Clinical Case Studies 1

CLINICAL CASE STUDIES

Case Report

BS Psychology

Student’s Name: Sadia Miraj

Students Roll No. F19-BS-PSY-R-1029

Supervisor

Ms. Bushra Farooq

Department of Psychology

University of Okara
Session: 2019-2023
Clinical Case Studies 2

DEDICATION

This work is dedicated to

The Holy Prophet (PBUH)
Whom I am disciple and
Who is the mercy for universe,
And to my respected parents
Whose utmost love, care and struggle
Against all odds brought me to this fight of knowledge
With the blessing of almighty Allah
Clinical Case Studies 3

ACKNOWLEDGEMENT

Words are always lost whenever I want to say thanks to the Almighty Allah for His unli
mited blessings, favor and the He;

“WHO TAUGHT WRITING BY THE PEN. TAUGHT MAN WHAT NOT.”

(AL-QURAAN; SURAH AL-ALAQ, Ver. No. 4 and 5)

I can never forget to acknowledge the ever-great personality of the world, Hazrat Muha
mmad (PBUH) who has always been a role model for me in the way of knowledge.

With deep sense of acknowledgement, I would like to express my humble gratitude to my

worthy supervisor Ms. Bushra Farooq department of Psychology University of Okara, for his d
ynamic supervision, intellectual vigor and adroit guidance. My work would not have seen the da
y light without their constant encouragement and moral support.

My special thanks are to my Respected Teachers for their moral support, precise discour
se and lending me helping hands for my entire life. Last but not the least my heartiest gratitude is
for my dear sister and bothers for their selfless care, love and prayers throughout my educational
career. My acknowledgement could never adequately express obligation to my beloved Parents
whose hands always rose in prayers for me. May Allah bless all these people with long, happy an
d peaceful lives (Ameen).

Student’s Name: Sadia Miraj

Clinical Case Studies 4

DECLARATION

The work reported in these Clinical Case Studies was carried out by me under the supervision of
Mam Bushra Farooq.

I hereby declare that “Clinical Case Studies” and the contents of this report work is the pr
oduct of my own work and no part has been copied from any published source (except copies of
standardized psychological tests) I further declare that this work has not been submitted for awar
d of any other degree or diploma.

Signature of the Student………………

Roll No: F19-BS-PSY-R-1029
Clinical Case Studies 5

CERTIFICATE

It is certified that Sadia Miraj Roll No. F19-BS-PSY-R-1029 has completed his case reports un

der the supervision of Ms. Bushra Farooq according to the prescribed format of University of Ok

ara.

External Supervisor Internal Supervisor

-------------------------- ---------------------------
Clinical Case Studies 6

TABLE OF CONTENTS
Serial no Contents Page no

Acknowledgments 3

1 Clinical Case Study no 1 7

2 Clinical Case Study no 2 15

3 Clinical Case Study no 3 25

4 Clinical Case Study no 4 33

5 Clinical Case Study no 5

6 Clinical Case Study no 6

Appendices
Clinical Case Studies 7

Case no 1

Case Summary

The client M.I was a 25 years old male, educated BSC double math. He belongs to
middle class family. He has 4 siblings. He was the resident of Lahore and coming the hospital in
OPD in Mayo Hospital Lahore with presenting complaints of hand shivering in half arm, low
mood, lake of confidence and anxiety. Informal assessment was carried out using clinical
interview, mental status examination, and subjective rating of symptoms. Formal assessment was
conducted to implement the management plans of Cognitive behavior therapy and therapeutic
interventions. After completing history taking informal and formal assessment the client was
diagnosed, according to DSM-5, as having Conversion Disorder300.11 (functional neurological
symptom disorder) (F44.5) with attacks or seizures.
Clinical Case Studies 8

Identifying Data

Name M.I

Age 25 years

Sex Male

Education. Bsc Double Mathematics

Siblings. 4 siblings

Marital Status. Unmarried

Religion. Islam

Informant. Brother

Reason for Referral

The client was taken from Mayo hospital. He visited hospital with his brother Psychological
assessment ment and management with complaint of shivering in half arms, Confidence, low mo
od.

Presenting Complaints. Duration

Hath kanpaty hain 1 years

Sir dard hota hai 1 year

Bechaini 6 months

Kam aitmad, nazryn nahi milata 2 years

Udas rehta hu 1year

Presenting complaints symptoms with duration

Acccording to the client, from 12 november (2017) he has experienced Following symptoms
fits of shivering For almost 15 minutes, forget that he does this work or not and after wazoo he th
ink that be washes the hand or not, he was done complete wazno are not ete He thinks that if he o
Clinical Case Studies 9

ffers prayer his shivering and anxiety will be improve. The informant reported that client had the
following symptoms lasted from one and half month: the informant tells us that his hand shiver,
and this shivering remain 15 minutes, and low confidence and sensitive

History of Present Illness

According to the informant, client was not strictly attach to religion in terms of adherence
Religious practices before the death of mother, But after death of his mother, his inclination towa
rds religion increased. According to informant, client more attach to his mother and he share his
personals to his mother he though that without mother his life was boring and dull. In 2014 his m
other died. He was upset and has been ill since five days.After that he was reciting the Quran the
n the first shivering fits starts early in the morning with the duration of 15 minutes. After this shi
vering Started again the afternoon and evening with same duration and ended after 15 minutes. H
e went to doctor ad complete checkup All reports of arm are cleared doctor asked him to a psych
ologist. After his mother he was Worried due to his young and unmarried sisters. His father was
a strict man and he was not attached with him but he respected him. When someone blame him
he cannot defend himself. He beards all hardships without saying anything because He was the
elder son and responsible for all daily domestic routine work and he was a teacher. He felt anxio
us when someone annoyed him. During that time he was going to the clinical psycthologist For c
heck up and start to do sessions and medication. And second time in 2016 fits start andelient rem
ain in this condition within three months. He Begun to have Martial conflicts due to himself. He
was not interested to share his intentions with that girl and he finished this relationship and after t
his his condition comes again in severe form he admitted in muyo hospital and again started with
clinical psychologist.

Family History

Client belonged to a middle class. He lived in nuclear family. Client was living with his fath
er, one brother and three sisters. Home environment was peaceful. According to informant. His f
ather age was 45year old his father was a shopkeeper. He was supportive and autonomous. Client
relationship with his father were not friendly. He felt afraid to his father because he cannot disob
ey him. When he had a fear then he concentrates on reciting the Quran and praying for help from
Allah that he did not out range with his father
Clinical Case Studies 10

Client’s mother was house wife. She had kind nature and was soft spoken. Client had caring
relation with his mother. As client was sensitive son, therefore, his mother was more attentive to
wards him he was a shy person and does not find easy to talk his father and other persons Client
had two sisters and one brother. Both sisters were studying 8 class. His brother helped his father i
n his shop. He was not attach to his brother and sisters. He was responsible but not friendly with
his siblings Client was always felt difficulty to discuss his problem with them. Client loved sister
s and want that they concentrate on her study so she helped both of them in domestic work. They
had caring and affectionate relation with each other.

Personal history

Clients told That when his mother was live he has an affair, but he left that girl due to some
conflicts she was interested to know about his personals but he thinks that he cannot talk to him v
ery much and he disturbed when he thinks that he told him about herself. He shared his all probl
ems just his mother. And after the death of her mother, he achieves again inter in an affair but he
was not last long because client ignored her she was his student. He cannot marriage with her.w
hen she left him his problems came again. Client told that he cannot spoke with any thought tha
t he lost his ability to express his emotions. His brother reported that his mother was everything f
or him. He could not spoke daily paid before his students. He also reported that he like loneliness
after the death of his mother.

Educational history

Client school life was good. He was a good student he had done BSC double Math. He was f
ound of studies and wanted to join the teaching as profession his favorite subject was maths, He
did not participate in activities. He had normal relationship with his teachers he had no friends h
e did not like too socialize with other classmates. Client was like to remain lonely in his house a
nd didn't like gatherings.

Occupational History

Client started teaching in 2014. He had not suffered with any extreme occupational but he st
arted a part time job to stay busy. Due to this shivering condition, client was unable to concentrat
e his teaching work, he left the part time job. Client was satisfied with his salary. Client had just
professional relationship with his teachers and students.
Clinical Case Studies 11

Sexul History

According to informant client reached puberty at the age of 15 years. He did not show any
unusual reaction to his bodily changes. And he has no heterosexual and homosexual experience.

Pre-morbid personality

Before illness client had normal relations with others. Because he did not like too socializ
e with other so he did not attach for everyone. But he behave friendly by his mother and share th
eir thoughts to his mother easily.

Previous and present psychological problem

Client was not strictly attach to religion in terms of adherence Religious practices before t
he death of mother, But after death of his mother, his inclination towards religion increased. Clie
nt did not like social gatherings. Client more attach to his mother and he share his personals to hi
s mother he though that without mother his life was boring. he was reciting the Quran then the fir
st shivering fits starts early in the morning.

Psychological Assessment

The psychological assessment was conducted on two levels:

 Formal level
 Informal level

Informal assessment

It was done using following ways

 Clinical interview
 Mental status examination (M.S.E)
 Subjective rating of symptoms

Clinical Interview

Client provided the problem of his life in detail during interview, he was confused. She Bec
ame irritated very quickly. He brings unexpected information about him, which might not Possib
le in any other way. Through the answer question about her life activities, symptoms and Other r
Clinical Case Studies 12

elated information’s obtained which was helpful in diagnosis. In order to develop rapport. Inform
ant was let to talk freely. Confidentiality and privacy of client information was ensured at The be
ginning of the interview,

Mental Status Examination

Client was 25 years old. His dress was clean and weather appropriate. His height was well
according to his age. His facial expressions were elation. Eye contact was normal. He was cooper
ative. The amount of the speech was limited and flow was not appropriate.

Subjective Rating Symptoms

Client’s and informant’s Rating (over 0-10 rating scale) of the symptoms of the client

Symptoms. Client’s Ratings

Poor appetites 4

Headache. 6

Shivering. 9

Excess of Sleep. 6

Loss of interest. 8

Low mood. 6

Diagnosis according to DSM 5

The client was diagnosed, according to DSM-5, as having Conversion Disorder300.11

(functional neurological symptom disorder) (F44.5) with attacks or seizures.

Prognosis

His marked that prognosis of conversion disorder is good. There are different aspects Which
effects the client porognosis. A better prognosis is associated with a sudden onset, lack of co-
morbid psychiatric disorders, and absence to the illness. The longer conversion symptoms are pre
sent, the client is aware about her stressors, had good pre-morbid and duration of illness in sho
rter therefore she reflected good prognosis formal assessment.
Clinical Case Studies 13

Management Plan

Management plan is designed to help the client and to aid the natural process of adjustment,
to develop a positive self-concept and to reduce symptoms like shivering. The Following therapi
es would be used in Management plan of the client.

 Psycho education
 Behavioral therapy
 Family therapy
 Cognitive therapy

Therapeutic Interventions

Psycho-education

Psycho-education is not a therapy but a specific form of education. Psycho-education includ

es the provision and exploitation of information to clients about what is widely known about char
acteristics of their diagnosis. Individuals often require specific information about their diagnosis,
such as the meaning of specific symptoms and what is known about the causes, effects, and impli
cations of the problem. Information is also provided about medications, Prognosis, and alleviatin
g and aggravating factors. Information is also provided about early signs of relapse and how they
can be actively monitored and effectively managed. Individuals are helped to understand their dis
order to enhance their therapy and assist them to live more poctive and fulfilled lives (Australian
Psychological Society, 2010).

Progressive Relaxation

Progressive relaxation involves relaxing various skeletal muscle groups: arms, face, neck, s
houlders, chest, abdomen, and legs. Clients first learn to differentiate relaxation from tension by
sensing and then releasing each set of muscles (Spiegler & Guevremont, 2010),

Exposure and Response Prevention

Exposure and Response Prevention includes both prolonged exposure to obsessional cues an
d procedures aimed at blocking rituals. Exposure exercises are often done in real life settings. In
vivo and imaginal exposure exercises are designed specifically to prompt obsessional distress. It
is believed that repeated, prolonged exposure to feared thoughts and situation provides Informati
Clinical Case Studies 14

on that dis confirms mistaken associations and evaluations held by the patient. Exposure is usuall
y done gradually by confronting situations that provoke moderate distress before confronting mo
re upsetting ones. Exposure and Response Prevention treatments are found quite effective in treat
ing obsessive compulsive disorder (Barlow, 2014)

Limitations

 Client information was taken in one session that is limited time to exposure the client's Pr
oblem
 Information was gathered from the informant.

Suggestions

 More session was required to get detail information about the client
 Interview was taken directly from the client.

Case no 2
Clinical Case Studies 15

Case Summary

This case revolves around a 29-year-old male who is divorced and is diagnosed with prematu
re ejaculation and depression disorder. The client himself reported the symptoms that he had wit
nessed become intense after an accident that he had. He also separated from his wife which led t
o aggravation of his condition and he became very aggressive. The client reported ejaculating ne
arly 15 to 30 seconds after vaginal penetration. Since his wife was not satisfied with him, he beca
me very displeased and angry at himself. He began feeling less of a man and had trouble keeping
his temper under control. He had a son from his marriage and after the separation from his wife h
e was unable to meet as well. Because of the sexual conflicts, the marriage was terminated. The d
iagnosis has revealed that the client was also suffering from depression, and it could be a major c
ause of premature ejaculation. The client’s distress also causes him to lose his job as he would sh
ift jobs 20 to 25 times this year that is the indication of maladjustment.

Identifying Data
Clinical Case Studies 16

Name: X.Y.Z

Age: 29 Years

Gender: Male

Marital Status: Divorced

Education: Bachelors

Residence: Kallar Saeeda

Informant: Cousin

Presenting Complaints

 Zabani jarhiyat
 Bohat gusa karna
 Ghabrahat
 Bechaini
 Hyper bay khawabi
 Pre-mature ejaculation

History of presenting complaints

Client himself reported that these symptoms become intense after his accident from the last fi
ve and half years and after his separation from the wife. The client became frustrated and shows t
emper outbursts and verbal aggression on minute issues. Pre-mature sexual ejaculation was repor
ted by him after his son’s birth. Client reported he ejaculated after 15-30 seconds of vaginal pene
tration. His wife was not satisfied with him. Client reported that he used to spend most of the tim
e in sleeping.

Past psychiatric history

Client did not report any past psychiatric examination before this. No psychiatric history was
found in first or second degree relatives.

Past medical history

Clinical Case Studies 17

Client was taken medicine for the pre-mature ejaculation. He was having head injury in the ac
cident and for this he was hospitalized and was kept under observation of doctors.

Family history

Father was died and mother is alive. Client was attached with his father. He had five siblings i.
e. Three sisters and two brothers. He got married at the age of 21 years and he had one son. Initia
lly he was having healthy relationships with the family members but later on the relationship bec
ame poor day-by-day. Client was separated before five and half year from his wife. His wife too
k the son with her and did not allow client to meet with the son. Client asked the ex-wife that he
would be paying all the expenses of his son but she refused to take the expenses.

Personal History

Client was an active member of the family. Client was quite distressed due to his separation
because he was attached with his wife and they were having love marriage. His wife got separate
d because she was not satisfied with his pre-mature ejaculation. He got released in 15-30 seconds
of vaginal penetration. He had a lot of sexual conflicts with his wife. Client was having normal e
jaculation till the two and half years of marriage. He reported multiple intimate relationships bef
ore the marriage. Client reported that he ejaculated even in 1530 seconds during masturbation.
His wife suspected on him and after his pre-mature ejaculation issue she was also involved in oth
er boys. Client reported that he used to stay in room alone after separation and watches pornogra
phy and masturbate. Client was quite distressed and due to this his occupational life was also dist
urbed. He changed 20-25 jobs per year. He used to show verbal aggression at work place and did
not fulfill the duties.

Pre-morbid Personality

Client was having healthy relationships with family, friends, relatives, neighbors and wife. H
e used to enjoy gatherings before his problem of pre-mature ejaculation. Client reported loving a
nd caring attitude toward everyone.

Social History
Clinical Case Studies 18

Clients’ aggressive nature and temper outbursts had great impact on his life. No-one talked to
him because whenever anybody talked to him he used to show verbal aggression and temper out
bursts. He confined his life to his room.

Assessments

Following assessments were administered onto the client:

Beck depression inventory (BDI)

Beck Anxiety Inventory (BAI)

House tree person (HTP)

Mental state examination Appearance and Behavior

Clients’ behavior was reluctant initially but later on he showed co-operative behavior. He
was dressed according to the season. He seemed quite anxious and distressed due to her pre-matu
re ejaculation. His mood was low during clinical investigation.

Speech

Clients’ speech was fluent and normal. He responded to all cues and questions later on coope
ratively. Voice tone was normal and audible.

Mood

Clients’ mood was normal during the clinical investigation but when it comes to his sexual d
ysfunctioning and career he became hopeless and seemed quite emotional and down.

Thought Content

Clients’ thought was continuous and he was conscious enough to answer all of the questions d
uring clinical investigation.

Perception

No hallucinations and delusions were reported by the client.

Cognition
Clinical Case Studies 19

Client was conscious enough to answer all the cues. He was well-oriented to time, place and
person.

Psychometric investigations

Beck Depression Inventory

This self-report rating inventory test is constructed to measure the attributes of attitudes and
symptoms of depression. This test has been developed to adequately understand the mental condi
tion of any patient who is believed to be diagnosed with depression. It evaluates the key sympto
ms of depression that include self-dissatisfaction, self-dislike, social withdrawal, insomnia, soma
tic preoccupation, body image change, punishment, and fatigue ability among many others.

Test Administered Score Interpretation

Beck Depression Inventory 29 Severe depression

Beck Anxiety Inventory

The BAI test is used to evaluate the magnitude of any physical or cognitive symptoms a p
erson has been exhibiting in the past week. This is a self-report that measures somatic symptoms
of anxiety.

Test Administered Score Interpretation

Beck Depression Inventory 29 Severe depression

House Tree Person

This is a projective test that is intended to measure various aspects of the personality
of the test taker. This test is designed in a way to interpret the drawings and responses of the
test taker to multiple questions; the premise of the test depends on the notion that a person's
Clinical Case Studies 20

personality is reflected to have the answer to any given question. There is great support for
the reliability and validity of this test and it is also used to differentiate people with different
types of brain damages.

House

Closed doors Not social personality

Missing chimney Lack of psychological warmth

Weak lines Weakness of ego boundaries

Long pathways Someone who is aloof initially but later on

accessible

Tree

Age of tree 10-12 years

Lacking details Withdrawal

Clinical Case Studies 21

One dimensional tree Shattering and disintegrating experiences of

self

No roots Instable personality

Vertical emphasis Poor reality contact

Person

Figure depicted in motion Fantasy

Omitted facial features Withdrawal

Nudity Signs of mal-adjustment related to sexual

difficulties

Arms extended from body External aggression

Shading Anxiety, aggression and conflict

Eyes omitted Distorted self-image

Neck excessively large Awareness of physical impulses with an effort

to control them

Hair omitted Sexual concerns

Tentative Diagnosis

Premature Ejaculation 302.75 with specifier severe co-morbid with Major Depressive Disorde
r with specifier severe recurrent episode 296.33

Prognosis

Prognosis of the client is favorable because of the clients’ cooperative behavior and insight to
the problem.
Clinical Case Studies 22

Treatment Plan

Session # 1

The goal of the session was to do a clinical interview and take the presenting complaints of t
he client. The clinical interview had the aim of identifying the core problems of the client and su
bjective ratings of the presenting complaints. Lastly, the rapport was built in this session by emp
athizing and listening to the client attentively. The goal of the session was achieved effectively.

Session # 2

The goal of the session was to continue clinical interview with the client and mental status e
xamination was administered upon the client to check the current mental functioning of the client.
The client was given a chance of catharsis and deep breathing was taught to him. The work was
done successfully. The client was assigned the homework of practicing deep breathing.

Session # 3

The goal of the session was to provide psycho-education to the client and his wife regarding
the problem of the client. Moreover, the client was introduced with the ABC model to identify th
e antecedent, behavior/belief and consequences to help him in better understanding of the conseq
uences of his reaction over the event. The client was given the homework of completing a works
heet of negative automatic thoughts.

Session # 4

The goal of the session was to do a clinical interview of the client’s attendant regarding his
problem. The client and cousin were involved in family counselling session as well in better deal
ing with their problem. The session was done effectively with recommending a talk between clie
nt and family members.

Session # 5

The goal of the session was to administer the Beck Depression Inventory (BDI), Beck Anxie
ty Inventory (BAI), Rotters Incomplete Sentence Blank (RISB) to check the severity of the depre
Clinical Case Studies 23

ssion, anxiety and maladjustment to make the client perform and learn mediation with distraction
of counting. It was successfully done along with assigning homework of practicing daily.

Session # 6

The goal of the session was to work on the daily activity chart. For this purpose the activities
of the client were illustrated and made to help him have activities scheduled. The activities were
successfully illustrated and the client was given a worksheet to keep a check of his daily activitie
s. The “stop-start” exercises, and “pause and squeeze” technique was used to overcome sexual di
fficulties.

Session # 7

The goal of the session was to device goals of the client’s life and based upon his preference
and needs. The other goal was to let the client do catharsis in reducing this problem. The client w
as determined to follow the goals he had set after the session and showed conviction to start wor
king on them. Mindfulness was practiced in order to bring client attention to present moment and
forget about the past. Guided meditation was assigned as home task.

Session # 8

The goal of the session was to narrate the rationale of the thought diary and the client was gi
ven a task of writing a thought diary whenever he was in distress of excessive thoughts. The clie
nt was given papers and asked to write about his thoughts and the client was happy in doing the
work.

Session # 9

The goal of the session was to do a triple column technique with the client by making him wr
ite his automatic thoughts and giving them a cognitive error chosen from the list he was provided
with. Moreover, the client was helped in changing that thought to the acceptable and alternative t
hought to help him change the point of view in looking at his problem. This was done successfull
y.

Session # 10
Clinical Case Studies 24

The goal of the session was to create list of Master-Pleasure Orientated tasks for the client so
that he could concentrate on the work in his free time and would feel accomplished. Therefore, th
e client was given a worksheet to do the work once it was identified including poem writing and
diary writing. The goal was successfully achieved with the client.

Session # 11

The goal of the session was behavior skills training to be taught to the client. It was conduc
ted by explaining the rationale, ways of speaking and role playing. The training was helpful for t
he client and it was achieved successfully. The client was given the homework to practice the act
ivity.

Session # 12

The goal of the session was to do the reassessment of the Beck Depression Inventory (BDI)
to check the improvement after the management of therapeutic techniques and compare the progr
ess before and after the management. The administration of the tool was successfully done.

Session # 13

The goal of the session was to give therapy blueprint to the client. The purpose was to revis
e all the therapeutic techniques client had learned during the treatment and give him a therapy bl
ueprint so that he would know what he had to do in case of return of symptoms. This would help
him in relapse prevention. The goal was achieved successfully.
Clinical Case Studies 25

Case no 3

Case Summary

Client was a 35 years old female, brought the hospital by her sister. She had issues with a
ppetite, disturbed sleep, nightmares, helplessness and hopelessness. Her sister had reported that s
he stays distressed and apprehensive that something wrong might happen to her family or daught
ers. Client is married, she had a son and two daughters. Eight months ago they meta a road accid
ent when she was out with her husband and her 1.5-year-old son. They collided with a fast appro
aching car and she became unconscious. When she woke up in the hospital her son had expired l
eaving her devastated. Ever since she is not able to overcome the effects of this tragic event. She
doesn’t want to eat or sleep. If she ends up sleeping, wakes up crying. She reports of having drea
ms of her son’s bleeding face. He was so small and now is dead. She is scared to let her daughter
leave the house and thinks something bad is going to happen to them too. According to the clien
t’s sister, her husband is very supportive and helps the client overcoming her emotions.
Clinical Case Studies 26

Bio data
Name S.J

Age 35 years

Gender Female
Date of birth Dec, 1986

Siblings 1 sister

Birth order 1st born

Education F.A

Socioeconomic status Lower class

Marital status Dependent

Referral Sister

Religion Islam

Reason and source of referral

Client was brought to the hospital by her younger sister for counselling. She was having t
rouble sleeping at night, experiencing of nightmares. She had feelings of anxiety and wants to ru
n away from house. She also had reported diminished interests in daily life activities.

Presenting Complaints

‫دماغ کام نہیں کرتا۔‬

‫کب پتہ نہیں کیا ہو جاۓ۔‬،‫ڈر لگتا ہے زندگی سے‬

‫بیٹا بہت یاد آتا ہے۔‬

‫بس اسی کو یاد کرتی رہتی ہوں۔‬

‫ہر وقت بیٹیوں کی فکر رہتی ہے۔‬

Clinical Case Studies 27

History of Present Illness

Client was brought to the hospital for exhibiting symptoms of fear, anxiety, feeling of hel
plessness and hopelessness. She is having nightmares form the past 6 months. She also reported t
hat she has feelings of detachment from others. All these symptoms started after the death of her
son when they met a road accident. She was going with her husband and son to a nearby market
when suddenly their motorbike collided with an approaching car and they had a serious accident.
She and her husband got injured and her son had a serious stroke on head and was heavily bleedi
ng. At this sight patient became unconscious. They were taken to the hospital and when she regai
ned her consciousness her son was dead. He was a year and a half old at the time.
From that time onwards she experienced anxiety, is detached from the family members.
Although she tries not to think about her son’s death but is disturbed by the recurrent thoughts an
d flash backs of accident. She fears being on roads as this brings back the feelings she experience
d when she met a severe accident. This also is disturbing her daily life activities. She reported tha
t she is worried what will happen to her life ahead.

Background history
Personal History
Client was born in Abbottabad and had a normal birth. She was a healthy child. When she
was six years old she started going to school. When she was very young her home environment
was quite stressing. Her father was an educated person and mother was illiterate due to which the
re was lack of understanding between them and secondly her father got married to her mother wit
hout his will.
When she was 7 years old her father divorced her mother and she had left the house. Clie
nt was a sensitive girl. So, she felt lonely & helpless. But with the passage of time she and her sis
ter were able to cope with the situation because their father was very loving and caring. After one
year of their divorce her mother got married to someone else. Both sisters talked to their mother
occasionally but do not meet with her.
When the client did her intermediate, her father arranged her engagement with her cousin.
She was very happy in her married life. Her father died after one year of her marriage when she
was 26. That was a very stressful period of her life. But life goes on she became busy with her fa
Clinical Case Studies 28

mily life. In the same year she gave birth to a son. Everyone was very happy on his birth. After t
wo years she gave birth to twin daughters.
Family History
The client belonged to a middle class family. Her father was educated and was manager i
n a company. Her mother was a house wife. She was an UN-educated woman. Her father got mar
ried to her mother without his will due to which their relationship was disturbed. There was lack
of understanding between her parents.
When client was seven years old, her father divorced his wife. Patient was the first daugh
ter of her parents. She had one younger sister also. These two sisters were disturbed at that time a
nd felt alone and helpless. Their father was very caring and loving so they got settled with their f
ather and completed their studies. After completing her F.A she stopped her studies as, she had t
o take care of home. Her father got her married to one of her cousins. After one year of her marri
age her father died. Her younger sister also got married and is happy in her life. Both sisters are v
ery close to each other and have very good relations.
Premorbid personality
Client was a sensitive girl. She was disturbed because of family So, she felt lonely
& helpless. After her engagement with her cousin. She was very happy in her married life. Client
are very close to her sister and have very good relations.
Informal Assessment
Interview
A semi structured interview was done with both the client and referral. Questions were as
ked about the client’s problem and related environmental factors.
Behavioral Observation
Behavioral observations were also made. Patient seemed to be hopeless and worried.
Mental Status Examination (MSE)

Client, a 35 years old female was dressed properly & had combed hair. She had insight of
her problem, when asked about her illness she said that she was suffering from mental illness. Sh
e seemed worried and anxious. She was taking pauses during her conversation started crying whe
n asked about her son. Her conservation was clear and relevant. Her hygienic condition was good.
She had the orientation of time and place. Her attention span was not that good and said to repea
t what she was asked about.
Clinical Case Studies 29

Formal Assessment
Following tests were administered on the client.

1. PTSD Checklist
2. Beck’s Anxiety Inventory (BAI)
3. Rotter Incomplete Sentence Blank (RISB)

PTSD Checklist
Client had reported about her repeated and disturbing memories from the incident of her s
on’s death. She had feelings as if the same thing will happen again. This results in hear pounding ,
trouble breathing and at times sweating. Loss of interest in daily life activities and feelings of un
certainty were also reported. Flashbacks of the incident also troubles the client falling asleep at ni
ght.

Beck’s Anxiety Inventory

Quantitative Interpretation

Score Range Category

42 36 and above Severe Level of Anxiety

Qualitative Interpretation

Client had score 42 on the scale which shows her high levels of anxiety. Her response on
different indicates her being anxious most of the times, weakness and trembling in hands and bod
y. Feelings of extreme fear of death and uncertainty were shown in her responses.
Clinical Case Studies 30

Rotter Incomplete Sentence Blank (RISB)

Quantitative Interpretation

Score Cut off score Category

169 135 Maladjusted

Qualitative Interpretation
On RISB patient scored 169, this is greater than the cutoff score of 135. This shows that s
he might not be well adjusted in her life. Her responses on the test items also show that she think
s her life especially her past as painful. She is very sensitive about her daughters especially after
his son’s death is afraid that she might lose her daughters too.

Tentative diagnosis
309.81 (F43.10) Post traumatic Stress Disorder

Case Formulation
Client’s problem started when she faced the traumatic death of her only son. Her son died
in front of her eyes. At this sight patient became unconscious. They were taken to the hospital an
d when she regained her consciousness her son was dead.
This traumatic event was unbearable for her. From that time onwards she has lost interest
in her life and she mourns for the death of her son. Patient reports that she is unable to sleep as th
e flash backs of that accident keep coming again and again. After 7 months of this event she is no
t able to recover from its effects. Although patient had many stressful events in life but she was u
nable to cope with this particular event. She faced the time in her childhood when her parents got
separated. She and her sister were left alone with their father but she managed to cope with the si
tuation. But the death of his beloved was unbearable. She got seriously disturbed and her after th
at traumatic event her daily life got disturbed.
Clinical Case Studies 31

Social cognitive theory (Be-night & Bandura, 2004) suggests that those who try to incor
porate the experience of trauma into existing beliefs about oneself, others, and the world often wi
nd up with unhelpful understandings of their experience and perceptions of control of self or the
environment (i.e., coping self-efficacy). Same is the case with our client that she is constantly sk
eptical of what might happen in her life now. She is scared of taking her daughters anywhere that
something bad might happen to them.

Emotional processing theory (Rauch & Foa, 2006) suggests that those who have experi
enced a traumatic event can develop associations among objectively safe reminders of the event
(e.g., news stories, situations, people), meaning (e.g., the world is dangerous) and responses (e.g.,
fear, numbing of feelings). Changing these associations that lead to unhealthy functioning is the
core of emotional processing
Client experiences fear, feelings of helplessness, night mares, anxiety, loss of interest in d
aily activities, disturbed social relations. She avoids going out of home because sight of cars on r
oads bring back the memories of accident.

According to Kushner (1992), people who generally view life excessive events as beyond
their control, develop more severe post-traumatic stress symptoms after criminal assaults than pe
ople who feel no control over aversive events. Patient of the present study also faced negative ev
ents in her life and to some extent was able to cope with them but her son’s traumatic death affec
ted her much and she feels helpless this time.

The Dual Representation Theory of post traumatic stress disorder by Brewin & Joseph, (1
996) states that many of the features and details of some traumatic event-the sounds, smells, and
sights, for example-are initially retained in a system called situational accessible memory. Somet
imes, after a traumatic experience, individuals attempt to dissociate from the event. They might, f
or example, attempt to distract themselves from memories of this event. In the present case patie
nt also tries to avoid being out on roads as it elicits the same fearful feelings. Cues or stimuli in t
he environment that are associated with this traumatic event will tend to activate or prime the con
tents of this memory system. Individuals will thus experience intrusive images and flashbacks th
at are obvious from the current case also.
Clinical Case Studies 32

According to Davidson (1991) people whose childhood have been characterized by pover
ty, whose parents separated or divorced, appear more likely to develop post-traumatic stress diso
rder later in life, than people without such experiences. In the present case, client had gone throu
gh the trauma of separation of her parents and it had lasting effects on her mind.

Case 4
Clinical Case Studies 33

Summary

The 4-year male client B.C referred to the trainee clinical psychologist with the complaint

s of limited speech and poor communication, poor eye contact, repetition of words, lack of respo

nse to his name or indifferent to caregivers, hypersensitivity and crying spells to loud sound. At t

he age of two and half years, a doctor diagnosed him with Autism spectrum disorder at abroad (L

ondon). History was taken from the client’s mother. Informal assessment was done, while for th

e formal assessment the Child autism rating scale (CARS) will be administered. The individualiz

ed educational plan will be proposed on the basis of informal and formal assessment to manage h

is poor communication, poor eye contact and social skills.

Identifying Data

Name B.C
Clinical Case Studies 34

Age 4years

Gender Male

Group Play

School Special

Birth Order 1st

Source and Reason for Referral

The client was referred by her mother for management of less speech, insistence on same

ness, limited speech, poor communication, poor eye contact, repetition of words, lack of respons

e to his name or indifferent to caregivers, hypersensitivity and crying spells to loud sound.

Presenting Complaints

Presenting Complaints of the client according to Mother.

 Baat cheet nahi krta

 Alfaaz m takrar

 Nazryn niche rakhta ha

 Apny naam ka jawab nahi deta

 Unchi awaz m rota ha

History of Present Illness

Clinical Case Studies 35

According to the mother there was problem of limited speech at the age of 2 years. The cl

ient was unable to speak single word when he was 2 years old. Mother thought that it was might

be due to lack of socialization at her home when they were at abroad. The client also has lack of

eye contact. Mother reported that when she calls him. He does not response to mother in any mat

ter. The mother reported that the client never sit appropriately in the house. He has some wanderi

ng behavior. He walks here and there in the house but not sit properly. When he requires somethi

ng like food or water he uses signals towards that thing. Mother reported that he insists on the sa

me shape of the bread and also insists on the same chair. According to mother the client does not

response to anyone in the house. He does not know the smile or facial expressions. Mother report

ed that client shows the repetition of the words in the house. Problems were started at the age of

2 years then mother took it serious and decided to check him to Doctor at abroad. Doctor diagnos

ed Autism. Mother reported that they shifted in Pakistan and they admitted the client in a Special

Education Department where client learned some alphabetic, colors and counting.

Background Information

Family History

The client belonged to middle socioeconomic status. First two years family lived in abroa

d in private flat. After that family shifted in Pakistan. Now he has joint family system. Grandpare

nts, uncle, aunty, mother, father and one younger brother live in this house.

Grandfather is government retired officer and grandmother has loving behavior with the child.

Uncle and Aunty is both cooperative and loving towards the client. Client’s father is 31 years ol

d man. He is educated person runs his own private business. Due to business he often spends m

ost of the time out of city. His behavior towards client is kind. Client’s mother is 32 years old w
Clinical Case Studies 36

oman. Client’s mother education is M.A. She is housewife and her behavior to child is kind. Cli

ent has one sibling. He has 1 younger brother who is not school going. He is physically and me

ntally stable as reported. Home atmosphere is satisfactory. Father’s family relationships are sati

sfactory. All family members are supportive and cooperative with each other and loving toward

s client.

Personal History

The client was born in private hospital with C-Section. He was underweight when he was

born. As his color was normal and birth weight was low. The Doctors did not indicate any physic

al or mental abnormality at that time. Mother also reported that client did not cry at the time of bi

rth. In his infancy he did experience jaundice when he was 2 month.

According to the informant milestones was normal but he did not speak. he spoke only on

e word at the age of 2 years. At the age of 4 years he started repetition. Mother told that he insist

ed to sit on the same chair and also insists to eat food of same shape. He likes franchise. Howeve

r, the client had normal developmental milestones as he started siting, walking without support in

the early age.

Table 1
Clinical Case Studies 37

Developmental milestones, Normal Age and client’s Age of Achievement.

Developmental Normal Age of Achievement Client Age of

(Cook, Klein, &Tessier, 2008)

Milestones Achievement

Neck holding 1-3 months 3 months

Sits without support 5-9 months 7 months

Stand without support 9-11 months 10 months

Walks without support 10-15 months 15 months

Single word speech 9-12 months 2years

Speaks in phrases 16-30 months 3years

Toilet training 3 years Not achieved yet

Significant delay

Educational History

The client was 4 years old male and he was admitted in a specialized institution.

He joined school when he was 3 years old. He was unable to achieve academic goals. Her

teacher reported that he could make card picture. Mother also did this practice in the hom

e. But after 3 month due to summer vacation institute was closed and he disturbed again.

Teacher said that he knew only few words when something asked to him. According to te

acher he was very weak in reading and writing. He had limited speech.
Clinical Case Studies 38

History of Psychiatric Illness in Family

There is no any medical or psychiatry reported by the informant. All family members hav

e good physical and mental health.

Assessment

Psychological assessment of the client was done on both formal and informal levels to rec

ognize his strengths and weaknesses, to find out the precipitating and maintaining factors of his p

resent problems and to assess the current level of client’s functioning in intellectual and adaptive

areas of functioning.

Table 1.2

Measurement for informal and formal assessment.

Informal Assessment Formal Assessment

Clinical Interview CARS

Behavioral Observation

Reinforce Identification

DSM V checklist
Clinical Case Studies 39

Informal Assessment

Clinical Interview

The clinical interview involves a professional relationship or any clearly defined assessm

ent or therapeutic contact between a mental health provider and a patient or his/her informant (Ol

lendick, 2012).

The interview was started by greeting giving introduction of therapist. Then the question

answer session was started. The mother of the child was cooperated during the session of intervie

w and she gave detail answers about the history of client. The mother reported his presenting co

mplaints that he showed poor eye contact, low speech, on seat behavior, sometime repetition and

insistence of sameness. Then different question were asked by mother related to history of birth t

he mother reported that the child was born in a hospital with C-Section and child was weak at the

time of birth. Then the developmental milestones were asked which were delayed that included s

ingle word speech, speaks in phrases and toilet training. Then the session was ended with smile.

Checklist for Intellectual Disability

The checklist was used to assess the three domains; practical, social and conceptual. It h

elps to check the severity level of intellectual disability

Behavioral Observation
Clinical Case Studies 40

Behavioral observation can be referred to the collection of qualitative data regarding the b

ehavioral phenomena occurring in that particular setting or context (Caution &Lilienfeld, 2015).

Behavior observation of the client was done with continuous recording method during a 30-minu

tes time interval and in a clinical setting i.e. in a room with different stimulus and activities. His

mother was seated in one corner as he got upset without his presence mutually.

In the first session, the client picked up a puzzle with English alphabets, sat on the floor a

nd started lining them up. He sat for about one minute doing this and then started exploring other

activities in the room. The pattern of lining up objects was observed also with toy cars, cards wit

h numbers written on them and Lego blocks in subsequent sessions as well. He attended the pres

ence of therapist by at her for 2 seconds however he did not maintain eye contact any longer. He

did not response to his name and did not understand the commands such sit down or give me. Th

e client showed annoyance on loud sounds (hearing another child cry, loud sound in a video on p

hone) by shouting. But after sometime client became relaxe when they stopped. On the next day,

the client searched for the same puzzle with alphabets and lined them up in random manner.
Clinical Case Studies 41

DSM V symptom Checklist:

In order to verify diagnosis, the client was evaluated on DSM-V criteria for Autistic

spectrum Disorder.

Formal Psychological Assessment

Childhood Autism Rating Scale (CARS)

(The Childhood Autism Rating Scale (CARS) is a behavior rating scale intended to help t

o diagnose autism. CARS were developed by Eric Schopler, Robert J.Reichier and Barbara Roch

en Renner. The scale was designed to help differentiate children with autism from those with oth

er developmental delays, such as intellectual disability. It is a behavioral rating scale used for as

sessing the presence and severity of symptoms of autism spectrum disorders. ... 2000) is a semi-

structured standardized assessment of communication, social interaction and play behaviors.

Diagnosis

299.00 (F84.0) Autism Spectrum Disorder

Case Formulation

Initials: B.C was a 4-year-old from Play group.

Clinical Case Studies 42

Presenting Complaints: limited speech, poor eye contact, restricted behaviors, poor onse

t behavior, stubbornness, repetitive patterns like to repeat words after others, restricted patterns o

f behaviors like to eat specific food and hypersensitive to loud noise.

Predisposing Factors: Mother illness (Diabetes) during pregnancy, Scizerion birth due

wrong position in mother womb, Low weight at birth, jaundice at the age of 2 months, Delayed S

peech, Poor eye contact, Poor speech, and restricted (eating specific food item) patterns of Behav

iors.

Precipitating Factors: Delayed Speech, Delayed Self-help skills like fixation, Poor com

munication.

Maintaining Factors: Poor eye contact, poor communication, and Poor self-help skills.

Protective Factors: Supportive family especially mother, Psychologist, Special School te

acher

DSM 5 Criteria for Autism Spectrum Disorder:

The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition

(DSM-5) provides standardized criteria to help diagnose ASD which is billow.

A. Persistent deficits in social communication and social interaction across multiple c

ontexts, as manifested by the following, currently or by history (examples are illustrative,

not exhaustive, see text):

Clinical Case Studies 43

 Deficits in social-emotional reciprocity, ranging, for example, from abnormal soci

al approach and failure of normal back-and-forth conversation; to reduced sharing

of interests, emotions, or affect; to failure to initiate or respond to social interactio

ns.

 Deficits in nonverbal communicative behaviors used for social interaction, rangin

g, for example, from poorly integrated verbal and nonverbal communication; to ab

normalities in eye contact and body language or deficits in understanding and use

of gestures; to a total lack of facial expressions and nonverbal communication.

 Deficits in developing, maintaining, and understanding relationships, ranging, for

example, from difficulties adjusting behavior to suit various social contexts; to dif

ficulties in sharing imaginative play or in making friends; to absence of interest in

peers.

Specify current severity: Severity is based on social communication impairments and rest

ricted repetitive patterns of behavior.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by

at least two of the following, currently or by history (examples are illustrative, not exhaus

tive; see text):

 Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple

motor stereotypes, lining up toys or flipping objects, melancholia, idiosyncratic ph

rases).
Clinical Case Studies 44

 Insistence on sameness, inflexible adherence to routines, or ritualized patterns or v

erbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with

transitions, rigid thinking patterns, greeting rituals, need to take same route or eat

food every day).

 Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., str

ong attachment to or preoccupation with unusual objects, excessively circumscrib

ed or perseverance interest).

 Hyper- or hyperactivity to sensory input or unusual interests in sensory aspects of

the environment (e.g., apparent indifference to pain/temperature, adverse response

to specific sounds or textures, excessive smelling or touching of objects, visual fas

cination with lights or movement).

Specify current severity: Severity is based on social communication impairments and rest

ricted, repetitive patterns of behavior. (See table below.)

C. Symptoms must be present in the early developmental period (but may not becom

e fully manifest until social demands exceed limited capacities or may be masked by lear

ned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual d

evelopmental disorder) or global developmental delay. Intellectual disability and autism s

Clinical Case Studies 45

pectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum di

sorder and intellectual disability, social communication should be below that expected for

general developmental level.

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Clinical Case Studies 46

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hment. Hillsdale, NJ: Lawrence Erlbaum Associates.

Amstadter, A. (2008). Emotion regulation and anxiety disorders. Anxiety

Disorders, 22, 211–221.

Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity. Journal of

Child Psychology and Psychiatry, 40, 57–87.

Armsden, G., & Greenberg, M. (1987). The inventory of parent and peer attachment:

Individual differences and their relationship to psychological wellbeing in ado

lescence. Journal of Youth and Adolescence, 16, 427–454.

Clinical Case Studies 49

Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007a). Predicting children’s

anxiety from early attachment relationships. Journal of Anxiety Disorders, 21,

1061–1068.

Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M., & van IJzendoor

n, M. (2007b). Threat-related attentional bias in anxious and nonanxious indiv

iduals: A meta-analytic study. Psychological Bulletin, 133, 1–24.

Ruchensky, J. R., Edens, J. F., Corker, K. S., Donnellan, M. B., Witt, E. A., & Blonig

en, D. M. (2018). Evaluating the structure of psychopathic personality traits:

A meta-analysis of the Psychopathic Personality

Inventory. Psychological Assessment, 30(6), 707–718.

Kolvin I. Studies in childhood psychoses: I. Diagnostic criteria and classification. Brit

J Psychiatry. 1971;118:381–4.

Klin A. Asperger syndrome: an update. Rev Bras Psiquiatr. 2003;25:103–9.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Ains

worth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attac

hment. Hillsdale, NJ: Lawrence Erlbaum Associates.

Amstadter, A. (2008). Emotion regulation and anxiety disorders. Anxiety

Disorders, 22, 211–221.

Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity. Journal of

Child Psychology and Psychiatry, 40, 57–87.

Clinical Case Studies 50

Armsden, G., & Greenberg, M. (1987). The inventory of parent and peer attachment:

Individual differences and their relationship to psychological wellbeing in ado

lescence. Journal of Youth and Adolescence, 16, 427–454.

Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007a). Predicting children’s

anxiety from early attachment relationships. Journal of Anxiety Disorders, 21,

1061–1068.

Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M., & van IJzendoor

n, M. (2007b). Threat-related attentional bias in anxious and nonanxious indiv

iduals: A meta-analytic study. Psychological Bulletin, 133, 1–24.

Ruchensky, J. R., Edens, J. F., Corker, K. S., Donnellan, M. B., Witt, E. A., & Blonig

en, D. M. (2018). Evaluating the structure of psychopathic personality traits:

A meta-analysis of the Psychopathic Personality

Inventory. Psychological Assessment, 30(6), 707–718.

Kolvin I. Studies in childhood psychoses: I. Diagnostic criteria and classification. Brit

J Psychiatry. 1971;118:381–4.

Klin A. Asperger syndrome: an update. Rev Bras Psiquiatr. 2003;25:103–9.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Clinical Case Studies 51