Topic:
Case Report
Submitted to:
Mam Shumaila
Submitted by:
Qamar ul Islam
Department of psychology
University of Sargodha Gujranwala campus
Bio data
Name
A.A
Age
25 years
Gender
Female
Education
B.A
Socio-economic status
Moderate
Number of siblings
5 brothers and 5 sisters
Order of birth
Middle child
Marital status
Divorced
Informant
Client herself
Source of referral
Client’s family
Place of referral
Civil hospital Gujranwala
Reason of referral
Client was referred to hospital because of her problems and
change in behavior after divorce.
Presenting complaints
Symptoms
Worthlessness
Restlessness
Irritation
Headache
Fatigue
Hopelessness
Weeping
Sadness
History of present illness
Client was 25 years old woman. She came to the hospital with the compliant of weeping,
hopelessness, fatigue, headache, irritation, sadness, restlessness and worthlessness. Client
came to the hospital after 11 months of her marriage. Client was married 11 months ago.
Client’s husband and in laws was not in good terms with her. They lied to client and her
family before marriage. Client’s husband doubted and blamed her without any reason. Her
husband divorced her after 19 days of her marriage. Client’s problem started after she got
divorced. Client’s family members noticed change in her behavior and referred her to hospital
for treatment.
Family history
Client had good relation with her father. Client had loving relation with her mother. Client
was 10 siblings, 5 brothers and 5 sisters. Client’s brother was disabled. Client was middle
child. Client was in good terms with her siblings. But she was not too close to share her
feelings and other things with her family members. Overall home environment was good.
Personal history
Client had normal birth. Client’s childhood was good. Client was satisfied with her
childhood.
Educational history
Client was educated woman. She got degree of B.A. She had healthy relation with her
teachers and fellows in school and college too.
Occupational history
Client had a job after she completed her education but she quit her job for marriage.
Marital history
Client got married with her permission. Client’s marriage happened in hurry within 8 days.
Her marriage was not successful marriage. She did not have strong and good relation with her
husband. Her husband did not treat her well and doubted her without any reason. She got
divorced after 19 days of her marriage.
Premorbid personality
Client was active and fresh before this incidence.
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 had hunched posture of
shoulder while sitting. She talked nervously and was not confident. She did not maintain eye
contact. She had tears in her eyes during conversation. She was not willing to interact. Her
mood was very sad. She was hopeless about her future. She was aware of her problem.
Beck depression inventory report
Beck depression inventory was used to evaluate the depression level of client.
Quantitative analysis
Raw score
Range
Category
33
29-63
Severe
Qualitative analysis
Beck depression inventory was used to assess level of depression of client. Client scored 33
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, irritated and sad. She was hopeless about her
future.
Case formulation
Client was 25 years old woman. She came with the compliant of weeping, hopelessness,
fatigue, headache, irritation, sadness, restlessness and worthlessness.
Client considered her father as good person and was in good terms with her father. Client had
a loving relation with her mother. Client was 10 siblings, 5 brothers and 5 sisters. She was the
middle child. Her brothers were disabled beings. She got married at the age of 24. She had
issues with her marital life. Her husband divorced her after 19 days of her marriage. Her
problem started after divorce. Mental status examination and beck depression inventory was
used to assess client behavior and mental status. She was sad and weeping during
conversation. She had insight of her problem. Beck depression inventory was used to assess
level of depression of client. Client scored 33 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,
irritated and sad. She was hopeless about her future. By considering all aspects client
condition falls in the criteria of depression.
Psychosocial and environmental stressors are known risk factors for depression. According to
Harris (1976), those who face long term difficulties (issues with marital life, divorce) were
more likely to appear to disturb. The client had faced the problem with marriage life.