INTERNSHIP REPORT

Name : Manisha GC

Enrolment No. : 2002731728

Study Centre : Amar Jyoti Rehabilitation and

Research Centre (0734D)

Region Centre : RC 2 Delhi

Course Code : MPCE15

Mobile Number : 9818192052

Email ID : [email protected]

Agency Supervisor : Varun Muthuchamy

Agency Name :Institute of Mental Health &

Psychological Sciences (IMHAPS)

Discipline of Psychology

School of Social Sciences (SOSS)

Indira Gandhi National Open University (IGNOU)

Indira Gandhi National Open University Maidan Garhi,

New Delhi – 110068

1
 TABLE OF CONTENT
Sl. No Title Page Number
( From –To)
Approval Mail form Maidan Garhi, IGNOU 4
1.
Consent Mail from Dr. Anjum Mahdi 5
2.
Student ID Card 6
3.
Acknowledgement 7
4.
Appendix –I Declaration 8
5.
Appendix –II Reference Letter 9
6.
Appendix –III Consent letter ( agency supervisor) 10
7.
Appendix –IV Record of activity by learner 11-16
8.
Self Evaluation 17-19
9.
Appendix –V Evaluations scheme for Internship ( 20
10. Agency Supervisor)
Appendix –VI Evaluation scheme for Internship ( 21
11. Academic Counsellor )
Appendix –VII Evaluation scheme for Internship ( 22
12. External Examiner )
Appendix VIII Certificate 23
13.
Profile of the Organisation 24-25
14.
A note on the Agency Supervisor 26
15.
Introduction to Internship 27
16.
The Core Skills of Clinical Psychology & 30
17. Applications of Clinical psychology
Case History Taking & Mental State Examination 39-55
18.
The DSM and ICD 56-57
19.
Major Psychological, Neuro Affective Disorders 58-61
20.
Psychoanalytic Therapy 62-67
21.
Expressive Art Therapy and Mindfulness 68-70
22.
Case study 1 71-84
23.
Case Study 2 85-
24.
Case study 3
25.
Case Study 4
26.
Case study 5
27.

2
 Case Study 6
28.
Case study 7
29.
Case Study 8
30.
Case study 9
31.
Case Study 10
32.
Conclusion
33.

3
 ACKNOWLEDGEMENT

At the outset, I would like to show my gratitude for my internship opportunity at

KPS-IMHAPS – INSTITUTE OF MENTAL HEALTH & PSYCHOLOGICAL
SCIENCES, which has been a great chance for learning and professional
development. I consider myself to be a blessed and lucky individual to be provided
with this opportunity. I extend my heartfelt gratitude for having an amazing
opportunity to meet so many wonderful professionals in the field of Mental Health
and Clinical Psychology; all who have led me to this have a very comprehensive
internship experience.

It is with my radiant respect that I owe my deepest sense of gratitude to Mr SENTHIL

VADIVEL P (Chairperson), to let me work with his team of clinical psychologists;
And to MR VARUN MUTHUCHAMY (Clinical Psychologist). It is for his careful
and precious guidance, monitoring and constant encouragement which have been
extremely valuable for my educational understanding; both theoretical and practical.
The blessing, help and guidance given by his from time to time shall always stay with
me and help me move forward to a long way in the journey of life on which I am
about to embark. I will always remain grateful for his natural affection and able
guidance.

Thank you to Dr. ANJUM MAHDI (Academic Counsellor) and all my teachers in
IGNOU study centre, for their valuable guidance, direction and support

5
APPROVAL MAIL FROM MAIDAN GARHI , IGNOU

6
CONSENT MAIL FROM Dr ANJUM MAHDI

7
 APPENDIX – I DECLARATION

I Ms./Mr./Dr Manisha GC Enrolment no 2002731728 , hereby declare that I am a

Learner

of M.A Psychology (Part II), July 2021 year, at the Study Centre Code Amar Jyoti

Rehabilitation and Research Centre (0734D)., Regional Centre RC-2 Delhi and I want to

do my Online Internship (MPCE-015/MPCE-025/MPCE-035) at KPS-IMHAPS –

Institute of Mental Health & Psychological Sciences on my own free will. I will adhere

to the standards of the organization and display professionalism during my internship.

Signature of Learner

Name of the Learner: Manisha GC Date: 05 March 2022

Enrollment No: 2002731728 Place: New Delhi

8
 APPENDIX-II FORMAT FOR REFERENCE LETTER
Date :05 March 2022

To,

Mr. VARUN
Institute of Mental Health and Psychological Sciences
143, Kamarajar Street, Puliyakulam, Coimbatore
India,

Dear Sir/ Madam,

This is state that Ms MANISHA G.C Enrollment No. 2002731728 is a student of

IGNOU and is presently pursuing MA in Psychology from IGNOU Regional Centre
DELHI-2,Study Centre Amar Jyoti Rehabilitation & Research Centre (0734D. As a
part of MA Psychology programme he/ she has to carry out internship (MPCE-015)
for 240 hours. You are requested to kindly provide him/her with permission to
undergo internship at your esteemed organization.

You are also requested to assign one supervisor under whom the learner will
carry out his/ her internship. The supervisor will also have to evaluate the
learner as per the given criteria.

Yours faithfully,

Academic Counsellor/Study-Centre Coordinator

/Regional Director

9
 APPENDIX – III CONSENT LETTER (AGENCY SUPERVISOR)

This is to certify that the internship in MPCE-015 for the partial fulfilment of MAPC
Programme of IGNOU will be carried out by Ms MANISHA GC

Enrolment No. ____2002731728 under my supervision.

(Signature)

Name of Agency Supervisor: M. Varun

Designation: M.Sc., M.Phil in Clinical Psychology (NIMHANS)

Address: Institute of Mental Health & Psychological Sciences (IMHAPS), 143,

Kamarajar Street, Puliyakulam, Coimbatore – 641045
Date: 05 March 2022

10
 APPENDIX – IV RECORD OF ACTIVITIES CARRIED
OUT BY THE LEARNER

Date Time Place Nature of work Name and signature

From To of authority

15/03/2022 6pm 9pm Online Lecture and M. Varun

(Tuesday) Discussion on

Orientation towards

Clinical Psychology

16/03/2022 6pm 9pm Online Lecture and M. Varun

(Wednesday) Discussion on

Orientation towards

Clinical Psychology

18/03/2022 10am 1pm Online Lecture and M. Varun

(Friday) Discussion on

Orientation towards

Clinical Psychology

18/03/2022 6pm 9pm Online Lecture and M. Varun

(Friday) Discussion on

Diagnostic

Classification

Systems

19/03/2022 10am 1pm Online Lecture and M. Varun

(Saturday) Discussion on

Diagnostic

11
 Classification

Systems

19/03/2022 6pm 9pm Online Lecture and M. Varun

(Saturday) Discussion on Case

History Taking

21/03/2022 6pm 9pm Online Lecture and M. Varun

(Monday) Discussion on Case

History Taking

23/03/2022 10am 1pm Online Lecture and M. Varun

(Wednesday) Discussion on

Mental Status

Examination

23/03/2022 6pm 9pm Online Lecture and M. Varun

(Wednesday) Discussion on

Mental Status

Examination

25/03/2022 10am 01pm Online Lecture and M. Varun

(Friday) Discussion on

Neurotic Disorders

25/03/2022 6pm 9pm Online Lecture and M. Varun

(Friday) Discussion on

Neurotic Disorders

26/03/2022 10am 01pm Online Lecture and M. Varun

(Saturday) Discussion on

Affective Disorders

12
26/03/2022 10am 1pm Online Lecture and M. Varun

(Saturday) Discussion on

Affective Disorders

28/03/2022 6pm 9pm Online Role Play M. Varun

(Monday)

30/03/2022 06pm 09pm Online Role Play M. Varun

(Wednesday)

01/03/2022 10am 01pm Online Lecture and M. Varun

(Friday) Discussion on

Psychological

Assessments

01/04/2022 6pm 9pm Online Lecture and M. Varun

(Friday) Discussion on

Psychological

Assessments

02/04/2022 10am 1pm Online Group Discussion M. Varun

(Saturday)

02/04/2022 6pm 9pm Online Group Discussion M. Varun

(Saturday)

04/04/2022 6pm 9pm Online Lecture and M. Varun

(Monday) Discussion on

13
 Essential Skills of

Clinical

Psychologist

06/04/2022 6pm 9pm Online Lecture and M. Varun

(Wednesday) Discussion on

Essential Skills of

Clinical

Psychologist

08/04/2022 10am 01pm Online Lecture and M. Varun

(Friday) Discussion on

Essential Skills of

Clinical

Psychologist

08/04/2022 06pm 09pm Online Role Play M. Varun

(Friday)

09/04/2022 10am 01pm Online Role Play M. Varun

(Saturday)

09/04/2022 6pm 9pm Online Lecture and M. Varun

(Saturday) Discussion on

Psychological

Assessments

11/04/2022 6pm 9pm Online Lecture and M. Varun

(Monday) Discussion on

14
 Psychological

Assessments

13/04/2022 6pm 9pm Online Lecture and M. Varun

(Wednesday) Discussion on

Psychological

Assessments

15/04/2022 10am 01pm Online Role Play M. Varun

(Friday)

15/04/2022 6pm 9pm Online Lecture and M. Varun

(Friday) Discussion on

Psychoanalysis

16/04/2022 10am 01pm Online Lecture and M. Varun

(Saturday) Discussion on

Psychoanalysis

16/04/2022 6pm 9pm Online Lecture and M. Varun

(Saturday) Discussion on

Psychoanalysis

18/04/2022 6pm 9pm Online Lecture and M. Varun

(Monday) Discussion on

Psychosocial

Interventions

20/04/2022 10am 1pm Online Lecture and M. Varun

(Wednesday) Discussion on

Psychosocial

15
 Interventions

22/04/2022 6pm 9pm Online Lecture and M. Varun

(Friday) Discussion on

Psychosocial

Interventions

23/04/2022 6pm 9pm Online Lecture and M. Varun

(Monday) Discussion on

Expressive Art

Therapy and

Mindfulness

25/04/2022 6pm 9pm Online Lecture and M. Varun

(Wednesday) Discussion on

Expressive Art

Therapy and

Mindfulness

27/04/2022 6pm 9pm Online Lecture and M. Varun

(Wednesday) Discussion on Path

Towards Clinical

Psychologist

29/04/2022 6pm 9pm Online Lecture and M. Varun

(Friday) Discussion on Path

Towards Clinical

Psychologist

30/04/2022 10am 1pm Online Viva M. Varun

(Saturday)

16
30/042022 6pm 9pm Online Viva M. Varun

(Saturday)

Note: This does not include the time spent on case studies and assignments.

Signature of the learner Signature of Academic Counsellor

Name of the learner : Manisha GC

Enrollment No. 2002731728

Place : New Delhi

17
Self Evaluation
Items for self evaluation and evaluation by the supervisor
1) Name of the learner: Manisha GC
2) Name of the Agency in which the learner was placed for training : Institute of
Mental Health & Psychological Sciences (IMHAPS)
3) Name of the supervisor at the Center : Dr. Anjum Mahdi
4) Name of the supervisor at the agency : M Varun
5) Duration of training : 45 days Date of Joing : 15 March 2022
6) Date of completing : 30 April 2022
7) Attendance at the place of training: Regular/Irregular/Excellent/Average/Poor
8) Attendance at the supervisory conferences:
Regular/Irregular/Excellent/Average/Poor
9) No. of cases referred for Case history : 10
10) No. of cases referred for testing : 02
11) No. of cases observed at therapy sessions : 10
12) What the learner has learned : How to take interview and take details case
history
13) What the learner is good at : Taking case history and rapport formation

I. Interpersonal and professional competence

1. Maintains professional conduct (timeliness, dress code, language etc) 5 4 3 2 1

2. Interacts well with supervisors 54321
3. Interacts well with other trainees 54321
4. Interacts well with office staff 54321
5. Interacts well with other professionals 54321
6. Interacts appropriately with patients and their families 54321
7. Respects roles and boundaries 54321
8. Is aware of how he / she impacts others 54321
9. Is able to openly reflect on personal behaviour / choices 54321
10. Is able to effectively resolve interpersonal problems 54321
11. Maintains appropriate patient confidentiality 54321
12. Adheres to ethical practices 54321
13. Overall interpersonal and professional competency 54321

18
2. Assessment

1. Obtains thorough and relevant patient history 54321

2. Obtains relevant information from outside sources when appropriate 54321
(family members, agencies like school etc)
3. Observes and reports accurately on patient behavior 54321
4. Administers psychological tests as per standard procedures 54321
5. Accurately scores and summarizes the data 54321
6. Properly interprets and integrates results of assessments 54321
7. Demonstrates knowledge of diagnosis and is able to make 54321
differential diagnosis.
8. Makes appropriate and useful treatment recommendations 54321
9. Clearly communicates results of comprehensive assessment in written report 5 4 3 2 1
10. Submits written reports to supervisor by due date 54321
11. Synthesizes feedback from supervisor’s comments in written reports 54321
12. Learns from previous mistakes in subsequent reports 54321
13. Provides understandable and useful feedback to patients 54321
14. Demonstrates knowledge and applicability of legal and ethical 54321
principles regarding assessment.
15. Overall Assessment Competency 54321

3 Interviewing and understanding of therapy session

1. Demonstrates the ability to establish rapport with patients 54321

2. Demonstrates empathy and caring for patients 54321

3. Appears comfortable and confident in therapy sessions 54321

4. Maintains appropriate boundaries with patients 54321

5. Maintains necessary documentation and submits notes within allotted time 54321

6. Develops appropriate and realistic treatment plans collaboratively with patients 54321

7. Demonstrates knowledge of theoretical orientations and techniques

associated with each 54321

8. Demonstrates ability to conceptualise a patients problem 54321

9. Demonstrates sensitivity to diversity issues 54321

10. Demonstrate appropriate termination of interview plans 54321

19
 4 Supervision.

1. Comes prepared to supervision sessions 54321

2 Uses supervision to gain skills and knowledge 54321

3. Is open to and receives constructive feedback 54321

4. Provides evidence of incorporating supervisor’s suggestions in workwith 54321

patients
5. Seeks extra super vision as needed 54321
6. Effectively presents case formulation 54321

7. Effectively presents assessment findings 54321

8. Establishes and monitors personal goals for training 54321

Rating
5 = Exemplary competency
4 = Competency
3 = Developing competency
2 = Inadequate skills
1 = Incompetent / requires remediation

(Signature)
Name of Agency Supervisor: Varun Muthuchamy
Designation: Consultant Clinical Psychologist
Address: Institute of Mental Health & Psychological Sciences (IMHAPS), 143,
Kamarajar Street, Puliyakulam, Coimbatore – 641045
Place: Coimbatore
Date: 02 May 2022

20
 APPENDIX – V EVALUATION SCHEME FOR
INTERNSHIP (AGENCY SUPERVISOR)

Name of the Programme: MAPC -II Course Code: MPCE-015

Study Centre: Amar Jyoti Rehabilitation & Regional Centre : 29 Delhi 2
Research Centre (0734D)
Name of the Learner: Ms. Manisha GC
Enrolment no.: 2002731728
Internal Marks by Agency Supervisor:

Regional Centre: IGNOU Maximum Marks

Marks Obtained
Sincerity and Professional competence 10 9
Assessment (Case History, Mental Status 15 14
Examination, Interview, Psychological Testing,
etc.)
Overall interaction with patients, clients & 5 5
employees and handling of cases
Total Marks 30 28

Comments, if any:
…………………………………………………………………………………………

(Signature)
Name of Agency Supervisor: Varun Muthuchamy
Designation: Consultant Clinical Psychologist
Address: Institute of Mental Health & Psychological Sciences (IMHAPS), 143,
Kamarajar Street, Puliyakulam, Coimbatore – 641045
Place: Coimbatore
Date: 02 May 2022

21
 APPENDIX-VI EVALUATION SCHEME FOR
INTERNSHIP (ACADEMIC COUNSELLOR

Name of the Programme: MAPC -II Course Code: MPCE-015

Study Centre: Amar Jyoti Rehabilitation & Regional Centre : 29 Delhi 2
Research Centre (0734D)
Name of the Learner : Manisha GC

Enrolment No.: 2002731728

Internal Marks by Academic Counsellor

Details Maximum Marks Marks Obtained
Report 20
Provisional diagnosis and Planning of 5
Intervention
Overall Understanding of Cases 5

Total Marks 30

Comments, if any:

Signature _______________
Name of Academic Counsellor
Dr Anjum Mahdi

Date:
Note:
1. At the end of the Internship the marks are to be given by the Academic
Counsellor.
2. The concerned Study Centre will then send the marks given by the Academic
Counsellor along with the marks given by the Agency Supervisor to the
Regional Centre while sending the Internship Reports of the Learners to the
Regional Centre.
3. The marks given by the Academic Counsellor and the Agency Supervisor will
be totaled and entered in the Award Sheet during the TEE of the Internship at the
Regional Centre. Thetotal internal marks are 60.

22
 APPENDIX-VII EVALUATION SCHEME FOR
INTERNSHIP (EXTERNAL EXAMINER)

Name of the Programme: MAPC - II Course Code: MPCE-015

Study Centre: Amar Jyoti Rehabilitation & Regional Centre : 29 Delhi 2
Research Centre (0734D)
Name of the Learner : Manisha GC

Enrolment no.: 2002731728

External Marks (Viva Voce)

Details Maximum Marks Marks Obtained
Viva 40

Total Marks 30

Comments, if any: --------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------

Signature
Name & Address of External Examiner

Date:

Note: The marks given by the External Examiner are to be entered in the Award
Sheet alongwith the internal marks received from the Study Centre at the time of
TEE of Internship.

23
Student Identity Card

4
 APPENDIX-VIII CERTIFICATE
CERTIFICATE

This is to certify that __Ms. MANISHA GC of MA Psychology Second Year (MAPC

Programme) has conducted and successfully completed the Internship in MPCE 015 in
the place Institute of Mental Health & Psychological Sciences ( IMHAPS).

Name : Manisha GC Name : Dr. Anjum Mahdi

Enrollment No. 2002731728 Designation : Academic Counsellor
Name of the Study Centre : Amar Jyoti Place : New Delhi
Rehabilitation and Research Centre (0734D) Date :
Regional Centre : 29 Rajghat Delhi 02
Place : New Delhi
Date : 09 May 2022

(Signature)
Name of Agency Supervisor: M. Varun
Designation: M.Sc., M.Phil in Clinical Psychology (NIMHANS)
Address: Institute of Mental Health & Psychological Sciences (IMHAPS), 143,
Kamarajar Street, Puliyakulam, Coimbatore – 641045
Date: 09 May 2022

24
 IMHAPS
INSTITUTE OF MENTAL HEALTH AND
PSYCHOLOGICAL SCIENCES

Certificate of Completion
This is Ĩo cerĨify ĨhaĨ Manisha GC
Of IGNOU
has successfully compleĨed 45 Days (240 hours) of Skill Based Online Internship in
Clinical Psychology from 15.03.2022 to 30.04.2022.

This is Ĩo cerĨify ĨhaĨ

This Internship in Clinical Psychology from 01.09.2021 Ĩo 18.10.2021
Mr. SENTHIL VADIVEL P
FOUNDER
REG NO: OICP029
Profile of the Organization/Institution

About IMHAPS :-
Institute of Mental Health & Psychological Sciences (IMHAPS) was founded in the year of
2015 by Dr. P. Senthilvadivel, MOT., (Occupational therapist) and Mrs. Ramya. R., (Senior
Nutritionist), the Secretary of IMHAPS. The institute was established in order to enrich the
practical knowledge of budding mental health professionals (Psychiatrist, Psychologist,
Counsellors, Clinicians, Clinical Social Workers) and paramedical trainees (Occupational
therapist, Speech therapist, Nursing & Pharmacologist) by offering workshops, internships,
seminars, certificate courses, expert guidance’s to the students from above mentioned
disciplines.

For more than 5 years, we have been successfully delivering a mental health support
including psychometric evaluation, psychological consultations, psychotherapy & Clinical,
special education, rehabilitation, and community services. The Skill Based Online Internship
in Clinical Psychology is one among the salient part of our service by offering an internship
to enhance a mental health professional’s skills and knowledge through online mode. Hope
we will definitely meet all of your expectations.

Our Vision
We envision a nation with well qualified mental health professionals and educators in the
field of Psychology, where a person in need of psychological help gets timely assistance and
a student thriving for knowledge gets the best guidance.

Our Mission
 Provide a 24x7 support for people struggling with mental health problems

 Ensure the best quality programs at affordable prices

 Offer a dynamic and interactive educational environment that engages students in

thelearning process.
 Provide carefully crafted program modules approved by our panel of authentic
experts toenhance the participant's skills and knowledge.
 Provide constructive feedback to promote student's self-assessment and motivation.

26
  Offer scholarships for students from low socioeconomic backgrounds.

Please find more information about this organization in their website link
http://imhaps.com/
Resource Persons

 Dr. Manoj Kumar Sharma Ph.D., Professor, Shut Clinic, Department of Clinical
Psychology, NIMHANS, Bangalore

 Dr. P. Thamilselvan, RCI No. : A23794, PhD. in NIMHANS, Assistant Professor,

Department of Psychology (Aided) PSG College of Arts & Science, Coimbatore.

 Mr. Srinivasan Jayaraman, RCI No. : A24949, M.Phil. M.S (Glasg), CPsychol (UK),
Assistant Professor of Clinical Psychology Department of Psychiatry, SRM Medical
College Hospital & Research Centre, Chennai

 Mr. Vigraanth Bapu K. G, RCI No. : A60290, M.Phil. in Clinical Psychology

(LGBIRMH), Assistant Professor & Co-Ordinator, Department of Psychology
(PG),Krishna Jayanthi College, Bangalore

 Mr. Azhagannan K, RCI No. A60253. Clinical Psychologist, Adult Psychiatry,

Department of Clinical Psychology, NIMHANS, Bengaluru.

 Mr. Varun Muthuchamy, RCI No. : RCI-99038-A, M.Phil. in Clinical Psychology

(NIMHANS), Assistant Professor & Head (i/c) PSG College of Arts & Science,
Coimbatore.

 Mr. Rojo Shalom George, M.Phil. in Clinical Psychology, Junior Consultant, Centre
for Addiction Medicine, Department of Clinical Psychology, NIMHANS, Bengaluru

27
A Note on the Agency Supervisor:

I was supervised by Varun M, Assistant Professor, Department of Psychology, PSG College

of Arts & Science, Coimbatore & He is a Consultant Clinical Psychologist at IMHAPS. RCI
No.: A99038, who has immense expertise in

 Psychological Assessments (Personality, IQ, Specific learning disability and

behavioral assessments, Cognitive Style and Brain Dominance),
 Relationship Counseling ((Premarital relationship counseling for relationship discord,
post marital counseling and couples counseling).

 He has M Phil in Clinical Psychology from NIMHANS. And he has participated in

several publications, and research like.

 A study on the Relationship between Field Dependent-Independent (FD-I) Cognitive

Style and Brain Dominance among College Students
 Gaze movement pattern among Field Independent and Dependent Cognitive Style.

 Development and Validation of PSG-Personality Disorder Inventory (PSG-PDI)

IMHAPS has given the opportunity to get immense knowledge not only from our Supervisor
but also others resource person mentioned above.

IT was a great experience overall to understand the Applications of Clinical Psychology

28
INRODUCTION

An internship is a trained and supervised experience in a professional setting in which the

student is learning and gaining essential experience and expertise. Internship is meant for
introducing candidates either full-time or part-time to a real world experience related to their
career goals and interests. It may, but does not have to be related connected to one’s
academic major or minor. Internships can be done during the academic semester and or
summer depending upon the spaced out curriculum. There are several varieties of internship:
some are paid some arenot and some offer credit towards graduation.
Internship is an excellent way to build those all important connections that are invaluable in
developing and maintaining a strong professional network for the future. Internships provide
real world experience to those looking to explore or gain the relevant knowledge and skill
required to enter into a particular career field. Internship is relatively short term in nature with
the primary focus on getting some on the job training and taking what’s learning in the
classroom and applying it to the real world. Interns generally have a supervisor who assigns
specific tasks and evaluates their overall work. For internship for credit, usually a faculty
sponsor will work along with the site supervisor to ensure that the necessary learning is taking
place. Internship can be done by high school or college students to gain relevant experience in
a particular career field as well as to get exposure to determine if they have a genuine interest
in the field.

An internship is a way to determine if the industry and the profession is the best career option
to pursue. Interns not gain practical work experience in a field that students intend to pursue
but also build experience in local, national and international platforms.
It also assists students in making informed career decisions. Through daily activities and
interpersonal interactions, interns are able to gather valuable information about their field.
They also get a chance to evaluate their own strengths and preferences before they formally
enter the job market. Such information can be helpful in deciding if they have made the right
career choiceand can reinforce doubts or resolves relating to their career goals.
Internships may present a potential for an offer of full time employment. Professional work
experience is the most beneficial advantage that can be acquired by completing an internship
for students or fresh graduates, having this work experience on their resume can be the best

29
way to get the foot in the door. This can result in more job offers as compared to individuals
who lack such work experience.
OBJECTIVES OF INTERNSHIP :-

The main objective of the internship course is to facilitate reflection on experiences obtained
in the internship and to enhance understanding of academic material by application in the
internship setting. Internships will provide students the opportunity to test their interest in a
particular career before permanent commitments are made. Apart from it is more important
because:
 Internship students will develop employment records or reference that will
enhanceemployment opportunities.
 Internship will provide students the opportunity to develop attitudes conducive to
effectiveinterpersonal relationship
 Internship will provide students with an in-depth knowledge of the formal functional
activitiesof a participating organization
 Internship programs will enhance advancement possibilities of graduates

 Internship will help the trainees to develop skills and techniques directly applicable
to theircareers.
 Internship will provide students the opportunity to develop attitudes conducive to
effectiveinterpersonal relationships.

PURPOSE OF INTERSHIP IN PSYCHOLOGY :-

 To develop facility with a range of diagnostic skills, including: interviews, case

history-taking, risk assessment, child protective issues, diagnostic formulation, triage,
disposition, and referral.
 To develop further skills in psychological intervention, including: environmental
interventions, crisis intervention, short-term, goal-oriented individual, group, and
family psychotherapy, exposure to long-term individual psychotherapy, behavioral
medicine technique, and exposure to psychopharmacology, case management, and
advocacy.

30
 To develop facility with a range of assessment techniques, including: developmental
testing (elective), cognitive testing, achievement testing, assessment of behavior,
emotional functioning, assessment of parent-child relationship and family systems,
and neuropsychological evaluation (elective). Assessment training across will
include both current functioning and changes infunctioning.
 To develop facility with psychological consultation, through individual cases and
participation in multidisciplinary teams, including consultation to: parents, mental
health staff (e.g., psychiatrists, social workers) medical staff (e.g., physicians, nurses,
PT, OT, etc.), school systems, and the legal system. Consultation training occurs in
both the inclient and outclient setting, both downtown and in the suburbs, and ranges.
 To learn the clinical, legal, and ethical involved in documentation of mental health
services within a medical setting.
 To learn to promote the integration of science and practice, related to theories and
practice of assessment, intervention, and consultation. Interns are trained in
empirically-supported treatments (e.g., parent training groups, inclient treatment
protocols for school avoidance, eating disorders), and behavioral medicine protocols
(e.g., medical noncompliance, pain management, headache treatment, toilet training).

31
The Core Skills of Clinical Psychology & Applications of Clinical psychology

What is Clinical Psychology?

Clinical psychology is the psychological specialty that provides continuing and

comprehensive mental and behavioral health care for individuals and families; consultation
to agencies and communities; training, education and supervision; and research-based
practice. It is a specialty in breadth — one that is broadly inclusive of severe
psychopathology — and marked by comprehensiveness and integration of knowledge and
skill from a broad array of disciplines within and outside of psychology proper. The scope of
clinical psychology encompasses all ages, multiple diversities and varied systems.

According to APA (American Psychological Association): “Clinical psychology is the

psychological specialty that provides continuing and comprehensive mental and behavioural
health care for individuals and families; consultation to agencies and communities; training,
education and supervision; and research-based practice.” Thus, Clinical psychology is the
branch of psychology concerned with the assessment and treatment of mental illness,
abnormal behaviour, and psychiatric problems.

Nature of Clinical pyschology

Clinical psychology mostly deals with mental health issues it primarily focuses on analysis,
recognition, identification and treatment of psychological disorders. Clinical psychology is
applied in hospitals, drug rehabilitation centres, NGOs etc

Scope of Clinical Psychology :

 Early definitions stressed assessments, evaluation and diagnosis

 More recent inclusion of intervention in various forms as well as prevention
 Evidence based practice
 Active debate on the „science of clinical psychology‟
Characteristics of Clinical Psychology :

 Emphasis on science
 Emphasis on maladjustment

32
  Emphasis on the individual
 Emphasis on helping

Opportunities

Clinical psychologists work in a variety of settings (hospitals, clinics, private practice,

universities, schools, etc.) and in many capacities. All of them require these professionals to
draw on their expertise in special ways and for different purposes.

Some of the job roles performed by those working in clinical psychology can include:

 Assessment and diagnosis of psychological disorders, such as in a medical setting

 Treatment of psychological disorders, including drug and alcohol addiction
 Offering testimony in legal settings
 Teaching, often at the university level
 Conducting research
 Creating and administering programs to treat and prevent social problems

Activities of Clinical Psychologist :

01 Intervention And Therapy

 A major activity of clinical psychologist is intervention and treatment.

 Many clinical psychologist work directly with people who have a mental
illness or psychological disorder.
 By choosing an appropriate treatment, clinical psychologist can help such
people overcome their problem or, at minimum, manage their symptom.
 All psychological intervention rests on the ability to develop and maintain
functional therapeutic relationships with clients.
 Psychotherapy is the activity that most frequently engages the typical
clinician‟s efforts and to which the most time is devoted.
2- Assessment and Diagnosis :

• Assessment has long been a critical part of the clinical psychologist‟s role.

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 • Assessment whether through the observation, testing or interview, is a way of
gathering information so that an important question can be solved.
• Assessment of an individual‟s development, behavior, intellect, interests,
personality, cognitive processes, emotional functioning and social functioning
are performed by clinical psychologists as are assessment activities directed
towards families, couples and groups.
• The process of assessment is very important as it leads to the diagnosis of the
clients problems.
• Interpretation of assessment results, and integration of these results with other
information available, in a way that is sensitive to the client, is an essential
skill of clinical psychologist.

3- Teaching :-

Clinical Psychologist who have full or part-time academic appointments obviously devote a
considerable amount of time to teaching. Those whose responsibilities are primarily in the
area of graduate education, teach course in advance psychopathology, psychological testing,
interviewing, intervention, personality theory and so on. Some also teach abnormal
psychology, introduction to clinical psychology.

4- Clinical Supervision :-

This activity is another form of teaching. However, it typically involves more one- to- one
teaching, small group approaches and other less formal, non class room varieties of
instruction. Clinical psychologists often spend significant portions of their time supervising
students, interns and others. In short one learns by doing but under the controlled and secure
conditions of a trainee – supervisor relationship.

5 – Research :-

Clinical psychology has grown out of an academic research tradition. As a result, when
clinical training programs were first established after world war 2, the scientist – practitioner

34
model was adopted. This meant that is contrast to other mental health workers such as
psychiatrist or social worker, all clinicians were to be trained both as scientist and
practitioner. Although this research emphasis may not be so prominent in some training
programs as it once was, the fact remains that clinical psychologists are in a unique position
both to evaluate research conducted by others and to conduct their own research.

Roles and Responsibilities of Clinical Psychologist:-

Clinical psychologists meet with clients to identify problems such as emotional, mental and
behavioural in their lives. Through observation and by using specific methods the
psychologist will diagnose any existing or potential disorders and they are able to understand
and they know how to treat people suffering from psychological problems

Psychologist do not engage knowingly in behaviour that is harassing to the person to whom
they interact in their work based on such factor such as age, gender.

Goals of Clinical Psychologist :-

They help people, frequently through talk therapy resolve a variety of emotional, behavioural
and mental health problems. To meet this goal, they first determine a person's condition and
how serious it is by asking some questions and sometimes providing psychological tests.

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Critical skills for clinical psychologists:

1. Empathy and sympathy

Empathy and sympathy refer to a person's ability to interpret how someone is feeling and
imagine how it would be to have a similar experience. Having empathy and sympathy is this
social skill that helps people build strong interpersonal connections, and it helps people with
different backgrounds or life experiences understand one another and learn from one another.
As a clinical psychologist, your clients are likely to come to you for guidance regarding their
personal history, relationships and challenges. It's important to have empathy and sympathy
to build the trust and connection necessary for offering affective behavioral guidance and
emotional and psychological care.

2. Critical thinking and problem-solving

A person's critical thinking and problem-solving skills represent their ability to use logic,
reason and creativity to resolve problems or find solutions to challenges. Clinical
psychologists need to possess in-depth knowledge of emotional and behavioral disorders and
psychological theories. They need to be able to apply that knowledge alongside their critical
thinking and problem-solving skills to help identify, diagnose and treat behavioral, emotional
or psychiatric conditions.

3. Social responsibility and ethics

Clinical psychologists study ethics as a part of their core courses in college, and they abide
by a code of ethics in their practice and treatment of clients. Due to the nature of their jobs,
psychologists are privy to sensitive information and need to maintain the confidentiality of
their clients as well as the safety of their clients and other people.

It's imperative that psychologists obtain can send from their clients when carrying out
research, conducting studies or publishing findings. They must also respect client
confidentiality and privacy and maintain healthy and ethical client-doctor relationships.

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4. Organization and attention to detailWorkplace organization and attention to detail
represent a person's ability to organize and categorize information easily and their ability to
be thorough and accurate when completing tasks.

As a psychologist, you will need to take diligent notes, complete forms and maintain physical
and electronic files. Psychologists also need to manage schedules, appointments and
treatment plans. Their organization is crucial to their ability to treat clients effectively and
maintain proper confidentiality. They also need to have a high degree of attention to detail
when writing reports, creating treatment plans and filling out forms or health insurance
documentation.

5. Keen observation

Psychologists use their observation skills to collect data for research. They need to be able to
make connections and correlations between differences in behaviors, treatments and feelings
in order to accurately comment on study results. They also need keen observation skills to
monitor and address client progress. The ability to attentive while making clinical
observations also helps them be more sympathetic and empathetic and aides in the diagnosis
process.

6. Active listening

Active listening is a social and professional technique that improves conversations and
interpersonal relationships. It involves observing nonverbal cues, careful listening,
paraphrasing and sympathy and empathy. In order to properly understand their client's lives,
circumstances and challenges, a psychologist needs to practice active listening during their
sessions. Here are six important things to do while someone else is speaking to ensure that
you're engaging in active listening:

• Pay attention to the words the speaker uses.

• Watch the speaker's body language.

• Refrain from making personal judgments.

• Interpret how a person may be feeling.

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• Reflect on what has been said, and clarify by asking questions.

• Affirm the speaker by making consoling statements or summary statements.

7. Written and verbal communication

Psychologists use written and verbal communication when writing reports, creating treatment
plans and documenting client progress. I'm important that they are able to convey their
thoughts, feelings and assessments properly so that that the correct information is received by
insurance providers and other medical professionals.

The skills focused on during the internship are-

Basics of listening: Counsellors need to be particularly able to listen effectively, giving their
full attention to the client. They need to be aware of body language and other non-verbal
communication. Clients will often communicate far more non-verbally than verbally, so this
is an important area of skill. Active listening is a technique that is used in counseling,
training, and solving disputes or conflicts. It requires the listener to fully concentrate,
understand, respond and then remember what is being said. This is opposed to other listening
techniques like reflective listening and empathic listening.

Questioning open communication: Effective questioning helps guide the Clinical

conversation and may assist in enriching the client’s story. Questioning is useful in the
information gathering stage of the interview. It can however be an important skill to use
throughout the entire process. “What would you like to talk about today?” “When does the
problem occur.

Observational Skill:-

By accurately observing non-verbal behavior, a counsellor can gauge the affect her/his words
and actions have upon the client. Skilled client observation also allows the counsellor to
identify discrepancies or incongruities in the client’s or their own communication.
Observation is a skill that is utilized throughout the entire Clinical interview. Observing body
language, tone of voice and facial expressions. For example, when a client enters into the
office of the counsellor, the counsellor can gain some indication of how the client is feeling

38
about the session (are they reticent, comfortable, awkward?) by the way the client walks in,
takes their seat, and greets the counsellor. If a client is resentful about the Clinical session
taking place, they may keep their eyes lowered, seem dismissive of the counsellor and sit in a
closed position, not encouraging communication.

Paraphrasing skills:-

Paraphrases can be just a few words or one or two brief sentences. Capturing the essence of
what the client is saying, through rephrasing. Example: “I have just broken up with Jason.
The way he was treating me was just too much to bear. Every time I tried to touch on the
subject with him he would just clam up. I feel so much better now”. Paraphrase: You feel
much better after breaking up with Jason. That is good, I understand that you went through a
tougher time. The skill to draw the sketch and crux of what is said by the client. It is also
often referred as “Reflection” – for empathizing the feeling of the individual sitting with
factual information. Using summaries is different from using paraphrasing, as a summary
usually covers a longer time period than a paraphrase. Thus, summarizing may be used after
some time: perhaps halfway through – or near the end of – a Clinical session. The summary
’sums up’ the main themes that are emerging

Enhanced emotional experience, Observing and Reflecting feelings: Emotions and

feelings underlie our cognitions, thoughts, speech and behavior. Emotions are our biological
engines; without the support of our feelings, change in cognitions and behavior becomes far
more difficult. Our words, thoughts, and behaviors are all intertwined with emotions and the
emotions often take the lead in what we say and do. Identifying the key emotions of a client
and feed them back to clarify the affective experience. With some clients, the brief
acknowledgment of feeling may be more appropriate. Reflection is often combined with
paraphrasing and summarizing. The purpose of reflection of feeling is to make emotional life
more explicit and clear to the client discovering the “heart of the matter.” Underlying clients’
words, thoughts, and behaviors are feelings and emotions that motivate and drive action.

39
It helps discriminate the intensity of feelings

Summarizing Skills: Using summaries is different from using paraphrasing, as a summary

usually covers a longer time period than a paraphrase. Thus, summarizing may be used after
some time: perhaps halfway through or near the end of a Clinical session. When
summarizing, the counsellor is ‘reflecting back’ the main points of the session so that the
client has the opportunity to recap, and to ‘correct’ the counsellor if any parts of the summary
feel inaccurate. Summaries are therefore useful for:

 clarifying emotions for both the counsellor and the client

 reviewing the work done so far, and taking stock
 bringing a session to a close, by drawing together the main threads of the discussion
 beginning a subsequent session, if appropriate
 starting the process of focusing and prioritising ‘scattered’ thoughts and feelings
 moving the Clinical process forward.
 While the above uses are all in keeping with a person-centered approach to Clinical,
other uses may also be more relevant in more directive modalities.
 providing ‘a useful orientation towards homework and future sessions’
Reflection of meaning, Interpretation, and reframing: Reflection of meaning refers to the
deeply held thoughts and meanings underlying life experiences. For the counsellor who uses
reflection of meaning in their work, they will find that clients will search more deeply into
the aspects of their own life experiences. For example, imagine two individuals who take a
holiday on an island resort: the same island, the same resort, the same time of year. One of
them enthusiastically expresses the wonders of the sunsets, walks along the beach and
leisurely life style. While the other complains about the heat, sunburn and boredom they

40
experienced. This example illustrates how the same event can have a totally different
meaning to the different individuals experiencing the event. Hence, the skill of reflection of
meaning is to assist clients to explore their values and goals in life, by understanding the
deeper aspects of their experiences.

Through interpretation/reframing, the client is encouraged to perceive their experience in a

more positive fashion. The counsellor encourages this shift by offering alternative ways of
viewing their experience. The counsellor, while acknowledging the client’s loss, could
reframe the event to be perceived as an opportunity to experience new places, people and
things: an opportunity for growth. Interpretation/reframing encourage the client to view life
situations from an alternative frame of reference. This strategy does not change the facts of a
situation, nor does it trivialize the hurt or pain the client may be experiencing.

CASE HISTORY TAKING :-

Introduction :-

History taking is an art, a skill that one takes many years to do well. Medical history can be
agonizingly long for the novice, but may just be a short interview by the expert. Medical
history often turns into detective story, where every possible sign is explored and the final
diagnosis is subsequently made by means of examination, investigations or at times empirical
therapy.

For beginners, asking the right questions in a given time period may be daunting, particularly
when clients are aware that the interviewer is a trainee. A checklist of questions is useful so
as to not feel guilty that the interviewer has forgotten a particular point.

If the professionals have learnt to be nice to people, appear interested and smile, one can
begin with case history taking. The steps in history taking have remained unchanged over the
years with client’s data, chief complaints, history of present illness, past history, personal
history, family history, treatment and drug history being sought on that order. As the
psychologist takes history, they learn what to let go and what to hold on to for more
information (Stalin & Viswanathan, 2016).

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History and its Beginning

According to Cambridge (2019) “History is the study of past events considered together,
especially events or development of a particular period. Or it‟s something that has been done
or experienced by a person, it can also be a record of past events relating to a particular
person or event. It‟s the record of actions or events that have happened often over a period of
time”

Case History Introduction

A case history basically refers to a file containing relevant information pertaining to an

individual client or group. Case history is maintained by a broad range of professional
organizations including those in the field of psychiatry, psychology, healthcare and social
work.

Diagnosis in mental health professions depends mostly on case history taking. Most of the
psychological disturbances are the end products of a series of life experiences a person goes
through right from early childhood. Hence, it’s of utmost importance that a dynamic life
picture must be portrayed when the history is taken. The experience and life events of the
client just prior to the onset of psychiatric disturbance must be detailed and the past life
experience during childhood, schooling, adolescence, martial life, and work situation must be
evaluated critically. One should try and imagine oneself in the client’s everyday life, at work
and at home and try to picture the world as the client experiences it. Thus, a good cross-
sectional and longitudinal history will provide a dynamic picture of the client and will help in
diagnosis and management.

In case history, an attempt should be made to ensure that the client is comfortable and
relaxed. This process of taking case history shouldn’t be rushed. The client must be helped to
understand that there is no element of threat in discussing his or her experiences, life events
and sharing his/her concerns. A lot of note taking shouldn’t be taken as it can disturb the
client, so just jot down the important points which can be developed later (Verghese &
Abraham, 2008).

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The case history taking process becomes therapeutic, in the sense that, the initial history
taking marks the beginning of a therapeutic relationship with the client.

Formal Definition of Case History

The formal definition of case history is, a detailed account of the facts affecting the
development or condition of a person or group under treatment or study, especially in
medicine, psychiatry or psychology (American Heritage Dictionary, 2016).

According to the Merriam- Webster Dictionary (2016), case histories are records containing
relevant information pertaining to client’s environments. This information is useful in many
different fields for the purpose of illustration and case analysis.

Ways to Gather Information

There are three methods used to collect the information:

Interviews: At the initial phase of interview the organization can gather basic information
pertaining to client’s concerns and lifestyles. They can also determine, whether or not, clients
have used the services of similar organizations, which can encourage clients to release this
information to add into their case histories.

Self-report measures and check list: A self-report is a test measure or survey that relies on the
individual’s own report of their symptoms, behaviors, beliefs or attitudes. Self-report data is
gathered typically from paper-pencil format. Checklists are assessment tools that set out
specific criteria, which helps the professionals gauge skill development. This approach is
great for organizations that have little spare time to sit and converse with the clients. The
disadvantage of this method is that some issues may be overlooked.

Combination: Combining these two methods are the best way to gather data for case history.
When an organization uses methods in different combination, clients are better able to
provide detailed histories and there is little chance of overlooking the essential information.
Maintaining complete case history is an important aspect of providing quality services to
clients. A complete case history can help the professionals to determine the best way to serve
the clients at the moment of collecting information and in future (Ahuja, 2011).

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Purpose of Case History:-

The purpose of case history is to help to make a diagnosis, determine possible ethology and
estimate prognosis. Here the main purpose is to obtain information about client’s behaviour
and problems which they may be reluctant to share. Collecting detailed case history helps in
gathering the presenting problems. To identify the factors that explains the disorder
pertaining to the client, there are 3 factors, that are: pre- disposition, precipitating and
perpetuating.

Predisposing factors: are the contributing factors to the person’s problem over their lifetime.
These many include genetics, life events or temperament.

Precipitating factors: they are the factors that trigger or are specific to an event to the onset of
the illness or cause a related behavioral response. E.g.: negative pain experiences.

Perpetuating factors: these are the factors which maintain the negative symptoms of an
illness or condition once it has been established. E.g.: parent behavior, parent anxiety, child
behavior and child cognition.

Based on these factors the professionals can formulate the case which will help us to focus on
one particular area and find the treatment for that particular problem. With the treatment
plan, the core problem is solved and the other relating factors are also reduced. When the
suffering is reduced the confidence of the client is won

When and by Whom is Case History Taken :-

Case history is taken when the client comes in with a problem for the first time. The clients
tell their story in their own words along with which relevant questions are asked by the
psychologist.

Case history cannot be taken by all the people. All the mental health professionals like the
psychiatrist, the clinical/counseling psychologist, psychiatric nurse, and the psychiatric social
worker can make use of the case history format which will help them for the treatment
purpose (Verghese & Abraham, 2006).

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From Whom the Information Is Collected

Case history taking is quite a long process for the professionals to get the relevant
information which is needed. In child case history, the informant will be the child’s parent or
the primary care giver. While in case of an adult, the informant will be the client themselves.
But if there is any discrepancy found in the given information, then there can be another
informant who is related to the client or knows about the client and is staying with them. In
case the client is suffering from psychosis, the information cannot be elicited from the client.
In such cases, the professionals need to talk to the relatives of the client and/ or others who
are in contact with the client

Case History Procedure :-

Identification of Data

Case history taking begins by obtaining some identification data which may include Name
(including aliases and pet names), Age, Sex, Marital status, Education, Occupation, Income,
Residential and Office Address(es), Religion, and Socioeconomic background, as appropriate
according to the setting. It is useful to record the source of referral of the client. In medico
legal cases, in addition, two identification marks should also be recorded (Ahuja, 2011).

Informants

Mention here the source of information, relationship of the informant to the client, intimacy
and length of acquaintance with the client and reliability of the information. It is necessary to
obtain information from more than one source. In certain type of illness like psychosis,
relatives will be able to provide more information. While in neurotic illness, the client would
be the best informant. When information is collected from more than one source, do not
collate the account of several informants into one, but record them separately.

The reliability of the information provided by the informants should be assessed on the
following parameters:

 Relationship with client,

 Intellectual and observational ability,

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  Familiarity with the client and length of stay with the client, and
 Degree of concern regarding the client (Ahuja, 2011).

Complaints and their Duration :-

Record the complaints in a chronological order. Do not write a long list of complaints, but
present the salient disturbances in the different areas of functioning. Some clients/relatives
elaborate list of their complaints, other might not spontaneously report their difficulties
unless more direct questions are posed. Hence use your skills and discretion in eliciting the
complaints.

History of Present Illness :-

Give a detailed and coherent account of the symptoms from the onset to the time of
consultation including their chronological evolution and course. Specific attention must be
paid to the following:

Onset: note if the onset of the symptoms is acute- that is, developing within few hours, sub-
acute- few days to few weeks, or gradual- few weeks to few months.

Precipitating factors: these could be physical or psychological in nature. Ascertain whether

the events clearly preceded the illness or were consequences of the illness (e.g. job loss
following the onset of a schizophrenic illness).

Course of the illness: it can be episodic-discrete symptomatic periods with intervening

periods of normalcy, continuous or fluctuating-periodic exacerbation of continuous illness.
Also, different pattern of symptoms may evolve in a continuous illness. For example:
delusions, hallucinations and intense affects may be prominent in the initial phases of a
schizophrenic illness, while in the later stages apathy and emotional blunting might be
prominent.

Associated disturbances: enquiry should also be made of impairment in other areas of

functioning. These include disturbances in sleep, appetite, weight, sexual life, social life, and
occupation. The specific nature of the disturbance and the degree of disability should be

46
recorded. Certain historical details must be routinely enquired into, to rule out the organic
etiology. This includes history of trauma, fever, headache, vomiting, disorientation, memory
disturbance, history of physical illnesses like hypertension/diabetes and history of substance
abuse. While these details are important regardless of the nature of presentation, they are
particularly important in the elderly.

Past History

Enquire about both past physical illnesses, and past psychiatric illnesses. Try to ascertain the
nature and duration of symptoms, the nature of treatment received, and pattern of response.
In certain it may be more meaningful to describe the previous episodes in the history of past
illness rather than in the past history.

Family History

Give a description of the individual family members (parents and siblings). The description
should include information as to whether they are living or dead, age, education, occupation,
marital status, personality and relationship with the client. Enquire about the physical or
psychiatric illnesses in the family and record it in detail. Describe the socio-economic
condition of the family, leadership pattern, role function and communication within the
family.

Personal History

Birth and Early Development: Record the details of the prenatal, natal and postnatal period.
Was the birth at full term? Whether delivered in a hospital or at home? Any complications
during delivery? Any physical illnesses in the postnatal period? Ascertain whether milestones
of development were normal or delayed.

Behavior during Childhood: Enquire about sleep disturbances, thumb sucking, nail biting,
temper tantrums, bed wetting, stammering, tics, and mannerisms. Look for conduct
disturbances in the form of frequent fights, truancy, stealing, lying and gang activities. Also
enquire about relationship with parents, siblings and peers.

47
Physical Illnesses during Childhood: Record physical illnesses suffered in childhood.
Enquire specifically regarding epilepsy, meningitis and encephalitis.

School: Enquire about age of beginning and finishing school, type of school attended,
scholastic performance, attitudes towards peers and teachers.

Occupation: Age of starting work, jobs held, in chronological order, work satisfaction,
competence, future ambitions.

Sexual History: Enquire about age at onset of puberty, level of knowledge regarding sex and
mode of gaining the dame, masturbatory practices, anxiety related to sexual
fantasies/practices. Homosexual and heterosexual fantasies, inclinations and experiences,
extra marital relationships.

Marital History: Enquire regarding age at time of marriage, whether arranged by elders or
by self, was there mutual consent of the partners, age, education, occupation, health and
personality of partner, quality of marital relationship, any separation or divorce. Note the
number of children, their age and health status.

Use and Abuse of Alcohol, Tobacco and Drugs: Enquire about smoking and drinking
pattern and abuse of other drugs like cannabis, opiates, barbiturates etc.

Attitudes to Others in Social, Family and Sexual Relationships:

Ability to trust others: make and sustain relationships, anxious or secure, leader or follower,
participation, responsibility, capacity to make decisions, dominant or submissive, friendly or
emotionally cold, evidence of any jealousy, suspiciousness, guardedness etc. Evidence of
difficulty in role taking – gender, sexual, families, parental or work.

Attitudes of Self:

Egocentric, selfish, indulgent, dramatizing, critical, deprecatory, over concerned, self-

conscious, satisfaction or dissatisfaction with work. Attitudes towards health and bodily
functions. Attitudes to past achievements and failures, and to the future.

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Moral and Religious Attitudes and Standards:

Evidence of rigidity or compliance, permissive or over conscientiousness, conformity and

rebellion. Enquire specifically about religious beliefs.

Mental Status Examination

Mental status examination (MSE) is a standardized format in which the clinician records the
psychiatric signs and symptoms present at the time of the interview. MSE should describe all
areas of mental functioning. Some areas, however, may deserve more emphasis according to
the clinical impressions that may arise from the history; for example, mood and affect in
depression, and cognitive functions in delirium and dementia. MSE has to be repeated
several times during the course of illness to know the evolution of symptoms, effectiveness
of treatment etc. (Ahuja, 2011)

The MSE gives the clinician a snapshot of the client’s mental status at the time of the
interview and is useful for subsequent visits to compare and monitor changes over time. The
psychiatric MSE includes cognitive screening most often in the form of the Mini-Mental
Status Examination (MMSE), but the MMSE is not to be confused with the MSE overall.
The components of the MSE are presented in this section in the order one might include them
in the written note for organizational purposes, but as noted above, the data are gathered
throughout the interview (Kaplan & Sadock, 2015).

Following account highlights the major components of MSE

General Appearance and Behavior

This section consists of a general description of how the client looks and acts during the
interview. Does the client appear to be his or her stated age, younger or older? Is this related
to the client’s style of dress, physical features, or style of interaction?

Items to be noted include what the client is wearing, including body jewelry, and whether it
is appropriate for the context. For example, a client in a hospital gown would be appropriate
in the emergency room or inclient unit but not in an outclient clinic. Distinguishing features,

49
including disfigurations, scars, and tattoos, are noted. Grooming and hygiene also are
included in the overall appearance and can be clues to the client’s level of functioning.

The description of a client’s behavior includes a general statement about whether he or she is
exhibiting acute distress and then a more specific statement about the client’s approach to the
interview. The client may be described as cooperative, agitated, disinhibited, disinterested,
and so forth. Once again, appropriateness is an important factor to consider in the
interpretation of the observation. If a client is brought involuntarily for examination, it may
be appropriate, certainly understandable, that he or she is somewhat uncooperative,
especially at the beginning of the interview (NIMHANS, n. d.; Kaplan & Sadock, 2015).

Impression formed: cooperative/agitated/disinhibited/disinterested

Psychomotor Activity

Motor activity may be described as normal, slowed (bradykinesia), or agitated

(hyperkinesia). This can give clues to diagnoses (e.g., depression vs. mania) as well as
confounding neurological or medical issues. Gait, freedom of movement, any unusual or
sustained postures, pacing, and hand wringing are described. The presence or absence of any
tics should be noted, as should be jitteriness, tremor, apparent restlessness, lip- smacking, and
tongue protrusions. These can be clues to adverse reactions or side effects of medications
such as tardive dyskinesia, akathisia, or Parkinson features from antipsychotic medications or
suggestion of symptoms of illnesses such as attention- deficit/hyperactivity disorder
(NIMHANS, n. d.; Kaplan & Sadock, 2015).

Impression formed: normal/slowed/agitated or increased/normal/decreased

Speech

Elements considered include fluency, amount, rate, tone, and volume. Fluency can refer to
whether the client has full command of the English/ mother-tongue language as well as
potentially subtler fluency issues such as stuttering, word finding difficulties, or paraphrase
errors. The evaluation of the amount of speech refers to whether it is normal, increased, or
decreased. Decreased amounts of speech may suggest several different things ranging from

50
anxiety or disinterest to thought blocking or psychosis. Increased amounts of speech often
(but not always) are suggestive of mania or hypomania.

A related element is the speed or rate of speech. Is it slowed or rapid (pressured)? Finally,
speech can be evaluated for its tone and volume. Descriptive terms for these elements include
irritable, anxious, dysphonic, loud, quiet, timid, angry, or

Impression formed: irritable/anxious/dysphonic/loud/quiet/timid/

Thought :-

Norma1is a goal directed flow of ideas, symbols and associations initiated by a problem or a
task, characterized by rational connections between successive ideas or thoughts, and leading
towards a reality-oriented conclusion. Therefore, thought process that is not goal- directed, or
not logical, or does not lead to a realistic solution to the problem at hand, is not considered
normal.

Traditionally, in the clinical examination, thought is assessed (by the content of speech)
under the four headings of stream, form, content and possession of thought.

However, since there is widespread disagreement regarding this subdivision, „thought‟ is

discussed here under the following two h1eadings of „stream and form‟, and „content‟.

Stream and form of Thought

For obvious reasons, the „stream of thought‟ overlaps with examination of speech‟.
Spontaneity, productivity, flight of ideas, prolixity, poverty of content of speech, and thought
block should be mentioned here. The „continuity‟ of thought is assessed; whether the thought
processes are relevant to the questions asked; any loosening of associations, tangentially,
circumstantiality, illogical thinking, perseveration, or verbiage is noted.

Content of Thought

Any preoccupations; Obsessions (recurrent, irrational, intrusive, ego dystonic, ego-alien

ideas) Contents of phobias (irrational fears); Delusions (false, unshakable beliefs) or Over-
valued ideas; Explore for delusions/ideas of persecution, reference, grandeur, love, jealousy

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(infidelity), guilt, nihilism, poverty, somatic (hypochondriacally) symptoms, hopelessness,
helplessness, worthlessness, and suicidal ideation. Delusions of control, thought insertion,
thought withdrawal, and thought broadcasting are Schneiderian first rank symptoms (SFRS).
The presence of neologisms should be recorded here).

Impression formed: present/absent (with specifications)

Mood and Affect

Mood is the pervasive feeling tone which is sustained (lasts for some length of time) and
colors the total experience of the person. Affect, on the other hand, is the outward objective
expression of the immediate, cross-sectional experience of emotion at a given time. The
assessment of mood includes testing the quality of mood, which is assessed subjectively
(„how do you feel‟) and objectively (by examination). The other components are stability of
mood (over a period of time), reactivity of mood (variation in mood with stimuli), and
persistence of mood (length of time the mood lasts).

The affect is similarly described under quality of affect, range of affect (of emotional
changes displayed over time), depth or intensity of affect (normal, increased or blunted) and
appropriateness of affect (in relation to thought and surrounding environment). Mood is
described as general warmth, euphoria, elation, exaltation and/or ecstasy (seen in severe
mania) in mania; anxious and restless, in anxiety and depression; sad, irritable, angry or
despaired in depression; shallow, blunted, indifferent, restricted, inappropriate or labile in
schizophrenia. Anhedonia may occur in both schizophrenia and depression (NIMHANS, n.
d.; Ahuja, 2011).

Impression formed: General warmth/ euphoria/ elation/ exaltation/ ecstasy/ anxious/ restless/
sad/ irritable/ angry/ despaired/ shallow/ blunted/ indifferent/ restricted/ inappropriate.

Perception

Perception is the process of being aware of a sensory experience and being able to recognize
it by comparing it with previous experiences. Perception is assessed under the following
headings:

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Hallucinations

The presence of hallucinations should be noted. A hallucination is a perception experienced

in the absence of an external stimulus. The hallucinations can be in the auditory, visual,
olfactory, gustatory or tactile domains. Auditory hallucinations are commonest types of
hallucinations in non-organic psychiatric disorders. It is really important to clarify whether
they are elementary (only sounds are heard) or complex (voices heard). The hallucination is
experienced much like a true perception and it seems to come from an external objective
space (for example, from outside the ears in the case of an auditory hallucination).

If the hallucination does not either appear to be a true perception or comes from a subjective
internal space (for example, inside the person‟s own head in the case of auditory
hallucination), then it is called as a pseudo hallucination. It should be further enquired what
was heard, how many voices were heard, in which part of the day, male or female voices,
how interpreted and whether these are second person or third person hallucinations (i.e.
whether the voices were addressing the client or were discussing him in third person); also
enquire about command (imperative) hallucinations (which give commands to the person).
Enquire whether the hallucinations occurred during wakefulness, or were they hypnagogic
(occurring while going to sleep) and/or hypnopompic (occurring while getting up from sleep)
hallucinations.

Illusions and misinterpretations.

Whether visual, auditory, or in other sensory fields; whether occur in clear consciousness or
not; whether any steps taken to check the reality of distorted perceptions.

Depersonalization/Derealization

Depersonalization and derealization are abnormalities in the perception of a person’s reality

and are often described as “as-if‟ phenomena..

Cognitive Functions

Assessment of the cognitive or higher mental functions is an important part of the MSE. A
significant disturbance of cognitive functions commonly points to the presence of an organic

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psychiatric disorder. It is usual to use Folstein’s mini mental state examination (MMSE) for a
systematic clinical examination of higher mental functions

Attention and Concentration

Is the attention easily aroused and sustained; Ask the client to repeat digits forwards and
backwards (digit span test; digit forward and backward test), one at a time (for example,
client may be able to repeat 5 digits forward and 3 digits backwards). Start with two-digit
numbers increasing gradually up to eight-digit numbers or till failure occurs on three
consecutive occasions.

Can the client concentrate; Is he easily distractible; Ask to subtract serial sevens from
hundred (100-7 test), or serial threes from fifty (50-3 test), or to count backwards from 20, or
enumerate the names of the months (or days of the week) in the reverse order. Note down the
answers and the time taken to perform the tests.

Impression formed: aroused and sustained

Orientation

Whether the client is well oriented to time (test by asking the time, date, day, month, year,
season, and the time spent in hospital), place (test by asking the present location, building,
city, and country) and person (test by asking his own name, and whether he can identify
people around him and their role in that setting). Disorientation in time usually precedes
disorientation in place and person.

Impression formed: present/absent or oriented to time/place/person

Memory

Immediate Retention and Recall

Use the digit span test to assess the immediate memory; digit forwards and digit backwards
subtests (also used for testing attention; are described under attention).

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Recent Memory

Ask how did the client come to the room/hospital; what he ate for dinner the day before or
for breakfast the same morning. Give an address to be memorized and ask it to be recalled 15
minutes later or at the end of the interview.

Remote Memory

Ask for the date and place of marriage, name and birthdays of children, any other relevant
questions from the person’s past. Note any amnesia (anterograde / retrograde), or
confabulation, if present.

Impression formed: intact/impaired

General Information :-

The tests should be varied according to the educational level and background of the client.
Some common questions include:

Name of the prime minister

Major cities of India

Name of the state, capital, chief minister

Intelligence :-

Client’s intelligence should be gauged from his educational level, occupational record, his
general knowledge and supplemented by clinical tests appropriate to the client’s background.
More standardized tests can be used if necessary.

Impression formed: average/ below average

Abstract thinking :-

Abstract thinking testing assesses client’s concept formation. The methods used are: Proverb
Testing: The meaning of simple proverbs (usually three) should be asked.

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Similarities (and also the differences) between familiar objects should be asked, such as:
table/ chair; banana/orange; dog/lion; eye/ear.

The answers may be overly concrete or abstract. The appropriateness of answers is judged.
Concretization of responses or inappropriate answers may occur in schizophrenia.

Impression formed: conceptual/concrete/functional

Judgment

Judgment is the ability to assess a situation correctly and act appropriately within that
situation. Both social and test judgment are assessed.

Social judgment is observed during the hospital stay and during the interview session. It
includes an evaluation of „personal judgment‟.

Test judgment is assessed by asking the client what he would do in certain test situations,
such as „a house on fire‟, or „a man lying on the road‟, or „a sealed, stamped, addressed
envelope lying on a street‟.

Impression formed: Good/Intact/Normal or Poor/ Impaired/Abnormal.

Insight

Insight is the degree of awareness and understanding that the client has regarding his illness.
Ask the client’s attitude towards his present state; whether there is an illness or not; if yes,
which kind of illness (physical, psychiatric or both); is any treatment needed; is there hope
for recovery; what is the cause of illness.

Depending on the client’s responses, insight can be graded on a six-point scale:

Complete denial of illness.

Slight awareness of being sick and needing help, but denying it at the same time.

Awareness of being sick, but it is attributed to external or physical factors.

Awareness of being sick, due to something unknown in self.

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Intellectual Insight: Awareness of being ill and that the symptoms/failures in social
adjustment are due to own particular irrational feelings/thoughts; yet does not apply this
knowledge to the current/future experiences.

True Emotional Insight: It is different from intellectual insight in that the awareness leads to
significant basic changes in the future behavior.

Summary

The purpose of a summary is to provide a concise description of all the important aspects of
the case to enable others who are unfamiliar with the client to grasp the essential features of
the problem.

Initial Formulation

This is the counselor’s own assessment of the case rather than a restatement of the facts. Its
length, layout and emphasis will vary considerably from one client to another. It should
always include a discussion of the diagnosis, of the etiological factors which seem important,
a plan of management and an estimate of the prognosis. Regardless of the uncertainty or
complexity of the case, a provisional diagnosis should always be specified using the ICD.

Investigations Treatment and Follow Up

Biochemical, radiological or psychometric investigations should be carried out wherever

appropriate. All aspects of management viz. physical, psychological and social interventions
should be included in the treatment package though the relative emphasis may differ from
case to case. Progress notes should be systematically recorded.

Final Formulation

This is a revision of the initial formulation drawn up at the time of discharge. It should
specify any divergences of opinion and should state the views of the consultant clearly. It
should be written in the light of client’s response to treatment and other information
becoming available since the time of admission. Its length and layout will vary considerably
but it should always include a final diagnosis, with amplifying comments and an estimate of
the diagnosis

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Diagnostic classification system

When diagnosing physical health problems, doctors examine and talk to their clients, to
create lists of signs and symptoms. Signs are objective indicators like a rash or a high
temperature, while symptoms are the clients’ subjective experiences, e.g. sore throat or
tingling sensation. This information is used to reach a diagnosis, which informs treatment
and the expected prognosis.

Many Westerners believe that mental disorders can be addressed in a similar way and
manuals such as the ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM) and the
‘International Statistical Classification of Diseases and Related Health Problems’ (ICD)
provide checklists of symptoms that commonly cluster together allowing practitioners to
identify and diagnose hundreds of different disorders.

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The DSM & THE ICD

The DSM

The DSM, published by the American Psychiatric Association (APA), originated from a
system used to classify disorders experienced by World War 2 soldiers. It was first published
in 1952 and has been revised several times. It is used all over the US and much of the
Western world and generates considerable revenue for the APA, (American Psychological
Association, 2018).The current version, DSM-5, was published in May 2013 and contains
over 300 disorders, divided into over 20 categorie

The ICD

The International Statistical Classification of Diseases and Related Health Problems includes
both physical and mental disorders. It originated from the 1893 International List of Causes
of Death used to monitor global mortality and morbidity statistics (i.e. data on death and
disease). In 1948, The World Health Organisation (WHO) became involved and like the
DSM, the ICD has seen many revision overs the years. The current version, ICD10 was
published by the WHO in 1992 and ICD11 is destined to be published in 2018. This
multilingual, freely available resource is used by clinicians and researchers, policy makers
and client organisations around the world. It provides a ‘common language’ so that data
collected in different countries can be usefully compared.

What is the difference between the ICD and DSM?

The ICD is produced by a global health agency with a constitutional public health mission,
while the DSM is produced by a single national professional association.

WHO's primary focus for the mental and behavioral disorders classification is to help
countries to reduce the disease burden of mental disorders. ICD's development is global,
multidisciplinary and multilingual; the primary constituency of the DSM is U.S.
psychiatrists.

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The ICD is approved by the World Health Assembly, composed of the health ministers of all
193 WHO member countries; the DSM is approved by the assembly of the American
Psychiatric Association, a group much like APA's Council of Representatives.

The ICD is distributed as broadly as possible at a very low cost, with substantial discounts to
low-income countries, and available free on the Internet; the DSM generates a very
substantial portion of the American Psychiatric Association's revenue, not only from sales of
the book itself, but also from related products and copyright permissions for books and
scientific articles.

DMS 5 it is strictly for mental disorders, which includes conditions such as schizophrenia,
eating disorders, substance related disorders, depression whereas ICD 10 includes conditions
such as schizophrenia, eating disorders, substance related disorders, depression, as well as
many others and also includes conditions and diseases related to all other body systems,
including genitourinary, respiratory, gastrointestinal, circulatory, and musculoskeletal to
name a few.

DSM 5 has much better reliability than ICD-10. The DSM-5 basically used by clinicians with
the criteria and gives a accurate definitions to them by determine a client’s diagnosis by
thoroughly describing disorders. In DSM 5 common language is used which derives client
care very effectively where as

ICD codes apply only to in-client care, observations over 12 hours, and same-day surgery.
The mental health section of ICD-10 is mentioned as "Mental, Behavioral and
Neurodevelopmental Illness". It is used by mental health counselors and other mental health
professionals all over the world although it has low reliability as against DSM.

DSM contains better descriptions, symptoms, and other necessary tools for diagnosing
mental health disorders along with the statistics and research findings regarding which sex is
most affected by the illness, typical age of onset, effects of treatment and common treatment
approaches, where as though it is very similar to DSM but there are some diagnoses that we
see in the ICD doesn't appear in the DSM. For example, ICD-11 has Complex PSTD,
Gaming Disorder, Compulsive Sexual Behaviour Disorder, etc

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Major Psychological, Neuro Affective Disorders

Over View of Disorder

The term "disorder" is used throughout the classification, so as to avoid even greater
problems inherent in the use of terms such as "disease" and "illness". "Disorder" is not an
exact term, but it is used here to imply the existence of a clinically recognizable set of
symptoms or behavior associated in most cases with distress and with interference with
personal functions. Social deviance or conflict alone, without personal dysfunction, should
not be included in mental disorder as defined here. Psychological disorders, also referred to
as mental disorders, are abnormalities of the mind that result in persistent behavior patterns
that can seriously affect your day-to-day function and life.

Many different psychological disorders have been identified and classified, including eating
disorders, such as anorexia nervosa; mood disorders, such as depression; personality
disorders, such as antisocial personality disorder; psychotic disorders, such as schizophrenia;
sexual disorders, such as sexual dysfunction; and others. Multiple psychological disorders
may exist in one person.

Psychotic Disorders: These are a group of serious illnesses that affect the mind. They make
it hard for someone to think clearly, make good judgments, respond emotionally,
communicate effectively, understand reality, and behave appropriately.

When symptoms are severe, people with psychotic disorders have trouble staying in touch
with reality and often are unable to handle daily life. But even severe psychotic disorders
usually can be treated.

There are different types of psychotic disorders, including:

Schizophrenia: Schizophrenia is a serious mental disorder in which people interpret reality

abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and
extremely disordered thinking and behavior that impairs daily functioning, and can be
disabling. People with this illness have changes in behavior and other symptoms such as
delusions and hallucinations that last longer than 6 months. It usually affects them at work or
school, as well as their relationships.

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Schizoaffective disorder: Schizoaffective disorder is a mental health disorder that is marked
by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood
disorder symptoms, such as depression or mania. People have symptoms of both
schizophrenia and a mood disorder, such as depression or bipolar disorder.

Schizophreniform disorder: Schizophreniform disorder is a mental disorder diagnosed

when symptoms of schizophrenia are present for a significant portion of time (at least a
month), but signs of disturbance are not present for the full six months required for the
diagnosis of schizophrenia. This includes symptoms of schizophrenia, but the symptoms last
for a shorter time: between 1 and 6 months.

Brief psychotic disorder: Brief psychotic disorder is a sudden, short-term display of

psychotic behavior, such as hallucinations or delusions, which occurs with a stressful event.
People with this illness have a sudden, short period of psychotic behavior, often in response
to a very stressful event, such as a death in the family. Recovery is often quick usually less
than a month.

Delusional disorder: Delusional disorder, previously called paranoid disorder, is a type of

serious mental illness called a “psychosis” in which a person cannot tell what is real from
what is imagined. The main feature of this disorder is the presence of delusions, which are
unshakable beliefs in something untrue. The key symptom is having a delusion (a false, fixed
belief) involving a real-life situation that could be true but isn't, such as being followed,
being plotted against, or having a disease. The delusion lasts for at least 1 month.

Shared psychotic disorder (also called folie à deux): This is an unusual mental disorder
characterized by sharing a delusion among two or more people who are in a close
relationship. The (inducer, primary) who has a psychotic disorder This illness happens when
one person in a relationship has a delusion and the other person in the relationship adopts it,
too. Learn more about shared psychotic disorder and how it develops.

Substance-induced psychotic disorder: Substance or medication-induced psychotic disorder

is characterized by hallucinations and/or delusions due to the direct effects of a substance or
withdrawal from a substance in the absence of delirium. Episodes of substance-induced
psychosis are common in emergency departments and crisis centers. This condition is caused

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by the use of or withdrawal from drugs, such as hallucinogens and crack cocaine, that cause
hallucinations, delusions, or confused speech.

Psychotic disorder due to another medical condition: Other medical disorders that may
cause psychosis include brain tumors and infections, stroke, migraine, and some hormone
disorders. However, people who have delirium from a severe medical illness or drug
withdrawal are not considered to have psychotic disorder due to a medical condition.
Hallucinations, delusions, or other symptoms may happen because of another illness that
affects brain function, such as a head injury or brain tumor.

Affective Disorders: Neurosis refers to a class of functional mental disorder involving

distress but not delusions or hallucinations, where behavior is not outside socially acceptable
norms. It is also known as psychoneurosis or neurotic disorder. This includes Anxiety, OCD
Trichotillomania. Affective disorders are illnesses that affect the way you think and feel. The
symptoms may be quite severe. In most cases, they won't go away on their own. The most
common affective disorders are depression and bipolar disorder.

NEUROTIC STRESS RELATED AND SOMATOFORM DISORDERS

Phobic Anxiety Disorder

This group of phobias includes agoraphobia, social phobia, and specific phobias, e.g.
arachnophobia. A client presents with agoraphobia and manifests symptoms of a well-
defined, external phobic situation, anticipatory anxiety, and autonomic symptoms.

Anxiety Disorders

This group of disorders includes panic disorder, generalized anxiety disorder, and mixed
anxiety and depressive disorder. A client presents with autonomic symptoms and associated
secondary fear of loss of control.

Generalized Anxiety Disorder

Anxiety disorders are marked by continuous anxiety, depressive mood, and variation in
intensity. Depression should be considered and ruled out. A client presents with motor
tension, apprehension, inability to relax, autonomic overactivity, and early insomnia.

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Obsessive-Compulsive Disorders

A young woman client with obsessive-compulsive disorder presents with the following
symptoms: mounting tension, resistance to the act, a sense of relief, and unpleasantly
repetitive behavior that she recognizes as inappropriate.

Stress Reactions and Adjustment Disorders

Clients with these disorders have experienced an exceptionally stressful life event or life
change. Within this group of disorders are acute stress reaction, post- traumatic stress
disorder, and adjustment disorder.

Dissociative Disorders

Symptoms include partial or complete loss of normal integration. Symptoms do not arise
from a physical disorder, and they usually resolve within a few months. A client presents
with a dissociative motor disorder and four of the symptoms of dissociative disorders.

Somatoform Disorders

Symptoms of these disorders include repeated presentation of physical symptoms, requests

for medical investigations, and denial of a psychological basis. A client presents with
multiple symptoms of somatization disorder.

Somatization Disorder

A client presents with multiple symptoms of somatization disorder, including a history of

somatic complaints, lack or reassurance, multiple referrals, and social dysfunction. She is
unable to accept a psychological basis for her pain.

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PSYCHOANALYTIC THERAPY

Founder - Sigmund Freud (1856 to 1939) was the founding father of psychoanalysis,

Contributions

Psychoanalysis :

Sigmund Freud was the founder of psychoanalysis and the psychodynamic approach to
psychology. Freud believed that the human mind was composed of three elements: the id,
the ego, and the superego.

Psychoanalysis is a type of therapy that aims to release pent-up or repressed emotions and
memories in or to lead the client to catharsis, or healing (McLeod, 2014). In other words, the
goal of psychoanalysis is to bring what exists at the unconscious or subconscious level up to
consciousness.

This goal is accomplished through talking to another person about the big questions in life,
the things that matter, and diving into the complexities that lie beneath the simple-seeming
surface.

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STRUCTURE OF PERSONALITY

According to Freud's theory, there are three primary structural elements of personality which
are id, ego, and superego. They reside in the unconscious as forces and they can be inferred
from the ways people

(1) Id: It is the source of a person's instinctual energy. It deals with the immediate
gratification of primitive needs, sexual desires, and aggressive impulses. It works on the
pleasure principle, which assumes that people seek pleasure and try to avoid pain. Freud
considered much of a person's instinctual energy to be sexual, and the rest as aggressive. Id
does not care for moral values, society, or other individuals.

(2) Ego:- It grows out of id, and seeks to satisfy an individual's instinctual needs in
accordance with reality. It works by the reality principle and often directs the id towards
more appropriate ways of behaving. The ego is client,

(3) Superego:- The best way to characterize the superego is to think of it as the moral branch
of mental functioning. The superego tells the id and the ego whether gratification in a
particular instance is ethical. It helps control the id by internalizing the parental authority
through the process of socialization.

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Thus, in terms of individual functioning, Freud thought of the unconscious as being
composed of three competing forces. In some people, the id is stronger than the superego; in
others, it is the superego. The relative strength of the id, ego, and superego determines each
person's stability. Freud also assumed that id is energized by two instinctual forces, called
life instinct and death instinct. He paid less superego; in others, it is the superego. The
relative strength of the id, ego, and superego determines each person's stability. Freud also
assumed that id is energized by two instinctual forces, called life instinct and death instinct.
He paid less attention to the death instinct and focused more on the life (or sexual) instinct.
The instinctual life force that energizes the id is called libido. It works on the pleasure
principle and seeks immediate gratification.

LEVEL OF CONSCIOUS:

Freud has given three level of conscious :-

1. Conscious: This is where our current thoughts, feelings, and focus live;
2. Preconscious : (sometimes called the subconscious): This is the home of everything
we can recall or retrieve from our memory;
3. Unconscious : At the deepest level of our minds resides a repository of the processes
that drive our behavior, including primitive and instinctual desires (McLeod, 2013).

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DEFENCE MECHANISM :-

Freud believed these three parts of the mind are in constant conflict because each part has a
different primary goal. Sometimes, when the conflict is too much for a person to handle, his
or her ego may engage in one or many defense mechanisms to protect the individual.

These defense mechanisms include:

 Repression: The ego pushes disturbing or threatening thoughts out of one’s

consciousness;
 Denial: The ego blocks upsetting or overwhelming experiences from awareness,
causing the individual to refuse to acknowledge or believe what is happening;
 Projection: The ego attempts to solve discomfort by attributing the individual’s
unacceptable thoughts, feelings, and motives to another person;
 Displacement: The individual satisfies an impulse by acting on a substitute object or
person in a socially unacceptable way (e.g., releasing frustration directed toward your
boss on your spouse instead);
 Regression: As a defense mechanism, the individual moves backward in
development in order to cope with stress (e.g., an overwhelmed adult acting like a
child);
 Sublimation: Similar to displacement, this defense mechanism involves satisfying an
impulse by acting on a substitute but in a socially acceptable way (e.g., channeling
energy into work or a constructive hobby) .

The 5 Psychosexual Stages of Development

Finally, one of the most enduring concepts associated with Freud is his psychosexual stages.
Freud proposed that children develop in five distinct stages, each focused on a different
source of pleasure:

1. First Stage: Oral—the child seeks pleasure from the mouth (e.g., sucking);
2. Second Stage: Anal—the child seeks pleasure from the anus (e.g., withholding and
expelling feces).

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 3. Third Stage: Phallic—the child seeks pleasure from the penis or clitoris (e.g.,
masturbation);
4. Fourth Stage: Latent—the child has little or no sexual motivation;
5. Fifth Stage: Genital—the child seeks pleasure from the penis or vagina (e.g., sexual

FREE ASSOCIATION :-

Sigmund Freud was in the process of developing free association from 1892 to 1898. He
planned on using it as a new method for exploring the unconscious. It would
replace hypnosis in this respect. Freud claimed free association gave people in therapy
complete freedom to examine their thoughts. This freedom would come, in part, from a
lack of prompting or intervention by a therapist. Freud proposed the technique helped
prevent three common issues in therapy:
1. Transference. The process of transferring feelings one has for one person to a
different person.
2. Projection. The process of projecting one’s own qualities onto someone else.
3. Resistance. The practice of blocking out certain feelings or memories.

How does Free Association work ?

In traditional free association, a person in therapy is encouraged to verbalize or write all
thoughts that come to mind. Free association is not a linear thought pattern. Rather, a
person might produce an incoherent stream of words, such as dog, red, mother, and
scoot. They may also jump randomly from one memory or emotion to another. The idea
is that free association reveals associations and connections that might otherwise go
uncovered. People in therapy may then reveal repressed memories and emotions.

OEDIPUS AND ELECTRA COMPLEX :-

The Electra complex is referred to as the female counterpart of the Oedipus complex. Unlike
the Oedipus complex, which refers to both males and females, this psychoanalytic term refers
only to females. It involves a daughter’s adoration for her father and her jealously toward her
mother. There’s also a “penis envy” element to the complex, in which the daughter blames
the mother for depriving her of a penis.

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The Electra complex was defined by Carl Jung, one of the pioneers of psychoanalysis and
former collaborator of Freud’s. It was named after the Greek myth of Electra. In the myth,
Electra persuades her brother to avenge her father’s murder by helping her kill her mother
and her lover.

DREAM ANALYSIS :-

In psychoanalysis, dream interpretation is used to reveal unconscious thoughts. Freud

thought that repressed ideas and feelings rise to the surface of the mind through dreams.
However, the content of dreams is often altered. Therefore, the psychoanalyst must help the
client interpret and understand the dream’s substance to discover its hidden meanings.

Freud is, of course, famous for his views on dream interpretation. Basically, he believed that
when we dream, our defenses are down, and things that we are deeply concerned about rise
to the surface. You may have noticed that things happen in your dreams that you wouldn't
even consider in the daytime, such as vicious acts of aggression, uncharacteristic sexual
adventures, and horrible humiliations. But people who are truly repressed may, even in their
dreams, hide behind symbols rather than face such things directly. Freud's clients often had
problems involving sexually repression - a commonplace thing in his very conservative times
- and would dream about things that only hinted at their true desires. Things like snakes and
swan necks might symbolize the penis, entering into a cave might represent the sex act, a
burning fire might be sexual desire, and a floor collapsing underneath you might really refer
to orgasm. Psychologists today don't consider dreams quite as important as Freud did, and
are more likely to ask the client what he or she thinks the dream means than try to interpret it
for them. But dreams will always be an interesting part of life and therapy!

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Expressive Art Therapy and Mindfulness

Meaning of Art Therapy

An art therapy is a mental health profession that uses the creative process of making art to
improve and enhance the physical mental and emotional well being of individuals of all ages.

Art therapy involves the creation of art in order to increase awareness of self and others, this
in turn may promote personal development increase coping skills and enhance cognitive
function.

It is based on personality theories, human development, psychology family systems and art
education. Art therapists are trained on both art and psychological therapy. It is based on the
belief that the Creative process involved in expressing one’s self artistically can help people
to resolve issues as well as develop and manage theirs behaviors and feeling, reduce stress,
improve behaviors and feelings, reduce stress, improve self-esteem and self-awareness, and
achieve insight ( American Art Therapy Association ).

AIMS OF ART THERAPY

 To create circumstances through which healing can occur using art.

 To heal by creating pathway into the worlds of individuals and groups which allow
them to map and dialogue with aspects of themselves and their world using art.
 To ease the pain and resolve them
 Empathetic relationship should be their

SCOPE OF ART THERAPY

 Art therapy is a hybrid discipline based primarily on the fields of art and psychology.
 They use art in treatment assessment and research, and provide consultations to allied
professionals.
 Art therapies work with people of all ages. Individuals, couples, families, groups and
communities.
 They provide services, individually and as part of clinical teams, in settings that

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 include mental health, rehabilitation, medical and forensic institutions community
outreach programs, wellness centers, schools, nursing homes corporates structures,
open studios and independent practices.

GOALS OF ART THERAPY

 To provide a means for strengthening the ego.

 To provide a cathartic experience.
 To provide a means to in cover anger.
 T offer an avenue to reduce guilt.
 To facilitate impulse control.
 To help patents/ clients use as a new outlet during incapacitating illness.
ART THERAPY ENHACES

 Mindfulness
 Recognition of process
 Sensory and psychological integration.
 Perspectives
 Mind/ body connections
 Self-esteem and Trust in self

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  The creative imagination
 Pattern recognition
 It connects time and place

BENEFITS OF ART THERAPY

 Allow client to communicate

 Art therapy help clients fell understood
 Encourage clients to build trust in a safe environment
 Increase their self- esteem and self respect.
 Art therapy assists client in gaining a new, more objective perspective on their
challenges difficult life circumstances.
 It allows clients to begin to experiment with change that can later be applied outside
the therapy room.
 It provide a sage outlet for feeling such as fear, guilt, pain, rage and anger.
 Art therapy encourages clients to make positive choices and to gain hope for the
future.

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CASE STUDY

IDENTIFICATION DATA

Registration No : ***** Address : XYZ

Name : Mr. A.S Date :

Age: 28

Gender : Male

Educational qualification : Graduated

Occupation : Run his father Business

Income : N. A

Marital status : Not married

Clients stays with parents : Yes

Stays with spouse : No

About Family

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Has any siblings, if so, how many : 1 Brother 1 sister

What is the position of the client in the family : Youngest

Any one in the family is suffering/has suffered from any mental disorder : No

Any one in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : Himself and brother

Information : Adequate and reliable

Referred by : Brother

Presenting complaints :-

 Uneasy feeling and get sensation of cold feet and hands

 Trouble breathing
 Fear of losing control
 Chest pain
 Have problem to be in closed places like lifts , planes, and not able to use elevator
 Feel anxious when he was alone at home.

Nightmare : 3 months
Poor Concentration : 3 months
Fear of happening : a traumatic events 3 months
Disturbed sleep : 3 months
Change in eating habits : 3 months
Uninterested at work : 3 months

Date of onset of illness (The first attack) :- 3 Months ago

Precipitating factor if any: Nil

Duration of illness :- 03 Months

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Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between ,duration of such period of wellness :- No

Was there any precipitating factor at each relapse: Nil

How many relapses: Nil

Any other treatment tried in between :- No

What was the effect: Nil

In what ways the illness causes inconvenience?

The Client is denied to to travel by plane , afraid of travelling in plane he came by train
whereas his brother came by plane.

He feels that lift will be closed and he will be stuck in lift.

He also experiences anxiety before sleeping and live in fear that he may have attack any time
as a result he feels stressed and restless most of the time which is causing a lot of distress to
family as well

Past History

No any Physical illness during childhood , client difficulty breathing and palpitation. He
thought he had heart problem and have poor concentration on things , and have fear about
death and future, not able to make interested at work.

As a result, he had many physical examinations like ECG etc. But everything came out
normal. He had gone to many doctors for treatment including homeopathy, naturopathy,

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Behavioral problems during childhood:

No any significant disturbance were reported in behavioral problems during childhood not
having bed wetting , not thumb sucking, no any stealing mentality, not having habit of nail
biting and taking care of self bathing , brushing , toilet and eating and dress up.

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : Have good bonding

Father : Father has Expired ( but had good behavior earlier with good
bonding)

Brother : Very Close

Sister : Normal

Client’s relationship with friends:

How many friends does the client have? : N.A

How does the client relate to them : N.A

Client’s Relationship with Neighbour : Trouble taking with stranger

Client’s Relationship with school and classmates : Not in touch

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate : N.A

In the game field : Like to play cricket

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EDUCATIONAL HISTORY:

In school college

Client studied in a English medium school. Client is graduated . He didn’t have much interest
in studying as a result he joined his family business after graduation.

How is the client in studies and academic performance : Below average

Does the client come up to the expectations of parents and teachers ? Normal

How has the performance been over the years ? : Normal

Do they find that there is sudden deterioration in studies and academic performance :
N.A

Have they received any complaint from the school authorities regarding the client
performance? : No

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : N.A

Have they done anything about it so far? If so, what? : N.A

Has there been any improvement after their efforts? : N.A

When did they decide to consult a mental health specialist ? When the Client is denied to
travel by plane , afraid of travelling in plane he came by train whereas his brother came by
plane.

While they are travelling and they mostly used lift for getting up down but he denies to use
lift he feels that lift will be closed and he will be stuck in lift.

WORK HISTORY

What occupation is the client involved? : Run his father Business

How regular is the client for work? : very regular

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Has the client been complaining about work place? If so what? : No

Has the client been on leave? If so for how long? : No

When was the time they noticed that the client was reluctant to go for work? Never

What reasons were given by client for not attending to work? N.A

Generally how has the client been fairing in work? N.A

Has there been any complaint about non performance etc. about the client? No

What is their perception about client’s relationship in the workplace? No

With Boss : Normal

With colleagues : Normal

With subordinates : Normal

Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints? N.A

If Married:

Relationship with spouse in terms of

Day to day dealings : N.A

Sex life : N.A

Work relationship (if spouse is working) : N.A

Relationship with children : Unmarried

Relationship with opposite sex persons : N.A

Decision making (who takes the decision - spouse or self) : N.A

Sharing of work at home with the spouse : N.A

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Relationship with spouse’s relatives : N.A

Relationship with spouse’s friends : N.A

MENTAL STATUS REPORT (MSE )

Appearance : He was cooperative for all the sessions. Eye contact was maintained.
Attention could be aroused and sustained. He was alert and in touch with his surroundings.
Comprehension was adequate. Rapport could be established. He was adequately dressed.
Movement and behavior : His psychomotor activity is normal. Notices, mannerisms and
restlessness are present.
Affect : Extremely delighted and over experienced
Mood :

 Subjectively :- “I am worried”.
 Objectively :- The client is concerned about his health. The depth and the intensity
of the affect is normal. Mood is observed as congruent to the thought,
communicable and appropriate to the situation.
Speech :

a) the volume of the person’s voice : Speech is normal

b) the rate or speed of speech : Normal

c) the length of answers to questions : Lengthy

d) the appropriateness of the answers : Detailed answer

e) clarity of the answers and similar characteristics : Very expressive

Thought content : No any abnormality detected

Thought process : The client had preoccupation about fear of closed spaces

Cognition :
Attention and concentration:
His attention was tested with the digit span test. He was able to repeat 6 digits forward and 5

80
digits backwards. He was able to do serial subtraction of seven.
Orientation: He was oriented to time, place and person.

Memory:

 Immediate memory:
intact

 Recent memory:
intact

 Remote memory:
intact
General information: He was able to name the Chief Minister of India, five major cities, the
state that he lives in, its capital and chief minister. His general information is therefore
adequate.
Intelligence : Clinically he was found to be average in intelligence. Abstraction including
differences and similarities as well as proverbs was used to test his intelligence. He was able
to give appropriate answers.
Judgment : If he found a stamped, sealed and addressed envelope on the street he said that
he would give it to the nearest post office. If he was in a theater that caught fire he said that
he would run to safety and then use a fire extinguisher. His test judgment is preserved.

Insight. 3/6 ( Client has illness due to external factor )

Interview Session With clients

Client’s name : Mr. A.S

Interview No : 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview :

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest and take detailed case history and MSE

81
Start of the session:

The client Mr. X came in. He looked a little confused as to whether he was in the right place.
I saw the client entering and told him to please come in. I then offered the seat opposite to
my chair to sit. He was accompanied by his elder brother.

I offered them also a ‘seat. However as the interview started I asked Mr. X if it would be all
right we both talked alone and his brother and mother waited for a while outside.

Client’s appearance: The client was well dressed, neat and clean. He looked depressed and
also anxious. He looked a little nervous and confused.

He sat down and was rubbing his hands as if he is anxious and nervous. I decided to make
sure that the client is comfortable and told him that he is in the right place. I am a
psychologist working here and would like to talk to him. Mr. A.S. smiled and said that he
knew I am a clinical psychologist and wondered why he has been referred to me. I said, well,
if you tell me about yourself and the problem for which you approached the hospital, I will
be able to tell you why you are here. I continued as I found the client silent. I asked him if he
had any particular problem or illness or symptoms that are bothering him. May be I could
help if he tells me something about the reason for his approaching the hospital.

Then Mr. A.S. started to tell me that he has not been doing well for the past few months.
The problem has started, after my father's expired, I could not complete my travel through air
way and not able to use lift, Whenever I am in crowd or I think about being in crowd then I
feel uneasy and get sen sation of cold feet and hands. I feel like I will die” “I have problem to
be in closed places like lifts and planes. But I also feel anxious when I am alone at home.”

(He looked sad and sounded worried). I nodded my head to indicate that I understand his
problem and asked him to continue.

Symptoms as told by Mr A.S. :

 Most of the time uneasy feeling and get sensation of cold feet and hands
 I have trouble breathing
 Fear of losing control and often I have chest pain

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  I have problem to be in closed places like lifts , planes, and not able to use elevator
 I feel anxious when I was alone at home.
Mr. A.S. I think today we have discussed your problem particularly from the relationship and
your experience angles. It has been possible to understand when your problems started what
precipitated it and how you have been handling the same. Your efforts are really appreciated.
However there are many things. We need to discuss with each other. For instance, the
difficulties you are facing in your office and your relationship with your family members in
the last few years need further exploration.

Do you think I have understood your problems correctly?

Would you like to come for another session sometimes next week as is convenient to you?

Can we fix up next Thursday 12 p.m, for the next session?

May be we will like to give some psychological tests which may help us and you to
understand your problem better.

The client responded he would like to come next week at the time specified which was
suitable to him also. We both stood up, and shook hands and the client took leave,

My observation:- When the client left I found that he was looking slightly more relaxed and
smiled before he left. My-feeling is that his talking about his problems and verbalizing his
feelings had relaxed him considerably–

Plan of action: Continue the interview and gather more information about the dynamics
underlying the various conflicts that he has expressed. I need also to talk to his family
members to understand the problem from their points of view..

The purpose with which today’s session was started was achieved.

Interview Session With clients

Client’s name : Mr. A.S

Interview No : 02 Date: ****

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Session No : 02 Time: *****

Purpose of the Interview :

The client was referred to me for taking case history and gave him therapy.

Start of the session:-

The client Mr. A. S. came with his brother. The body language was seem little change as
earlier and the session started by usual talks,

How you feel today ?

The client answered comfortably as he feel refreshed.

I asked him has this problem happened to any of your family members as well ? Then he
answered no, and then I asked with his brother about his family relationship neighbor relation
and educational history and all.

I have given him ten minutes rest and told him to go out side and take fresh air and after then
we have take his Mental status examination , he has answered all the question very
comfortably.

As per the different symptoms shown by the Mr. A.S we have applied the claustrophobia
scale test for measuring the severity of the disorder , we have diagnosed that client is
suffering with claustrophobia, so for recovered with this disorder we have gave him
Exposure therapy Exposure therapy focuses on changing your response to the object or
situation that you fear. Gradual, repeated exposure to the source of your specific phobia and
the related thoughts, feelings and sensations may help you learn to manage your anxiety.

Client is afraid of elevators, exposure therapy may progress from simply thinking about
getting into an elevator, to looking at pictures of elevators, to going near an elevator, to
stepping into an elevator. Next, you may take a one-floor ride, then ride several floors, and
then ride in a crowded elevator.

After completing his therapy we have asked with client how you feel now and then he replied
I feel refreshed and have less fear .

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And we have end up the session suggest her to start her Clinical as soon as possible.

My observation:- When the client left I found that he was looking slightly more relaxed and
smiled before he left. My-feeling that he could cope up with the fear in future.

Plan of action: The counselor continues therapy and examine the progress of the client till
the claustrophobia of client is cured and client feel good enough

The purpose with which today’s session was started was achieved.

Test Administered

The Claustrophobia Questionnaire

The claustrophobia questionnaire (CLQ) is another diagnosis instrument. An early version of

the CLQ was designed to evaluate two separate, but related fears: the fear of suffocation and
the fear of restriction. A shortened version of the CLQ has been developed that retains
accurate measures of claustrophobia and its component fears.

CASE SUMMARY :-

Mr A. S aged 28 years, educated up to graduation , unmarried hailing from middle class

family and lived with his brother and old mother.

Reported with the complaints of whenever he was in crowd or he were think about being in
crowd then he felt uneasy and get sensation of cold feet and hands. he felt like he would die”,
He has problem to be in closed places like lifts and planes. But he also feel anxious when he
was alone at home.”

Duration of the problem arises since 3 moths, Symptoms were seen as anxiety and panic
attacks. Client had afraid of travelling in plane alone, not able to use elevator and have
problem to use lift also. All of these problem have been arisen after his father expired .His
family history shows that his father expires then after he has to join his father business but
he could not able to travel alone. So he has fear about his business how could he run his
business. The client is attached to all the siblings, and his educational history is also average,
and about his work history he is very regular to his work and punctual.

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On MSE he has dressed adequately with well kempt hair. His psychomotor activity was
within

normal limits, his speech was relevant and coherent, and he showed no disturbances in the
stream, form of thought but showed tension, fear and nervousness. His mood was
subjectively and objectively reported to be anxious. No perceptual disturbances were
reported; his cognitive functions were intact. He has insight level of III.

The client exhibit symptoms of hot flashes, panic attacks, sensation of cold feet and hands .
According to all the different symptoms as per DSM we can diagnose that client may have
suffer from Claustrophobia

Exposure therapy has given to client to cope up with the problem and advised take care of
yourself: Eat a well-balanced diet, follow good sleep habits and exercise for 30 minutes at
least five days a week. Healthy lifestyle choices can decrease your anxiety.

INTERNVENTION :-

Cognitive behavioral therapy (CBT) psychotherapy (talk therapy) focuses on managing

your phobia by changing the way you think, feel and behave.

During CBT, you’ll:

 Discuss your symptoms and describe how you feel.

 Explore your phobia more deeply to gain an understanding of how to respond.
 Learn how to recognize, reevaluate and change your thinking.
 Use problem-solving skills to learn how to cope.
 Face your phobia instead of avoiding it.
 Learn how to keep your mind and body calm.

In addition to seeing your primary healthcare provider or psychologist, you can try any of the
following that make you feel comfortable:

Talk to someone you trust: Having someone listen to your claustrophobic fears can be
helpful to you.

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 Learn strategies to relax: Try deep breathing exercises (breathe in slowly and deeply
through your nose, hold for three seconds, breathe out slowly through your
mouth), mediation, mindfulness, progressive muscle relaxation (tensing and relaxing
muscle groups) and other methods to relax. Visualize and focus your attention on
something that makes you calm.
Join a support group: Support groups can be helpful in knowing you are not alone and
for sharing tips and advice.
Check if an organization provides a course for overcoming your fear: For example, if
you’re afraid of flying, check if an airline or your local airport offers a class on fear of
flying.
Take care of yourself: Eat a well-balanced diet, follow good sleep
habits and exercise for 30 minutes at least five days a week. Healthy lifestyle choices
can decrease your anxiety.

Virtual reality (VR). This uses computer simulations of tight spaces like elevators or MRI
machines. Getting the experience of a tight space in the virtual world can help you get over your
fear in a setting that feels safe.

Relaxation and visualization. You can learn ways to calm your fear when you’re in a situation
that usually scares you.

Medical treatment :- If therapy isn't enough, your doctor can prescribe

anxiety drugs or antidepressants to help you deal with the situations that cause your fear.

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CASE STUDY

IDENTIFICATION DATA

Registration No : ***** Address : XYZ

Name : Mr. G P Date :

Age: 46

Gender : Male

Educational qualification : 10 th Pass out

Occupation : Lift Technician

Income : N. A

Marital status : Married

Clients stays with parents : No

Stays with spouse : No

About Family

Has any siblings, if so, how many : 01 Brother ( Married )

What is the position of the client in the family : Youngest

Any one in the family is suffering/has suffered from any mental disorder : No

Any one in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : Son

Information : Adequate and reliable

88
Referred by : Son

Presenting complaints :-

(According to the client)

 He sees scenes of the blast scene, the injured, bleeding people,
 he has immense feeling of guilt of killing his colleagues.

(According to the Informant)

 he stays very irritates and has become very sensitive to noise, closing doors
would get on his nerves.
 He keeps quiet.
 now he doesn’t let them cook and eat meat.

Disturbed sleep : 2 months

Change in eating habits : 2 months

Uninterested at work : 2 months

Irritability : 2 months

Date of onset of illness (The first attack) :- N.A

Precipitating factor if any: Nil

Duration of illness :- 02 months

Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between ,duration of such period of wellness :- No

Was there any precipitating factor at each relapse: Nil

How many relapses: Nil

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Any other treatment tried in between :-No

What was the effect: Nil

In what ways the illness causes inconvenience?

Since the client had seen so much of flesh and blood in the rescue operation he has developed
an aversion to meat and did not want to see anyone eating it, let alone eat it himself. His
family had to prepare and take it elsewhere. His workmates and friends kept asking him
about that fateful day. He now started actively avoiding such people in order to avoid talking
about what he had experienced and isolated himself. He has further difficulties with sleep,
loss of appetite, started experiencing palpitations, had an uncomfortable sensation in his
stomach, a sense of fear, and a feeling that something bad is going to happen (foreboding).
He is constantly worried; he developed feelings of guilt, wondering why he had survived
when so many people had died in the blast. He is irregular in his job after this incident so it’s
bringing financial crisis also.

Past History

No physical or mental illness during childhood. Client has diabetes but no history of other
medical and psychiatric illness.

Behavioral problems during childhood:

No significant disturbances were reported in behavioral problems during childhood.

No bed wetting, thumb sucking, stealing mentality, habit of nail biting was observed during
the client’s childhood. He used to bath daily brush his teeth for two minutes and he was toilet
trained too. He used to eat and dress properly in childhood.
INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member

With Wife : Good

Son : Good
Daughter : Good

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There is no consanguinity between parents of the client. The client’s parents have died. The
client’s younger brother who is married lives in same city. The client has a 15 year daughter
and a 10 year son.

Client’s relationship with friends:

How many friends does the client have? : 10-20

How does the client relate to them : Friendly nature

Client’s Relationship with Neighbor : Normal

Client’s Relationship with school and classmates : Normal

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate In the game : N.A

field

EDUCATIONAL HISTORY:

In school/college

The client was below average in academic. However, he loved to participate in school
activities. His hobbies were watching movies and singing. He left school after 10th.

How is the client in studies and academic performance : Below Average

Does the client come up to the expectations of parents and teachers ?No

How has the performance been over the years ?: Normal

Do they find that there is sudden deterioration in studies and academic performance
:N.A

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Have they received any complaint from the school authorities regarding the client
performance? : Yes

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : N.A

Have they done anything about it so far? If so, what? : N.A.

Has there been any improvement after their efforts? : N.A.

When did they decide to consult a mental health specialist? When referred by a General
Practitioner.

WORK HISTORY

What occupation is the client involved? : Lift technician

How regular is the client for work? : Irregular

Has the client been complaining about work place? If so what? : The client often
complains about his workmates who keep on asking him about that fateful day.

Has the client been on leave? If so, for how long? : 1 week

When was the time they noticed that the client was reluctant to go for work? 3 months
ago

What reasons were given by client for not attending to work? He keeps seeing images
of the blast scene workmates and friends keep asking him about the accident.

Generally how has the client been fairing in work? Not good

Has there been any complaint about non performance etc. about the client? Yes

What is their perception about client’s relationship in the workplace?

With Boss : Normal

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With colleagues : Bad (avoiding them)

With subordinates : N.A.

Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints? No importance given

If Married: Yes

Relationship with spouse in terms of

Day to day dealings : Good

Sex life : deteriorate

Work relationship (if spouse is working) : normal

Relationship with children : Good

Relationship with opposite sex persons : N.A

Decision making (who takes the decision - spouse or self) :both (mutually)

Sharing of work at home with the spouse : Yes

Relationship with spouse’s relatives : Good

Relationship with spouse’s friends : N.A

MENTAL STATUS REPORT (MSE )

Appearance : He was cooperative for all the sessions. Eye contact was maintained.
Attention could be aroused and sustained. Client was seen week and tired. He was alert and
in touch with her surroundings. Proper eye contact is maintained. Rapport could be
established with the client and there was positive attitude towards the examiner. The client
was comprehensive to simple rules from the clinician and was cooperative for the session.

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Movement and behavior : Slow psychomotor is observed from the client.

Affect : Broad congruent with mood

Mood:

 Subjectively :- “I am sad”
 Objectively :- The client is sad and tearful
The depth or intensity of mood is not normal. The mood is low. They are congruent to the
thought and communicable and appropriate to the situation.
Speech :

a) the volume of the person’s voice : Speech is soft

b) the rate or speed of speech : slow

c) the length of answers to questions : short

d) the appropriateness of the answers : normal

e) clarity of the answers and similar characteristics : Very expressive

Thought content :No any abnormality detected

Thought process :The client was preoccupied with his thoughts.

Cognition :
Attention and concentration:
His attention was tested with the digit span test. He was able to repeat 6 digits forward and 5
digits backwards. He was able to do serial subtraction of seven.

Orientation: He was oriented to time, place and person.

Memory:

 Immediate memory: intact

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 Recent memory: intact

 Remote memory: intact

General information: He was able to name the president of India, chief minister of his state
and number of states and union territories in our country. His general information is therefore
adequate.

Intelligence: Clinically he was found to be average in intelligence. Abstraction including

differences and similarities as well as proverbs was used to test his intelligence. He was able
to give appropriate answers.

Judgment :

When asked what she would do on occasion, on family function she said that she would
attend the function if she was in a bus that caught fire she said that she would run to safety
doors and then use a fire extinguisher or call the fire brigade after evacuating safely.
Therefore, Judgment is preserved.

Insight:

He is aware of his illness and attributes the cause to himself hence her insight is at level V.

Interview Session With clients

Client’s name: Mr. G P Date: *****

Interview No : 01 Time: *****

Session No : 01

Purpose of the Interview :

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest and take detailed case history and MSE.

95
Start of the session:

The client Mr M came in. He was greeted and offered a seat. The client was then asked if she
would be comfortable if we talk alone and his wife waits outside.

The client was well dressed, neat and clean. He looked stress, and tired.

I asked Mr. M how he was feeling and what brought him to a psychologist. I asked him to
share his problems, what he has been facing but before that I wanted to make sure that the
client feels comfortable enough to share things so it was informed to him that whatever he
shares will be completely confidential. Only the necessary information will be passed on to
the other family members.

Mr. M started telling his problem. To which I nodded my head to indicate that I understand
her problem and asked him to continue.

I feel sad every time, I cannot sleep. I keep seeing images of the blast scene, the injured,
bleeding people, the bodies we were stepping over. I took a leave of 1 week and after that
decided to use my work as distraction got back to work but my workmates and friends kept
asking me about that day. It became tad more difficult for me to forget that incident. Now I avoid
everybody. But I am afraid of being alone. I have immense guilt, I feel because of me my two
colleagues died. I have trouble breathing. I experience strange sensation in stomach and
palpitation. I have a feeling that something bad is going to happen.

I asked how his relationship with his family members is. He said he shares a good
relationship with them but due to his illness it’s taking a toll on his family. He said that his
family is very supportive and he feels bad for them that they have to go through this.on
questioning about his work life he said that he took a leave of 1 week and went back to work
but everybody who came to me just discussed the same incident which mad me more
anxious. I can’t stay at home because of the financial constraints but I avoid everybody in my
workplace. I don’t like it but there’s nothing I can do about it other than staying quiet. I
asked if he has friends to which he said that I have bunch of friends but now he avoids
everybody. He finds it difficult to communicate with those around him including his own
family members. On questioning about his sex life he said that he has lost all sexual interest,

96
and could not achieve an erection.
Mr M, I think today we have discussed your problem regarding the trauma after the accident
and how it’s affecting you. It has been possible to understand when your problems started
what precipitated it and how you have been handling the same. Your efforts are really
appreciated. However there are many things. We need to discuss with each other.

Do you think I have understood your problems correctly? Yes

Would you like to come for another session sometimes next week as is convenient to you?
Yes

Can we fix up next Monday 12 p.m, for the next session? Yes

May be we will like to give some psychological tests which may help us and you to
understand your problem better.

The client responded she would like to come next week at the time specified which was
suitable to him also.

My observation:-When the client left I found that he was looking slightly more relaxed.
Talking about his problems verbalizing his feelings and sympathizing with him relaxed him
considerably.

Action Plan : Continue the interview and gather more information about the dynamics
underlying the various conflicts that she has expressed. I need also to talk to her family
members to understand the problem from their points of view and have some test and gave
her some therapy which could help her to cope up with the problem.

The purpose with which today’s session was started was achieved.

Interview Session With clients

Client’s name: Mr. G P Date: *****

Interview No : 02 Time: *****

Session No : 02

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The client Mr G P came in. He was greeted and offered a seat.

I asked how he was feeling ?

I am better.

Then I asked to explain

I asked if there’s anything other than the accident which is troubling him.

Problems are part and parcel of life. I am lift technician, not financially well. it troubles me
that I could have done better in life but that just a momentarily though it doesn’t make me
awake for whole night. it just the accident that’s keeping me awake irritated. I used to be an
heavy meat eater but now I feel as if we are eating those dead bodies which were in the
accident. My wife loves meat but I don’t let her cook it now. I feel I’m ruining their life with
mine. I don’t want to live this way. I just think I should have died with my colleagues at least
I would not be in immense guilt.

Did you ever feel suicidal?

No, never. I never got any suicidal although I have my whole family behind me. how can I
do this. who will take care of them after me.

Have you ever tried talking about your problems before coming here ?

no, I just described the accident scene to my wife and she has been very supportive but other
than this I dint share anything with anyone. People got to know about the accident from here
and there. Now they come to me and just talk about how lucky I was and that makes me feel
guiltier. So I have stopped talking to anyone.

Mr G P I understand that you are going through a rough time in your life. I understand how
you feel. My kind sympathies are with you. I think today, we have discussed your problem
and its root cause.

My observation:-When the client left I found that he was looking more relaxed.

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Plan of action: The counselor continues therapy and examine the progress of the client till
the Post traumatic stress disorder of client is cured and client feel good enough.

----------------------------------------------------------------------------------------------------------------

Test administered

Clinical Administered PTSD Scale for DSM-5 (CAPS-5) was applied to check the severity of
the case

CASE SUMMARY :-

Mr. G P aged 48 years, educated up to 12th passed, hails from a lower middle class family
and lives with his family which consists of his wife, daughter and son

The client started to show the symptoms 2 months ago when an explosion happened while he
was repairing the lift. Since then client feels that he has caused the death of his two
colleagues. Since he had seen so much of flesh and blood in the rescue operation he
developed an aversion to meat and did not want to see anyone eating it, let alone eat it
himself. His family had to prepare and take it elsewhere. He tried to use his work to distract
himself from what he had gone through, but as workmates and friends kept asking him about
that fateful day this proved rather difficult. He now started actively avoiding such people in
order to avoid talking about what he had experienced and isolated himself. These did not give
him any relief. He had further difficulties with sleep, loss of appetite, started experiencing
palpitations, had an uncomfortable sensation in his stomach, a sense of fear, and a feeling
that something bad was going to happen (foreboding). He is constantly worried, his mood
became low, he developed feelings of guilt, wondering why he had survived when so many
people had died in the blast.

On MSE he has dressed adequately with well kempt hair. His psychomotor activity was
within normal limits, his speech was relevant and coherent, and he showed no disturbances
in the stream, form of thought but showed tension, fear and nervousness. Her mood was
subjectively and objectively reported to low. No perceptual disturbances were reported; his
cognitive functions were intact. He has insight level of V.

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Client was diagnosed with Post traumatic Stress Disorder. The client exhibit symptoms of
nightmares, vivid recollections/flashbacks, a feeling of re-living the episode; Persistent
avoidance of any stimuli that remind one of the trauma and numbing of general
responsiveness - the building, going into town, work-mates and; A hyper arousal state
leading to hyper vigilance, startle reflexes, sleep disturbance.

CBT Therapy has given to client to cope up with the problem and advised take care of
himself: Eat a well-balanced diet, follow good sleep habits and exercise for 30 minutes at
least five days a week. Healthy lifestyle choices can decrease his stress of the trauma.

INTERNVENTION :-

 Psychotherapy was started to help him synthesis, and to help him understand what
exactly was happening to him.

 CBT is most helpful for the Client as , Cognitive behavioral therapy (CBT), a type of
psychotherapy, is effective for many people with PTSD.

 Eye movement desensitization and reprocessing (EMDR) refers to an interactive

psychotherapy technique used to relieve psychological stress. According to the theory
behind the approach, traumatic and painful memories can cause post-traumatic stress
when you don’t process them completely. Then, when sights, sounds, words, or
smells trigger those unprocessed memories, you re-experience them. This re-
experiencing leads to the emotional distress and other symptoms recognized as post-
traumatic stress disorder (PTSD). EMDR aims to reduce symptoms of trauma by
changing how your memories are stored in your brain. In a nutshell, an EMDR
therapist does this by leading you through a series of bilateral (side-to-side) eye
movements as you recall traumatic or triggering experiences in small segments, until
those memories no longer cause distress.

 He is started on a hypnotic and SSRI to help with his symptoms.

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 Psychotherapy was started to help him synthesis the experience he had gone through
,and to help him understand what exactly was happening to him.

 He was advised to do physical activity and relaxation.

 Eat a well-balanced diet, follow good sleep habits and exercise for 30 minutes at least
five days a week. Healthy lifestyle choices can decrease your his stress of the trauma..

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CASE STUDY

IDENTIFICATION DATA

Registration No :-***** Address :-****

Name :- Mrs. S S Date :-****

Age:- 26

Gender :- Female

Educational qualification : Graduated

Occupation : Housewife

Income : N. A.

Marital status : Marital Status

Patients stays with parents : No

Stays with spouse : Yes

About Family

Has any siblings, if so, how many : 1 sister (27) and 1 brother (23)

What is the position of the patient in the family: Eldest

Anyone in the family is suffering/has suffered from any mental disorder :

Aunt on client’s mother's side was diagnosed with bipolar disorder and another aunt was
"mentally ill"

Anyone in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : Husband

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Information : Adequate and reliable

Referred by : Brother

Presenting complaints:-

According to the client

 she has daily crying spells, feels sad "all the time",
 She has trouble sleeping at night,
 overeating
 thinking and worrying a lot.

Poor Concentration : 1 Year

Disturbed sleep : 1 Year
Change in eating habits : 1 Year
Uninterested at work : 1 Year

Date of onset of illness (The first attack) :- N.A

Was there any predisposing factor: Nil

Duration of illness :- 01 Year

Intensity of illness (on a scale of 10):

Treatment taken: :- Yes, 6 months ago

Got well at any time in between, duration of such period of wellness :- No

Was there any predisposing factor: Nil

Was there any precipitating factor at each relapse: Nil

How many relapses: 1

Any other treatment tried in between :- Yes, sought help for post-partum depression six
months ago

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What was the effect: Good sleep

In what ways the illness causes inconvenience?

Mrs. S S acknowledged that depression was affecting her life in a number of ways. For
one, she reported that it was affecting her relationship with her husband and children.
Secondly, she stated that depression affected her socially because it was keeping her from
participating in family events. She reported that she felt unable to work outside her home at
this time,

Behavioral problems during childhood:

No significant disturbances were reported in behavioral problems during childhood.

No bed wetting, thumb sucking, stealing mentality, habit of nail biting was observed during
the client’s childhood. She used to bath daily brush her teeth for two minutes and she was
toilet trained too. She used to eat and dress properly in childhood.

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member

Father : Bad
Mother : Good
With Husband : Good
Son : Good
Daughter : Good
Daughter : Good

The client lives with her husband, her nine years old daughter, four year old son, and ten
month old son.

client shares a bitter relationship with her father because he left the house when the client
was 11 years old and came back after a long time when the client was 16 years old.

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Client’s relationship with friends:

How many friends does the client have? :1

How does the client relate to them : Normal

Client’s Relationship with Neighbor : Normal

Client’s Relationship with school and classmates : Not in touch

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate In the game : N.A

field

EDUCATIONAL HISTORY:

In school/college

The client was average in academic. since she was an introvert she didn’t participate in any
school activities.

How is the client in studies and academic performance? average

Does the client come up to the expectations of parents and teachers ?Yes

How has the performance been over the years ? Normal

Do they find that there is sudden deterioration in studies and academic performance :
N.A

Have they received any complaint from the school authorities regarding the client
performance? : No

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : N.A

105
Have they done anything about it so far? If so, what? : N.A.

Has there been any improvement after their efforts? : N.A.

When did they decide to consult a mental health specialist? When she just used to cry and
feel sad..

WORK HISTORY

What occupation is the client involved? : The client is presently a housewife but she
used to work as a software developer in a MNC company.

How regular is the client for work? The client was regular in her previous job.

Has the client been complaining about work place? If so what? : N.A.

Has the client been on leave? If so, for how long? : N.A.

When was the time they noticed that the client was reluctant to go for work? N.A.

What reasons were given by client for not attending to work? N.A.

Generally how has the client been fairing in work? N.A.

Has there been any complaint about nonperformance etc. about the client? No

What is their perception about client’s relationship in the workplace?

With Boss : Normal

With colleagues : Normal

With subordinates : Normal

Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints?

If Married: Yes

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Relationship with spouse in terms of

Day to day dealings : Good

Sex life : deteriorate

Work relationship (if spouse is working) : normal

Relationship with children : normal

Relationship with opposite sex persons : Normal

Decision making (who takes the decision - spouse or self) :both (mutually)

Sharing of work at home with the spouse : Yes

Relationship with spouse’s relatives : Good

Relationship with spouse’s friends : Normal

MENTAL STATUS REPORT (MSE)

Appearance : She was cooperative for all the sessions. Client was seen anxious and tired.
She was alert and in touch with her surroundings. Proper eye contact was maintained.
Attention & Concentration could be aroused and sustained. Rapport could be established
with the client. The client was not well dressed and was unable to concentrate in her daily
routines like brushing, bathing, combing etc. Her vitals were stable.

Movement and behavior: Decreased psychomotor activity is observed from the client. Her
movement was slow.
Affect: Broad congruent with mood

Mood:

 Subjectively :- “I am not a good mother and wife. I’m worried”

 Objectively :- The client is anxious and tearful

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The depth or intensity of mood is not normal. The mood is low. They are congruent to the
thought and communicable and appropriate to the situation.

Speech:

a) The volume of the person’s voice: Speech is low

b) The rate or speed of speech: Decreased

c) The length of answers to questions: Long

d) The appropriateness of the answers: Appropriate

e) Clarity of the answers and similar characteristics: Monotonous

Thought content: No any abnormality detected

Thought process: The client was preoccupied with her thoughts.

Cognitive functions:

Attention and concentration:

Her attention was tested with the digit span test. She was able to repeat 6 digits forward and 5
digits backwards. She was able to do serial subtraction of eight.

Orientation: She was oriented to time, place and person.

Memory:

 Immediate memory: intact

 Recent memory: intact

 Remote memory: intact

General information: She was able to name chief minister of her state and number of states,

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union territories in our country, the national bird, the national animal our country. Her
general information is therefore adequate.

Intelligence: Clinically she was found to be average in intelligence. Abstraction including

differences and similarities as well as proverbs was used to test her intelligence. She was able
to give appropriate answers.

Judgment:

When asked what she would do if she was in a bus that caught fire she said that she would
run to safety doors and then use a fire extinguisher or call the fire brigade after evacuating
safely. Therefore, Judgment is preserved.

Insight:

She is aware of her illness and attributes the cause to himself hence her insight is at level V.

Interview Session With clients

Client’s name : Mrs S S

Interview No : 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview :

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest and take detailed case history and MSE.

Start of the session:

The client Ms S came in. She was greeted and offered a seat. The client was then asked if
she would be comfortable if we talk alone and her husband waits outside. the client agreed to
it.

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The client was not well dressed. She was wearing a grey top with red trousers. She looked
worried and tired.

I asked Mrs. S how she was feeling and what brought her to a psychologist. I asked her to
share her problems, what she has been going through but before that I wanted to make sure
that the client feels comfortable enough to share things so it was informed to her that
whatever she shares will be completely confidential. Only the necessary information will be
passed on to the other family members.

Mrs. S started telling how she was feeling, the problems she was facing. To which I nodded
my head to indicate that I understand her problem and asked him to continue.

I cry daily, I feel sad "all the time". My sleep is disturbed, it frequently takes me several
hours to fall asleep, some nights I cannot fall asleep at all, and if I do, I sleep for only a few
hours. I spend the time awake, "thinking" and "worrying". During that time all I think about
is that I am not a good mom, I feel that I’m a problem to my husband. I also think about my
family of origin and my unsatisfactory relationship with my father. I feel all right, always
down.

I asked how her relationship with her family members is.

I live with my husband of six years and three children. My husband has a small roofing
business and puts in many long hours. I feel bad that I have to stay at home away from my
husband with children for long hours. Sometimes we go to parties and spend quality with
each other time but that rarely happens. But my husband is very supportive. He recognized
that I have some kind of problem, and he was supportive for seeking treatment. I love my
children but I don’t know why I feel sad after my third baby. my family of origin and I are in
contact with each other but there are frequent arguments and conflicts that are due to the
many unresolved issues the family still has. My father was an alcoholic he left the home
when I was 11 years old and came back when I was 16 years old. My mother and father stay
together with my brother. I have immense love and respect for my mother even though she
was a single parent but she raised us very well. My relationship with my father is a concern
for me, and I would like it to improve. Now is not a heavy drunker like before but we s till
have frequent arguments. He was not there for me as I grew up, and I’m not there for him

110
now. My father was selfish and did not care about me or my children like he should. I did
errands for my father, drove him to work, and did all that was asked of him, but my father did
not reciprocate. My father makes up excuses and don’t help me out when asked. I feel
resentful and angry, and then afterwards, I feel guilty. My sister is married and lives in
Gurgaon.
I asked her about her work life.
I am a housewife right now. I used to work as a software developer in a IT company. But
after my third baby I left my job. I used to love my job but keeping in view the need of
mother for a baby I let my job.
I asked if she has friends .
I used to be an introvert, shy girl so I don’t have a bunch of friends. I have just one friend with
whom I used to share things but now she’s also married and a mother so she’s also busy in her
own life. We do talk but not like we used to do before. other than that I’m not in contact with
any of my classmates, college friends.
I asked her if she’s comfortable enough to share her sex life to which she said.
We didn’t have sex after our third baby. I feel tired every time I never initiate it and my
husband is running busy from a long time because he had to take leave from work during my
pregnancy to keep up with the finances he’s working a bit more than usual.

I asked her if she took any treatment before coming here.

I sought help for post-partum depression six months ago following the birth of my third
child, Z. I became depressed when I found out that I was pregnant, and the depression
continued to worsen after the child's birth. During the initial months of my pregnancy, I
recall being tired, sad, having no energy, and crying several times a week. I felt exhausted
but could not sleep. I felt like I "lost control of my life". These feelings continued after
Zeke's birth. My gynecologist prescribed 20 mgs. of Paxil, which I continued to take for a
few months. I discontinued the medication because I did not think it was helping me. It did
not work, and she felt no difference in her depression. I did not like taking medications.
There are no other periods of depression in my life.

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Ms S, I think today we have discussed your problem and how it’s affecting you. It has been
possible to understand when your problems started what precipitated it and how you have
been handling the same. Your efforts are really appreciated. However there are many things.
We need to discuss with each other.

Do you think I have understood your problems correctly? Yes

Would you like to come for another session sometimes next week as is convenient to you?
Yes

Can we fix up next Monday 12 p.m, for the next session? Yes

May be we will like to give some psychological tests which may help us and you to
understand your problem better.

The client responded she would like to come next week at the time specified which was
suitable to him also.

My observation:-When the client left I found that she was looking slightly more relaxed.
Talking about her problems, just listening about her problems, verbalizing her feelings and
sympathizing with her relaxed her considerably.

Plan of action: Continue the interview and gather more information about the dynamics
underlying the various conflicts that he has expressed.

The purpose with which today’s session was started was achieved.

Interview Session With patients

Patient’s name : Mrs. S

Interview No : 02 Date: ****

Session No : 02 Time: *****

Purpose of the Interview :

The client was referred to me for taking case history and gave her therapy.

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The client, Mrs S came in. She was greeted and offered a seat.

The client was asked how she feels today.

I am okay not happy but not sad also.

The client was asked what perception does she has of herself.

I feel am I not a good mother. I do not think that I am an adequate mother to my children. I
fear I was emotionally distant at times and that this would affect my relationship with them.
I’m afraid that I her depressive behaviors were pushing my husband away, and that he
would eventually be tired of helping me deal with my depression.

I want to be a good wife, good mother, a good daughter and a good sister but I cant. I am
not a good daughter my mother asked me to do something for her, and I refused. She had a
heart attack that evening I blame myself for this. I am not a good granddaughter also i
remember my grandmother was hospitalized instead of visiting my grandmother, I went out
on a date, and my grandmother died the next day. I have immense guilt and sadness of these
two incidents till date. Now I end up helping other people out even if I does not want to
because I fears that something bad will happen to them.

I asked if she ever discussed anything with her family members.

My husband and her sister act as my supports. I talked to them and shared how I was
feeling but only to a certain extent. They did not know how depressed I really was because I
did not disclose everything to them. I attempted to act more upbeat around them than I was
feeling. My brother is the reason I am coming here to a psychologist for therapy. He had
suggested it since he noticed that I was unhappy and angry especially in.

On asking how she has been coping in the past before coming to the therapy

I feel smoking helps me reduce my stress for some time. I know its negative but it still do it.
I smoke approximately ten cigarettes a day to feel relaxed. The second one is eating. I am
eating more than I used to and gaining weight I should be one diet but I think it helps me. I
exercise for 40 mins a day. and I feel great physically and mentally. I also seek guidance
from friends family that when I talk to them, listen them I feel relieved.

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on asking if she feel therapy is helping her.

I was just going to tell this that since I started seeking therapy I feel a lot better. may be its
helping me cope more with the illness. As I talk to you I feel good and you being a stranger
will not judge my makes me feel relieved and comfortable to share things.

How do you feel now?

I feel light. I vented everything.

My observation:-When the client left I found that she was looking more relaxed and she did
smile. Talking about her problems and listening to her made her feel relaxed.

Plan of action: The counselor continues therapy and examine the progress of the client till
the Major Depressive Disorder of client is cured and client feel good enough.

The purpose with which today’s session was started was achieved.

___________________________________________________________________________

Test Administered:

BDI-II was applied to check the severity of the client.

CASE SUMMARY

The client is a 29 year old female who presented with symptoms of depression. She stated
that she had daily crying spells, felt sad "all the time", had trouble sleeping at night, and
was overeating. She reported that her sleeping was disturbed in that it frequently took her
several hours to fall asleep, that some nights she could not fall asleep at all, and if she did,
she slept for only a few hours. She stated that she spent the time awake "thinking" and
"worrying". She acknowledged that some of her worries included thoughts that she was not
a good mom, and she felt that she was a problem to her husband. She reported that she
thought about her family of origin and her unsatisfactory relationship with her mother.

She stated that she thought her depression had worsened after the birth of her third child ten
months ago. During the initial intake interview, the client noted that she felt "all right,

114
always down". The "all right" response came out immediately, almost automatically. After
a pause, she added "always down". She revealed that she was constantly thinking and
worrying, and that she felt "like everyone is looking at me". She denied suicidal behavior
and ideations. She said it would be nice to run away from her problems, but she added that
she knew she could not do that. She expressed unhappiness that she was not the person she
wanted to be, and she stated that her depression was "wrecking my life".

Mrs. S reported that she sought help for post-partum depression six months ago following
the birth of her third child. She stated that she became depressed when she found out she
was pregnant, and the depression continued to worsen after the child's birth. During the
initial months of her pregnancy, she recalled being tired, sad, having no energy, and crying
several times a week. She reported that she felt exhausted but could not sleep. She stated
that she felt like she "lost control of her life". She acknowledged that these feelings
continued after birth of her third child.

She reports that her husband is supportive. She has anger and resentment towards her father
who was an alcoholic and left them for a long time. She recalls having a chaotic childhood
characterized by a great deal of stress and instability. She reported that her relationship with
her mother is a concern for her, and that she would like it to improve. She says that she has
some coping mechanism of her own which include smoking , eating, exercising, talking to
loved ones and seeking therapy. The client understands that she has some disorder and is
willing to work for her betterment.

INTERVENTION :

 Behavioral Therapy
 Behavioral therapy focuses on the relationship between behavior and mood to target
current problems and symptoms and focus on changing patterns of behavior that
lead to difficulties in functioning
 Cognitive Therapy
 Cognitive therapy entails modifying pessimistic evaluations and unhelpful thinking
patterns with the goal of disrupting these and reducing their interference with daily
life

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 Cognitive-Behavioral Therapy (CBT)
 Cognitive-behavioral therapy targets current problems and symptoms and focuses
on recognizing the relationship between behaviors, thoughts, and feelings and
changing patterns that reduce pleasure and interfere with a person’s ability to
function at his/her best.
 Interpersonal Psychotherapy (IPT)
 Interpersonal psychotherapy focuses on improving problematic relationships and
circumstances that are most closely linked to the current depressive episode.
 Mindfulness-Based Cognitive Therapy (MBCT)

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CASE STUDY

IDENTIFICATION DATA

Registration No :- ***** Address :-******

Name :- Mrs. G.S Date :-

Age:- 52

Gender :- Female

Educational qualification : 10th pass

Occupation : Housewife

Income : N. A

Marital status : Widow

Clients stays with parents : No

Stays with spouse : No

About Family

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Has any siblings, if so, how many : 01 Brother ( Married )

What is the position of the client in the family : Youngest

Any one in the family is suffering/has suffered from any mental disorder : No

Any one in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : Son

Information : Adequate and reliable

Referred by : Son

Presenting complaints :-

 She has a problem of forgetfulness

 Worries a lot and get panic easily
 She spent lots of time completing things like in take too much time in bathroom to
bath and for eating meal.
 She has a fear of contamination or dirt.

 She is excessively washing hands

 Mostly she redoing tasks
 she also refusing to touch objects with bare hands
 If any guest come at home she gets panic

(According to informant)

Poor Concentration : 1 Year

Disturbed sleep : 1 Year
Change in eating habits : 1 Year
Uninterested at work : 1 Year

Date of onset of illness (The first attack) :- N.A

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Precipitating factor if any: Nil

Duration of illness :- 01 Year

Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between ,duration of such period of wellness :- No

Was there any precipitating factor at each relapse: Nil

How many relapses: Nil

Any other treatment tried in between :- No

What was the effect: Nil

In what ways the illness causes inconvenience?

Client has started to show the symptoms one year ago when she started to forget things. She
feels that something is falling (dust) so she washes hands frequently. She has two sons .one
of them is living separately with the wife and other one got divorced and living with client.
She worries a lot about his second son. She reports that praying helps her a lot and she does
not have any thoughts of washing or cleaning at that time. Even though she was not much
social but had 2 close friends with whom she used to meet but recently she has lost interest
in everything and does not want to meet anyone. She has arthritis and she find it difficult to
do chores but cannot help. if guests come at home she gets panic.

Past History

No any Physical illness during childhood. Client has arthritis and diabetes and no history of
medical illness.

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Behavioral problems during childhood:

Client shared good bond with her parents. In school she felt isolated and had low self esteem.
She had very few friends growing up. She was overweight and felt that she is not as good
looking as her cousin. As a result, she had low self confidence. She was good in academic.
Her parents encouraged her to focus on household chores than study because it will be useful
for him after marriage and not her qualification.

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : NA

Father : NA

Brother : Normal

Sister : NA

There is no consanguinity between parents of the client. The client’s parents have died. The

client’s younger brother lives in same city. The client has 2 sons. One of them is married and
live

separately whereas other son is divorced and live with his mother.

Client’s relationship with friends:

How many friends does the client have? : 02

How does the client relate to them : Friendly nature

Client’s Relationship with Neighbour : Trouble taking with stranger

Client’s Relationship with school and classmates : Not in touch

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

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Client’s Relationship with playmate : N.A

In the game field : N.A

EDUCATIONAL HISTORY:

In school college

The client was good in academic. However, she never participated in any social activity
because she thought she was overweight and people will make fun of her. Her hobbies were
reading and writing.

How is the client in studies and academic performance : Above Average

Does the client come up to the expectations of parents and teachers ? Normal

How has the performance been over the years ? : Normal

Do they find that there is sudden deterioration in studies and academic performance :
N.A

Have they received any complaint from the school authorities regarding the client
performance? : No

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : N.A

Have they done anything about it so far? If so, what? : N.A

Has there been any improvement after their efforts? : N.A

When did they decide to consult a mental health specialist ?

When the Client is frequently wash her hand , spent lots of time doing every thing, have fear
of dirt germs .

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WORK HISTORY

What occupation is the client involved? : Housewife

How regular is the client for work? : N.A

Has the client been complaining about work place? If so what? : N.A

Has the client been on leave? If so for how long? : N.A

When was the time they noticed that the client was reluctant to go for work? N.A

What reasons were given by client for not attending to work? N.A

Generally how has the client been fairing in work? N.A

Has there been any complaint about non performance etc. about the client? N.A

What is their perception about client’s relationship in the workplace? N.A

With Boss : N.A

With colleagues : N.A

With subordinates : N.A

Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints? N.A

If Married: Client husband was dead

Relationship with spouse in terms of

Day to day dealings : N.A

Sex life : N.A

Work relationship (if spouse is working) : N.A

Relationship with children : Good

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Relationship with opposite sex persons : N.A

Decision making (who takes the decision - spouse or self) : N.A

Sharing of work at home with the spouse : N.A

Relationship with spouse’s relatives : N.A

Relationship with spouse’s friends : N.A

MENTAL STATUS REPORT (MSE )

Appearance : She was cooperative for all the sessions. Eye contact was maintained.
Attention could be aroused and sustained. Client was seen overweight. She was alert and in
touch with her surroundings. The client has touch with the surrounding. Proper eye contact is
maintained. Rapport
could be established with the client and there was positive attitude towards the examiner. The
client was comprehensive to simple rules from the clinician and was cooperative for the
session.

Movement and behavior : Slow psychomotor is observed from the client.

Affect : Extremely delighted and over experienced

Mood :

 Subjectively :- “I am anxious”.
 Objectively :- The client is anxious and tired
The depth or intensity of mood is normal. The mood is stable. They are congruent to
the thought and communicable and appropriate to the situation.
Speech :

a) the volume of the person’s voice : Speech is normal

b) the rate or speed of speech : Normal

c) the length of answers to questions : Lengthy

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 d) the appropriateness of the answers : Detailed answer

e) clarity of the answers and similar characteristics : Very expressive

Thought content : No any abnormality detected

Thought process : The client had preoccupation of illness.

Cognition :
Attention and concentration:
Her attention was tested with the digit span test. She was able to repeat 6 digits forward and 5
digits backwards. she was able to do serial subtraction of seven.
Orientation: she was oriented to time, place and person.

Memory:

 Immediate memory:
intact

 Recent memory:
intact

 Remote memory:
intact
General information: She was able to name the Prime Minister of India, Capital of our
Country the state that he lives in, its capital and chief minister. Her general information is
therefore adequate.
Intelligence : Clinically she was found to be average in intelligence. Abstraction including
differences and similarities as well as proverbs was used to test his intelligence. she was able
to give appropriate answers.
Judgment : If she found a stamped, sealed and addressed envelope on the street he said that
he would give it to the nearest post office. If she was in a theater that caught fire he said that
he would run to safety and then use a fire extinguisher. her test judgment is preserved.

Insight. Client has insight level of 6 which means she had true emotional insight

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Interview Session With clients

Client’s name : Mrs G.S

Interview No : 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview :

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest and take detailed case history and MSE

Start of the session:

The client Mrs GS came in. She looked a little confused as to whether she was in the right
place. I saw the client entering and told her to please come in. I then offered the seat opposite
to my chair to sit. She was accompanied by her younger sons.

I offered them also a ‘seat. However as the interview started I asked Mrs. G.S if it would be
all right we both talked alone and her son waited for a while outside.

Client’s appearance: The client was well dressed, neat and clean. She looked depressed and
also anxious. She looked a little nervous and confused.

She sat down and was rubbing his hands as if she is anxious and nervous. I decided to make
sure that the client is comfortable and told him that she is in the right place. I am a
psychologist working here and would like to talk to him. Mrs. G.S smiled and said that she
knew I am a clinical psychologist and wondered why she has been referred to me. I said,
well, if you tell me about yourself and the problem for which you approached the hospital, I
will be able to tell you why you are here. I continued as I found the client silent. I asked him
if he had any particular problem or illness or symptoms that are bothering him. May be I
could help if she tells me something about the reason for his approaching the hospital.

Then Mrs. G.S started to tell me that she has not been doing well for the past one year. The
problem has started after the separation of her elder son from her and younger son is
divorced. Having lots of worried about her second son, she started to forget things, she feel

125
that something is falling but she washed hands frequently. She has lost interest in everything
she arthritis and she find it difficult to do chores but cannot help , if guest come at home she
gets panic.

(She looked sad and sounded worried). I nodded my head to indicate that I understand her
problem and asked her to continue.

Symptoms as told by Mrs. G.S :

 Most of the time uneasy feeling

 I have trouble breathing
 Fear of losing control
 Washing hands frequently
 I feel everywhere is having germs
 I feel anxious when guest come at home.
Mrs G.S. I think today we have discussed your problem particularly from the relationship and
your experience angles. It has been possible to understand when your problems started what
precipitated it and how you have been handling the same. Your efforts are really appreciated.
However there are many things. We need to discuss with each other. For instance, the
difficulties you are facing in your relationship with your family members in the last few
years need further exploration.

Do you think I have understood your problems correctly?

Would you like to come for another session sometimes next week as is convenient to you?

Can we fix up next Monday 12 p.m, for the next session?

May be we will like to give some psychological tests which may help us and you to
understand your problem better.

The client responded she would like to come next week at the time specified which was
suitable to him also. We both stood up, and shook hands and the client took leave,

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My observation:- When the client left I found that she was looking slightly more relaxed
and smiled before she left. My-feeling is that her talking about her problems and verbalizing
her feelings had relaxed her considerably–

Plan of action: Continue the interview and gather more information about the dynamics
underlying the various conflicts that she has expressed. I need also to talk to her family
members to understand the problem from their points of view and have some test and gave
her some therapy which could help her to cope up with the problem.

The purpose with which today’s session was started was achieved.

Interview Session With clients

Client’s name : Mrs. G.S

Interview No : 02 Date: ****

Session No : 02 Time: *****

Purpose of the Interview :

The client was referred to me for taking case history and gave her needed therapy.

Start of the session:-

The client Mrs. G.S came with her son. The body language was seem little change as earlier
and the session started by usual talks,

How you feel today ?

The client answered comfortably as she feel better today .

I asked her has this problem happened to any of your family members as well ? Then she
answered no, and then I asked with son about his family relationship neighbor relation and
educational history and all.

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I have given her ten minutes rest and told her to go out side and take fresh air and after then
we have take his Mental status examination , she has answered all the question very
comfortably.

As per the different symptoms shown by the Mrs G.S, the client is diagnosed and found out
that client is suffering with Obsessive compulsive disorder so for recovered with this
disorder we have gave her cognitive-behavioral therapy Over two-thirds of people who
complete either form of therapy for OCD notice a substantial decrease in the frequency and
severity of their symptoms.

After completing her therapy we have asked with client how you feel now and then she
replied I feel refreshed and have less fear.

And we have end up the session suggest her to start her Clinical as soon as possible.

My observation:- When the client left I found that she was looking slightly more relaxed
and smiled before she left. My-feeling that she could cope up with the problem in future.

Plan of action: The counselor continues therapy and examine the progress of the client till
the OCD of client is cured and client feel good enough.

The purpose with which today’s session was started was achieved.

Test Administered:

No any test is applied to check the severity of the client, here psychiatrist can check the
symptom and diagnosed the case.

CASE SUMMARY :-

Mrs.G. S.aged 52 years, educated up to 12th passed, widowed hailing from middle class
family and lived with her younger son.

Reported with the complaints of The Client has problem of forgetfulness. She worries a lot
and get panic very often. She washes her hands and perform her task very slow. She spends
most of the time in kitchen where she would keep washing utensils and cleaning the floor of

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the kitchen. She also spends a lot of time in bathroom to bath and go toilet. If any guest
comes at home she gets panic.

Duration of the problem arises since 01 year, all of these problem have been arisen after .
One of them is married and live separately whereas other son is divorced and live with his
mother. She has worried for her sons also.

Her family history shows that hers family lifestyle is not so good all family member are
separated and her husband is no more, she has fear of about the future of younger sons, as she
thought that she was running in old age, how can each and everything would he handled.
client is attached to all the siblings, and her educational history is also average, and about
her work history she was housewife not working any where but towards her household work
she was is very punctual and regular to her work , she kept each everything in typical
manner.

On MSE he has dressed adequately with well kempt hair. Her psychomotor activity was
within normal limits, her speech was relevant and coherent, and she showed no disturbances
in the stream, form of thought but showed tension, fear and nervousness. Her mood was
subjectively and objectively reported to be anxious. No perceptual disturbances were
reported; her cognitive functions were intact. she has insight level of III.

The client exhibit symptoms of Fear of losing control, .Fear of fainting. Feelings of dread.
Feeling overwhelming anxiety. Feeling an intense need to leave the situation. According to
all the different symptoms as per DSM we can diagnose that client may have suffer from
obsessive compulsive disorder

CBT Therapy has given to client to cope up with the problem and advised take care of
yourself: Eat a well-balanced diet, follow good sleep habits and exercise for 30 minutes at
least five days a week. Healthy lifestyle choices can decrease your anxiety.

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INTERNVENTION :-

CBT is most helpful for the OCD Client as , Cognitive behavioral therapy (CBT), a
type of psychotherapy, is effective for many people with OCD. Exposure and
response prevention (ERP), a component of CBT therapy, involves gradually
exposing you to a feared object or obsession, such as dirt, and having you learn ways
to resist the urge to do your compulsive rituals. ERP takes effort and practice, but you
may enjoy a better quality of life once you learn to manage your obsessions and
compulsions.

MedicationsCertain psychiatric medications can help control the obsessions and

compulsions of OCD. Most commonly, antidepressants are tried first.

Antidepressants approved by the U.S. Food and Drug Administration (FDA) to

treat OCD include:

 Clomipramine (Anafranil) for adults and children 10 years and older

 Fluoxetine (Prozac) for adults and children 7 years and older
 Fluvoxamine for adults and children 8 years and older
 Paroxetine (Paxil, Pexeva) for adults only
 Sertraline (Zoloft) for adults and children 6 years and older

she was advised to do physical activity and relaxation.

Eat a well-balanced diet, follow good sleep habits and exercise for 30 minutes at least
five days a week. Healthy lifestyle choices can decrease your anxiety.

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CASE STUDY

IDENTIFICATION DATA

Registration No :- xxxxxx Address :-XYZ

Name :- Mr. R. S Date :-

Age:- 18

Gender :- Male

Educational qualification : Graduated

Occupation : unemployed

Income : N. A

Marital status : Not married

Clients stays with parents : Yes

Stays with spouse : No

About Family

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Has any siblings, if so, how many : 1 Brother

What is the position of the client in the family : Youngest

Any one in the family is suffering/has suffered from any mental disorder : No

Any one in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : father

Information : Adequate and reliable

Referred by : father

Presenting complaints:-

 Always stay in single room

 Sleep disturbance
 Repetitive thought
 Talking with god
 Loss of interest in daily activities
Nightmare : 6 months
Poor Concentration : 6 months
Disturbed sleep : 6 months
Change in eating habits : 6 months
Uninterested at work : 6 months

Date of onset of illness (The first attack) :- at age of 16 after 10th class

Precipitating factor if any: Nil

Duration of illness :- 02 year

Intensity of illness (on a scale of 10):

Treatment taken: :- No

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Got well at any time in between ,duration of such period of wellness :- no

Was there any precipitating factor at each relapse: Nil

How many relapses: Nil

Any other treatment tried in between :- No

What was the effect: Nil

In what ways the illness causes inconvenience?

The client lost interest in social activities remain alone in a room, unable to cope up with
anxiety due to and fear of black magic and powers. Client try talk to god when alone this take
him away from reality and he became violent on small thing , bed wetting and low
confidence

Past History

No any Physical illness during childhood, the client failed in 10th class examination after
which he remain alone.

Behavioral problems during childhood:

No any significant disturbance were reported in behavioral problems during childhood

not having bed wetting , not thumb sucking, no any stealing mentality, not having habit of
nail biting and taking care of self bathing , brushing , toilet and eating and dress up.

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : Separated in childhood

Father : Have normal behavior

Brother : not to close

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Client’s relationship with friends:

How many friends does the client have? : No friends

How does the client relate to them : N.A

Client’s Relationship with Neighbour : Fear when taking with stranger

Client’s Relationship with school and classmates : Not in touch

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate : N.A

In the game field : Like to play cricket

EDUCATIONAL HISTORY:

In school college

Client studied in a English medium school. Client study till 9th standard. He loss interest in
study when he failed in 10th standard exam

How is the client in studies and academic performance : Below Average

Does the client come up to the expectations of parents and teachers? No

How has the performance been over the years? : normal

Do they find that there is sudden deterioration in studies and academic performance:
yes

Have they received any complaint from the school authorities regarding the client
performance? : Sometimes

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : after 10th class result

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Have they done anything about it so far? If so, what? : No

Has there been any improvement after their efforts? : N.A

When did they decide to consult a mental health specialist? When the Client return from
his uncle home. He became more violent, frequent bed wetting and communicating with god,
the experience of hallucination and delusion is increased, loss of control on small things.

WORK HISTORY

What occupation is the client involved? : N.A

MENTAL STATUS REPORT (MSE )

Appearance : client appearance was inappropriate. Sitting was not proper.

Movement and behavior: client manner of walking and coordination of body was
abnormal. He continuously stares at counselor. Sometime he repeated counselor statement
Affect: aggressive face expression and body language.
Mood:

 Subjectively: - “I am talking to god don’t disturb me.”.

 Objectively :- client was aggressive
 Speech :
a) The volume of the person’s voice: Speech is abnormal

b) The rate or speed of speech: faster than normal

c) The length of answers to questions: unusual

d) The appropriateness of the answers : not specific

e) Clarity of the answers and similar characteristics: Very poor

Thought content: abnormal

Thought process: abnormal due to hallucination and delusion

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Cognition:
Attention and concentration:
His attention was tested with the digit span test. He was unable to repeat 6 digits forward and
5 digits backwards. He was unable to do serial subtraction of seven.
Orientation: He was not oriented to time, place and person.

Memory:

 Immediate memory: not

intact

 Recent memory: not

intact

 Remote memory: not

intact
General information: He was unable to name the prime Minister of India, five major cities,
the state that he lives in, its capital and chief minister. His general information is therefore
inadequate.
Judgment: low judgment making capability and decision making is poor

Insight: 1/6

Interview Session With Clients and His father

Client’s name: Mr. R S

Interview No: 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview:

The purpose of the interview was to get familiar with the client, establish rapport and take
detailed case history and MSE.

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Start of the session:

The client came with his father he looks lost in his own world. The counselor told him to
come and offered seat. The client was not in position to tell anything about him so the
counselor talk with his father about his present situation. The father tell that the client has
disturbed sleep, headache, low interest in study and social disturbance since he was studied in
class 10th when he got failed in first time in his life. After that he start living alone, feels
anxiety, think that he has ability to talk with god, believe that everyone is doing black magic
on him, he loss all his contact. The father look really worried about the client. Due to his this
behavior his father send him to his uncle house for change of mood his condition is
improving there but on returning home the clients condition became more worst he
experience excessive phases of hallucination and delusion, loss control on himself, get
violent easily, bed wetting(symptom told by client father). His father also tells that he and her
wife get separated during the childhood of the client. During the talking with client father the
client continuously stared at counselor he looks aggressive and counselor observe that
sometime the client is talking to someone who is not present.

Psychologist also tries to communicate with the client but the client look completely lost me
merely respond to the questions. Psychologist ask client father to go a psychiatrist for
medicine and came gain after seven days.

My observation:- When the client left I found that he was looking disturbed and completely
lost it look like symptom of schizophrenia as he has hallucination and delusion .

Plan of action: Continue the interview and gather more information about the dynamics
underlying the various conflicts that his father has expressed. In next season psychologist try
to carry CBT with client.

The purpose with which today’s session was started was achieved.

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Interview Session With clients

Client’s name : Mr. R S

Interview No : 02 Date: ****

Session No : 02 Time: *****

Purpose of the Interview :

To give the client CBT therapy

Start of the session:-

In this session the psychologist started CBT with the client. Psychologist also uses STP,
anxiety and ocd inventory on client. Psychologist also starts token economy to the client and
makes a daily schedule for client and asked client to follow that. psychologist also suggest to
client to take medicines on regular basis

My observation: - When the client left I found that he was looking slightly more relaxed and
smiled before he left. My-feeling that he could cope up with his condition in future.

Plan of action: The counselor continues therapy and examine the progress of the client till
the client is overcome his delusions and hallucinations

The purpose with which today’s session was started was achieved.

Summary

The Client Mr. RS came with his father , he looked lost his in own world. He is not dressed
properly and body coordination and movement also not align. The client got his first attack
when he failed in 10th class exam after that his performance in study was deteriorating day
by day and he start to remain alone. According to the symptom told by the father , it can be
concluded that the client has experienced hallucination, Negative symptom, disorganized
speech and movements according to all this symptom as per DSM 5 it can be diagnosed that
the client may suffer from Schizophrenia.

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Intervention:-

Common psychological treatments for schizophrenia include:

• Cognitive behavioural therapy (CBT)

• Family therapy
Cognitive behavior therapy (CBT). This can help the person change their thinking and
behavior. A therapist will show them ways to deal with voices and hallucinations. With a
combination of CBT sessions and medication, they can eventually tell what triggers their
psychotic episodes (times when hallucinations or delusions flare up) and how to reduce or
stop them. Read more on how cognitive behaioral therapy can help thinking patterns.

Family intervention

A family intervention involves a series of therapy sessions with the individual with
schizophrenia as well as their family and friends who are involved in the life of the client.
Evidence has shown that a strong support network is particularly beneficial to help people to
cope with symptoms of schizophrenia; therefore, family intervention uses this knowledge to
its advantage.

A family intervention usually helps clients to improve their rapport and engagement in the
family, which can subsequently lead to the client experiencing the positive benefits of a
stronger support group in surpassing challenges that present as a result of living with the
condition.

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CASE STUDY

IDENTIFICATION DATA

Registration No :- **** Address :-XYZ

Name :- Miss P.S Date :-

Age:- 15

Gender :- Female

Educational qualification : 11th (science)

Occupation : Student

Income : N. A

Marital status : Unmarried

Clients stays with parents : Yes

Stays with spouse : No

About Family

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Has any siblings, if so, how many : 2 brothers

What is the position of the client in the family : middle

Any one in the family is suffering/has suffered from any mental disorder : No

Any one in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : Mother

Information : Adequate and reliable

Referred by : Mother

Presenting complaints :-

 Blushing and excessive sweating

 trembling or shaking and

 difficulty in speaking

 dizziness or lightheadedness

 rapid heart rate

 Intense fear of interacting or talking with strangers

 having a shaky voice

 Could not travel alone

 Could not continue her coaching class due to intense fear

According to informant

Disturbed sleep : 3 months

Change in eating habits : 3 months
Uninterested at work : 3 months

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Date of onset of illness (The first attack) :- 1 year ago (at the time of tuition )

Precipitating factor if any: In childhood father was abused and misbehaved in mob
Duration of illness :- 01 year

Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between ,duration of such period of wellness :- No

Was there any precipitating factor at each relapse: Nil

How many relapses: Nil

Any other treatment tried in between :- No

What was the effect: Nil

In what ways the illness causes inconvenience?

The Client is denied to travel alone , She always need someone go for a short distance also.

She denied for any social occasion like birthday party and picnic etc.

She has fear of talking with stranger. Most of the time she is refusing to speak in social
situations

Past History

No any Physical illness during childhood ,

Behavioral problems during childhood:

No any significant disturbance were reported in behavioral problems during childhood

not having bed wetting , not thumb sucking, no any stealing mentality, not having habit of
nail biting and taking care of self bathing , brushing , toilet and eating and dress up.

142
INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : Have good bonding

Father : Normal

Brother : Normal

Sister : NA

Client’s relationship with friends:

How many friends does the client have? : N.A

How does the client relate to them : Not in touch

Client’s Relationship with Neighbour : Trouble taking with stranger

Client’s Relationship with school and classmates : Normal

Client’s Relationship with the teachers in school : Normal

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate : N.A

In the game field : like to play individual online

games

143
EDUCATIONAL HISTORY:

In school college

Client studied in a highly reputed school in 11 th standard. She didn’t have much interest in
school activity but her academic skill is normal

How is the client in studies and academic performance : Average

Does the client come up to the expectations of parents and teachers ? Normal

How has the performance been over the years ? : Normal

Do they find that there is sudden deterioration in studies and academic performance :
N.A

Have they received any complaint from the school authorities regarding the client
performance? : No

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : N.A

Have they done anything about it so far? If so, what? : N.A

Has there been any improvement after their efforts? : N.A

When did they decide to consult a mental health specialist ? When the Client is denied to
travel by plane , afraid of travelling in plane he came by train whereas his brother came by
plane.

While they are travelling and they mostly used lift for getting up down but he denies to use
lift he feels that lift will be closed and he will be stuck in lift.

WORK HISTORY

What occupation is the client involved? : Student

How regular is the client for work? : N .A

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Has the client been complaining about work place? If so what? : N .A

Has the client been on leave? If so for how long? : N .A

When was the time they noticed that the client was reluctant to go for work? N .A

What reasons were given by client for not attending to work? N.A

Generally how has the client been fairing in work? N.A

Has there been any complaint about non performance etc. about the client? N .A

What is their perception about client’s relationship in the workplace? N .A

With Boss : N .A

With colleagues : N .A

With subordinates : N .A

Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints? N.A

If Married:

Relationship with spouse in terms of

Day to day dealings : N.A

Sex life : N.A

Work relationship (if spouse is working) : N.A

Relationship with children : Unmarried

Relationship with opposite sex persons : N.A

Decision making (who takes the decision - spouse or self) : N.A

Sharing of work at home with the spouse : N.A

145
Relationship with spouse’s relatives : N.A

Relationship with spouse’s friends : N.A

MENTAL STATUS REPORT (MSE )

Appearance : She was cooperative for all the sessions. Eye contact was maintained.
Attention could be aroused and sustained. She was alert and in touch with his surroundings.
Comprehension was adequate. Rapport could be established. She was adequately dressed.
Movement and behavior : her psychomotor activity is normal. Notices, mannerisms and
restlessness are present.
Affect :
Mood :

 Subjectively :- “I am worried”.
 Objectively :- The client is concerned about her health. The depth and the intensity
of the affect is normal. Mood is observed as congruent to the thought,
communicable and appropriate to the situation.
Speech :

a) the volume of the person’s voice : Speech is normal

b) the rate or speed of speech : Normal

c) the length of answers to questions : Average

d) the appropriateness of the answers : Point to point

e) clarity of the answers and similar characteristics : Expressive

Thought content : No any abnormality detected

Thought process : The client had preoccupation about mob will harm her

Cognition :

Attention and concentration:

Her attention was tested with the digit span test. she was able to repeat 6 digits forward and 5

146
digits backwards. she was able to do serial subtraction of seven.
Orientation: She was oriented to time, place and person.

Memory:

 Immediate memory:
intact

 Recent memory:
intact

 Remote memory:
intact
General information: She was able to name the president of India, five major cities, the
state that he lives in, its capital and chief minister. His general information is therefore
adequate.
Intelligence : Clinically she was found to be average in intelligence. Abstraction including
differences and similarities as well as proverbs was used to test his intelligence. she was able
to give appropriate answers.
Judgment : If she found a stamped, sealed and addressed envelope on the street she said
that she would give it to the nearest post office. If she was in a theater that caught fire she
said that she would run to safety and then use a fire extinguisher. Her test judgment is
preserved.

Insight. 3/6 ( Client has illness due to external factor )

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Interview Session With clients

Client’s name : Miss P.S

Interview No : 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview :

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest , take detailed case history and MSE

Start of the session:

The client Miss P.S came in. She looked a little confused as to whether she was in the right
place. I saw the client entering and told her to please come in. I then offered the seat opposite
to my chair to sit. She was accompanied by her mother.

I offered them also a ‘seat. However as the interview started I asked Miss P.S if it would be
all right we both talked alone and her mother waited for a while outside which could be seen
from the window.

Client’s appearance: The client was well dressed, neat and clean. She looked depressed and
also anxious. She looked a little nervous and confused.

She sat down and was rubbing her hands as if she is anxious and nervous. I decided to make
sure that the client is comfortable and told her that she is in the right place. I am a
psychologist working here and would like to talk to him. Miss P.S smiled and said that she
knew I am a clinical psychologist and wondered why she has been referred to me. I said,
well, if you tell me about yourself and the problem for which you approached the hospital, I
will be able to tell you why you are here. I continued as I found the client silent. I asked him
if she had any particular problem or illness or symptoms that are bothering him. May be I
could help if he tells me something about the reason for his approaching the hospital.

Then Miss P.S started to tell me that while When I was a student in class 10th, I had gone to
a Dussehra fair with my father at that time: in the scuffle, someone harmed her father, abused

148
her, since then I have been sitting at a rate, now I will never go out alone, my parents has
send me to take a coaching from coaching institute to clear the entrance exam, but I can't go
there because of fear of surrounding . I can not travel alone, I am afraid of meeting some
unknown person.

(She looked sad and sounded worried). I nodded my head to indicate that I understand his
problem and asked her to continue.

Symptoms as told by Miss P.S

 Most of the time uneasy feeling and get sensation of cold feet and hands
 I have trouble breathing
 Fear of situations in which I could be judged negatively

 Avoidance of doing things or speaking to people out of fear of embarrassment

 Intense fear of interacting or talking with strangers

Miss P. S. I think today we have discussed your problem particularly from the relationship
and your experience angles. It has been possible to understand when your problems started
what precipitated it and how you have been handling the same. Your efforts are really
appreciated. However there are many things. We need to discuss with each other. For
instance, the difficulties you are facing in your office and your relationship with your family
members in the last few years need further exploration.

Do you think I have understood your problems correctly?

Would you like to come for another session sometimes next week as is convenient to you?

Can we fix up next Wednesday 12 p.m, for the next session?

May be we will like to give some psychological tests which may help us and you to
understand your problem better.

The client responded he would like to come next week at the time specified which was
suitable to him also. We both stood up, and shook hands and the client took leave,

149
My observation:- When the client left I found that she was looking slightly comfort and
smiled before she left. My-feeling is that his talking about her problems and verbalizing her
feelings had relaxed him considerably–

Plan of action: Continue the interview and gather more information about the dynamics
underlying the various conflicts that she has expressed. I need also to talk to her family
members to understand the problem from their points of view.

The purpose with which today’s session was started was achieved.

Interview Session With clients

Client’s name : Miss. P.S

Interview No : 02 Date: ****

Session No : 02 Time: *****

Purpose of the Interview :

The client was referred to me for taking case history and gave her suitable therapy to cope
up with the problem.

Start of the session:-

The client Miss P.S. came with her mother. The body language was seem little change as
earlier and the session started by usual talks,

How you feel today ?

The client answered comfortably as she feel refreshed.

I asked her , has this problem happened to any of your family members as well ? Then she
answered no, and then I asked with his mother about her family relationship neighbor
relation and educational history and all.

150
I have given him ten minutes rest and told her to go out side and take fresh air and after then
we have take her Mental status examination , she has answered all the question very
comfortably.

As per the different symptoms shown by the Miss P.S we have applied the unstructured
interview to identify the disorder. we have diagnosed that client is suffering with social
phobia, so for recovered with this disorder we have gave her and CBT therapy she can learn
different ways of reacting to thoughts and feelings, and she can learn to engage in different
behaviors that result in decreased fear. CBT also helps in learn and practice social skills
when there is a deficit.

After completing her therapy we have asked with client how you feel now and then she
replied I feel refreshed and have less fear .

And we have end up the session suggest her to start her Clinical as soon as possible.

My observation:- When the client left I found that she was looking more relaxed and smiled
before she left. My-feeling that he could cope up with the fear in the future.

Plan of action: The counselor continues therapy and examine the progress of the client till
the social phobia of client is cured and client feel good enough

The purpose with which today’s session was started was achieved.

CASE SUMMARY :-

Miss. P.S aged 15 years, educated up to 11th standard , unmarried hailing from higher class
family and lived with her parents and two brothers

Reported with the complaints of whenever she was in crowd or she were think about being in
crowd then she felt uneasy and get sensation of cold feet and hands, she always denied to go
out side and she has intense fear of interacting or talking with strangers, most of the time she
feel embarrassing , mother is worried about her future how could she complete clear her
entrance class as she is denied to continue her coaching class.

151
Duration of the problem arises since 1 year , Symptoms were seen as anxiety and panic
attacks. Client had afraid of travelling alone, not able to meet any outsider not having too
much familiar with the people and having bad relationship with friends and mates. All of
these problem have been arisen after the incident happen with her father in the Dushera fair.
Her family history also well educated but one day incident happened with her father, she
went to Dushera fair with her father at that some people harm her father and start abusing
him in the mob , After then the fear is fixed in her mind she could never go out side alone
and refusing to travel alone even a short distance , most of the time she was spent her time
lonely and denied to join the family function, she has fear about the some people will
embarrassed her. The client is attached to all the siblings, and her educational history is also
average,

On MSE she has dressed adequately with well kempt hair. Her psychomotor activity was
within normal limits, her speech was relevant and coherent, and she showed no disturbances
in the stream, form of thought but showed tension, fear and nervousness. Her mood was
subjectively and objectively reported to be anxious. No perceptual disturbances were
reported, her cognitive functions were intact. She has insight level of III.

The client exhibit symptoms of panic attacks, sensation of cold feet and hands, nervousness.
According to all the different symptoms as per DSM we can diagnose that client may have
suffer from Social Phobia

CBT therapy has given to client to cope up with the problem and advised take care of
yourself: Eat a well-balanced diet, follow good sleep habits and exercise for 30 minutes at
least five days a week. Healthy lifestyle choices can decrease your anxiety.

INTERNVENTION :-

 Participate in social situations by reaching out to people with whom you feel
comfortable.

 Trying to share your feelings with friend and relative.

 Exercise is a physical activity that is planned, structured and repetitive, and aims to
improve or maintain physical fitness. It may improve anxiety levels and mood

152
 generally, provide opportunities to interact with others or function as a form of
exposure (for example, for people with a fear of blushing or sweating) and for this
reason is classed as a psychological intervention.

 In exposure-based CBT, you gradually work up to facing the situations you fear most.
This can improve your coping skills and help you develop the confidence to deal with
anxiety-inducing situations. You may also participate in skills training or role-playing
to practice your social skills and gain comfort and confidence relating to others.
Practicing exposures to social situations is particularly helpful to challenge your
worries.
 Though several types of medications are available, selective serotonin reuptake
inhibitors (SSRIs) are often the first type of drug tried for persistent symptoms of
social anxiety. Your health care provider may prescribe paroxetine (Paxil) or
sertraline (Zoloft)
 To reduce the risk of side effects, your health care provider may start you at a low
dose of medication and gradually increase your prescription to a full dose. It may take
several weeks to several months of treatment for your symptoms to noticeably
improve.
 Mindfulness training encourages individuals to gain psychological distance from their
worries and negative emotions, seeing them as an observer would see them, rather
than being engrossed in them. Treatment starts with general education about stress
and social anxiety. Participants then attend weekly groups in which they are taught
meditation techniques. Formal meditation practice for at least 30 minutes per day
using audiotapes for guidance is also encouraged.

153
CASE STUDY

IDENTIFICATION DATA

Registration No :***** Address : *******

Name : Master V S Date :

Age : 07 Years old

Gender : Male

Educational qualification : Studied in 3rd standard

Occupation : Student

Income : N. A

Marital status : Not married

Clients stays with parents : Yes

Stays with spouse : No

About Family

154
Has any siblings, if so, how many : 1 Elder sister

What is the position of the client in the family : Youngest

Any one in the family is suffering/has suffered from any mental disorder : No

Any one in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : His Mother

Information : Adequate and reliable

Referred by : Class teacher

Presenting complaints :-

According to informant

 He has difficulty in class work from his first standard.

 He writes slowly. he reads everything, but he doesn’t complete the exam papers.
 There was spelling errors even in those words which he has practiced for many times.
 He is unable to remember whatever he reads.
 When he reads any paragraph and if immediately asked questions he remembers
almost correctly. But he tends to forget with in a hour which leads him to fail in the
exams.
 He reads the first few words of each question and then when he gets an idea about
which lesson the question is from, he writes some answer for that question. Because
of this, he fails in some exams.
 he could not write a passage on his own about some topic. However, he is not able to
put the idea across in writing. Grammatical errors were reported in his writing.
According to the client
 He reported that he has problem in remembering what he reads at the exam time.
 He prays to God every day that he should try to study well.

155
Difficulty in reading : 02 Years
Slow in writing : 02 Years
Not able to remember what he needs : 02 Years
Poor scholastic performance : 02 Years

Date of onset of illness (The first attack) :- Years ago

Precipitating factor if any: Nil

Duration of illness :- 02 Years

Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between ,duration of such period of wellness :- No

Was there any precipitating factor at each relapse: Nil

How many relapses: Nil

Any other treatment tried in between :- No

What was the effect: Nil

In what ways the illness causes inconvenience?

The teacher told his mother that he does not like to read in the class as he was worried that
other children would make fun of him when he reads wrong. The mother then noticed at
home that, whenever he does not know a word, he guesses it and says a word that is similar
to the original word (for eg. for the word “awake” he says “away” and for “beauty” he says
“beuchy”). He also spells out most of the words when he finds it difficult. However, when
taught the material orally, he was able to reproduce it. But if the same material is shown in
the book, he finds it difficult to read.

He writes slowly. Mother reported that he reads everything, but he doesn’t complete the
exam papers,. This habits result him in failure of exams.

156
It has resulted that he low self esteem.

Past History

No significant somatic complaints were reported apart form the headaches ad stomach pain.

Behavioral problems during childhood:

No any significant disturbance were reported in behavioral problems during childhood.

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : Have good bonding

Father : Good

Brother : NA

Sister : Very Close

The client live with his father 42 years and has studied up to 12th standard. He works as a
building contractor in private sector. He earns 15000 to 20000 per month. His earning is the
main source for the family. There is no financial stress present. He was abusing alcohol and
used to smoke regularly. He stopped consuming alcohol and he stopped smoking as he was
diagnosed with diabetics and hypertension. It was reported that his father also had speech
difficulty in his childhood. He was extremely affectionate with the child and spends one to
two hours per day with him.

Client mother was 42 years and has studied up to 10th standard. She was a homemaker. She
had hypertension and hyperthyroidism. The client was attached to the mother and the mother
was affectionate towards him. The client elder sister was 18 years old and was studying B.Sc
clinical nutrition in a private college. Her academic performance is above average.

Client is attached to his sister and the sister is affectionate towards him. All of his family
members are affectionate with him because he was born ten years after his sister’s birth.

157
Client’s relationship with friends:

How many friends does the client have? : 10-15

How does the client relate to them : Good

Client’s Relationship with Neighbour : Normal

Client’s Relationship with school and classmates : Friendly

Client’s Relationship with the teachers in school : Normal

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate : Good

In the game field : Like to play chess and football

EDUCATIONAL HISTORY:

In school college

The client was admitted to L.K.G at the age of 3, in an English medium, CBSE school. He
was continuing in the same school and goes to school regularly. He was currently studying
in 3rd standard. Teacher reported to his mother that he has always been below average in
academic activities. He mingles easily with other children. Teachers reported that he doesn’t
pay attention in the class and despite repeated practice and warning there is no improvement
on his reading and writing. They told mother that he is very slow in writing and doesn’t take
interest in class. His writing was not legible, though his comprehension level was good. He
had many friends at school and was cordial with all of them.

How is the client in studies and academic performance : below average

Does the client come up to the expectations of parents and teachers ? No

How has the performance been over the years ? : Not so good

Do they find that there is sudden deterioration in studies and academic performance :
Yes Not able to complete his work own

158
Have they received any complaint from the school authorities regarding the client
performance? : Yes

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : 02 Years

Have they done anything about it so far? If so, what? : No

Has there been any improvement after their efforts? : N.A

When did they decide to consult a mental health specialist ?

Due to the constant complaints in school, the teachers have suggested to consult ,

WORK HISTORY

What occupation is the client involved? : Student

How regular is the client for work? : NA

Has the client been complaining about work place? If so what? : NA

Has the client been on leave? If so for how long? : NA

When was the time they noticed that the client was reluctant to go for work? NA

What reasons were given by client for not attending to work? N.A

Generally how has the client been fairing in work? N.A

Has there been any complaint about non performance etc. about the client? NA

What is their perception about client’s relationship in the workplace? NA

With Boss : NA

With colleagues : NA

With subordinates : NA

159
Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints? N.A

If Married:

Relationship with spouse in terms of

Day to day dealings : N.A

Sex life : N.A

Work relationship (if spouse is working) : N.A

Relationship with children : Unmarried

Relationship with opposite sex persons : N.A

Decision making (who takes the decision - spouse or self) : N.A

Sharing of work at home with the spouse : N.A

Relationship with spouse’s relatives : N.A

Relationship with spouse’s friends : N.A

MENTAL STATUS REPORT (MSE )

Appearance : The Client was cooperative for all the sessions. Eye contact was maintained.
Attention could be aroused and sustained. He was alert and in touch with his surroundings.
Comprehension was adequate. Rapport could be established. He was adequately dressed.
Movement and behavior : His psychomotor activity was within the normal range.
Fidgeting, restlessness tics or other and mannerisms were not present
Mood and Affect: This was found to be pleasant and cheerful.
Speech :

a) the volume of the person’s voice : Speech is normal

160
 b) the rate or speed of speech : Normal

c) the length of answers to questions : Normal

d) the appropriateness of the answers : Detailed answer

e) clarity of the answers and similar characteristics : Very expressive

Thought content : No any abnormality detected

Thought process : No delusions or other abnormalities were seen in the thought process.

Cognition :
Attention and concentration:
His attention was tested with the digit span test. He was able to repeat 6 digits forward and 5
digits backwards. He was able to do serial subtraction of seven.
Orientation: He was oriented to time, place and person.

Memory:

 Immediate memory:
intact

 Recent memory:
intact

 Remote memory:
intact
He could recall and tell what he had for breakfast and dinner. He could recall and tell his date
of birth.

General information: He was able to name the Chief Minister of India, five major cities, the
state that he lives in, its capital and chief minister. His general information is therefore
adequate.

161
General Intelligence :

When asked for the meaning of proverbs he was able to tell the abstract meaning and also
similarities and differences between two things. His intelligence is adequate.

Judgment : If he found a stamped, sealed and addressed envelope on the street he said that
he would give it to the nearest post office. If he was in a theater that caught fire he said that
he would run to safety and then use a fire extinguisher. His test judgment is preserved.

Insight : I have an illness due to unknown factor ( Level IV)

Interview Session With clients

Client’s name : Mr. V S

Interview No : 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview :

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest and take detailed case history and MSE

Start of the session:

The client Master V S came in. He looked a little confused as to whether he was in the right
place. I saw the client entering and told him to please come in. I then offered the seat
opposite to my chair to sit. He was accompanied by his mother.

I offered them also a ‘seat. However as the interview started I asked Mr. V S if it would be
all right we both talked alone then he denied to give interview alone he wants his mother to
accompany him.

What brought you here ,how can I help you ?

Then his mother replied “He has difficulty in class work from his first standard.

He writes slowly. he reads everything, but he doesn’t complete the exam papers.

162
There was spelling errors even in those words which he has practiced for many times.
When he reads any paragraph and if immediately asked questions he remembers almost
correctly. But he tends to forget in the exams.
He reads the first few words of each question and then when he gets an idea about which
lesson the question is from, he writes some answer for that question. Because of this, he fails
in some exams.
he could not write a passage on his own about some topic. However, he is not able to put the
idea across in writing. Grammatical errors were reported in his writing.
His teacher complains that he has poor attention level and is bad at spelling as well.
He is not able to differentiate among phonetic.

I have heard the problem reported your mother now I want to listen from you .
He reported that he has problem in remembering what he reads at the exam time. He prays to
God every day that he should try to study well.

Have you taken any treatment ?

Then his mother replied” As of now no , his class teacher suggested us to consult a
counsellor
(He looked sad and sounded worried). I nodded my head to indicate that I understand his
problem and asked him to continue.

How is your relationship with your family ?

Then his mother replied “ They share a good relationship

Master VS I think today we have discussed your problem particularly from the relationship
and your experience angles. It has been possible to understand when your problems started
what precipitated it and how you have been handling the same. Your efforts are really
appreciated. However there are many things. We need to discuss with each other. For
instance, the difficulties you are facing in your school and we need further exploration.

Do you think I have understood your problems correctly?

Would you like to come for another session sometimes next week as is convenient to you?

163
Can we fix up next Wednesday 12 p.m, for the next session?

May be we will like to give some psychological tests which may help us and you to
understand your problem better.

The client responded he would like to come next week at the time specified which was
suitable to him also. We both stood up, and shook hands and the client took leave,

My observation:- Client’s appearance was well dressed, neat and clean. He looked a little
nervous and confuse. The client smiled before he left.

Plan of action: Continue the interview and gather more information about the dynamics
underlying the various conflicts that he has expressed. I need also to talk to his family
members to understand the problem from their points of view and give some therapy .

The purpose with which today’s session was started was achieved.

Interview Session With clients

Client’s name : Master V S

Interview No : 02 Date: ****

Session No : 02 Time: *****

Purpose of the Interview :

The client was referred to me for taking case history and gave him therapy.

Start of the session:-

The client Mr. X came with his Mother. The body language was seem little change as earlier
and the session started by usual talks,

How you feel today ?

The client answered” I am good .

164
As per your mother reported that you have face problem in reading and writing , so shall we
start your dictation and reading some story .

Then he hesitated to give dictation, but we have divert his mind as told him we will play a
word game.

Then he agreed and start to give dictation

We have noticed that he is not able to write all the words correctly.

After we have give him a story book for reading then he start reading.

He was not able to pronounciate the word properly.

Asked him has this problem happened to any of your family members as well ? Then he
answered no,

I have given him ten minutes rest and told him to go out side and take fresh air and after then
we have take his Mental status examination , he has answered all the question very
comfortably.

As per the different symptoms shown by the Master , we have applied the WISC –V test
for checking the intelligence level and we have applied SLD ( Specific Learning disability )
and we have applied Aptitude test also.

We have asked with client how you feel now and then he replied I feel ok .

My observation:- When the client left I found that he was looking slightly relaxed and
smiled before he left.

Plan of action: The counselor continues therapy and examine the progress of the client till
the Learning disability with ( Dyslexia and Dysgraphia) of client is cured and client feel good
enough

The purpose with which today’s session was started was achieved.

165
Test Administered

DTLD – (Diagnostic Test of Learning Disability) The authors of DTLD are Smriti Swaroop
and Dharmishta Mehta. The test diagnoses learning disability in ten areas-from
Auditory/Visual Perception to Cognitive areas. It consists of 10 sub-tests. It is to be
individually administered on the age group 8-11 years old.

WISC-V Test (Wechsler Intelligence Scale for Children)

The WISC Test (Wechsler Intelligence Scale for Children) is an IQ test administered to
children between ages 6 and 16 by school districts and psychologists.

Aptitude tests are used to measure potential ability to learn, rather than what the student has
learned in school during the year. In addition, Macklem states that aptitude tests cover a
broad area, and look at a wide range of experiences

The SLD ( Specific Learning disability ) battery has been developed separately for younger
students Level I (5 to 7 years) and older students Level II (8 to 12 years).

(a) Attention Test (Number cancellation). Learning Disabilities: Nature, Causes and
Interventions166

(b) Language Test (Reading, Writing, Spelling and Comprehension)

(c) Arithmetic (Addition, Subtraction, Multiplication, Division and Fractions)

(d) Visuo-motor Skill (The Bender Gestalt Test and the Developmental Test of Visuo-Motor
Integration).

(e) Memory (Auditory and Visual).

CASE SUMMARY

The client Master V S came with his mother he look nervous as he enter the cabin during
the interview session his mother told that he faces problem from past 2 year, his Mother also
reported that he is unable to remember whatever he reads. When he reads any paragraph and
if immediately asked questions he remembers almost correctly. But he tends to forget in the
exams. She also reported that it could be because Master .V does not read the complete

166
question in the question paper. He reads the first few words of each question and then when
he gets an idea about which lesson the question is from, he writes some answer for that
question. Because of this, he fails in some exams. She also reported that he could not write a
passage on his own about some topic. However, he is not able to put the idea across in
writing. Grammatical errors were reported in his writing.

Master.VS mother has tried to send him to tuitions where individual attention was also
focused. However, his reading and writing has not improved due to this. Due to the constant
complaints in school, the teachers have suggested to consult.

On MSE he has dressed adequately with well kempt hair. his psychomotor activity was
within normal limits, his speech was relevant and coherent, and he showed no disturbances
in the stream, form of thought but showed tension, nervousness. His mood was subjectively
and objectively reported to be anxious. No perceptual disturbances were reported, his
cognitive functions were intact. He has insight level of IV .

The client exhibit symptoms of reading and writing problem. According to all the different
symptoms as per DSM we can diagnose that client may have suffer from Learning
disability with Dyslexia and dysgraphia.

INTERNVENTION :-

Behavioural Interventions : In many cases the behaviour problems of the child with
learning disability are as much of a concern as the learning disability itself. Behavioural
characteristics such as inattention and hyperactivity have social consequences, putting a
strain on interpersonal relationships and lead to negative self-evaluation. Because of
consistent reports from teachers regarding these problems such as frequent out-of-seat
behaviour, fidgetiness and other identifiable classroom behaviours, biofeedback and
relaxation training have been identified as relatively non-intrusive methods Learning
Disabilities: Nature, Causes and Interventions167 180 Clinical: Theory, Research and
Practice for dealing with these problems. A number of studies have demonstrated that
biofeedback and relaxation can improve the behaviour and emotional well being of children
with learning disabilities. (Amerikaner & Summerlin, 1982; Carter & Russell, 1985;
Loffredo et al., 1984

167
Social Skills Training : Several procedures have been used to improve the social skills
performance of students with learning disabilities. According to Maag (1989), a basic
principle of social skills instructions is that behaviours chosen for instructions should be
those valued by persons important in the learner’s environment. In an analysis of social
behaviours selected for individualized educational programs, Pray, Hall & Markley (1992),
found that academically related social skills (e.g., task related skills such as following
directions or being on task) were much more prominent than interpersonal skills (e.g.,
making conversation or accepting authority). They recommended more emphasis on inter-
personal skills for students with learning disabilities. To foster peer interaction social skills
curriculum needs to focus on four main areas: conversation skills (e.g., introducing oneself,
asking and answering questions),168 181 friendship skills (making friends, joining group
activities, giving help), skills for difficult situations (accepting and giving criticism, resisting
peer pressure) and problem solving skills (negotiating, persuading, asking for feedback).
Bender & Wall (1994), reported that social skills training have been successful in helping
students with learning disabilities.

Peer Tutoring : Several studies have focused on the effectiveness of peer tutoring (an
instructional arrangement in which the teacher pairs two students in a tutor-tutee relationship
to promote learning of academic skills) for students with learning disabilities. Peer tutoring
has been found to improve academic skills, foster self esteem, develop appropriate
behaviours and promote positive relationships and co-operation among peers (Mercer, 1997).
The Class Wide Peer Tutoring Programme has been found to improve the academic and
social performance of students with learning disabilities (Maheady, Harper, & Mallette,
1991).

Family Interventions : Parents and families help determine the social, intellectual and
physical well being of their children. With the identification of a learning disability in their
child, parents often have an immediate reaction of denial. As problems continue, denial or
non acceptance of the child’s difficulty is replaced by depression and guilt in the parents.
Depression that the child is impaired, the child’s future is uncertain, the child cannot fulfill
their wishes for him and guilt that the child may have inherited their learning disability.
Parents may exhibit external causal attributions that make them feel powerless to help their

168
child cope with problems. Anger may be directed at all who are involved with the child, at
the family members, school authorities and at the child himself. At times, the anger is
suppressed and with the mechanism of reaction formation. The learning disabled child may
become demoralized, anxious and begin to harbor feelings of low self-esteem. Further, the
unmet high expectation of parents with regard to the academic achievement of their learning
disabled child adds to the child’s feelings of worthlessness and guilt. Sharma (1993), found
that parents of learning disabled children were having very poor or low expectation of their
child’s academic achievement. These parents also mostly perceived their children as socially
incompetent with several problems.

Parental Clinical and family therapy would help to improve patterns of communication
within the family members, between the parents and the child, thereby contributing to the
development of a positive self concept in the learning disabled child.

169
CASE STUDY

IDENTIFICATION DATA

Registration No :- **** Address :-XYZ

Name :- Mrs K K Date :-

Age:- 32

Gender :- Female

Educational qualification : Graduate

Occupation : Home maker

Income : N. A

Marital status : Married

Clients stays with parents : Yes

Stays with spouse : Yes

About Family

170
Has any sibling, if so, how many : 1 Brother

What is the position of the client in the family : Daughter – In Law

Anyone in the family is suffering/has suffered from any mental disorder : No

Anyone in the family is suffering/has suffered from any physical disorders : No

Type of Family : Nuclear

Informant : Husband

Information : Adequate and reliable

Referred By : Husband

Presenting Complaints

 Always stay in single room

 Sleep Disturbance
 Negative thought
 Feeling insecure

Date of onset of illness (The first attack) :- N.A

Precipitating factor if any: Nil

Duration of illness :- 05 months

Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between, duration of such period of wellness: - no

Was there any precipitating factor at each relapse: - Nil

How many relapses: Nil

Any other treatment tried in between: - No

171
What was the effect:-Nil

In what ways the illness causes inconvenience?

The client is insecure about husband, she faces fear that her in law want to kill her, try to
remain alone , having nightmares, she continuously having the negative about her in laws.

Past History

No any physical illness during childhood

Behavioral problems during childhood:

No any significant disturbance were reported in behavioral problems during childhood

not having bed wetting , not thumb sucking, no any stealing mentality, not having habit of
nail biting and taking care of self bathing , brushing , toilet and eating and dress up.

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : Good

Father : Good

Brother : Good

Client’s relationship with friends:

How many friends does the client have? : 1-2

How does the client relate to them : N. A

Client’s Relationship with Neighbour : less talking

Client’s Relationship with school and classmates : Not in touch

Client’s Relationship with the teachers in school : Not in touch

172
Client’s Relationship with other authority figure : Normal

Client’s Relationship with playmate : N.A

In the game field : N.A.

EDUCATIONAL HISTORY:

In school college

Client does her graduation form Delhi University

How is the client in studies and academic performance : - Normal

Does the client come up to the expectations of parents and teachers? Yes

How has the performance been over the years? : - No

Do they find that there is sudden deterioration in studies and academic performance: -
No

Have they received any complaint from the school authorities regarding the client
performance? : N.a.

Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : N.a.

Have they done anything about it so far? If so, what? : No

Has there been any improvement after their efforts? : N.A

WORK HISTORY

What occupation is the client involved? : N.A

If Married
Relationship with spouse in terms of

Day to day dealings : not normal getting insecure about him

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Sex life : not so normal

Work relationship (if spouse is working) : normal

Relationship with children : no children

Relationship with opposite sex persons : normal

Decision making (who takes the decision - spouse or self): spouse

Sharing of work at home with the spouse: No

Relationship with spouse’s relatives : Not good

Relationship with spouse’s friends : Not good

MENTAL STATUS REPORT (MSE )

 APPEARANCE : client is wearing a saree not so properly she looked bit tensed and
fearful
 MOVEMENT AND BEHAVIOR: client manner of walking and coordination was
not so perfect because she was fast and tensed she was not making eye contact
 AFFECT: sad and tensed generally but became insecure on question about husband
and in law.
 MOOD:
 Subjectively: - “I think my husband not love me now.”
 Objectively :- client was insecure and afraid
 SPEECH :
a) The volume of the person’s voice: Speech is abnormal

b) The rate or speed of speech: faster than normal

c) The length of answers to questions: unusual

d) The appropriateness of the answers : normal

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 e) Clarity of the answers and similar characteristics: normal

 THOUGHT CONTENT: Not present of hallucination and delusion

 THOUGHT PROCESS: Normal
 COGNITION:
1. Attention and concentration:
His attention was tested with the digit span test. He was unable to repeat 6 digits forward
and 5 digits backwards. He was unable to do serial subtraction of seven.
2. Orientation: she was oriented to time, place and person.

3. Memory:

 Immediate memory: intact

 Recent memory: intact

 Remote memory: intact

4. General information: She was able to name the prime Minister of India, five
major cities, the state that she lives in, its capital and chief minister. Her general
information is therefore inadequate.
 JUDGMENT: she was not able to judge right in some situation mostly she judge in
negative way.
 INSIGHT: client had no insight about her problem

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INTERVIEW SESSION WITH CLIENT

Client Name : Mrs. KK

Interview No. : 01 Date : *****

Session No. : 01 Time : *****

Purpose of Interview :

The purpose of the interview was to get familiar with the client, establish rapport and take
detailed case history and MSE.

Start of the session:

The client Mrs K K came in. she looked feared and tensed by face.

I saw the client coming with her husband and offer them seat. Her husband is looked worried
about her condition.

However the interview start I ask her if it would be nice we both talked alone and her
husband wait outside the room. Firstly she looked toward her husband with some tension
then after sometime she said ok.

The client look neat and clean but her dress was not well manage by her she looked tense and
afraid. She also rub her hand in nervousness.

After making her sure that she will be in right place and clam her make her comfortable. I
said her that I am her to talk to her so don’t worry.

Mrs. K K looked at me and nodded then I asked her about herself and what she was thinking
from past days. She remain silent and try to not to make eye contact. I asked him again if
there is anything she want to share with me that make her not feeling good maybe I could
help you in that then the client started to tell me that she was thinking that her husband not
love her anymore like before by saying this she get sad and depressed. she also added that
might her husband want to get rid from him I asked her the reason of her thinking she remain
silent. Then she said that I don’t want to loose my husband I love him. She said that she feel

176
that her in laws try to disgrace her all time. Due to this type of feeling her mood remains sad
and she faces fear and insecurity all time.

Then I ask him is her husband shout on him on which she replied no .

as her in laws make her feel uncomfortable can you tell me any one of the situation on
respond of this she remain silent and try to not make eye contact. I ask her if she hear some
voice telling all this to her on which she replied no instantaneously.

Mrs. K K I think today we have discussed about your thoughts and what you are feeling this
days. Your effort is really appreciated however there are many things we need to discuss with
each other would you like to come for another session sometime in next week. Maybe we
will like to give some psychological tests which may help us to understand your problem
better the client nodded in yes we both stood up and greet each other and client took leave.

My Observation : - When the client left I found that he was looking slightly relaxed and
greet me good bye correctly when she left. I feel that by talking about her thoughts and
feeling now she feel some relived in her mind.

Plan of Action : Continue the interview and gather more information about the dynamics
underlying the various conflicts that he has expressed. I need also to talk to his family
members to understand the problem from their points of view..

The purpose with which today’s session was started was achieved.

INTERVIEW SESSION WITH CLIENT

Client Name : Mrs. K K

Interview No : 02 Date: *****

Session No. : 02 Time: *****

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Purpose of the Interview:

The client was referred to me for taking psychological test and to know more about her
family and social relations

Start of the session:

The client Mrs K K came with her brother. The body language was seem little change as
earlier and the session started by usual talks,

How you feel today?

The client answered comfortably that she feels fine. Then I ask him that can I asked some
question to her in reply to which she say yes

I asked her has this problem happened to any of your family members as well ? Then she
answered no, and then I asked her about her relation with her husband on which the client
reply that he cares him all time but she has fear of losing him. She thinks that after some time
he will not love her. She became tensed, I make her calm down and further ask her how is
her relation with her in laws on reply she remain silent.

I asked her is her in laws not good she said they are are not too bad. She seems confused.

I asked her about her sex life on which she remains silent and became awkward.

I asked her how is your relation with your parent she replied it’s very good

I asked her is she have friends on which she replied that she was not in touch with them.

I gave her ten minute rest and said that after that we will give her a psychological test on
hearing this she became nervous.

After that the beck depression inventory test was taken to know to screen for depression and
to measure behavioral manifestations and severity of depression.

My observation: - When the client left I found that she was looking slightly more relaxed
and smiled before she left. I feel that she could cope up with the fear in future.

178
Plan of action: In the next session the psychologist takes the case to give her some therapy
and suggest her some daily routine and activities.

The purpose with which today’s session was started was achieved.

Test Administered

Beck Depression Inventory (BDI)

Construct: Depressive symptoms

Depression Description of Measure: The Beck Depression Inventory (BDI) is a 21-item, self-
report rating inventory that measures characteristic attitudes and symptoms of depression
(Beck, et al., 1961). The BDI has been developed in different forms, including several
computerized forms, a card form (May, Urquhart, Tarran, 1969, cited in Groth-Marnat,
1990), the 13-item short form and the more recent BDI-II by Beck, Steer & Brown, 1996.
(See Steer, Rissmiller & Beck , 2000 for information on the clinical utility of the BDI-II.)
The BDI takes approximately 10 minutes to complete, although clients require a fifth – sixth
grade reading level to adequately understand the questions (Groth-Marnat, 1990)

----------------------------------------------------------------------------------------------------------------

CASE SUMMARY

Mrs K K was a married lady she came to me with her husband. Her husband bring her here as
she continuously remain sad and low. she have insecurity about her husband she thinks that
her husband not going to love her in future , she also think that her in law's want to disgrace
her in front of her husband. So, that he loss interest in her she thinks negatively about most
of the time when her husband talk on phone she became insecure. Most of the time she
remain afraid and tensed. as per the different shown in the client it has been diagnosed that
she has facing moderate depression without psychotic symptom as also the result of test
administered show. Her husband in my observation is good and caring she has problem of
thinking negatively all time and remain sad and depressed. After taking case history and
mental status examination and administering the test the case is handed over to a
psychologist for giving a suitable intervention to the client.

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INTERNVENTION:

 Behavioral Therapy Behavioral therapy focuses on the relationship between

behavior and mood to target current problems and symptoms and focus on changing
patterns of behavior that lead to difficulties in functioning
 Cognitive Therapy Cognitive therapy entails modifying pessimistic evaluations and
unhelpful thinking patterns with the goal of disrupting these and reducing their
interference with daily life
 Cognitive-Behavioral Therapy (CBT) Cognitive-behavioral therapy targets current
problems and symptoms and focuses on recognizing the relationship between
behaviors, thoughts, and feelings and changing patterns that reduce pleasure and
interfere with a person’s ability to function at his/her best.
 Interpersonal Psychotherapy (IPT) Interpersonal psychotherapy focuses on
improving problematic relationships and circumstances that are most closely linked to
the current depressive episode.
 Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-based cognitive
therapy combines strategies of cognitive therapy with mindfulness meditation to
modify unhelpful thoughts and develop a kinder, more loving self-view.

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CASE STUDY

IDENTIFICATION DATA

Registration No : **** Address : ******

Name : Ms. A S Date : ******

Age: 15

Gender : Female

Educational qualification : 10th (result awaited)

Occupation : Student

Income : N.A.

Marital status : Unmarried

Client stays with parents : Yes

Stays with spouse : No

About Family

Have any siblings, if so, how many : 01 Brother

What is the position of the client in the family: Eldest

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Anyone in the family is suffering/has suffered from any mental disorder: Yes, mother
has bipolar affective disorder and now she is under the treatment.

Anyone in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : Father
Information : Adequate and reliable
Referred by : Uncle
Presenting complaints :-

According to the client she has powers of lord shiva.

According to the informant, she has become very aggressive and abuses her parents. She
claims that she is having a power of Lord Shiva.

Disturbed sleep : 6 months

Change in eating habits : 6 months
Irritability : : 6 months
Grandiosity speech : 3 weeks

Date of onset of illness (The first attack) :-N.A.(sudden)

Precipitating factor if any: Fear of securing less marks in class X th boards

Duration of illness:-3 weeks

Intensity of illness (on a scale of 10):

Treatment taken:- No

Got well at any time in between, duration of such period of wellness: - No

Was there any predisposing factor: Family history of the bipolar affective disorder for her
mother

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Was there any precipitating factor at each relapse: Fear of getting less marks in her 11th
board examination

How many relapses: Nil

Any other treatment tried in between:-No

What was the effect: Nil

In what ways the illness causes inconvenience?

The client claims that she’s having the powers of Shiva. She has become aggressive and
abuses her family members, friends, neighbors. She has not been eating and sleeping well
since 6 months. She has become severely underweight. She has increased activity and is
super energetic. She jumps, runs, climbs trees. She speaks irrelevantly without any pause.

Past History

No history of physical or mental illness during childhood.

Behavioral problems during childhood:

No significant disturbances were reported in behavioral problems during childhood.

Habit of bed wetting, thumb sucking, and nail biting was observed during the client’s
childhood. However, no stealing mentality was observed. She used to bath daily brush his
teeth for two minutes and he was toilet trained too. She used to eat and dress properly in
childhood.
INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member

With father : Bad

Mother : Bad
Brother : Not so good

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There is no consanguinity between parents of the client. The client’s father is 47 years old
and her mother is 40 years old. The client’s younger brother is 12 years old.

Client’s relationship with friends:

How many friends does the client have? : 1-2

How does the client relate to them : Friendly with them

Client’s Relationship with Neighbor : Normal

Client’s Relationship with school and classmates : Normal

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

Client’s Relationship with playmate In the game : N.A.

field
EDUCATIONAL HISTORY:

In school/college

The client was above average in academic. However, being an introvert she was very shy and
never participated in school activities. Her hobbies were watching reading and listening to
music. She is studying in 1oth class.

How is the client in studies and academic performance : above average

Does the client come up to the expectations of parents and teachers ?Yes

How has the performance been over the years ? : good

Do they find that there is sudden deterioration in studies and academic performance
:Yes

Have they received any complaint from the school authorities regarding the client
performance? :Yes

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Since when have they noted that the client is not the same in regard to academics as he
or she used to be? : 6 months

Have they done anything about it so far? If so, what? : No

Has there been any improvement after their efforts? : N.A.

When did they decide to consult a mental health specialist? When the client started
claiming that she has powers of Shiva and started abusing, acting very weird.

WORK HISTORY

What occupation is the client involved? : N.A.

How regular is the client for work? : N.A.

Has the client been complaining about work place? If so what? : N.A.

Has the client been on leave? If so, for how long? : N.A.

When was the time they noticed that the client was reluctant to go for work? N.A.

What reasons were given by client for not attending to work? N.A.

Generally how has the client been fairing in work? N.A.

Has there been any complaint about non performance etc. about the client? N.A.

What is their perception about client’s relationship in the workplace?

With Boss : N.A.

With colleagues : N.A.

With subordinates : N.A.

Has the client ever mentioned about anyone bothering at workplace? How much
importance have they given to client’s such complaints? N.A.

If Married: No

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Relationship with spouse in terms of

Day to day dealings : N.A.

Sex life : N.A.

Work relationship (if spouse is working) : N.A.\

Relationship with children : N.A.

Relationship with opposite sex persons : N.A

Decision making (who takes the decision - spouse or self) :N.A.

Sharing of work at home with the spouse : N.A.

Relationship with spouse’s relatives : N.A.

Relationship with spouse’s friends : N.A

MENTAL STATUS REPORT (MSE)

Appearance : She was not cooperative for the sessions. Client was seen super energetic and
aggressive. She was alert and in touch with her surroundings. Proper eye contact was
maintained. Attention & Concentration is aroused and sustained. Rapport could be
established with the client. The client was badly dressed and was unable to concentrate in her
daily routines. Her vitals were stable.

Movement and behavior: increased psychomotor activity is observed from the client.

Affect: Broad congruent with mood

Mood:

 Subjectively :- “I have powers of lord Shiva”

 Objectively :-the client has delusion of grandiose
The depth or intensity of mood is not normal, she is excessively happy. The mood is ecstatic.

Mood-irritable, euphoric

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Mood- Affect are congruent to each other.
Speech :

a) The volume of the person’s voice: Speech is loud

b) The rate or speed of speech: Increased

c) The length of answers to questions: Long

d) The appropriateness of the answers: Not Appropriate

e) Clarity of the answers and similar characteristics: not clear, irrelevant

Thought content: Ideas of grandiosity, Form-flight of ideas, rapid thinking,

tangentially (where the client doesn’t come to the point).
Thought process : The client was preoccupied with her thoughts.

Cognitive functions:

 The client is oriented to time, place and date

 Attention & Concentration is aroused and sustained

 Memory:

 Immediate memory: intact

 Recent memory : intact

 Remote memory: intact

 Abstraction:

 Similarities: adequate

 Differences: adequate

 Proverb : adequate
 General fund of knowledge :adequate

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JUDGMENT:

 Personal : intact

 Social : intact

 Test : intact

INSIGHT :
Level 1 -complete denial of the illness.

__________________________________________________________________________

Interview Session With clients

Client’s name: Ms. K

Interview No : 01 Date: *****

Session No : 01 Time: *****

Purpose of the Interview:

The purpose of the interview was to get familiar with the client and ask question further only
if the client show any kind of interest and take detailed case history and MSE.

Start of the session:

The client Ms. K came in. She was greeted and offered a seat. The client was accompanied
by her father.

The client was not well dressed. She looked very energetic.

I asked Mr. K how she was feeling and what brought her to a psychologist. I asked her to
share her problems, what she has been facing but before that I wanted to make sure that the
client feels comfortable enough to share things so it was informed to her that whatever she
shares will be completely confidential. Only the necessary information will be passed on to
the other family members.

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I asked how is she
I’m good actually I’m very happy. I have power of lord shiva but nobody believes me all are
mad. I will punish everybody.

do you feel a special connection with the god ?

yes, I I have power of shiva. I see him in my dreams.

So do you consider yourself as special ?

yes, ofcourse. only I have the powers of lord shiva so I am a special person Shiva has chosen
me for the betterment of the society

Do you think god has special purpose for you ?

Shiva has chosen me for the betterment of the society. Now I will change the society and
punish everyone who will not obey me.
How is your relationship with your family?
I don’t share good relationship with them. Previously they used to scold me for securing
second position in my class. But they barely said anything to my brother who just used to
barely pass. From there I’ve developed kind off a hatred towards all three of them. When my
friends talk about their parents I feel so sad that my relationship is so bitter with my parents.
They just want me to study every time (crying).
The client was given time to sob. Once she became comfortable the interview was started
again.
So how are your studies going?
I used to be a good student but not anymore. I fear that I will score less in class X th. I got
second position even after studying o much and now I know I will fail.

Have you ever experienced opposite of depression when you have been very happy, on top
of the world doing things out of the character?
Yes. sometimes I start jumping laughing running all of a sudden.

189
how long does it lasts ?
Around 10 minutes.

do you find it difficult to control yourself at that time ?

yes. my parents ask me to not climb the tree but I don’t listen to them. I cant control my
thoughts.

Have you come across some brilliant ideas lately?

Yes that I have powers of shiva. I have also started dressing like him. people make fun og=f
me I will punish them

Have you been in trouble with the police or your family because of this?
Yes, I remember I was claiming that I have powers of god shiva and nobody in my
neighborhood was believing me to I abused them and threw stones on them. They came to
my house and warned my parents that they will call the police next time. I was scolded by
my parents and also punished by them.

Do you have friends?

I don’t have many friends. I have just 2 friends. They are very kind to me. But like others
they also don’t believe that I have powers of shiva. I even had a fight with them because of
this. I get so angry on them. I don’t want to, but they don’t believe me. Nobody believes me.

Are you going to school these days?

No, i have given my boards this year. I am waiting for my results.

Has it affected your social life.

Yes, I never had many friends I only had one to two friends but now I am left with none.
People are scared of me. I’m not a bad person.

How do you see any change in your behavior ?

Yes, sometimes I’m very happy but when people don’t believe about my claims I get very

190
irritate and I fight with them. everybody says that I am mad but I’m not mad. I have the
powers of shiva. people are not understanding this.

Ms K, I think today we have discussed your problem and how it’s affecting you. It has been
possible to understand when your problems started what precipitated it and how you have
been handling the same. Your efforts are really appreciated. However there are many things.
We need to discuss with each other. an interview will be scheduled with your fater to
understand your problem in depth

My observation: As the client left, she smiled back to me.

Action Plan: Continue the interview and gather more information about the dynamics
underlying the various conflicts that she has expressed. I need also to talk to her family
members to understand the problem from their points of view and have some test and gave
her some therapy which could help her to cope up with the problem.

The purpose with which today’s session was started was achieved.

Informant’s name: Mr R
Interview No : 02 Date: *****

Session No : 02 Time: *****

Mr. r was greeted and given a seat. He was made comfortable with the surroundings and was
informed that the interview conducted will be confidential and will be solely for the purpose
of diagnosing of Ms. K.

From when Ms. k started acting like this?

There was change in sleep and eating habits of K since 6 months and she was very irritated
too but I don’t know how 3 weeks ago she started claiming that she has powers of lord shiva.

Can you explain how she reacts.

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she makes tall claims like I have all powers of shiva if you don’t obey me god shiva will
punish you. she even gets aggressive and abuses us. but after sometime she gets normal and
gets very sad, irritated.

what kind of a relationship fo you have with her.

I love her. I just want her to study and do well in life and sometimes i scold her too.

did anybody in your family had any mental or a physical illness.

Physically nobody has history of illness. I am a client of hypertension I take medicines for
that. My wife was diagnosed with bipolar disorder 5 years ago.

Is there anything which you find different about K

she used to be a studious girl but now she cant concentrate. she was very quiet introvert girl
but now she talks excessively and that too has no senses.

did she take any treatment for this?

No, but I took her to the pandit ji because I thought may be she has got some spirit. but that
didn’t help. my brother in law asked me to consult a psychologist or psychiatrist.

Mr R, I think we have discussed her problems, I have got an idea of her illness. since her
mother was also diagnosed with bipolar disorder she may have bipolar disorder too. Mental
disorder are genetic too. I will be starting with the treatment and she will be alright. have
faith.

my observation: When the informant left I found that he was looking slightly more relaxed.
He smiled and had faith in the psychologist.

Plan of action: The counselor continues the interview, therapy and examine the progress of
the client till the Bipolar disorder of client is cured and client feel good enough.

The purpose with which today’s session was started was achieved.

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CASE SUMMARY

A 16-year-old female came to the psychologist with the complaints of decreased sleep,
irritable and excessively happy, irrelevant and increased speech, use of abusing words to her
parents, and had a grandiose idea that she is having a power of Lord Shiva for past 3 weeksd.
Her onset of symptoms is sudden with 6 months of duration. She had a predisposing factor as
family history of the bipolar affective disorder for her mother and now she is under the
treatment. She was an introvert person, she isolated herself, and she did not maintain a good
relationship with her family members and friends. She had a fear of getting less marks in her
10th board examination. then she developed the symptoms of feeling sad, not interacting
with her family members, and not able to maintain her activities of daily living (ADL).

The family took her to the priest but after her condition started deteriorating father’s brother
in law advised them to consult a psychologist or psychiatrist Then she was brought to the
psychologist for the management; there she underwent investigations such as history
collection, mental status examination, etc., and based on the ICD 10 criteria she was
diagnosed as having the bipolar affective disorder. She completely denies her illness. she is
under pharmacology and psychotherapy.

Diagnosis/ Intervention

She was prescribed mood stabilizers. She was asked to come after a week. Based on her
condition she will be given various psychosocial treatments such as cognitive behavior
therapy, interpersonal therapy etc.

Following are the treatment plans which are helpful for bipolar client.

Medication – Medication is the cornerstone of bipolar disorder treatment. Taking a mood

stabilizing medication can help minimize the highs and lows of bipolar disorder and keep
symptoms under control.

Psychotherapy – Therapy is essential for dealing with bipolar disorder and the problems it
has caused. Working with a therapist, client can learn how to cope with difficult or
uncomfortable feelings, manage stress, and regulate mood.

Lifestyle management – By carefully regulating lifestyle, client can keep symptoms and

193
mood episodes to a minimum. This involves maintaining a regular sleep schedule, avoiding
alcohol and drugs, eating a mood-boosting diet, following a consistent exercise program,
minimizing stress, and keeping sunlight exposure stable year-round.
Support – Living with bipolar disorder can be challenging, and having a solid support
system in place can make all the difference in outlook and motivation of the client. The
support of friendsand family is invaluable.

194
CASE STUDY

IDENTIFICATION DATA

Registration No: - **** Address:-****

Name : Mrs. R S Date : *******

Age : 29 years

Gender : Female

Educational Qualification : Post Graduated

Occupation : not working

Income : N.A.

Marital Status : Married

Client stays with parents : yes

Stays with spouse : yes

About Family

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Has any sibling, if so, how many : 1 Brother

What is the position of the client in the family : Eldest

Anyone in the family is suffering/has suffered from any mental disorder : No

Anyone in the family is suffering/has suffered from any physical disorders : No

Type of family : Nuclear

Informant : husband

Information : Adequate and reliable

Referred By : husband

Presenting Complaints

 Anxiety
 Fainting
 Shivering
 Weakness
 Nervousness
Date of onset of illness (The first attack) :- 2 years ago

Precipitating factor if any: Nil

Duration of illness :- 02 year

Intensity of illness (on a scale of 10):

Treatment taken: :- No

Got well at any time in between, duration of such period of wellness: - no

Was there any precipitating factor at each relapse: - Nil

How many relapses: Nil

Any other treatment tried in between: - No

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What was the effect:-Nil

In what ways the illness causes inconvenience?

Past History

Nothing specific

Behavioral problems during childhood:

Nothing specific

INTERVIEW WITH FAMILY MEMBERS:

Client's relationship with family member.

With Mother : Good and very close

Father : Have normal behavior

Brother : Close

Client’s relationship with friends:

How many friends does the client have? : 3-4

How does the client relate to them : like friends

Client’s Relationship with Neighbour : get nervous when talking

Client’s Relationship with school and classmates : Not in touch

Client’s Relationship with the teachers in school : Not in touch

Client’s Relationship with other authority figure : N.A

EDUCATIONAL HISTORY:

In school college

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Client complete her master from Open University and her overall behavior is normal during
studies

How is the client in studies and academic performance : - very well

Does the client come up to the expectations of parents and teachers? yes

How has the performance been over the years? : - normal

Do they find that there is sudden deterioration in studies and academic performance: -
no

Have they received any complaint from the school authorities regarding the client
performance? : No

WORK HISTORY

What occupation is the client involved? : N.A

IF MARRIED:

Relationship with spouse in terms of

Day to day dealings : normal

Sex life : normal

Work relationship (if spouse is working) : normal

Relationship with children : normal

Relationship with opposite sex persons : normal

Decision making (who takes the decision - spouse or self): spouse

Sharing of work at home with the spouse: No

Relationship with spouse’s relatives : normal

Relationship with spouse’s friends : Normal

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 MENTAL STATUS REPORT (MSE )

 APPEARANCE : the client was 29 year female by appearance she looking good
and fine.
 MOVEMENT AND BEHAVIOR: client manner of walking and coordination of
body was normal. Proper eye contact is maintained.
 AFFECT: stressed and irritated.
 MOOD:
 Subjectively: - “I am not liking the condition in which I m.”
 Objectively :- client was sad, irritated and stressed.
 SPEECH :
a) The volume of the person’s voice: Speech is little disturbed

b) The rate or speed of speech: slightly faster than normal

c) The length of answers to questions: normal

e) Clarity of the answers and similar characteristics: normal

 THOUGHT CONTENT: normal

 THOUGHT PROCESS: abnormal due to hesitation and nervousness
 COGNITION:
5. Attention and concentration:
Her attention was tested with the digit span test. She was able to repeat 6 digits forward
and 5 digits backwards. She was able to do serial subtraction of seven.
6. Orientation: she was oriented to time, place and person.

7. Memory:

 Immediate memory: intact

 Recent memory: intact

 Remote memory: intact

8. General information: she was able to name the prime Minister of India, five
major cities, the state that she lives in, its capital and chief minister. Her general

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 information is therefore adequate.
 JUDGMENT: the judgment making capacity of client is slightly disturbed.
 INSIGHT: client has insight about her problem

INTERVIEW SESSION WITH CLIENTS

CLIENT’S NAME : Mrs R.S

INTERVIEW NO : 01 DATE: *****

SESSION NO : 01 TIME: *****

PURPOSE OF THE INTERVIEW:

The purpose of the interview was to get familiar with the client, establish rapport and take
detailed case history and MSE.

Start of the session:

The client Mrs. R.S came with her husband. She looked slightly irritated and stressed when
she came in we exchange the greetings that is normal from her. Then I offered them to sit and
ask her is she is alright if we talked alone on which she agreed. she looked dressed well and
neat clean. Her movement may be slightly disturbed due to nervousness. She makes eye
contact properly. She is shaking her leg as if she is anxious and nervous. I make her feel
comfortable and told her that she is in the right place. On which she smiled.

I said, well tell me about yourself and problem for which you approached the clinic on which
she remain silent look like she is hesitating.

I asked her is anything that is bothering her maybe I could help if you tells me something
about the reason for her approached to the hospital.

Then client started to tell me that she was not doing well for past 2 years but from last six
month its going worsen. She looks irritated. She said that she remain anxious all time. She
became nervous when talking to someone who is outsider. She mot want to do work

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suddenly she start shivering and sometime she may faint down. She feels weakness also like
no energy in body. I said ok I understand your problem.

Then I asked her is anything she have fear about on which she remain silent the client look
confused

Is you hear any sound she says no she not hear any unusual sound.

Is your relation is good with your husband on which she reply that yes its good but he not
spend enough time with her due to work commitment. The client shows loneliness and
anxiety.

Have you faces any trauma in your past live on which she replied no.

Are you became angry on little little things these days on which she replied sometime I don’t
know what happen I became angry and after sometime I regret for that also. The client looks
sad.

Ok Mrs. R. S I think today we discussed your problem and your experiences from your
angles. we need to discuss further more to know about the problem you are facing. We can
arrange next session with you on next Sunday that is ok with you on which she replied yes
she want to get healthy as soon as possible and after that I suggest her to spend sometime
with her husband ,Try to get social with friends and family and maintain a thought dairy for
the next week on which she nodded in yes she will try to do all things we exchange good bye
greetings she passes a good smile.

My Observation : as the client left she look less nervous and more confident. She passes a
smile before leaving which indicate that she is not irritated now.

Plan of Action : The Psychologist Continue the interview and gather more information about
the dynamics underlying the various conflicts that she has expressed. Psychologist need also
to talk to his family members to understand the problem from their points of view.

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CASE SUMMARY

The client Mrs. R S came with her husband she look irritated and nervous as she enter the
cabin during the interview session she tells that she faces problem from past 2 year but from
past 6 month the situation became worsen she became nervous when talking to any unknown
person. She shivered and sometime she faint also she remains irritated due to this reason. She
also tells that her husband is not spending much time with him. Due to her condition she
remain irritated and short tempered on little things which also make her relations complicated
.as per the different symptom tell by the client and from the observation its concluded that
provisional diagnosis is panic attack with anxiety. In next session clinical psychologist try to
get more information about her problem form her and her family and figure out the most
appropriate intervention for her.

INTERNVENTION:-

Panic-Focused Psychodynamic Therapy (PFPP)

Panic-focused psychodynamic psychotherapy is a form of treatment for panic disorder based

on certain psychoanalytic concepts. In general, these concepts assume that people are shaped
by early relationship experiences and that unconscious motives and psychological conflicts
are at the core of certain current symptoms and behavior. The unconscious mind, or
subconscious, is a hiding place for painful emotions. Defense mechanisms keep these painful
emotions hidden, but if these painful emotions can be brought in to the conscious mind, they
can be dealt with more adaptively and the symptoms of panic disorder and associated
behaviors can be eliminated or reduced.

Group Therapy

According to the American Psychiatric Association, the benefits of group therapy may
include:

1. Decreasing shame and stigma by providing experiences with others who have similar
symptoms and difficulties;

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 2. Providing opportunities for modeling, inspiration, and reinforcement by other group
members; and
3. Providing a naturally-occurring exposure environment for clients who fear having
panic symptoms in social situations.

Couples and Family Therapy

The symptoms of panic disorder can affect relationships among family members or
significant others. Family therapy to address the dependency needs of the panic sufferer,
support issues, communication, and education may be beneficial as an adjunct treatment. It is
not recommended that family therapy be the sole therapeutic intervention for those with
panic disorder.

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CONCLUSION

Internship is an opportunity that students get, to gain work experience in particular field.
Understanding the Psychiatric disorders, the characteristics and eligibility criteria and the
nuances of Case History, discussing the points in favor that add up to a diagnostic
impression, planning the assessment, and therapeutic interventions were very enriching. They
gave very good foundation to clinical aspects of core skills of Clinical Psychology, Case
History Taking & Mental Status Examination and how to connect to treatment models and
were complimenting the theory that we learnt in the text books. The sessions were very
interactive, collaborative and encouraged us to apply the concepts we learnt in the Master’s
Course to actual scenarios while dealing with human beings. Paying attention to basics of
Client’s appearance, posture, dressing, observing the vivid details of tone, volume, stillness,
behavior, content to the importance all these have in case formulation to planning
assessments required and application of therapies were eye openers.

The understanding of Cognitive distortions and Cognitive Behavioral Therapy and other
humanistic and person centered theories unraveled the distortions that we give in to without
our conscious awareness. Concepts like Reflection of Meaning, Reflection of feeling, applied
behaviour analysis and its Scientific way of approaching observable behaviour with
antecedents and consequences to modify or stabilize the behaviour were true eye opener for
me.

I hereby, offer my heartfelt gratitude to all the resources personals of Institute of Mental
Health and Psychological Sciences (IMHAPS) and my Agency Supervisor Mr. Varun M for
all the learning he imparted and the guidance of the Academic Counselor Dr Ajum Mahdi at
Amar Jyoti Rehabilitation and Research Centre my Study Centre.

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Reference

1. Jones, J. (n.d.). About the free associations method. Retrieved from

http://www.freudfile.org/psychoanalysis/free_associations.html
2. Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2010). Abnormal
psychology. Hoboken, NJ: John Wiley & Sons.
3. NIMHANS, (n. d.). scheme for case taking; Departement of Clinical Psychology.
Bangalore

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