CLINICAL REPORTS
Submitted By:
Ushna Nawaz
University Roll No. BPSF15M004
B.S Psychology
Session 2015 – 2019
Submitted to:
Mam Shumaila Ishaq
Department Of Psychology
University of Sargodha (Gujranwala Campus)
In partial fulfillment of requirement of the degree of Bachelors of Science in
Psychology
Department of Psychology
University of Sargodha (Gujranwala Campus)
I certified that the candidate, Miss Ushna Nawaz, University roll# BPSF15M004 has
conducted the case report under the supervision of Miss Shumaila Ishaq. He has prepared the
case reports according to the standards of University of Sargodha.
Head of Department
Dated:
Supervisor
Acknowledgements
I would like to thank the supervisor, head of department mam Shumaila Ishaq, institutes
which permit me to write case report. I also like to acknowledge the clients who permit me to
talk with them.
Ushna Nawaz
Table of content
Serial no.
Case no
1
Case 1
2
Case 2
3
Case 3
4
Case 4
1
Case Report
Bio data
Name: M.A
Age: 32 years old
Gender: Male
Education: Under Matric
Number of siblings: 11 brothers and sisters
Birth order: Eldest among all siblings
Occupation: Nil
Socio-economic status: High socio-economic status
Marital Status: Married
Children: 2 male children
Informant: Client himself
Source of referral: Referred by family members
Place of referral: Mian Afzal Trust Hospital (MATH)
Reason for referral: Client was referred in Mian Afzal Trust Hospital because he was drug
addict, to inhibit the habit of taking drugs
Duration in hospital: 2.5 months, not discharged yet
Presenting complaints
History of present illness
Client was 32 years old man. He came with complaints of depression, suicidal attempts,
hopelessness and mainly the problem of drug addiction. His problem started when his wife
left his home with his 2 children and went back to her parent home. He smoke on daily basis
as time pass and drink visky occasionally when working in abroad (did not cause problematic
behavior). After his wife and children gone he started to take heroine and alcohol. Because of
taking drugs he was having an element of low self-worthiness. He thought it’s better to die
rather than having such miserable life so he attempted suicide two times. Client’s family
admitted him in the Mian Afzal Trust Hospital as a better option. After taking treatment and
sessions with psychologists, client’s condition is stable now. He is moving towards
betterment.
Family history
Client had good relations with his family members. They support client. Client father was
retired form 1992. His mother was a house wife. They were 11 siblings, 1 brother who was
unmarried and 7 sisters among them 6 are married. Other siblings died already. His brother
was good at his occupation.
Personal history
Client was eldest brother. As he was eldest of all he has to take responsibility of his family.
He worked hard to fulfill his responsibilities. He was happy to do it and to fulfill his
responsibilities.
Educational history
He went to school for short duration. He was under-matric.
Occupational history
He worked in multiple countries like Saudia Arabia, Germany and Italy. He was good at his
salary. After coming back to Pakistan he had travel agency in which had 2 big trucks.
Marital history
Client marriage had arranged marriage. He was happy because of his marriage. He liked his
wife. He gave his best to please her wife. He has 2 male children. He loved his children. His
marriage life had ups and downs. His marriage had duration of 4.5 years after that his marital
life become more complicated. Client’s marital life has few issues. Issues were mostly due to
his in laws.
Premorbid personality
Client was an easy going person. He was happy. He was independent. He was responsible for
his duties.
Assessment tools
Following assessment tools were used to examine client:

Rosenberg Self-esteem scale

HTP (house-tree-person)

Mental status examination
Mental status examination report
Mental status examination was used to assess the current mental condition and behavior
client. Client showed good hygiene. He had good flow of speech and was talking confidently.
He had insight of his problem. He had good decision making sense. He knew his problem and
desire to improve it.
Rosenberg Self-esteem scale report
Self-esteem scale was used to evaluate the current self-esteem of client.
Quantitative analysis
Raw score
Range
Category
19
15-25
Normal
Qualitative analysis
Rosenberg self-esteem scale was used to measure self-esteem. Client scored 19
points. The scores indicate a good level of self-esteem in client, which was the indication of
betterment in client behavior. The result indicated that: client is satisfied with himself. He
was feeling respectful for himself. He no longer had the feelings of low self-worthiness. He
had positive attitude towards himself. He can do things which other people are capable to do.
He had number of good qualities. He had good plans about the future.
HTP (house-tree-person) report
HTP was used to better understand the client’s personality. The clients report that he was not
good at drawing. Client was flexible person with satisfactory adjustment. He was reasonably
secure person. The large size of drawing shows that he was aggressive with acting out
tendencies, expansive with euphoric and grandiose tendencies, feeling of inadequacy that
may be unconscious, emotionally hyperactive, alcoholism, weak conscience and antisocial
traits and suspicious, low trust. The vertical shading shows assertiveness, determined and
high activity level. The uncoordinated, shaky shading represents organic/neurological
condition, alcoholism and poor contact with reality. The long strokes indicate self-controlled
sometime to the point of over-inhibition. The important detailing shows condition of
deteriorating and decompensating.
Client holds in ager than explosive episodes. The drawing predicted the perfectionist attitude
of client and fear of losing control and may depersonalize under stress. It predicted the hostile
negativism of client.
The drawing of house predicts the client was accessible and expresses feeling on
interpersonal warmth. The very large image showed that the client feel great frustration over
a restrictive environment uses fantasy and overcompensating to defend against fears, hostile
and aggressive tendencies and feelings of great tension and irritability. The omission of
chimney represents the lack of psychological warmth in home and difficulty with sexuality
and possible sex dysfunction. The client involved with others only on their terms. The open
door indicated a strong need of emotional warmth from environment. The client excessively
seeks satisfaction from fantasy and concerned about controlling fantasy. He client feel
anxious. The client shows feeling of unreality and poor reality contact. The absence of
windows shows the hostile behavior of client.
The tree indicated the desire for children, immature and tends to retreat the immature
behavior under stress, regression. The client was self-centered. Stereotypical male
characteristics e.g. achievement, dominance, competitive, and striving competent. Client
retreats the regression. The drawing predicts him poor reality contact.
The drawing of persons indicated the withdrawal from other people, but may be critical and
accusatory. Is predicts the anxiety conflict which may be manifest in sexual acting out. It
shows the evasive and superficiality in interpersonal relations, inadequate environmental
contacts and withdrawing tendencies, excessively cautious and fearful, demonstrates hostile
impulses, organic/neurological disorder, thought disorder and poor prognosis for effect of
therapy. The pointed eyes represent the severe mental/emotional condition, thought disorder
and psychosis. The omission of ears represents the healthy with normal adjustment and
minimize contact with environment. The drawing predicts the tendencies towards exhibition
of body. The omission of mouth predicts that the client feels guilty over verbal aggression,
depressed, stress related physical illness, usually respiratory, difficulties with communicating
others and rejects need of affection. Client separates intellect/ideas from emotion causing
difficulty controlling impulses, dissatisfied with body image and cultured, socially rigid,
formal and moralistic. The square shaped body indicates the severe mental/emotional
condition, thought disorder and psychosis. The out stretched arms predict the desire for
interpersonal relation and a cry for help. The long legs show the need of independency. The
v-shaped feet represent the depression with psychotic features related to ageing (late mid-life)
and involutional melancholia. The figure shows the front view represents the honesty,
accessibility and frankness to others.
Case formulation
The client was 32 years male. He came in the hospital with the complaints of drug addiction,
depression, suicidal thoughts and suicidal attempts. Client starts to take drugs after his wife
and children left him.
He has good relation with his family. Client’s father was retired in 1992. Client’s family
supports him. After taking treatment and sessions with psychologist the client is recovering.
Rosenberg Self-esteem scale was used to measure the current self-esteem of client. Client
score 19 points which indicates good self-esteem of client. Apparently client inhibits the habit
of drug addiction but the qualitative result of projective test (HTP) indicates alcoholism.
Mental status examination was also used to assess the client which indicates improvement in
mental well-being and behavior of client.
Treatment plan
Relaxation therapies will be used for treatment. Drug treatment can include behavioral
therapy (such as cognitive-behavioral therapy or contingency management), medications, or
their combination. Behavioral therapies can help motivate people to participate in drug
treatment, offer strategies for coping with drug cravings, teach ways to avoid drugs and
prevent relapse, and help individuals deal with relapse if it occurs.
Prognosis
It might take 3 to 4 weeks for the further treatment of problem drug addiction of this
client.
Case report-2
Bio data
Name
S.M
Age
22 year
Education
Uneducated
Gender
Female
Number of siblings 5 siblings, 4 sisters and 1 brother
Order of siblings
Eldest
Marital status
Married
Socio-economic status
Moderate
Informant
Client herself
Source of referral
Client’s family
Place of referral
Civil Hospital Gujranwala
Reason for referral Client was referred to Civil Hospital Gujranwala for psychological
assessment.
Presenting complaints
Symptoms
Recklessness
Worthlessness
Restlessness
Irritation
Aggression
Self-harm
Itching
Headache
Fatigue
Suicidal thoughts
Suicidal attempts
History of present illness
Client was 22 years old female. She came to hospital with complaints of headache, reckless
behavior, fatigue, aggression, self-harm, worthlessness, hopelessness, suicidal thoughts and
attempts, irritation and restlessness. Client bit and scratch her lips. Client came to hospital
after 2 months of her marriage. Client’s family played a role in developing this condition.
Client was not in good terms with her sisters and mother. Client’s actual problem started after
her marriage. She had marital issues. She was married out of family. Her in-laws did not treat
her well. Client’s husband hit her and did not understand her. He did not support client.
Client did not felt confident in sharing her problem with others because whenever she shared
her problem, her father, mother, husband and mother in law accused her of lying. Client’s
family brought her to the hospital for psychological assessment.
Family history
Client’ father was a heart patient. She had a good relation with her father. Client’s mother did
not have a loving relation with her and client’s mother did not support her. Client’s sisters
beat her for no reason. Client’s father asked her sisters to behave well with her but her mother
support her younger sisters and take their side. Client had an average relation with her
brother. Overall home environment was normal.
Personal history
Client had a normal birth. Her childhood was not good as she was eldest of all she had to take
responsibility of her younger siblings and her younger siblings did not treat her well.
Educational history
She had gone to school up to 8th class. She had good relation with her teachers and school
fellows.
Marital history
She was married at the age of 22 and without her permission. Her husband was from out of
family. Her husband was not good with her. He was not caring, loving and understanding. He
often beat her. Client was not happy with her marital life.
Premorbid personality
Client was sensitive female. She was innocent and dependent on her family for financial
support.
Assessment tools
Assessment tools were used to assess the present condition of client. Following tools were
used:

Mental status examination (MSE)

Beck depression inventory (BDI)
Mental status examination report
Mental status examination was used to assess the current mental condition and behavior of
client. Client showed low flow of speech. She was taking pause while answering. She was
not sitting comfortably. She was sitting with her face down. She talked nervously and was not
confident. She did not maintain eye contact. Client bit and scratch her lips, most of the time
her lips were bleeding. Her mood was depressed. She had suicidal thoughts. She had
attempted suicide 2 times already. She showed poor concentration. Client had poor judgment.
She did not have insight about his problem.
Beck depression inventory report
Beck depression inventory was used to evaluate the depression level of client.
Quantitative analysis
Raw score
Range
Category
52
29-63
Severe
Qualitative analysis
Beck depression inventory was used to assess level of depression of client. Client scored 52
point in test which indicates severe form of depression. This level of depression of client can
cause her physical harm and can also affect the mental well-being of client. This result
indicates that client was feeling worthless, aggressive, and irritated. She was feeling sad. She
was hopeless about her future.
Case formulation
Client was 22 years old female, eldest among 5 siblings. She came with the problem of
headache, reckless behavior, fatigue, aggression, self-harm, worthlessness, hopelessness,
suicidal thoughts and attempts, irritation and restlessness.
The client considered her father to be good. Client’s mother did not treat her well. Client did
not have good relation with her siblings except her brother. She was in good terms with her
brother. The personality of client was assessed by using mental status examination (MSE)
which indicates that client was not well mentally. She had poor concentration and judgment.
Her mood was depressed. Beck depression inventory (BDI) was used to measure the level of
depression of client. She showed severe form of depression with 52 scores. She was hopeless
about her future. Keeping all points in consideration client was diagnosed severe depression.
Tentative diagnosis
Severe depression
Psychological and environmental stressors are known as risk factors for depression.
According to Harris (1976) those who were facing long term difficulties (strict behavior of
family, marital issues of client) were more likely to appear to disturb. The client had face the
same problems.
Treatment plan
Medication such as antidepressants can be used to treat client. Therapies such as cognitive
behavior therapy can be used. Other techniques like relaxation therapy can be used for
treatment.
Prognosis
This degree of depression will need duration of 4 to 8 months or depending on recovery may
lessen to 3 to 6 months.
Case report-3
Bio data
Name
R.A
Age
28 years
Gender
Female
Education
Matric
Number of siblings 4 sisters and 3 brothers
Order of birth
Middle child
Socio-economic status
low socio-economic status
Marital status
Divorced
Number of children
2 daughters
Source of referral
Client herself thought that she should visit hospital for her
problem.
Place of referral
Civil hospital Gujranwala
Reason of referral
Client was referred to the hospital because of her recurrent
behavior.
Presenting complaints
Symptoms
Recurring hand wash
Recurring face wash
Recurring rinsing
Skin problem
Loss of interest in daily activities
History of previous illness
Client went to civil hospital when she first realized her problem. Client took psychotherapy.
Client took medicine for 4 months but because of some financial problem she quit the
medicine for 4 months.
History of present illness
Client was 28 years old woman. She came with the problem of recurring hand wash,
recurring face wash, recurring rising, skin problem and loss of interest in daily activities.
Client got married at the age of 23. She had issues with marital life. Client’s husband was
drug addictor, he beat client and did not take financial responsibility of client and their
children. Client’s husband did not fulfill his responsibility. This situation caused tension to
client and in response of this client began to show recurring behavior which causes skin
problem too. Client got divorce from her husband and was detached from her children for 3
years. Client came to hospital for treatment. Client condition got better after getting
treatment.
Family history
Client father died. Client had good relation with her mother. Client was in good terms with
her siblings. Overall home environment was good.
Personal history
Client had normal birth. Client was satisfied with her childhood. Her childhood was good.
Educational history
Client studied in school and completed matric. Client had good interaction with her teachers
and fellows. She had to quit education because of financial issues.
Marital history
Client was not ready for marriage. She was not happy with her marriage. She had issues with
her husband. Her husband was drug addictor and beat client. Client’s husband did no fulfill
his responsibilities. Client got divorced by his husband. Her husband also took away their
children from client.
Premorbid history
Client was responsible to perform her duties. She was active in her daily routine.
Assessment tool
Assessment tool used to assess the behavior was mental status examination.
Mental status examination report
Mental status examination was used to assess the current mental condition and behavior of
client. Client’s hygiene was good. She was wearing neat clothe and was according to
weather. Her attitude was co-operative. Client had good flow of speech. Client was willing to
talk and active in response. Client was good at insight and was aware of her problem. She had
maintained eye contact. She was willing to get better and was working on it. She had good
decision making sense. She was aware of her surroundings. She was good in orientation.
Case formulation
Client was 28 years old woman. She came with the problem of recurring hand wash,
recurring face wash, recurring rising, skin problem and loss of interest in daily activities.
Client father died. Client had loving relation with her mother. She shared some of her
feelings with her mother. Client had good interaction with her siblings. Client got married at
the age of 23 years. She had marital issues and got divorced. She lived away from her
children for 3 years which was stressful for client. Mental status examination was used to
assess the current mental condition and behavior of client which indicates that the client was
aware of her problem and fighting for its betterment. She had plans for her future. By looking
at the problems presented by client, client fall in the criteria of obsessive compulsive
disorder.
Diagnosis
Obsessive compulsive disorder
According to Dr. Jeffrey Schwartz’s March/April 1997 Science & Medicine article, entitled
"Obsessive-Compulsive Disorder," scientists have discovered new evidence that explains
some causes of OCD. In short, OCD is an illness in which patients experience obsessions and
then act on them by performing compulsions. Obsessions occur when the brain generates
repetitive, powerful thoughts that are intrusive and produce anxiety. In essence, patients
cannot "move on," forget about or control their own thoughts. Compulsions are the physical
actions or mental thoughts a patient carries out to reduce or eradicate the feelings associated
with obsessive worrying (i.e., anxiety). The same problem was represented by client.
Treatment plan
Psychotherapy
Cognitive behavioral therapy (CBT), a type of psychotherapy, is effective for many people
with OCD. Exposure and response prevention (ERP), a type of CBT therapy, involves
gradually exposing you to a feared object or obsession, such as dirt, and having you learn
healthy ways to cope with your anxiety. ERP takes effort and practice, but you may enjoy a
better quality of life once you learn to manage your obsessions and compulsions. Therapy
may take place in individual, family or group sessions.
Medications
Certain psychiatric medications can help control the obsessions and compulsions of OCD.
Most commonly, antidepressants are tried first.
Prognosis
It depends on individual need; averagely 6 to 12 months will be needed for treatment.
Case report-4
Bio data
Name
R
Age
18 years
Gender
Female
Education
Inter
Socio-economic status
Moderate
Number of siblings
Five
Order of birth
1st
Informant
Client herself
Source of referral
Client’s family
Place of referral
Civil hospital Gujranwala
Reason of referral
Client was referred to hospital for assessment and treatment.
Presenting complaints
Symptoms
Sleep walk
Fatigue
Problem in emotion regulation
Aggression
Sensitive
Behavioral problem
Weeping
Fear of detachment from parents
Grief
Sadness
Fear of getting low scores
History of present illness
Client was 18 years female. She came to hospital with the complaint of sleep walk, fatigue,
problem in emotion regulation, aggression, behavioral problem, sensitive, weeping, and fear
of detachment from parents, grief, sadness, fear of getting low scores. Client had family
issues. Client’s father had an affair, about which client knew. She was very much attach to
his father she had fear of losing him. She also had the fear that she would not be able to score
good marks in part 2 of inter. She always came to hospital with her grandmother because her
mother was not allowed to come out. She came to hospital for assessment and treatment of
her problem.
Family history
Client father was a school teacher. Client was very much attached to her father. Her father
had an affair. Client’s mother was a house wife. Client had loving relation with her mother.
Client had 5 siblings. Client had nice relation with her siblings. Overall home environment
was a bit strict.
Personal history
Client had average childhood. She had some pleasant memory related to her childhood. She
was satisfied with her childhood.
Educational history
Client was still getting education. Her education is not completed yet. She had a fear of
scoring low grades so that she cannot make to fulfill the criteria for further studies.
Premorbid personality
Client had emotional control. She was sensible and responsible.
Assessment tools
Mental status examination was used to assess the present mental status and behavior of client.
Mental status examination report
Mental status examination was used to examine the client’s present mental status and
behavior. Client was had too much fear. Before saying anything she asked if the interviewee
would not hit her. She started to weep before answering any question. She did not have any
emotional control. She showed aggressive and irritated behavior. She was not sitting
comfortably. She was not willing to explain herself. She had the sense of dressing according
to environment and weather. She was not aware of her problem. She did not have any insight.
Case formulation
Client was 18 years female. She came to hospital with the complaint of sleep walk, fatigue,
problem in emotion regulation, behavioral problem, aggression, sensitive, weeping, and fear
of detachment from parents, grief, sadness, fear of getting low scores.
Client father was a school teacher. Client was very much attached to her father. Her father
had an affair. Client’s mother was a house wife. Client had loving relation with her mother.
Client had 5 siblings. Client had nice relation with her siblings. Client had family issues. To
examine her current condition mental status examination was used. She showed irritated and
aggressive mood during interview. She was not aware of her problem. She was full of fear
about different things especially about getting away from her parents. If we consider the
symptoms of client, abnormal grief can be given as diagnosis to client.
Tentative diagnosis
Abnormal grief
Treatment plan
Cognitive therapies can be used to treat the client. Client should take sessions from therapist.
Family therapy should also be the part of treatment. Medication can also be used reduce the
symptoms.
Prognosis
Average 6 to 12 months will be consider as the time for treatment.