Clinical Internship Report

By
Aqsa Arif
S24BAPSY3M02015

Advance Diploma In Clinical Psychology

2024 – 2025

Department of Applied Psychology

Faculty of Social Sciences
The Islamia University Bahawalpur

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 Clinical Internship Report

Internship Report Submitted by

Aqsa Arif
S24BAPSY3M02015

In Partial Fulfilment of the Requirements for the Degree of

Advance Diploma In Clinical Psychology

2024 – 2025
Supervisor by

Dr .Rabia Arif

Department of Applied Psychology

Faculty of Social Sciences
The Islamia University of Bahawalpur
Pakistan

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 Student’s Declaration

It is hereby solemnly declared that my dedicated work entitled Internship Report has been

done by me and not has been presented by anyone of her partial fulfilment of any degree.

Aqsa Arif
S24BAPSY3M02015

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 Supervisor’s Declaration

It is certificated that Aqsa Arif in report titled Clinical Internship Reports has been carried out
under my supervision. In my opinion it is fully adequate in scope and quality for the degree of
Advance Diploma In Clinical Psychology from the Department of Applied Psychology, The
Islamia University of Bahawalpur.

Dr.Rabia Arif
(Supervisor)

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 Approval Certificate

This is to certify that Ms. Aqsa Arif successfully completed a 200-hour placement at the
Arrahma Hospital Multan , gaining required attendance and treating 10 clients. The
student's clinical report was completed in a timely manner which is plagiarism free and
demonstrated a solid understanding of the subject matter. This experience enhanced their
skills in history taking, assessment, counseling and psychotherapy.

1. Supervisor
Dr. Rabia Arif

2. Co-Supervisor

3. External Examiner

4. External Examiner

5. Chairman/Director

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 Dedication

This study is wholeheartedly dedicated to my beloved parents, especially my father who

have been my source of inspiration and gave me strength when we thought of giving up,

who continually provide their moral, spiritual, financial support. To my teachers, friends,

brother, who shared their words of advice and encouragement to finish this study.

Aqsa Arif

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 Acknowledgement

I own patients at hospital who voluntary participate in this internship report , for their
valuable cooperation and providing me data. Their contribution cannot be under
emphasized, without which this work could have been completed. The suggestions of
respected teachers cannot be forgotten to mention. Those suggestions helped in-
completion of this internship report. The supportive and collaborative attitude of my
fellows, during the data collection of this work has been worth mentioning. Special thanks
to my Internship supervisor Dr Rabia Arif at hospital for her fruitful supervision and
Internship Incharge Madam Dr.Areeha Khan Durrani for her constant guidance personal
interest which have been a motivation force throughout the completion of this task.

Aqsa Arif

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 Arrahma Hospital for Mental Health - Detailed Overview

Arrahma Hospital for Mental Health is a comprehensive mental health facility situated in Multan,
South Punjab, Pakistan. Known for its high standards in psychiatric care, the hospital is designed to offer
comfort and holistic treatment to its patients, promoting mental wellness in a nurturing environment. This
facility is fully equipped to handle a wide range of mental health issues and offers both inpatient and
outpatient services.

Facility and Infrastructure

The hospital is thoughtfully designed with modern amenities to ensure a therapeutic environment for
patients and visitors alike. Its infrastructure includes:

1. Two Wards:

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 o Old Ward and New Ward – Each ward contains three rooms, providing ample space for
patients who require extended care. These rooms are air-conditioned and furnished for
comfort, allowing for a peaceful recovery environment.

2. Patient Rooms and Hall Space:

o Indoor Patient Rooms: Dedicated rooms are available for patients requiring inpatient
care, ensuring privacy and a controlled environment for treatment.

o Outdoor Hall Space: A spacious hall is designated for outpatient consultations, allowing
flexibility and comfort for patients visiting the hospital for shorter sessions.

3. Support and Auxiliary Facilities:

o Help Desk: The hospital’s help desk is located near the entrance, assisting patients and
visitors with information and appointment bookings. Staff at the help desk are trained to
provide guidance and support with a compassionate approach.

o Report Room: This room is designated for handling patient reports and documentation,
ensuring confidentiality and proper record-keeping.

o Test Rooms: The hospital includes two medical and diagnostic test rooms – one in each
ward – for conducting necessary medical evaluations and tests, supporting accurate
diagnosis and monitoring.

4. Pharmacy and Canteen:

o On-site Pharmacy: An in-house pharmacy is available for patients to conveniently

access prescribed medications.

o Canteen: The canteen offers refreshments and meals for patients, visitors, and staff,
ensuring nourishment and comfort within the hospital premises.

5. Outdoor Spaces:

o Green Grounds: The hospital is surrounded by green lawns on all four sides, creating a
serene environment that contributes to the therapeutic ambiance. The greenery is a
significant part of the hospital's atmosphere, fostering relaxation and mental well-being.

o Parking Area: A dedicated parking space is available for visitors and staff, offering easy
access to the hospital.

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 o Security Office: The hospital’s security team is stationed at the main gate, ensuring a
safe and secure environment for patients, staff, and visitors.

6. Ground Floor Layout:

o The entire hospital facility is situated on a single ground floor, enhancing accessibility for
patients of all ages and mobility levels.

Appointment and Admission Process

Patients are encouraged to schedule appointments in advance, ensuring organized care and reduced
waiting times. The hospital’s staff is well-trained, courteous, and attentive, dedicated to making the
appointment and admission process smooth and efficient for every patient.

Medical Team and Specializations

Arrahma Hospital boasts a team of highly qualified and professional psychiatrists, clinical psychologists,
and mental health professionals. Each specialist brings extensive experience in treating diverse
psychiatric conditions. Key members of the team include:

1. Dr. Omer Ismail Khalid – Consultant Neuropsychiatrist with expertise in ADHD, anxiety,
depression, bipolar disorder, and PTSD. He also offers ketamine therapy for resistant cases of
depression and chronic pain.

2. Dr. Neelam Sarwar – Consultant Neuropsychiatrist with a focus on child and adolescent
psychiatry, treating conditions like schizophrenia, OCD, PTSD, and marital issues.

3. Dr. Kausar Shaheen Khalid – Family Physician & Psychiatrist, specializing in anxiety,
depression, phobias, and sleep disorders.

4. Dr. Rabia Arif – Clinical Psychologist offering therapeutic support for anxiety, stress, ADHD,
personality disorders, and rehabilitation.

5. Dr. Khalid Mahmood – Consultant Neuropsychiatrist with a wealth of experience in treating

severe psychiatric conditions, including schizophrenia, OCD, and social phobias.

Comprehensive Services

Arrahma Hospital provides a broad range of services tailored to meet the mental health needs of each
patient, including but not limited to:

• ADHD, anxiety, and bipolar disorder treatments

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 • Electroconvulsive therapy (ECT) for severe depression cases

• Stress management and hypnotherapy

• Rehabilitation and detoxification support for addiction

• Cognitive behavioral therapy (CBT), group therapy, and family counseling

Environment and Patient Experience

The hospital environment is meticulously maintained to promote recovery and comfort. Air-conditioned
rooms, green grounds, and courteous staff contribute to a welcoming atmosphere where patients feel
cared for and valued. The facility’s focus on professional, compassionate care ensures that each patient
receives tailored support in their journey toward mental wellness.

Location and Contact Information

• Address: Industrial Estate Area, Nadirabad Phatak, Sher Shah Road, Multan

• Phone: (061) 653 8885, (+92) 300 732 6920

• Website: www.arrahmahospital.pk

Conclusion

Arrahma Hospital for Mental Health is dedicated to providing high-quality, accessible mental health
services in a supportive environment. With its skilled team, modern facilities, and serene surroundings,
the hospital stands as a sanctuary for those seeking mental health treatment in Multan. Through
personalized care and advanced treatment options, Arrahma Hospital continues to make a positive impact
on the mental well-being of the South Punjab community.

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1. Case Study Method

Case Studies: An In-Depth Approach to Psychological Research:

The case study method is a research approach that involves a thorough examination of an individual or a
small group over an extended period. Unlike broader research methods, case studies provide a detailed
and nuanced view of psychological phenomena by focusing on specific cases. This method is particularly
effective in uncovering intricate details about complex mental health issues that are often missed by more
generalized research.

How Case Reports Enhance Our Understanding:

Case reports are essential for gaining a deeper understanding of psychological disorders. They document
real-life instances of mental health conditions, providing valuable insights into the experiences of
individuals. These reports help clinicians and researchers identify unique patterns, assess the efficacy of
different treatment approaches, and contribute to the development of new theoretical frameworks and
interventions.

2. Introduction to the Psychological Assessment Process

The Psychological Assessment Journey:

Psychological assessments involve a systematic process to evaluate an individual’s mental health through
a combination of interviews, tests, and self-report questionnaires. This comprehensive approach allows
clinicians to gather detailed information about a person's cognitive, emotional, and behavioral
functioning.

The Importance of Assessments in Mental Health:

Assessments play a critical role in diagnosing mental health conditions and developing effective treatment
plans. By providing a structured framework for evaluating symptoms and functioning, psychological
assessments help clinicians make accurate diagnoses and tailor interventions to meet each individual's
needs. This process ensures that treatments are based on a thorough understanding of the patient's
condition, leading to better outcomes and more personalized care.

3. Introduction to Disorders

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A Brief Look at Common Psychological Disorders:

• Mood Disorders: Mood disorders, such as depression and bipolar disorder, involve significant
disturbances in emotional states. These conditions can result in prolonged periods of depression
or extreme mood swings, affecting an individual’s overall well-being.
• Anxiety Disorders: Anxiety disorders, including generalized anxiety disorder and panic disorder,
are characterized by intense and persistent feelings of worry, fear, or panic. These disorders can
lead to significant distress and hinder daily activities.
• Psychotic Disorders: Psychotic disorders, such as schizophrenia, involve severe disruptions in
thinking and perception. Symptoms may include hallucinations, delusions, and disorganized
speech, which can profoundly impact an individual’s ability to function in everyday life.
• Personality Disorders: Personality disorders are characterized by enduring patterns of behavior
and thought that deviate from cultural expectations and cause significant distress. Examples
include borderline personality disorder, marked by unstable emotions and relationships, and
narcissistic personality disorder, characterized by a pervasive sense of grandiosity and need for
admiration.

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 CASE NO.1
1. Case History
1.1 Introduction
• Code: GH 1
• Age: 32
• Gender: Male
• Marital Status: Married
• Occupation: Farmer
• Reason for Referral: Bipolar I Disorder, recurrent episode of mania with psychotic features,
following conflict with family members.
• Date of Admission: 29-07-2024
• Date of Examination: 30-07-2024

1.2 History of Present Illness

• Complaints and Symptoms:
o Psychological: Overtalkativeness, decreased need for sleep, impulsivity, aggression, and
high energy levels. GH 1 also displays demanding behavior and has shown persistent
irritability.
o Duration: Symptoms have persisted for 14 years with varying intensity; the current
episode has lasted for 15 days.
• Precipitating Factors: Sudden onset following a conflict with a family member.
• Course of Illness: This episode is characterized by heightened energy, impulsive acts, and
difficulty calming down. Symptoms are consistent with previous manic episodes.

1.3 Psychiatric History

• First Episode: 2010
o Initial diagnosis of a manic episode with psychotic features.
• Subsequent Episodes:
o Second Episode: 2019

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 o Current Episode: Presenting with increased manic symptoms, aggression, and
impulsivity.

1.4 Physical Illness

• Current Health Status: No major medical conditions reported during the current episode.

1.5 Family History

• Mental Health: Family history of psychiatric illness in a sibling.
• Substance Use: No reported substance abuse.
• Cultural Background: Middle-class, Baloch.
• Religious Background: Practicing Muslim.

1.6 Personal History

• Developmental History: No notable developmental delays or issues reported.
• Education and Employment: Completed FA; works as a farmer.
• Social Relationships: Maintains mixed social relationships; interpersonal conflicts have
occasionally led to episodes.
• Marital Status: Married with four children (three daughters and one son).
• Hobbies and Interests: Minimal engagement due to episodic symptoms impacting focus.

2. Mental Status Examination (MSE)

1. Appearance: Appropriately dressed but appears slightly disheveled.
2. Behavior:
o Activity Level: Highly restless and impulsive.
o Interaction: Frequently overtalkative, difficult to interrupt.
3. Speech:
o Speed: Rapid and pressured.
o Volume: Loud, often overwhelming.
4. Mood:
o Self-Reported: Feels "high" or overly excited.
o Observed Mood: Euphoric.

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 5. Affect:
o Range: Broad, fluctuates rapidly.
o Intensity: Intense and difficult to regulate.
6. Thought Process:
o Pattern: Disorganized, jumps quickly from one topic to another.
o Content: Displays persecutory delusions.
7. Thought Content:
o Delusions: Reports feeling targeted or judged by others.
o Concerns: Worries about perceived threats from others.
8. Cognition:
o Awareness: Oriented to time, place, and person.
o Focus: Poor concentration, easily distracted.
o Memory:
▪ Recent: Mild difficulty recalling recent events.
▪ Past: Retains good recall of past events.
9. Insight: Limited insight into his illness.
10. Judgment: Poor, especially during periods of heightened impulsivity.

3. Psychological Testing and Assessment

For GH 1, given his symptoms and diagnosis of Bipolar I Disorder with psychotic features, the most
suitable tests would be:
1. Young Mania Rating Scale (YMRS):
o Purpose: This scale specifically assesses the severity of manic symptoms, such as
elevated mood, increased motor activity, irritability, and pressured speech.
o Relevance: GH 1 exhibits classic manic symptoms like impulsivity, restlessness, and
high energy, making the YMRS an ideal tool to quantify these symptoms and monitor
treatment response.
2. Positive and Negative Syndrome Scale (PANSS):
o Purpose: This scale measures positive symptoms (e.g., delusions), negative symptoms
(e.g., social withdrawal), and general psychopathology.
o Relevance: PANSS is useful for capturing GH 1's psychotic features, such as persecutory
delusions, and for tracking the severity of these symptoms over time.

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 3. Mood Disorder Questionnaire (MDQ):
o Purpose: Screens specifically for symptoms of bipolar spectrum disorders, including
manic and hypomanic episodes.
o Relevance: Given GH 1’s recurrent mood episodes, the MDQ can help confirm the
presence and extent of manic episodes, further supporting the bipolar diagnosis.
4. Brief Psychiatric Rating Scale (BPRS):
o Purpose: Provides a comprehensive assessment of psychiatric symptoms, including
thought disorder, hostility, and emotional withdrawal.
o Relevance: BPRS can offer a broader view of GH 1’s symptom profile, complementing
the YMRS and PANSS by capturing mood symptoms alongside psychotic features.
The YMRS would be the primary test for monitoring manic symptoms, while PANSS would be essential
for evaluating and tracking psychotic symptoms.
1. Young Mania Rating Scale (YMRS) for GH 1
1. Elevated Mood
o Score: 5 (Expansive; inappropriate laughter; frequent talking)
o Rationale: GH 1 shows elevated mood with episodes of expansive behavior, laughing at
inappropriate times, and talking more frequently than usual.
2. Increased Motor Activity-Energy
o Score: 5 (Continuous hyperactivity; difficult to sit still)
o Rationale: GH 1 exhibits continuous restlessness, high energy, and finds it challenging to
remain calm or still.
3. Sleep
o Score: 4 (Severe reduction in sleep)
o Rationale: GH 1 reports a significant reduction in the need for sleep, often sleeping very
little without feeling tired.
4. Irritability
o Score: 6 (Frequently irritable; displays short temper and frustration easily)
o Rationale: GH 1 is consistently irritable, with a low tolerance for frustration, often
leading to short and curt responses.
5. Speech (Rate and Amount)
o Score: 6 (Pressured speech; difficult to interrupt; continuously talking)
o Rationale: His speech is rapid and continuous, making it hard for others to interrupt or
engage in a balanced conversation.
6. Language-Thought Disorder

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 o Score: 4 (Flight of ideas; tangential thoughts)
o Rationale: GH 1 demonstrates flight of ideas, with frequent topic shifts that make his
thoughts difficult to follow.
7. Content
o Score: 5 (Paranoid delusions and grandiose ideas)
o Rationale: GH 1 holds paranoid ideas about being targeted by others and displays
grandiose beliefs about his abilities.
8. Disruptive-Aggressive Behavior
o Score: 5 (Shows aggressive tendencies and demands immediate attention)
o Rationale: GH 1 has demonstrated occasional aggression, making demands of those
around him.
9. Appearance
o Score: 3 (Poorly groomed; disheveled)
o Rationale: His grooming is below normal, and he sometimes appears disheveled.
10. Insight
o Score: 2 (Limited insight; acknowledges behavior change but denies illness)
o Rationale: GH 1 recognizes that his behavior has changed but does not fully accept that
he has an underlying condition.

Total YMRS Score: 45

Interpretation: A score of 45 on the YMRS suggests severe manic symptoms. This score aligns with GH
1’s diagnosis of Bipolar I Disorder with psychotic features, highlighting the need for targeted treatment to
manage his elevated mood, irritability, and psychotic symptoms.

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2. PANSS Scoring for GH 1
• Positive Scale (P1-P7): 6, 5, 5, 5, 4, 5, 4
o Score: 34 (High positive symptoms; persecutory delusions and paranoia)
• Negative Scale (N1-N7): 4, 4, 4, 5, 4, 4, 4
o Score: 29 (Moderate to moderately severe negative symptoms, including social
withdrawal)
• General Psychopathology Scale (G1-G16): 5, 4, 4, 5, 3, 4, 3, 4, 6, 1, 4, 5, 4, 3, 5, 6
o Score: 66 (High general psychopathology symptoms)

Results and Interpretation: PANSS

• Positive Scale: 34 (High positive symptoms)
• Negative Scale: 29 (Moderate to moderately severe negative symptoms)
• General Psychopathology Scale: 66 (High general psychopathology symptoms)
• Total Score: 129 (Severe overall psychopathology)

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Interpretation: GH 1’s PANSS score of 129 indicates severe overall psychopathology, with high
positive symptoms (paranoid delusions, grandiosity) and moderate negative symptoms (social
withdrawal). This score reinforces the need for a treatment plan addressing both manic and psychotic
symptoms.

4. Diagnosis
Symptoms:
• Positive Symptoms: Paranoid delusions, grandiosity, expansive mood, and heightened energy.
• Negative Symptoms: Social withdrawal and inconsistent self-care.
• Mood Symptoms: Intense irritability, flight of ideas, impulsive and aggressive behavior, and
euphoria.
• Behavioral Symptoms: Limited insight, poor decision-making, and demanding behavior.
DSM-5-TR Diagnosis:
• Primary Diagnosis: Bipolar I Disorder, severe manic episode with psychotic features.
• DSM-5-TR Code: 296.44
• ICD-10 Code: F31.2
Differential Diagnosis:
1. Schizoaffective Disorder, Bipolar Type (F25.0):

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 o Reason for Inclusion: The combination of manic symptoms with psychotic features
suggests the potential for schizoaffective disorder.
o Reason for Exclusion: The episodic nature of GH 1’s symptoms, with clear manic
episodes, aligns more closely with Bipolar I Disorder.
2. Borderline Personality Disorder (F60.3):
o Reason for Inclusion: Symptoms of mood instability and impulsive behavior may
suggest borderline traits.
o Reason for Exclusion: GH 1’s symptoms are more episodic and intense, consistent with
manic episodes rather than pervasive personality traits.
3. Generalized Anxiety Disorder (GAD) (F41.1):
o Reason for Inclusion: Persistent restlessness and worry could suggest underlying
anxiety.
o Reason for Exclusion: The intense mood fluctuations and psychotic features are more
aligned with bipolar mania.
Potential Comorbidities:
1. Generalized Anxiety Disorder (GAD) (F41.1):
o Reason for Inclusion: GH 1’s impulsivity and restlessness suggest a possible underlying
anxiety disorder.
o Why it's a possible comorbidity: Addressing anxiety could help manage impulsivity and
irritability during manic episodes.
2. Obsessive-Compulsive Disorder (OCD) (F42.2):
o Reason for Inclusion: Persistent and intrusive thoughts about persecution indicate some
obsessive thinking patterns.
o Why it's a possible comorbidity: Differentiating between obsessive thoughts and
delusional paranoia can help clarify treatment.

5. Treatment Plan
Short-Term Goals:
1. Crisis Management Plan: Develop a structured safety plan to manage impulsivity and
aggression.
2. Psychoeducation for GH 1 and Family: Educate GH 1 and family on Bipolar Disorder, manic
symptoms, and strategies for managing episodes.
3. Mood Stabilization: Begin medication to stabilize mood and reduce manic symptoms.
4. Address Delusions with CBT: Focus on challenging paranoid and grandiose thoughts through
Cognitive Behavioral Therapy.

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 5. Self-Care Routine Development: Create a structured self-care plan to improve personal hygiene,
sleep patterns, and daily structure.
6. Mindfulness and Relaxation Techniques: Introduce relaxation techniques to manage stress and
reduce impulsivity.
7. Family Support: Involve family to create a supportive environment and reinforce coping
strategies.
Long-Term Goals:
1. Achieve and Maintain Mood Stability: Minimize the recurrence of manic or depressive
episodes.
2. Relapse Prevention Plan: Develop personalized strategies to recognize and address early signs
of relapse.
3. Strengthen Social and Family Support: Foster supportive relationships within family and
community.
4. Enhance Self-Awareness and Emotional Regulation: Improve insight into the condition and
develop skills to regulate emotions.
5. Address Possible Comorbidities: Address any underlying anxiety or obsessive traits to improve
overall emotional balance.

6.Therapy Sessions for GH 1

Session 1: Crisis Management and Safety Planning

Goal: Develop a safety plan and establish immediate support strategies.

1. Identifying Triggers and Early Warning Signs

o Therapist (T): "GH 1, let’s discuss situations that often lead to stress or agitation for
you. Are there any recent examples?"
o GH 1 (G): "I get really irritated when people don’t listen or when they try to control me.
It makes me feel disrespected."
o T: "That makes sense. Feeling disrespected or controlled can be very frustrating. Let’s
identify a few steps you could take to feel more in control when that happens."

Urdu Translation:
"GH 1، ‫"آئیں ان حاالت پر بات کریں جو آپ کے لیے تناؤ یا بے چینی کا باعث بنتے ہیں۔ کیا حال ہی میں ایسا کچھ ہوا ہے؟‬
" ‫مجھے غصہ آتا ہے جب لوگ میری بات نہیں سنتے یا مجھے کنٹرول کرنے کی کوشش کرتے ہیں۔ اس سے میں بے عزتی‬
‫"محسوس کرتا ہوں۔‬

2. Creating a Safety Plan

o T: "If you feel agitated, who would be the best person to reach out to for support? This
could be a family member or close friend."
o G: "I can talk to my wife. She usually helps me calm down."
o Plan:

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 ▪ Step 1: Contact his wife for immediate support.
▪ Step 2: Practice deep breathing or read a calming verse from the Quran to help
refocus and ground him.

Urdu Translation:
" ‫اگر آپ کو بے چینی محسوس ہو تو کون سا شخص ہے جس سے آپ فورا ً بات کر سکتے ہیں؟ یہ آپ کی فیملی کا کوئی فرد یا‬
‫"کوئی قریبی دوست ہو سکتا ہے۔‬
‫ فورا ً اپنی بیوی سے بات کریں۔‬:‫پہال قدم‬
‫ گہری سانس لینے کی مشق کریں یا قرآن پاک کی کوئی آیت پڑھیں تاکہ سکون محسوس کریں۔‬:‫دوسرا قدم‬

Homework: GH 1 will identify triggers and follow the safety steps whenever he feels agitated.

Session 2: Family Psychoeducation and Support

Goal: Educate GH 1’s family about his condition and ways to support him.

1. Explaining Bipolar Disorder in Simple Terms

o T (to family): "GH 1 experiences something called Bipolar I Disorder, which means he
has intense mood swings. During certain times, he may feel extremely energetic and even
angry. This can make him act in ways that may feel confusing or even worrying."
o Family Member: "Yes, sometimes it’s hard to understand him, especially when he
seems distant or irritable."
o T: "That’s completely understandable. It’s important to stay calm and provide a
supportive space. GH 1 may not mean to seem distant or irritable, but it’s part of his
mood cycle."

Urdu Translation:
"GH 1 ‫ جس کا مطلب ہے کہ ان کے موڈ میں کبھی کبھی بہت زیادہ اتار چڑھاؤ آتا ہے۔‬،‫بائی پولر ڈس آرڈر کا سامنا کر رہے ہیں‬
‫"کچھ اوقات میں وہ بہت زیادہ توانائی محسوس کر سکتے ہیں اور کبھی کبھار غصے میں بھی آ سکتے ہیں۔‬
"‫ خاص کر جب وہ دور یا چڑچڑے محسوس ہوتے ہیں۔‬،‫ کبھی کبھار انہیں سمجھنا مشکل ہوتا ہے‬،‫"جی ہاں‬

2. Family’s Role in Support

o Example Supportive Phrases:
▪ "If GH 1 seems upset, you could gently say, ‘Let’s take a moment to breathe
together.’ This can help him feel grounded."
o Practice for Family: Remind GH 1 of his breathing exercises or calming verses when he
feels agitated.

Urdu Translation:
"‫ اگر‬GH 1 ‫ ہم اکٹھے کچھ سانسیں لیں۔' اس سے انہیں سکون محسوس‬،‫ 'آئیں‬،‫کو پریشانی محسوس ہو رہی ہو تو آپ کہہ سکتے ہیں‬
‫"ہوگا۔‬
‫ جب‬:‫ پریکٹس‬GH 1 ‫کو بے چینی محسوس ہو تو ان کو سانس لینے کی مشق یا قرآن پاک کی کوئی آیت یاد دالئیں۔‬

Session 3: Managing Delusions through Thought Checking

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Goal: Help GH 1 recognize and challenge his delusional thoughts.

1. Using a Thought Record for Tracking Beliefs

o T: "GH 1, when you feel that people are judging or targeting you, try writing down your
thoughts. Then we’ll work together to find other explanations."
o Example Thought Record:
▪ Thought: “People are talking about me because they think badly of me.”
▪ Alternative Explanation: “Maybe they’re just looking around or talking about
something unrelated.”

Urdu Translation:
" ‫ تو اسے لکھنے کی کوشش کریں۔ پھر ہم اس کا کوئی‬،‫جب آپ کو لگے کہ لوگ آپ کو جانچ رہے ہیں یا آپ کو نشانہ بنا رہے ہیں‬
‫"اور مطلب تالش کرنے کی کوشش کریں گے۔‬
‫ "لوگ میرے بارے میں بات کر رہے ہیں کیونکہ وہ مجھے برا سمجھتے ہیں۔‬:‫"خیال‬
‫ "شاید وہ بس اِدھر اُدھر دیکھ رہے ہیں یا کسی اور موضوع پر بات کر رہے ہیں۔‬:‫"متبادل وضاحت‬

Session 4: Establishing a Self-Care Routine

Goal: Create a structured routine to improve mood stability and self-care.

1. Developing a Morning Routine

o T: "Let’s create a simple morning routine, GH 1. This could include basic steps like
brushing your teeth, washing your face, and dressing in fresh clothes. A routine can help
create a sense of calm and predictability."
o Example Morning Routine:
▪ Step 1: Brush teeth and wash face.
▪ Step 2: Wear fresh clothes.
▪ Step 3: Eat a light breakfast and take a moment to read a calming verse or prayer.

Urdu Translation:
" ‫ چہرہ دھونا اور صاف کپڑے پہننا شامل ہو سکتا ہے۔ یہ معمول‬،‫ ہم ایک سادہ صبح کا شیڈول بنائیں۔ اس میں دانت صاف کرنا‬،‫آئیں‬
‫"آپ کو سکون اور استحکام کا احساس دے گا۔‬
‫مثال‬:
‫ دانت صاف کریں اور چہرہ دھوئیں۔‬:‫پہال قدم‬
‫ صاف کپڑے پہنیں۔‬:‫دوسرا قدم‬
‫ ہلکا ناشتہ کریں اور کوئی پرسکون دعا یا آیت پڑھیں۔‬:‫تیسرا قدم‬

Session 5: Mindfulness Techniques for Impulsivity Management

Goal: Introduce mindfulness techniques to help GH 1 manage impulsive behavior.

1. Practicing a Simple Breathing Exercise

o T: "Let’s try a breathing exercise together, GH 1. Breathe in slowly through your nose,
hold for a moment, then breathe out slowly. This can help calm you down whenever you
feel too much energy."
o Example Practice:

24
 ▪ Step 1: Inhale slowly for 4 counts.
▪ Step 2: Hold the breath for 1 count.
▪ Step 3: Exhale slowly for 4 counts.

Urdu Translation:
" ‫ پھر آہستہ سے سانس باہر‬،‫ ایک لمحے کے لیے روکیں‬،‫ ہم ایک سانس لینے کی مشق کریں۔ ناک سے آہستہ سانس اندر لیں‬،‫آئیں‬
‫"نکالیں۔ جب آپ کو زیادہ توانائی محسوس ہو تو یہ آپ کو سکون دے سکتا ہے۔‬
‫مثال مشق‬:
‫ گنتی تک آہستہ سے سانس اندر لیں۔‬4 :‫پہال قدم‬
‫ ایک لمحے کے لیے روکیں۔‬:‫دوسرا قدم‬
‫ گنتی تک آہستہ سے سانس باہر نکالیں۔‬4 :‫تیسرا قدم‬

Session 6: Family Involvement for Relapse Prevention

Goal: Develop a relapse prevention plan involving family.

1. Identifying Early Signs of Relapse

o T: "Let’s make a list of signs that might appear if symptoms start to come back. GH 1,
what are some signs that you or your family notice when things start feeling difficult
again?"
o Examples of Early Signs:
▪ Increased irritability or agitation.
▪ Decreased sleep or restlessness.
▪ Frequent mood swings or high energy.

Urdu Translation:
" ‫آئیں ہم ان عالمات کی فہرست بنائیں جو اس وقت ظاہر ہو سکتی ہیں جب عالمات دوبارہ آنا شروع ہو جائیں۔ آپ اور آپ کے خاندان‬
‫"کو ایسی کون سی عالمات محسوس ہوتی ہیں جب حاالت مشکل محسوس ہونے لگتے ہیں؟‬
‫مثال عالمات‬:

o‫چڑچڑاہٹ یا بے چینی میں اضافہ۔‬

o‫نیند کی کمی یا بے سکونی۔‬
o‫موڈ کے اتار چڑھاؤ یا زیادہ توانائی۔‬
2. Action Plan for Early Signs
o T: "If any of these signs appear, your family can remind you to follow your routine or
reach out to a therapist early."

Urdu Translation:
" ‫اگر یہ عالمات ظاہر ہوں تو آپ کا خاندان آپ کو معموالت پر عمل کرنے کی یاد دالئے یا جلدی سے معالج سے رابطہ کرنے کا‬
‫"کہے۔‬

Session 7-10: Strengthening Social Interactions and Self-Care

Goal: Reinforce coping techniques, including social engagement.

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 1. Role-Playing Social Scenarios
o T: "Let’s practice how you might greet someone when you’re feeling high-energy. We’ll
keep it calm and friendly. For example, you could say, ‘Hello, I’m GH 1. Nice to meet
you.’"

Urdu Translation:
"‫ میں‬،‫ 'ہیلو‬،‫آئیں ہم یہ مشق کریں کہ جب آپ زیادہ توانائی محسوس کر رہے ہوں تو کسی سے سالم کیسے کریں۔ آپ کہہ سکتے ہیں‬
GH 1 ‫ آپ سے مل کر خوشی ہوئی۔‬،‫"'ہوں‬

Homework: Practice greeting family members in a calm tone and observe how it makes him feel.

7. Case Summary

GH 1, a 32-year-old married farmer, is diagnosed with Bipolar I Disorder, presenting with manic
symptoms and psychotic features. Symptoms include paranoid delusions, elevated mood, grandiosity,
impulsivity, and episodic aggression. Family support and structured self-care are central to managing his
symptoms. Treatment will focus on mood stabilization, cognitive therapy for delusions, and coping tools.
Long-term stability will depend on consistent family involvement and a proactive relapse prevention plan.

26
 CASE NO. 2
1. Case History
1.1 Introduction
• Name (Pseudonym): NA 1
• Age: 56
• Gender: Male
• Marital Status: Married
• Occupation: Teacher (26 years in current job)
• Reason for Referral: Symptoms of Bipolar Disorder, including impulsivity, euphoric mood,
verbal aggression, and visual hallucinations, reported by a family member.
• Date of Admission: 17-08-2024
• Date of Examination: 19-08-2024

1.2 History of Present Illness

• Complaints and Symptoms:
o Physical: Insomnia lasting for two months; cold drink cravings.
o Psychological: Intense religious interest, over-talkativeness, euphoric feelings, verbal
aggression, visual hallucinations, and increased stress response.
• Precipitating Factors: Recent death of a brother (occurred approximately one month before the
escalation of symptoms).
• Duration of Symptoms: Ongoing for several years with episodes of recurrence, latest episode
ongoing for two months.

1.3 Psychiatric History

• First Episode: 1996
o Initial symptoms included mood instability, impulsivity, and aggression.
o Progress: Multiple episodes over the years with fluctuating intensity, requiring episodic
treatment.
• Other Psychiatric Disorders: Episodes of elevated blood pressure reported alongside psychiatric
symptoms, though no distinct treatment history was noted.

27
1.4 Physical Illness
• Reports experiencing multiple instances of recurrent illnesses four times per year (details
unspecified).

1.5 Family History

• Father: Alive, with a history of mania.
• Mother: Deceased.
• Siblings: One sister and four brothers, all deceased.
• Family Psychiatric History: Reports of mania, but no other specific psychiatric disorders or
history of suicide attempts.
• Cultural and Religious Background: Punjabi, practicing Muslim.

1.6 Personal History

• Developmental History: No notable developmental issues reported.
• Education and Employment: Completed a Bachelor of Arts (BA); employed as a teacher for 26
years.
• Social Relationships: Interactions with friends and family appear limited during episodes, with
fluctuating interpersonal relationships.
• Marital Status: Married with one son.
• Personality Traits: Generally social, with fluctuating levels of friendliness and impulsivity.
Describes himself as optimistic but notes impulsive tendencies.

2. Mental Status Examination (MSE)

1. Appearance: Well-groomed and appropriately dressed for the examination.
2. Behavior:
o Activity Level: Restless, impulsive actions noted.
o Facial Expression: Euphoric expressions observed.
3. Speech:
o Speed: Increased rate, often pressured.
o Volume: Loud and over-talkative.
4. Mood:
o Self-Reported: Euphoric and "high."

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 o Observed Mood: Elevated and elated mood.
5. Affect:
o Range: Broad with noticeable intensity.
o Intensity: Sudden shifts to intense excitement.
6. Thought Process:
o Pattern: Disorganized with frequent topic shifts.
o Content: Religious preoccupations and paranoid themes.
o Hallucinations: Reports visual hallucinations.
7. Thought Content:
o Delusions: Paranoid delusions, believing he is being watched.
o Concerns: Persistent religious concerns.
8. Cognition:
o Awareness: Oriented to time, place, and person.
o Memory: Intact for both recent and past events.
9. Insight:
o Self-Awareness: Limited insight into his symptoms.
10. Judgment:
• Decision-Making: Impulsive and often unwise.

3. Psychological Testing and Assessment

Based on NA's symptoms, the following tests are recommended:
1. Mood Disorder Questionnaire (MDQ): Screening for bipolar symptoms.
2. Positive and Negative Syndrome Scale (PANSS): To assess severity of psychotic features.
3. Young Mania Rating Scale (YMRS): To gauge intensity of manic symptoms.
4. Wechsler Adult Intelligence Scale (WAIS): To assess cognitive baseline.
5. Personality Assessment Inventory (PAI): For a comprehensive personality profile.
Young Mania Rating Scale (YMRS) Scoring
Based on his symptoms of elevated mood, impulsivity, verbal aggression, sleep issues, and euphoric
episodes, here’s a possible scoring:
1. Elevated Mood:

29
 o Score: 4 (Euphoric; inappropriate laughter; singing)
o Rationale: Nazeer experiences euphoric moods and religious enthusiasm, showing signs
of elevated mood with inappropriate reactions at times.
2. Increased Motor Activity-Energy:
o Score: 4 (Motor excitement; continuous hyperactivity, cannot be calmed)
o Rationale: He is described as restless and impulsive, showing difficulty in calming
down.
3. Sleep:
o Score: 4 (Reports decreased need for sleep)
o Rationale: Nazeer has had insomnia for two months, a common sign of manic episodes.
4. Irritability:
o Score: 5 (Frequently irritable; short-tempered throughout the examination)
o Rationale: Displays verbal aggression and irritable behaviors, particularly during manic
episodes.
5. Speech (Rate and Amount):
o Score: 5 (Increased rate and amount, difficult to interrupt)
o Rationale: His speech is pressured, loud, and over-talkative, indicating manic speech
patterns.
6. Language-Thought Disorder:
o Score: 4 (Flight of ideas; tangentiality; difficult to follow)
o Rationale: Shows disorganized thoughts, shifting quickly from topic to topic, with
religious delusions.
7. Content:
o Score: 5 (Paranoid ideas; religious delusions)
o Rationale: Experiences paranoid thoughts and believes others are watching him,
combined with intense religious preoccupations.
8. Disruptive-Aggressive Behavior:
o Score: 4 (Demanding; occasional verbal threats)
o Rationale: Verbal aggression and irritability are noted, with occasional threats though not
physically aggressive.
9. Appearance:
o Score: 2 (Moderately disheveled; slightly inappropriate clothing)

30
 o Rationale: He appears generally well-groomed but occasionally disheveled, reflecting
impulsive self-care habits during episodes.
10. Insight:
o Score: 3 (Limited insight into illness)
o Rationale: Lacks full awareness of his symptoms, indicative of limited insight.
Total YMRS Score: 36
• Interpretation: A score of 36 suggests severe manic symptoms, aligning with a manic episode
and supporting the Bipolar I Disorder diagnosis.

Positive and Negative Syndrome Scale (PANSS) Scoring

This scoring reflects Nazeer's psychotic symptoms, such as visual hallucinations and paranoid delusions.
1. Positive Scale (P1-P7):
o P1 (Delusions): 6 (Severe; paranoid and religious delusions)
o P2 (Conceptual Disorganization): 5 (Moderate to severe disorganized thought patterns)
o P3 (Hallucinatory Behavior): 5 (Moderate severity; visual hallucinations)
o P4 (Excitement): 5 (Moderate to severe; elevated mood and euphoria)
o P5 (Grandiosity): 4 (Moderate grandiosity related to religious beliefs)

31
 o P6 (Suspiciousness/Persecution): 6 (Severe suspiciousness)
o P7 (Hostility): 4 (Moderate verbal aggression)
Positive Scale Total: 35
Interpretation: Indicates high positive symptoms, confirming the presence of severe psychotic features.
2. Negative Scale (N1-N7):
o N1 (Blunted Affect): 3 (Mild; occasional restricted affect)
o N2 (Emotional Withdrawal): 4 (Moderate withdrawal from social interactions)
o N3 (Poor Rapport): 3 (Mild to moderate, due to fluctuating sociability)
o N4 (Passive Social Withdrawal): 4 (Moderate withdrawal)
o N5 (Difficulty in Abstract Thinking): 3 (Mild difficulty, especially with religious
preoccupations)
o N6 (Lack of Spontaneity and Flow of Conversation): 3 (Moderate due to occasional
impulsive speech patterns)
o N7 (Stereotyped Thinking): 4 (Moderate repetitive thoughts, especially religious)
Negative Scale Total: 24
Interpretation: Indicates moderate negative symptoms, showing some level of social withdrawal and
thought restriction.
3. General Psychopathology Scale (G1-G16):
o Selected items:
▪ G1 (Somatic Concern): 3 (Moderate; includes reported physical symptoms)
▪ G2 (Anxiety): 4 (Moderate to severe anxiety)
▪ G3 (Guilt Feelings): 3 (Moderate; guilt related to religious beliefs)
▪ G4 (Tension): 4 (Moderate to severe restlessness and stress)
▪ G9 (Unusual Thought Content): 5 (Severe religious and paranoid delusions)
▪ G12 (Lack of Judgment and Insight): 4 (Moderate lack of insight)
▪ G16 (Active Social Avoidance): 4 (Moderate social avoidance during episodes)
General Psychopathology Total: 56
Interpretation: Indicates high general psychopathology symptoms.
PANSS Total Score: 115
• Interpretation: This score indicates severe overall psychopathology, aligning with Nazeer's
symptoms of Bipolar I Disorder with psychotic features.

32
Summary of Results
• YMRS Score: 36 – Indicates severe mania.
• PANSS Total Score: 115 – Indicates severe psychotic symptoms.
These scores together substantiate the diagnosis of Bipolar I Disorder with severe manic and psychotic
features, validating the need for a focused treatment plan targeting both mood stabilization and
management of psychotic symptoms.
4. Diagnosis
Symptoms:
• Positive Symptoms: Paranoid delusions, religious preoccupations, visual hallucinations,
euphoric mood, and pressured speech.
• Negative Symptoms: Social withdrawal, emotional restriction, and occasional difficulties in
maintaining rapport.
• Mood Symptoms: Impulsivity, irritability, insomnia, and verbal aggression.
• Behavioral Symptoms: Lack of insight, aggressive behavior, poor judgment, and intermittent
self-care.
DSM-5-TR Diagnosis:
• Primary Diagnosis: Bipolar I Disorder, current manic episode with psychotic features.

33
 • DSM-5-TR Code: 296.44
• ICD-10 Code: F31.2
Differential Diagnosis:
1. Schizoaffective Disorder, Bipolar Type (F25.0):
o Reason for Inclusion: Nazeer’s presentation includes both mood (euphoric and
impulsive) and psychotic symptoms (delusions and hallucinations), which may indicate
schizoaffective disorder.
o Reason for Exclusion: The distinct manic episodes with episodic psychotic symptoms
align more with Bipolar I Disorder, as schizoaffective disorder often presents with
continuous psychotic symptoms outside mood episodes.
2. Borderline Personality Disorder (F60.3):
o Reason for Inclusion: Symptoms like impulsivity, unstable relationships, and emotional
volatility can suggest borderline personality disorder.
o Reason for Exclusion: Nazeer’s symptoms, particularly the clear episodic pattern with
psychotic features during manic episodes, are more indicative of Bipolar I Disorder.
3. Post-Traumatic Stress Disorder (PTSD) (F43.1):
o Reason for Inclusion: Recent bereavement could have contributed to emotional distress.
o Reason for Exclusion: Nazeer’s symptoms are more characteristic of mood instability
rather than typical PTSD features such as flashbacks or hyperarousal.

Potential Comorbidities
1. Generalized Anxiety Disorder (GAD) (F41.1):
o Reason for Inclusion: Nazeer shows signs of persistent worry, restlessness, and
irritability, which are consistent with generalized anxiety symptoms.
o Why It’s a Possible Comorbidity: Anxiety could exacerbate his paranoia and stress,
which may in turn trigger impulsive or aggressive outbursts.
2. Somatic Symptom Disorder (F45.1):
o Reason for Inclusion: Reports of multiple recurring physical symptoms, such as cold
drink cravings and sleep disturbances, may point to a somatic disorder.
o Why It’s a Possible Comorbidity: These physical symptoms could be related to his
mood disorder, as individuals with mood instability sometimes experience somatic
symptoms.
5. Treatment Plan
Short-Term Goals:

34
 1. Mood Stabilization: Initiate medication to stabilize mood and reduce manic symptoms, such as a
mood stabilizer (e.g., lithium or valproate) or an antipsychotic (e.g., olanzapine or risperidone).
2. Crisis Management and Safety Planning: Establish a crisis plan to manage aggressive or
impulsive behaviors, including a support system for immediate help during intense episodes.
3. Reduce Delusional Thinking: Use cognitive behavioral techniques to challenge delusions,
particularly related to paranoia and religious beliefs.
4. Establish a Sleep Routine: Improve sleep hygiene to counter insomnia, with specific sleep
habits and possible medication support for restful sleep.
5. Psychoeducation for Family: Educate family members on Nazeer’s condition and provide them
with tools to help manage symptoms and provide support.
Long-Term Goals:
1. Achieve and Maintain Mood Stability: Focus on long-term medication management and
therapy to prevent manic episodes and reduce psychotic features, aiming for sustained mood
stability.
2. Strengthen Family and Social Support Systems: Encourage involvement from family and
friends, ensuring Nazeer has a support network that can recognize early signs of relapse and
provide emotional stability.
3. Enhance Insight and Self-Awareness: Increase Nazeer’s understanding of his condition and
teach emotional regulation skills to help him recognize symptoms early and respond
appropriately.
4. Develop Coping Mechanisms for Anxiety and Aggression: Equip Nazeer with relaxation
techniques and coping skills to manage anxiety and reduce irritability, helping him maintain self-
control during triggering situations.
5. Build Consistent Self-Care Habits: Encourage a structured daily routine, with self-care
practices that include regular sleep, exercise, and mindfulness to enhance his overall well-being.
6.Therapy Sessions
Session 1: Crisis Management and Safety Planning
• Goal: Establish a safety plan to manage impulsive or aggressive behaviors.
• Objectives:
o Identify personal triggers and early warning signs.
o Develop a structured crisis response plan with actionable steps.
• Session Details:
1. Identifying Triggers and Early Warning Signs:
▪ Therapist (T): "Nazeer, let’s identify situations that make you feel agitated or
upset. For example, is there anything specific that you notice before you start to
feel tense?"

35
 ▪ Nazeer (N): "I get worked up when people stare at me, or when I’m alone for too
long."
▪ Urdu Translation: " ‫ آئیں ہم ان حاالت کی نشاندہی کریں جو آپ کو پریشان یا بے چین‬،‫نذیر‬
‫ کیا آپ کو کچھ خاص محسوس ہوتا ہے جو آپ کو پریشان‬،‫محسوس کراتے ہیں۔ مثال کے طور پر‬
‫"کرتا ہے؟‬
2. Creating a Safety Plan:
▪ T: "Let’s create a safety plan. When you feel overwhelmed, who can you reach
out to? This could be family members or close friends."
▪ N: "I can call my son or a friend when I feel this way."
▪ Plan:
▪ Step 1: Contact a support person (son or close friend).
▪ Step 2: Practice breathing exercises or recite a calming prayer.
▪ Urdu Translation: " ‫جب آپ کو پریشانی محسوس ہو تو اس حفاظتی منصوبے پر عمل‬
‫کریں‬:
▪ ‫ کسی سپورٹ پرسن سے رابطہ کریں جیسے کہ بیٹا یا دوست۔‬:‫پہال قدم‬
▪ ‫ گہری سانس لینے کی مشق کریں یا کوئی پرسکون دعا پڑھیں۔‬:‫"دوسرا قدم‬

Session 2: Psychoeducation for Family Involvement

• Goal: Educate Nazeer’s family on Bipolar Disorder and empower them to provide effective
support.
• Objectives:
o Explain the symptoms and impact of Bipolar I Disorder with psychotic features.
o Train family members on supportive communication techniques.
• Session Details:
1. Explaining Bipolar Disorder in Simple Terms:
▪ T (to Family): "Nazeer has Bipolar I Disorder, which means he sometimes has
extreme highs and lows in his mood. These changes affect his thoughts and
behavior. Your support and understanding are very helpful for him."
▪ Urdu Translation: " ‫ جس کا مطلب ہے کہ اس کے جذبات میں‬،‫نذیر کو بائی پولر ڈس آرڈر ہے‬
‫"کبھی کبھار اتار چڑھاؤ آتے ہیں۔ آپ کی سمجھ بوجھ اور مدد اس کے لیے بہت مفید ہو سکتی ہے۔‬
2. Family’s Role in Support:
▪ T: "When Nazeer seems agitated, a calm approach is very helpful. Try gentle
reminders like, ‘Let’s take a few deep breaths together,’ or ‘Let’s talk this through
calmly.’"

36
 ▪ Example for Family: "If Nazeer feels anxious, you could say, ‘Let’s sit down
and take a few breaths together.’ This helps him feel supported and calms him
down."
▪ Urdu Translation: " ‫ 'آئیں ہم‬،‫اگر نذیر کو بے چینی محسوس ہو رہی ہو تو آپ کہہ سکتے ہیں‬
‫"اکٹھے بیٹھ کر چند گہری سانسیں لیں۔' اس سے اسے سکون محسوس کرنے میں مدد ملتی ہے۔‬

Session 3: Managing Delusions through Cognitive Restructuring

• Goal: Help Nazeer recognize and challenge his delusional thoughts.
• Objectives:
o Introduce a thought record to track delusional beliefs.
o Practice re-evaluating paranoid thoughts with alternative explanations.
• Session Details:
1. Using a Thought Record for Tracking Beliefs:
▪ T: "Nazeer, when you feel that people are watching or judging you, try writing it
down. Then, we can work together to look for other explanations."
▪ Example Thought Record:
▪ Thought: "People at the market are staring because they think I’ve done
something wrong."
▪ Alternative Explanation: "Maybe they’re just looking around. It’s not
about me."
▪ Urdu Translation: " ‫جب آپ کو لگے کہ لوگ آپ کو دیکھ رہے ہیں یا آپ کے بارے میں سوچ‬
‫ تو اسے لکھ لیں۔ پھر ہم اس کا متبادل خیال تالش کریں گے‬،‫رہے ہیں‬:
▪ ‫ 'لوگ مجھے دیکھ رہے ہیں کیونکہ وہ سمجھتے ہیں کہ میں نے کچھ غلط کیا ہے۔‬:‫'خیال‬
▪ ‫ 'شاید وہ صرف اِدھر اُدھر دیکھ رہے ہیں اور یہ میرے بارے میں نہیں‬:‫متبادل وضاحت‬
‫"'ہے۔‬

Session 4: Mood Stabilization through Structured Self-Care

• Goal: Establish a structured daily routine to improve mood stability and daily functioning.
• Objectives:
o Create a morning and evening routine to support self-care and sleep hygiene.
• Session Details:
1. Developing a Morning and Evening Routine:

37
 ▪ T: "Let’s plan a simple routine that you can follow each morning and evening.
This will help keep you grounded and manage your mood."
▪ Example Morning Routine:
▪ Step 1: Brush teeth, wash face, and wear fresh clothes.
▪ Step 2: Have a light breakfast and do a short breathing exercise.
▪ Urdu Translation: "‫آئیں ہم ایک سادہ صبح کا شیڈول بنائیں‬:
▪ ‫ اور صاف کپڑے پہنیں۔‬،‫ منہ دھوئیں‬،‫ دانت برش کریں‬:‫پہال قدم‬
▪ ‫ ہلکا ناشتہ کریں اور کچھ گہری سانسیں لیں۔‬:‫"دوسرا قدم‬

Session 5: Mindfulness Techniques for Impulsivity Management

• Goal: Teach mindfulness techniques to help Nazeer manage impulsive behaviors during high-
energy phases.
• Objectives:
o Practice breathing exercises to manage impulsive thoughts.
o Encourage mindfulness in recognizing physical signs of agitation.
• Session Details:
1. Breathing Exercise:
▪ T: "Let’s practice a breathing exercise. Slowly breathe in through your nose, hold
it for a second, then breathe out through your mouth. This can help you feel calm
when you’re feeling impulsive."
▪ Example Practice:
▪ Step 1: Inhale slowly for a count of 4.
▪ Step 2: Hold for 1 count.
▪ Step 3: Exhale slowly for a count of 4.
▪ Urdu Translation: "‫آئیں ہم ایک سانس لینے کی مشق کریں‬:
▪ ‫ گنتی تک سانس اندر لیں۔‬4 :‫پہال قدم‬
▪ ‫ ایک لمحے کے لیے سانس روکیں۔‬:‫دوسرا قدم‬
▪ ‫ گنتی تک سانس باہر نکالیں۔‬4 :‫"تیسرا قدم‬
2. Mindfulness of Physical Sensations:
▪ T: "Notice any physical signs, like a fast heartbeat or tightness. This can be a
signal for you to pause and take a few breaths."

38
 ▪ Urdu Translation: " ‫اپنے جسمانی احساسات کو محسوس کریں جیسے کہ دل کی دھڑکن تیز‬
‫"ہونا۔ یہ آپ کے لیے ایک اشارہ ہو سکتا ہے کہ آپ توقف کریں اور چند گہری سانسیں لیں۔‬

Session 6: Family Meeting for Relapse Prevention Planning

• Goal: Develop a relapse prevention plan with family involvement to manage early signs of
relapse.
• Objectives:
o Identify early warning signs of symptom recurrence.
o Create a family-supported action plan for responding to early signs.
• Session Details:
1. Identifying Early Signs of Relapse:
▪ T (to Nazeer and Family): "Let’s make a list of signs that may appear if
symptoms start to return, like feeling extra irritable or sleeping less."
▪ Example Early Signs:
▪ Increased irritability or impatience.
▪ Reduced need for sleep.
▪ Sudden, unexplained excitement.
▪ Urdu Translation: " ،‫ہم ابتدائی عالمات کی فہرست بنائیں گے جو دوبارہ ظاہر ہو سکتی ہیں‬
‫"جیسے کہ زیادہ چڑچڑاہٹ یا کم نیند۔‬
2. Developing an Action Plan for Early Signs:
▪ T: "If these signs appear, your family can gently remind you to stick to your
routine or reach out for help."
▪ Urdu Translation: " ‫ تو آپ کے فیملی ممبران آپ کو اپنے معموالت‬،‫اگر یہ عالمات ظاہر ہوں‬
‫"پر عمل کرنے یا معالج سے رابطہ کرنے کی یاد دہانی کروا سکتے ہیں۔‬

Sessions 7-10: Strengthening Coping Strategies and Family Support

• Goal: Reinforce coping strategies and provide family guidance for ongoing support.
• Objectives:
o Role-play common social scenarios to strengthen social skills.
o Encourage supportive family responses to Nazeer’s stress or anxiety.
• Session Details:

39
 o Example Practice: Role-play a scenario where Nazeer feels anxious in public. He
practices introducing himself calmly to a new person.
o Response Practice: Family members practice using calm phrases like,
•

o “Let’s talk this through,” if Nazeer appears agitated.

o Urdu Translation: " ‫ایک منظرنامے کی مشق کریں جہاں نذیر کو بے چینی محسوس ہو رہی ہو۔ فیملی کو‬
‫"پرسکون رہ کر بات کو سمجھانے کی مشق کروائی جائے۔‬

Sessions 11-15: Emotional Regulation and Relapse Prevention

• Goal: Build emotional regulation skills and finalize a relapse prevention toolkit.
• Objectives:
o Use journaling to increase emotional awareness.
o Establish a list of coping strategies Nazeer can rely on during distress.
• Session Details:
1. Journaling for Emotional Awareness:
▪ T: "When you feel strong emotions, try writing them down. This helps you see
patterns and understand triggers."
▪ Example Journal Entry:
▪ Emotion: “I felt very angry when my son didn’t call me back.”
▪ Possible Reason: “I feel worried he doesn’t want to talk.”
▪ Urdu Translation: " ‫جب آپ کو شدید جذبات محسوس ہوں تو انہیں لکھنے کی کوشش کریں۔ یہ‬
‫"آپ کو پیٹرن اور محرکات کو سمجھنے میں مدد دیتا ہے۔‬
2. Creating a Coping Toolkit:
▪ T: "Let’s make a list of activities you can turn to when you feel symptoms
returning, like breathing exercises or calling a family member."
▪ Example Coping Toolkit:
▪ Activity 1: Breathing exercises.
▪ Activity 2: Calling a family member.
▪ Urdu Translation: " ‫ایک فہرست بنائیں جس میں آپ ایسی سرگرمیاں شامل کریں جو‬
‫"آپ عالمات کے واپس آنے پر کر سکتے ہیں۔‬

40
7. Case Summary
NA, a 56-year-old male, is diagnosed with Bipolar I Disorder, current manic episode with psychotic
features. His symptoms include elevated mood, paranoia, visual hallucinations, and religious
preoccupations, likely intensified by a recent bereavement. The treatment plan involves mood
stabilization, family education, and structured therapy to improve self-awareness, impulse control, and
social skills.

41
 CASE NO. 3
1. Case History
1.1 Introduction
• Name (Pseudonym): MK 1
• Age: 28
• Gender: Male
• Marital Status: Married
• Occupation: Farmer
• Reason for Referral: Detoxification due to alcohol dependence, aggression, poor appetite, and
hallucinations.
• Date of Admission: 19-03-2024, 8:30 AM
• Date of Examination: 20-03-2024

1.2 History of Present Illness

• Complaints and Symptoms:
o Psychological: Dependence on alcohol, auditory hallucinations, aggression, and
disrupted sleep.
o Physical: Poor appetite, dry mouth, and stomach issues.
• Precipitating Factors: Influence of social circle and unresolved family conflicts.
• Duration of Symptoms: Approximately six months, with progressive worsening.

1.3 Psychiatric History

• First Episode: One instance of using "bhang" (a cannabis-based substance), resulting in a mild
reaction but without ongoing dependency.
• Other Mental Health Issues: Persistent alcohol use, aggression, and hallucinations.

1.4 Physical Illness

• Gastrointestinal Issues: Reports of stomach problems likely related to poor dietary habits and
alcohol use.

42
1.5 Family History
• Father: Deceased due to an accident.
• Mother: Alive and in good health.
• Siblings: Conflicts noted with stepmother and stepbrothers; the family has experienced instances
of addiction.
• Family Psychiatric History: No major psychiatric issues reported, though the family has a
history of alcohol use.

1.6 Personal History

• Developmental History: Normal developmental milestones reported, with no major physical or
cognitive concerns.
• Education and Employment: Illiterate; has been a farmer for 12 years, holding stable
employment.
• Social Relationships: Conflicted relationship with stepfamily and ongoing conflicts with family
members. Generally sociable but has issues with impulsive behavior and aggressive tendencies.
• Personality Traits: Introverted and impulsive, with periods of aggression likely exacerbated by
alcohol use. Described as dependent on others for emotional support.

2. Mental Status Examination (MSE)

1. Appearance: Disheveled, indicative of neglect in personal care.
2. Behavior:
o Activity Level: Displays signs of restlessness and impulsive actions.
o Facial Expression: Often appears aggressive.
3. Speech:
o Speed: Rapid and occasionally pressured.
o Volume: Tends to be loud and assertive.
4. Mood:
o Self-Reported: Reports irritability and mood swings.
o Observed Mood: Periodic agitation and restlessness.
5. Affect:
o Range: Limited and constricted, often reflecting frustration.

43
 o Intensity: Moderate, with occasional intensification during discussions about family or
drinking.
6. Thought Process:
o Pattern: Tangential with occasional blocking.
o Content: Auditory hallucinations and preoccupation with family conflicts.
7. Thought Content:
o Delusions: Mild persecutory thoughts about stepfamily members.
o Concerns: Persistent feelings of neglect and frustration with his family situation.
8. Cognition:
o Awareness: Oriented to time, place, and person.
o Memory: Generally intact for recent and remote events.
9. Insight:
o Self-Awareness: Limited insight into the impact of alcohol on his health and behavior.
10. Judgment:
• Decision-Making: Poor, especially regarding alcohol consumption and social interactions.

3. Psychological Testing and Assessment

For Muhammad Kaleem, given his alcohol dependence, aggressive tendencies, and hallucinations, the
following assessments are appropriate:
1. Alcohol Use Disorders Identification Test (AUDIT): To evaluate the severity of alcohol use and
identify harmful drinking patterns.
2. Brief Psychiatric Rating Scale (BPRS): To assess the presence and severity of symptoms such
as hallucinations, aggression, and disorganized thinking.
AUDIT Scoring for MK

Question Score

1. How often do you have a drink containing alcohol? 4

Rationale: Kaleem drinks almost daily, indicative of severe frequency in alcohol consumption.

2. How many units of alcohol do you drink on a typical day when you are drinking? 4

Rationale: His alcohol intake is likely high per session, around 10 or more units per day.

3. How often have you had 6 or more units on a single occasion in the last year? 4

44
Question Score

Rationale: Reports indicate regular binge drinking, with 6+ units consumed nearly every time he
drinks.

4. How often during the last year have you found that you were not able to stop drinking once
4
you had started?

Rationale: He regularly struggles to stop drinking once he begins, showing significant difficulty
with control.

5. How often during the last year have you failed to do what was normally expected from you
3
because of your drinking?

Rationale: Monthly difficulties in fulfilling responsibilities due to alcohol use, impacting both
work and family.

6. How often during the last year have you needed an alcoholic drink in the morning to get
3
yourself going?

Rationale: He occasionally drinks in the morning to manage withdrawal symptoms, indicating

dependence.

7. How often during the last year have you had a feeling of guilt or remorse after drinking? 3

Rationale: Experiences monthly guilt or regret about his drinking, especially concerning its impact
on family.

8. How often during the last year have you been unable to remember what happened the
3
night before because you had been drinking?

Rationale: Reports monthly blackouts, unable to recall events after heavy drinking.

9. Have you or somebody else been injured as a result of your drinking? 2

Rationale: There have been instances of harm or injury due to his drinking, though not within the
last year.

10. Has a relative or friend, doctor, or other health worker been concerned about your
4
drinking or suggested you cut down?

Rationale: Family has recently shown significant concern and encouraged him to reduce his
alcohol intake.

Total AUDIT Score: 34

Interpretation

45
A Total AUDIT score of 34 indicates a severe level of alcohol dependence with a high risk of harm.
This score confirms that Kaleem’s alcohol use is beyond social drinking levels, resulting in impaired
control, dependency, and family conflict. The high score justifies a treatment plan focused on
detoxification, addressing alcohol-related behaviors, and involving family support to prevent relapse.

BPRS Scoring for Muhammad Kaleem

Item Description Score Rationale

Degree of concern over Reports issues with appetite and dry mouth,
1. Somatic Concern 3
bodily health. likely related to alcohol use and stress.

Worry or fear over Expresses moderate anxiety about his family

2. Anxiety 4
present or future. conflicts and future due to dependency issues.

3. Emotional Deficiency in relating to Mild withdrawal observed, likely influenced by

3
Withdrawal others. ongoing family issues and substance use.

Mild disorganization noted; some tangential

4. Conceptual Disorganized thought
2 thinking during discussions about family
Disorganization processes.
conflicts.

Remorse or concern for Occasionally expresses guilt about his impact

5. Guilt Feelings 3
past behavior. on family due to drinking.

Physical manifestations Moderate physical tension observed, including

6. Tension 4
of nervousness. restlessness and irritability during the interview.

46
Item Description Score Rationale

7. Mannerisms and Unusual motor behaviors Some mild mannerisms and restlessness
2
Posturing or mannerisms. observed, likely due to withdrawal and anxiety.

Shows mild signs of exaggerated confidence,

Exaggerated self-
8. Grandiosity 2 likely when discussing his role within the
opinion.
family.

Mild depressive symptoms, especially when

Despondency or sadness
9. Depressive Mood 3 discussing family issues and dependency
in mood.
struggles.

Animosity or
Moderately severe hostility noted, particularly
10. Hostility belligerence towards 5
toward stepfamily; reports verbal aggression.
others.

Suspicion of others’ Holds moderately severe suspicions about his

11. Suspiciousness 5
intent. stepfamily, contributing to family conflicts.

12. Hallucinatory Perceptions without Reports moderate auditory hallucinations,

4
Behavior stimulus. possibly worsened by alcohol use and stress.

Reduction in energy or Mild motor retardation at times, linked to poor

13. Motor Retardation 2
slowed movements. physical health and alcohol use.

Moderately uncooperative during questioning,

Resistance or lack of
14. Uncooperativeness 4 especially on topics related to alcohol
cooperation.
dependence.

Displays mild unusual thoughts, occasionally

15. Unusual Thought
Odd or bizarre thoughts. 3 expressing irrational beliefs about his family
Content
dynamics.

Mild reduction in affect; emotions appear

16. Blunted Affect Reduced emotional tone. 3
restrained in response to personal matters.

Moderate excitement observed, with occasional

Heightened emotional
17. Excitement 4 bursts of agitation, especially around family
tone or agitation.
discussions.

Generally oriented, but very mild confusion at

Confusion regarding
18. Disorientation 1 times, possibly due to alcohol use and
person, place, or time.
withdrawal effects.

Total BPRS Score: 59

47
Interpretation
A BPRS score of 59 indicates moderate to severe psychiatric symptoms, aligning with Kaleem’s
diagnosis of Alcohol Use Disorder with dependence and associated psychiatric challenges, including
hostility, hallucinations, and anxiety. The score reflects significant impact on his mental state, suggesting
the need for structured treatment focusing on detoxification, management of aggression, and support for
improved emotional regulation.

4. Diagnosis
Symptoms:
• Substance Use Symptoms: Severe alcohol dependence with daily use, frequent binges, and
inability to stop once started.
• Psychological Symptoms: Moderate to severe aggression, auditory hallucinations, suspicion
toward family, irritability, and emotional withdrawal.
• Physical Symptoms: Poor appetite, dry mouth, and gastrointestinal issues, potentially related to
both alcohol use and stress.
DSM-5-TR Diagnosis:
• Primary Diagnosis: Alcohol Use Disorder, Severe, with Dependence
• DSM-5-TR Code: 303.90
• ICD-10 Code: F10.24 (Alcohol Dependence with Withdrawal Symptoms)
Differential Diagnosis:

48
 1. Psychotic Disorder Due to Alcohol (F10.251):
o Reason for Inclusion: Hallucinations, suspicions, and occasional disorganized thought
processes suggest psychotic features linked to alcohol use.
o Reason for Exclusion: Symptoms are primarily related to his alcohol dependence and
are anticipated to diminish with treatment.
2. Generalized Anxiety Disorder (F41.1):
o Reason for Inclusion: Ongoing anxiety about family and future due to dependency.
o Reason for Exclusion: Anxiety is directly related to substance use and family dynamics
rather than a separate anxiety disorder.
Potential Comorbidities:
1. Personality Disorder (Unspecified, F60.9):
o Reason for Inclusion: Shows signs of impulsivity, aggression, and distrust in family
relationships, possibly exacerbated by prolonged alcohol use.
o Why It’s a Possible Comorbidity: Personality traits may impact treatment response and
require tailored therapeutic strategies.

5. Treatment Plan
Short-Term Goals:
1. Detoxification and Withdrawal Management:
o Initiate a medically supervised detox program to manage physical symptoms and
cravings associated with alcohol withdrawal.
2. Aggression and Impulse Control Techniques:
o Employ cognitive-behavioral techniques to manage anger, prevent outbursts, and
establish coping strategies for irritability.
3. Family Education and Involvement:
o Engage family members in the therapeutic process to promote understanding and
minimize conflict at home.
4. Address Hallucinatory and Suspicious Thoughts:
o Use therapeutic techniques to reduce hallucinations and challenge suspicious beliefs.
5. Establish Consistent Daily Routine:
o Set a structured daily schedule, including self-care routines, sleep hygiene, and relaxation
activities, to support his recovery.
Long-Term Goals:

49
 1. Achieve and Maintain Sobriety:
o Through continued therapy and family support, aim for long-term abstinence and
improved quality of life.
2. Improve Emotional Regulation and Coping Skills:
o Equip Kaleem with tools to manage stress and prevent aggressive behaviors without
relying on alcohol.
3. Strengthen Family Relationships:
o Work on communication and trust-building exercises to improve relationships with
family members and reduce conflict.
4. Build Self-Awareness and Insight:
o Develop insight into the consequences of alcohol use on his mental health and social
relationships, fostering long-term behavioral change.
5. Relapse Prevention and Support Network:
o Develop a relapse prevention plan and connect with community or support groups for
ongoing motivation.

6. Therapy Sessions
Session 1: Detoxification and Initial Support
• Goal: Prepare Kaleem for the detox process and manage initial withdrawal symptoms with
support.
• Objectives:
o Educate Kaleem on detoxification steps and provide emotional support for this
transitional phase.
• Session Details:
1. Explaining Detox and Withdrawal Symptoms:
▪ Therapist (T): "Kaleem, during detox, you may experience some withdrawal
symptoms like irritability and cravings. We’re here to help you through it."
▪ Urdu Translation: " ‫ ڈیٹاکس کے دوران آپ کو کچھ عالمات جیسے چڑچڑاہٹ اور‬،‫کلیم‬
‫"خواہشات کا سامنا ہوسکتا ہے۔ ہم اس میں آپ کا ساتھ دیں گے۔‬
2. Identifying Family Support Contacts:
▪ T: "Is there someone in your family who can help support you during this
period?"
▪ Urdu Translation: " ‫کیا آپ کے خاندان میں کوئی ہے جو اس عرصے کے دوران آپ کا ساتھ‬
‫"دے سکتا ہے؟‬

50
Session 2: Family Psychoeducation and Conflict Resolution
• Goal: Educate Kaleem’s family about alcohol dependence and improve family dynamics.
• Objectives:
o Explain alcohol dependence effects on mental health and provide strategies for reducing
conflict at home.
• Session Details:
1. Understanding Alcohol Dependence and its Effects:
▪ T (to Family): "Kaleem’s alcohol use affects his behavior, leading to irritability
and aggression. Understanding this can help you support him better."
▪ Urdu Translation: " ‫ جس کی وجہ سے‬،‫کلیم کا شراب نوشی ان کے رویے کو متاثر کرتی ہے‬
‫"وہ چڑچڑاہٹ اور جارحیت کا مظاہرہ کرتے ہیں۔ اس کو سمجھنا آپ کے لئے فائدہ مند ثابت ہوگا۔‬
2. Encouraging Supportive Communication:
▪ T: "Try to approach him calmly when discussing sensitive topics. Avoid
arguments and encourage him to share his feelings."
▪ Urdu Translation: " ‫جب حساس موضوعات پر بات کریں تو پرسکون انداز اپنائیں۔ جھگڑوں‬
‫"سے بچیں اور انہیں اپنی باتیں بانٹنے کی حوصلہ افزائی کریں۔‬

Session 3: Cognitive-Behavioral Techniques for Aggression and Suspicion

• Goal: Address Kaleem’s aggressive tendencies and challenge suspicious thoughts.
• Objectives:
o Identify triggers for aggressive behavior and teach thought-challenging techniques.
• Session Details:
1. Identifying Triggers for Aggression:
▪ T: "Kaleem, let’s talk about situations that make you feel angry. Can you identify
when you’re most likely to become aggressive?"
▪ Urdu Translation: " ‫ آئیں ان حاالت پر بات کریں جو آپ کو غصے میں التے ہیں۔ کیا آپ‬،‫کلیم‬
‫"کو پتہ ہے کہ آپ کب زیادہ جارحیت اختیار کرتے ہیں؟‬
2. Challenging Suspicious Thoughts:
▪ Example: Encourage Kaleem to write down suspicious thoughts and discuss
alternative explanations in the following session.
▪ Urdu Translation: " ‫اپنے شکوک کو لکھیں اور اگلے سیشن میں ان کے متبادل وضاحتیں پر‬
‫"بات کریں۔‬

51
Session 4: Hallucination Management and Reality Testing
• Goal: Reduce the impact of hallucinations on Kaleem’s daily life.
• Objectives:
o Teach grounding techniques to help him distinguish between real and imagined
experiences.
• Session Details:
1. Grounding Exercise for Hallucinations:
▪ T: "When you hear something that feels unreal, try grounding yourself by
focusing on a real object or sound around you."
▪ Urdu Translation: " ‫ تو اپنے ارد‬،‫جب آپ کو کوئی ایسی آواز سنائی دے جو غیر حقیقی لگے‬
‫"گرد کسی حقیقی چیز یا آواز پر توجہ مرکوز کرنے کی کوشش کریں۔‬
2. Reality Testing Practice:
▪ Have Kaleem keep a record of any hallucinatory experiences, noting when they
occur and practicing reality checks.
▪ Urdu Translation: " ‫کسی بھی غیر حقیقی تجربات کا ریکارڈ رکھیں اور حقیقی اور غیر حقیقی‬
‫"کو جانچنے کی مشق کریں۔‬

Session 5: Developing a Structured Daily Routine

• Goal: Introduce consistency in Kaleem’s daily life to reduce stress and improve self-care.
• Objectives:
o Establish a structured morning and evening routine to support emotional regulation and
recovery.
• Session Details:
1. Setting a Morning Routine:
▪ T: "Let’s create a morning routine that includes basic self-care activities like
brushing your teeth and having breakfast."
▪ Urdu Translation: " ‫آئیں ہم ایک صبح کا شیڈول بناتے ہیں جس میں بنیادی دیکھ بھال اور ناشتہ‬
‫"شامل ہو۔‬
2. Planning an Evening Routine:
▪ Limit screen time before bed and include calming activities such as reading or
listening to music.
▪ Urdu Translation: " ‫سونے سے پہلے اسکرین کا وقت کم کریں اور پرسکون سرگرمیاں جیسے‬
‫"کہ کتاب پڑھنا یا موسیقی سننا شامل کریں۔‬

52
Session 6: Relapse Prevention and Family Support Involvement
• Goal: Develop a relapse prevention plan with active family involvement.
• Objectives:
o Identify early warning signs of relapse and outline supportive actions family can take.
• Session Details:
1. Identifying Relapse Triggers:
▪ T: "Let’s list some triggers that might lead to drinking again, like feelings of
frustration or family conflicts."
▪ Urdu Translation: " ‫آئیں ان عوامل کی فہرست بناتے ہیں جو دوبارہ پینے کا باعث بن سکتے‬
‫ جیسے کہ مایوسی کے احساسات یا خاندانی جھگڑے۔‬،‫"ہیں‬
2. Creating a Supportive Family Action Plan:
▪ Family can remind Kaleem of the positive changes since he stopped drinking and
gently encourage him to use coping tools.
▪ Urdu Translation: " ‫خاندان کے افراد مثبت تبدیلیوں کو یاد دال سکتے ہیں اور انہیں سکون سے‬
‫"مثبت رویے اپنانے کی حوصلہ افزائی کر سکتے ہیں۔‬

Sessions 7-10: Coping Skills for Emotional Regulation and Anxiety

• Goal: Equip Kaleem with tools to manage stress, regulate emotions, and cope with anxiety
without alcohol.
• Objectives:
o Teach him breathing exercises and other grounding techniques to manage anxiety and
frustration.
• Session Details:
1. Breathing Exercises for Stress Relief:
▪ T: "When you feel anxious or stressed, try taking deep breaths, inhaling slowly
and then exhaling fully."
▪ Urdu Translation: " ‫جب آپ کو بے چینی محسوس ہو تو آہستہ سانس لینے اور چھوڑنے کی‬
‫"مشق کریں۔‬
2. Grounding Techniques:
▪ Practice body awareness and grounding exercises to help Kaleem stay present
and manage impulsive reactions.
▪ Urdu Translation: " ‫جسمانی آگاہی اور زمین سے جڑے رہنے کی مشق کریں تاکہ موجودہ‬
‫"لمحے میں رہیں اور جلدی ردعمل سے بچیں۔‬

53
Sessions 11-15: Building Insight and Emotional Reflection through Journaling
• Goal: Increase Kaleem’s awareness of emotional triggers and consequences of alcohol use.
• Objectives:
o Use journaling to help Kaleem reflect on emotional responses and understand the impact
of his actions on relationships.
• Session Details:
1. Journaling for Emotional Awareness:
▪ T: "When you feel strong emotions, try writing down what you felt and what
may have caused it. This can help you identify patterns."
▪ Urdu Translation: " ‫جب آپ کو شدید جذبات محسوس ہوں تو ان کو لکھنے کی کوشش کریں۔‬
‫"اس سے آپ اپنے جذبات کو سمجھ سکیں گے۔‬
2. Reflecting on Alcohol’s Impact:
▪ T: "Think about how drinking has affected your relationships and health.
Recognizing this can motivate change."
▪ Urdu Translation: " ‫سوچیں کہ شراب نے آپ کے رشتوں اور صحت پر کیا اثر ڈاال ہے۔ اس کو‬
‫"پہچاننا آپ کو تبدیلی کی ترغیب دے سکتا ہے۔‬

7. Case Summary
Patient Overview: Muhammad Kaleem, a 28-year-old farmer, is diagnosed with Alcohol Use Disorder,
Severe, with Dependence and associated psychiatric symptoms such as aggression, hallucinations, and
social conflict. His symptoms are exacerbated by family issues, distrust, and emotional stress,
compounded by frequent alcohol use.
Diagnosis and Treatment Focus: The primary diagnosis is alcohol dependence, with a focus on reducing
aggression, improving family dynamics, and supporting Kaleem through detox and emotional regulation
strategies.
Therapeutic Approach: Therapy sessions address aggression management, family involvement, and
grounding techniques to manage hallucinations and prevent impulsive behavior. The plan includes
psychoeducation for family members to facilitate understanding and support.
Relapse Prevention and Recovery Focus: The relapse prevention plan centers on identifying early
warning signs, family support involvement, and establishing consistent coping skills.

CASE NO.4

54
1. Case History
1.1 Introduction
• Name (Pseudonym): MY
• Age: 32
• Gender: Male
• Marital Status: Married
• Occupation: Unemployed
• Reason for Referral: Schizoaffective Disorder (Depressive Type) with somatic delusions, social
withdrawal, hallucinations, and depressive symptoms.
• Date of Admission: 29-08-2024 at 7:40 PM
• Date of Examination: 30-08-2024

1.2 History of Present Illness

• Complaints and Symptoms:
o Physical: Frequent headaches, poor appetite, gastric issues.
o Psychological: Somatic delusions (beliefs about physical health issues), auditory
hallucinations, and feelings of sadness.
o Emotional: Persistent depressive mood, social withdrawal, irritability, and low
motivation.
o Behavioral: Limited social interactions, reduced communication, and lethargy.
• Duration of Symptoms: Approximately one year, with an increase in severity over the past 15
days.
• Precipitating Factors: Conflict with colleagues, financial concerns, and social stress.

1.3 Psychiatric History

• First Episode: 2023
o Initial Diagnosis: Schizoaffective Disorder (Depressive Type).
o Progress: Experienced intermittent symptoms with partial improvement during
treatment. This is the second significant episode since the initial diagnosis.
o Treatment Compliance: Inconsistent.

1.4 Physical Illness

55
 • Reported history of chronic gastric issues, managed intermittently with medications.

1.5 Family History

• Father (Alive, 62): Healthy, supportive.
• Mother (Alive): Supportive, with no known psychiatric issues.
• Psychiatric Family History: Brother diagnosed with schizoaffective disorder, history of
depressive episodes, and suicidal ideations.

1.6 Personal History

• Developmental History: No significant developmental issues.
• Education and Employment: Completed matriculation; previously held various jobs but
currently unemployed for the past year.
• Social Relationships: Limited social connections, prefers isolation.
• Religious Background: Practicing Muslim, no significant religious ideations.

2. Mental Status Examination (MSE)

1. Appearance: Mildly disheveled, appears tired.
2. Behavior: Withdrawn, avoids eye contact.
3. Speech: Slow, with minimal elaboration.
4. Mood: Depressed, with self-reported feelings of hopelessness.
5. Affect: Restricted, with limited emotional expression.
6. Thought Process: Logical but marked by somatic delusions.
7. Thought Content: Somatic delusions, occasional auditory hallucinations.
8. Cognition: Oriented to time, place, and person; slight memory lapses.
9. Insight: Partial; understands need for treatment but struggles with acknowledging the impact of
delusions.
10. Judgment: Impaired, especially in social situations and decision-making.

3. Psychological Testing and Assessment

1. Positive and Negative Syndrome Scale (PANSS)
o Positive Scale Score: 32 (Moderate to Severe)

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 o Negative Scale Score: 27 (Moderate)
o General Psychopathology Score: 68 (Severe)
o Total PANSS Score: 127 (Severe)

2. Brief Psychiatric Rating Scale (BPRS)

o Total Score: 70 (Severe)
Interpretation: The scores on both PANSS and BPRS reflect severe psychotic and depressive symptoms,
aligning with a diagnosis of Schizoaffective Disorder, Depressive Type.

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4. Diagnosis
DSM-5-TR Diagnosis:
• Primary Diagnosis: Schizoaffective Disorder, Depressive Type.
• DSM-5-TR Code: 295.70
Differential Diagnosis:
1. Major Depressive Disorder with Psychotic Features: Excluded due to prominent psychotic
features present without mood episodes.
2. Schizophrenia: Excluded due to mood symptoms being significant in presentation.

5. Treatment Plan
Short-Term Goals:
1. Stabilize mood and reduce psychotic symptoms through medication.
2. Improve insight into illness and encourage consistent treatment compliance.
3. Address depressive symptoms and social withdrawal.

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 4. Educate the patient and family on schizoaffective disorder and its management.
Long-Term Goals:
1. Maintain symptom stability and minimize relapse risk.
2. Improve social functioning and communication.
3. Equip the patient with coping strategies to manage stress and depressive episodes.
4. Develop a long-term relapse prevention plan.

6. Therapy Sessions
Session 1: Psychoeducation on Schizoaffective Disorder and Medication Compliance
• Goal: Enhance understanding of schizoaffective disorder, encourage consistent medication
adherence.
• Activities:
o Symptom Awareness: Explain schizoaffective disorder in relatable terms.
▪ Example: “Yaqoob, the feelings of sadness and the unusual thoughts are
symptoms of your condition.”
▪ Urdu Translation: " ‫ یہ افسردگی اور غیر معمولی خیاالت آپ کی بیماری کی عالمات‬،‫یعقوب‬
‫"ہیں۔‬
o Role of Medication: Emphasize the importance of medication for symptom
management.
▪ Example: “Consider your medication as a tool that keeps your mind clear and
balanced.”
▪ Urdu Translation: "‫"دوائیں آپ کی ذہنی کیفیت کو بہتر بنانے میں مدد دیتی ہیں۔‬
Session 2: Cognitive Behavioral Therapy for Delusional Thoughts and Negative Thinking
• Goal: Address delusional beliefs and negative thoughts through structured CBT techniques.
• Activities:
o Identifying and Recording Delusions: Instruct Yaqoob to note down distressing
thoughts.
▪ Example Entry: “Today, I felt intense pain in my head, which made me think I
have a severe illness.”
▪ Urdu Translation: " ‫ جس سے میں نے سوچا کہ مجھے‬،‫آج میں نے سر میں درد محسوس کیا‬
‫"کوئی بڑی بیماری ہے۔‬

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 o Challenging Delusional Beliefs: Encourage Yaqoob to question the evidence for and
against these thoughts.
▪ Example Technique: “Can you find any concrete evidence for this thought, or
could there be another explanation?”
▪ Urdu Translation: " ‫کیا آپ کے پاس اس خیال کے ثبوت ہیں؟ یا اس کا کوئی اور مطلب ہو سکتا‬
‫"ہے؟‬
Session 3: Mood Regulation and Depression Management
• Goal: Develop strategies to manage depressive symptoms and improve mood.
• Activities:
o Behavioral Activation: Engage Yaqoob in simple, enjoyable activities.
▪ Example: “Let’s try scheduling one activity each day that brings you comfort,
like listening to a favorite recitation or going for a short walk.”
▪ Urdu Translation: " ‫ جیسے‬،‫روزانہ ایک ایسی سرگرمی کی کوشش کریں جو آپ کو سکون دے‬
‫"کوئی پسندیدہ دعا سننا۔‬
o Mood Tracking: Use a daily mood journal to track emotional changes.
▪ Example Entry: “Today, I felt low in the morning but better after talking to
family.”
▪ Urdu Translation: " ‫ لیکن خاندان سے بات کرنے کے‬،‫آج صبح میں نے افسردگی محسوس کی‬
‫"بعد بہتر محسوس ہوا۔‬
Session 4: Family Psychoeducation and Support Training
• Goal: Equip family members to support Yaqoob effectively.
• Activities:
o Understanding Illness and Symptoms: Educate family on schizoaffective disorder.
▪ Example: “Yaqoob’s withdrawal and negative thinking are symptoms of his
illness, not his personality.”
▪ Urdu Translation: "‫"یعقوب کا پیچھے ہٹنا اور منفی خیاالت اس کی بیماری کی عالمات ہیں۔‬
o Calming Techniques for Family: Teach family members grounding techniques to help
Yaqoob during episodes.
▪ Example Technique: “If Yaqoob feels anxious, calmly remind him to breathe
slowly and focus on something around him.”
▪ Urdu Translation: "‫ تو انہیں گہرے سانس لینے اور اردگرد‬،‫جب یعقوب بے چین محسوس کریں‬
‫"پر توجہ دینے کی یاد دالئیں۔‬
Session 5: Social Skills Training and Encouraging Interaction
• Goal: Improve Yaqoob’s social interactions and comfort in engaging with others.

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 • Activities:
o Role-Playing Social Scenarios: Practice social interactions in safe, controlled settings.
▪ Example Scenario: Greeting a neighbor and maintaining a simple conversation.
▪ Urdu Translation: "‫"پڑوسی سے سالم دعا کی مشق کریں۔‬
o Active Listening and Responding: Encourage listening fully before responding in
conversations.
▪ Example Technique: “When someone speaks, try repeating their main points to
show understanding.”
▪ Urdu Translation: " ‫ تو اس کی بات کا خالصہ کر کے سمجھنے کا اظہار‬،‫جب کوئی بات کرے‬
‫"کریں۔‬
Session 6: Relapse Prevention and Coping Skills Development
• Goal: Establish a plan for recognizing relapse signs and employing coping mechanisms.
• Activities:
o Identifying Triggers and Warning Signs: Guide Yaqoob to recognize early signs of
relapse, such as increasing social withdrawal or delusional thoughts.
o Building a Support Network: Create a list of trusted contacts for Yaqoob to reach out to
when feeling overwhelmed.
▪ Example List: “Brother, cousin, or family friend.”
▪ Urdu Translation: "‫ یا خاندانی دوست سے رابطہ کریں۔‬،‫ کزن‬،‫"بھائی‬
o Coping Strategies: Develop quick actions to manage anxiety, such as breathing exercises
or using grounding techniques.

7. Case Summary
MY, a 32-year-old male diagnosed with Schizoaffective Disorder (Depressive Type), presents with
depressive symptoms, somatic delusions, and social withdrawal. Family support and psychoeducation are
critical for his recovery, along with CBT to challenge delusions and techniques to manage depressive
symptoms.

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 CASE NO.5
1. Case History
1.1 Introduction
• Name (Pseudonym): FA
• Age: 35
• Gender: Female
• Marital Status: Married
• Occupation: Housewife
• Reason for Referral: Manic Episode, suspected Bipolar Disorder with recurrent manic episodes.
• Date of Admission: 27-08-2024 at 7:30 PM
• Date of Examination: 28-08-2024

1.2 History of Present Illness

• Complaints and Symptoms:
o Psychological: Elevated mood, grandiosity, excessive talkativeness, religious delusions.
o Behavioral: Overactivity, impulsivity, increased religious interest, and involvement in
multiple engagements and marriages.
o Physical: Insomnia and physical restlessness.
o Emotional: Euphoria, irritability, and heightened excitability.
• Duration of Symptoms: Recurrent manic episodes since 2014, with the current episode
persisting for 15 days.
• Precipitating Factors: Recent excitement over family engagement events.

1.3 Psychiatric History

• First Episode: 2014
o Diagnosis: Bipolar Disorder, Manic Type.
o Progress: The patient has had approximately five relapses with intervals of partial
recovery. Treatment has shown good prognosis but inconsistent compliance.
o Current Episode: Observed symptoms are consistent with her previous manic episodes.

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1.4 Physical Illness
• No known significant physical health issues reported that impact her psychiatric condition.

1.5 Family History

• Father (Alive, 55): Healthy and supportive.
• Mother (Alive): History of blood pressure issues.
• Psychiatric Family History: Brother has a history of mania, suggesting a possible genetic
predisposition.

1.6 Personal History

• Developmental History: Normal developmental milestones.
• Education: Completed BA with average grades.
• Social Relationships: Generally maintains good relationships but experiences fluctuations during
manic episodes.
• Religious Background: Practicing Muslim with heightened religious ideation during manic
episodes.

2. Mental Status Examination (MSE)

1. Appearance: Well-dressed, bright-colored attire, slightly overdone makeup.
2. Behavior: Overactive, animated gestures, and frequently interrupting others.
3. Speech: Rapid, loud, and difficult to interrupt.
4. Mood: Euphoric and excessively cheerful.
5. Affect: Broad and intense with mood swings.
6. Thought Process: Disorganized with flight of ideas, frequent topic changes.
7. Thought Content: Grandiosity, religious delusions, and impulsive statements.
8. Cognition: Fully oriented, with a slight decrease in concentration.
9. Insight: Lacks insight into her current manic episode.
10. Judgment: Impaired due to impulsivity and delusional thinking.

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3. Psychological Testing and Assessment
1. Young Mania Rating Scale (YMRS)
o Total YMRS Score: 45 (Severe Manic Symptoms)
o Interpretation: The high score reflects a severe manic episode, consistent with her
presentation of elevated mood, impulsivity, and grandiosity.

2. Positive and Negative Syndrome Scale (PANSS)

o Positive Scale Score: 28 (Moderate Positive Symptoms)
o Negative Scale Score: 18 (Mild Negative Symptoms)
o General Psychopathology Score: 54 (Moderate General Symptoms)
o Total PANSS Score: 100
o Interpretation: The PANSS score confirms the presence of positive symptoms such as
delusions and thought disorder, which align with her manic presentation.

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4. Diagnosis
DSM-5-TR Diagnosis:
• Primary Diagnosis: Bipolar I Disorder, Severe Manic Episode with Psychotic Features.
• DSM-5-TR Code: 296.44
Differential Diagnosis:
1. Schizoaffective Disorder, Bipolar Type: Excluded due to the episodic nature of her symptoms
that fit more consistently with Bipolar Disorder.
2. Borderline Personality Disorder: Excluded, as the impulsivity and mood instability are more
characteristic of a manic episode rather than a pervasive personality disorder.

5. Treatment Plan
Short-Term Goals:
1. Stabilize mood and control manic symptoms with medication.

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 2. Reduce grandiosity and delusional thinking through cognitive-behavioral interventions.
3. Educate her and her family on managing symptoms and maintaining treatment adherence.
4. Encourage sleep hygiene and regular routines to support recovery.
Long-Term Goals:
1. Achieve and maintain mood stability to prevent relapse.
2. Equip her with skills to manage impulsivity and interpersonal relationships.
3. Establish a structured plan for early intervention in future episodes.
4. Improve insight into the nature of her illness to encourage long-term treatment compliance.

6. Therapy Sessions
Session 1: Psychoeducation on Bipolar Disorder and Medication Adherence
• Goal: Increase awareness of Bipolar Disorder and the importance of medication.
• Activities:
o Explaining Symptoms and Illness:
▪ “Faiza, the high energy, talkativeness, and religious thoughts are symptoms of
your condition, which can improve with consistent treatment.”
▪ Urdu Translation: " ‫ آپ کی توانائی اور مذہبی خیاالت آپ کی بیماری کی عالمات ہیں جن‬،‫فائزہ‬
‫"میں عالج سے بہتری آ سکتی ہے۔‬
o Medication Role: Emphasize that medication can stabilize mood and reduce impulsivity.
▪ Example: “Think of medication as a tool to help keep your thoughts balanced and
steady.”
▪ Urdu Translation: "‫"دوائی آپ کی سوچ کو متوازن رکھنے میں مدد دیتی ہے۔‬
Session 2: Cognitive Behavioral Therapy for Delusions and Impulsivity
• Goal: Address grandiosity and impulsivity through CBT.
• Activities:
o Identifying Delusional Beliefs: Encourage Faiza to record delusional or exaggerated
thoughts.
▪ Example Entry: “Today, I felt extremely powerful and thought I had special
powers.”
▪ Urdu Translation: "‫"آج مجھے لگا کہ میرے پاس خاص طاقتیں ہیں۔‬
o Reality Testing: Challenge grandiose beliefs by exploring alternative explanations.

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 ▪ Example Technique: “Could there be another explanation for these feelings
besides having powers?”
▪ Urdu Translation: "‫"کیا ان خیاالت کا کوئی اور مطلب ہو سکتا ہے؟‬
Session 3: Anger and Impulsivity Management
• Goal: Provide strategies to manage anger and reduce impulsive behavior.
• Activities:
o Breathing Exercises: Teach slow breathing exercises to calm impulsive reactions.
▪ Example Exercise: Inhale for 4 counts, hold for 2, exhale for 4.
▪ Urdu Translation: "‫ پھر آہستہ سے باہر نکالیں۔‬،‫ چند لمحے رکیں‬،‫"آہستہ سے سانس لیں‬
o Journaling Triggers: Encourage Faiza to identify situations that trigger her anger or
impulsivity.
▪ Example: “When someone questions my beliefs, I feel angry.”
▪ Urdu Translation: "‫"جب کوئی میرے خیاالت پر سوال کرتا ہے تو مجھے غصہ آتا ہے۔‬
Session 4: Sleep Hygiene and Relaxation Techniques
• Goal: Improve sleep patterns to support mood stability.
• Activities:
o Establishing a Sleep Routine: Suggest a consistent bedtime routine that includes
relaxing activities.
▪ Example Routine: Warm shower, listening to calming recitations.
▪ Urdu Translation: " ‫سونے سے پہلے ایک آرام دہ معمول بنائیں جیسے کہ گرم پانی سے غسل‬
‫"یا دعا سننا۔‬
o Mindfulness Practice: Introduce basic mindfulness to help relax before sleep.
▪ Urdu Translation: "‫"سوچ کو سکون دینے کے لیے مراقبہ کی مشق کریں۔‬
Session 5: Family Education and Support Strategies
• Goal: Educate family members on supporting Faiza without reinforcing delusions.
• Activities:
o Understanding Symptoms: Explain manic symptoms to family, emphasizing that they
are part of her disorder.
▪ Example: “When Faiza talks about special powers, it’s her disorder, not reality.”
▪ Urdu Translation: " ‫جب فائزہ خاص طاقتوں کی بات کرتی ہے تو یہ اس کی بیماری کی عالمت‬
‫"ہے۔‬

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 o Supportive Communication: Guide family on how to respond calmly to Faiza’s
delusional or impulsive statements.
▪ Urdu Translation: "‫"فائزہ کے خیاالت کو پرسکون انداز میں سنیں اور اس کی مدد کریں۔‬
Session 6: Relapse Prevention and Coping Skills
• Goal: Equip Faiza with coping mechanisms to recognize and respond to early signs of relapse.
• Activities:
o Identifying Early Signs of Mania: Help her recognize when her energy level or
talkativeness becomes excessive.
o Building a Support Network: Create a list of family members she can reach out to if she
notices early symptoms.
▪ Example List: “Husband, sister, or close friend.”
▪ Urdu Translation: "‫ بہن یا قریبی دوست سے رابطہ کریں۔‬،‫"شوہر‬
o Using Coping Tools: Introduce relaxation techniques she can use if feeling excessively
energized.
▪ Urdu Translation: "‫"پرسکون رہنے کے لیے آرام کی تکنیک استعمال کریں۔‬

7. Case Summary
FA, a 35-year-old woman, presents with a diagnosis of Bipolar I Disorder, currently in a severe manic
episode. Symptoms include elevated mood, religious delusions, grandiosity, and impulsivity. A structured
treatment plan focusing on mood stabilization, CBT for delusional thoughts, family education, and relapse
prevention is recommended for her long-term well-being.

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 CASE NO.6
1. Case History
1.1 Introduction
• Code: AZ 6
• Age: 30
• Gender: Male
• Marital Status: Married
• Occupation: Accountant
• Reason for Referral: Exhibiting signs consistent with Obsessive-Compulsive Disorder (OCD)
and significant anxiety.
1.2 History of Present Illness
• Complaints and Symptoms:
o Psychological: Persistent intrusive thoughts focused on contamination, leading to
compulsive hand-washing and repetitive checking.
o Behavioral: Rigid routines and rituals impacting productivity and social interactions.
o Duration: Present for two years with worsening over the last six months.
• Precipitating Factors: Recent job changes, financial pressures, and new family responsibilities.
• Course of Illness: Gradual onset with periods of worsening, often triggered by stress.
1.3 Psychiatric History
• First Episode: 2022
o Initial Diagnosis: None; AZ has not sought prior psychological treatment.
o Progress: Symptoms have escalated, particularly in response to stressful events.
1.4 Physical Illness
• Current Health Status: No significant physical ailments reported, though AZ mentions
occasional tension headaches.
1.5 Family History
• Mental Health Background: No known family history of OCD, though AZ recalls his mother’s
emphasis on cleanliness.
• Cultural Background: From a middle-class background with moderate religious practices.
1.6 Personal History
• Developmental History: No significant developmental delays or emotional issues reported
during childhood.

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 • Education and Employment: Bachelor’s in Commerce; employed as an accountant for the past
five years.
• Social Relationships: Limited social engagements due to embarrassment related to compulsive
behaviors.
• Hobbies and Interests: Previously interested in reading and playing sports; recently avoids these
due to time consumed by compulsions.

2. Mental Status Examination (MSE)

1. Appearance: Clean and orderly, though tense.
2. Behavior: Frequently adjusts clothing and sanitizes hands during the session.
3. Speech: Clear and logical but frequently interrupted by urges to check surroundings.
4. Mood: Reports feeling anxious and frustrated.
5. Affect: Restricted and anxious, consistent with stated mood.
6. Thought Process: Logical but preoccupied with cleanliness and order.
7. Thought Content: Marked by intrusive thoughts related to contamination.
8. Cognition: Fully oriented with intact memory and concentration, although intrusive thoughts
occasionally interrupt focus.
9. Insight: Aware that behaviors are excessive but feels unable to resist.
10. Judgment: Intact, though limited control over compulsive behaviors.

3. Psychological Testing and Assessment

3.1 Hamilton Anxiety Rating Scale (HAM-A)
• Purpose: Measures the severity of anxiety symptoms.
• Total Score Calculation: 32 (Moderate to Severe Anxiety).
• Interpretation: AZ’s score indicates moderate to severe anxiety, with particularly high scores in
categories such as Anxious Mood (3), Tension (4), and Intellectual Difficulties (3).
Detailed HAM-A Scoring:

Item AZ’s Score Description of Symptoms

Anxious Mood 3 Frequent worries, fear of contamination.

Tension 4 Frequent feelings of restlessness and difficulty relaxing.

Fears 3 Fears of contamination and infection.

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Item AZ’s Score Description of Symptoms

Insomnia 2 Difficulty with restful sleep, awakens frequently.

Intellectual (Concentration) 3 Difficulty in concentration due to intrusive thoughts.

Depressed Mood 3 Lack of pleasure and early awakening with fatigue.

Somatic (Muscular) 2 Muscle tension, especially during compulsive behavior.

Somatic (Sensory) 2 Hot flushes and pricking sensations, especially when anxious.

Cardiovascular Symptoms 1 Mild tachycardia when under stress.

Respiratory Symptoms 1 Occasional shortness of breath during anxious episodes.

Gastrointestinal Symptoms 2 Nausea and abdominal discomfort during stress.

Genitourinary Symptoms 1 Occasional urgency during anxiety episodes.

Autonomic Symptoms 3 Dry mouth and sweating when distressed.

Behavior at Interview 3 Fidgeting and visible signs of distress during questioning.

3.2 Obsessive-Compulsive Inventory - Revised (OCI-R)

• Purpose: Assesses OCD symptom severity across multiple dimensions.
• Total Score Calculation: 39 (Above the recommended cutoff of 21, indicating probable OCD).

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 • Interpretation: AZ scored highly in checking and washing domains, aligning with his reported
contamination fears.
Detailed OCI-R Scoring:

AZ’s
Item Description of Symptoms
Score

I check things more often than Frequently checks doors, locks, and surfaces for
3
necessary. cleanliness.

I feel compelled to count while doing

1 Occasional counting during routine tasks.
things.

I find it difficult to control my Frequently distressed by intrusive, uncontrollable

3
thoughts. thoughts.

Strong urge to repeatedly check for cleanliness or

I repeatedly check doors, windows, etc. 4
order.

I wash my hands more often than Excessive hand-washing after any perceived
4
necessary. contamination.

Disturbed by frequent, unwanted thoughts of

I am upset by unpleasant thoughts. 3
contamination.

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4. Diagnosis
DSM-5-TR Diagnosis:
• Primary Diagnosis: Obsessive-Compulsive Disorder (OCD), moderate to severe, predominantly
checking and washing subtypes.
• DSM-5-TR Code: 300.3
• ICD-10 Code: F42
Differential Diagnosis:
1. Generalized Anxiety Disorder (GAD):
o Reason for Exclusion: Although anxiety is present, it is specific to contamination fears
rather than general worry.
2. Specific Phobia (Contamination):
o Reason for Exclusion: The compulsive behaviors go beyond simple avoidance and align
more with OCD.

5. Treatment Plan
Short-Term Goals:
1. Reduce Compulsive Behaviors: Use Exposure and Response Prevention (ERP) to gradually
reduce compulsive checking and washing.
2. Manage Anxiety and Intrusive Thoughts: Incorporate cognitive restructuring and relaxation
techniques.
3. Family Education: Provide AZ’s family with information on OCD to prevent reinforcement of
compulsions.
Long-Term Goals:
1. Develop Coping Skills for Anxiety Management: Equip AZ with tools to reduce dependency on
compulsions.
2. Increase Social and Occupational Engagement: Address embarrassment related to compulsive
behaviors to improve social confidence.
3. Relapse Prevention: Establish a plan for early detection of symptom recurrence.

6. Therapy Sessions
Session 1: Psychoeducation on OCD and Introduction to ERP

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 • Goal: Help AZ understand his OCD symptoms and introduce him to ERP, the primary treatment
technique.
• Objectives:
o Educate AZ about the cycle of obsessions and compulsions.
o Explain ERP as a way to confront fears without performing compulsive rituals.
Detailed Steps:
1. Explain the OCD Cycle:
o Begin with a clear explanation of how obsessions (intrusive thoughts) create anxiety,
leading to compulsions (rituals) that temporarily relieve anxiety but reinforce the
obsessive-compulsive cycle.
o Urdu Translation: " ‫ تو اس کے نتیجے میں آپ کو کچھ حرکات‬،‫جب کوئی خیال آپ کو خوفزدہ کرتا ہے‬
‫ لیکن اصل میں آپ کے خوف کو بڑھا دیتی ہیں۔‬،‫ جو وقتی طور پر سکون دیتی ہیں‬،‫"کرنا پڑتی ہیں‬
2. Introduce Exposure and Response Prevention (ERP):
o Explain that ERP is a method where AZ will gradually face his fears (e.g., touching
“contaminated” objects) without engaging in compulsions (e.g., hand-washing).
o Example Script: “By not washing your hands immediately, you’ll allow yourself to
experience and cope with the anxiety until it naturally subsides.”
o Urdu Translation: " ‫ تو آپ اپنی بے چینی کو خود ہی کم‬،‫جب آپ فوری طور پر ہاتھ نہیں دھوئیں گے‬
‫"ہونے کا موقع دیں گے۔‬
3. Homework Assignment:
o Ask AZ to observe his compulsions throughout the week, noting what situations trigger
hand-washing or checking behaviors.
o Urdu Translation: " ‫اپنے روزمرہ میں اُن حاالت کو نوٹ کریں جب آپ کو بے چینی محسوس ہوتی ہے‬
‫"اور آپ کو کچھ خاص حرکات کرنے کی ضرورت محسوس ہوتی ہے۔‬

Session 2: Trigger Identification and Creation of Exposure Hierarchy

• Goal: Identify specific OCD triggers and create a step-by-step exposure hierarchy for ERP.
• Objectives:
o Help AZ recognize specific situations or objects that trigger his anxiety.
o Develop an exposure list, starting with mild triggers and working up to more intense
fears.
Detailed Steps:
1. Identify Triggers:

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 o Collaborate with AZ to list situations that cause his anxiety, such as touching public
doorknobs, shaking hands, or handling shared items at work.
o Urdu Translation: "‫ ان کی فہرست بنائیں۔‬،‫"وہ تمام چیزیں اور حاالت جو آپ کو بے چینی دیتے ہیں‬
2. Create an Exposure Hierarchy:
o Together, rank these situations from least to most anxiety-provoking. For example:
▪ Low: Touching a clean table surface at home without hand-washing.
▪ Medium: Touching a public surface like an office desk.
▪ High: Shaking hands without washing immediately after.
o Urdu Translation: "‫"ان حاالت کو کم سے زیادہ بے چینی پیدا کرنے والے ترتیب میں رکھیں۔‬
3. Homework Assignment:
o Ask AZ to practice noting his distress level (0–10 scale) when he encounters triggers and
to rank any new triggers he experiences.
o Urdu Translation: " ‫اپنی بے چینی کی سطح کو نوٹ کریں جب بھی آپ کسی مشکل صورتحال کا سامنا‬
‫"کرتے ہیں۔‬

Session 3: First Low-Level Exposure Practice

• Goal: Begin ERP with a low-level exposure exercise.
• Objectives:
o Have AZ engage in an exposure activity (e.g., touching a home surface) and resist
washing his hands afterward.
o Track his anxiety levels throughout the exercise.
Detailed Steps:
1. Introduce the Low-Level Exposure Exercise:
o Select a mild trigger from the hierarchy, such as touching a surface at home.
o Guide AZ to touch the surface, observe his anxiety, and resist washing his hands for 10
minutes.
o Urdu Translation: " ‫ اپنے بے چینی کو محسوس کریں اور‬،‫اس سطح کو چھوئیں اور اپنے ہاتھ نہ دھوئیں‬
‫"اس کو خود ہی کم ہونے دیں۔‬
2. Anxiety Rating:
o Have AZ rate his anxiety before, during, and after the exposure on a scale from 0 to 10,
discussing any changes he notices.
o Urdu Translation: " ‫ اور دیکھیں کہ کس طرح وقت کے ساتھ وہ کم‬،‫اپنی بے چینی کی سطح کو نوٹ کریں‬
‫"ہوتی ہے۔‬

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 3. Homework Assignment:
o Encourage AZ to repeat this exercise daily and track his anxiety ratings to observe any
reduction over time.
o Urdu Translation: " ‫اس مشق کو روزانہ دہرائیں اور دیکھیں کہ کس طرح آپ کی بے چینی کی سطح میں‬
‫"کمی آتی ہے۔‬

Session 4: Cognitive Restructuring of Intrusive Thoughts

• Goal: Teach AZ to challenge and restructure his intrusive thoughts.
• Objectives:
o Identify specific intrusive thoughts and explore their impact on his emotions.
o Practice rethinking these thoughts to reduce anxiety.
Detailed Steps:
1. Identify and Record Intrusive Thoughts:
o Have AZ write down a recent intrusive thought, such as, “If I don’t wash my hands, I’ll
get sick.”
o Urdu Translation: " ‫وہ خیاالت لکھیں جو آپ کو پریشان کرتے ہیں جیسے کہ ’اگر میں ہاتھ نہیں دھوؤں گا‬
‫"‘تو بیمار ہو جاؤں گا۔‬
2. Challenge and Restructure Thought:
o Encourage AZ to explore alternative, less distressing explanations, such as “Not every
surface has germs that cause sickness.”
o Urdu Translation: " ‫ جیسے کہ ’ہر‬،‫اپنے خیاالت پر سوال اٹھائیں اور ان کے متبادل وضاحت تالش کریں‬
‫"‘سطح پر جراثیم نہیں ہوتے جو بیماری پیدا کریں۔‬
3. Homework Assignment:
o Ask AZ to record at least two intrusive thoughts daily and practice restructuring them.
o Urdu Translation: "‫"روزانہ دو خیاالت کو نوٹ کریں اور ان کو نئے انداز میں سوچنے کی کوشش کریں۔‬

Session 5: Family Involvement and Education

• Goal: Involve AZ’s family to prevent them from unintentionally reinforcing his compulsive
behaviors.
• Objectives:
o Educate the family on supportive responses.
o Guide family members to avoid participating in AZ’s rituals.

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Detailed Steps:
1. Explain Family’s Role in OCD Management:
o Discuss how family members can either support AZ’s progress or reinforce his
compulsions.
o Urdu Translation: "‫ خاندان کے افراد‬AZ ‫کے عالج میں مددگار ہو سکتے ہیں یا اس کے خیاالت کو بڑھا‬
‫"سکتے ہیں۔‬
2. Train Family in Supportive Communication:
o Encourage family to calmly remind AZ of his coping tools without helping him perform
compulsions.
o Example: “I know this feels hard, but let’s try the breathing exercise we talked about.”
o Urdu Translation: "‫ لیکن آئیں ہم وہ مشق کریں جو ہم نے سیکھی تھی۔‬،‫"میں جانتا ہوں کہ یہ مشکل ہے‬
3. Homework Assignment:
o Family members to practice supportive responses and reflect on their impact.
o Urdu Translation: "‫ خاندان کے افراد‬AZ ‫"کی مدد کے لئے مناسب جواب دینے کی مشق کریں۔‬

Session 6: Higher-Level Exposure Practice with More Challenging Triggers

• Goal: Introduce a higher-level exposure, using moderate to high anxiety triggers.
• Objectives:
o Support AZ in confronting triggers that provoke more intense anxiety.
o Practice extended response prevention (resisting compulsion longer).
Detailed Steps:
1. Moderate Exposure Exercise:
o Have AZ engage in a moderately distressing activity, such as touching an office desk or
public surface.
o Gradually extend the delay before hand-washing from 10 minutes to 20 minutes.
o Urdu Translation: "‫"پہلے سے زیادہ مشکل سطح کو چھوئیں اور ہاتھ نہ دھونے کا وقت بڑھائیں۔‬
2. Monitor and Record Anxiety Levels:
o Guide AZ to note his anxiety before, during, and after exposure, observing any decrease
over time.
o Urdu Translation: " ‫اپنی بے چینی کو نوٹ کریں اور دیکھیں کہ کس طرح وقت کے ساتھ وہ کم ہوتی‬
‫"ہے۔‬
3. Homework Assignment:

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 o Ask AZ to continue with both low and moderate exposures, aiming to decrease his
anxiety levels over time.
o Urdu Translation: " ‫اپنی مشق جاری رکھیں اور دیکھیں کہ کس طرح وقت کے ساتھ بے چینی میں کمی‬
‫"آتی ہے۔‬

Session 7: Mindfulness and Relaxation Techniques for Impulse Control

• Goal: Teach AZ mindfulness and relaxation to reduce anxiety without compulsions.
• Objectives:
o Introduce breathing and mindfulness exercises as tools to manage distress.
o Practice mindfulness techniques to increase AZ’s tolerance to distress.
Detailed Steps:
1. Breathing Exercises:
o Teach AZ to inhale for a count of four, hold for two, and exhale for four. This can be
practiced whenever he feels an urge to perform a compulsion.
o Urdu Translation: "‫ اور آہستہ سے سانس باہر نکالیں۔‬،‫ کچھ لمحوں کے لیے رکیں‬،‫"آہستہ سے سانس لیں‬
2. Body Scan Meditation:
o Guide AZ through a body scan, helping him to observe sensations without judgment,
fostering acceptance.
o Urdu Translation: " ‫اپنے جسم کے مختلف حصوں پر توجہ دیں اور انہیں بغیر کسی قضاوت کے محسوس‬
‫"کریں۔‬
3. Homework Assignment:
o Practice mindfulness daily, especially when facing a triggering situation.
o Urdu Translation: " ‫ خاص طور پر جب کوئی بے چینی پیدا کرنے والی‬،‫ہر روز مراقبہ کی مشق کریں‬
‫"صورتحال سامنے آئے۔‬
Case Summary
Patient Overview: AZ, diagnosed with OCD, presents with contamination fears, compulsive hand-
washing, and checking behaviors. His symptoms disrupt daily activities, relationships, and occupational
functioning.
Diagnosis and Treatment Focus: The primary focus is to reduce compulsions and intrusive thoughts
through ERP, cognitive restructuring, and family involvement.
Therapeutic Approach: ERP and CBT sessions address compulsions and associated anxiety, with
support from family education to prevent ritual reinforcement.
Relapse Prevention: Relapse strategies include regular ERP practice, family support, and mindfulness
techniques for long-term stability and anxiety management

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 CASE NO.7
Clinical Case Report
Name (Pseudonym): RS
Age: 27
Gender: Female
Marital Status: Married
Occupation: Teacher
Reason for Referral: Severe anxiety, obsessive-compulsive symptoms, and pervasive feelings of
hopelessness.
Date of Admission: 20-10-2024
Date of Examination: 22-10-2024

1. Case History
1.1 Introduction
RS is a 27-year-old female who was referred for a psychological assessment due to significant levels of
anxiety, compulsive behaviors, and a high degree of hopelessness. These symptoms have begun affecting
her personal, professional, and family life. Her mood fluctuations, obsessive thoughts, and overall despair
have caused her distress and impaired daily functioning.
1.2 History of Present Illness
RS reports experiencing persistent and distressing thoughts over the past year, primarily related to
contamination and a need for order. She performs compulsive cleaning and checking behaviors to
alleviate these obsessive thoughts, yet feels temporary relief. Recently, her anxiety has increased, with
symptoms such as restlessness, difficulty relaxing, and fear of the future. RS also describes profound
hopelessness about her future, which has escalated over the past two months.
1.3 Psychiatric History
RS has had a history of generalized anxiety since early adulthood. While she has occasionally used
coping mechanisms, this is her first formal psychological assessment. There are no previous treatment
records.
1.4 Physical Illness
No significant history of physical illness was reported.
1.5 Family History
RS’s family background shows no formal mental health diagnoses, but she describes a highly structured
and strict household environment. She was often expected to maintain order and cleanliness, which may
have contributed to her current obsessive-compulsive tendencies.
1.6 Personal History

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Raised in a disciplined household, RS was often described as meticulous and conscientious.
Academically, she has been successful and is currently employed as a teacher. However, her social
interactions are limited, and she prefers solitude due to discomfort in group settings.

2. Mental Status Examination (MSE)

1. Appearance: Well-dressed and neat, though somewhat tense.
2. Behavior: Restless, often checking her surroundings.
3. Speech: Coherent but slowed when discussing anxieties.
4. Mood: Self-reports feeling anxious and hopeless.
5. Affect: Restricted, with minimal emotional range.
6. Thought Process: Logical but dominated by obsessive thoughts.
7. Thought Content: Preoccupation with cleanliness and despair about the future.
8. Cognition: Fully oriented; attention and concentration slightly impaired due to anxious thoughts.
9. Insight and Judgment: Partial insight into her behaviors but feels unable to control them.

3. Psychological Testing and Assessment

3.1 Hamilton Anxiety Rating Scale (HAM-A)
Purpose: The HAM-A evaluates the severity of anxiety symptoms across 14 items, with each scored on a
0-4 scale. A total score of 18-24 indicates mild to moderate severity, while 25-30 indicates moderate to
severe anxiety.

Not Present Mild Moderate Severe Very Severe RS’s

Symptom
(0) (1) (2) (3) (4) Response

Anxious mood ☑ 3

Tension ☑ 3

Fears ☑ 1

Insomnia ☑ 2

Intellectual impairment ☑ 2

Depressed mood ☑ 3

Somatic (muscular) ☑ 1

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 Not Present Mild Moderate Severe Very Severe RS’s
Symptom
(0) (1) (2) (3) (4) Response

Somatic (sensory) ☑ 2

Cardiovascular
☑ 1
symptoms

Respiratory symptoms ☑ 1

Gastrointestinal
☑ 2
symptoms

Genitourinary symptoms ☑ 1

Autonomic symptoms ☑ 1

Behavior at interview ☑ 3

Total HAM-A Score: 26

Interpretation: RS’s HAM-A score of 26 indicates moderate to severe anxiety.
3.2 Obsessive-Compulsive Inventory – Revised (OCI-R)
Purpose: The OCI-R assesses distress related to obsessive-compulsive symptoms over the past month,
with scores ≥21 suggesting the presence of OCD.

Not at All A Little Moderately A Lot Extremely RS’s

Symptom
(0) (1) (2) (3) (4) Response

Saved unnecessary items ☑ 2

Checks things excessively ☑ 2

Upset by misarrangements ☑ 2

Compulsive counting ☑ 1

Difficulty touching items ☑ 1

Difficulty controlling
☑ 2
thoughts

Collecting unnecessary
☑ 2
items

Rechecking doors/windows ☑ 2

Upset by others’ changes ☑ 1

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 Not at All A Little Moderately A Lot Extremely RS’s
Symptom
(0) (1) (2) (3) (4) Response

Compulsion to repeat
☑ 2
numbers

Excessive handwashing ☑ 3

Upset by unwanted
☑ 1
thoughts

Total OCI-R Score: 28

Interpretation: RS’s OCI-R score of 28 indicates moderate to severe obsessive-compulsive symptoms.
3.3 Beck Hopelessness Scale (BHS)
Purpose: The BHS assesses the level of hopelessness, with scores ≥15 indicating severe hopelessness.

Statement Response Score

I look forward to the future with hope and enthusiasm. False 1

I can’t imagine what my life would be like in 10 years. True 1

All I can see ahead of me is unpleasantness. True 1

Total BHS Score: 18

Interpretation: A BHS score of 18 indicates severe hopelessness, underscoring the need for immediate
intervention.

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4. Diagnosis
Based on DSM-5-TR criteria:
• Primary Diagnosis: Generalized Anxiety Disorder with Obsessive-Compulsive Features
• Secondary Diagnosis: Major Depressive Disorder, Moderate Severity with Severe Hopelessness
• Differential Diagnoses:
o Persistent Depressive Disorder (Excluded due to episodic nature of symptoms)
o Panic Disorder (Excluded due to lack of panic attacks)

5. Treatment Plan
Short-Term Goals:
1. Reduce Anxiety: Implement relaxation techniques and initiate medication.
2. Manage Compulsive Behaviors: Address distressing behaviors using cognitive restructuring.
3. Address Hopelessness: Use Cognitive Behavioral Therapy (CBT) to reframe negative thoughts.
4. Improve Sleep Quality: Introduce sleep hygiene practices.
Long-Term Goals:
1. Maintain Symptom Control: Regular therapy sessions to sustain gains in reducing obsessive-
compulsive symptoms.
2. Promote Positive Thinking: CBT for hopelessness and cognitive restructuring for positive
outlook.
3. Prevent Relapse: Family support and continued monitoring of early signs.
4. Develop Self-Care Routine: Encourage activities that foster well-being and improve daily
functioning.
6. Therapy Sessions for RS
Session 1: Introduction to Anxiety Management Techniques
• Objective: Teach RS immediate anxiety-reduction techniques through structured relaxation
exercises.
• Step-by-Step Process:
1. Introduction to Breathing Exercises:
▪ Explanation: Explain the concept of deep breathing and its role in calming the
nervous system.

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 ▪ Instruction: “Inhale slowly through your nose for a count of four, hold for a
count of two, and exhale through your mouth for a count of four. Repeat this five
times or until you notice your heart rate slowing down.”
▪ Urdu Translation: " ‫ دو‬،‫آہستہ سے ناک کے ذریعے چار تک گنتی میں سانس لیں‬
‫ اور پھر منہ سے آہستہ سانس چھوڑیں۔ اس عمل کو پانچ بار دہرائیں یا‬،‫سیکنڈ تک روکیں‬
‫"جب تک آپ کو دل کی دھڑکن کی رفتار کم ہوتی محسوس نہ ہو۔‬
▪ Practice: Guide RS through this exercise in-session, observing her technique,
correcting any issues, and asking her to note her level of anxiety before and after
each cycle.
▪ Urdu Translation: " ‫ کسی‬،‫ ان کی تکنیک کا جائزہ لیں‬،‫سیشن میں یہ مشق کروائیں‬
‫ اور انہیں ہر سائیکل سے پہلے اور بعد میں اپنی بے چینی کی سطح‬،‫غلطی کو درست کریں‬
‫"کو نوٹ کرنے کو کہیں۔‬
▪ Homework: Encourage RS to practice this twice daily and log her anxiety levels
before and after each session.
▪ Urdu Translation: " ‫انہیں اس مشق کو روزانہ دو بار کرنے اور سیشن سے پہلے اور‬
‫"بعد میں بے چینی کی سطح کو نوٹ کرنے کی ترغیب دیں۔‬
2. Introduction to Progressive Muscle Relaxation (PMR):
▪ Explanation: “We’ll work on tensing and releasing each muscle group, which
helps release stored tension.”
▪ Urdu Translation: " ‫ہم ہر پٹھے کے گروپ کو کھینچنے اور چھوڑنے پر کام کریں‬
‫ جس سے جمع شدہ تناؤ کو چھوڑنے میں مدد ملتی ہے۔‬،‫"گے‬
▪ Guided Exercise: Start with her hands, asking her to clench fists tightly for five
seconds, then release. Move to arms, shoulders, and legs sequentially.
▪ Urdu Translation: " ‫ انہیں پانچ سیکنڈ تک مٹھی کو‬،‫پہلے ہاتھوں سے شروع کریں‬
‫ کندھوں اور ٹانگوں کی طرف‬،‫ پھر چھوڑ دیں۔ پھر بازو‬،‫سختی سے بند کرنے کو کہیں‬
‫"جائیں۔‬
▪ Reflection: Ask her to describe sensations and feelings during and after each
muscle release, noting areas with high tension.
▪ Urdu Translation: " ‫انہیں پٹھے کو چھوڑنے کے دوران اور بعد میں محسوسات کو‬
‫ اور ان عالقوں کو نوٹ کریں جہاں زیادہ تناؤ محسوس ہوتا ہے۔‬،‫"بیان کرنے کو کہیں‬
▪ Homework: Encourage her to use PMR before bed to help with sleep quality.
▪ Urdu Translation: " ‫انہیں سونے سے پہلے پی ایم آر کا استعمال کرنے کی ترغیب‬
‫"دیں تاکہ نیند کے معیار میں بہتری آئے۔‬

Session 2: Cognitive Restructuring for Compulsive Thoughts

• Objective: Identify, challenge, and reframe obsessive thoughts and cognitive distortions
associated with OCD.

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• Step-by-Step Process:
1. Thought Record Introduction:
▪ Instructions: Provide RS with a journal to write down any obsessive thoughts.
Each time she feels compelled to perform a ritual, she should log what triggered
the thought, the associated compulsion, and her feelings.
▪ Urdu Translation: "RS ‫کو ایک جرنل فراہم کریں تاکہ وہ کسی بھی جبری خیال کو‬
‫ وہ خیال‬،‫لکھ سکے۔ ہر بار جب وہ کسی رسم کو انجام دینے کی ضرورت محسوس کریں‬
‫ اس کے نتیجے میں پیدا ہونے والی عادت اور اپنے احساسات کو نوٹ کریں۔‬،‫"کے محرک‬
▪ Example Entry: “I felt anxious when I saw my desk was not organized, and I
felt I needed to arrange everything perfectly.”
▪ Urdu Translation: " ‫مجھے بے چینی محسوس ہوئی جب میں نے دیکھا کہ میری میز‬
‫ اور میں نے محسوس کیا کہ مجھے سب کچھ مکمل طور پر ترتیب دینا‬،‫منظم نہیں ہے‬
‫"چاہئے۔‬
2. Cognitive Reframing Technique:
▪ Explanation: Introduce cognitive reframing, explaining that obsessive thoughts
often contain distortions (e.g., catastrophizing or black-and-white thinking).
▪ Urdu Translation: " ‫ یہ بتاتے ہوئے کہ جبری‬،‫دماغی دوبارہ سازی کا تعارف کرائیں‬
‫"خیاالت اکثر بگاڑ پیدا کرتے ہیں )جیسے کہ مکمل تباہی کا سوچنا یا بلیک اینڈ وائٹ سوچ(۔‬
▪ Practice in Session: Select an entry from her thought record. Discuss the
likelihood and rationality of her fears (e.g., “If I don’t organize, I’ll lose
control”), guiding her to question their accuracy.
▪ Urdu Translation: " ‫ان کے خیال کے ریکارڈ سے ایک اندراج کا انتخاب کریں۔ ان‬
‫ اور ان کی رہنمائی کریں کہ وہ ان کی‬،‫کے خوف کی امکانات اور معقولیت پر بات کریں‬
‫"درستگی پر سوال کریں۔‬
▪ Homework: For each recorded thought, encourage RS to write an alternative,
balanced statement.
▪ Urdu Translation: "‫ہر درج شدہ خیال کے لیے‬، RS ‫کو متبادل اور متوازن بیان‬
‫"لکھنے کی ترغیب دیں۔‬
3. Behavioral Experimentation:
▪ Instruction: Challenge RS to reduce one of her compulsive behaviors slightly
(e.g., reduce hand washing by 10%).
▪ Urdu Translation: "RS ‫کو ان کی کسی ایک جبری عادت کو تھوڑا سا کم کرنے کا‬
‫ فیصد کم کرنا(۔‬10 ‫ ہاتھ دھونے کو‬،‫"چیلنج دیں )مثال کے طور پر‬
▪ Reflection and Journal Entry: Ask her to log her anxiety before, during, and
after resisting the compulsion.
▪ Urdu Translation: " ‫ دوران اور بعد میں بے چینی‬،‫انہیں عادت کو روکنے سے پہلے‬
‫"کو نوٹ کرنے کے لئے کہیں۔‬

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Session 3: Coping Strategies for Hopelessness Using Cognitive Behavioral Therapy
• Objective: Address hopelessness by challenging negative beliefs about the future through a
structured CBT approach.
• Step-by-Step Process:
1. Identify Hopeless Thoughts:
▪ Exercise: Ask RS to identify situations where she felt hopeless in the past week.
Record these in her journal.
▪ Urdu Translation: "RS ‫سے کہیں کہ وہ ان حاالت کی نشاندہی کریں جہاں انہیں‬
‫"پچھلے ہفتے مایوسی محسوس ہوئی ہو اور ان کو جرنل میں نوٹ کریں۔‬
2. Challenging Negative Beliefs:
▪ Example Discussion: Pick a belief such as “Nothing will change.” Ask her to
provide evidence supporting and contradicting this thought.
▪ Urdu Translation: " ‫مثال کے طور پر ایک خیال کا انتخاب کریں جیسے کہ 'کچھ نہیں‬
‫"بدلے گا' اور ان سے کہیں کہ وہ اس خیال کی تائید اور مخالفت میں ثبوت فراہم کریں۔‬
▪ Alternative Thinking: Help her create a balanced thought, such as “I’ve
overcome challenges in the past, so things can improve.”
▪ Urdu Translation: " ‫ جیسے کہ 'میں نے‬،‫انہیں ایک متوازن خیال بنانے میں مدد کریں‬
‫ اس لئے چیزیں بہتر ہو سکتی ہیں۔‬،‫"'ماضی میں چیلنجز کا مقابلہ کیا ہے‬
3. Setting Small, Achievable Goals:
▪ Activity: Ask RS to set one small, positive goal each day.
▪ Urdu Translation: "RS ‫ مثبت مقصد مقرر‬،‫سے کہیں کہ وہ روزانہ ایک چھوٹا‬
‫"کریں۔‬
▪ Homework: At the end of the day, reflect on each goal’s completion.
▪ Urdu Translation: "‫ ہر مقصد کی تکمیل پر غور کریں۔‬،‫"دن کے اختتام پر‬

Session 4: Establishing Self-Care Routines

• Objective: Build structured daily routines to support well-being, focusing on consistent self-care
habits for anxiety and mood stabilization.
• Step-by-Step Process:
1. Create a Morning Routine:
▪ Activity Plan: Develop a sequence of activities for her morning routine.
▪ Urdu Translation: "‫"صبح کے معمول کے لئے سرگرمیوں کا ایک سلسلہ تیار کریں۔‬

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 ▪ Practice: Role-play the morning routine in session.
▪ Urdu Translation: "‫"سیشن میں صبح کے معمول کی عملی مشق کریں۔‬
2. Evening Routine for Sleep Hygiene:
▪ Preparation Tips: Limit screen time 30 minutes before bed and engage in a
calming activity.
▪ Urdu Translation: " ‫ منٹ پہلے اسکرین کے وقت کو محدود کریں اور‬30 ‫سونے سے‬
‫"ایک پرسکون سرگرمی میں شامل ہوں۔‬
▪ Homework: Follow this routine nightly.
▪ Urdu Translation: "‫"اس معمول کو ہر رات فالو کریں۔‬

Session 5: Family Education and Support Strategies

• Objective: Equip RS’s family with techniques to support her without reinforcing compulsive
behaviors.
• Step-by-Step Process:
1. Educate on Anxiety and OCD:
▪ Explanation: Describe RS’s condition and explain how support without
accommodation can help.
▪ Urdu Translation: "RS ‫کی حالت کی وضاحت کریں اور یہ بتائیں کہ کیسے بغیر‬
‫"سہولت کے مدد کر سکتے ہیں۔‬
2. Supportive Phrasing Practice:
▪ Role-Playing Exercise: Practice responses with the family.
▪ Urdu Translation: "‫"خاندان کے ساتھ ردعمل کی عملی مشق کریں۔‬
3. Boundaries to Avoid Compulsion Reinforcement:
▪ Guidelines: Encourage family members to avoid participating in her
compulsions.
▪ Urdu Translation: " ‫خاندان کے افراد کو ان کی جبری عادات میں شامل نہ ہونے کی‬
‫"ترغیب دیں۔‬

Session 6: Relapse Prevention and Coping Skills Development

• Objective: Develop RS’s ability to recognize early signs of relapse and use coping mechanisms
for sustained improvement.
• Step-by-Step Process:
1. Recognize Warning Signs:

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 ▪ Journal Exercise: Help RS list early signs.
▪ Urdu Translation: "RS ‫"کی مدد کریں کہ وہ ابتدائی عالمات کی فہرست بنائیں۔‬
2. Develop a Relapse Prevention Action Plan:
▪ Action List: Create a “when I notice…” list with steps to follow.
▪ Urdu Translation: "‫' کی فہرست تیار کریں۔‬...‫"جب میں محسوس کروں‬
3. Establish a Support Network:
▪ Contacts: Identify specific people to reach out to.
Urdu Translation: "‫"ایسے لوگوں کی شناخت کریں جن سے رابطہ کیا جا سکتا ہے۔‬
7. Case Summary
RS, a 27-year-old teacher, presents with generalized anxiety, obsessive-compulsive symptoms, and severe
hopelessness. Scores on the HAM-A, OCI-R, and BHS reflect moderate to severe levels across these
areas, indicating a need for structured therapeutic intervention. Treatment will focus on reducing anxiety,
managing obsessive behaviors, and improving her perspective on the future.

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 Case No. 8
1. Case History
1.1 Introduction
• Pseudonym: AR
• Age: 45
• Gender: Female
• Marital Status: Widowed
• Occupation: School Teacher
• Reason for Referral: Persistent depressive symptoms, hopelessness, and significant anxiety,
including frequent panic attacks.
• Date of Admission: 03-10-2024
• Date of Examination: 05-10-2024
1.2 History of Present Illness
• Complaints and Symptoms: AR reports pervasive feelings of hopelessness, intense worry about
her future, and frequent panic episodes. She experiences fatigue, insomnia, and a diminished
ability to focus on daily tasks, especially those related to her job as a teacher.
• Duration: Symptoms have persisted and intensified over the past six months, exacerbated by her
husband’s death.
• Impact on Life: Reduced functional capacity, difficulty performing job responsibilities, and
limited social interactions due to feelings of isolation.
1.3 Psychiatric History
• No formal history of psychiatric treatment. AR mentions self-managing past anxiety episodes
without seeking professional intervention.
1.4 Physical Illness
• No notable physical illness was reported.
1.5 Family History
• No family history of mental health disorders. Grew up in a supportive family environment.
1.6 Personal History
• Background: AR was raised in a close-knit, supportive family. She is a dedicated teacher with
over 20 years of experience.
• Education: Bachelor’s degree in Education.
• Social Relationships: Generally reserved, with limited social connections outside of work.

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2. Mental Status Examination (MSE)
1. Appearance: Appropriately dressed but appears fatigued and worn.
2. Behavior: Quiet and somewhat withdrawn, responding hesitantly.
3. Speech: Slow, with limited elaboration on answers.
4. Mood: Self-reports feelings of “emptiness” and a profound lack of hope.
5. Affect: Restricted, showing minimal emotional range.
6. Thought Process: Logical but preoccupied with negative thoughts and hopelessness.
7. Thought Content: Dominated by feelings of hopelessness and concerns about the future.
8. Cognition: Fully oriented, with occasional difficulty in maintaining attention.
9. Insight and Judgment: Aware of her symptoms but feels unable to control or change them.

3. Psychological Testing and Assessment

3.1 Hamilton Anxiety Rating Scale (HAM-A)
• Description: The HAM-A is a clinician-rated scale assessing the severity of anxiety symptoms
across various domains, including physical, cognitive, and behavioral aspects. Each item is scored
from 0 (not present) to 4 (very severe).
HAM-A Score Table:

Item Description Score

Anxious Mood Worries, anticipation of the worst, fearful anticipation, irritability 3

Tension Feelings of tension, fatigability, restlessness, inability to relax 4

Fears Of being left alone, strangers, crowds 3

Insomnia Difficulty sleeping, broken sleep, nightmares 3

Intellectual (Concentration) Poor memory and difficulty concentrating 2

Depressed Mood Loss of interest, prolonged sadness 4

Somatic (Muscular) Muscle tension, aches 3

Somatic (Sensory) Tinnitus, hot and cold flushes 3

Cardiovascular Symptoms Palpitations, chest pain 2

Respiratory Symptoms Chest tightness, shortness of breath 3

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Item Description Score

Gastrointestinal Symptoms Abdominal discomfort, nausea 3

Genitourinary Symptoms Slight urgency and frequency of urination 1

Autonomic Symptoms Sweating, giddiness 2

Behavior at Interview Fidgeting, restlessness 3

• Total HAM-A Score: 39

• Interpretation: AR’s total HAM-A score of 39 reflects moderate to severe anxiety, with
significant distress across several domains, particularly mood, tension, and somatic symptoms.

3.2 Beck Hopelessness Scale (BHS)

• Description: The BHS is a 20-item self-report scale assessing the degree of hopelessness. It
requires a true or false response to each statement, indicating whether the respondent has
experienced hopeless thoughts.
BHS Score Table:

Item Statement Response Score

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Item Statement Response Score

1 I look forward to the future with hope and enthusiasm False 1

2 I might as well give up because I can’t make things better for myself True 1

When things are going badly, I am helped by knowing they can’t stay that way
3 False 1
forever

4 I can’t imagine what my life would be like in 10 years True 1

5 I have enough time to accomplish the things I most want to do False 1

6 In the future, I expect to succeed in what concerns me most False 1

7 My future seems dark to me True 1

8 I expect to get more good things in life than the average person False 1

9 I just don’t get the breaks, and there’s no reason to believe I will in the future True 1

10 My past experiences have prepared me well for the future False 1

11 All I can see ahead of me is unpleasantness rather than pleasantness True 1

12 I don’t expect to get what I really want True 1

13 When I look ahead to the future, I expect I will be happier than I am now False 1

14 Things just won’t work out the way I want them to True 1

15 I have great faith in the future False 1

16 I never get what I want, so it’s foolish to want anything True 1

17 It is very unlikely that I will get any real satisfaction in the future True 1

18 The future seems vague and uncertain to me True 1

19 I can look forward to more good times than bad times False 1

There’s no use in really trying to get something I want because I probably won’t
20 True 1
get it

• Total BHS Score: 16

• Interpretation: AR’s score of 16 indicates severe hopelessness, with most responses reflecting
negative expectations and diminished belief in future satisfaction.

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4. Diagnosis
DSM-5-TR Diagnosis:
• Primary Diagnosis: Major Depressive Disorder, Moderate to Severe, with Anxious Distress
• DSM-5-TR Code: 296.32
• ICD-10 Code: F33.2
Differential Diagnosis:
1. Generalized Anxiety Disorder (GAD)
o Reason for Inclusion: Persistent worry across various life domains.
o Reason for Exclusion: Anxiety symptoms are embedded within her depressive disorder.
2. Persistent Depressive Disorder (Dysthymia)
o Reason for Inclusion: Long-standing depressive symptoms.
o Reason for Exclusion: Symptom intensity and episodic exacerbation align more with
major depressive disorder.
Potential Comorbidities:
1. Panic Disorder: Her frequent panic attacks may suggest co-occurring panic disorder.

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 2. Insomnia Disorder: Persistent insomnia is a distinct concern that may require focused
intervention.

5. Treatment Plan
Short-Term Goals:
1. Address and reduce hopelessness through cognitive restructuring and behavioral activation.
2. Manage and reduce panic attack frequency and intensity using relaxation techniques.
3. Improve sleep quality by implementing sleep hygiene practices.
4. Psychoeducation for AR and her family about her condition and available support strategies.
Long-Term Goals:
1. Enhance coping strategies for anxiety and stress.
2. Stabilize overall mood and reduce intensity of depressive symptoms.
3. Improve AR’s functional capacity in her professional and social life.
4. Prevent relapse through regular follow-ups and continuous family support.
6. Therapy Sessions for AR

Session 1: Psychoeducation on Anxiety and Depression

Goal: Increase AR's understanding of her symptoms to reduce fear and stigma associated with anxiety
and depression.
Activities:
1. Explain Depression and Anxiety:
o Therapist (T): "Depression ‫ اور‬anxiety ‫کی وجوہات اور عالمات کے بارے میں بات کریں گے۔ یہ‬
‫ بیماریاں جذبات پر قابو نہ رہنے سے پیدا ہوتی ہیں اور ان کو‬manage ‫"کرنے کے طریقے موجود ہیں۔‬
o Translation: "We’ll talk about the causes and symptoms of depression and anxiety.
These are illnesses that affect emotional control, and there are ways to manage them."
2. Symptom Awareness:
o T: "AR، ‫ نہ کہ‬،‫ وہ اس بیماری کی عالمات ہیں‬،‫کبھی کبھی جو خوف اور نا امیدی آپ کو محسوس ہوتی ہے‬
‫"آپ کی شخصیت۔‬
o Translation: "Sometimes, the fear and hopelessness you feel are symptoms of this
illness, not a part of your personality."
3. Role of Treatment:
o T: "‫"عالج آپ کے ذہنی اور جذباتی توازن کو بحال کرنے میں مدد دے سکتا ہے۔‬

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 o Translation: "Treatment can help restore your mental and emotional balance."
Homework: Encourage AR to write down her feelings daily to identify patterns or triggers of anxiety and
depression.

Session 2: Introduction to Relaxation Techniques and Deep Breathing

Goal: Teach relaxation techniques to manage anxiety and panic symptoms.
Activities:
1. Deep Breathing Exercise:
o Instructions: Guide AR through a simple breathing exercise.
o T: "‫ پھر آہستہ سے سانس باہر نکالیں۔ یہ مشق آپ کو‬،‫ گنتی تک روکیں‬4 ،‫ آہستہ سے سانس اندر لیں‬anxiety
‫"میں سکون دے سکتی ہے۔‬
o Translation: "Inhale slowly, hold for a count of 4, then exhale slowly. This exercise can
help calm you during anxiety."
2. Progressive Muscle Relaxation (PMR):
o Instructions: Teach AR how to tense and then relax each muscle group.
o T: " ‫اپنے جسم کے مختلف حصوں کو سخت کریں اور پھر چھوڑ دیں۔ یہ مشق آپ کے جسم میں سکون النے‬
‫"میں مددگار ثابت ہو سکتی ہے۔‬
o Translation: "Tense and then release each part of your body. This exercise can help bring
relaxation to your body."
Homework: Practice deep breathing twice daily, especially before bed, to manage anxiety and improve
sleep.

Session 3: Cognitive Restructuring for Hopeless Thoughts

Goal: Challenge and replace negative, hopeless thoughts with balanced and realistic ones.
Activities:
1. Identifying Negative Thoughts:
o T: " ‫آئیں ہم ان منفی خیاالت کی شناخت کریں جو آپ کو ناامیدی میں مبتال کرتے ہیں۔ آپ کو کیا خیال آتا ہے‬
‫"جب آپ اپنے مستقبل کے بارے میں سوچتی ہیں؟‬
o Translation: "Let's identify the negative thoughts that make you feel hopeless. What
comes to mind when you think about your future?"
2. Reality Testing:
o T: "‫"ان خیاالت کو حقیقت کے زاویے سے دیکھنے کی کوشش کریں۔ کیا یہ خیاالت حقیقت پر مبنی ہیں؟‬

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 o Translation: "Let’s try to see these thoughts from a reality-based perspective. Are these
thoughts truly based on reality?"
3. Reframing Exercise:
o Example: If AR says, "‫"( "میرا مستقبل بہت تاریک ہے‬My future feels dark"), help her reframe
to "‫ مگر میں آہستہ آہستہ ان کو‬،‫ ابھی حاالت مشکل ہیں‬manage ‫"( "کر سکتی ہوں۔‬The current situation
is tough, but I can manage it gradually.")
Homework: Use a thought record to document and reframe any hopeless thoughts that arise during the
week.

Session 4: Developing a Structured Daily Routine for Stability

Goal: Establish a consistent daily routine to improve mood and stability.
Activities:
1. Morning Routine Planning:
o T: " ‫ہم صبح کا ایک معمول بنائیں گے جو آپ کو دن کے لیے تیار ہونے میں مدد دے گا۔ اس میں دانت صاف‬
‫ اور کچھ دیر کے لیے ورزش شامل ہو سکتی ہے۔‬،‫ چہرہ دھونا‬،‫"کرنا‬
o Translation: "We’ll create a morning routine to help you get ready for the day. This can
include brushing your teeth, washing your face, and doing a short exercise."
2. Nighttime Routine:
o T: "‫"سونے سے پہلے کچھ آرام دہ سرگرمیاں کریں جیسے کتاب پڑھنا یا دعا کرنا۔‬
o Translation: "Do some calming activities before sleep, like reading a book or saying a
prayer."
3. Scheduling Enjoyable Activities:
o T: "‫ منٹ کی ہو۔‬10 ‫ چاہے وہ‬،‫"اپنے روزمرہ کے شیڈول میں کوئی خوشی بخش سرگرمی شامل کریں‬
o Translation: "Include at least one enjoyable activity in your daily schedule, even if it’s
only for 10 minutes."
Homework: Follow the set routine daily and note any changes in mood or anxiety levels.

Session 5: Addressing Sleep Issues with Sleep Hygiene Practices

Goal: Improve sleep quality by implementing sleep hygiene strategies.
Activities:
1. Sleep Routine Development:
o T: " ‫ایک باقاعدہ سونے کا وقت مقرر کریں اور سونے سے ایک گھنٹہ پہلے موبائل فون یا ٹی وی سے دور‬
‫"رہیں۔‬

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 o Translation: "Set a regular bedtime and avoid using your phone or watching TV an hour
before sleeping."
2. Relaxation Before Bed:
o T: "‫"سونے سے پہلے کچھ سکون بخش مشقیں کریں جیسے کہ سانس کی مشقیں یا ہلکی موسیقی سنیں۔‬
o Translation: "Do some relaxing exercises before bed, like breathing exercises or
listening to soft music."
Homework: Follow the nighttime routine consistently and record the quality of sleep each morning.

Session 6: Enhancing Positive Thinking with the Beck Hopelessness Scale Insights
Goal: Address and challenge feelings of hopelessness.
Activities:
1. Discuss BHS Results:
o T: "‫ ہم نے آپ کے‬hopelessness score ‫پر بات کی ہے۔ آئیے ان خیاالت کی نشاندہی کرتے ہیں جو ناامیدی‬
‫"کا باعث بن سکتے ہیں۔‬
o Translation: "We discussed your hopelessness score. Let’s identify the thoughts
contributing to these feelings of hopelessness."
2. Creating Positive Affirmations:
o T: "‫ جیسے کہ 'میں بہتر مستقبل کے لیے کام کر سکتی ہوں۔‬،‫"'ہر دن اپنے لیے ایک مثبت پیغام لکھیں‬
o Translation: "Write a positive message for yourself each day, such as 'I can work
towards a better future.'"
Homework: Each morning, write a positive statement about the future and repeat it to yourself
throughout the day.

Session 7: Introducing Problem-Solving Skills for Daily Challenges

Goal: Equip AR with problem-solving skills to help reduce anxiety about the future.
Activities:
1. Identifying Problems:
o T: "‫"آئیں ہم روزمرہ کے کچھ مسائل کی نشاندہی کریں جن کے بارے میں آپ کو پریشانی ہوتی ہے۔‬
o Translation: "Let's identify some daily issues that cause you anxiety."
2. Problem-Solving Steps:
o Step 1: Define the problem clearly.
▪ T: "‫"سب سے پہلے مسئلے کی نشاندہی کریں اور اس کی تفصیل لکھیں۔‬

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 ▪ Translation: "First, identify the problem and write it down in detail."
o Step 2: Brainstorm possible solutions.
▪ T: "‫"کچھ ممکنہ حل سوچیں۔‬
▪ Translation: "Think of possible solutions."
o Step 3: Choose and act on one solution, then evaluate the outcome.
Homework: Practice using the problem-solving steps on a minor issue each day.

Session 8: Building Social Support Networks

Goal: Encourage AR to re-engage with her social network and build a support system.
Activities:
1. Identifying Supportive People:
o T: " ‫کون کون سے لوگ ہیں جن کے ساتھ آپ بات چیت کر سکتی ہیں اور جو آپ کے لیے مددگار ثابت ہو‬
‫"سکتے ہیں؟‬
o Translation: "Who are the people you can talk to who might be supportive for you?"
2. Setting Social Goals:
o T: "‫"ہفتے میں کم از کم ایک بار کسی دوست یا رشتہ دار سے رابطہ کرنے کا ہدف مقرر کریں۔‬
o Translation: "Set a goal to connect with a friend or family member at least once a week."
3. Role-Playing Social Interactions:
o Practice greeting and initiating a conversation in a comfortable setting.
o T: "‫"آئیں ہم کسی گفتگو کا آغاز کرنے کی مشق کریں۔‬
o Translation: "Let’s practice starting a conversation."
Homework: Reach out to a friend or family member at least once this week and note how it feels.

Session 9: Mindfulness and Present-Moment Awareness

Goal: Introduce mindfulness to reduce AR’s tendency to dwell on negative thoughts.
Activities:
1. Basic Mindfulness Exercise:
o T: "‫ واپس اپنی سانس پر لے آئیں۔‬،‫"اپنے سانس پر توجہ مرکوز کریں۔ جب بھی آپ کا دھیان بھٹکے‬
o Translation: "Focus on your breathing. Whenever your mind wanders, gently bring it
back to your breath."
2. Gratitude Practice:

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 o T: "‫"ہر دن کے آخر میں تین ایسی چیزیں لکھیں جن کے لیے آپ شکر گزار ہیں۔‬
o Translation: "At the end of each day, write down three things you are grateful for."
Homework: Practice mindfulness for five minutes each day and write three things you’re grateful for
before bed.

Session 10: Reviewing Progress and Developing a Relapse Prevention Plan

Goal: Summarize the therapy journey, review coping skills, and set up a relapse prevention plan.
Activities:
1. Review Achievements and Skills Learned:
o T: "‫"ہم نے بہت سے نئے ہنر سیکھے ہیں جو آپ کی مدد کر سکتے ہیں۔ آئیں ان کو یاد کریں۔‬
o Translation: "We’ve learned many new skills that can help you. Let’s review them."
2. Develop a Relapse Prevention Plan:
o Identify early signs of relapse.
o Create a plan for reaching out to family, friends, or a therapist if symptoms reappear.
3. Setting Future Goals:
o T: "‫"آئندہ چند ماہ کے لیے آپ کے کیا اہداف ہیں؟ ہم ان پر کام کریں گے۔‬
o Translation: "What are your goals for the next few months? We’ll work on these."
Homework: Follow the relapse prevention plan and schedule a follow-up appointment.
7.Summary
AR, a 28-year-old woman diagnosed with Generalized Anxiety Disorder and Major Depressive Disorder,
exhibits moderate hopelessness and moderate to severe anxiety impacting her daily life, relationships, and
sleep. Her primary symptoms include pervasive worry, insomnia, and social withdrawal over the past six
months. Psychological assessments using the Hamilton Anxiety Rating Scale (HAM-A) and Beck
Hopelessness Scale (BHS) yielded scores of 29 and 12, respectively, confirming moderate to severe
anxiety and moderate hopelessness. Therapy sessions emphasized psychoeducation, cognitive
restructuring to counter negative thinking, relaxation techniques, and mindfulness exercises, along with a
structured routine to stabilize mood and promote better sleep. AR has shown promising progress in
understanding and managing her symptoms, with a relapse prevention plan in place and further sessions
recommended to reinforce coping skills and emotional resilience.

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 Case No. 9
1. Case History
1.1 Introduction
• Pseudonym: SF
• Age: 38
• Gender: Female
• Marital Status: Married
• Occupation: Homemaker
• Reason for Referral: Persistent anxiety, depressive symptoms, feelings of hopelessness, and
functional impairment.
• Date of Admission: 05-11-2024
• Date of Examination: 06-11-2024
1.2 History of Present Illness
• Complaints and Symptoms: SF reports excessive worry, a strong sense of hopelessness,
irritability, and avoidance of social situations. She experiences insomnia, fatigue, and muscle
tension.
• Duration: These symptoms have persisted and worsened over two years, becoming more
prominent in the past six months.
• Impact on Life: SF’s anxiety and hopelessness have led to significant impairment in her daily
activities, particularly affecting family interactions and self-care.
1.3 Psychiatric History
• Previous Episodes: SF has experienced mild depressive episodes in her thirties but managed
them without professional intervention.
• Treatment History: No history of pharmacological treatment, with sporadic counseling sessions
in the past.
1.4 Physical Illness
• Reported Conditions: None.
1.5 Family History
• Mental Health History: SF’s mother showed mild anxiety symptoms in later years; no other
significant family mental health issues.
1.6 Personal History
• Background: SF grew up in a supportive family environment and has been dedicated to her role
as a homemaker.

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 • Education: High school graduate.
• Social Relationships: Limited social interactions outside the family, describing herself as
introverted and anxious in social situations.

2. Mental Status Examination (MSE)

1. Appearance: Appears fatigued, dressed appropriately but looks unwell and worn out.
2. Behavior: Fidgety, hesitant in speech, frequently wringing hands.
3. Speech: Soft, slow-paced, limited details in responses.
4. Mood: Self-reports feeling “worried and down” with a pervasive lack of optimism.
5. Affect: Restricted, displaying minimal range of emotions.
6. Thought Process: Logical but dominated by themes of failure and worry.
7. Thought Content: Persistent feelings of hopelessness, constant fear regarding family and future.
8. Cognition: Oriented to time, place, and person; occasional difficulty focusing.
9. Insight and Judgment: Recognizes the problem but feels unable to control it, often
catastrophizing.

3. Psychological Testing and Assessment

3.1 Hamilton Anxiety Rating Scale (HAM-A)
• Description: The HAM-A evaluates anxiety severity across domains such as mood, tension, and
physical symptoms, with items rated from 0 (not present) to 4 (very severe).

Item Description Score

Anxious Mood Worries, fear, irritability 3

Tension Feelings of tension, restlessness 4

Fears Fear of crowds, strangers 2

Insomnia Difficulty sleeping, interrupted sleep patterns 3

Intellectual (Concentration) Poor memory, concentration difficulties 2

Depressed Mood Lack of pleasure, prolonged sadness 3

Somatic (Muscular) Muscle aches, stiffness 3

Somatic (Sensory) Hot/cold flushes, weakness 2

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 Item Description Score

Cardiovascular Symptoms Palpitations, chest pain 3

Respiratory Symptoms Constriction in chest, shortness of breath 2

Gastrointestinal Symptoms Nausea, abdominal pain 2

Genitourinary Symptoms Reduced libido, urinary frequency 1

Autonomic Symptoms Dry mouth, giddiness, sweating 3

Behavior at Interview Fidgeting, furrowed brow, pacing 3

• Total HAM-A Score: 36

• Interpretation: SF’s score reflects moderate to severe anxiety, impacting her life across multiple
domains, particularly in tension and somatic symptoms.

3.2 Beck Hopelessness Scale (BHS)

• Description: The BHS assesses SF's level of hopelessness, indicating how frequently she
experiences negative thoughts about the future.

Statement Response Score

I look forward to the future with hope False 1

I might as well give up True 1

Things won’t stay bad forever False 1

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 Statement Response Score

I can’t imagine my life in 10 years True 1

I have time to achieve my goals False 1

I expect to succeed in what matters most False 1

My future seems dark True 1

I expect more good things than average False 1

I don’t get breaks, and it won’t change True 1

All I see is unpleasantness ahead True 1

I don’t expect to get what I want True 1

I expect to be happier in the future False 1

Things won’t work out True 1

I have faith in the future False 1

It’s foolish to want anything True 1

I’m unlikely to get satisfaction in future True 1

The future is uncertain True 1

I look forward to more good than bad times False 1

Trying to get what I want won’t work True 1

• Total BHS Score: 18

• Interpretation: SF’s score reflects severe hopelessness, necessitating intensive psychological
support and intervention.

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4. Diagnosis
DSM-5-TR Diagnosis
• Primary Diagnosis: Generalized Anxiety Disorder (GAD), co-occurring depressive symptoms
(F41.1).
• Secondary Diagnosis: Persistent Hopelessness and Catastrophic Thinking.
Differential Diagnosis
1. Major Depressive Disorder (MDD): Considered but excluded; while depressive symptoms are
present, primary anxiety symptoms are predominant.
2. Adjustment Disorder with Anxiety: Excluded, as SF’s symptoms extend beyond typical
adjustment periods.
Potential Comorbidities
1. Persistent Depressive Disorder (Dysthymia): Persistent low-level depressive symptoms may
overlap.
2. Social Anxiety Disorder: SF exhibits avoidance and anxiety in social interactions.

5. Treatment Plan
Short-Term Goals
1. Reduce anxiety symptoms using cognitive behavioral therapy (CBT) and relaxation techniques.
2. Address hopeless thoughts through cognitive restructuring.

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 3. Psychoeducation for SF and her family.
Long-Term Goals
1. Improve overall coping strategies and resilience.
2. Develop positive, realistic future outlooks and emotional stability.
3. Reinforce family support and self-care practices.

6. Therapy Sessions for SF

Session 1: Psychoeducation on Anxiety and Depression
• Goal: Increase SF’s understanding of her symptoms to reduce fear and stigma.
• Activities:
o Explanation of Anxiety and Depression:
▪ Therapist (T): "Anxiety ‫ اور‬depression ‫جذبات کو متاثر کرتے ہیں لیکن اس پر قابو پایا جا‬
‫"سکتا ہے۔‬
▪ Translation: "Anxiety and depression impact emotions but can be managed."
o Example: Discuss how symptoms such as fear and hopelessness are related to these
conditions and are manageable.
o Role of Treatment: Emphasize the role of therapy in restoring emotional balance.
Session 2: Relaxation Techniques and Breathing Exercises
• Goal: Introduce relaxation techniques to manage anxiety.
• Activities:
o Deep Breathing Exercise:
▪ Instructions: "‫ پھر باہر نکالیں۔‬،‫ گنتی تک روکیں‬4 ،‫"آہستہ سانس لیں‬
▪ Translation: "Inhale slowly, hold for 4 counts, then exhale."
▪ Example: Guide SF through breathing exercises she can use during moments of
anxiety, like before sleep.
o Progressive Muscle Relaxation (PMR): Teach SF to tense and relax muscles from head
to toe, focusing on reducing physical tension.
Session 3: Cognitive Restructuring for Hopelessness
• Goal: Challenge and alter negative thoughts.
• Activities:
o Identify Negative Thoughts: Explore thoughts that drive feelings of hopelessness.

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 ▪ Example: If SF expresses "My future is hopeless," help her explore reasons she
believes this and then reframe the thought to a realistic perspective.
o Reframing Thoughts: Use guided exercises to help her replace these thoughts.
▪ Example: Reframe "Nothing will change" to "I can gradually work on changing
things that I control."
Session 4: Establishing Daily Routine for Stability
• Goal: Improve mood and stability through a structured routine.
• Activities:
o Morning Routine: Design a simple routine for SF.
▪ Example: Include steps such as "Have breakfast at a set time" and "Spend 10
minutes on a hobby."
o Evening Routine: Establish a wind-down process for better sleep.
▪ Example: Reading or listening to calming music before bed.
Session 5: Implementing Sleep Hygiene Practices
• Goal: Address insomnia by improving sleep habits.
• Activities:
o Routine and Relaxation Techniques: Guide SF to avoid screens an hour before bed and
engage in calming activities.
▪ Example: Practice breathing exercises to aid in relaxation before bed.
Session 6: Positive Affirmations and Gratitude Practice
• Goal: Cultivate a positive outlook and combat hopelessness.
• Activities:
o Daily Affirmations: Guide SF in creating daily affirmations.
▪ Example: “Today, I will focus on the things I can control.”
o Gratitude Journal: Encourage SF to list three things she's grateful for each day.
Session 7: Problem-Solving Skills Development
• Goal: Equip SF with skills to handle challenges.
• Activities:
o Identifying Issues and Solutions: Work through real-life examples.
▪ Example: "What steps can you take when feeling anxious about household
tasks?"
o Evaluating Outcomes: Encourage SF to review results and adjust as needed.

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Session 8: Building Social Support Networks
• Goal: Encourage SF to strengthen her support system.
• Activities:
o Identifying Supportive People: List friends or family she can reach out to.
▪ Example: "Set a goal to call or meet one supportive friend weekly."
o Social Interactions Role-Play: Practice casual conversations.
Session 9: Mindfulness and Present-Moment Awareness
• Goal: Introduce mindfulness to reduce negative thoughts.
• Activities:
o Breath Focus Exercise: Practice staying in the present moment.
▪ Example: Focus on breathing whenever her mind wanders to worries.
Session 10: Review and Relapse Prevention Plan
• Goal: Summarize progress and set a long-term plan.
• Activities:
o Review Skills Learned: Go over tools SF has practiced.
o Relapse Prevention: Identify early signs of relapse and create a support plan.

7. Summary
SF, a 38-year-old woman with Generalized Anxiety Disorder and depressive symptoms, scores 36 on
HAM-A and 18 on BHS, indicating moderate to severe anxiety and severe hopelessness. Therapy sessions
covered psychoeducation, relaxation, cognitive restructuring, and mindfulness practices. SF has
developed skills to manage anxiety and hopelessness, with a structured relapse prevention plan
emphasizing family support, self-care, and continuous progress monitoring.

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 Case No. 10
1. Case History
1.1 Introduction
• Pseudonym: MS
• Age: 52
• Gender: Male
• Marital Status: Divorced
• Occupation: Office Manager
• Reason for Referral: Persistent anxiety, depressive symptoms, frequent worry, and recent
experiences of social withdrawal.
• Date of Admission: 10-11-2024
• Date of Examination: 11-11-2024
1.2 History of Present Illness
• Complaints and Symptoms: MS reports experiencing constant worry, feelings of sadness,
avoidance of social gatherings, and occasional irritability. He has difficulty sleeping, frequent
headaches, and feels fatigued and unmotivated.
• Duration: Symptoms began two years ago, increasing in severity over the past eight months,
particularly after his recent divorce.
• Impact on Life: MS’s symptoms have affected his work performance, leading to reduced
productivity and strained relationships with coworkers and family.
1.3 Psychiatric History
• Previous Episodes: Mild depressive symptoms following a job change five years ago; managed
without formal treatment.
• Treatment History: No history of prior psychiatric treatment or medications.
1.4 Physical Illness
• Reported Conditions: High blood pressure, currently managed with medication.
1.5 Family History
• Mental Health History: Family history includes a brother with a history of depression.
1.6 Personal History
• Background: MS grew up in a stable family environment and worked diligently throughout his
career.
• Education: Holds a bachelor’s degree in business management.

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 • Social Relationships: Describes himself as sociable in the past but has become increasingly
withdrawn over the past year.

2. Mental Status Examination (MSE)

1. Appearance: Neatly dressed but appears tired and somewhat unkempt.
2. Behavior: Hesitant and avoids eye contact; visibly anxious.
3. Speech: Low volume, slow in pace, with frequent pauses.
4. Mood: Self-reports feelings of “hopelessness” and “worry.”
5. Affect: Restricted, showing limited range of emotions.
6. Thought Process: Logical but dominated by repetitive thoughts of worry and self-doubt.
7. Thought Content: Predominantly focused on themes of failure, regret, and pessimism about the
future.
8. Cognition: Fully oriented; occasional struggles with attention and memory, especially during
moments of anxiety.
9. Insight and Judgment: Aware of his symptoms but feels unable to manage them, often
catastrophizes outcomes.

3. Psychological Testing and Assessment

3.1 Hamilton Anxiety Rating Scale (HAM-A)
• Description: The HAM-A is a clinician-rated scale that assesses anxiety severity, including
mood, cognitive, and somatic symptoms. Scores range from 0 to 4 on each item, with higher
scores indicating more severe anxiety.

Item Description Score

Anxious Mood Worries, irritability 4

Tension Restlessness, inability to relax 3

Fears Fear of being alone, social situations 2

Insomnia Difficulty initiating and maintaining sleep 3

Intellectual (Concentration) Memory problems, reduced concentration 3

Depressed Mood Persistent sadness, lack of pleasure 4

Somatic (Muscular) Muscle tension, headaches 3

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 Item Description Score

Somatic (Sensory) Hot flushes, weakness 2

Cardiovascular Symptoms Palpitations, chest tightness 3

Respiratory Symptoms Shortness of breath 2

Gastrointestinal Symptoms Nausea, abdominal discomfort 2

Genitourinary Symptoms Increased urinary frequency 1

Autonomic Symptoms Sweating, dry mouth 2

Behavior at Interview Restlessness, fidgeting 3

• Total HAM-A Score: 35

• Interpretation: A score of 35 suggests moderate to severe anxiety, with predominant symptoms
in anxious mood, insomnia, and somatic symptoms.

3.2 Beck Hopelessness Scale (BHS)

• Description: The BHS assesses hopelessness severity, examining MS’s outlook and future
expectations. It uses true/false statements, with higher scores indicating greater hopelessness.

Statement Response Score

I look forward to the future with hope False 1

I might as well give up True 1

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 Statement Response Score

Things won’t stay bad forever False 1

I can’t imagine my life in 10 years True 1

I have time to achieve my goals False 1

I expect to succeed in what matters most False 1

My future seems dark True 1

I expect more good things than average False 1

I don’t get breaks, and it won’t change True 1

All I see is unpleasantness ahead True 1

I don’t expect to get what I want True 1

I expect to be happier in the future False 1

Things won’t work out True 1

I have faith in the future False 1

It’s foolish to want anything True 1

I’m unlikely to get satisfaction in future True 1

The future is uncertain True 1

I look forward to more good than bad times False 1

Trying to get what I want won’t work True 1

• Total BHS Score: 18

• Interpretation: MS’s score of 18 on the BHS indicates a high level of hopelessness, associated
with negative future expectations and limited optimism.

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4. Diagnosis
DSM-5-TR Diagnosis
• Primary Diagnosis: Major Depressive Disorder, Moderate to Severe (296.32)
• Secondary Diagnosis: Generalized Anxiety Disorder (F41.1)
Differential Diagnosis
1. Persistent Depressive Disorder: While chronic depressive symptoms are present, the episodic
worsening aligns more closely with major depressive disorder.
2. Adjustment Disorder with Anxiety: Excluded due to symptom duration and severity.
Potential Comorbidities
1. Social Anxiety Disorder: Avoidance and anxiety in social settings may indicate co-occurrence.
2. Insomnia Disorder: Persistent sleep issues may require focused intervention.

5. Treatment Plan
Short-Term Goals
1. Reduce anxiety and increase mood stability using cognitive and relaxation strategies.
2. Decrease hopelessness and pessimistic thoughts through structured cognitive therapy.
3. Improve sleep quality by implementing sleep hygiene practices.
Long-Term Goals
1. Stabilize mood and enhance overall coping mechanisms.

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 2. Rebuild social connections and support network.
3. Prevent relapse through continuous monitoring and skill reinforcement.

6. Therapy Sessions for MS

Session 1: Psychoeducation on Anxiety and Depression
• Goal: Increase MS’s understanding of anxiety and depressive symptoms.
• Activities:
o Overview of Symptoms: Explain that anxiety and depressive symptoms are common
and manageable.
▪ Example: "Anxiety ‫ اور‬depression ‫ لیکن‬،‫آپ کے ذہنی اور جذباتی توازن کو متاثر کرتے ہیں‬
‫"ان کا عالج ممکن ہے۔‬
▪ Translation: "Anxiety and depression impact your mental and emotional
balance, but they are treatable."
o Symptom Recognition: Encourage MS to recognize symptoms as part of a treatable
condition.
Session 2: Relaxation Techniques and Breathing Exercises
• Goal: Introduce relaxation techniques to alleviate anxiety symptoms.
• Activities:
o Deep Breathing: Guide MS through slow, mindful breathing exercises.
▪ Example: "‫"آہستہ سانس اندر لیں اور باہر نکالیں۔ یہ مشق آپ کو پرسکون کر سکتی ہے۔‬
▪ Translation: "Inhale and exhale slowly. This exercise can help you calm down."
o Muscle Relaxation: Teach him to tense and relax each muscle group to release physical
tension.
Session 3: Cognitive Restructuring for Hopelessness
• Goal: Address and restructure negative thoughts contributing to hopelessness.
• Activities:
o Identifying Negative Thoughts: Help MS list common hopeless thoughts.
▪ Example: “If MS says, ‘There’s no hope for my future,’ encourage him to
explore the reality of this belief and consider evidence to the contrary.”
o Reframing: Guide him to modify these thoughts to a balanced perspective.
Session 4: Developing a Daily Routine for Stability
• Goal: Establish consistent routines to improve mood and resilience.

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 • Activities:
o Morning Routine: Develop a simple daily routine to encourage productivity.
▪ Example: “Wake up at a set time, have breakfast, and engage in one enjoyable
activity.”
o Bedtime Routine: Structure a relaxing nighttime routine.
Session 5: Sleep Hygiene Education
• Goal: Improve sleep quality through better sleep practices.
• Activities:
o Implement Relaxation Techniques: Guide MS to perform a calming activity before bed.
o Limit Screen Use: Discuss the impact of screens on sleep and encourage screen-free
time an hour before bed.
Session 6: Gratitude and Positive Affirmations
• Goal: Shift focus to positive elements in life.
• Activities:
o Daily Gratitude Journal: Encourage MS to list three things he’s grateful for each day.
o Affirmations: Create a positive statement to repeat daily.

7. Summary
MS, a 52-year-old male office manager diagnosed with Major Depressive Disorder and Generalized
Anxiety Disorder, displays severe hopelessness and moderate to severe anxiety symptoms. Scoring 35 on
the Hamilton Anxiety Rating Scale and 18 on the Beck Hopelessness Scale, he presents a challenging
clinical picture. Treatment includes psychoeducation, relaxation, cognitive restructuring, and routine
establishment to stabilize mood and improve functionality. Structured therapy sessions aim to reduce
symptoms, develop positive coping skills, and implement a relapse prevention plan to foster long-term
stability and prevent relapse.

114
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