CLINICAL INTERVIEW

Presenting Complaints
Patient reports experiencing symptoms as follows:
 Feels hopeless/despair about the future
 Sometimes feels panic and is constantly anxious about life
 Feels like he doesn’t know himself
 Difficulty making decisions
 Feels like a failure
 Has foggy thoughts
 Feels misunderstood
 Reduced concentration
 Easily losing interest in things (can’t complete even a movie)
 Irritability
 Difficulty in sleeping at night
 Frequent headaches and backache
Mode of onset: Gradual.
Duration: 2011 - Present
History of Presenting Complaints
The patient reports first experiencing the symptoms in 2011 while still in high school. He never
sought medical attention for the symptoms until 2022. He sought medical attention for the
physical symptoms at Kikuyu Hospital, that is, backpain and headaches. All tests were
inconclusive (Normal bloodwork, MRI & Lumbar Sacral X-Ray scans) which is when the
attending physician referred him for psychiatric evaluation (May, 2022). The patient described
feeling anxious about his life and hopeless about the future. He was particularly unhappy with
the fact that he didn’t have employment despite being a graduate. He expressed that he wasn’t
happy living at home; feels like his parents don’t understand him and think he’s lazy. He
explained that most times he wakes up in the morning feeling like his thoughts are “foggy”,
like he can’t think clearly. He spends most of his time in his room and has little energy to do
anything. His mother expressed that he can spend several hours sometimes even days indoors,
barely doing any chores around the house. She has to insist on him cleaning his room. The few
days he seems better, he helps her around the shop in the evenings but he hasn’t been there for
some months now. Patient had suicidal ideations earlier in the year (2022, July being the most
recent). He hasn’t been suicidal since; no suicidal attempts. He first presented at Mathare
Psychiatric OPD in June, was put on Duloxetine 30mg for 2 months. He reported little to no
improvement in his symptoms which is when he was switched to Fluoxetine 20 mg &
Quetiapine 50mg and referred for psychotherapy.
Vegetative state
 Feeding: Poor feeding and low appetite
 Sleep: Disturbed sleep (difficulty falling asleep)
 Bowel: Irregular bowel movements
 Energy: Low energy levels
 Libido: Low (not sexually active at the moment)
Functioning: Strained relationship with parents; restricted social life.
Psychosocial stressors: Being unemployed. The patient didn’t perform as well as he expected
to in college (graduated with a “Pass”). Patient feels this is the main reason why he hasn’t been
able to secure a job in his field of study (Bio-chemistry). Violent alcoholic father.
Dysfunctional family dynamics
Past psychiatric history: Index incident
Past medical history: No major acute and chronic physical illnesses, no admissions and
surgical interventions.
No known food or drug allergies.
Family History
Patient is the second born in a family of 3 siblings (all male). Both parents are alive. Mother is
the sole breadwinner, while father is an alcoholic who is sometimes abusive and violent. The
patient has a strained relationship with both parents, but relates well with siblings.
Genogram

Farmers Farmers
85
D: 1992 D: 2002 D: 2008
Suicide CVA/?HTN DM

61 53

2nd Born among 8 siblings Last born among 5 siblings

Form 4 Form 4
Laid off from company 17 years ago Shopkeeper
Alcoholic

31 P 21
Univeristy Univeristy In college
Graphics designer Unemployed Single
Single Single

Family Psychiatric & Medical History

 Paternal grandfather (died to suicide in 1992)
 Maternal uncle (2nd born; died to suicide in 2007)
 Father (alcohol use disorder)
 Maternal Grandfather - Type II Diabetes
 Paternal Grandmother - Hypertension
Personal History
Early Childhood History: Mother had a normal pregnancy and attended ANC clinics. Patient
born through spontaneous vaginal birth at full term. Mother reports no complications. He
attained all milestones without delays. He was a lively and happy child.
Psychosexual History: The patient transitioned well into puberty. Was circumcised right after
completing primary school in 2009.
Education History: He started school at the age of 4. He was an average student. Repeated
class 7. He did his KCPE in 2009, got 311 (PCEA Githurai Primary School); KCSE in 2013,
got C+ (Gaichanjiru High School); completed university in 2017 with a degree in Biochemistry
(Kenyatta University – “Pass”).
Work History: Interned at KEMRI for 6 months in 2018. Worked at mother’s shop from 2019-
2021, mother would give him monthly allowances. He stopped when the back pains and
headaches got worse. He’s currently not employed.
Drug & Substance Use History: Alcohol & Marijuana (for a few months in 2016 while in
college). As a coping mechanism for stress caused by dysfunctional family dynamics.
Forensic History: No history of arrests.
Social History: Has few friends; he’s currently in a relationship. Hobbies include taking walks
and listening to music. He is a Christian, but doesn’t attend church regularly. When he does,
he attends Githurai PCEA with his mother, sometimes participates in youth activities in church.
Premorbid Personality: The mother describes the patient as usually calm and introverted. He
described himself as always being a worrier, keen to details, analytical and a perfectionist. He
also said he thinks he has OCD (engages in repetitive behaviour like cleaning; obsessive
thinking/preoccupation) though it doesn’t affect functioning.
Present Life Circumstances
Patient lives with his mother, younger brother and father in their home in Githurai 45. Mother
works as a shopkeeper, she’s the sole breadwinner. Father lost employment 17 years ago. He
has since become an alcoholic. He tends to be violent most times. Patient has a strained
relationship with both parents. He reports that the mother is controlling and overprotective. She
doesn’t allow him the autonomy to decide for himself. Patient is disengaged/estranged with the
father.
MENTAL STATUS EXAMINATION
 Appearance: Well kempt, cooperative, slouched posture
 Behaviour: Poor eye contact, psychomotor retardation
 Rapport: Well established and maintained
 Speech: Reduced in rate and volume
 Mood: “Sad”
 Affect: Dysphoric, Mood congruent, Stable.
 Thought process: Logical and coherent
 Thought content: No delusions or obsessions. No suicidal ideations (has feelings of
despair). History of suicidal ideations in July 2022, no plan or attempt.
 Perception: No perceptual disturbances
 Cognition: Well oriented to time, person and place; reduced attention and
concentration; Memory intact.
  Judgement: Fair
 Insight: Partial
CASE FORMULATION
The patient is a 28-year-old living in Githurai. He presented with feelings of hopeless/despair
about the future, constant anxiety about life, feeling like his mind is foggy, reduced energy
levels, reduced interest in things, feeling misunderstood, irritability and frequent headaches
and backache. The symptoms have been gradually getting worse since 2011. The patient had
some suicidal ideation but no attempts. The major psychosocial stressors identified include:
lack of employment and family strain. The patient is the 2nd born in a family of 3 siblings, both
parents alive. He has a strained relationship with both parents, but relates well with siblings.
The patient’s paternal grandfather and maternal uncle both died to suicide and the father has
an alcohol use disorder. The patient had a normal childhood, has few friends and enjoys taking
walks and listening to music. Upon assessment he had a slouched posture, poor eye contact,
reduced speech in rate and volume, and dysphoric affect.
Diagnostic Impression: Major Depressive Disorder with comorbid generalised anxiety
disorder (GAD)
Assessment Tools
 Beck’s Depression Inventory: Scored: 38 (Severe Depression)
 Beck’s Anxiety Inventory: Scored: 23 (Moderate Anxiety)
 Yale Brown OCD scale: Scored 16: Moderate OCD)
Psychiatric review: Patient is currently on: Fluoxetine 20mg & Quetiapine 50mg for 3 months.
CASE CONCEPTUALIZATION
 Predisposing Factors: Genetic predisposition, alcoholic/violent father
 Precipitating Factors: Unemployment; violent/alcoholic father
 Perpetuating Factors: Dysfunctional family dynamics; strained relationship with parents;
poor adherence to medication.
 Protective Factors: Supportive mother and siblings, high education level.
TREATMENT PLAN
Rational Emotive Behaviour Therapy (REBT)
Rationale: Patient had a lot of self-defeating thoughts and negative feelings that needed to be
addressed. The aim of this intervention is to help the patient understand how unhealthy beliefs
and thoughts result in emotional distress which then lead to maladaptive behaviours that affect
goal achievement and day to day functioning.
 Session 1: Psychological assessment and psychoeducation on diagnosis and treatment
plan.
Immediate intervention: Psycho-educated the patient on diagnosis. Motivational
interviewing to explore and resolve ambivalence related to medication. Goal setting:
The goals as stated by the patient include:
 Finding meaning and purpose in life
  Achieve social balance
 Enhance hope/optimism
 Become independent (financially and in his living situation)
 Session 2: Psycho-educate on the ABC Model (Activating event, beliefs and
consequences).
 Session 3: Teach cognitive coping techniques: relaxation, mindfulness e.g. mindful
breathing, positive affirmation, self-compassion. Others: psycho-educate on sleep
hygiene, pleasant activity scheduling.
 Session 4-5: Cognitive restructuring techniques (ABC-DE). Identify cognitive
errors/biased ways of thinking about self and the world, use Socratic questioning to
challenge and reframe irrational thought patterns, keeping thought records (Disputation
and Effective new belief).
 Sessions 6: Awareness raising: Emotions identification and regulation.
 Session 7-8: Teach problem solving techniques, assertiveness training, social skills
training, decision making skills, self-esteem enhancement.

SESSION 2 Date:
Subjective: The patient reported persistent feelings of hopelessness and expressed that no one
understands him. He verbalized perceiving himself as a failure and described his mind as
feeling “foggy”, like he cannot think clearly. Patient noted some slight improvement in mood
since starting the new prescription, with decreased irritability. He also reported improvement
in both sleep and appetite. He recounted being low most of the days, and spending most of his
time indoors. However, he was able to clean his room once and help out his mother on a few
chores at home like washing the verandas. He stated that he has been compliant with his
medications.
Objective: Patient accompanied by the mother. He came on time. He is lucid and well oriented.
Appeared low in mood but engaged actively during the session. No acute distress observed.
MSE –
 A & B: Well kempt, maintained fair eye contact, able to establish rapport, cooperative
 Speech: Normal in rate and volume
 Mood: “Sad”
 Affect: Dysphoric, constricted, mood congruent
 Thought process: logical, goal-directed & coherent
  Thought Content: no suicidal ideations, no delusions or obsessions
 Perception: No perceptual disturbances
 Cognition: Well oriented to time, place and person; good concentration and attention.
 Judgement: Good
 Insight: Present
Assessment: Patient continues to exhibit depressive symptoms including hopelessness,
impaired concentration and negative self-evaluation which continue to interfere with overall
functioning. However, there’s some observable improvement in irritability, sleep and appetite
since initiation of treatment, indicating fairly good response to interventions. Good compliance
to medication and positive attitude towards treatment are good protective factors.
Interventions: Rational Emotive Behavioural Therapy
 Psycho-educated the patient on the ABC model (The external event that activates how
we feel or think, the automatic beliefs about the event, himself and other people and the
consequences in-terms of his emotional or behavioral responses.
 Taught the patient some stress inoculation techniques like deep breathing exercise,
grounding and self-compassion (GLAD technique) exercises.
 Encouraged the patient to keep an ABC monitoring journal (demonstrated how) and
when possible to practice the GLAD technique (Grateful, Learnt, Achieved, Delight).
Homework assignment: ABC monitoring tool, GLAD logs, download a phone application for
guided meditation.
Plan: Patient is to continue taking medications as prescribed. Psychotherapy. Patient to consult
physiotherapist.

SESSION 3 Date:
Subjective: Patient accompanied by his mother who reports noting some improvement in terms
of communication (says patient is talking a bit more) and self-care (patient is now cleaning his
room and clothes). She says that he’s now taking personal initiative with a few tasks/chores
around the house. Patient reports persistent insomnia, foggy thoughts, headaches and anxiety
though to a lesser extent in comparison to before he started treatment. He complained to
occasional headaches and backpains. On a symptom scale of 1-10, patient rates himself at a 4
(1 being where he started). He still feels anxious about life, has fear of the unknown. He feels
his mother doesn’t understand him; feels like a failure. When questions about coping over the
past 2 weeks, patient expressed that he has been coping through thought journaling, deep
breathing exercises, grounding techniques (counting things around him), taking walks and
listening to music.
Objective: Patient is lucid and well oriented. Was appropriately dressed and attentive
throughout the session. His speech was low in volume, fairly spontaneous. Homework
assignment done and reviewed. The predominant themes noting in patient’s ABC record
include: uncertainty of life, feeling like a failure. Patient demonstrates strength and
proactiveness in citing/documenting exceptions and breaks in his depressed mood. These
include moments of delight, moments where he doesn’t feel as depressed or anxious (GLAD
log).
MSE – Unremarkable
Assessment: Patient’s depressive symptoms remain largely unchanged, with ongoing feelings
of hopelessness and despair. Some slight improvement in functional engagement noted as he
has began initiating conversations and participating in chores. The reported headache and back
pains ought to be monitored, possibly psychosomatic. Overall, patient has fairly improved.
Interventions: Rational Emotive Behavioural Therapy
 Acknowledged and validated patient’s effort in keeping a daily ABC log and practicing
previously taught coping skills.
 Encouraged the patient to amplify the exceptions to enhance mood and break the
depressive cycle.
 Identified some cognitive errors/biased ways of thinking about self and the world with
the patient; used the logs written by the patient. Some cognitive errors identified
include: Labelling “I’m a failure”, All-or-nothing thinking “my parents never
understand me” and should statements “I should be happy” I should get a job” I should
be out of my parent’s house by now”
 Psychoeducation on behavioural tension reduction techniques: progressive muscle
relaxation technique.
Homework assignment: Demonstrated and encouraged the patient to continue doing the ABC
logs but to include ABC/DE (Disputing and adopting Effective new beliefs). Demonstrated
how.
Plan: Patient is to continue taking medications as prescribed. To review the DTR in the next
session.