6

Case No: 1
(Psychotic)
(Major Depressive Disorder +Schizophrenia)
 7

Bio Data

Name: Abd-ur-Rahman

Age: 28 years

Gender: Male

Birth Order: 4th

No. of Siblings: 8 (5 Brothers, 3 Sisters)

Marital Status: Nill

No. of Children: Nill

Religion: Islam

Education: Under Matric

Occupation: Rice Polishing

Social Economic Status: Middle Class

Residence: Kamaliya city

Admission: 2nd

Informant: His brother

 8

Identification Factors:

Patient name is Abd-Ur-Rahman. He is 28 years old and belongs to middle class family status.
He has 8 siblings. Her birth order is 4th. He is living in joint family system.

Reason & Source of Referral:

Patient is referred by his brother due to his unusual state of health and admitted in Psychiatry
Department of District Head Quarter (DHQ) Faisalabad.

Presenting Complaints: Duration: 6 years ago

 Low Mood
 Irritable Mood
 Isolated
 Mutism. (10 days back)
 Visual Hallucinations
 Suicidal attempts
 Aggression
 Suspiciousness
 Muscle Weakness
 Low Appetite
 Disturb sleep

History of Present Illness:

Patient was reported with USOH and USOM. He starts drugs from last 10 months; and run away
from home to last 1 year back. Now he quite from drugs 3 months back. And now he shows
some psychotic symptoms such as ;( isolation, mutism, suicidal attempts, visual hallucinations,
etc.) His first admission in this department is 6 years back. Now he admitted in second time for
treatment.

Past Psychiatric History:

 Significant (He admitted y years ago with same symptoms and diagnosis).
 9

Past Medical and Surgical History:

 9

No significant past medical and surgical history.

Family History:

Patient Parents are alive. Both father and mother are uneducated. He has 8 siblings (5
brothers and 3 sisters). His birth order is 4 th. The relationship of patient with his parents was
good and cooperative. But during the days of illness his relationship with his parents are not
good. He showed aggressive behavior with his parents and siblings and run away from home.

Personal History:

Patient birth us normal. All milestones achieved at age; birth order is 4 th. Patient education is
Under Matric. He is un- married and have his own Rice Polishing business.

Forensic History:

There is no significant forensic history.

Present Social Circumstances:

He lived with his family in his own 1 kanal house. He lives in joint family system. He
belongs to middle class family. His all-house expenses by his father and his elder brother.

Premorbid Personality:

Before his disturbed level of behavior, he was living normal life. His mental functioning
was normal. He was very responsible among his siblings. He was friendly and nice to people.

Mental State Examination:

 Appearance: Kempt
 Behavior: Cooperative
 Talk: Normal
 Mood: Happy
 Thought: About discharge from hospital
 Perception: Intact
 Orientation: Intact
 10

 Insight: Present

Psychological Assessment:

Informal Assessment

 Behavioral Observation
 Clinical Interview

Formal Assessment

 Rotter Incomplete Sentence Black (RISB)

 Slosson Drawing Coordination Test (SDCT)
 Depression, Anxiety and Stress Scale (DASS)

Formal Assessment:

Rotter incomplete Sentence Blank

(RISB)
Quantitative Analysis:

Sr. No Responses Value No. of Responses Scored

1 Positive P1 = 2 P1 = 5 5 x 2 = 10
P2 = 1 P2 = 4 4x1=4
P3 = 0 P3 = 1 1x0=0
2 Conflict C1 = 4 C1 = 6 6 x 4 = 24
C2 = 5 C2 = 3 3 x 5 = 15
C3 = 6 C3 = 5 5 x 6 = 30
3 Neutrals N=3 N = 11 11 x 3 = 33
4 Omission O=1 O =1 1x1 = 1
5 Total = 116

Qualitative Analysis:
 11

Cut of Score: RISB score did not show the maladjusted behavior. The cut of score is 135 if the
score is increase from the 135 then they showed maladjusted behavior.

Family Attitude: Family attitude consists on items (35, 11) which shows our positive feeling.
The individual complaining words provides a healthy relationship with his parents.

Social and Sexual Attitude: Social attitude is not clearly indicated but in sexual attitude patient
have no feeling and clear thoughts about this.

Characteristics State: Patient hate the noise. Noise is become the patient aggressive. He thinks
that he does not doing powerful work. He wants to be a healthy person and he became able to
make money for his parents.

General Attitude: He has positive attitude. He likes play cricket. He upset when anyone does
not accept their opinions. He wants a healthy and be independent and achieved their desires.

Slosson Drawing Coordination Test

(SDCT)
Quantitative Analysis:

Formula= Test (obtained score) / Test (total score) × 100

 T.S/T. S ×100 = 08/36 × 100 = 22.25 %

Total score Obtained score Error Percentage

36 08 30 22.25%

Qualitative Analysis:
Due to his scores his Eye-hand coordination action is seems too defective.

Depression Anxiety Stress scale

(DASS)
DASS Qualitative Analysis Quantitative analysis
Depression Sever 26-33
Anxiety Extremely sever 20+
Stress Sever 21-27
 12

Informal Assessment:

Behavioral Observation:

The patient was clean. He was talking very well but his mood was too low. He was little
scared. He was sitting quite comfortably. His body postures showed that he was secure about
himself. His eye contact was good. His voice tone was low from normal.

Clinical Interview:

His brother reported that he showed aggressive behavior with his family. He stays in the
room alone. He also reported that according to patient words patient when he cut his thyroid, he
seeing his (father’s sister, paternal aunt). He also reports that his father’s sister wants to kill
him and his brother reported that nobody is there when he cut it. His brother also reports that it’s
just his hallucinations.

Tentative Diagnoses:

 Major depressive disorder + schizophrenia

Recommendation:

 Psychoeducation
 Daily Activity Chart
 CBT
 Muscle Relaxation Therapy
 Deep Breathing.

Sessions

There are 4 sessions are held with patient.

1st Session:

In first session I build rapport and collect overall history and bio data from patient
brother.
 13

2nd Session:
 13

In second session patient behavior is too much cooperative. Appearance was kempt.
Sleep and appetite were disturbed. Mood was normal. Thoughts were normal not too much
negative and positive it’s are neutral. Psychological work has planned. In this session I talk with
patient about his thoughts.

3rd Session:

In 3rd session Psychoeducation is applied on patient and his family. Patient condition was
little bit improved. Behavior was cooperative. Appearance was kempt. Sleep and appetite was
little improved.

4th Session:

In this session patient’s conditions was little bit improved. Behavior was cooperative. He
was paying attention properly. He agreed all my conversation. Appearance was kempt. Sleep and
appetite were little improved. In this session I applied deep breathing and muscle relaxation
technique. This is my last session with patient’s.

Conclusion:

After a week patient condition was much improved. He wants to go back home and became able
to do something for his parents and don’t want to do suicidal attempts again. And try to give their
best for his health and also for his family.
 14

Appendix I
15
16
17
18
19
20
21
 22

Case No: 2
(Child)
(Post Traumatic Disorder + Depressive Episodes)
 23

Bio Data

Name: Amina Ramzan

Age: 15 years

Gender: Female

Birth Order: 2nd

No. of Siblings: 3 (1 Brothers, 2 Sisters)

Marital Status: Nill

No. of Children: Nill

Religion: Islam

Education: Under Matric

Occupation: Nill

Social Economic Status: Middle Class

Residence: Ropa wali

Admission: 2nd

Informant: her self

 24

Identification Factors:

Patient name is Amina Ramzan. She is 15 years old and belongs to middle class family status.
She has 3 siblings. Her birth order is 2nd. She is living in joint nuclear system.

Reason & Source of Referral:

Patient is referred by his parents due to her unusual state of health and admitted in Psychiatry
Department of District Head Quarter (DHQ) Faisalabad.

Presenting Complaints: Duration: 2 years ago

 Low Mood
 Fits (10 days ago)
 Irritable Mood
 Isolated
 Active mutism
 Aggression
 Suspiciousness
 Muscle Weakness
 Low Appetite
 Disturb sleep

History of Present Illness:

Patient was reported with USOH and USOM. She suffers from these symptoms from last 2 years
back with the gap of few days and months consistently. She has thus symptoms due to a trauma
which is the death of her grandmother. After the death of her grandmother, she had these
symptoms and suffered from these conditions. Firstly, she admitted in Allied hospital
Faisalabad for her medical equipment. After the testing process of the hospital, they referred her
for cheak up and have a good treatment there. Her first admission in this department is 1 year
back. Now he admitted in second time for treatment.
 25

Past Psychiatric History:

 No significant psychotic features patient has.

Past Medical and Surgical History:

No significant past medical and surgical history.

Family History:

Patient Parents are alive. Both father and mother are uneducated. He has 3 siblings (1
brothers and 2 sisters). Her birth order is 2 nd. The relationship of patient with her parents was
good and cooperative. But during the days of illness his relationship with his parents are not
good. She showed aggressive behavior with his parents and siblings even she had fighting with
her siblings.

Personal History:

Patient birth was normal. All milestones achieved at age; birth order is 2 nd. Patient education is
Under Matric. She is un- married and till studied in class 9th.

Forensic History:

There is no significant forensic history.

Present Social Circumstances:

She lived with her family in her own 10 kanal house. She lives in joint family system.
She belongs to middle class family. Her all-house expenses mat by her father and her elder
brother.

Premorbid Personality:

Before his disturbed level of behavior, she was living normal life. Her mental functioning
was normal. She was very responsible among her siblings. She is a friendly and nice girl to
people.

Mental State Examination:

 26

 Appearance: Kempt
 Behavior: Cooperative
 26

 Talk: Normal
 Mood: normal
 Thought: About discharge from hospital
 Perception: Intact
 Orientation: Intact
 Insight: Present

Psychological Assessment:

Informal Assessment

 Behavioral Observation
 Clinical Interview

Formal Assessment

 Human figure drawing (HFD)

 Standard Progressive Matrix (SPM)

Formal Assessment:

Human figure drawing

(HFD)

DRAWING EXPRESSIONS
Acceptance of task with minimal protest Depression
Inability to complete drawing, marked paucity Significant depression
of detail
Right side drawing Egocentric
Upper right corner drawing Regression
Tiny drawing Withdrawal, emotional dependency
Heavy pressure Antisocial personality, epileptics, organicity,
retardates, aggressive tendencies
Erasure Neurotic tendency possibly
 27

Dim body line or no body Compensatory defense

Younger figure than subject’s age Immaturity
Hand drawn last Conflict over interpersonal relation
Open mouth Orality
Neck long Schizoid, hysterical swallowing inhibition,
inhibition
Thin neck Depression
Off balance figure Pre-schizophrenic possibility
Grape finger Immaturity
Fingers without hands Mach-over indices differentiating assaultive
from non-assaultive subject
 27

Standard Progressive Matrix

(SPM)

Quantitative analysis:
 Total score 15
 Percentile 5%
 Grade +111

Qualitative Analysis:
 Patient is intellectually defective

Informal Assessment:

Behavioral Observation:

The patient was clean. She was talking very well but her mood was too low. She was
little scared. She was sitting quite comfortably. Her eye contact was good. Her voice tone was
low from normal.
 28

Clinical Interview:

Her sister reported that she showed aggressive behavior with her family. She stays in the
room alone. And don’t doing things well. But when she suffering from these symptoms, she is
not able to do anything and any work. She reported that she feels dizzy and restless and couldn’t
able to do something.

Tentative Diagnoses:

 Post traumatic disorder + depressive episodes.

Recommendation:

 Psychoeducation
 Daily Activity Chart
 Muscle Relaxation Therapy
 Deep Breathing.

Conclusion:

After 2 weeks patient condition was much improved. She wants to go back home and became
able to do something for her parents and don’t want to continue her study. And live happily with
her siblings and parents.
 29

Appendix II
30
 31

Case No: 3
(Drug)
(Substance Used Disorder)
 32

Bio Data:

Name: Amir

Age: 45 years

Gender: Male

Birth Order: Middle

No. of Siblings: 5 (4 Brothers, 1 Sisters)

Marital Status: Married

No. of Children: 3 Sons

Education: I. Com

Occupation: Working in textile mill

Social Economical Status: Middle class family

Residence: Faisalabad

Informant: By self

Drug: Alcohol (2 bottles), Cigarette (per day), Tabacco

Pan (4 daily)

Duration: 20-25 years

Admission: 1st admission

 33

Presenting Complaints: Duration: 25 years ago

 Restlessness
 Irritability
 Body aches
 Body Weakness
 Appetite Disturb
 Sleep Disturb

History of Present Illness:

Patient was in unusual state of health. He starts taking drug at age 15 years old, starting
from (cigarette and pan) from 20 to 25 years ago. Then he starts drinking (Alcohol) after few
years; with his friends at a marriage event. After this he start drinking Alcohol consistently from
25 years back. Now he wants to quite from this due to the un- usual state of health and or issues
about his respect. His last Intake is 10 days back. After withdrawal he had some symptoms such
as; (Restlessness, irritability, body ache, etc). Now he quite it for his family. Patient is motivated
and taking medicine regularly.

Past Psychiatric History:

Patient has any no psychiatric history.

Past Medical Surgical History:

Patient suffer with diabetes and high blood pressure.

Family History:

Patient’s father alive and mother died. It has 4 brothers and 1 sister and all siblings are
married. He is married and has 2 sons. His wife is a educated lady and doing job as a teacher at
an private school. The relationship with his family is good and cooperative. Family drug history
non-significant.
 34

Personal History:

Patient birth was normal and achieved all milestone normal. He has married and 3 sons.
He working in textile mill. His education is I.com. His occupation is to work at an garments shop

Forensic History:

Forensic history is non-significant.

Present Social Circumstances:

He lived in his own house which is consist of 3 malas. He belongs to middle class family.
All expenses of his house are mat by his own self and by his wife.

Premorbid Personality:

He is an Introvert personality. But have good relationship with others.

Mental Status Examination:

 Appearance: Unkempt
 Behavior: Cooperative
 Talk: Normal
 Mood: Low (Subjectively, objectively)
 Thought: normal
 Perception: intact
 Orientation: intact
 Insight: Present

Psychological Assessment:

Informal Assessment

 Behavioral Observation
 Clinical Interview
 35

Formal Assessment

 Human Figure Drawing (HFD)

 Slosson drawing coordinate test (SDCT).

Human figure drawing

(HFD)

DRAWING EXPRESSIONS
Inability to complete drawing, marked paucity Significant depression
of details
Younger figure than subject’s age Immaturity
Stand tight, rigid posture Schizoid, constriction, defensiveness, defense
restriction of activity
Neck short & thick Self-indulgence
Hands omitted Inadequacy, withdrawal
Feet and hands omitted Schizoid
Trunk incomplete Regression
Single line mouth Passive-aggression (Oral aggression)
Arms close to body Tension
Legs omitted Discouragement, withdrawal
Feet omitted Withdrawal
Pressure variation Withdrawal, adaptability, flexibility,
moodiness
 36

Slosson drawing coordinate test

(SDCT)

Quantitative Analysis;

Formula= Test (obtained score) / Test (total score) × 100

 T.S/T. S ×100 = 06/36 × 100 = 16.6 %

Total score Obtained score Error Percentage

36 6 30 16.6%

Qualitative Analysis;
Her score on SDCT test is 16.6% so her eye-hand coordination action seems to be defective
she has some deficit in this processing system.

Informal Assessment:

Behavioral Observation:

The patient was clean. He was talking very well but his mood was too low. He was little
scared or nervous. He was sitting quite comfortably. His eye contact was good. His voice tone
was low from normal.

Clinical Interview:

His nephew reported that he showed aggressive behavior with his family. He stays in the
room alone. And don’t doing things well. But when he suffering from these symptoms, he is not
able to do anything and any work. He reported that he feels dizzy and restless and couldn’t able
to do something.

Tentative Diagnoses:

 Substance used disorder (∆ SUD)

 37

Recommendation:

 Psychoeducation
 Daily Activity Chart
 Muscle Relaxation Therapy
 Deep Breathing.

Conclusion:

After few weeks patient condition was much improved. He wants to go back home and became
able to do something for his children’s, his wife and for his parents. And live happily with his
siblings and family.
 38

Appendix III
39
40
 41

Case No: 4
(Neurotic)
(Major Depressive Disorder + SUD)
 42

Bio Data

Name: Sumaira

Age: 35 years

Gender: Female

Birth Order: 2nd

No. of Siblings: 4 (3 Brothers, 1 Sisters)

Marital Status: Married

No. of Children: 2 (1 daughter, 1 son)

Religion: Islam

Education: BSC Nursing

Occupation: Staff nurse at Allied Hospital Faisalabad

Social Economic Status: Middle Class

Residence: Aly town

Admission: 1st

Informant: her mother

 43

Identification Factors:

Patient name is Sumaira. She is 35 years old and belongs to middle class family status. She has 4
siblings. Her birth order is 2nd. She is living in nuclear system.

Reason & Source of Referral:

Patient is referred by her parents due to her unusual state of health and admitted in Psychiatry
Department of District Head Quarter (DHQ) Faisalabad.

Presenting Complaints: Duration: 2 years ago

 Low Mood
 Lack of interest
 Lack of energy
 Run away from home
 Irritable Mood
 Aggression
 Suicidal thoughts
 Muscle Weakness
 Severe headache
 Low Appetite
 Disturb sleep

History of Present Illness:

Patient was reported with USOH and USOM. She suffers from these symptoms from last 2 years
back with the gap of few days and months consistently. She has these symptoms due to the usage
of injection (spinal Anesthesia) which is used in her C- Section time (on her child delivery)
After her first use she again trying to use when she done a surgical process with her surgeon
team. After this she start using this injection consistently. And became habitual of this injection.
With the usage of these injects she had some disturbance in her health and she became lazy, feel
restlessness, irritability and aggression also. Then her behavior with her family is became
 44

changed, and her family doctor asked her that she have some deficits in her brain part (spinal)
functions or
 44

her brain’ s dysfunctions due to the usage of injection; then she realized this everything. She
thinks that she quite from this. When she tries to quiet, she became depressed due to the concern
of her family her children’s. Now she was admitted in Fatima Ward DHQ hospital Faisalabad
for treatment reported with the symptoms such as: (low mood, lack of interest, lack of energy,
suicidal thoughts, disturbance appetite etc.).

Past Psychiatric History:

 No significant psychotic features patient has.

Past Medical and Surgical:

 Medical history was significant (she had dysfunctions in brain’s part (spinal)).
 Not significant surgical history

Family History:

Patient Parents are alive. Both father and mother are educated. She has 3 siblings (2
brothers and she is only sisters). Her all siblings are married and educated. Her birth order is 2 nd
She is married and has conflict with her husband. relationship of patient with her parents was
good and cooperative. But during the days of illness her relationship with her parents are not
good.

Personal History:

Patient birth was normal. All milestones achieved at age; birth order is 2 nd. Patient education is
BSC Nursing. She is married and has 2 Childs (1 daughter, 1 son). She studied BSC nursing. And
doing job at Allied Hospital Faisalabad as staff nurse.

Forensic History:

There is no significant forensic history.

Present Social Circumstances:

She lived with her family in her own 05 marlas house. She lives in nuclear family system.
She belongs to middle class family. She is the only bread earner of her house.
 45

Premorbid Personality:

Before her disturbed level of behavior, she was living normal life. Her mental functioning
was normal. She was very responsible among her siblings. She is a friendly and nice lady to
people.

Mental State Examination:

 Appearance: kempt
 Behavior: Cooperative
 Talk: Normal
 Mood: normal
 Thought: ‫ میرے گھر کا کیا ہو گا‬. ‫ میں مر جاؤں گی‬. ‫ میرے بچوں کا کیا ہو گا‬.‫میرا کیا ہو گا‬
 Perception: Intact
 Orientation: Intact
 Insight: Present

Psychological Assessment:

Informal Assessment

 Behavioral Observation
 Clinical Interview

Formal Assessment

 Human figure drawing (HFD)

 Beck Depression inventory (BDI)
 46

Formal Assessment:

Human figure drawing

(HFD)

FIGURE A (GIRL) FIGURE B (BOY)

DRAWING EXPRESSIONS DRAWING EXPRESSIONS
Pressure variation Neurotic depression Pressure variation Neurotic depression
Erasure Neurotic tendency Erasure Neurotic tendency
possible possible
Younger figure than Immaturity Younger figure than Immaturity
subject age subject age
Hair given much Narcissism Unpressed hair Inadequate virility
attention
Hair emphasizes with Anxiety over sexual No pupil Anxiety over sexual
heavy shading needs possibly needs possibly
No pupil Egocentrism, Heal clearly indicated Feeling of anxiety or
immaturity, hysteric, of inferiority relate to
regression body functions
Eye brow brushy Uninhibitedness Eye brow brushy Uninhibitedness
Sigle line mouth Passive and oral Sigle line mouth Passive and oral
aggression, simple aggression, simple
schizophrenia schizophrenia
Concave mouth Dependency, passive Concave mouth Dependency, passive
dependent dependent
Thick neck Self-indulgence Thin neck Repression
Arm pressed to sides Difficulty in social Less than five fingers Dependency
contract
Shoulder drooping dejection
 47

Beck Depression inventory

(BDI)
Category Quantitative analysis Qualitative Analysis
Depression Severe depression 31-40

Informal Assessment:

Behavioral Observation:

The patient was clean. She was talking very well but her mood was too low. She was
little scared. She was sitting quite comfortably. Her eye contact was good. Her voice tone was
low from normal.

Clinical Interview:

Her sister reported that she showed aggressive behavior with her family. She stays in the
room alone. And don’t doing things well. But when she suffering from these symptoms, she is
not able to do anything and any work. She also reports that when she does not take injection, she
becomes angry and beating her children’s and run away from home.

Tentative Diagnoses:

 Major depressive disorder + ∆ SUD

Recommendation:

 Psychoeducation
 Daily Activity Chart
 Muscle Relaxation Therapy
 Deep Breathing.
 CBT (Thought recorder and thought re- structuring techniques)
 48

Conclusion:

After 2 weeks patient condition was much improved. She wants to go back home and became
able to do something for her family and children’s. And doing her nursing job at another hospital
and don’t want to take this injection again.
 49

Appendix IV
50
51