CLINICAL CASE REPORT

A Case Report on Model Clinical Assessment Sessions, submitted to the

Department of Clinical Psychology at the University of Rajshahi, in partial
fulfillment of the requirements for the degree of B.Sc. (Hons) Part-IV, 2024

Course code: CPSY-407

Course Title: Clinical Assessment

Submitted by
ID:2112162103
Session:2020-21
Department of Clinical Psychology,
University of Rajshahi.

Supervised by
Mst. Anamika Yeasmin
Assistant Professor,
Department of Clinical Psychology,
University of Rajshahi.

DEPARTMENT OF CLINICAL PSYCHOLOGY

UNIVERSITY OF RAJSHAHI, RAJSHAHI
 DECLARATION

It is my humble declaration that this Clinical case report for the fourth-year course, of the

Department of Clinical Psychology is completely new and original work of mine. This report

has not been submitted before to any other university or institute for any degree.

Id: 2112162103
Session: 2020-21
Department of Clinical Psychology
University of Rajshahi
Rajshahi, Bangladesh.

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 CERTIFICATE

This is to certify that the clinical case report has been successfully conducted by ID:

2010262123, session: 2019-20 of the Clinical Psychology department at the University of

Rajshahi as part of the requirements for the B.Sc. (Hons) Part- IV examination. He has done

this study under my direction and supervision. This is the candidate’s own piece of work. Its

submission for the B. Sc. Degree has my approval.

Supervisor

……………………………………
Mst. Anamika Yeasmin
Assistant Professor
Department of Clinical Psychology
University of Rajshahi.

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 ACKNOWLEDGEMENT

I would like to express my profound gratitude to all those whose support and contributions

have been instrumental in the successful completion of this model clinical case report.

First and foremost, I am deeply thankful to my respected supervisor, Mst. Anamika Yeasmin

mam, for her continuous support, insightful guidance, and constructive feedback. Her

encouragement and mentorship have been crucial in navigating the complexities of this clinical

work and in enhancing the overall quality of the report.

I am sincerely grateful to the patients who took part in this study. Their openness in sharing

personal experiences has added meaningful depth to the research and underscored the

significance of compassion and understanding in mental health care.

I also extend my heartfelt thanks to my friends and family members. Their constant

encouragement, patience, and emotional support have provided me with the strength and

determination needed to overcome the challenges encountered during this journey.

This report stands as a reflection of the collective efforts, guidance, and support of all the

individuals mentioned above, whose contributions I deeply value and acknowledge with great

respect.

Id: 2112162103
Session: 2020-21
Department of Clinical Psychology
University of Rajshahi
Rajshahi, Bangladesh.

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 Table of Contents

Contents Page No.

DECLARATION .................................................................................................... i
CERTIFICATE ......................................................................................................ii
ACKNOWLEDGEMENT .................................................................................. iii
CLINICAL CASE- I ............................................................................................. 1
CLINICAL CASE- II .......................................................................................... 13
CLINICAL CASE- III......................................................................................... 23
CLINICAL CASE- IV ........................................................................................ 32
CLINICAL CASE- V .......................................................................................... 43
CLINICAL CASE- VI ........................................................................................ 53

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 CLINICAL CASE- I

CASE HISTORY

A. Demographic information

Miss S is a 22 years old unmarried female who grew up in a nuclear Muslim family with her

parents and siblings. Now she studies in hons 2nd year at University of Rajshahi and staying

in university hall.

B. Chief complaint

She came to me with some problem which was relationship problem with friends, failure

feelings, sleep problem, concentration problem and sometimes she wishes she could die in an

accident. This problem is going for over years. He is referred to me by a psychiatrist.

C. Assessment tools

Assessment is a continuous process that involves gathering information about clients, often

beginning with a normal conversation. The initial assessment starts with collecting

demographic details and then gradually explores symptoms, severity, mood, relevant history,

current situation, and present problems across different areas of functioning. Various

psychological tools were used to collect this information.

 Clinical Interview

In-depth clinical interview was done by me through open-ended and closed

questions, active listening with empathetic. During this time observation was

focused on the attention of the client, her appearance, eye contact, gesture, posture,

congruence of mood speech, and mood.

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  Objective Rating

Client’s anxiety was measured by an objective Anxiety scale which was developed by Farah

Deeba and Dr. Roquia Begum (2004). Depression scale which is developed by

Md. Zahir Uddin and Dr. Mahmudur Rahman (2005) was administered to assess

the level of depression

Subjective Ratings of Mood and Overall Problems

In this procedure the client was asked to rate her overall problems and mood as

she was considering. She was asked to rate her mood and overall problems from

0-10 scale where 0 level was the lowest and 10 was the highest level of well-

being.

0 1 2 3 4 5 6 7 8 9 10

Figure: Subjective Rating Scale

Session Subjective Rating

1st 2
2nd 3
3rd 4
4th 4
5th 5
6th 6
7th 7
8th 8

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 D. History of present illness and relevant background history

Miss S came with some issues which caused significant distress and impairment in her daily

activities. The client is a 22-year-old female, currently a second-year honors student at the

University of Rajshahi. She reported that her emotional problems started approximately 1.5

years ago, around the time she failed to secure admission to medical school—a goal she had

nurtured since childhood. The client grew up as the youngest child in a loving family where

she was adored and praised for her academic performance. From childhood, she internalized

the belief that her self-worth depended on being an exceptional student and achieving high

goals (e.g., becoming a doctor).

When she failed to get admitted to medical school, it shattered her core belief: “I am only

valuable if I achieve big goals.” This early conditional self-worth created a vulnerability to

depression because any academic failure or criticism strongly affected her self-esteem.

After not being accepted into medical school, she experienced profound disappointment and

began believing that “there is nothing left in my life.” Although she denies active suicidal

intent, she admits to passive suicidal ideation, such as thinking, “If I died in an accident, it

would be better.” She knows that suicide is a sin, which prevents her from actively attempting

it, but she feels hopeless about the future.

She reported that her confidence decreased after joining university. When given assignments,

she often feels anxious and thinks she cannot complete them, which leads to avoidance and

procrastination. She frequently experiences a sense of failure and inadequacy. Additionally, she

described interpersonal problems with friends, primarily miscommunication and feeling

misunderstood, which have contributed to social withdrawal and loneliness.

She has also experienced persistent sleep problems, including difficulty maintaining sleep and

non-restorative rest. She often wakes up several times at night and feels tired during the day.

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She reports episodes of crying without any specific trigger, persistent low mood, hopelessness,

worthlessness, and difficulty concentrating on academic tasks.

The client denies any previous psychiatric treatment. She reports no history of psychotic

symptoms, mania, or substance abuse. Her symptoms have been persistent and have gradually

worsened over the past four years, with no symptom-free period longer than two months.

These issues affected following areas of functioning:

a. Emotional symptoms

 Hopelessness

 Feeling anxious

 Frequent crying

 Feeling overwhelmed by even small problem

b. Cognitive symptoms

 Indecisiveness

 Passive suicidal ideation

 Consider herself as unworthy because of lack of confidence.

 Thought that nobody understands her point of view.

c. Behavioral symptoms

 Withdrawn communication

 Seeking help to complete any kind of small assignment.

d. Physiological symptoms

 Trouble sleeping (fragmented sleep)

 Chest pain

 Terrible migraine headache

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 E. Psychiatric history

Miss S has no prior history of psychiatric treatment or diagnosis. She denies any previous

episodes of depression, anxiety, or other mental health concerns.

F. Personal and social history

 Premorbid Personality: Described herself as hardworking, perfectionistic, and

sensitive to criticism. She was generally introverted and highly achievement-

oriented.

 Social History: She has a supportive family and lives with them. However, she has

strained interpersonal relationships with friends due to miscommunication and

social withdrawal.

 Hobbies and Interests: Previously enjoyed studying and planning for a medical

career but currently reports reduced interest in previous activities.

G. Medical history

No significant surgical or chronic medical conditions reported apart from migraine.

H. Mental status check

 General appearance and behavior: Appears stated age, dressed neatly, minimal eye

contact, psychomotor retardation observed.

 Speech

 Rate: Slow

 Rhythm: Normal

 Volume: Low

 Content: Preoccupied with themes of failure and hopelessness.

 Mood: Depressed

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 Affect: Constricted, congruent with mood

 Thought

 Form: Logical and coherent

 Content: Hopelessness, worthlessness, passive suicidal ideation.

 Stream: Slow, occasional blocking.

 Perceptual disturbance: No hallucinations or delusions reported.

 Cognitive functions

 Consciousness: Clear

 Attention & Concentration: Impaired

 Orientation (time & place): Intact

 Memory: Intact

 Abstract Thinking: Mildly impaired (likely secondary to mood)

 Intelligence: Average

 Judgement: Mildly impaired (pessimistic decision-making)

 Insight: Partial (aware of illness but doubts recovery potential)

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I. DSM-5 diagnosis

Primary Diagnosis: Major Depressive Disorder (MDD), Moderate Episode

Symptoms Present:

 Persistent sad mood and frequent crying spells

 Feelings of hopelessness and failure (“There is nothing left in life”)

 Passive suicidal ideation (“It would be better if I died in an accident”)

 Loss of confidence (especially in academics, assignments)

 Difficulty concentrating on studies

 Sleep disturbance (difficulty maintaining sleep, waking up frequently at night)

 Interpersonal conflicts with friends (miscommunication, social withdrawal)

 Reduced motivation for academic tasks

 Episodes lasting more than 2 weeks and present for 1.5 years.

Additional DSM-5 Criteria Met

1. At least five symptoms present nearly every day during the same 2-week period (mood

disturbance, anhedonia, concentration issues, fatigue, feelings of worthlessness,

suicidal ideation).

2. Symptoms cause clinically significant distress and impairment in social, academic, and

interpersonal functioning.

3. Episode is not attributable to substance use or medical condition.

4. There is no history of manic or hypomanic episodes (rules out bipolar disorder).

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Differential Diagnosis (DSM-5)

1. Persistent Depressive Disorder (Dysthymia)

 Reason for consideration: Client reports chronic low mood and confidence issues.

 Reason for ruling out: Client’s depressive episodes are severe, with passive suicidal

ideation and marked functional impairment, more consistent with MDD episodes rather

than persistent low-grade depression.

2. Generalized Anxiety Disorder (GAD)

 Reason for consideration: Client reports anxiety symptoms (low confidence,

assignment worries).

 Reason for ruling out: Anxiety is secondary to depressive mood rather than primary

and generalized across multiple domains.

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CASE FORMULATION

Early Experience

youngest child, praised mainly for academic success, Strong family value on
achievement → conditional self-worth

Core Beliefs
Self: “I am a failure if I don’t achieve.”
Others: “People value me only if I succeed.”
Future: “My life will never improve.

Dysfunctional Assumption
“If I fail in my career, I am worthless and unlovable.”
proves I am undesirable.”

Critical Incident
Failure to enter medical school, conflicts with friends.

Negative Automatic Thought

I am incompetent.”
“There’s nothing left for me.”
“I don’t deserve happiness.”

Symptoms

Behavioral Cognitive
Social withdrawal, low academic Poor concentration, self-criticism,
engagement. hopelessness.


Affective
Physiological
Sadness, anxiety, guilt and crying Sleep disturbance, low energy,
diminished pleasure.

Figure-2: Problem formulation of the client using case conceptualization model for
Depression by A.T. Beck (1993)

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 A. Specific formulation

TREATMENT PLAN

Problem list Treatment goals Plan for treatment/techniques

Depressed mood, hopelessness Improve mood, reduce CBT (cognitive restructuring,

hopelessness behavioral activation)
Sleep disturbance Improve sleep quality Sleep hygiene, relaxation
training
Concentration & academic Enhance academic focus Problem-solving therapy, time
difficulty management skills
Social withdrawal & Improve social functioning Social skills training, graded
miscommunication exposure
Passive suicidal ideation Ensure safety Safety planning, crisis
intervention if needed

1.Cognitive Restructuring

Helps the client identify and challenge negative automatic thoughts such as “I am incompetent”

or “My life is over.” Through Socratic questioning and evidence testing, the therapist guides

the client to replace irrational beliefs with balanced thoughts, improving mood and confidence.

2. Behavioral Activation

Focuses on increasing engagement in meaningful and pleasurable activities that have been

avoided due to depression. By scheduling and gradually increasing positive behaviors, it helps

break the cycle of inactivity and low mood, restoring motivation and pleasure.

3. Problem-Solving Training

Teaches the client structured methods to tackle academic and interpersonal issues contributing

to distress. The client learns to define problems clearly, generate options, evaluate outcomes,

and implement solutions, which enhances coping skills and reduces hopelessness.

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4. Sleep Hygiene & Relaxation Techniques

Introduces healthy sleep practices (consistent sleep schedule, reducing stimulants, creating a

calm bedtime routine) and relaxation methods (deep breathing, progressive muscle relaxation).

These reduce physiological arousal and improve sleep quality, lowering fatigue and irritability.

5. Social Skills & Communication Training

Addresses interpersonal difficulties and miscommunication with peers. Through role-plays and

assertiveness training, the client practices expressing needs effectively and building supportive

relationships, which reduces isolation and boosts self-esteem.

I applied Cognitive Restructuring by teaching the client to identify negative automatic thoughts

like “I am a failure” and guided her through Socratic questioning to generate balanced

alternative thoughts. Behavioral Activation was implemented by collaboratively creating an

activity schedule focusing on pleasurable and mastery-oriented tasks. I introduced Sleep

Hygiene strategies (fixed bedtime, reduced screen use) and Relaxation Techniques to address

sleep disturbances. Social Skills Training was used through role-play to improve her

communication with peers. Over sessions, she reported increased mood, reduced self-critical

thinking, and improved academic engagement.

TREATMENT OUTCOME

 Short-term: Improved sleep and mood, reduced crying spells, better concentration.

 Medium-term: Improved academic performance, better interpersonal relationships.

 Long-term: Reduced risk of relapse, improved self-worth, and restructuring of

maladaptive core beliefs.

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DISCUSSION

A total of 8 CBT sessions were conducted over two months focusing on cognitive restructuring,

behavioral activation, problem-solving skills, sleep hygiene, and social skills training. Over the

course of treatment, the client showed significant improvement in mood, reduced frequency of

negative automatic thoughts, improved sleep, and increased engagement in academic and social

activities. Passive suicidal thoughts decreased, and confidence in completing academic tasks

improved.

However, residual symptoms such as occasional feelings of worthlessness and mild social

withdrawal persisted, especially during stressful academic periods. The client also required

additional work on building long-term resilience and relapse prevention skills. Overall, the

treatment outcome was positive, with substantial reduction in depressive symptoms and

improved daily functioning, though booster sessions were recommended to strengthen coping

strategies and prevent relapse.

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 CLINICAL CASE- II

CASE HISTORY

A. Demographic information

A 24 years old married female who study at the University of Rajshahi in hons 3 rd year. She

lives with her husband near university campus.

B. Chief complaint

I feel very anxious when things are not perfectly organized. I spend a lot of time arranging and

checking things, fearing that if I leave things out of place, something bad will happen.

C. Assessment tools

 Subjective assessment

For conceptualizing the client assessment has done through subjective interview and

accomplishment of home works, work sheets and so on.

 Objective rating

To get the objective rating of the client, one scale was used in the client’s assessment: The

Bangla Y-BOCS (Yale-Brown Obsessive-Compulsive Scale), developed by Wayne K.

Goodman and colleagues in 1989 and adapted and validated by (Islam & Nahar, 2021).

 Subjective rating

In this procedure the client was asked to rate his overall problems and mood as he was

considering. He was asked to rate his mood on a one item Likert scale between 0 to 10. 1

represents extremely low well-being—characterized by persistent dissatisfaction, negative

emotions, and a lack of fulfillment—while 10 represents extremely high well-being, indicating

complete satisfaction with life, emotional stability, and a strong sense of purpose. The

following table shows the subjective well-being.

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 Sessions Subjective rating

1st 4

2nd 3

3rd 5

4th 5

5th 6

6th 6

D. History of present illness and relevant background history

The client is a 29-year-old married woman who reports experiencing obsessive thoughts and

compulsive behaviors primarily focused on organization and orderliness. She recalls a

significant event from her past when, due to her carelessness, a flowerpot fell on a dog’s head,

causing its death. She described this incident as traumatic and stated, “Since then, I feel if I

don’t keep things perfectly organized, something bad will happen.”

Her obsessive thoughts are mainly centered on potential harm caused by disorganized objects

(e.g., “If this item falls, someone could be injured”). These thoughts trigger intense anxiety and

guilt, which she can only reduce by repeatedly organizing and checking household items to

ensure everything is perfectly aligned.

She spends significant time every day checking and arranging items, often repeating the same

actions several times until it “feels right.” She is aware that her fears are excessive and irrational

but feels unable to stop herself. If she resists organizing, she experiences severe anxiety,

restlessness, and difficulty concentrating.

She reports that her symptoms interfere with daily life, including delaying household chores

and sometimes causing conflict with her spouse, who does not understand the need for such
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extreme organization. She denies any previous psychiatric treatment. No history of psychosis,

substance abuse, or major medical illness is reported.

Emotional symptoms

 Anxiety when items are disorganized

 Guilt linked to the past incident (dog’s death)

 Irritability when interrupted during organizing tasks

 Relief but short-lived after compulsions

Cognitive symptoms

 Obsessive thoughts: “If things are not perfectly organized, harm will occur.”

 Overestimation of responsibility

 Catastrophic thinking about possible harm

Behavioral symptoms

 Repeated checking and organizing until it “feels right”

 Avoiding leaving items in random places

 Spending excessive time arranging objects

Physiological symptoms

 Muscle tension while thinking about disorganization

 Increased heart rate and restlessness during anxiety episodes

 Headache due to prolonged tension

E. Psychiatric history

No prior psychiatric treatment. No history of psychosis, mania, or depression requiring

hospitalization.

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F. Personal and social history

 Premorbid Personality: Perfectionistic, highly conscientious, and responsible.

 Social History: Married life generally stable, but frequent disagreements with her

spouse about her organizing behaviors. Limited social life as she spends considerable

time arranging items at home.

G. Medical history

No significant physical illnesses reported.

H. Mental status check

 General appearance and behavior: Well-groomed, cooperative but visibly anxious
when discussing disorganized items.
 Speech
o Rate: Normal
o Rhythm: Normal
o Volume: Normal
o Content: Preoccupied with organization and harm prevention.
 Mood: Anxious
 Affect: Tensed, restricted
 Thought
o Form: Logical, coherent
o Content: Obsessive thoughts about harm caused by disorganization.
o Stream: Repetitive focus on safety concerns.
 Perceptual disturbance: No hallucinations or delusions.
 Cognitive functions
o Consciousness: Clear
o Attention & Concentration: Distracted by obsessions
o Orientation: Intact
o Memory: Intact
o Abstract Thinking: Intact
o Intelligence: Average

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  Judgement: Compromised by obsessive fear
 Insight: Good (aware that fears are excessive but unable to control them)

I. DSM-5 diagnosis

Obsessive-Compulsive Disorder (OCD)

DSM-5 Code: 300.3 (F42)(American Psychiatric Association, 2013)

A. Presence of obsessions, compulsions, or both:

The client experiences both obsessions and compulsions:

 Obsessions:

She reports intrusive and distressing thoughts that disorganization in her environment

may lead to harm to others (e.g., "If this item falls, someone could be injured"). These

thoughts are recurrent, unwanted, and anxiety-provoking, fulfilling the definition of

obsessions.

 Compulsions:

In response to these thoughts, she engages in repetitive organizing, arranging, and

checking behaviors. These compulsions are aimed at reducing her anxiety and

preventing perceived harm, even though she recognizes these fears are excessive.

Therefore, she has compulsions in the form of organizing and checking rituals to

neutralize obsessive fears.

B. The obsessions or compulsions are time-consuming (e.g., more than 1 hour per day)

or cause clinically significant distress or impairment

 The client spends a significant portion of the day arranging and checking items.

 Her compulsions interfere with daily responsibilities and cause relationship conflict

with her spouse.

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  She reports severe distress if unable to perform these rituals.

C. The symptoms are not attributable to substance use or another medical condition

 The client denies substance use, psychosis, or medical illness.

 No indication that her behaviors are due to medication or neurological issues.

D. The disturbance is not better explained by another mental disorder

 The obsessive fear of harm and the compulsive rituals are specific to OCD, not better

explained by generalized anxiety disorder, major depressive disorder, or other

conditions.

 She does not meet criteria for psychosis, PTSD, or autism spectrum disorder.

Comorbidity

Generalized Anxiety Disorder (GAD) – Likely

Justification:

 The client experiences persistent anxiety, even beyond her OCD triggers.

 She shows signs of excessive worry, restlessness, and difficulty concentrating,

especially when rituals are disrupted.

 If anxiety is present across various domains, not just related to obsessions, GAD may

be co-occurring.

2. Major Depressive Disorder (MDD) – Possible

Justification:

 Chronic OCD often leads to frustration, hopelessness, and relationship conflict,

increasing risk for depression.

 Although the client does not explicitly report depressive symptoms like low mood,

anhedonia, or suicidal ideation, the functional impairment and guilt could indicate

underlying depressive features.

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 CASE FORMULATION

A. Specific formulation

Early experience Critical Incidents

the client experienced a traumatic The death of the dog was perceived as a turning point,
incident: a flowerpot fell on a forming a causal link in her mind: “If I had been more
careful, that wouldn’t have happened.”
dog’s head, leading to its death.
This incident triggered a long-standing pattern of
She associates this with her own
compulsive organizing to prevent future harm, despite
carelessness. no actual danger. This theme of magical thinking and
guilt continues to guide her current behavior

Assumptions / General Beliefs: activates

“I am responsible for preventing harm.”
“If I don’t keep things perfectly aligned, something bad will happen.”
“Even a small mistake like a misaligned object can lead to serious
consequences.”
“A good person keeps everything under control”

Intrusive Thoughts, Images, Urges, Doubts:

“What if someone gets hurt because something is out of place?”
“If this item falls, I’ll be responsible.”
“Things must be arranged just right or else something terrible
might occur.”

Neutralizing Actions Reasoning Bias

Repeatedly arranging household items until Biased reasoning like "just to be safe" or “If I
“perfect.”, Checking that objects are aligned don’t fix this, I’m responsible for the
and cannot fall. consequences,” “If I organize everything
Restarting tasks multiple times until they perfectly, I can prevent harm.”
feel “safe.”, Avoiding moving on until the “A disorganized space equals danger.”
setup feels “just right.”

Misinterpretation of Intrusions (Core of OCD):

“If I don’t fix this, I’m responsible for the consequences.”
“If I organize everything perfectly, I can prevent harm.”
“A disorganized space equals danger.”

Counterproductive Safety Strategies Mood Changes

Avoiding completing tasks until High anxiety when prevented from
arranging is done. completing rituals.
Not trusting her initial perception — Guilt and self-blame over the past
always re-verifying. incident and potential future harm.
Strained interactions with spouse over Low mood, mental fatigue, and
unexplained rituals. irritability due to constant mental
effort.

Figure: The cognitive model of OCD

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TREATMENT PLAN

Problem list Treatment goals Plan for

treatment/techniques

Obsessive fears of harm Reduce anxiety related to Cognitive restructuring,

disorganization psychoeducation

Compulsive organizing and Reduce compulsions Exposure and Response

checking Prevention (ERP)

Associated anxiety and guilt Improve emotional Relaxation training,

regulation mindfulness

Interpersonal conflict Improve relationship Couple counseling,

functioning communication skills
training

1. Exposure and Response Prevention (ERP)

ERP involves exposing the client to anxiety-provoking situations (e.g., leaving items slightly

disorganized) while preventing the compulsive behavior (repeated organizing/checking). Over

time, anxiety decreases naturally (habituation), and the client learns that feared consequences

do not occur, reducing compulsive urges.

2. Cognitive Restructuring

Focuses on identifying and challenging maladaptive beliefs such as “If things are not perfect,

something bad will happen.” The therapist helps the client evaluate evidence and develop

balanced thoughts, reducing catastrophic thinking and excessive responsibility beliefs.

3. Relaxation Training

Techniques like deep breathing and progressive muscle relaxation help manage the

physiological anxiety that arises during exposure tasks. Reducing body tension improves

emotional regulation and supports ERP compliance.

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4. Psychoeducation

Educates the client about OCD, explaining how obsessions and compulsions are maintained

through negative reinforcement. This helps build insight and motivation for therapy, reducing

shame and self-blame.

5. Relapse Prevention Planning

Focuses on recognizing early warning signs of OCD relapse and creating an action plan to

maintain progress, including continued exposure practice and cognitive strategies for future

stressors.

I primarily used Exposure and Response Prevention (ERP), asking the client to deliberately

leave items slightly unorganized while refraining from compulsive arranging/checking.

Anxiety levels were monitored, showing gradual reduction with repeated exposure. Cognitive

Restructuring was applied to challenge beliefs like “Something bad will happen if things are

not perfect.” I used Relaxation Training before exposure to manage physiological arousal and

Psychoeducation to normalize symptoms and increase compliance. Progressively, the client

showed reduced compulsions and improved tolerance of uncertainty.

TREATMENT OUTCOME

Short-term: Reduction in anxiety intensity and organizing frequency.

Medium-term: Improved tolerance for minor disorganization, better relationship with spouse.

Long-term: Significant reduction in obsessive-compulsive cycle and improved daily

functioning.

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DISCUSSION

A total of 6 CBT sessions were conducted focusing primarily on ERP and cognitive

restructuring, supported by relaxation training and psychoeducation. The client reported

significant reduction in compulsive organizing behaviors and decreased anxiety when items

were slightly disorganized. Intrusive thoughts about potential harm diminished in frequency

and intensity.

Despite improvements, mild residual anxiety persisted in highly triggering situations (e.g.,

sudden unexpected disorder at home). The client showed strong insight and willingness to

continue practicing ERP independently. Booster sessions were recommended to strengthen

coping strategies and prevent relapse, ensuring long-term maintenance of treatment gains.

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 CLINICAL CASE- III

CASE HISTORY

A. Demographic information

Miss T is 26 years old female client who lives with her family. She is unmarried and a private
job holder.

B. Chief complaint
I suddenly feel intense fear, my heart races, I can’t breathe properly, and I feel like I might

die or lose control.

C. Assessment tools

 Subjective assessment

For conceptualizing the client assessment has been done over the sessions through subjective

interviews, reviews of home works, and work sheets.

 Objective rating

Mental Status Exam – Anxious mood, good insight, no psychosis.

BAI (Beck Anxiety Inventory) – To assess anxiety severity.

 Subjective rating

In this procedure the client was asked to rate his overall problems and mood as he was

considering. He was asked to rate his mood on a one item Likert scale between 0 to 10. 1

represents extremely low well-being—characterized by persistent dissatisfaction, negative

emotions, and a lack of fulfillment—while 10 represents extremely high well-being,

indicating complete satisfaction with life, emotional stability, and a strong sense of purpose.

The following table shows the subjective well-being.

Page | 23
D. History of present illness and relevant background history

The client is a 26-year-old female who reported experiencing sudden episodes of intense fear

and discomfort, accompanied by physical sensations such as palpitations, breathlessness,

sweating, dizziness, and trembling. These attacks started approximately six months ago and

occur two to three times per week, usually in crowded places or when traveling alone.

She described the first attack as occurring while she was shopping in a crowded market. She

suddenly felt her heart racing, her breathing became rapid, she experienced dizziness, and a

strong fear of dying. She thought she might be having a heart attack. Since then, she has

developed anticipatory anxiety and avoids crowded places for fear of another attack.

She worries about having a panic attack in situations where escape might be difficult and has

reduced social and work-related outings. During attacks, she often thinks, “I’m losing control…

I might die or faint right here.” These thoughts intensify the physical symptoms, leading to

more fear and avoidance.

She denies substance abuse or major medical illness. No history of psychotic symptoms or

previous psychiatric treatment. No family history of psychosis, but her mother had an anxiety

disorder.

Emotional symptoms

 Intense fear of dying or losing control during attacks

 Anticipatory anxiety about next attack

 Irritability due to constant fear

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Cognitive symptoms

 Catastrophic misinterpretations: “I might die”, “I’m going to faint”

 Preoccupation with bodily sensations

 Overestimating danger in public places

Behavioral symptoms

 Avoiding crowded places or situations where escape feels difficult

 Safety behaviors (sitting near exits, carrying water, checking pulse)

 Reduced social/work outings

Physiological symptoms

 Palpitations, sweating, trembling

 Shortness of breath, chest tightness

 Dizziness, nausea, hot flashes

E. Psychiatric history: No prior psychiatric treatment.

F. Personal and social history

Premorbid Personality: Anxious, responsible, and sensitive to bodily sensations.

Social History: Supportive family, but social life has reduced due to fear of attacks in public.

G. Medical history: No significant chronic medical illness.

H. Mental status check

 General appearance and behavior: Appears anxious, restless, frequently fidgets

during interview.

 Speech

o Rate: Slightly fast during anxiety

Page | 25
 o Rhythm: Normal

o Volume: Normal

o Content: Fear of dying, losing control.

 Mood: Anxious

 Affect: Tense, congruent with mood

 Thought

o Form: Logical

o Content: Catastrophic thoughts during attacks

o Stream: Ruminative

 Perceptual disturbance: None

 Cognitive functions

o Consciousness: Clear

o Attention & Concentration: Impaired during anxiety

o Orientation: Intact

o Memory: Intact

o Abstract Thinking: Intact

o Intelligence: Average

 Judgement: Intact but influenced by catastrophic thinking

 Insight: Good (aware panic attacks are excessive but cannot control them)

I. DSM-5 diagnosis

Panic Disorder (DSM-5 Code: 300.01 / F41.0),(American Psychiatric Association, 2013)

Recurrent unexpected panic attacks, with four or more symptoms such as:

 Palpitations

 Shortness of breath

 Dizziness
Page | 26
  Trembling

 Fear of dying or losing control

Met – client reports typical panic symptoms during episodes.

B. At least one attack followed by 1 month (or more) of:

 Persistent concern or worry about additional attacks.

 Significant maladaptive change in behavior (e.g., avoidance).

Met – client has anticipatory anxiety and avoids situations.

C. Not attributable to a substance or medical condition.

Met – no substance use or medical cause reported.

D. Not better explained by another mental disorder.

Met – no psychosis or other psychiatric diagnosis reported.

Differential Diagnoses Considered:

 Social Anxiety Disorder (but no fear of judgment)

 Agoraphobia (may be comorbid, needs further assessment)

 Generalized Anxiety Disorder (worry is not general or chronic)

Page | 27
CASE FORMULATION

A. Specific formulation
Dysfunctional Beliefs
B.
“Physical symptoms mean something is dangerously wrong.”
“Crowded places are dangerous because I can’t escape”

Triggers
Internal: Rapid heartbeat, dizziness
External: Crowded market, university setting

Threat Appraisal
Overestimates danger (“This might be a heart attack”)
Underestimates coping (“I am going to die”)

Panic Attack Symptoms

Peaks in physical Palpitations,
and emotional chest tightness,
distress → Escape dizziness,
or avoidance shortness of
behavior breath, nausea

Catastrophic Attention Bias

Misinterpretation Hypervigilance to
Misreads symptoms bodily sensations
as life-threatening (“Is my heart
or socially racing?”), intensifies
humiliating (“I’m perception
dying,” “I’ll faint”) Symptom Escalation
Increased anxiety
amplifies physical
symptoms (e.g.,
hyperventilation →
dizziness)

Figure: Cognitive model of Panic Disorder (Sokol & G. Fox, 2019)

Page | 28
TREATMENT PLAN

Problem list Treatment goals Plan for

treatment/techniques
Recurrent panic attacks Reduce frequency and CBT with psychoeducation,
severity interoceptive exposure
Fear of physical sensations Reduce catastrophic Cognitive restructuring
misinterpretation
Avoidance of public places Reduce avoidance Graded exposure with
relaxation
Anticipatory anxiety Improve coping strategies Breathing retraining,
mindfulness techniques

1. Psychoeducation

Explains the nature of panic disorder and how physical symptoms (palpitations, dizziness,

breathlessness) are misinterpreted as life-threatening. Understanding the fight-or-flight

response helps reduce catastrophic thinking (“I’m dying” or “I’m losing control”) and builds

treatment motivation.

2. Cognitive Restructuring

Focuses on challenging catastrophic misinterpretations of bodily sensations. For example, “My

heart is racing, I might die” is restructured into “This is just anxiety, not a heart attack.” This

reduces fear intensity and improves control over anxious thoughts.

3. Interoceptive Exposure

Involves deliberately inducing feared bodily sensations (e.g., spinning to feel dizziness,

running to increase heart rate) to demonstrate they are not dangerous. Repeated exposure

decreases fear responses and helps break the panic cycle.

Page | 29
4. Breathing Retraining & Relaxation

Teaches slow diaphragmatic breathing to control hyperventilation and progressive muscle

relaxation to reduce overall physiological arousal, giving the client a sense of control during

early treatment phases.

5. Relapse Prevention

Helps the client recognize triggers, early warning signs, and develop coping plans for future

panic episodes. Clients learn to continue using exposure and cognitive techniques

independently.

I used Psychoeducation to explain the panic cycle and differentiate harmless bodily sensations

from actual threats. Interoceptive Exposure exercises (e.g., spinning, running in place) were

practiced in-session to reduce fear of physical sensations. Cognitive Restructuring targeted

catastrophic misinterpretations like “I will die during an attack.” Breathing Retraining and

Progressive Muscle Relaxation were taught for physiological control. The client gradually

reduced avoidance behaviors and reported fewer panic attacks with increased confidence in

managing bodily symptoms.

TREATMENT OUTCOME

 Short-term: Reduced attack intensity, improved coping skills.

 Medium-term: Increased participation in social/work activities.

 Long-term: Minimal avoidance, improved quality of life.

DISCUSSION

A total of 10 CBT sessions were conducted over 2.5 months focusing on psychoeducation,

interoceptive exposure, breathing retraining, and cognitive restructuring. The client

Page | 30
demonstrated significant reduction in the frequency and severity of panic attacks, decreased

avoidance of previously feared situations (like crowded places), and improved confidence in

managing bodily sensations.

Some residual anticipatory anxiety persisted in high-stress situations, but it was far less

disabling. The client successfully applied learned techniques outside sessions and gained

improved quality of life. Booster sessions were recommended for relapse prevention and to

strengthen coping in unexpected future stressors.

Page | 31
 CLINICAL CASE- IV

CASE HISTORY

A. Demographic information

Mst. N is a female client who is married and lived with her husband and two children. Her age

is 32 years. She is a school teacher.

B. Chief complaint

I keep worrying about almost everything—my children, my work, finances, even small things.

I can’t stop thinking and feel tense all the time.

C. Assessment tools

 Subjective assessment

Assessment process continued over the sessions through clinical interviews. Client reported

persistent, excessive worry across multiple life domains, including her children’s safety,

school-related responsibilities, finances, and routine activities. She described being unable to

control her thoughts and experiencing near-constant tension and mental fatigue. Emotional

experiences included irritability, nervousness, and anticipatory fear. Client acknowledged sleep

disturbance and reported muscle tension and restlessness.

 Objective rating

Over the sessions client had been provided many worksheets, coping cards and homework

tasks. Beck Anxiety Inventory (BAI) – Bengali Version was also used to check the level of

anxiety she had.

Page | 32
  Subjective rating

In this procedure the client was asked to rate his overall problems and mood as he was

considering. He was asked to rate his mood on a one item Likert scale between 0 to 10. 1

represents extremely low well-being—characterized by persistent dissatisfaction, negative

emotions, and a lack of fulfillment—while 10 represents extremely high well-being, indicating

complete satisfaction with life, emotional stability, and a strong sense of purpose. The

following table shows the subjective well-being.

Sessions Subjective rating

1st 2

2nd 3

3rd 4

4th 5

5th 4

6th 4

7th 6

8th 6

9th 6

10th 6

D. History of present illness and relevant background history

The client is a 32-year-old married woman who reports experiencing excessive, uncontrollable

worry about multiple areas of her life for the past two years. She worries daily about her

children’s safety, her job performance, family finances, and even minor events like household

chores. She described feeling restless, irritable, and “on edge” most of the time.

Page | 33
She stated that even when situations are under control, she finds herself imagining worst-case

scenarios, such as “What if my children get into an accident?” or “What if I make a mistake at

work and lose my job?” These worries are accompanied by physical symptoms, including

muscle tension, headaches, and trouble sleeping. She often takes longer than 1 hour to fall

asleep and wakes up feeling unrefreshed.

The client reported difficulty concentrating during work because her mind is constantly

occupied with anxious thoughts. She has become less patient with her children and husband,

which sometimes leads to family conflict. She denies panic attacks but admits that her worry

sometimes escalates into feeling overwhelmed.

She has no history of psychiatric illness or substance abuse and has not received any prior

mental health treatment. There is a family history of anxiety (her father had similar excessive

worrying tendencies).

Emotional symptoms

 Chronic worry about multiple domains (family, work, finances)

 Restlessness and irritability

 Feeling “on edge” most of the day

Cognitive symptoms

 “What if” thinking (“What if something bad happens to my children?”)

 Difficulty controlling worry

 Poor concentration due to intrusive thoughts

Behavioral symptoms

 Over-preparing for small events

 Avoiding uncertainty (excessive checking, seeking reassurance)

Page | 34
  Reduced leisure/social activities

Physiological symptoms

 Muscle tension (shoulder/back pain)

 Sleep disturbance (difficulty falling asleep, unrefreshed sleep)

 Fatigue and headaches

E. Psychiatric history

No previous psychiatric consultation or treatment.

F. Personal and social history

Premorbid Personality: Responsible, conscientious, and perfectionistic, with a tendency to

overthink.

Social History: Supportive husband and family but strained interactions at times due to

irritability. Social life limited because she feels too tired and worried to engage in leisure

activities.

G. Medical history

Occasional migraine and back pain. No chronic systemic illness reported.

H. Mental status check

 General appearance and behavior: Well-groomed, cooperative, appears tense,
fidgeting hands noted.
 Speech
o Rate: Normal but slightly pressured during anxiety
o Rhythm: Normal
o Volume: Normal
o Content: Preoccupied with worries about family and work.
 Mood: Anxious
 Affect: Tense, congruent with mood

Page | 35
  Thought
o Form: Logical
o Content: Excessive worry, catastrophizing, “what if” thinking
o Stream: Continuous worry loops

 Perceptual disturbance: None

 Cognitive functions
o Consciousness: Clear
o Attention & Concentration: Impaired by intrusive worries
o Orientation: Intact
o Memory: Intact
o Abstract Thinking: Intact
o Intelligence: Average
 Judgement: Intact but overly cautious due to worry
 Insight: Good (recognizes excessive worrying but feels unable to control it.

I. DSM-5 diagnosis

Generalized Anxiety Disorder (GAD) – 300.02 (F41.1)(American Psychiatric Association,

2013)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not

for at least 6 months, about a number of events or activities (such as work or school

performance).

The client has experienced excessive worry for over 2 years about multiple life areas

including her children, work performance, finances, and daily responsibilities.

B. The individual finds it difficult to control the worry.

She reports that she cannot stop the worrying, even when situations are under control.

C. The anxiety and worry are associated with three (or more) of the following six

symptoms (with at least some present for more days than not for the past 6 months):

o Restlessness or feeling keyed up or on edge

Page | 36
 o Being easily fatigued

o Difficulty concentrating or mind going blank

o Irritability

o Muscle tension

o Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying

sleep)

She presents with restlessness, concentration difficulties, irritability, muscle tension,

and sleep disturbances.

D. The anxiety, worry, or physical symptoms cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning.

Her anxiety affects her work performance and family relationships.

E. The disturbance is not attributable to the physiological effects of a substance or another

medical condition. There is no indication of substance use or relevant medical

conditions.

F. The disturbance is not better explained by another mental disorder.

There are no signs of panic disorder, obsessive-compulsive disorder, posttraumatic

stress disorder, or psychotic disorders.

Differential Diagnosis

1. Major Depressive Disorder (MDD)

Why considered:

 Overlapping symptoms: insomnia, fatigue, concentration difficulties, irritability

Why ruled out:

 Client does not report core symptoms of depression: persistent sadness, anhedonia, or
hopelessness.

Page | 37
2. Panic Disorder

Why considered:

 Anxiety, feelings of being overwhelmed

Why ruled out:

 No history of sudden panic attacks or intense fear with physical symptoms (e.g.,
palpitations, shortness of breath).

3. Obsessive-Compulsive Disorder (OCD)

Why considered:

 Intrusive thoughts could mimic excessive worry

Why ruled out:

 Client’s worries are about real-life situations, not intrusive, irrational obsessions. No
mention of compulsions or rituals.

Page | 38
CASE FORMULATION

A. Specific formulation

Trigger
Upcoming work tasks,
Child’s responsibility, bills and
Daily responsibilities

Positive Meta-Beliefs About Worry

“If I don’t worry, I might miss something important.”
“I should worry for betterment”

Type-1 worry
She engages in worry about real-life situations:
 Safety of her children
 Fear of making mistakes at work
 Minor daily hassles

Negative Meta Beliefs activated

“Worrying is harmful, for my health”
“I can’t control my thoughts.”
“I’m a crazy person.”

Type-2 Worry
The client begins to worry about the fact that
she is worrying, escalating her distress:
"What if I never stop worrying?" "This means
I’m weak." This meta-worry leads to heightened
emotional dysregulation and reinforces a cycle

Emotion: Thought Control Behavior Physiological

Attempts
Persistent Avoidance of Muscle
anxiety Attempts to suppress household tasks Tension
or stop thoughts
Emotional Reassurance-seeking Headaches
exhaustion Leads to mental from others
Sleep
fatigue and
Irritability Social withdrawal Disturbance,
frustration
Fatigue

Figure: Adrian Wells' Metacognitive Model of Generalized Anxiety Disorder (GAD)

Page | 39
TREATMENT PLAN

Problem list Treatment goals Plan for

treatment/techniques

Excessive uncontrollable Reduce frequency and CBT (cognitive restructuring,

worry intensity of worry worry scheduling)
Sleep disturbance Improve sleep quality Sleep hygiene, relaxation
training
Muscle tension & irritability Reduce physical symptoms Progressive muscle relaxation,
breathing training
Poor concentration Improve focus Mindfulness training, attention
exercises
Family conflict Enhance emotional regulation Stress management,
communication skills training

1. Psychoeducation

Explains how excessive worry and hypervigilance maintain anxiety and physical tension.

Understanding the anxiety cycle and difference between productive vs. unproductive worry

helps the client engage with therapy and reduces fear of symptoms.

2. Cognitive Restructuring

Focuses on challenging “What if” thinking patterns (e.g., “What if something bad happens to

my family?”). The client learns to identify cognitive distortions, evaluate evidence, and

generate balanced alternative thoughts, reducing catastrophic beliefs.

3. Worry Scheduling & Problem-Solving

The client learns to postpone worry to a set “worry period” and practice structured problem-

solving for realistic concerns. This reduces constant rumination and gives a sense of control

over stressful situations.

Page | 40
4. Relaxation Techniques

Progressive muscle relaxation, breathing exercises, and guided imagery are taught to reduce

physiological arousal and chronic muscle tension, which are common in GAD.

5. Mindfulness Training

Helps the client stay focused on the present instead of worrying about future uncertainties.

Mindfulness meditation reduces worry-driven attention bias and improves emotional

regulation.

I introduced Cognitive Restructuring to challenge persistent “what if” thinking patterns and

replace them with evidence-based thoughts. Worry Scheduling was implemented to contain

excessive rumination, and Problem-Solving Skills Training helped address realistic stressors

systematically. Progressive Muscle Relaxation and Mindfulness were practiced to reduce

somatic tension and improve focus on the present moment. Over time, the client reported

reduced frequency of worry, better concentration, and improved sleep quality.

TREATMENT OUTCOME

 Short-term: Reduction in worry episodes, better sleep.

 Medium-term: Improved concentration, reduced irritability, better family interactions.

 Long-term: Increased resilience, development of healthier coping strategies.

DISCUSSION

A total of 10 CBT sessions were conducted over three months focusing on psychoeducation,

cognitive restructuring, relaxation training, and mindfulness techniques. The client showed a

Page | 41
marked reduction in excessive worry and physical tension, with improved concentration and

sleep. Problem-solving and mindfulness skills enhanced her ability to manage daily stressors.

However, occasional worry episodes persisted during major life stress events, indicating a need

for ongoing self-practice and booster sessions to consolidate coping skills. Overall, treatment

led to substantial improvement in daily functioning and emotional well-being.

Page | 42
 CLINICAL CASE- V

CASE HISTORY

A. Demographic information

Mr. S is a 23 years old unmarried undergraduate male. He is staying in university residence.

He is referred from university mental health center.

B. Chief complaint

“I feel very anxious when I have to speak in front of others or meet new people. I worry they
will judge me or think I am foolish.”

C. Assessment tools
 Subjective assessment
Ongoing assessment was conducted through clinical interviews across multiple sessions. The

client consistently described persistent and uncontrollable worry across several life areas,

including his children's safety, school-related responsibilities, financial concerns, and daily

routines. He reported significant difficulty managing these thoughts, often feeling mentally

fatigued and tense. Emotionally, he experienced frequent nervousness, irritability, and

anticipatory anxiety. He also reported disrupted sleep, along with physical symptoms such as

muscle tension and restlessness, all contributing to his overall psychological distress.

 Objective rating

Over the sessions client had been provided many worksheets, coping cards and homework

tasks. Beck Anxiety Inventory (BAI) – Bengali Version was also used to check the level of

anxiety she had.

 Subjective rating

In this procedure the client was asked to rate his overall problems and mood as he was

considering. He was asked to rate his mood on a one item Likert scale between 0 to 10. 1

represents extremely low well-being—characterized by persistent dissatisfaction, negative

Page | 43
emotions, and a lack of fulfillment—while 10 represents extremely high well-being, indicating

complete satisfaction with life, emotional stability, and a strong sense of purpose. The

following table shows the subjective well-being.

Sessions Subjective rating

1st 2

2nd 3

3rd 5

4th 5

5th 5

6th 6

7th 6

8th 6

9th 7

10th 7

D. History of present illness and relevant background history

The client is a 23-year-old male who reported persistent fear and anxiety in social and

performance situations for the past three years. He worries excessively about being negatively

judged, embarrassed, or humiliated by others. He avoids situations such as speaking in class,

asking questions to teachers, meeting strangers, or attending social gatherings.

He reported that his symptoms started in late high school when he had to deliver a speech in

front of classmates and forgot part of his presentation. Peers laughed, which he interpreted as

humiliation. Since then, he has become fearful of similar situations, thinking, “If I speak, I’ll

make a mistake and people will laugh at me again.”

Page | 44
Before social interactions, he experiences physical symptoms such as sweating, trembling,

palpitations, and a shaky voice. These symptoms often make him more anxious because he

fears others will notice. He sometimes avoids group projects and limits social outings,

preferring online communication. His avoidance has impacted academic performance and his

ability to form friendships.

He denies any substance use, depressive episodes, or psychotic symptoms. There is no previous

psychiatric history, but his father was described as shy and socially withdrawn.

Emotional symptoms

 Fear of humiliation and negative judgment

 Intense anxiety in social/performance settings
 Shame and embarrassment after interactions

Cognitive symptoms

 Negative self-evaluation: “I will embarrass myself.”

 Anticipatory anxiety before social events
 Mind blanking during performance situations

Behavioral symptoms

 Avoiding public speaking, group projects, and social gatherings

 Minimal eye contact and low voice when speaking
 Prefer online/text communication over face-to-face

Physiological symptoms

 Trembling voice, sweating, blushing

 Palpitations, dry mouth during interactions
 Muscle tension and nausea before social situations

E. Psychiatric history

No prior psychiatric treatment or hospitalization.

Page | 45
F. Personal and social history

Premorbid Personality: Introverted, perfectionistic, sensitive to criticism.

Social History: Supportive family but limited peer network. Few close friends due to

avoidance of social activities.

G. Medical history

No significant medical conditions.

H. Mental status check

 General appearance and behavior: Avoids eye contact, appears tense during

interview, fidgets frequently.

 Speech

o Rate: Slow and hesitant in anxiety-provoking topics

o Rhythm: Normal

o Volume: Low

o Content: Preoccupied with fear of negative evaluation.

 Mood: Anxious
 Affect: Constricted, congruent with mood
 Thought
o Form: Logical
o Content: Negative self-evaluation and fear of embarrassment.
o Stream: Goal-directed but anxious focus on perceived judgment.
 Perceptual disturbance: None
 Cognitive functions
o Consciousness: Clear
o Attention & Concentration: Distracted in social contexts
o Orientation: Intact
o Memory: Intact
o Abstract Thinking: Intact
o Intelligence: Average

Page | 46
  Judgement: Intact but influenced by fear-based thinking
 Insight: Good (aware fear is excessive but difficult to control)

I. DSM-5 diagnosis

Diagnosis: Generalized Anxiety Disorder (GAD). DSM-5 Code: 300.02(American

Psychiatric Association, 2013)

A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about

a number of events or activities (such as work or school performance).

→ The client has experienced persistent worry for over 2 years about various life areas:

her children’s safety, job performance, finances, and minor issues like chores.

B. The individual finds it difficult to control the worry.

→ She reports being unable to stop the worrying, even when circumstances are under

control.

C. The anxiety and worry are associated with three (or more) of the following six

symptoms:

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying

sleep)

→ She experiences:

o Restlessness

o Irritability

Page | 47
 o Concentration difficulties

o Muscle tension

o Sleep disturbances (takes >1 hour to fall asleep, wakes up unrefreshed)

→ At least five of the six symptoms are present.

D. The anxiety, worry, or physical symptoms cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning.

→ Her anxiety affects job performance and causes family conflict.

E. The disturbance is not due to the physiological effects of a substance (e.g., drug abuse,

medication) or another medical condition.

→ No history of substance use or medical causes.

F. The disturbance is not better explained by another mental disorder (e.g., panic disorder,

OCD, PTSD).

→ No symptoms of panic, obsessions/compulsions, or trauma history

Page | 48
CASE FORMULATION:

Specific formulation

Social Situation
The client enters a situation involving potential social
evaluation—for example, attending a team meeting or
speaking to a group.

Activates Assumptions (Underlying Beliefs)

“If I make a mistake, people will think I’m incompetent.”
“I always say stupid things.”

Perceived Social Danger (Negative Automatic Thoughts)

“They’ll notice I’m nervous.” “I’m boring.”
“Everyone is judging me.”


Processing of Self as a Social Object

The client shifts attention inward and begins to monitor
themselves, imagining how they look to others.

Safety Behaviors During social exposure, she

To reduce perceived danger, Tania engages experiences:
in:
 Physical: rapid heartbeat,
 Avoiding eye contact
sweating, shaking, mind going
 Speaking briefly or quietly
 Over-preparing blank
 Mentally rehearsing responses  Cognitive: Difficulty
These prevent disconfirmation of her concentrating, Fear of losing
fears and maintain anxiety in the long control, Rumination after the
term.
event

Figure: Clark & Wells’ (1995) Cognitive Model of Social Anxiety Disorder (SAD)

Page | 49
TREATMENT PLAN

Problem list Treatment goals Plan for

treatment/techniques

Fear of social/performance Reduce anxiety in social Cognitive restructuring,

situations settings behavioral experiments
Avoidance of social situations Increase participation Graded exposure hierarchy

Negative self-evaluation Improve self-confidence Assertiveness and social skills

training
Physical anxiety symptoms Reduce physiological arousal Relaxation and breathing
exercises

1. Psychoeducation

Provides information on how fear of judgment and avoidance behaviors maintain social

anxiety. Normalizing anxiety reactions helps reduce shame and motivates the client to engage

with therapy.

2. Cognitive Restructuring

Targets maladaptive beliefs such as “Everyone is judging me” or “If I make a mistake, people

will humiliate me.” Through Socratic questioning and evidence testing, the client learns to

develop balanced, realistic thoughts.

3. Exposure Therapy (Social Exposure Hierarchy)

Gradual exposure to feared social situations (e.g., asking a question in class, attending group

discussions) helps reduce anxiety through habituation and builds confidence. Avoidance is

systematically reduced over time.

Page | 50
4. Social Skills Training

Helps improve communication, assertiveness, and conversation skills. Role-playing exercises

and feedback increase confidence in real-life social situations.

5. Relaxation & Breathing Techniques

Used to manage physiological symptoms such as tremors, sweating, and increased heart rate

during social interactions. It enhances control over anxiety responses in triggering situations.

I started with Psychoeducation to normalize social anxiety and reduce shame. Cognitive

Restructuring targeted distorted beliefs like “Everyone is judging me.” I implemented a graded

Exposure Hierarchy, starting with small social tasks (e.g., greeting peers) and progressing to

more challenging tasks (e.g., speaking in group settings). Social Skills Training using role-play

and feedback improved conversational confidence. Relaxation Techniques were practiced to

manage physiological anxiety during exposure. The client became more socially engaged and

reported less anticipatory anxiety.

TREATMENT OUTCOME

 Short-term: Reduced anticipatory anxiety, improved coping in mild social settings.

 Medium-term: Increased participation in class and social gatherings.

 Long-term: Improved self-esteem, reduced avoidance, better academic and social

functioning.

DISCUSSION

A total of 10 CBT sessions were conducted over three months, focusing on psychoeducation,

cognitive restructuring, and graded exposure supported by social skills training. The client

gradually engaged in feared social situations and reported a significant reduction in anxiety and
Page | 51
avoidance. Confidence in social interactions improved, and academic performance benefited

from increased participation in class.

Residual anxiety remained in high-pressure situations (e.g., public speaking to large

audiences), indicating a need for further exposure and booster sessions. Overall, treatment

outcomes were positive, with notable functional and emotional improvement.

Page | 52
 CLINICAL CASE- VI

CASE HISTORY

A. Demographic information

Client N was a 28-year-old married woman. She is a housewife.

B. Chief complaint

“I keep seeing that accident in my mind, I wake up with nightmares, and I feel scared and alert

all the time.”

C. Assessment tools

 Subjective assessment

The assessment process was carried out over multiple sessions using clinical interviews and

observation. The client, a 28-year-old married woman, reported experiencing ongoing

psychological distress following a traumatic event. She described frequent intrusive memories

and distressing flashbacks, often triggered by reminders of the trauma. She also reported

nightmares, emotional numbness, and a persistent sense of threat. The client expressed efforts

to avoid thoughts, conversations, and situations associated with the traumatic experience. She

endorsed symptoms of hyperarousal, including irritability, exaggerated startle response,

restlessness, and difficulty sleeping. These symptoms have significantly impacted her daily

functioning and interpersonal relationships, particularly within her family life.

 Objective rating

Over the sessions client had been provided many worksheets, coping cards and homework

tasks. Posttraumatic Stress Disorder Checklist – Civilian Version (PCL-C), Bangla Version

used for assessment also.

Page | 53
  Subjective rating
In this procedure the client was asked to rate his overall problems and mood as he was

considering. He was asked to rate his mood on a one item Likert scale between 0 to 10. 1

represents extremely low well-being—characterized by persistent dissatisfaction, negative

emotions, and a lack of fulfillment—while 10 represents extremely high well-being, indicating

complete satisfaction with life, emotional stability, and a strong sense of purpose. The

following table shows the subjective well-being.

Sessions Subjective rating

1st 2

2nd 2

3rd 2

4th 4

5th 5

6th 4

7th 6

8th 7

9th 8

10th 8

11th 8

D. History of present illness and relevant background history

The client is a 28-year-old married woman who reported experiencing persistent distress

following a severe road traffic accident one year ago, in which her car was hit by a truck.

Although she survived with minor physical injuries, another passenger in the accident died.

Page | 54
She described vivid memories of the incident: the sound of the crash, screams, and seeing

blood.

Since the accident, she has been experiencing recurrent intrusive memories and nightmares

about the event. At times, she feels as though she is “back in the accident,” accompanied by

intense anxiety and physical symptoms such as palpitations, sweating, and shaking. She avoids

driving or being near highways and avoids talking about the accident, fearing it will trigger

panic.

She reported hypervigilance, easily startled responses, irritability, and difficulty sleeping.

Concentration at work has decreased, and she often feels emotionally numb, disconnected from

her family, and unable to enjoy activities she previously liked. She feels guilty for surviving

when another person died in the accident, thinking, “I should have done something to save

them.”

She has no prior psychiatric history or substance use. Family history is negative for mental

illness. No psychotic symptoms were reported.

Emotional symptoms

 Intense fear and helplessness during flashbacks

 Persistent guilt (“I should have saved them”)

 Emotional numbing and loss of interest

Cognitive symptoms

 Intrusive trauma memories and flashbacks

 Overgeneralized danger beliefs: “I am never safe.”

 Survivor guilt and self-blame

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Behavioral symptoms

 Avoiding driving, highways, and trauma-related conversations

 Hypervigilance and exaggerated startle response

 Social withdrawal and reduced work engagement

Physiological symptoms

 Nightmares and disturbed sleep

 Palpitations, sweating, trembling during flashbacks

 Increased startle response and muscle tension

E. Psychiatric history

No previous psychiatric treatment or hospitalization.

F. Personal and social history

Premorbid Personality: Social, responsible, emotionally stable prior to the trauma.

Social History: Supportive spouse and family, but she avoids social gatherings since the

trauma.

G. Medical history

Mild physical injuries from the accident, fully healed. No chronic medical illness reported.

H. Mental status check

 General appearance and behavior: Anxious, easily startled by loud noises during

interview, avoids eye contact when describing the trauma.

 Speech

o Rate: Normal but tremulous when discussing accident

o Rhythm: Normal

o Volume: Normal

o Content: Preoccupied with trauma memories, guilt.

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  Mood: anxious and fearful

 Affect: Constricted, tearful at times

 Thought

o Form: Logical, coherent

o Content: Intrusive trauma memories, survivor guilt

o Stream: Ruminative, trauma-focused

 Perceptual disturbance: Flashbacks present, no hallucinations

 Cognitive functions

o Consciousness: Clear

o Attention & Concentration: Impaired by intrusive thoughts

o Orientation: Intact

o Memory: Intrusive traumatic memories

o Abstract Thinking: Intact

o Intelligence: Average

 Judgement: Intact but emotionally influenced

 Insight: Good (aware symptoms are trauma-related but unable to control them)

I. DSM-5 diagnosis

Posttraumatic Stress Disorder (PTSD). DSM-5 Code: 309.81(American Psychiatric

Association, 2013)

Criterion A: Exposure to Trauma

The client has been exposed to a traumatic event (details not specified but assumed based on

PTSD presentation).

Criterion B: Intrusion Symptoms

She reports:

 Recurrent distressing memories or flashbacks

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  Nightmares related to the trauma

Criterion C: Avoidance

She actively avoids:

 Thoughts and conversations about the trauma

 Situations that remind her of the event

Criterion D: Negative Alterations in Cognition and Mood

She reports:

 Emotional numbness

 Persistent negative emotions

 Difficulty feeling connected to others

Criterion E: Arousal and Reactivity

She experiences:

 Irritability

 Hypervigilance

 Sleep disturbances

 Exaggerated startle response

Criterion F: Duration

Symptoms have been present for more than one month.

Criterion G: Functional Impairment

Her symptoms interfere with daily functioning and family life.

Criterion H: Exclusion

No indication that the symptoms are due to substances or another medical condition.

Differential Diagnosis

1. Adjustment Disorder (with Anxiety or Mixed Features)

Why considered:

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  Triggered by identifiable stressors

 May involve anxiety, low mood, or mild avoidance

Why ruled out:

 PTSD includes specific symptoms (e.g., re-experiencing, hypervigilance, nightmares)

that are not present in adjustment disorder

 Client's symptoms are trauma-specific and more severe

2. Major Depressive Disorder (MDD)

Why considered:

 Overlap in symptoms such as sleep problems, concentration difficulties, low mood, and

anhedonia

Why ruled out:

 Client has trauma-related triggers, re-experiencing symptoms, and avoidance—core

features of PTSD not explained by MDD

 Depression could be a comorbid condition, but it does not better explain the primary

presentation

3. Generalized Anxiety Disorder (GAD)

Why considered:

 Includes excessive worry, restlessness, sleep disturbance

Why ruled out:

 GAD is not typically trauma-specific

 Absence of flashbacks, nightmares, and trauma-related avoidance in GAD

CASE FORMULATION

A. Specific formulation

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 Prior Experience, Beliefs, and
Coping Style Characteristics of the Trauma
The traumatic event was experienced as
The client likely held pre-existing
sudden, overwhelming, and uncontrollable,
beliefs such as “I must be in control”
possibly involving a threat to life, dignity, or
and “The world is safe if I’m careful,”
safety. It involved intense emotional and
along with a history of early stress,
physiological arousal.
high anxiety sensitivity, or passive
coping, increasing her vulnerability to
post-trauma distress.

Cognitive Processing During Trauma

During the trauma, her information processing was
dominated by sensory impressions (data-driven), rather
than reflective understanding. As a result, the trauma memory
was stored in a disjointed and fragmented form, easily
activated by similar cues (e.g., sounds, smells, places).

Nature of Trauma Memory

Negative Appraisal of Trauma and
o Vivid and sensory-laden Sequelae
o Lacking in time-sequencing o “I’m permanently damaged.”
and context o “I’m weak for reacting this
o Easily triggered by internal way.”
or external cues o “The world is dangerous, and
I can’t keep my family safe.”

Current Threat Perception

Because of intrusive symptoms (e.g., flashbacks, nightmares), hyperarousal
(e.g., jumpiness, poor sleep), and strong emotions (e.g., fear, shame), the client
experiences an ongoing feeling of being under threat.

Maladaptive Strategies to Control Threat and Symptoms

 Avoiding reminders of the trauma
 Suppressing thoughts and memories
 Emotional withdrawal from loved ones
 Over-monitoring for danger or physical symptoms

Figure: Ehlers and Clark’s Cognitive Model of PTSD (2000).

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TREATMENT PLAN

Problem list Treatment goals Plan for

treatment/techniques

Intrusive trauma memories Reduce frequency and Trauma-focused CBT,

distress EMDR
Avoidance of Resume driving and reduce Graded exposure, behavioral
driving/highways avoidance activation
Hypervigilance & startle Reduce physiological Relaxation training,
arousal breathing retraining
Sleep disturbance, Improve sleep Sleep hygiene, imagery
nightmares rehearsal therapy for
nightmares
Survivor guilt Address maladaptive Cognitive restructuring, self-
trauma-related beliefs compassion interventions

1. Psychoeducation

Explains how traumatic memories, avoidance, and hyperarousal maintain PTSD symptoms.

The client learns that flashbacks and nightmares are a normal response to trauma and can be

managed, reducing fear and shame associated with symptoms.

2. Trauma-Focused Cognitive Restructuring

Addresses maladaptive beliefs such as “I should have saved them” or “I am never safe.”

Through Socratic questioning, the client examines evidence, reframes survivor guilt, and builds

balanced, realistic perspectives about the trauma and future safety.

3. Exposure Therapy (Imaginal & In-Vivo)

Helps the client process traumatic memories by safely revisiting them through guided imagery

(imaginal exposure) and gradually confronting avoided trauma-related cues (e.g., driving on

highways). This reduces emotional distress and avoidance behaviors.

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4. Relaxation & Grounding Techniques

Includes breathing exercises, progressive muscle relaxation, and grounding skills to manage

physiological arousal during flashbacks or triggers. These techniques restore a sense of present-

moment safety and control.

5. Relapse Prevention & Coping Skills

Prepares the client to handle future stressors and trauma reminders, reinforcing coping

strategies and preventing symptom recurrence.

I utilized Trauma-Focused Cognitive Restructuring to challenge maladaptive beliefs like “I

should have saved them.” Imaginal Exposure was conducted using narrative retelling of the

traumatic event in a safe therapeutic environment, combined with In-Vivo Exposure to avoided

situations (e.g., driving). Grounding Techniques were taught to manage flashbacks and

hyperarousal. Psychoeducation was provided to normalize trauma responses and motivate

participation. The client reported decreased flashbacks, reduced avoidance, and improved

emotional regulation over sessions.

TREATMENT OUTCOME

 Short-term: Reduced distress from trauma memories, improved sleep.

 Medium-term: Increased tolerance for driving-related cues, reduced avoidance.

 Long-term: Resolved survivor guilt, improved functioning, and quality of life.

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DISCUSSION

A total of 11 CBT sessions were conducted over 3 months focusing on trauma processing,

cognitive restructuring, and exposure-based interventions. The client showed reduced

frequency and intensity of flashbacks and nightmares, improved sleep, and decreased

avoidance of trauma-related triggers such as driving. Survivor guilt diminished, and emotional

numbing reduced, allowing better connection with family and daily activities.

However, mild hypervigilance persisted in highly stressful environments, highlighting the need

for ongoing self-practice and booster sessions. Overall, treatment significantly improved

emotional functioning, trauma processing, and quality of life.

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References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders (Fifth Edition). American Psychiatric Association.

https://doi.org/10.1176/appi.books.9780890425596

Islam, M., & Nahar, J. S. (2021). Adaptation and Validation of the Bangla Version of the

Yale-Brown Obsessive-Compulsive Scale | SciTechnol.

https://www.scitechnol.com/peer-review/adaptation-and-validation-of-the-bangla-

version-of-the-yalebrown-obsessivecompulsive-scale-JlgS.php?article_id=15178

Sokol, L., & G. Fox, M. (2019). The Comprehensive Clinician’s Guide to Cognitive

Behavioral Therapy.

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