1

Summary
A.A was 9 years old boy and was referred by Agosh foundation to therapist for the

behavioral and emotional assessment. He might be a client of Narcissistic

Personalityu Disorder with presenting complaints anger outburst, self-biting, nail

biting, lack of empathy, fantasies of unlimited success, lose temper, loneliness,

grandiosity sense of self, feelings of superiority and constant thoughts about being

more successful and powerful. The problem was started after the death of his father

and the sudden change of environment from home to orphanage and rejection from

his domestic life. Case formulation was done in accordance with bio psycho social

model, as by knowing the 4p’s. Assessment tools were used to assess the client’s

problem and nature of the problem. A brief clinical interview was conducted;

behavioral observation was done to assess the client’s personality. House Tree Person

Test (HTP) Test was used to assess the maladjustment of the client. So according to

Diagnostic Statistic manual (DSM-V) client might be diagnosed with Narcissistic

Personality Disorder. The proposed management plan will be advised to manage his

problems. Therapeutic techniques will be used, as psycho-education and

psychotherapy or talk therapy to the client to manage his problems.

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Identifying Information

Name A.A

Age 9 years

Gender Male

Education 2nd class

Marital status Single

Family System Nuclear

No of siblings 3

Birth order 2

Informant Client school principal

Total No. of session 4

Date seen 17-10 - 2022

Source and Reason of Referral

The client was referred by AGOSH foundation for the purpose of

psychological assessment and management with the symptoms of anger outburst, self-

biting, nail biting, lack of empathy, fantasies of unlimited success, lose temper,

loneliness, grandiosity sense of self, feelings of superiority and constant thoughts

about being more successful, powerful, smart, loved or attractive than others.
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Presenting Complaints
Presenting Complaints and Duration of the Client’s Problems According to

Psychologist

‫عالمات‬

‫دورانیہ‬
‫ت‬
‫سال سے‬2 ‫ے‬ ‫دوسروں کو مار ا ہ‬
‫غ ن‬ ‫ٹ‬ ‫ن‬
‫سال سے‬2 ‫ے سے چ ھو وں پر صہ کالت ا ہ‬
‫ے‬ ‫اپ‬

‫سال سے‬2 ‫ناخنوں کو چبھا تا ہے‬

‫ن‬ ‫نٹ‬
‫سال سے‬2 ‫دوسروں کو ل رول کر ا چ اہ ت ا ہ‬
‫ے‬

‫سال سے‬2 ‫بےچینی ہوتی ہے‬

‫سال سے‬2 ‫اکیال رہتا ہے‬ 

‫سال سے‬2 ‫اپنے آپ کو دوسروں سے اعلئ تر سمجھتا ہے‬

Initial Observation

The client was 9 years old boy with presenting complaints of anger outburst, self-

biting, nail biting, lack of empathy, fantasies of unlimited success, lose temper,

loneliness, grandiosity sense of self, feelings of superiority and constant thoughts

about being more successful and powerful. He was basically an orphan child and

lived in an orphanage (agosh). Client father was dead due to heart attack and he

missed his father very much. He had 3 siblings 2 brothers and I sister. Both the

brothers are in Roshni Home (orphanage) one name is Zain who was studying in prep

class and the other name is Uzair who was studying in nursery class. While the sister

lived with his mother in home. The client school teacher reported that he had strong

attachment with his mother. His mother came to meet him after every two or three

weeks. His mother brings some fruits or homemade food for him and he will be very

happy after meeting with her mother. His aunt also came to meet him and brought
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many fruits. It was observed that the child behavior in school and in his hostel was

disturb and had some psychological problems which are needed to be diagnosed. The

hygienic condition of client was quite good and appropriate. The client very hesitant

at the beginning and continuously rubbing his hand and after establishing good

rapport, he gradually became relaxed and comfort. Session was started with clinical

interview. He didn’t know the purpose of coming therefore session structure was little

bit difficult.

According to behavioral observations client was little bit cooperative in his

nature, made less eye contact and his tone was not so high. He sat alone in the class

and felt comfortable in his loneliness. In hostel, it was observed that the child is not

involved in physical activities like other children. His teacher reported that when he

came to orphanage he was not good in study but now he improved his grade in

school. He was confident that other student.. In school it was observed that the client

behavior was not much aggressive. Client reported that Mujeeb (one of his roommate)

called him bomb ( ulty name se bulata tha) because he was basically from bombawala

a village near Daska city. So once, he planned with his other friends to beat the

mujeeb. So, his other friends held the Mujeeb and the client beat him.

After session his hostel warden, she reported about the mood and behavioral

changing of client. She said that he is not aggressive and remain silent most times.

She reported that he is the in-charge of his room. If the other children didn’t follow

his rule or his order, he told it to the warden. Basically he had feeling of superiority

in him and he want that everyone obey his rule and if anyone didn’t follow or obey

his rule, he became aggressive.

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Development History of the Problem

Client father died due to heart attack his mother leaves him in orphanage due to

financial issue. This sudden change of environment and the death of his father trigger

the symptoms anger outburst, self-biting, nail biting, lack of empathy, fantasies of

unlimited success, lose temper, loneliness, grandiosity sense of self, feelings of

superiority and constant thoughts about being more successful and powerful.

Background Information

Personal History. Client basically from Daska city. After the death of his

father, his mother’s leave him in orphanage due to financial issue. Client A.A

reported that he want to become a lawyer because he wanted to earn so much money.

He had fantasies of unlimited success in future. He wake up early in the morning and

didn’t show any laziness. The hygiene condition of the client was quite well. His

mother visit after every two weeks and he will be very happy after meeting with his

mother. Client favorite subject is Math. Teacher gave him a question which he solved

easily. He likes to offer prayers five times a day.

Educational History. Client A.A learning skills was quite good and his

learning abilities skills are better than other kids in class. He was not dependent on

others because he did his work himself. Teacher reported that he show great

improvement in his studies and in every class test, he got good marks. His reading

skills were also good. Teacher gave him a paragraph which he read easily. His aim to

became a lawyer and earn money so he is hard working.

Family History. The client lived in an orphanage. His family history taken

from his school teacher, school principal or his hostel warden . Client father died due

to heart attack. Client A.A mother visit the child after two or three weeks. Client visit

his home after a month where he spent some days and then return to orphanage.
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Client mother is not available in this session so it is very difficult to take history from

his mother.

History of Psychiatry Illness in Family. There was no psychiatry illness in

family, whereas, client father is died due to heart attack. This condition or all

behavioral changes of client started after the death of his father and the sudden

change of environment (shifting from home to orphanage) or might be due to

separation from his family.

Sexual History. There was no sexual history of the client because the client

didn’t reaches the age of puberty.

Provisional Formulation. After taking session from client, his teacher or his warden;

it was observed that the client had the symptoms of anger outburst, self-biting, nail

biting, lack of empathy, fantasies of unlimited success, lose temper, loneliness and

hyperactive. These symptoms developed after the death of his father and the sudden

change of his environment from home to orphanage or due to his separation from

family.

Psychological Assessment

Psychological assessment is a testing procedure that uses a variety of methods

to generate some assumptions regarding a person's behavior, personality, and

aptitudes. Psychological testing or administering a psychological battery to a subject

are other terms for psychological assessment. To evaluate the client's numerous areas

of dysfunction triggered by symptomatic behavior, both formal and informal

psychological diagnostic procedures were used.

Types of Psychological Assessment

There are two types of assessment.

 Informal assessment
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 Formal assessment

Informal Psychological Assessment

Informal assessment is a technique for learning about a client's behavior in

normal circumstances. This is accomplished without creating test conditions, as

would be the case with a formal evaluation. Since informal evaluation is conducted

throughout time, it is occasionally called continuous assessment. Compared to

nationally developed approaches, informal evaluation methods typically take less

time, money, and expertise because they are often customized to meet treatment-

specific assessment needs. It consists of the following.

 Clinical Interview

 Behavioral Observation

Clinical Interview. A talk with a purpose or goal is what is known as an

interview. (Matarazzo, 1965; Bingham & Moore, 1924). The primary method of

collecting data from clients, parents, and other informants is the clinical interview.

An exchange between a psychologist and a patient known as a clinical interview is

intended to aid the psychologist in making a diagnosis and creating a treatment plan

for the patient (Natalie Boyd). Interviews are adaptable, reasonably priced, very

portable, and—possibly most importantly—capable of giving the clinician examples

of both the client's verbal and nonverbal behavior at the same time. The purpose of

the interview was to determine the nature, severity, and cause of the patient's issue.

Therapist observed the present complaints and history of present illness to know

about the duration of the problem along with the predisposing, precipitating and

maintaining factors. At the time of interview, client was confused. His tone of voice

was slow and high pressure of speech. Overall, Good rapport was established with the

client.
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Behavioral Observation. Behavioral observation approaches can be used to

gather a number of data that offer important information and are beneficial for making

a variety of psychoeducational judgments due to their flexibility and simplicity of

usage. Behavioral observation is especially well suited for real-world settings because

of its direct nature and can produce a systematic record of behavior that can be used in

preliminary evaluation, intervention planning and design, the documentation of

changes over time, and as part of a multimethod-multisource evaluation that

incorporates other forms of assessment (like interviews and rating scales) and sources

(e.g., teachers, parents, and children).

Under observation during the session, it was observed that, client was

confused at start but gets normalized after sometime; during session client’s behavior

was also observed. The client was 9 years old boy. He sits alone in the class and feels

comfortable in his loneliness. In hostel, it was observed that the child is not involved

in physical activities like other children. He had fantasies of unlimited success which

is validated by the client that he wants to become a monitor of the class and to control

the others. In school it was observed that the client behavior was not much aggressive.

Client reported that Mujeeb (one of his roommate) called him bomb ( ulty name se

bulata tha) because he was basically from bombawala a village near Daska city. So

once, he planned with his other friends to beat the mujeeb. So, his other friends held

the Mujeeb and the client beat him.

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Formal Psychological Assessment

Formal assessment methods are considered to be more objective. In

psychology, a formal assessment combines an interviewing procedure with the use of

relevant test instruments and written evaluations to identify the issues present in the

case and to arrive at an appropriate diagnosis. Depression, anxiety, substance

use/abuse, stress, and other features and symptoms are some of the things that are

commonly examined for. The ability to analyze clinical symptoms is important when

evaluating the responses to a questionnaire. Formal assessment involves the use of

tools such as tests, Questionnaires, checklist and rating scales. The purpose of

evaluation is to determine the client’s personality, problems which impair the client’s

normal functioning and severity of disorder. The functioning of various areas of

personality has been assessed by

Diagnostic Assessment

 House Tree Person

 Aggression questionnaire

House, Tree, Person

The house-tree-person test (HTP) is a projective personality test, a type of

exam in which the test taker responds to or provides ambiguous, abstract, or

unstructured stimuli (often in the form of pictures or drawings). In the HTP, the test

taker is asked to draw houses, trees, and persons, and these drawings provide a

measure of self-perceptions and attitudes. As with other projective tests, it has flexible

and subjective administration and interpretation.

The primary purpose of the HTP is to measure aspects of a person’s

personality through interpretation of drawings and responses to questions. It is also

sometimes used as part of an assessment of brain damage or overall neurological

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functioning. The HTP was developed in 1948 by Buck, and later updated in 1969 by

Buck and Hammer. Tests requiring human figure drawings were already being

utilized as projective personality tests. Buck believed that drawings of houses and

trees could also provide relevant information about the functioning of an individual’s

personality.

Administration

The client was given with a pencil and an eraser, the client was completely

guided. The client draws the drawing in 15 mints.

Behavioral Observation

Client was sitting in class and he remained calm while drawing. The purpose

to apply this test was not clarified to client. He made the drawing in his first attempt.

Qualitative analysis

House shows sense of belongingness, nurturance and stability and the part of

self that is concerned with the body. Client made medium size house and the

interpretation of the house indicates that the client somehow face rejection from his

domestic life which is validate by this, that he is living separated from his mother and

his siblings.. Client made medium roof which shows that he had fantasy life which is

validate by behavioral observation. Client made no chimney which indicates that the

client had lack of psychological warmth in his home’s life, client also made a pathway

directed to doors which indicates indicate client accessibility, openness and direct

acquisition.

The interpretation of the client tree indicates that the client has less interaction

with others. According to the figure drawn, the client made fantasy like tree which

indicates his Unrealistic thoughts and disturbed perception of world and his is validate

in clinical interview. He also made faint line sketches represent some insecurities and
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passivity He made no roots which represent insecurities and no feelings of being

grounded. He is insecure, aggressive and has no feeling of being grounded.

Client made large head which indicates Grandiosity and intellectual ego and.

this is validate during behavioral observation, Client made small feet which show that

he had less attachment with others. And he made small arms with no hands which

show that he had some insecurity.

Suggested scale

Aggression Questionnaire (Buss & Perry, 1992)

This questionnaire The BPAQ has 29 items, subdivided in four factors (which

resulted from factor analysis): Physical aggression (9 items), Verbal aggression (5

items), Anger (8 items) and Hostility (8 items). This questionnaire was basically

applied on teacher and she gave the answers according to client behavior. And the

interpretation of this questionnaire indicates that client have high scores on physical

aggression and anger.

Case Formulation

The client A.A was 9 years old. After the death of his father, client mother

leave him in orphanage due to low financial issue. He might had Narcissistic

Personality Disorder with prominent symptoms of grandiosity (in fantasy or

behavior), need for admiration, and lack of empathy, feelings of superiority and

constant thoughts about being more successful and powerful. The client was brought

for informal assessment which includes Clinical interview, behavioral observation

while in formal assessment, standardized tests are administered.

DSM-5 checklist was used. The client might be diagnosed with “Narcissistic

Personality Disorder”. As per mentioned criteria in DSM-V for NPD are of

grandiosity (in fantasy or behavior), need for admiration, and lack of empathy,
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feelings of superiority and constant thoughts about being more successful and

powerful.

The formulation was done according to bio-psycho social model. According to

Bio model, the client was only the single child and his father died when he was 2 year

old. His mother was not financially strong to meet his expenses so he left the child in

Agosh foundation. Death of his father, rejection from his domestic life and the sudden

change of environment from home to orphanage cause some psychological discomfort

to client. Due to this happening client became very aggressive, emotionally disturbed

and develop feeling of superiority.

HTP was used to measure his personality. The assessment of personality tests

revealed that he is insecure, has fantasy life and have withdrawal and feelings of

loneliness, insecurities, grandiosity sense of self, feelings of superiority and constant

thoughts about being more successful, powerful, smart, loved or attractive than others.

The predisposing factor is not discovered as his parents had no disorder and

couldn’t get information from his mother. It might be due to his change in

temperament. The Precipitating Factor was the death of his father and the sudden

change of environment from his home to orphanage. The perpetuating factor of the

client disorder was the same environment and ignorance for treatment.

The treatment and management plan were done in reference to therapeutic

treatment as psycho-education, talk therapy,

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Case Conceptualization

Presenting Complaints: Assessment:

 Clinical Interviews
 Anger outburst  Behavioral
 Feeling of superiority observation
Client A.A  House tree person
 Fantasy life
( HTP)
 self-biting
 Aggression
 nail biting questionnaire
 lack of empathy,
 Fantasies of unlimited
success

Predisposing Precipitating Perpetuating Protective Factors

Factors Factors Factors  Change social
 Death of  Living in setting
 Temperam
father same  Increase
ent
mother visit
 Sudden environment
 Counselling
change of  Ignorance of
 Contact with
enviorment treatment
reality

Diagnosis
Narcissistic Personality
Disorder (NPD)
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Diagnosis

Client might be diagnosed with Narcissistic Personality Disorder (NPD) with code

301.81 (F60.81) according to DSM-V.

Proposed Management Plan

The management plan is made according to the current level or situations of

the client’s functioning. He was facing problems such anger outburst, self-biting, nail

biting, lack of empathy, fantasies of unlimited success, lose temper, loneliness,

grandiosity sense of self, feelings of superiority and constant thoughts about being

more successful and powerful..

Psycho-education. Psycho-education (PE) is defined as an intervention with

systematic, structured, and didactic knowledge transfer for an illness and its treatment

In order to help patients cope with their condition and increase treatment adherence

and efficacy. For this, we can psycho-educate the client teachers, his hostel warden

and his mother. It will be very helpful for the better recovery of the client.

Psychotherapy or Talk Therapy. Psychotherapy, or talk therapy, is a way to

help people with a broad variety of mental illnesses and emotional difficulties.

Psychotherapy can help eliminate or control troubling symptoms so a person can

function better and can increase well-being. It will be applied on client to make his

contact with reality and to overcome his feelings of superiority and aggressiveness.  

Limitation

Limitations are as following:

 No informant was available throughout the assessment. Information from

the family members wasn’t obtained so it could be more helpful in

identifying more information.

 Due to shortage of time, assessment will not take properly.

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 As the mother of client was not available, it was very difficult to take

history from the client.

 As the client was only observed in school setting, so it was very difficult to

take session with client due to the disturbance of other students.

Recommendation

Following recommendation could be helpful in conducting session successfully.

 Assessment should be carried out in an open environment which is free of

distractions.

 Time period for case study should be extended.

 Information should be gathered from the people in close contact of the client.

 There should be proper guidance from the universities while issuance of

permission letter.
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References

Diagnostic, A. P. A. (2013). Statistical manual of mental disorders, (DSM-5)

Washington. DC: Author.

Narcissistic personality disorder. In: Diagnostic and Statistical Manual of Mental

Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013.

http://dsm.psychiatryonline.org. Accessed Sept. 25, 2017Sims, A. G. (1995).

Buck, J. N. (1966). The house-tree-person technique: Revised manual. Western

Psychological Services.

Wiswede D, et al. 2014. Tracking Functional Brain Changes in Patients with

Depression under Psychodynamic Psychotherapy Using Individualized Stimuli. PLoS

ONE. 2014