PSYCHODIAGNOSTIC REPORT # 04

Bio data:

Name: xyz
Age: 15 year
Education: 8th grade
Father’s Name: abc
Siblings: 03
Birth order: first
Marital status: Single
Belongs To: Rawalpindi
Examiner: Sadaf Irfan Abbasi (clinical psychologist)

REASONS FOR REFERRAL

Parents brought the client before two weeks to the hospital when she was suffering from Tension
Headache, Guilty Feelings, Pain in uterus, Anxiety, Fear of death, Hysterical fits and Reflux.
According to the informants (Her parents referred her) the reasons for referral was her continues
unrest coupled with anxiety which had adverse affects on her sleeping and eating routine.

PRESENTING COMPLAINTS

Client has been suffering from Guilt Feelings, Illusions, Auditory hallucinations, lack of sleep,
Pain in uterus, Vomiting, Fear of death and Restlessness. Preliminary investigation further
reveals that the client most rottenly showing her own state of mind in which she repeatedly says
that “Earth is being broken in major parts” and consistently repeats that “she cannot marry
Waqar due to the family disputes” it shows her inborn fear and anxiety which is deep routed to
her sub-conscious due to the shocking incident occurred in her childhood.
SYMPTOMS:

Following symptoms has been observed according to DSM IV TR

 Recurrent Thoughts of Death

 Hallucinations
 Inappropriate guilt
 Nausea
 Insomnia or hypersomnia
 Feelings of restlessness
 Illusions

FAMILY HISTORY
Client was born in a lower class socio-economic family without any sort of birth complications
and lives in a traditional joint family system. The birth order of client is 1 st one and she has three
younger sisters. Ages of sisters are 13 and 10 years respectively and the youngest one is of 6
months old and two sisters are studying in a school. Her father is the only source of earning. He
is a home servant at his Brigadier house and he is earning approximately 25,000 to 30,000 per
month. Her mother is a house wife having no educational background. Reportedly, there was no
track record of serious biological and psychological illnesses in her family. Her relationship is
good with her family members, especially with her mother and sisters however, her father is a
hardliner and very strict in keeping up his traditions and most often getting harsh upon her in the
event of crossing the traditional boundaries.

PAST PERSONAL HISTORY

Client was born in May, 1996 in a lower class family. According to her parents, she never had
any complications in her pre-natal and post-natal stage. Incidentally, she was obsessed by a
classmate girl and deeply felt infatuated to her without knowing the real intentions or motive
behind the overflowing sentiments and attachment. To some extent, she become fanatical in
those affairs for a considerable period but afterwards, she felt enormously guilty and started
blaming herself considering it morally as well as religiously sinful and wrong act. In such a state
of mind coupled with the overflow of inner feelings and aggression she started masturbation
considering it as a course of self punishment which caused her physical harm as she felt an acute
pain in her uterus and was eventually increased while urinating which caused minor infection in
her uterus. On the other hand, she also suffered from high fever once upon a time that made
adverse affects on her physically due to loss of appetite and non availability of an adequate
medical treatment.

Yet another shocking incident was occurred to her at the age of (9) years when her cousin
namely Waqar harassed her sexually while playing outside her home. This incident placed her in
complete psycho-syndrome as she was profoundly cherished with him with a determination to
acquire his affection. On contrary, she was hopeless in getting married with him due to the
family enmity and hardship of her father.

HISTORY OF PRESENT ILLNESS

Client is suffering from Recurrent Thoughts of Death, Hallucinations, Inappropriate guilt,
Nausea, Insomnia or hypersomnia, Feelings of restlessness, Illusions and also physical weakness.
In the first instance, she was taken to a physician but there was no significant response and by
the time passes the symptoms become more complicated and psychologically problematic.
Hence, the client was taken to the psychological assessment and thereafter, parents of client have
taken extra precautions for her appropriate treatment.

PSYCHOLOGICAL ASSESMENT
Psychological assessment was carried out through formal and informal ways. Formal ways
include behavioral observation and it was concluded that the client was in the state of tension,
mental stress, anxiety and sadness. Her physical movements seemed restless and hyperactive but
her interpersonal communication was considerably slow, showing abnormal reluctance. She was
absolutely uncooperative during the process of therapeutic treatment. Her attitude with
compliance to the therapist was problematic and she seemed not at all receptive. The client’s
perception is pessimistic with distorted thoughts which have placed her in an unhealthy condition
physically as well as psychologically.

Informal ways include following tests that are as follows:

 Standard Progressive Matrices. (SPM)

 Bender Gestalt Test. (BGT)

 Human Figure Drawing Test.(HFD)

 Thematic Apperception Test. (TAT)

Psychometric Assessment Report:

The IQ screening test indicates that the patient’s IQ falls in intellectually below average
category.
The patient scored 6 on Bender Gestalt Test (BGT), the neurological screening test which

indicates the strong evidence of neurological impairment. While the indicators on BGT she that

the patient might have lack of planning and organizational ability, anxiety, internalized hostility,

repression, depression and neuroticism. The patient seems to have lack of confidence and

emotional instability.

The emotional indicators revealed by the patient on Human Figure Drawing (HFD) projective

technique showing that the patient might have instability, immaturity, impulsivity, poor

coordination, rigidity, ambition for achievement or for acquisition including striving for love and

affection. she seems to have poor inner control and regression to some serious emotional

disturbance. The results also revealed that the patient has poor coordination of impulses and

behavior,shy,tendency to withdraw, concern over school achievement. she might have difficulty

reaching out into the world and towards others, lack of aggression and leadership, slower rate of

maturation, sign of neurological impairment, castration fear, infantile social behavior, passive

aggressive attitude, neurotic tendency. she also has withdrawal tendency, rigid emotional control,

sensitivity to criticism and sensitivity to attitude of others.

While responding to Thematic Apperception Test (TAT) projective personality test stimulus
pictures, the patient revealed that she has insecurity, helplessness, indecisiveness, dejection,
pessimism, apprehension and suspiciousness. The stories on TAT are showing that the patient
might have need for achievement, need for succorance, need for nurturance, need for retention,
need for recognition and need to repress aggression. She may perceive forces of the environment
as uncongenial, claustrum and feels intense emotional affiliation and dependency. She seems to
have intra psychic conflicts and the conflict of trust versus mistrust. She may use defense
mechanism of rationalization, withdrawal, fantasy and denial while dealing with her daily life
stresses. She might perceive her environment as threatening, hostile, exploitable, dejected,
disappointing and terrifying.

Clinical Impression:

Diagnosis:

Conversion disorder.

MULTIAXIAL DIAGNOSIS

 Axis I 300.11,conversion disorder

 Axis II V71.09

 Axis III None

 Axis IV Housing problems(inadequate housing)

 Axis V GAF=21(current)

Diagnostic Criteria Conversion Disorder :

DSM-IV defines conversion disorder as follows:

 One or more symptoms or deficits are present that affect voluntary motor or sensory

function suggestive of a neurologic or other general medical condition.

 Psychological factors are judged, in the clinician's belief, to be associated with the

symptom or deficit because conflicts or other stressors precede the initiation or exacerbation
 of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by

up to 15 years is not unusual.

 The symptom or deficit is not intentionally produced or feigned (as in factitious

disorder or malingering).

 The symptom or deficit, after appropriate investigation, cannot be explained fully by a

general medical condition, the direct effects of a substance, or as a culturally sanctioned

behavior or experience.

 The symptom or deficit causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning or warrants medical evaluation.

 The symptom or deficit is not limited to pain or sexual dysfunction, does not occur

exclusively during the course of somatization disorder, and is not better accounted for by

another mental disorder.

The nature of the association between the psychological factors and the neurological symptoms

remains unclear. Earlier versions of theDSM-IV employed psychodynamic concepts, but these

have been incrementally removed from successive versions.

The tenth revision of the World Health Organization's International Classification of

Diseases uses the term "conversion" as an alternative descriptor for the dissociative

disorders class of mental and behavioural disorders (i.e. the F44 class), with the explicit

suggestion that dissociative and conversion symptoms probably share common psychological

mechanisms. In ICD-10, the dissociative [conversion] disorders class includes 10 disorders that,
in addition to specific criteria for each individual disorder, must each meet the following general

criteria:

 No evidence of a physical disorder that can explain the symptoms that characterize the

disorder (but physical disorders may be present that give rise to other symptoms);

 Convincing associations in time between the symptoms of the disorder and stressful

events, problems or needs.

CASE FORMULATION

The client was born in a lower class socio-economic family. She is getting psychological
treatment from Capital Hospital Islamabad, Psychiatry department. Through psycho analysis and
critical observations certain symptoms were taken into the consideration for the formulation of
the case study. The conclusive result is made after her personality assessment, Intellectual
Functioning and findings show that she is suffering from Conversion Disorder.

The Psychodynamic view by Freud

Freud developed a psychodynamic model of conversion disorder, he proposed that a conversion

disorder results when a person experiences an emotionally arousing event, but the event is not
expressed and the memory of the event is cut off from consciousness. Freud theorized that
conversion disorder in women is rooted in an unresolved Electra-Complex. The young female
child has sexual feelings toward her father and if her parents respond to these feelings in a harsh
manner, the feelings are repressed.

The result is an unconscious preoccupied with sex coupled with a conscious avoidance of it. In
later life sexual excitement reawakens her repressed impulses, created anxiety which is then
converted in to physical symptoms. Thus the conversion disorder lets the women avoid her
unresolved Electra Complex Freud also pointed that the symptoms could also let the person
avoid an unpleasant life situation or obtain attention.

Cognitive behavior view:

Cognitive behavioral model suggests that a number of different mechanisms contribute to

somatoform disorders. This model is believed to start with a physiological symptom, as a result
of either a medical illness or a non pathological change in physiological functioning.
The process is thought to begin when a person notices a physical anomaly, because physical
symptoms are so common, that these models tend to focus on cognitive and behavioral processes
that guide responses to physical symptoms. Everybody experiences physical sensations and pays
a certain amount of attention to it, but people who are prone to conversion disorder appear to
have a cognitive style characterized by paying much attention to these things. Once people with
conversion disorder notice physical symptoms they also seem to make more negative attribution
about them. The specific attribution will very with the somatoform disorder. Fear that a bodily
sensation signifies illness or one’s physical appearance signifies ugliness is likely to have two
behavioral consequences. First, the person may assume the role of being sick and avoid work and
this can intensify symptoms by limiting exercise and other healthy behaviors. Second, the person
may seek reassurance from doctor and from family and this help seeking behavior may be
reinforce if ut results in the person getting attention or sympathy.

Biological view:

The negative emotion (recall of a traumatic event) was linked to conversion disorder symptoms.
When examined in a functional magnetic resonance imaging scanner, a woman with a right hemi
paresis showed increased activity in her right medial temporal lobe (including the amygdala,
involved in emotional recall) and concurrent deactivation of her contra lateral (left) primary
motor cortex when cued to remember a key traumatic event linked to the onset of her symptoms,
psychological stressors and the development of conversion disorder using a cognitive model of
memory suppression.

Personality theory by Freud

Sigmund Freud has given psychosexual phallic stage under which some children face physical
fixation and its name is Electra complex. According to the observation client is having physical
fixation and that is why she masturbates herself.

Personality theory of Adler

According to Adler’s birth order stages the first born child takes responsibility and care for
others unfavorable outcome feels insecure, pessimistic, problematic and maladjusted child.
According to the critical observations, she has all these traits.
PROGNOSIS
Seems to be poor.

TREATMENT AND THERAPUTIC SUGGESTIONS:

In many cases, symptoms of conversion disorder get better by psycho counseling without a
physical treatment, especially after reassurance from the doctor that their symptoms aren't caused
by a serious underlying problem. One may benefit from treatment if conversion disorder signs
and symptoms linger on or keep reverted; it has severe symptoms, or other mental or physical
health conditions. Treatment will depend on particular signs and symptoms and may include:

Medication

Medication started. Along with medication like Axal 0.5 mg, panadol and other anti depressants,

the cognitive behavior therapy sessions were done to deal with the maladaptive thoughts.

Counseling (psychotherapy)

Seeing a psychologist or professional counselor can help treat symptoms of conversion disorder
and prevent it from coming back. This can be especially helpful if you have anxiety, depression
or other mental health issues.

Physical Therapy

Working with a physical therapist may prevent complications of certain symptoms of conversion
disorder. For example, regular movement of arms or legs may ward off muscle tightness and
weakness if you have paralysis or loss of mobility.
Treating related stress and other conditions

Conversion disorder may improve when you get treatment for stress, anxiety or another
underlying problem. Your doctor may prescribe anti-anxiety medications, antidepressants or
other drugs as part of your treatment plans, depending on your individual health profile.

Hypnosis

Undergoing hypnosis with a trained expert may help a person identify and resolve psychological
issues. Hypnosis is usually done along with another form of psychotherapy in treating conversion
disorder.

Tran cranial magnetic stimulation

Some reports have shown that people with conversion disorder may benefit from this type of
treatment, which involves exciting brain activity by using weak electrical currents. This
stimulation is believed to alter the brain's biochemistry and can improve symptoms of various
mental disorders.

Cognitive behavior therapy

Cognitive behavior therapists have applied many different techniques in help people with
conversion disorders. Generally these includes, identify and change the emotions that trigger
their somatic concerns, change their cognitions regarding their somatic symptoms, change their
behaviors so they stop playing the role of a sick person and gain more reinforcement for
engaging in other types of social interaction, behavioral techniques might involve helping people
resume healthy activities and decrease their reliance of playing sick role.