Summary

In this clinical case report, we present the case of a young

female. She was of 54 years of age and has been experiencing various
presenting complaints, including anxiety, stress, fear, irritability,
increasing cough, sleeplessness, loss of appetite, gas and acidity etc.
Her personal hygiene habits was normal but not good. The patient came
from a small family, having a husband or two sons. The patient’s
medical history reveals that she was gone through a c- section before
during her first baby. After conducting a thorough assessment, which
included behavior observations, clinical interviews, various formal
assessments, such as the Behavior Rating Scale, SMSP-A, and a mental
state examination, we diagnosed her with Anxiety due to specific
phobia. In our management plan, we implemented a combination of
interventions, including psychotherapy and cognitive behavioral
therapy, and relaxation techniques, tailored to address her specific
needs and improve her overall quality of life.
Identifying Data
Name S.R
Father’s Name R.A
Date of Birth 12/12/970
Assessment Dates 20 /01/2024
Age 54
Occupation Vegetable shop
Gender Female
Birth order 3rd
Examiner Mam Ayesha
Case No 03
Reason & Source for Referral
The client was referred of OPD from Allama Iqbal Hospital Gujranwala and she was
referred for the purpose of psychological assessment and management because she was intense,
pain in belly. She usually come and doctor give medicine to her. She got relief after that. But
last time when she comes doctors check some reports and asked her for operation because it
was kidney pain.
Presenting Complaints
Table 1
According to the Client, She had Following Symptoms

Duration symptoms

2‫مہینے سے‬ ‫پیٹ کے اطراف میں شدید درد‬

2 ‫مہینے سے‬ ‫مجھے پریشانیوں کا سامنا ہے۔‬

2 ‫مہینے سے‬ ‫مجھے کچھ غلط ہونے کا خوف ہے۔‬

2 ‫مہینے سے‬ ‫میں چھوٹی چھوٹی چیزوں پر پریشان ہونے لگتا ہوں‬

2 ‫مہینے سے‬ ‫زندگی مشکل ہے‬

2 ‫مہینے سے‬ ‫میں ہللا کی مدد سے اس تکلیف سے باہر نکل سکتا ہوں۔‬

2 ‫مہینے سے‬ ‫میں آپریشن کے بارے میں فکر مند تھا۔‬

Initial Observation
Upon the initial encounter with the client, she was seated alongside her father-in-law. Upon noticing
me, she swiftly averted her gaze, implying a sense of concealment or reservation. Throughout the session, she
struggled to maintain consistent eye contact, initially displaying nervousness about discussing her issues.
However, once reassured and put at ease, she became more open, readily sharing all aspects of her concerns.

History of Present Illness

The client, aged 54, began experiencing illness three months ago. When undergoing kidney treatment,
she encountered severe pain in her body, causing fear and persistent anxiety. She harbored negative thoughts,
worrying that doctors might indicate a need for a second operation due to inadequate wound care. This
concern intensified as she sustained an injury, contributing to her distress.

The client admitted to chronic tension and overthinking, leading to heightened stress. Gradually, she
developed symptoms such as easy fatigue, irritability, weakness, and abdominal pain, all emerging after the
kidney treatment. Regret set in as she questioned her decision to seek treatment. In an attempt to distract
herself, she immersed in various aspects of life, inadvertently neglecting post-operation care, resulting in the
potential need for a second operation.
Background Information

It consists on client family information and her home environment.

Personal History

The client, who is married and resides in a nuclear family, enjoys sending her husband to the fruit shop
and takes pleasure in preparing meals for him. She values maintaining a clean and orderly house. During her
leisure hours, she dedicates time to her grandchildren. Additionally, she adheres to a regular sleep schedule,
going to bed on time at night and waking up punctually in the morning.

Premorbid Personality
According to the client she was a healthy person physically and psychologically before
the onset of symptoms. She was social by nature and had a wide range of friends she was
interested in cooking. She enjoyed her life. She amused in nature. She liked to attend family
gathering. She had believed in religious values but she was not praying regularly.
Family History
The client’s father name was A.A He was 55 years. And was a worker in the company.
He was very hardworking and was a person who valued relationships.
 His relationship with client was very good. As a father, he tried to fulfill all his duties
well. Client’s father laid greatattention upon religious values and gave lectures to all family
members about importance of religion in life.
The client’s had six siblings, three brothers and three sisters. She was third born. The
client was loved to her siblings but she had a strong bonding with her elder sister. Her siblings
were loving and caring. They were very conscious about client’s health. The home atmosphere
was very religious and disciplined due to client’s father. But there was love and friendship
between client’s siblings and mother. But after her illness the home environment was affected
and became tensed.
The client’s husband name was R.A and he was 30 years old. He was a worker. He has
a fruit shop. He was authoritative and sticked person. He had rigid personality and had no
compromises on his rules.The financial position of client’s husband was average.
Educational History
She had full interest in study. She was monitor of her class. Her relations with friends
and teachers were very good. Her favorite subjectwas mathematics. She used to participate in
sports. She wanted to study more but due to financialcrises, she had to drop out of school.
Social History
The client had friendly nature. Before this operation, her relations with other people
were good. She had a broad social circle but after disorder, she remained sad and lonely and did
not enjoy the company of friends and other relatives. She wanted to help others but then she felt
the need for someone to help her. But after the complications of operation she became sudden
stressful.
Sexual History
The client entered puberty at the age of 14 and received sexual education from her mother. She did not
engage in any sexual relationships with individuals of the same or opposite sex during her adolescence. Her
reaction to the physical changes associated with puberty was entirely normal. She entered into marriage at the
age of 18 and maintained a healthy and satisfying sexual relationship with her husband, resulting in the birth
of two children. Importantly, she reported no history of harassment.
Occupational History
She had no occupational history. She was married and was a housewife.
Drug History
She had no any drug history.
Marital History
The client described her marital relationship as highly positive, expressing happiness and a strong
bond with her husband. However, when she experienced inappropriate touching, it had a profound negative
impact on her well-being, significantly affecting her married life and overall happiness. Her husband, too,
became discontented with the situation. The memories of the past incidents resurfaced whenever her husband
approached her, causing ongoing distress. Importantly, it's noted that the client has no history of extramarital
affairs.
Provisional Formulation
According to the client, when she was about to undergo kidney treatment, she experienced intense pain
that instilled fear and constant apprehension. She exhibited heightened vigilance, concentration difficulties,
and a tendency to exaggerate things.
Assessment
Psychological assessment is a process of testing that uses a combination of
techniques to help arrive at some hypotheses about a person and her behavior, personality
and capabilities. Psychological assessment is also referred to as psychological testing, or
performing a psychological battery on a person. (Jane Framingham)
Both formal and informal psychological assessment procedures was used to assess the
client’s various areas of dysfunction aroused due to symptomatic behavior.
Informal Assessment
 Clinical Interview
 Behavioral Observation
 Mental Status Examination
Formal Assessment
 Acute Stress Disorder
 NSESSS-7
Behavioral Observation
During observation assessment her affective expression was normal as when she was
talking with someone on phone. Her thought process indicated her worries .Her abstract
thinking was good as she answered the questions appropriately. Her concentration was neither
good nor bad. Her orientation towards doctor was not satisfactory as when asked her about her
doctor’s name she said she didn’t know. Her remote memory was not adequate due to all time
stress. Her recent past memory was good as shewas very happy and very entertaining spent a
lot of time to do different healthy activities. She like to chit chat. Her insight was good she
was aware of her problem and wanted to live a good life. She was cooperated. Her appearance
was normal had dark color.

Mental Status Examination

The mental status examination is often given quickly to gain initial information. The first
major category of the examination is the individual’s appearance and behavior. The second
category is motor activity and thought process. Another category is perception and a general
awareness of the surroundings. Final category describes intellectual functioning and insight.
(William J. Ray).
The mental status examination is a structured assessment of the client’s behavioral and
cognitivefunctioning. It includes description of the client’s appearance and general behavior,
posture, motor activity, level of consciousness and attentiveness, motor and speech quality,
mood and effect, thought and perception, attitude and insight.
The client was 54 years old. Her hair cutting was simple. She was looked much tensed.
Mental status examination was used to gain a general picture of client’s mental condition. She
seated on the chair very comfortable. She made an eye contact. She is comfortably sitting, but
she looked worried when she talked about the operation. She was suffering from sleep
disturbance, Restlessness, easy fatigue, irritability, muscle tension, difficulty in concentration,
dizziness, heart pounding, and headache, fear of dying, loss of appetite, tension and wobbliness
in legs, disorganized speech. She had fair color and had normal appearance. Her motor behavior
was normal. She was moving her head and hands during conversation. Her speech was normal
and fluent but had low pitch. Her attitude was supportive. She did not show any kind of bad
behavior.
Clinical Interview
An interview is a conversation which has a purpose or goal. (Bingham & Moore, 1924,
Matarazzo, 1965). A clinical interview is a dialogue between psychologist and patient that is

Designed to help the psychologist diagnose and plan treatment for the patient.
(Natalie Boyd). Interviews are flexible, relatively inexpensive, highly portable and
perhaps most Important, capable of providing the clinician with simultaneous
samples of client’s verbal and nonverbal behavior. The interview was conducted to
understand the nature, severity and etiologyof the patient’s problem. She was asked
about her present complaints and history of present illness to know about the duration
of the problem along with the predisposing, precipitating and maintaining factors.
 Client was asked some open-ended questions about her present health and psychological
illness. She was very weak and dizziness. She had some complaints of kidney stone, stomach
pain and back pain along with she had highly symptoms of stress.
Formal Assessment
Formal assessment methods are considered to be more objective. Formal Psychological
Assessment (FPA) tries to improve the assessment procedure by providing a formal framework
to build assessment tools. The FPA is a new methodology potentially capable of maximizing the
advantages of both semi-structured interviews and self-report questionnaires by overcoming the
limitations of these tools and managing the problems of traditional assessment. The ability to
analyze clinical symptoms is important when evaluating the responses to a questionnaire. FPA
goes beyond the score of the patient and investigates the diagnostic features implicated by the
responses. The crucial issue that represents the starting point of FPA is consideration of the
information that can be collected from a patient’s numeric score on a questionnaire. (Groth -
Marnat) Formal assessment involves the use of tools such as tests, Questionnaires, checklist and
rating scales. The purpose of evaluation is to determine the client’s personality and the problems
which impair the client’s normal functioning.
Acute Stress Disorder
The National Stressful Events Survey Acute Stress Disorder Short Scale (NSESSS) is
a 7-item measure that assesses
The severity symptoms of acute stress disorder in individuals age 18 and older following an
extremely stressful event or experience. Each item asks the individual receiving care to rate the
severity of his or her acute stress disorder during the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale

 0=Not at all

 1=A little bit;

 2=Moderately

 3=Quite a bit

 4=Extremely
 The total score can range from 0 to 28, with higher scores indicating greater severity of
acute stress disorder. The average total score reduces the overall score to a 5-point scale, which
allows the clinician to think of the severity of the individuals acute stress disorder in terms of
none (0), mild therefore, the individual receiving care should be encouraged to complete all of
the items onthe measure. Its treatment status consistently high scores on a particular domain may
indicate significant and problematic areas for the individual that might warrant further
assessment, treatment and follow up. Your clinical judgment should guide your decision. The
prorated score is calculated by summing the scores of items that were answered to get a partial
raw score.
Multiply the partial raw score by the total number of items on the NSESSS—Acute Stress
Disorder (i.e., 7) and divide the value by the number of items that were
Actually answered (i.e., 6). The formula to prorate the partial raw score to Total Raw Score is:
(Raw sum x 7)
Number of items that were actually answered.
If the result is a fraction, round to the nearest whole number.
Subjective Rating Scale
Table 1.1
Client’s Symptoms Pre-assessment Rating Scale (0-10)
Sr Symptoms Rating by client Rating by therapist

1 Intense fear 8 6

2 Nightmares 7 8

3 Feeling numbness 9 9

4 Low self esteem 9 8

5 Feeling overwhelmed 8 9

Table no. 1.2

Table Shows the Result of NSESSS 7-Items

Age Raw score Range Result

54 22 0-28 Moderate stress

So, raw score was 22, then multiply it with number of items that were 7, and then divided the
given answer by 7. The result was 22 which fall in moderate acute stress disorder.
DSM V Checklists for Specific Disorder.
According to the DSM-5 the client was suffering from MASD. The client shows the
symptomsof fear of wasting money second time, irritability, tension, pain, impulsive behavior,
and agitation impulsive behavior and agitation intense and her feeling for others changes
quickly and swing from extreme closeness to extreme dislike. But before of disturbance in the
operation she is very friendly and never got anger these feelings can lead to unstable operation
and emotional pain.
Tool kit Assessment
Assessment was used to examine the client behavioral mental and clinical health.
Subjective rating applied according to DSM-5 TR checklist. And then NSESSS-7 scale was
applied to check the client.
Qualitative Interpretation
The client shows the symptoms of Fear of moving, such as in the household work, she
was afraid to go to a doctor alone, even if her husband came to her. Feelings of loneliness, sleep
disturbance, lack of appetite. A pattern of intense and unstable relationships with family,
friends and loved ones or adistorted and unstable self-image or sense of self. According to the
symptoms, the NSESSS-7 Rating Scale was applied to her moderate to severe range of Acute
Stress Disorder.
Case Formulation
The client was 54 years old. She was confused and anxious, but as the rapport
established,she became comfortable. She expressed her problem. She had symptoms of stress.
Once she went to the doctor for kidney stone treatment and during the treatment, she felt a bad
pain by the operation due to which she was afraid of second operation. She was very upset due to
these mentally and physically symptoms. Her routine tasks were also affected.
The predisposing factor of client was that once she had no genetically problem with me
but there is some environment factor.
 People who think that they lack control over their environment appear to be at risk for a
broad range of stress disorders than people who do not have that belief. For example, people
withstress disorders report experiencing little sense of control over their surroundings.
The precipitating factor of client was bearing of past happening, carelessness and
attention she used to ask her husband for. The people who face a traumatic event are indeed
more likely to develop the general feelings of tension, stress and fatigue and the sleep
disturbances found in thisdisorder. Client’s negative thinking also responsible for worries.
People with ASD are persistently worried, often about minor things. The financial
problem was faced by the client who triggers uncontrollable worry. In recent years it has become
clear that only aproportion of those exposed to fear-producing events develop.
The Maintaining Factor for client’s disorder is environmental factors which include
lack of social support and family financial problems. She felt loneliness and worried about
children. The nearly constant worries leave her continuously upset, uneasy and discourage.
Client faced financial problems. Due to financial problems, she had lack of resources for
proper treatment. Throughout the past few decades, the literature relating to chronic pain and
ASD has become progressively more sophisticated, resulting in well-supported theories and
treatments for sufferers.

Protective factor Peer support can be considered as an alternatemethod of getting social

support. Client’s parents and siblings were very caring and loving. This social support method
was not as reliable as family support because client could easily withdrawfrom their own friends
if she became anxious. This would prevent those suffering client from getting any social support
at all.

Among 112 respondents who experienced a traumatic event, those with low self-
resilience had significantly higher rate of ASD symptoms than those with high self-resilience
even after correcting for the covariate of general, occupational, and psychological characteristics
Despite several limitations, these results suggest that a high degree of self-resilience may protect
police officers from critical incident-related ASD symptoms.
 Case Conceptualization

Presenting Complaints
 Irritability
 Restlessness
 Fear of second operation
 Loss of concentration
 Loss of sleep and tension

Assessment
 Behavioral Observation
 Clinical Interview
 MSE
 NSESSS-7
 Subjective rating scale
Predisposing Factor
Perpetuating Factor
 Environment factor
 Fear of second operation
 Financial Crises
 Future worries
Precipitati
ng factor
 1st operation
 carelessness
Protective Factor
 Sister-in-law support

Proposed Management
 Psych
education and
support
 CBT
 Relaxation training
 Diagnosis
According to symptoms of client and by using DSM-5 checklist, client might be
diagnosed with“Acute Stress Disorder’’ (ASD)
Prognosis
The prognosis seems to be improved if the client is recovered soon. The client has
insight abouther illness and wanted to be recovered. The client’s recovery can be enhanced by
changing her home environment and by motivating her to seek treatment regularly.
Reoccurrence is more likely if symptoms have not fully resolved with treatment. The client’s
prognosis can be furtherimproved by reducing her worrying thoughts.
The Point in Favor
 Being careful
 Strong
 Easygoing
 optimistic
While against Point
 Low financial status
 Grandchildren take care
Proposed Management plan
The management plan was designed according to the complaints addressed by the client.
Treatment for the symptoms of ASD involves three approaches either alone or in combination:
psychotherapy, and education and supportive measures. To date, no psychotropic medications
have been developed specifically for use in ASD. The sections that follow summarize specific
psychopharmacological, psychotherapeutic, and educational and supportive approaches to the
treatment of ASD.
 Mindfulness-Based Therapies
Mindfulness techniques, such s meditation and deep breathing exercises, can help
individuals stay grounded in the present moment and reduce excessive worry.
Relaxation Training
Christophe (1998) Relaxation training can involve relaxing muscle groups one by
one or generating calming mental image. It is used to promote calmness. (Derubies, Critis). It is
possible to learn ways of helping themselves deal with stress. Under stressful situations,
Relaxation training may be given to start with. She should be given a deep greeting exercise
immediately and then work on 16 groups of muscles to train her to relax her muscles and
achieve autonomic control. It is expected that the client will gradually be able to relax herself
during stressful situation. Relaxation training can play a key role in reducing her problem.
 Stress Management
Develop effective stress management techniques, such as time management,
settingrealistic goals and learning to prioritize tasks.
 Coping Statement
In this process the client will tell herself about her anxiety state and this will pass, this
is my phase. I do not have any heart problem and this is anxiety. I will be able to calm up
my self-etc.these types of coping statement will help the client to relax in stressful
situation.
 Gratitude Journal
Maintaining a gratitude journal is an extension of journaling about your mental health to
help process through emotion. A gratitude journal does not have to be a notebook or pen-and-
paper, it can be an app on your phone, a voice memo, or even a specific time set aside to reflect
internally on things for which you are grateful. Thinking about gratitude and especially
expressing gratitude, helps shift perspective towards the positive.
 Cognitive Behavioral therapy
This is a widely used and effective therapeutics approach for ASD. It helps individual
identifyand changes negative thought pattern and behavior associated with anxiety. It
also teaches practical skills for managing and reducing anxiety.
 Psych education and support
Provide information about ASD, its symptoms and the expected course of recovery. Educate
theindividual about common reactions to trauma and Supportive interventions are often used as
thecontrol intervention in studies of more specific treatments. However, clinical experience
indicates that both support and psych education appear to be helpful as early interventions to
reduce exposure to mass violence or disaster.
Intervention Strategies
Short-term Goals
 Rapport building will be used for building the trust of the client on the therapist.
 Deep breathing exercise to be used to keep her relaxes under certain situation,
when relaxation could not be used
 Stress management techniques to be taught to the client for his emotional outlet
in appropriate manner
 Relaxation exercise to be used to help her to overcome her muscle tension, to
calm down her stress and to improve quality of sleep
 Goal setting to be done to enhance her motivation and interest in life
regarding different areas of life
Long-term Goals
 Cognitive restructuring to change client’s way of thinking
 Encourage the client to have discuss her problematic issues in future and thus
to sustain her recoveries
 Improve physical functioning due to development of adequate mechanism for
stress management
 Family therapy session will be arranged to assist the family members increase
their positive support for the client
 Follow up sessions to be continued to monitor and assess the client functioning
 Limitations
 The time was too short to get extensive details.
 The client was not revealing mental readiness to complete lengthy test.
Recommendations
 Allocate adequate time for each session
 Work on improving the client’s interpersonal and involve them in a healthy
social life.
 Ensure that session is quite and free of distraction
 Engage the client in activities that positively impact her mood
 Session Report
Session 1 15-01-2024
In this session, history was done, client was asked open ended questions. Goal of session was to
build rapport with client. The client describes her state of stress and about her husband’s
behavior, her fear darkness, loneliness, shadow of someone and trust issues. Upon telling the
symptoms of fatigue client was given relaxation techniques and PMR of shoulders has been
given. Client was responded readily. In this session, feedback was taken, goal was to apply
formal and informal assessment tools. Goal was achieved up to some extent. Coping statements
and relaxation therapy was given. Rating scale of ASD is applied. Psycho-education was given.
Psycho educations interventions involve interact between the information provider and the
mentally ill person. It helps the client to change her thinking and also awareness about the
importance of the treatment. Counseling about negative thoughts has provided