Case 1

Summary of the case:

The client is a 13-year-old girl. She was in SOS Village, and the director of the SOS
referred her to me for psychological assessment and management of her problems. Her presenting
complaints were Headache, Muscle Pain, Eyes, Stomach Pain, and Problems in Breathing.For the
client assessment, the therapist used Clinical Interview, Clinical Observation, Mental Status
Examination (MSE), House Tree Person (HTP), Beck Depression Inventory (BDI), Sentence
Completion Test (SCT), and Basic Intelligence Scale (BIS).Management of the client was done
by using Rapport Building, Family Therapy, Social Skills Training, Behavior Therapy, and
Cognitive Behavior Therapy. The client showed lack of interest during the session. Total 5
sessions were done. Some of the client's problems were managed.
Identifying information

Name no one

Age 13 years

Gender female

Education middle

Birth order 3

Marital status unmarried

Source of referral

Her family admitted her in SOS village and the director of SOS referred to me for the
assessment and management of her problem.
Presenting Complaint:
Table 1: Presenting complaint of the client

Presenting Complaints Duration

Headache 2 weeks
Muscle pain 1 week
Pain in eyes 1.5 weeks
Stomach pain 2 weeks
Problems in breathing 3 weeks

Initial Observation:
The client was sitting in an appropriate posture. The client was slow, lack of eye contact,
depressed facial expression. Speech was organized but voice was slow. She was good in hygienic
condition.

History of Present Illness:

The client was physically fit, but due to certain circumstances, she faced headache, muscle pain,
pain in eyes, stomach pain, and problems in breathing. And for these problems, she used
painkillers. Antipsychotic drugs were not used. Aggression was developed in her personality due
to separation with her family. She had delusion of jealousy and paranoid delusion. The problem
was due to his parent's death.
Figure 1

Personal history

The client was like to live alone. She did not want to talk to anybody else. She want to
become singer in future because she thought her voice was very beautiful. She was not social.
She has few friends in school and SOS village. Aggression and loneliness was developed in
personality after separation from family,
Education:

The client was studying in 8th class. She was a good student and took interest in studies.
She wants to become a singer in her future.

Religious Inclination:

The client’s religion was Islam by birth. She offered five-time prayers and recites the
Holy Quran daily very regularly.

Drug History:

She has not used any antidepressant and anxiety-reducing drugs. The problem was from
the last 4 years. She used some pain killers, Panadol for the headache. There are no side effects of
drugs on the body.

Pre-Morbid Personality:

Before the disorder, the client was very active, social, and loving. The client was very
sensitive about his parents. But after the death of her parents, she remained depressed.

Family History:

The family system of the client was nuclear. There were three siblings of her. She was on
good terms with her family, especially the relation of the client with his family was very nice. It
was much attached to his father and mother. The client’s parents had died. Clients told me that
her father was a policeman. One day her father and his friend went to a place for urine, where an
evil soul came and took out their hearts from their bodies and therefore they both have died.

The client is told that her mother’s death was happened due to an accident. After the
death of her father, one person wanted to marry her mother due to her wealth. One day that
person came to her mother’s home and stole that box, which her mother saved some jewelry and
expenses. Her mother ran away behind the person, but during the road to cross a train came and
hit with train and died.
Genogram

Figure 2

Genogram describe the family tree of client

General Home Atmosphere

The client general home atmosphere was good. Every family member took care each
other. Her mother was main decision maker of family.
Family psychiatric or medical problem
There was not any psychological and physical problem in their family.

Assessment

Mental status examination (MSE)

Clinical interview
Behavioral observation
Medical history
Beck Depression Inventory (BDI)
Beck Anxiety Inventory (BAI)
Rotter's Incomplete Sentence Blank (RISB)
House Tree Person (HTP)
Mental Status Examination (MSE)

In order to deep understand of her mental state therapist used mental status examination
understood of her general appearance, thought patterns, emotional status. Therapist also judges
his consciousness and orientation of time, place and person.

The client had proper dressing. She was very calm and cooperative. She was tall but not
thin. She was much worried and fearful. She had not unusual movements or psychomotor
changes. Her speech rate was normal. Her mood was depressed. Her thought was goal directed
and logical. She had also suicidal ideation. She was very much time, place, person and self-
oriented (Opper, S. 1977. Appendices A)
Clinical interview

To get in-depth information, the clinical interview method was used. Therapist asked
question about her personal, family, social and educational life. Therapist asked about her social
interests, friendship patterns and her relationship patterns with others. As a result therapist got
clear cut understanding of her problem (L.Roche, 2005).

Behavioral Observation

She reported the age of 13 which match with her appearance. She was shy girl. She was
hidden their problems. She had not eye contact.
Medical History

The medical history of a patient is information gained by a physician by asking specific

questions, either of the patient or of other people who know the person and can give suitable
information, with the aim of obtaining information useful in formulating a diagnosis and
providing medical care to the patient (La Roche, 2005).
Beck Depression Inventory (BDI)

The Beck Depression Inventory (BDI, BDI-II), created by Dr. Aaron T. Beck, is a 21-
question multiple-choice self-report inventory, one of the most widely used instruments for
measuring the severity of depression.

Individual questions of the BDI assess mood, pessimism, sense of failure, self-
dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability,
social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily
preoccupation, and loss of libido. Items 1 to 13 assess symptoms that are psychological in nature,
while items 14 to 21 assess more physical symptoms (Beck. AT, 2006.See in Appendices)

Rating scale
Table 2

Scoring of beck depression inventory by the client

Statement statements Rating

no
1 Sadness 3
2 Pessimism 0
3 Past failure 2
4 Loss of pleasure 1
5 Guilty feeling 3
6 Punishment feeling 0
7 Self-dislike 0
8 Self-criticalness 0
9 Suicidal thought or wishes 0
10 Crying 3
11 Agitation 2
12 Loss of interest
13 Indecisiveness 1
14 Worthlessness 1
15 Loss of energy 1
16 Changes in sleeping pattern 3
17 Irritability 1
18 Changes in appetite 1
19 Concentration difficulty 2
20 Tiredness of fatigue 3
21 Loss of interest in sex 1
Table 3

Quantitative interpretation

Subtotal Subtotal Subtotal Subtotal Total Category

Page 1 Page 2 Page 3 Page 4
8 1 9 5 23 Moderate depression

Table 4

Categories of Scores

score Range
1-10 Normal
1-16 Mild mood disturbance
17-20 Borderline clinical depression
21-30 Moderate depression
31-40 Severe depression
Over 40 Extreme depression
Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory (BAI), created by Dr. Aaron T. Beck and other colleagues, is a 21-
question multiple-choice self-report inventory that is used for measuring the severity of an
individual's anxiety. The BAI was specifically designed as "an inventory for measuring clinical
anxiety" that minimizes the overlap between depression and anxiety scales (Beck AT. Steer RA,
1993.See in Appendices)

Rating scale
Table

Scoring of anxiety inventory

Statement no Statements Rating

1 Numbness or tingling 1
2 Feeling hot 1
3 Wobbliness in legs 1
4 Unable to relax 1
5 Dizzy or lightheaded 1
6 Heart pounding or racing 1
7 Unsteady 1
8 Terrified 1
9 Nervous 1
10 Feeling of chocking 1
11 Hands trembling 1
12 Shaky 1
13 Fear of losing control 1
14 Difficulty breathing 1
15 Fear of dying 1
16 Scared 1
17 Indigestion or discomfort in abdomen 1
18 Faint 1
19 Face flushed 1
20 Sweating (not due to heat) 1
Table 5

Quantitative interpretation

Total score Category

25 Moderate anxiety

Table 6

Category of scores

Severe anxiety Range

0-7 Minimal level of anxiety
8-15 Mild anxiety
16-25 Moderate anxiety
26-63 Severe anxiety

House Tree Person

The House-Tree-Person test (HTP) is a projective test designed to measure aspects of a

person's personality. The test can also be used to assess brain damage and general mental
functioning. The test is a diagnostic tool for clinical psychologists, educators, and employers
(Opper, S. 1977).

House: Little house shows that she is not social. Closed doors and windows shows knobs on door
indicate poor social relations and defensive personality of client. Triangles show the vaginal
symbols. Boundary walls show the insecurity. No pathways show that she is not social. She does
not share her feelings with others.

Tree: In the drawing of HTP, tree with house indicates that the client has need of somebody for
warmth and affection. Pointy branches show the aggression in her. Fruits show high need for
nurturance. Small branches show limited skills
Person: The client did not draw person's picture.

Rotter's Incomplete Sentence Blank (RISB)

The Rotter's Incomplete Sentence Blank is a projective psychological test developed by

Julian Rotter. It comes in three forms, for different age groups, and comprises 40 incomplete
sentences in 20 minutes, usually only 1-2 words long. The RISB-2 provides a screening
instrument that helps you assess overall adjustment in adolescents and adults (Julian B. Rotter,
Michael 1, Lah, & Janet E, Rafferty, 1992).

The Rotter's Incomplete Sentence Blank is an attempt to standardize the sentence

completion method for the use at college level. Forty stems are completed by the subject. These
completion are then scored by comparing them against typical items in empirically derived
scoring manuals for men and women and by assigning to each response a scale value from 0 to 6.
The total score is an index of maladjustment.

Table VIII
Quantitative Interpretation of RISB

Codes Scores Values Total

C3 2 4 30
C2 3 5 30
C1 4 4 30
P3 5 3 26
P2 6 25 20
P1 7 1 23
N 8 4 22

Total 100
Table 9

To represent scoring

Obtained score Cut of score Category level

92 115 adjusted

Diagnosis
Major Depressive Disorder, Mild with Melancholic Features (296.21, F32.0)

Diagnostic Criteria

Major Depressive Disorder

A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning: at least one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg,
feels sad, empty, and hopeless) or observation made by others (appears tearful).
(Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day.
(Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional nearly

every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by

subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical
condition.

Note: Criteria A-C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which
may resemble a depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive episode in addition to the
normal response to a significant loss should also be carefully considered. This decision.
inevitably requires the exercise of clinical judgment based on the individual's history and the
cultural norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and
unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanie episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance-induced or are attributable to the physiological effects of another medical condition
Prognosis

The client had features of depression. Because she had very mild symptoms and the
prognosis chances was more.
Case Formulation

The P.I.S was 13 years old. The client had depression features. Her problem started last 4
years. The client had disturbance in headache, muscles pain, pain in eyes, stomach pain, and
problems in breathing. Assessment was done by using different psychological instrument Clinical
Interview, Clinical Observation, and Medical History, Mental Status Examination (MSE), House
Tree Person (HTP), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and
Rotter's Incomplete Sentence Blank (RISB). For the purpose of treatment different psychological
intervention Social Skills Training, Behavior Therapy and Cognitive Behavior therapy used for
the assessment of his problem. On the basis of these symptoms he may be diagnosed as having
depression features.

Predisposing Factors

The client forefathers had no psychological and physical problem. But in the client physical
problem was exist. She was not physically fit. She had also psychological problem which was
depressedfeelings.

Precipitating Factors

After birth client was very fit because his parents alive. But after the death of her parents she
was very disappointed. Her behavior became aggressive. She was very depressed. She lived
alone. She did not like the people which lived around himself. Because no one who shared her
problem?
Maintaining Factors

The socio culture environment of the client was not supported. After the death of her
parents the other family member's attitude was irresponsible. She was a student and she was very
careful for his friends and friends were also cooperated for her.

Protective Factors

The parenting style was much supported. Her parents guided him always but not forced
him. He was very attached to them. Friends are good for her.

Assessment was done by using different psychological instrument Clinical Interview,

Behavioral Observation, Medical History. For the purpose of treatment different psychological
intervention Mental Status Examination (MSE), House Tree Person (HTP), Beck Depression
Inventory (BDI), Beck Anxiety Inventory (BAI) and Rotter's Incomplete Sentence Blank (RISB)
used for the assessment of his problem. On the basis of these symptoms he may be diagnosed as
having depression features. For the management of psychological problem Rapport Building.
Family Therapy, Social Skills Training, Behavior Therapy and Cognitive Behavior Therapy was
used. Total 6 sessions was done. Some improvement has seen in client.
Summary of case formulation
Management

Following management plan were used and divided into short term goals and long term goals

Short Terms Goal

Psycho education
Rapport building
Family counseling (Mother of SOS)

Psycho Education

Refers to the education offered to people with mental health condition. Frequently psycho
educational training involves individuals with schizophrenia, depression, anxiety, psychotic
illnesses, eating disorders, and personality disorders, as well as patient in the context of the
treatment of physical illnesses. Family members are also included. A goal is for the consumer to
understand and be better able to deal with the presented illness. Also, the patient's own strengths,
resources and coping skills are reinforced, in order to understand that relapse is a part of their
recovery, and contribute to their own on a long-term basis. The theory is, with better knowledge
the consumer has of their illness, the better the consumer can live with their condition.
(Labinowicz, E. 1985. Appendices A-2).

Rapport building

Therapists talked with the client to develop rapport with her. Talked on the topics she likes.
Asked question about her schooling, friends, liking in foods, dressing etc. therapist asked about
her hobbies, movies she likes, books of her interest so that rapport could develop quickly. So this
worked a lot and she openly shared her all type of information with therapist freely
(Miltenberger, n.d, 2000. Appendices A-1).

Family counseling (Mother of SOS)

Therapist used the technique of family counseling. Therapist told the problem of the client to
her mother of her SOS Village's house and suggested them to provide hearing aids to the client.
So that she can communicate and respond well in the society (E. Lichtmacher, 2001.Appendices
A-3)
Long Term Goal

Social skills
Behavior therapy
Muscles relaxation training
Deep Breathing

Social Skills

Social skills training involve discussion about social experiences of the patient. In this,
Social skill will be taught to the client like how to interact, how to behave, how to use non verbal
signs, how to respond in the social group and self care (Elder, & Narick, 1979. Appendices A-5).

Behavior therapy

Behavioral therapy is a form of therapy rooted in the principles of behaviorism. The school
of thought known as behaviorism is focused on the idea that we learn from our environment. In
behavioral therapy, the goal is to reinforce desirable behaviors and eliminate unwanted or
maladaptive ones. The techniques used in this type of treatment are based on the theories of
classical conditioning and operant conditioning (Labinowicz, E. 1985 Appendices A-7.).

Relaxation Training

Relaxation techniques include a number of practices such as progressive relaxation, guided

imagery, self-hypnosis, and deep breathing exercises. The goal is similar in all: to consciously
produce the body's natural relaxation response, characterized by slower breathing, lower blood
pressure, and a feeling of calm and well-being (Labinowicz, E. 1985. Appendices A-6).
Relaxation training was given to teach her, how to keep him calm in different situations.
Deep Breathing

Deep breathing is breathing that is done by contracting the diaphragm, a muscle located
horizontally between the chest cavity and stomach cavity. Air enters the lungs and the belly
expands during this type of breathing. The client was asked to use deep breathing exercise from
which her lungs will spread and passing of air will be done easily. This deep breathing is marked
by expansion of the abdomen rather than the chest when breathing. It is considered by some to be
a healthier way to breathe, and is considered by some a useful form of complementary and
alternative treatment (Labinowicz, E. 1985. Appendices A-4).
Limitations

There are some limitation which are found during the case study

 There was not proper environment

 There was very hustle and bustle
 People disturbed again and again.
 Client was not cooperated for me.
 He was hidden their life occasion
 I have faced much difficulty to build rapport with the client
 No proper chair for client and psychologist

Suggestions

Following suggestions were given

 Provides the proper environment

 There was a separated room for the interview
 People had no permission to enter in that room
 Session Report

5 sessions were taken with the client.

Session No 1

Session goal: To built rapport and trust. To get introduction from patient

Activity/ Techniques: Positive regard

Outcome: Gained trust and rapport was built. She shared little bit information

Performance: Client performance was improved according to the instructions

Session No 2

Session goal: To know about personal and family history

Activity/ techniques: Therapist showed empathic understanding towards client when she is
telling the client about personal life

Outcome: Client shared her knowledge freely when therapist showed empathy to her

Performance: Good ratings by the client to share everything.

Session No 3

Session goal: To be known about her problem

Activity/ techniques: Beck Depression Inventory, Beck Anxiety Inventory, House Tree Person,
RISB

Outcome: Test filled by the client easily with less time consumption

Performance: Good rating by the client to share everything.

Session No 4

Session goal: To counsel and apply technique to get rid of problems

Activity/ techniques: Family Counseling,. Behavior Therapy

Outcome: Improvement in aggression, social interaction etc

Performance: Effective and prolonged

Session No.5

Session goal: Techniques continued

Outcome: She got deep understanding of problem and realized her mistaken beliefs in life

Performance: Client showed willingness to act upon the suggestions the therapist.
References