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Case 3 Report

Submitted To: Dr. Mussarat

Submitted By: Anisa Habib

MSc Psychology

4th Semester

Section A

Reg no 871-FSS/MSCPSY/F18

Subject: Internship

International Islamic University Islamabad

2020
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Case Report

Identifying Data

Name: Ms. H

Age: 25 Years

Gender: Female

Marital status: Married

Children: Three (one son, two daughters)

Education: F.A

Family structure: Joint

Reasons for referral and resource

The client was self-referred. She was assessed in her home because of her conditions as

excessive worry or anxiety, fearfulness, restlessness, tensed and irritable mode, disturbed

sleep and appetite, aggression and fatigued.

Presenting Problems

According to the client.

‫سر سن ہوجاتا ہے ایسے لگتا پیچھے پیچھے جا رہی ہوں۔‬

‫بہت پریشان ہوتی ہوں ہاتھ بھی اکثرکانپنے لگتے جب سوچتی ہوں۔‬

‫وہمی ہوگئ ہوں جب سے حماد پیدا ہوا ہے بچوں کی پریشانی ہوتی ہے بہت۔‬

‫حماد کو جب بخار میں جھٹکے لگے تھے اور ہسپتال داخل تھا اس وقت کے بعد سے بہت خوفزدہ ہوگئ ہوں۔‬

‫دڑ لگتا ہے کچھ ُبرا ہو جائے گا وظیفے بھی کئے ہیں کافی۔‬
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‫بہت گھبراہٹ اور بے چینی رہتی ہے۔ غصہ بھی بہت آتا ہے برداشت نہیں کر پاتی۔ جسم میں درد اور کھچاؤ ہوتا۔‬

‫کھانا پینا بھی کچھ خاص اچھا نہیں۔‬

‫نیند بھی سہی نہیں آتی رات کو جب لیٹتی ہوں تو ساری سوچیں دماغ میں آجاتی ہیں پھر اتنی لیٹ سوتی ہوں کہ‬

‫نیند پوری نہیں ہوتی۔‬

Symptoms. The symptoms identified with reference to DSM-V are as:

1. Excessive worry and anxiety

2. Restlessness

3. Irritable and tensed mood

4. Fatigue

5. Muscle tension (body ache and headache)

6. Sleep disturbance (staying asleep, restless, unsatisfying sleep)

History of Present Problems

Client came with the presenting complaints of excessive worry, restlessness, fear that

something bad could be happen, tensed and irritable mood, fatigued, lack of appetite, muscle

tension (body ache and headache having numbness in head) and sleep disturbance.

According to the client her problem started when her first child hammad was born 3 years

ago, she became more conscious or alert about things for her children and was taking worry

about everything. She reported that her problem become more disturbing since her son

hammad had fever and got seizers attack and was hospitalized 1 year ago, after that situation

she become very tensed that her son become ill because of her as she could not take good

care of him. After that she is staying worried about everything for her children and family,

become much alert about everything and when thinking soo much her hands tremble, her

head become numb and she feel dizziness. Whenever her children become ill even of mild
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level she become tensed and cry and stay asleep full night to look after them. She said that

her too much worry is really affecting her, she could not able to get out of her problems. Her

current situation is very much affecting her life but she wants to make it better and cope with

situation in a better way.

Past Personal History

Client was born on 30 June 1995 in Karachi. The client’s mother health was good at

time of her birth. She had no prenatal and postnatal problems. The client’s delivery was

normal in the hospital and her health was normal at the birth. She achieved all the milestones

at appropriate age. No developmental delay was found.

In present the client had done F.A. She started schooling at age of 4. She said she

really enjoys her school time. She had very good friends and teachers and never get tensed

about studies. She obtained A grade in every class. She was actively participating in extra-

curricular activities like tablo, poem etc. In matric her mother become ill so she has to take

care of her mother and house at that time studies become burden for her. After matric she was

married and completed her F.A (through private) after marriage in in-laws.

The client reported about her social life as she said she enjoys moving out with

family, having get together and has good relationship with her family, friends and relatives.

She said she only get upset when she is worried and thinking too much then she does not

want to go out. Besides of all these she is very social.

No past medical and psychiatric history is found.

Family History

The client is a 25 years old girl. She is 2nd born child, having three sisters and one

brother. She has good relationship with her parents and siblings, she cares about them and
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loves them very much. She is living in middle class family. Now she is married living in joint

family setup with her in-laws. She has three children, one son and two daughters. She is

married to her cousin. She said her husband really loves her, they have happy relationship.

She said that she is happy with her husband but she has just this complaint from him that he

keeps busy with his mobile and does not give her and family proper time and attention. She

has mother in-law, father in-law, two sisters’ in-law and one brother in-law in her family.

They all are in good terms with her, taking care of her. She has very good relationship with

all of them especially very close with her younger sister in-law. She said that she really

respects them, care about them and loves them. She further reported that whenever something

happens to her any family member, she become very worried and excessively think that

something bad could happen. In the same way she said that she remains worried about her

children especially after the seizer attack of her son. These worries make her restless and

fatigued. There is no history of psychological illness found in her family.

Premorbid Personality

Client reported that she was a happy person and had good control over her anger and

worries. She said that from the start she was touchy and take tension about things but did not

get too much worried about the things like she is getting tensed or worried now.

Assessment

Formal and informal assessment has been taken from the client.

Informal assessment. Informal assessment includes following tools.

1. Mental State Examination (MSE)

2. Clinical interview and Behavioral observation

Mental state examination (MSE). Mental State Examination was administered to the

client. The client was wearing shalwar qameez, her hair was not combed, her overall

appearance was stable. She looked pale and appeared little dull. The tone of her voice was

high. Her attitude was cooperative. Her behavior was normal and she seated in a normal way

but seemed little uncomfortable and restless. She had openly answered each question. She

had not any suicidal ideation. Rapport was built with her after some time. Overall her

cognition was intact with no impairment in memory, language or speech and her insight and

judgment was also intact. The client was well oriented with time, place and person.

Clinical interview and behavior observation. Interview was conducted with the client

and information about her presenting problems, family and personal history, educational

history and social history was gathered. During the interview her attitude was cooperative she

was willingly answering each question, her behavior was normal but she seemed tensed and

worried. She appeared little dull and looked pale. During interview she was distractive and

restless. When she was telling about her worries she got teary and her hands little tremble.

During the interview, she was not in a state of aggression. Overall her behavior was

interactive and cooperative.

Formal assessment. Formal assessment includes following standardized tests.

1. Mini Mental State Examination (MMSE)

2. Beck’s Depression Inventory (BDI)

3. Beck’s Anxiety Inventory (BAI)

4. Depression Anxiety and Stress Scale-21 (DASS-21)

5. Clock Drawing Test (CDT)

6. House Tree Person (HTP)

Mini mental state examination (MMSE). Mini Mental State Examination is a

commonly used a set of questions for screening cognitive function. It provides measures of

orientation, registration, short term memory as well as language functioning. It was

developed in 1975 by Folstein and his colleagues as a simplified form of cognitive-mental

status examination (Folstein et al., 1975). The client performed test in normal home settings

and gave responses without delay just take little time in last question in drawing picture but

draw correctly. The client scored 30 that lie in normal range and shows no cognitive

impairment and has good orientation.

Beck’s depression inventory (BDI). A self-rating and interviewer rating depression

inventory consisting of 21 categories with 4 point scales was validated against combined

clinical ratings of depth of depression. It measures characteristic attitudes and symptoms of

depression. It was first developed by Beck in 1961 and then updated and published in its new

version in 1996 by Beck, Steer and Brown. It assesses the severity of depression in

adolescents and adults. The client scored 14 in this scale that lie in the level of mild mood

disturbance (Beck, Steer & Brown, 1996).

Beck’s anxiety inventory (BAI). It was developed by Beck, Epstein and their

colleagues in 1998. BAI is a 21-item self-report scale that measures the severity of anxiety in

adults and adolescents on 4- point scale. The items in the BAI describe the emotional,

physiological, and cognitive symptoms of anxiety. Beck Anxiety Inventory (BAI) is a 21-

item scale. The client score was 33 on this scale which indicate moderate anxiety (Beck,

Epstein et al., 1988).

Depression anxiety and stress scale-21 (DASS-21). The Depression Anxiety Stress

Scales (DASS) was developed to measure the constructs of depression, anxiety and stress.

The original DASS has 42 items measuring three dimensions of negative emotional states,
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namely depression (DASS-D), anxiety (DASS-A) and stress (DASS-S). Later, a shorter

version of the DASS, the DASS-21, was developed by Lovibond and Lovibond (1995) to

reduce administration time and has been used widely in clinical samples to screen for

symptoms at different levels of depression, anxiety and stress. It was a self-reporting

questionnaire with 21 items (seven items for each category) based on a four-point rating

scale. To calculate comparable scores with full DASS, each 7-item scale was multiplied by

two. Client’s score on Depression scale was 24 which is indicating severe depression. On

Anxiety scale, her score was 28 which indicating extremely severe level of anxiety and She

scored 22 on Stress level which shows her moderate level of stress (Tian et al., 2013).

Clock drawing test (CDT). The clock‐drawing test is cognitive screening instrument.

It taps into a wide range of cognitive abilities including executive functions, is quick and easy

to administer and score with excellent acceptability by subjects. It is a simple tool that is used

to screen people for signs of cognitive impairments, aphasia-related disorders and

neurological problems such as dementia (Shulman, 2000). Free drawn method was

administered and for scoring purpose Shulman scoring method was used. Shulman proposed

one of the first scoring systems which remain one of the most widely used scales in the

literature to this day. It consists of a hierarchical scale (i.e., a scale with severity ratings), in

which the clock is analyzed as a whole. The system was reviewed in 1993. According to this

method the client scored 5 that is perfect clock as she drew the clock correctly and put all

numbers on clock in right proportion and drew the hands of clock right showing right time.

The score 5 indicates normal cognitive functioning and no impairment (Shulman, 2000).

House tree person (HTP). The House-Tree-Person (H-T-P) technique, developed by

Buck (1948) and Hammer (1958), is one of the most widely used projective tests for children

and adults. It can be used with individuals aged 3 years and older and is almost entirely

unstructured; the respondent is simply instructed to make a freehand drawing of a house, a

tree, and a person. It was updated in 1969. Analysis of the H-T-P is a two-phased. In phase

one, the first step in testing is nonverbal and almost entirely unstructured; the medium of

expression is the freehand, pencil drawings of a house, tree, and person. The second step is

verbal, apperceptive, and more formally structured. In it, the subject is given the opportunity

to describe, define, and interpret his or her drawn objects and their respective environment,

and to respond to various open-ended questions. Buck felt artistic creativity represented a

stream of personality characteristics. The primary purpose of the HTP is to measure aspects

of a person's personality through interpretation of drawings and responses to questions

(Buck, 1948).

Interpretation. The client draws the picture of a girl. The size of drawing is large that

shows tension compensation and restrictive environment. Head is drawn large shows

aggression, poor emotional adjustment, anxious and pre-occupation with head pain. Shading

in figure shows anxiety. Neck missing shows immaturity and impulsivity. Arms open and

claw like fingers show overt aggression. Shading focused on head region shows over concern

about thoughts. Shoelaces shows some obsessive-compulsive tendency. Sketchy lines and

light pressure shows anxiety, depression and fearfulness. The client draws central and large

drawing of tree shows frustration, tension and restricted environment. Cloud like tree shows

fantasy and unrealistic thoughts. Faint and sketchy lines and shading in trunk and branches

indicates anxiety, passivity and depression. Cotton wrapped branches show guilt. Large trunk

shows more ego strength. No roots show insecurity. The client draws central and moderately

size normal house indicating it as nurturing place and high level of self-esteem. Roof shows

extra attention to fantasy and ideation. Doors open shows need for warmth and client is

welcoming, also large doors show dependency. Windows closed shows client is not open to

others regarding her feelings. Heavy pressure and strong lines show anxiety and worry.

Shading in whole picture shows anxiety and depression.

Client cooperatively draws each drawing and was showing interest in drawing. The

interpretation of the drawings reflects her anxiety, worry, passivity and depressive tendencies.

It also reflects her aggression, fearfulness and few obsessive-compulsive tendencies but also

shows her high self-esteem. Client’s drawing shows prominent symptoms of anxiety along

with some features of depression.

Tentative Diagnosis

On the basis of history taken from the client, DSM-V and other assessment tools

client is diagnosed as Generalized Anxiety Problem with co-morbid depressive symptoms.

Case Formulation

Client is 25 years old girl. She is married having three children, living in joint family

setup. She has done F.A. She came with the complaints of excessive worry, restlessness, fear

that something bad could be happen, tensed and irritable mood, fatigued, lack of appetite,

muscle tension (body ache and headache having numbness in head) and sleep disturbance.

The problem of the client precipitated when her son was hospitalized with fever and seizer

attack. She started to stay worried, more alert, tensed and with fear that something bad could

happen. Her excessive worries and anxiety really affecting her life.

Cognitive Perspective. The cognitive perspective explains the Generalized Anxiety

Disorder (GAD) in the best way. Proponents of this perspective believe that psychological

problems are caused by dysfunctional ways of thinking, hence GAD is characterized by

excessive worry (a cognitive symptom). The cognitive theorists suggested that GAD is

caused primarily by maladaptive assumptions. Ellis in 1950’s proposed that the presence of

basic irrational assumptions lead people to act in inappropriate ways. Similarly, another

theorist, Beck in 1950’s argued that those with GAD hold unrealistic silent assumptions
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implying approaching danger. In my case the client was also too much thinking and taking

excessive worry about uncertain situation and making assumption about worst situation or

consequences (Behar, 2009). In recent years, three new cognitive explanation of GAD have

emerged:

The Intolerance of Uncertainty Model (IUM). The Intolerance of Uncertainty Model

(IUM) of GAD was proposed by Dugas (1995) and his colleagues. According to this model

individual with GAD find uncertain or ambiguous situations to be “stressful and upsetting”

and experience chronic worry in response to such situations. These individuals believe that

worry will serve to either help them cope with feared events more effectively or to prevent

those events from occurring at all. This worry, along with its accompanying feelings of

anxiety, leads to negative problem orientation and cognitive avoidance, both of which serve

to maintain the worry (Behar, 2009).

The Metacognitive Model (MCM) of GAD. This model was proposed by Wells

(1995) postulates that individuals with GAD experience two types of worry i.e. Type 1

Worry, when individuals are initially faced with an anxiety-provoking situation, positive

beliefs about worry are developed (e.g., the belief that worry will help them cope with the

situation) and Type 2 Worry when during the course individual developed negative beliefs

about type 1 worry that their worry is uncontrollable and dangerous (worry about worry)

(Behar, 2009).

Behaviorist perspective. Learning theorist believed that anxiety is a learned behavior

by conditioning response (fear or worry) with the stimulus (situation) as described in classical

conditioning by Palov in 1927. Anxiety symptoms result from simple conditioned responses

with our traumatic or disturbed experiences. So the anxiety disorders that prevent people

from functioning normally are always associated with memories of traumatic experiences and

hence are the result of learning. Thus traumatic memories and the mechanism of conditioned
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fear are believed to play an important role in anxiety disorders. In my case the client also

associates or conditioned the worry or fear with her disturbing experience of her son’s seizer

attacks (Delprato & McGlynn, 1984).

Therapeutic Suggestions

For better prognosis following psychotherapies are suggested.

Cognitive behavioral therapy (CBT). Cognitive behavioral therapy was invented by

a psychiatrist Beck, in the 1960s. Cognitive behavioral therapy (CBT) is a short-term, goal-

oriented psychotherapy treatment that takes a hands-on, practical approach to problem-

solving. Its goal is to change patterns of thinking or behavior that are behind people’s

difficulties, and so change the way they feel. It is used to help treat a wide range of issues in a

person’s life, from sleeping difficulties or relationship problems, anxiety and depression

(Martin, 2019). CBT is the gold standard of psychotherapy and one of the most popular

treatments for GAD. Proven to work for adults. CBT focuses on present difficulties and

current situations. CBT focuses on the interplay between the conscious thoughts, feelings,

and behaviors that perpetuate anxiety (Deborah, 2019).

Acceptance and Commitment Therapy (ACT). Acceptance and Commitment

Therapy (ACT) is another present- and problem-focused talk therapy used to treat GAD, the

goal of ACT is to reduce the struggle to control anxious thoughts or uncomfortable sensations

and increase involvement in meaningful activities that align with chosen life values and better

cope with the situation. ACT can produce symptom improvement in people with GAD, and

may be a particularly good fit for adults (Deborah, 2019).

Relaxation Techniques. These are strategies used to reduce stress and anxiety.
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These techniques can also be used to manage symptoms of anxiety disorders including

Generalized anxiety disorder, panic disorder etc. and help a person to get through the

threatening situation. Relaxation techniques work to manage the fight-or-flight response, or

stress reaction, that is frequently triggered among people with anxiety disorders. These

techniques include Deep-Breathing exercises, Visualization (imagining yourself in more

calming situation), Progressive Muscle Relaxation, Meditation and Yoga (Star, 2020).

Prognosis

In this case prognosis is satisfactory as client has insight of her problem. She has high

self-esteem and above all she has will to bring change in herself to make her situation better.

The proper treatment, therapy and support from her family will be helpful in managing with

her current problems and make her life healthy functioning.

Limitations

In collecting the data for case formulation, I have faced following limitations;

 I found case in my neighborhood and face very delay in obtaining data as my

client was not free at her home to give me interview.

 And also I collected data from a general home setting so in that restricted

home environment I lacked the resources and clinical psychologist’s guidance

to further probe the client and provide with some therapies and techniques for

her betterment.
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References

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring

clinical anxiety: psychometric properties. Journal of Consulting and Clinical

Psychology, 56, 893–897. doi:10.1037/0022-006X.56.6.893

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck depression inventory-

II. San Antonio, TX: Psychological Corporation.

Behar E, et al., (2009). Current theoretical models of generalized anxiety disorder (GAD):

Conceptual review and treatment implications. Journal of Anxiety Disorder 23, 1011-

1023. doi: 10.1016/j.janxdis.2009.07.006

Buck, J. N. (1948). The H-T-P. Journal of Clinical Psychology, 4(2), 151–159.

doi:10.1002/1097-4679(194804)4:2<151::AID-JCLP2270040203>3.0.CO;2-O

Deborah R. G., (2019). Generalized Anxiety Disorder Treatment. Retrieved from

https://www.verywellmind.com/generalized-anxiety-disorder-treatment-4171993

Delprato D.J., McGlynn F.D. (1984) Behavioral Theories of Anxiety Disorders. In: Turner

S.M. (eds) Behavioral Theories and Treatment of Anxiety. Springer, Boston, MA. doi:

https://doi.org/10.1007/978-1-4684-4694-4_1

Folstein, M.F. (1975). "Mini-mental state". A practical method for grading the cognitive state

of patients for the clinician. Journal of Psychiatric Research,12(3):189-198.

doi:10.1016/0022-3956(75)90026-6

Martin B, (2019). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved from

https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
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Shulman KI. (2000). Clock‐drawing: is it the ideal cognitive screening test? International

Journal of Geriatric Psychiatry, 15(6), 548-561. doi:10.1002/1099-

1166(200006)15:6<548::AID-GPS242>3.0.CO;2-U

Star K. (2020). Popular Relaxation Techniques for Anxiety. Retrieved from

https://www.verywellmind.com/popular-relaxation-techniques-2584192

Tian P. S. Oei , Sukanlaya Sawang , Yong Wah Goh & Firdaus Mukhtar (2013). Using the

Depression Anxiety Stress Scale 21 (DASS-21) across cultures, International Journal

of Psychology, 48(6), 1018-1029. doi:10.1080/00207594.2012.755535

Appendix

MMSE
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BDI
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BAI
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DASS-21
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CDT
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HTP
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