked to do before her
illness was lost.
Preliminary Investigations
Clinical Interview
Mental State Examination
Behavioral observations
Beck Depression Inventory
Diagnosis
After this assessment, client was diagnosed Persistent Depressive Disorder.
Proposed Management plan
Rapport Building
Psycho education
Progressive Muscles Relaxation
Activity Scheduling
Cognitive Restructuring
Positive Affirmation
Journaling
Bio data
Client’s Name: M. I
Gender: Male
Age: 37 years
Reason for referral
The client was brought to fountain psychiatry department for treatment and then
referred by psychiatrist to trainee clinical psychologist for psychological assessment.
Presenting complaints
Symptoms Duration
Delusion 7 to 8 months
Hallucination 7 to 8 months
Asociality 7 to 8 moths
Anhedonia 7 to 8 months
Disturbed sleed 7 to months
History of Present Illness
The patient was 37-year-old male came with presenting complaints of
delusions (grandiose, erotomanic , persecutory), visual, auditory, tactile hallucinations)
asociality, anhedonia, disturbed sleep, abnormal behavior, disorganized thinking,
suspiciousness.
In 2006, the client's mother died. Two years later, the client began to have
problems. The client brother reported that he has a lot of anger issues, which causes
him to fight a lot with outsiders and is suspicious of the family and claiming about
that they were plotting behind me (persecutory delusions) he reported that he has
exceptional abilities(grandiosity).
His speech was completely disorganized (flight of ideas). The total duration is
12 years. The onset of the problem was at the age of 25 years. At that time, he was
having an active phase of psychosis. He got adverse behavioral issues , due to these
complaints, he was admitted to mental hospital twice for treatment, one was under
treatment for two months in Al-Ahmed Hospital, after that in Ali Hospital about 4
years ago he was under treatment for 3 months and his symptoms reduced a little.
After going home due to non-compliance of medicines he relapsed. He came
here with the symptoms of psychosis. According to the client's brother, earlier the
client was not so religious, but after the problems started, the client has become quite
religious after the symptoms started (negative symptom). The client is also showing
somatic symptoms that he will have a heart attack.
Background Information
Family History
The patient’s father was died at the age of 70 years, and he had a shop of
sweets. His education was matriculation. He died due to heart attack. Client’s mother
was a housewife. She died at the age of 52 years and her education was matriculation.
She had hepatitis. The client’s brother reported that they have joined family system.
The client's household consists of three sisters and four brothers of which the client is
the youngest. Relationships with family members were quite good.
Personal History
The client's birth order is last, and he had 7 siblings. Client birth is normal at
home. All the developmental milestones are achieved at the appropriate age.
Educational History
The client has studied school up to the fifth standard. He had lots of friends
and respected his teachers a lot. He was not good at his studies and his interest was
more in playing games.
Occupational History
He had work with his brothers in the shoe making shop. His brother reported,
we use Samadbond where we have business (making ladies shoes), and he liked the
smell of it very much but over time he started to hate the smell of Samadbond due to
which he also stopped going to work (Negative symptoms).
Past Medical History
There was no past medical history.
Psychiatric History
4 years ago, client remained admit in Al-Ahmad and Ali-Hospital for 3
months.
Preliminary Investigation
Clinical Interview
Mental State Examination
Behavioral observations
PANSS
Diagnosis
After this assessment, client was diagnosed Schizophrenia with multiple
episodes.
Proposed Management plan
Rapport Building
Psycho education
Progressive Muscles Relaxation
Medical Compliance
Improving Socialization
Distraction Techniques
Behavioral Activation
Bio data
Client’s Name: M. R
Gender: Male
Age:31
Reason for Referral
The client was brought to fountain house and then referred by supervisor to
trainee clinical psychologist for psychological assessment and management.
Presenting complaints
Symptoms Duration
Depressed mood 1 month
Loss of appetite 1 month
Sleeplessness 1 month
Loss of Interest 1 month
Headache and shoulder pain 1 month
Suicidal Thoughts 1 month
History of Present Illness
The client was 49-year-old male came with presenting complaints of loss of
sleep, headache, shoulder pain, heaviness on chest, suicidal
ideation, restlessness, fatigue, loss on interest, guilt feelings, loss of appetite,
depressed mood, dizziness.
According to the client, he can't sleep, he had a headache, his shoulders and
chest are heavy, he did not feel good about anything, and he feels like he's a failure.
His mother died 15 months ago due to a head injury that occurred after a fight
with the client's mother. According to the client's brother, the client stayed abroad for
15 years and came back two years ago due to loss of business abroad due to which the
client was a little sad and wanted to get married. During the discussion, the mother
was accidentally pushed by the client due to which his mother being injured, which
resulted in her being hospitalized for a week and then died.
After which the client started blaming himself and his condition worsened. The client
had suicidal thoughts because he no longer wants to live because he has not been able
to do anything in life and because of this his mother died and he couldn't do anything
for his mother.
Background Information
Family History
The client's father was passed away 15 years ago, he used to work in paper
mill shop he died due to heart attack. His mother died 15 months ago. She died due to
head injury. Client had five brothers and two sisters in which the client's birth order is
5th. The relationship with the family members has been quite good.
The client talked about his marriage that he did not get married because the
money he used to send to Pakistan was not saved here and it was all blown away by
his family. When he came back there was no money.
Educational History
The client has studied up to matriculation and the client was also Hafiz Quran.
According to the client he was quite good in school, at his studies and at sports,
mostly he used to play cricket and badminton. His relationship with teachers
and other friends was also quite good.
Occupational History
The client went to abroad 15 years ago and worked as a manager in a shop in
South Africa, then worked in Azerbaijan and finally worked in England where he
suffered a lot of losses after which he returned to Pakistan.
Past Psychiatric History
Due to the above symptoms, the client was going to a private psychiatrist
twice for the treatments, but due to not taking medicine, he did not recover and now
for about 1 month the client had been completely confined to the room and did not
even go to work.
Preliminary Investigations
Clinical Interview
Mental State Examination
Behavioral observations
BDI
Diagnosis
After this assessment, client was diagnosed Major Depressive Disorder.
Proposed Management plan
Psycho-education
Rapport building
Sleep hygiene
Progressive Muscles Relaxation
Cognitive Restructuring
Dysfunctional Thought Record
