NATIONAL COLLEGE OF BUSINESS

ADMINISTRATION & ECONOMICS Sub-

Campus, Multan.

Final Year Internship Report

On
Case study of Insomnia Disorder, Borderline
Personality Disorder, Cocaine Use Disorder,
Generalized Anxiety Disorder, Major Depressive
Disorder Conducted at Arrahma Hospital for Mental
Health Multan

Submitted By: Muhammad Mubashir Arif (121630327)

Supervised By: Ms. Iqra Munir

BACHELOR IN PSYCHOLOGY

August-2022

1
 NATIONAL COLLEGE OF BUSINESS
ADMINISTRATION & ECONOMICS
MULTAN
Case study Insomnia Disorder, Borderline Personality
Disorder, Cocaine Use Disorder, Generalized Anxiety
Disorder, Major Depressive Disorder Conducted at
Arrahma Hospital for Mental Health Multan
BY

Muhammad Mubashir Arif

A Project Report Submitted to School of Social Sciences, in partial
Fulfillment of the Requirements for the degree of
BACHELOR
IN
PSYCHOLOGY

Project Defense Committee:

Chairman

Member

Member

Pro-Rector
National College of Business
Administration &Economics
Sub Campus, Multan

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In the Name of ALLAH,
The Most Beneficent,
The Most Merciful.

3
 AUTHOR’S DECLARATION

I Muhammad Mubashir Arif S/O Muhammad Arif Hameed do hereby certify that this
work entitled “Clinical Internship Report on Insomnia Disorder, Borderline Personality
Disorder, Cocaine use Disorder, Generalized Anxiety Disorder, and Major Depressive
Disorder Conducted at Arrahma Hospital for Mental Health Multan” submitted in the
partial fulfillment of the degree of Psychology at NCBA&E Sub-campus Multan is my own and
the case history, assessment and management is my effort and if adapted then the source has
been acknowledged.
I also certify that this project work has not been submitted for obtaining a similar
degree from any other university/college.

Muhammad Mubashir Arif

August, 2022

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 National College of Business Administration & Economics Multan
Campus
Northern Bypass Near WAPDA Town Phase-II Multan

COURSE COMPLETION CERTIFICATE

Ref. No. R&D/Multan/PD-167- 175-2022/2 Dated: 29/09/2022

It is certified that the course requirements of Mr. Muhammad Mubashir Arif

Registration No. 121630327 for the program, B.S Psychology has been completed and
hir current CGPA is 3.40

Mr. Muhammad Asim Rajwana Prof. Dr. Tariq Mahmood Ansari, FRSC
Deputy Director (R&D) Pro-Rector

Copy to:
1. The Rector NCBA&E Lahore
2. The Director NCBA&E Multan Campus.
3. Notification file.

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 PROJECT COMPLETION CERTIFICATE

It is certified that the project work on clinical reports entitled Insomnia Disorder,
Borderline Personality Disorder, Cocaine Use Disorder, Generalized Anxiety Disorder,
Major Depressive Disorder Conducted at “Arrahma Hospital for Mental Health Multan”
has been carried out and completed by Muhammad Mubashir Arif under my supervision
during his BS Psychology program.

____________________
Ms. Iqra Munir
Supervisor

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 DEDICATED
TO
MY FAMILY AND TEACHERS.

7
 ACKNOWLEDGEMENT
I am thankful to Allah Almighty and Prophet Muhammad (PBUH) who gave me the
strength to complete my work and blessed me in my whole life. I would like to express my
gratitude to my supervisor Ms. Iqra Munir, for sharing her ideas and interests with me about my
study. Her contribution boosted my confidence and helped me in finishing my study in time.

I am much obliged by the kind guidance of Ms. Iqra Munir. Her support and
encouragement helped me through this project work. I would also like to Special thanks to the
administrative officers of NCBA&E who cooperated with me to make this project, I also want to
show my gratitude to all the participants who spared their precious time in answering my
questionnaires.

Muhammad Mubashir Arif

8
 DEDICATED
TO
MY FAMILY AND TEACHERS.

9
 TABLE OF CONTENTS

AUTHOR’S DECLARATION..........................................................................................iv

COURSE COMPLETION CERTIFICATE.....................................................................v

PROJECT COMPLETION CERTIFICATE.................................................................vi

DEDICATED.....................................................................................................................vii

ACKNOWLEDGEMENT...............................................................................................viii

DEDICATED......................................................................................................................ix

CHAPTER 1: INTRODUCTION......................................................................................1

1.1 Insomnia................................................................................................................................1

1.2 Borderline Personality Disorder.........................................................................................1

1.3 Cocaine Use Disorder...........................................................................................................2

1.4 Generalized Anxiety Disorder.............................................................................................3

1.5 Major Depressive Disorder.................................................................................................4

CHAPTER 2: LITERATURE REVIEW..........................................................................5

2.1 Insomnia................................................................................................................................5

2.2 Borderline Personality Disorder.........................................................................................9

2.3 Cocaine Use Disorder.........................................................................................................13

2.4 Generalized Anxiety Disorder...........................................................................................15

2.5 Major Depressive Disorder...............................................................................................17

CHAPTER 3: EXPERIMENTAL CASE........................................................................21

3.1 Insomnia..............................................................................................................................21

3.1.1 Identifying Data...........................................................................................................21

3.1.2 Source and Reasons for Referral...............................................................................21

3.1.3 Presenting Complaints................................................................................................21

3.1.4 History of Present Illness (HOPI)..............................................................................22

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3.1.5 Background Information............................................................................................22

3.1.5.1 Family History..........................................................................................................22

3.1.5.2 Sexual History.........................................................................................................106

3.1.5.3 Educational History...............................................................................................106

3.1.5.4 Marital History.......................................................................................................106

3.1.5.5 Occupational History.............................................................................................106

3.1.5.6 History of Psychiatry/Medical Illness...................................................................107

3.1.5.6.1 Premorbid Personality........................................................................................107

3.1.6 Psychological Assessment.........................................................................................107

3.1.6.1 Informal Assessment..............................................................................................107

3.1.6.1.1 Behavioral Observation......................................................................................107

3.1.6.1.2 Clinical Interview................................................................................................108

3.1.6.1.3 Mental Status Examination (MSE)....................................................................108

3.1.6.1.4 Subjective Ratings of Presenting Complaints...................................................109

3.1.6.2 Formal Assessment.................................................................................................109

3.1.6.2.1 Pittsburgh Sleep Quality Index..........................................................................109

3.1.6.2.2 Insomnia Severity Index.....................................................................................110

3.1.7 Case Formulation......................................................................................................111

3.1.8 Case Conceptualization.............................................................................................113

3.1.9 Diagnosis.....................................................................................................................114

3.1.10 Prognosis..................................................................................................................114

3.1.11 Management Plan....................................................................................................114

3.1.11.1 Short Term Goals.................................................................................................114

3.1.11.2 Long Term Goals..................................................................................................114

3.1.12 Summary of Therapeutic Interventions................................................................114

3.1.12.1 Rapport Building..................................................................................................114

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 3.1.12.2 Psycho Education.................................................................................................115

3.1.12.3 Relaxation Exercises.............................................................................................115

3.1.12.4 Sleep Hygiene........................................................................................................116

3.1.12.5 Thought Stopping.................................................................................................116

3.1.12.6 Stimulus Control Therapy...................................................................................117

3.1.13 Post Assessment.......................................................................................................118

3.1.13.1 Subjective Rating of the Symptoms....................................................................118

3.1.13.2 Graphical Representation of the Outcome of Management.............................118

3.1.14 Termination of Therapy.........................................................................................119

3.1.15 Limitations...............................................................................................................119

3.1.16 Recommendations...................................................................................................119

3.1.17 Session Report..........................................................................................................120

3.1.17.1 Session No. 1..........................................................................................................120

3.1.17.2 Session No. 2..........................................................................................................120

3.1.17.3 Session No. 3..........................................................................................................120

3.1.17.4 Session No. 4..........................................................................................................120

3.1.17.5 Session No. 5..........................................................................................................120

3.1.17.6 Session No. 6..........................................................................................................120

3.1.17.7 Session No. 7..........................................................................................................121

3.1.17.8 Session No. 8..........................................................................................................121

3.1.17.9 Session No. 9..........................................................................................................121

3.1.17.10 Session No. 10......................................................................................................121

3.1.17.11 Session No. 11......................................................................................................121

3.2 Borderline Personality Disorder.....................................................................................122

3.2.1 Identifying Data.........................................................................................................122

3.2.2 Source and Reason for Referral...............................................................................123

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3.2.3 Presenting Complaints..............................................................................................123

3.2.4 History of Present Illness (HOPI)............................................................................123

3.2.5 Background Information..........................................................................................123

3.2.5.1 Personal History.....................................................................................................123

3.2.5.2 Family History........................................................................................................124

3.2.5.3 Educational History...............................................................................................124

3.2.5.4 Sexual History.........................................................................................................125

3.2.5.5 Marital History.......................................................................................................125

3.2.5.6 History of Psychiatry/Medical Illness...................................................................125

3.2.5.6.1 Premorbid Personality........................................................................................125

3.2.6 Psychological Assessment.........................................................................................125

3.2.6.1 Informal Assessment..............................................................................................126

3.2.6.1.1 Behavioral Observation......................................................................................126

3.2.6.1.2 Clinical Interview................................................................................................126

3.2.6.1.3 Mental Status Examination (MSE)....................................................................127

3.2.6.1.4 Subjective Rating.................................................................................................128

3.2.6.2 Formal Assessment.................................................................................................128

3.2.6.2.1 McLean Screening Instrument for Borderline Personality Disorder (MSI-

BPD).....................................................................................................................................128

3.2.7 Case Formulation......................................................................................................129

3.2.8 Case Conceptualization.............................................................................................131

3.2.9 Diagnosis.....................................................................................................................132

3.2.10 Prognosis..................................................................................................................132

3.2.11 Management Plan....................................................................................................132

3.2.11.1 Long Term Goals..................................................................................................132

3.2.11.2 Short Term goals..................................................................................................132

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3.2.12 Summary of Therapeutic Interventions................................................................132

3.2.12.1 Rapport Building..................................................................................................132

3.2.12.2 Psycho Education.................................................................................................133

3.2.12.3 Relaxation Techniques.........................................................................................133

3.2.12.4 Cost Benefit Analysis............................................................................................134

3.2.12.5 Dialectical Behavioral Therapy (DBT)...............................................................134

3.2.12.6 Journaling.............................................................................................................134

3.2.12.7 STOP Skills...........................................................................................................135

3.2.12.8 SOS box.................................................................................................................135

3.2.12.9 Assertive Training................................................................................................135

3.2.13 Post Assessment.......................................................................................................136

3.2.13.1 Subjective Rating of the Symptoms....................................................................136

3.2.13.2 Graphical Representation of the Outcome of Management.............................136

3.2.14 Termination of Therapy.........................................................................................137

3.2.15 Limitations...............................................................................................................137

3.2.16 Recommendations...................................................................................................137

3.2.17 Session Report..........................................................................................................138

3.2.17.1 Session no 1...........................................................................................................138

3.2.17.2 Session no 2...........................................................................................................138

3.2.17.3 Session no 3...........................................................................................................138

3.2.17.4 Session no 4...........................................................................................................138

3.2.17.5 Session no 5...........................................................................................................138

3.2.17.6 Session no 6...........................................................................................................138

3.2.17.7 Session no 7...........................................................................................................138

3.2.17.8 Session no 8...........................................................................................................139

3.2.17.9 Session no 9...........................................................................................................139

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 3.2.17.10 Session no 10.......................................................................................................139

3.2.17.11 Session no 11.......................................................................................................139

3.3 Cocaine Use Disorder.......................................................................................................140

3.3.1 Identifying Data.........................................................................................................140

3.3.2 Source and Reason for Referral...............................................................................141

3.3.3 Presenting Complaints..............................................................................................141

3.3.4 History of Present Illness (HOPI)............................................................................141

3.3.5 Background Information..........................................................................................142

3.3.5.1 Personal History.....................................................................................................142

3.3.5.2 Family History........................................................................................................142

3.3.5.3 Educational History...............................................................................................142

3.3.5.4 Occupational History.............................................................................................143

3.3.5.5 Sexual History.........................................................................................................143

3.3.5.6 History of Psychiatric Illness in Family...............................................................143

3.3.6 Psychological Assessment.........................................................................................143

3.3.6.1 Informal Assessment..............................................................................................143

3.3.6.1.1 Behavioral Observation......................................................................................144

3.3.6.1.2 Clinical Interview................................................................................................144

3.3.6.1.3 Mental State Examination (MSE)......................................................................144

3.3.6.1.4 Subjective Rating.................................................................................................145

3.3.6.2 Formal Assessment.................................................................................................145

3.3.6.2.1 Drug Abuse Screening Test (DAST)..................................................................145

3.3.7 Case Formulation......................................................................................................146

3.3.8 Case Conceptualization.............................................................................................148

3.3.9 Diagnosis.....................................................................................................................149

3.3.10 Prognosis..................................................................................................................149

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3.3.11 Management Plan....................................................................................................149

3.3.11.1 Short Term Goals.................................................................................................149

3.3.11.2 Long Term Goals..................................................................................................149

3.3.12 Summary of Therapeutic Interventions................................................................150

3.3.12.1 Rapport Building..................................................................................................150

3.3.12.2 Psycho Education.................................................................................................150

3.3.12.3 Relaxation Training.............................................................................................150

3.3.12.4 Motivational interviewing....................................................................................151

3.3.12.5 Cost Benefits Analysis..........................................................................................151

3.3.12.6 Thought Stopping.................................................................................................151

3.3.12.7 Double Column Technique..................................................................................152

3.3.12.8 STOP Skills...........................................................................................................152

3.3.12.9 Covert Sensitization.............................................................................................152

3.3.12.10 Sleep Hygiene Therapy......................................................................................153

3.3.13 Post Assessment.......................................................................................................153

3.3.13.1 Subjective Rating of the Symptoms....................................................................153

3.3.13.2 Graphical Representation of the Outcome of Management.............................154

3.3.14 Termination of Therapy.........................................................................................154

3.3.15 Limitations...............................................................................................................155

3.3.16 Recommendations...................................................................................................155

3.3.17 Session Report..........................................................................................................156

3.3.17.1 Session No. 2..........................................................................................................156

3.3.17.2 Session No. 2..........................................................................................................156

3.3.17.3 Session No. 3..........................................................................................................156

3.3.17.4 Session No. 4..........................................................................................................156

3.3.17.5 Session No. 5..........................................................................................................156

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 3.3.17.6 Session No. 6..........................................................................................................156

3.3.17.7 Session No. 7..........................................................................................................157

3.3.17.8 Session No. 8..........................................................................................................157

3.3.17.9 Session No. 9..........................................................................................................157

3.3.17.10 Session No. 10......................................................................................................157

3.3.17.11 Session No. 11......................................................................................................157

3.4 Generalized Anxiety Disorder.........................................................................................158

3.4.1 Identifying data..........................................................................................................158

3.4.2 Source and Reason for Referral...............................................................................158

3.4.3 Presenting Complaints..............................................................................................159

3.4.4 History of Present Illness (HOPI)............................................................................159

3.4.5 Background Information..........................................................................................159

3.4.5.1 Personal History.....................................................................................................159

3.4.5.2 Family History........................................................................................................160

3.4.5.3 Educational History...............................................................................................160

3.4.5.4 Sexual History.........................................................................................................160

3.4.5.5 Occupational History.............................................................................................161

3.4.5.6 History of Psychiatry/Medical Illness...................................................................161

3.4.5.6.1 Premorbid Personality........................................................................................161

3.4.6 Psychological Assessment.........................................................................................161

3.4.6.1 Informal Assessment..................................................................................................161

3.4.6.1.1 Behavioral Observation......................................................................................161

3.4.6.1.2 Clinical Interview................................................................................................162

3.4.6.1.3 Mental Status Examination (MSE)....................................................................162

3.4.6.1.4 Subjective Rating.................................................................................................163

3.4.6.2 Formal Assessment.................................................................................................163

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3.4.7 Case Formulation......................................................................................................164

3.4.8 Case Conceptualization.............................................................................................166

3.4.9 Diagnosis.....................................................................................................................167

3.4.10 Prognosis..................................................................................................................167

3.4.11 Management Plan....................................................................................................167

3.4.11.1 Short Term Goals.................................................................................................167

3.4.11.2 Long Term Goals..................................................................................................167

3.4.12 Summary of Therapeutic Interventions................................................................167

3.4.12.1 Rapport Building..................................................................................................167

3.4.12.2 Psycho Education.................................................................................................168

3.4.12.3 Relaxation Techniques.........................................................................................168

3.4.12.4 Cost Benefit Analysis............................................................................................169

3.4.12.5 Worry Time...........................................................................................................169

3.4.12.6 Evidence................................................................................................................169

3.4.12.7 Roleplay.................................................................................................................169

3.4.12.8 Sleep Hygiene Therapy........................................................................................170

3.4.13 Post Assessment.......................................................................................................170

3.4.13.1 Subjective Rating of the Symptoms....................................................................170

3.4.13.2 Graphical Representation of the Outcome of Management.............................171

3.4.14 Termination of Therapy.........................................................................................171

3.4.15 Limitations...............................................................................................................172

3.4.16 Recommendations...................................................................................................172

3.4.17 Session Report..........................................................................................................173

3.4.17.1 Session No. 1..........................................................................................................173

3.4.17.2 Session No. 2..........................................................................................................173

3.4.17.3 Session No. 3..........................................................................................................173

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 3.4.17.4 Session No. 4..........................................................................................................173

3.4.17.5 Session No. 5..........................................................................................................173

3.4.17.6 Session No. 6..........................................................................................................173

3.4.17.7 Session No. 7..........................................................................................................174

3.4.17.8 Session No. 8..........................................................................................................174

3.4.17.9 Session No. 9..........................................................................................................174

3.4.17.10 Session No. 10......................................................................................................174

3.4.17.11 Session No. 11......................................................................................................174

3.5 Major Depressive Disorder.............................................................................................175

3.5.1 Identifying data..........................................................................................................175

3.5.2 Source and Reason for Referral...............................................................................176

3.5.3 Presenting Complaints..............................................................................................176

3.5.4 History of Present Illness (HOPI)............................................................................176

3.5.5 Background Information..........................................................................................177

3.5.5.1 Personal History.....................................................................................................177

3.5.5.2 Family History........................................................................................................177

3.5.5.3 Educational History...............................................................................................177

3.5.5.4 Sexual History.........................................................................................................178

3.5.5.5 Occupational History.............................................................................................178

3.5.5.6 History of Psychiatry/Medical Illness...................................................................178

3.5.5.6.1 Premorbid Personality........................................................................................178

3.5.6 Psychological Assessment.........................................................................................178

3.5.6.1 Informal Assessment..............................................................................................178

3.5.6.1.1 Behavioral Observation......................................................................................179

3.5.6.1.2 Clinical Interview................................................................................................179

3.5.6.1.3 Mental Status Examination (MSE)....................................................................179

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3.5.6.1.4 Subjective Rating.................................................................................................180

3.5.6.2 Formal Assessment.................................................................................................180

3.5.6.2.1 Beck Depression Inventory (BDI)......................................................................181

3.5.7 Case Formulation......................................................................................................181

3.5.8 Case Conceptualization.............................................................................................183

3.5.9 Diagnosis.....................................................................................................................184

3.5.10 Prognosis..................................................................................................................184

3.5.11 Management Plan....................................................................................................184

3.5.11.1 Short Term Goals.................................................................................................184

3.5.11.2 Long Term Goals..................................................................................................184

3.5.12 Summary of Therapeutic Interventions................................................................184

3.5.12.1 Rapport Building..................................................................................................184

3.5.12.2 Psycho Education.................................................................................................185

3.5.12.3 Relaxation Techniques.........................................................................................185

3.5.12.4 ABC Model............................................................................................................186

3.5.12.5 Cost Benefit Analysis............................................................................................186

3.5.12.6 Roleplay.................................................................................................................186

3.5.12.7 Concentration Exercise........................................................................................187

3.5.12.8 Sleep Hygiene Therapy........................................................................................187

3.5.13 Post Assessment.......................................................................................................188

3.5.13.1 Subjective Rating of the Symptoms....................................................................188

3.5.13.2 Graphical Representation of the Outcome of Management.............................189

3.5.14 Termination of Therapy.........................................................................................189

3.5.15 Limitations...............................................................................................................189

3.5.16 Recommendations...................................................................................................190

3.5.17 Session Report..........................................................................................................191

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 3.5.17.1 Session no 1...........................................................................................................191

3.5.17.2 Session no 2...........................................................................................................191

3.5.17.3 Session no 3...........................................................................................................191

3.5.17.4 Session no 4...........................................................................................................191

3.5.17.5 Session no 5...........................................................................................................191

3.5.17.6 Session no 6...........................................................................................................191

3.5.17.7 Session no 7...........................................................................................................192

3.5.17.8 Session no 8...........................................................................................................192

3.5.17.9 Session no 9...........................................................................................................192

CHAPTER 4: CONCLUSION.......................................................................................193

4.1 Insomnia............................................................................................................................193

4.2 Borderline Personality Disorder.....................................................................................193

4.3 Cocaine Use Disorder.......................................................................................................193

4.4 Generalized Anxiety Disorder.........................................................................................194

4.5 Major Depressive Disorder.............................................................................................195

References........................................................................................................................197

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 LIST OF FIGURES
Figure No. Title Title Page No.

Figure 1: 3.1.2 Case Conceptualization

Figure 2: 3 2.7 Case Conceptualization
Figure 3: 3.3.6 Case Conceptualization
Figure 4: 3.4.6 Case Conceptualization
Figure 5: 3.5.6 Case Conceptualization

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 CHAPTER 1: INTRODUCTION
1.1 Insomnia
Insomnia refers to a group of sleep disorders in which sufferers have difficulty initiating
and maintaining sleep. There is both acute and chronic form of the illness. It's possible that it will
fade away, too. Acute insomnia lasts from 1 night to a few weeks. If you've been experiencing
insomnia for at least three months straight, it's likely chronic. Insomnia can be either main or
secondary. When you have primary insomnia, it's because of issues getting to sleep rather than
another medical ailment. Asthma, depression, arthritis, cancer, heartburn, and acid reflux are all
examples of secondary insomnia, which can be exacerbated by pain, medication, or substance
abuse (Javaheri & Redline, 2017).
Trouble falling asleep is known as sleep-onset insomnia. Maintaining sleeplessness
occurs when a person has problems falling asleep and/or remaining asleep throughout the night.
It's possible to have problems getting asleep as well as maintaining sleep if you have mixed
insomnia. If you suffer from paradoxical insomnia, you tend to sleep less than you actually do.
You might get a lot less shut-eye than you think you do. Women and the elderly are more likely
to suffer from insomnia than males and younger adults. African Americans of all ages, but
particularly those in their 20s and 30s, are at increased risk. Factors that increase the likelihood
of an adverse outcome are chronic disease, Depression and anxiety, and having to work rotating
or overnight shifts (Patel, Steinberg, & Patel, 2018).

1.2 Borderline Personality Disorder

A borderline personality disorder is a mental health condition that has a negative impact
on human health. Extreme mood swings, shaky relationships, and difficulty managing emotions
are all symptoms of borderline personality disorder. People who are affected by this disease, are
more likely to commit suicide as well as engage in negative activities which create a lot of
problems. There are many people in the world who are affected by borderline personality
disorder (NIH, 2022). They struggle to control their emotions, particularly anger and have a
severe fear of being abandoned. Additionally, they frequently engage in risky and impulsive
actions like reckless driving and making threats of harm to themselves. It is challenging for them
to keep relationships going as a result of all of these actions.

1
 Personality disorders are characterized by persistent, rigid, dysfunctional behavior
patterns that cause social problems and discomfort. It is a mental disorder that is very different
from other mental disorders. The reasons for borderline personality disorder really aren't
completely understood, just like those of other mental health diseases. Moreover, a borderline
personality disorder may be related to environmental issues, like a history of child neglect or
abuse. The main cause is Genetics (NIH, 2022). There are many people who have this disease
because of their genes. There are two most important therapies used as a treatment of BPD. The
first is Dialectical Behavior Therapy and the second is Cognitive Behavioral Therapy

1.3 Cocaine Use Disorder

The background information of the case depends on the “Cocaine Use disorder”. The use
of Cocaine is more in the Pakistan, the majority of people are addicted to this disease. As
Cocaine is an illegal drug but the community of the Pakistan can use it despite legal restrictions
and so on. If the normal dosage of this drug is to be taken it cannot harmfully affect the internal
system of an individual (Suchting, et al., 2020). Furthermore, when it is taken from the normal
dosage and in form of different patterns on daily basis then individuals become addicted. The
different types of patterns are used by individuals to satisfaction from it. The use of Cocaine
disorder has become compulsory for individuals who use different patterns for this disease.
Many disorders are raised due to the overuse of this drug. The symptoms of these disorders are
as follows and they make the person dependent on them. Moreover, they are unable to perform,
different duties in life.
The symptoms of Cocaine, the most basic and initial are cravings for cocaine, the use of
the drug is made habitual, they will increase the dosage day by day, and an addicted person can
do everything to get some dosage of Cocaine. The discussed are the symptom which is founded
in the person who is the prey of the disease, disorder of Cocaine. Despite of discussed problems
and challenges the risk factor of this disorder is more which are founded on the person but
doctors prescribed these in this manner. The person who is using Cocaine use disorder than in
the body that person these symptoms occur. An addicted person has the risk of Anxiety,
depression, loneliness, alcohol, and usage of too much medicine. The rate of elaborated risk
factors of diseases is more and they will take the people and individuals to a destructive level.
Nutshell, it is recommended that individuals should not pay attention to the usage of Cocaine
because it may lead an individual’s life towards lots of destruction. According to the analysis of

2
reports from different doctors the life expectancy and average age of the people are declined who
are used Cocaine to get satisfaction from it (Mahoney III, 2019).

1.4 Generalized Anxiety Disorder

GAD (Common Anxiety Disorder) is a disorder of anxiety characterized by persistent
anxiety, excessive anxiety, and depression, even if it is mild or for no apparent reason. The GAD
physical symptoms are sleeping problems, difficulty in concertation, and restlessness.
Generalized Anxiety disorder is a form of mental health condition. If someone has a generalized
anxiety disorder, then he will respond to certain things and situations that will be fearful and
dreadful. Individuals can also face signs of physical anxiety like sweating and pounding about
something that could be harmful to their personality. But having generalized anxiety is a normal
thing that may have every individual in his personality regarding his daily life routine.
Mostly in Pakistan, a generalized anxiety disorder should be happening through a panic
disorder. When people got panic in a specific situation where they feel that they are not
comfortable, then they get into panic with that particular situation. Most females in Pakistan
getting panic very easily which leads them to generalized anxiety disorder. Mostly they are
getting panicked in test anxiety. The pressure of giving an exam or test leads them to feel
anxiety. Generalized Anxiety can be caused by facing difficult experiences in childhood,
adulthood, or adolescence, and the common trigger for problems of anxiety.
The anxiety you can feel when you are going through some stress or trauma when you are
young in which there are more chances of making a big impact on your personality for a whole
life. Mostly in Pakistan, people feel anxious or feeling very nervous when they have to face
some problems when they have to go for an interview when they have an exam, or have to take
an important decision about particular things. But the anxiety proves very beneficial for some
time. For example, feeling anxiety will help you to notice the dangerous situation and make
focus on your attention, through this process we feel and stay safe. An anxiety disorder may go
beyond the slight fear and regular nervousness you will feel from time to time.
The mixture of environmental and genetic factors may rise the risk for the person of
developing the anxiety disorder. You may feel high risk if your face mental health conditions
and family history of anxiety about certain events or things or Traumatic events or stressful
pressure in early adulthood or childhood or including certain physical conditions such as heart
arrhythmias and thyroid problems or Specific personality traits such as behavioral inhibition or
shyness, feeling uncomfortable about something to getting far from unfamiliar people.
3
Generalized Anxiety disorders mainly happen in women in Pakistan. The researchers of the
country will identify why this happens. May it cause by hormones, when these hormones
fluctuate throughout the month. Generalized Anxiety disorders mean mental illness. It doesn’t
come from personal weakness or flaws in upbringing. But mostly in Pakistan, people don’t know
what are the causes of anxiety disorder.

1.5 Major Depressive Disorder

Major depressive disorder under code 296.22 is one of the most common forms of
depression that is faced by individuals. This disorder is often known as clinical depression as it
has a major effect on the mind of the patient that how they feel, think or behave in practical life.
There are higher chances that individuals will feel a great variety of physical or emotional
problems in the individuals. There are multiple symptoms of this disorder and the most common
symptom is that there are persistent sadness and depression individuals (Ferber, et al., 2022). The
increased chances of disease cause negative thoughts in the minds of the individuals and they
may feel that they are not worth living. The individuals do not consider the importance of this
disorder and they take it as normal sadness. In reality, a major depressive disorder can affect the
whole life of the individual, and gradually it affects the physical activities of the patients, as well
as they, are considering themselves important.
There are higher chances that major depressive order under code 296.22 may occur once
in the life of an individual. The symptoms may occur in day-to-day activities of the individual
and he may feel that he is suffering from a serious illness or disorder. For example, there are
continuous feelings of sadness and emptiness. The individual may feel hopeless at times and may
not see any positivity in the day-to-day matters of life (Abdelbasset, et al., 2019). Besides that,
the most important issue that is felt by individuals is the lack of sleep. There is a continuous lack
of sleep and due to lack of sleep, there are higher chances that the patient is caught up with
severe mental illness. It harms the physical health of an individual. The reduced appetite in the
individuals is also observed in it which ultimately leads to weight loss. The inverse behavior is
very common in patients i.e. they may face increased food cravings that ultimately lead to weight
gain.
Major depressive disorder needs to be cured with medication and psychotherapy. There
are higher chances that patients will require long-term treatment to cure those diseases. The
reason is that it has a great impact on the mind of the individual and he feels no happiness
(Zukerman, Maor, Reichard, & Ben-Itzhak, 2022). It is necessary that friends and family

4
members of the patient have to be active so that the individual can come out of the state of
tension and depression and live a normal life.

CHAPTER 2: LITERATURE REVIEW

2.1 Insomnia
An insomnia three-factor model has been presented. These items serve as insomnia risk
factors, triggers, and maintainers. Over 45 women had 1.7 times more sleeplessness than males.
EEG waves and other physiological parameters classify sleep. N3 is characterized by slower
brain waves and deeper sleep. Stage R sleep, when people dream, amounts to 18% of senior
sleep duration. Perhaps seniors can handle less sleep than younger people. Age may reduce the
reliability of circadian rhythm markers. The American Insomnia Survey found older persons
experienced less insomnia than younger adults. Untreated sleeplessness can be dangerous (Patel,
Steinberg, & Patel, 2018).
Insomnia increases the risk of heart attack and stroke. Older people with insomnia are
more likely to get handicapped, miss employment, and perform badly. Insomnia can be a
primary problem or a subsequent sign of another illness. Sleep diaries and questionnaires can
assist evaluate insomnia. Antidepressants, antihistamines, sedatives, steroids, and anti-
hypertensives can impair sleep.
Insomnia can have serious physical and psychological implications at any age. Drug-free
and drug-based treatments are available. Sleep Restriction Therapy limits bedtime to sleep hours.
CBT for insomnia can help all ages, even the elderly. Progressive muscle relaxation, guided
visualization, paced diaphragmatic breathing, and meditation is CBT-I techniques. Long-term
use of these drugs increases the risk of tolerance, reliance, rebound sleeplessness, residual
daytime sleepiness, motor incoordination, cognitive impairment, and falls. FDA-approved doses
of doxepin for insomnia range from 3 to 6 mg. This 5-HT2 antagonist antidepressant may aid
insomnia. Mirtazapine provides calming effects by inhibiting H1 histamine receptors. FDA
approves remolten, the first dual orexin receptor antagonist. In Europe, melatonin can
temporarily alleviate insomnia in persons 55 and older. Suvorexant, a wakefulness-inducing
medication, targets sleep- and wakefulness-regulating neuropeptides (Patel, Steinberg, & Patel,
2018).

5
 Insomnia is the most common kind of sleep problem, and it is strongly associated with a
variety of cardiovascular disorders (CVDs). Several observational studies over the past decade
have linked sleeplessness to an increased risk of hypertension, coronary heart disease, and death
from cardiovascular disease (CVD) (HF). The current results indicate that insomnia, specifically
when accompanied by poor sleep, is linked to a greater risk for HTN, CHD, and periodic
coronary syndrome, and HF, even with some differences in the publications, likely due to
differences in just how insomnia is measured and defined (Javaheri & Redline, 2017).
Possible reasons include increased sympathetic nervous activity, inflammation, and
disruption of the hypothalamic-pituitary axis. This study summarizes the current literature on the
association between lack of sleep and cardiovascular disease, discusses the possible clinical
manifestations underlying this association, and calls for randomized trials to better understand
this association (Javaheri & Redline, 2017).
The effects of insomnia on society's health are substantial. It's really common, and it's
been linked to serious functional and quality-of-life declines, as well as increased risk of mental
illness, physical illness, and accidental injury. Therefore, it is crucial that patients receive
effective care in the clinic. This paper's goal is to do just that, reviewing key elements of
evaluating insomnia and the many treatment choices now accessible. Non-drug treatments, such
as cognitive behavioral therapy for insomnia, are available, as are a number of pharmacologic
therapies, such as benzodiazepines, "z-drugs," melatonin binding site agonists, sequential
histamine H1 antagonists, orexin antagonists, Lexapro, olanzapine, antidepressants, and quasi
antihistamines. Reviewing the literature, we find that some of the most routinely used treatments
for insomnia lack rigorous double-blind, randomized, controlled studies. However, there is a
wide range of therapies with well-characterized risk/benefit profiles that have been shown to
provide medicinal benefits in insomnia in studies with the aforementioned characteristics. These
methods can serve as the cornerstone of a comprehensive, research-based approach to treating
insomnia in clinical settings (Krystal, Prather, & Ashbrook, 2019).
The belief that one suffers from insomnia, known as "insomnia identity," is a sleep
complaint that can be evaluated independently of sleep. Conventional wisdom claims that sleep
complaints overlap with sleep quality difficulties, but when we cross nature and amount of nap
quality problems with insomnia characteristics, we find differences. About a quarter of the
population is totally disconnected infiltrators, suggesting there is a transducing of sleep
assessment and sleep evaluation, and those who support an insomnia identity are more likely to

6
suffer from a daytime impairment, according to a review of the literature on the topic. In light of
the evidence, it is clear that labeling sleep problems as pathologies comes at a price. Self-stigma,
sadness, suicidal thoughts, anxiety, hypertension, and exhaustion are all increased in those who
identify as having insomnia, regardless of their actual sleep patterns. The authors suggest a
comprehensive study agenda, including ideas concerning the causes, clinical mechanisms, and
therapeutic management of insomnia (Lichstein, 2017).
A wide range of estimates for the prevalence of insomnia can be attributed to
disagreements about how best to characterize the condition. Even when present in tandem with a
medical or psychiatric disease, it is increasingly understood to be a separate clinical diagnosis.
Women and shift workers are at a higher risk. Asians have a lower prevalence of insomnia than
people in other regions. Those with a history of anxiety and/or despair are more likely to have
sleeplessness. Insomnia affects the economy greatly because it is so costly for both employers
and the healthcare system to treat people who suffer from it. Conditions including depression,
high blood pressure, diabetes, and heart disease may all share a common risk factor: trouble
sleeping (Grewal & Doghramji, 2017).
It's no exaggeration to say that the mental toll of insomnia is significant. Insomnia
throughout a pandemic crisis has received little academic attention. The purpose of this research
was to examine sleep disturbances in Greece during the recent COVID-19 pandemic. With a
total of 2,427 people, this study has a very high participation rate (with 2,363 of them providing
all basic demographic data). Three-and-a-half percent of the people who took the survey had
sleep difficulties. Sleep issues were more common among women and city dwellers, but there
was no statistically significant age difference. Those who worried that they or a loved one had
gotten the virus had higher rates of insomnia as well. Finally, the regression analysis revealed
that heightened intolerance for ambiguity, COVID-19-related concern, loneliness, and severe
depressive symptoms were all significant predictors of sleeplessness. Findings could be utilized
to create treatments for persons who have trouble sleeping and to promote social policies that
would help them (Voitsidis, et al., 2020).
Common as it may be, insomnia is a disorder that has been linked to negative physical
and psychological consequences down the road. It is the pathophysiological mechanisms driving
insomnia or the causal relationships it has with the disease. Based on our findings, we
hypothesize that genes associated with ubiquitin-mediated proteolysis or genes expressed in
numerous brain areas, skeletal muscle, and the adrenal glands are enriched. We found that

7
recurrent insomnia symptoms or restless legs syndrome, as well as aging and cardio metabolic,
behavioral, mental, and reproductive features, have common genetic variables. Insomnia was
found to be associated with an increased risk of cardiovascular disease, depression, and a
decrease in subjective well-being (Lane, et al., 2019).
Polysomnography, a tool recently introduced to the field of psychiatric research, has
confirmed disruption of sleep consistency in patients suffering from depression, disclosing not
only a decline in Slow Wave Sleep but also a dissociation of REM (wakefulness) sleep, as
evidenced by a reduction in REM delay time, an increase in REM density, and a rise in total
REM sleep. Despite early optimism, it has been found that these REM sleep disorders cannot be
used to differentiate between different forms of depression. Almost all antidepressants inhibit
rapid eye movement (REM) sleep, and there appeared to be a time- and the dose-response
association between total REM sleep inhibition and therapeutic response (Riemann, Krone,
Wulff, & Nissen, 2020).
All these so Cholinergic REM Induction Studies showed that cholinomimetic drugs can
simulate REM sleep disorders. The Chrono-medical schedule of lack of sleep and specular
reflection on their beneficial effects on temperament in depression is another interesting line of
inquiry. Modern studies see insomnia, defined as a delay in falling asleep, difficulties staying
asleep, and waking up early, as a trans-diagnostic sign of many psychiatric diseases, with its
strongest linkage being depression. Considering insomnia a trans-diagnostic trait has opened
several opportunities to the research of causes and therapeutic treatment (Riemann, Krone,
Wulff, & Nissen, 2020).
Insomnia has been linked to an increased risk of developing depression. The purpose of
this systematic review is to determine if sleeplessness is a risk factor for the development of any
other mental illnesses. Studies that looked at the relationship between insomnia at baseline (both
nighttime- and daytime symptoms) and the development of psychopathology at any point over a
follow-up period of at least 12 months were considered for inclusion. Thirteen original research
studies were featured. According to the findings, insomnia is an important risk factor for the
development of mental health issues such as depression, anxiety, alcoholism, or psychosis.
Primary studies had a moderate overall probability of bias. Findings from this meta-analysis
show that sleeplessness is associated with an elevated risk of psychopathology. More prospective
studies employing recognized clinical definitions, assessing insomnia at baseline, and having
long-term follow-up spans evaluating a larger spectrum of mental disorders should be included

8
in future research agendas. Long-term prospective intervention studies are also needed to
examine whether or not treating insomnia can reduce the risk of developing a mental illness
(Hertenstein, et al., 2019).
Insomnia causes sleep discontent, difficulty napping, and early morning waking. 1
Insomnia is debilitating. 3 nights each week for 3 months, no medications, prescriptions, or other
disorders create sleep problems. That contrasts with insomnia from lack of sleep, which has
distinct causes and consequences. Insomnia is often associated with naps, and mental, or medical
issues. Increased neurological, somatic, and emotional arousal and sustained behavioral variables
may produce chronic insomnia (such as oversleeping). Acute insomnia, which satisfies all
diagnostic criteria except duration, may have distinct causes and treatment implications (Buysse,
Rush, & Reynolds, 2017).

2.2 Borderline Personality Disorder

In 2018 the research was conducted by Gunderson and his fellows. The main purpose of
the research is to determine the systems and the challenges that people faced when they affect by
borderline personality disorder. BPD patients frequently intimidate or alienate caregivers, which
exacerbates the clinical difficulties brought on by the severe morbidity, strong social costs, and
widespread incidence of this disorder in several healthcare settings. People with BPD have many
negative thoughts anger and mood swings have a great impact on their minds which affect their
relationships. They are lonely in this phase because they are unable to talk with their families
about their health.
The study focused on the different methods for data collection. A substantial percentage
of people seeking assistance for psychological issues in general healthcare facilities and between
15% and 28% of patients in mental clinics or hospitals are determined to have BPD, compared to
just 1.7% of the population (Gunderson, Herpertz, Skodol, Torgersen, & Zanarini, 2018).
Extreme sensitivity to perceived slights from others, a shaky sense of self, strong and erratic
emotionality, and impulsive behaviors that are frequently self-destructive are all traits of BPD.
The majority of patients experience symptomatic remission over time, and evidence-based
psychosocial interventions can quicken this process.
Although self-harming behaviors as well as crisis propensity might diminish over time,
BPD's normal course and other successful therapies typically leave many patients with
substantial social impairments linked to depression or self-harming activities that last for a long
time. According to the research, clinicians must actively inquire about the fundamental problems
9
of unstable identity and personal relations (Gunderson, Herpertz, Skodol, Torgersen, & Zanarini,
2018). Individuals with BPD are often misdiagnosed, which results in ineffective pharmaceutical
therapies that are rarely effective. Because we don't fully understand the nature of the mental
condition, there is a discussion about whether the classification of BPD should change.
Joel researched borderline personality disorder and its effect on people. The aim of the
paper was to determine how many people commit suicide due to this disorder. People are not
mentally well, and they suffer from a lot of problems, because of these problems people try to
commit suicide and do any other harmful activity. The study shows many patients do self-harm,
activities and control their emotions but they can’t control them. There are many
psychopathologies, including unpredictable mood, impulsive behavior, and tumultuous
interpersonal connections, that are linked to BPD. In their lifetimes, BPD individuals attempt
suicide three times on average, most often by overdosing.
Self-harming activities or NSSI are prevalent in BPD. NSSI typically manifests as little
wounds on the arms and wrists (Paris, 2019). NSSI, however, does not have a suicidal aim;
instead, BPD patients cut themselves compulsively to relieve uncomfortable inner emotions.
Cutting does not signify a desire to pass away; rather, it reduces emotional stress. Drug
overdoses can occasionally be fatal, but the nature and purpose of these actions vary
widely. According to research, young people are mostly affected by this disorder and when they
do not control their emotions they suffer from different problems and decide to commit suicide
and many other self-harm activities. The results of the research show that 10% of people commit
suicide who are affected by BPD. This disease not only creates problems for affected people but
also other people as well.
Choi-Kain and his fellow conducted research in 2017. The study focused on the treatment
of BPD and it also highlight the effects of the disease on people. It gives different useful
treatments for the people. The improvements in therapies for individuals with BPD over the
previous five years are outlined in this research. The study focused on previous studies and
collect authentic information which was helpful for the scholars to identify the best treatments
for people who are affected by BPD (Choi-Kain, Finch, Masland, Jenkins, & Unruh, 2017).
Evidence-based developments in the treatment of BPD consist of the differentiation
between generalist as well as specialist models of care, the identification of dialectical behavioral
therapy's (DBT) key components, and the adaption of DBT to treat both PTSD and BPD. Studies
on pharmacological therapies are still scarce, and none of the available drugs are effective as a

10
stand-alone form of treatment. It also refers to the different therapies which are beneficial for
BPD. It is a mental health problem and it takes time to recover. The patients face different
challenges but if they focused on therapies and follow all the recommendations of the doctors
they can easily improve their mental health. The therapies are helpful to improve and have a
positive impact on their relationship.
Borderline Personality Disorder is a disease that affects the mental health of people. The
study focused on the disease. The feasibility and relevance of identifying borderline personality
disorder in young people are discussed in this article. The etiology and clinical signs and
symptoms of this condition in adolescents are explored, and difficulties with psychotherapy,
medication, hospitalization and family participation are addressed in terms of care (Larrivée,
2022). This study attempts to clarify the issue in order to deal more effectively with patients
whose affecting instability as well as individuality disruption are more severe than what is
typical for adolescents and could increase morbidity and death if untreated or improperly
managed.
The paper examines the viability and relevance of diagnosing borderline personality
illness in young people. Moreover, the clinical manifestations of BPD in youths, are discussed,
and this research focuses on psychiatric, pharmaceutical, hospitalization-related, and family-
related issues (Larrivée, 2022). The results of the research show there are many treatments for
the diseases which are useful for the patients. The people should be focused on the treatments
and the mental conditions of the patients.
Experts in the field of psychology are hesitant to make a diagnosis of borderline
personality syndrome in early people because they believe that the characteristics of this disorder
are more indicative of typical growth and development than of a disordered personality.
Assumptions like these seem to presume that the procedures underlying personality growth,
identity construction, and managerial operations are limited to the years prior to the age of 18.
Health-related quality of life and psychopathological distress are significantly and equally
correlated with a diagnosis of BPD or subthreshold borderline characteristics in young persons.
Poorer functioning and increased usage of mental health services are both associated with
subthreshold BPD.
Around 13–50% of persons diagnosed with borderline personality disorder report
experiencing auditory verbal hallucinations. Both schizophrenic and non-schizophrenic AVH
share similar phenomenological characteristics, including a high degree of resemblance in terms

11
of regularity, interval, position, volume, and the source of the voices. Pathology associated with
BPD in young people can be measured with a number of different tools. The criteria for
diagnosing BPD are taken from Section II of the DSM-5. Adolescents can use the SWAP-II-A-
BPD scale and the BPDSI-IV-Adolescent Version with confidence. Individuals with no BPD
traits have better social and vocational working than patients with BPD, even young people.
Disruption of meaningful peer and romantic associations, educational completion,
employment, and independent functioning were all long-term effects for young persons with
BPD. Treatment for young persons with BPD results in moderate enhancements in the primary
outcome(s). Unfortunately, these enhancements do not last very long (Chanen, Nicol, Betts, &
Thompson, 2020).
Perhaps "personality pathology" should be interpreted a-dimensionally. Multiple
dimensions have long been used to assess personality features. Even while BPD kept its name in
DSM-5, a dimensional approach to diagnosis and distinction was a big development. Cluster B
personality disorders include BPD, or "borderline personality disorder" A categorical diagnosis
is used to define health conditions, but it's not limited to personality structure and pathology.
Suicide, self-harm, co-occurring disease, and impaired social functioning are typical of BPD.
BPD must meet five of nine diagnostic criteria. Negative emotional experiences in the absence of
other abuse indicate BPD. There are very few resources for BPD patients. Australia's mental
health facilities prioritize treating psychotic and affective diseases.
Stigma and prejudice against those who have been diagnosed with BPD have been the
subject of extensive study. There is widespread skepticism among medical experts about the
validity of the BPD diagnosis. Patients need an accurate curated diagnosis for two main reasons:
effective treatment and better disease prevalence estimates. Most healthcare systems rely on
diagnosis to provide access to therapy and care, which can be rather expensive. It is not known
whether the medicalization of personality disorder carries the same dangers of iatrogenic harm as
other so-called diseases.
Overdosing or misdiagnosing drugs causes iatrogenic injury. DSM-5 requires clinical
formulations for each diagnosis. Psychotherapy schools present realistic hypothetical
formulations. According to Fonagy and Adshead, most effective psychotherapies improve
patients' mentalization, which might modify brain structure and function. In Australia, a
diagnosis is needed to access treatment choices.

12
 Group therapy, individual counseling, and telephone coaching are all components of
Dialectical Behavior Therapy (DBT), which is an evidence-based psychotherapeutic treatment
for BPD. Access to appropriate therapies and fewer hospitalizations and calls to emergency
services should result from a precise diagnosis (Campbell, Clarke, Massey, & Lakeman, 2020).

2.3 Cocaine Use Disorder

According to Noelia Fernandez-Castillo and his team members, drug addiction is the
most important global health problem. The patient loses control of the intake of drugs,
withdrawal as well as cravings. Moreover, at the individual level, drugs create problems that
disturb the body system badly. According to the research paper, drug addiction shows a negative
impact on the family environment as well as workplace relationships badly. The research paper
identifies Cocaine as the psychostimulant substance that is the most important material for
medicines specifically, in Western Europe, America, as well as Australia. It is used for complex
multifactorial conditions that are driven by environmental influences as well as genetics. It refers
to the different behavioral issues that the patient shows.
According to the authors, in 2018, almost 9 million people used cocaine. The person who
uses cocaine faces changes in the structure as well as the function of the brain such as synaptic
plasticity and neuronal activity that affects the body functions of the body. The research paper
identifies the changes in the patient in their gene expression that affect the sexual activity of the
person badly. Moreover, the genes whose expression is altered by cocaine increase the genetic
risks and affect the response of the person. The research paper is related to the case because the
case is based on the behavioral changes of the person and creates problems in the workplace
(Fernàndez-Castillo, Cabana-Domínguez, Corominas, & Cormand, 2022).
Drug addiction is a serious problem that increases day by day with the use of different
drugs to release the stress of the patient. With time, the patients will be addicted to the drugs
which created problems for the patient to survey in society because drugs disturb the whole-body
functions that directly affect the immune system and increase the barriers in the blood increasing
the chance of heart attack. Moreover, according to the research paper, pharmacokinetic
antagonists use cocaine to reduce the pain of the patient but the continuous use of the drugs
changes the behavior of the patient effectively that creating problems in sleeping and increasing
mental disorders.
The research paper identifies the different strategies to reduce the effects on the patient
and promote the development of new anti-drug immunotherapies. Moreover, strategies reduce
13
drug addiction in the patient. The research paper identifies the different facts that are related to
drug addiction and different strategies that are required for the effective use of drugs and control
the drug addiction in patients. Different traditional therapies are the major causes of cocaine
(Xiaoshan, et al., 2020).
According to the research paper, the use of cocaine has increased among individuals with
opioid use disorders. The researchers conducted a systematic review of the medications for
stimulant use disorders in the population. The researchers use the primary method for the
collection of the data to identify the major causes of cocaine. In the results, thirty-four trials of
22 medications focus on cocaine use for the disorder in patent and the doctors used this as
medicine in the therapy. The use of cocaine in the therapy increases depression in the patient and
increases blood pressure which increases the heart rate of the patient. Moreover, the researchers
faced problems in the research because fewer researchers are present related to cocaine use
disorders (Chan, et al., 2020).
The research paper identifies the major impact of cocaine use disorder on the heart and
mind and disturb all the process of the body and decrease the level of immunity in the body for
effective processes.
According to the research paper, alcohol is less effective as compared to cocaine as well
as heroin. Moreover, the person who survives with cocaine use disorders is particularly
vulnerable to mortality. The researchers use the primary method for the data collection that
improves that researchers use authentic data that examines the ratio of the users and compared
the users of a different substance to identify the effect of cocaine use disorders. The research
paper also identifies the difference between alcohol as well as cocaine and investigates the
impact on the body and defines the proper level of the substance users (Butelman, Chen, Brown,
Lake, & Kreek, 2021).
The study describes the impact of cocaine use disorders and which age is more affected
and defines the different patterns of death. The research paper identifies methamphetamine use
disorders. The research study identifies the risks that are associated with the disorders. The
research uses the primary method to analyze the data and take opinions of the individuals related
to the disorders and how it affects their body and increases the chance of death rapidly
(Callaghan, et al., 2018).
A peer-reviewed article has been written by Kampman and his fellow members in the
year 2019, the investigation aims to investigate the effect of problems which are associated with

14
the usage of disorder of cocaine. But the selected article deals with the treatment of Cocaine
when an individual is addicted to this disease then what things will be beneficial for the
treatment of the disease? The least-square and questionnaires approaches have been used by an
individual of an investigation.
The results of the findings stated that when individuals are addicted to this drug then
CUB, CBT, and CM are the treatment methodologies that can use by doctors to overcome the
effects of barriers to overcome the effect. Suggested that individuals should be far away from
this disease if they caught themselves in this disease the above treatments should be used by
doctors and clinical staff members while an examination of the treatment (Kampman, 2019).
Summing up, an individual should enroll themselves in schemes, and programs that are for the
development and betterment of the individual then they will not take participate in disease
activities that destroy their life of individuals.
Another article has been written by Oliva and his companions in the year 2021. Today the
use of Cocaine is increased and the chances of adaptation are more i and its surroundings. Many
diseases and other associated problems are raised in teenagers and youngsters. Primary
methodology and survey approach have been used by researchers for finding out the problems,
and issues that have been associated with the over and lighter use of the drug Cocaine
(Niedzielska-Andres, et al., 2021). The outcomes of the research work stated that hypertension,
Insomnia, stress, loneliness, and other related types of problems are raised in individuals and
lead them towards destruction. Societies should pay attention to the awareness programs for
mitigating the effects of barriers from individuals, and also the teenagers who are overwhelmed
by the usage of Cocaine. Nutshell, proper training, exercises, and awareness schemes should use
by individuals then results will be good enough and the majority will not be affected by the
diseases (Oliva, et al., 2021).

2.4 Generalized Anxiety Disorder

Generalized Anxiety disorder is a specific mental condition that is caused something and
getting worried to be determined to recur. The individual can induce several physical symptoms
such as sweating, rapid shallow breathing, and feeling disturbance in sleeping. In Pakistan,
anxiety disorder considering the most common frequent illness of mental disease. In Pakistan,
there are almost 20 million people affected by anxiety. They feel nervous about the things that
are happening around their environment. They are feeling very anxious when the uncertainty
gets around them and they got panic into it and feel anxious about the current situation to think

15
about how they would tackle this particular situation to resolve the issue they are facing on the
spot. The people mostly feel anxiety disorder which is a traumatic and very stressful life
experience including bereavement or having a close family member with panic disorder.
However, there is a need to be well treated that individual who has this big issue in his/her life.
Generalized Anxiety is a specific situation or condition that is characterized by anxious
thoughts and intense emotions. Anxiety is an inner mind characteristic that generates by physical
change such as high blood pressure, intense emotions, anxious thoughts, and feeling nervous
about something that an individual feels as a threat. Anxiety disorders are established by
repetitive anxieties and thoughts. Individuals have to face this pressure of anxiety in certain
situations. The physical symptoms of the anxiety such as confusion, sweating, tremors, and rapid
action of the heartbeat may be present.
Generalized Anxiety comes from an individual through getting panic, getting fear, and
feeling discomfort with the current situation that will be a person or anything. It will make your
heart race, make you sweat, and may feel you restless or energized to do something
extraordinary. When you feel generalized anxiety the response of your personality about things
gets slow down due to feeling stress. Mostly in Pakistan, when an individual faces a particular
different situation at the workplace or anywhere, before an interview, before an exam, before
making decisions, before getting married, before doing something feeling nervous too much.
They are facing a lack of confidence that can lead to pushover to do the right things at the right
time without any fear stress or anxiety. This literature review of the article will be helpful for an
individual who is facing all these challenges and issues in their life. It will also help you to
survive. All the strategies and techniques that have been discussed in this chapter will give you
the strength and confidence to get out of the problems and hurdles. However, for an individual
with anxiety disorder, anxiety is potent and persistent.
Generalized Anxiety is a common thing that has an existence in all individuals of the
world. There is no wonder that feeling anxiety is very ridiculous and dangerous for humans. It is
natural and habitual. It is a common thing that arrives easily in the personality characteristics of
humans. Yes, it is a good thing on some occasions in our lives. Because it provides you the
attention to pay focus on the certain situation that put an impact on your life. So, in the anxiety,
there are some strategies and techniques this literature review will discuss that will beneficial for
avoiding getting anxious in our daily routine. An individual can eliminate the anxiety from their
personality by building confidence and self-esteem in their personalities.

16
 Every journey starts with hope. So, that’s why it can heal with the hope of the best.
Instead of feeling fear and uncomfortable, you have to take the responsibility for taking on new
challenges in your life especially those related to your academic field. If you want to reduce the
level of anxiety in your personality you have to take a great pathway of healing and living
joyfully. In this study, you will find the tools and skills that need to be learned to apply in their
personal life such skills as building confidence and self-esteem, make strengthening families and
marriage, increasing your happiness, and the ability to manage stress, all are these tools and
skills that will help to alleviate symptoms of anxiety and depression.
If you want to reduce the level of generalized anxiety in your personality you have to take
a great pathway of healing and living joyfully. In this study, you will find the tools and skills that
need to be learned to apply in their personal life such skills as building confidence and self-
esteem, make strengthening families and marriage, increasing your happiness, and the ability to
manage stress, all are these tools and skills that will help to alleviate symptoms of anxiety and
depression. An individual needs to give the power to create a life that is big beautiful and strong
without any tensions or full of worries.
According to a recent survey, in Pakistan people feels generalized anxiety through fear,
worry, and unease. Commonly, everyone feels anxiety in different situations in life, but some
people take it for a long time along with their life as permanent. Having generalized anxiety
already discussed is a positive thing and gives you the solution for resolving the issues in our
lives. But after great research, it has been founded that feeling anxiety for a long time can cause
more serious health issues and problems like increased blood pressure and heartbeat. If you are
facing an anxiety issue for a long period and it increases day-to-day life, then you are facing
panic disorder or anxiety disorder. So, being a human it’s your responsibility to get challenges
and get out from your comfort zone of life in which your will face more challenges and hurdles
that will shape your personality to work well in pressurizing conditions that will automatically
decrease the level of anxiety from your personality.

2.5 Major Depressive Disorder

Malnick and his fellow researcher researched to study the effects of major depressive
disorder on individuals. Major depressive disorder is one of the most common diseases that is
faced by individuals. The research explains that individuals that are suffering from major
depressive disorder face different other issues as well. The reason is that individuals are always
in a state of continuous depression and anxiety and they need something that can lessen their

17
tension so that they can enjoy reality. Most patients that are suffering from major depressive
disorder face the excessive use of alcohol and drugs. This ultimately leads to fatty liver and
alcoholic fatty liver diseases. Besides that, it is observed that patients that are suffering from the
major depressive disorder are facing the issue of obesity (Maor, Zukerman, Amit, Richard, &
Ben-Itzhak, 2022).
The reason is that there is increased consumption of food by individuals when they are in
a state of anxiety or depression. This ultimately leads to higher fats in the body and individual
suffers from obesity. There is a lack of movement in the patients because they lose interest in the
day-to-day business activities of life. There is a continuous feeling of loneliness in patients and
all they want is to be alone and not surrounded by people (Malnick & Maor, 2020).
Ferber et. al., conducted this research to study major depressive disorder under code
298.22 in patients and individuals. Major depressive disorder has become common over the past
few years, especially after the era pandemic. This time frame was considered the most chronic
time of this century. The reason is that most of the people were in lockdown. People lost their
loved ones which were one of the major reason for depression. Besides, living in a home for
weeks was also very difficult (Ferber, et al., 2022). The people started suffering the major
depressive disorder in that situation. The study conducted a probability-based internet survey of
the respondents. The major respondents of this research were adults. They explained that the
major reason for depression is living in a home and losing job opportunities.
The results of this study have indicated that there were different diseases observed in the
individuals and these diseases were majorly related to the mental health of the individuals.
Depression and anxiety were increased to a great extent. People started losing their lives as there
was no hope of coming out of this situation. Losing hope is one of the most important symptoms
that was observed in the individuals and they have explained that people and the government
nobody was willing to help in such a situation. Government must provide support so that
individuals have mental stability and they can continue their day-to-day business activities
effectively (Ferber, et al., 2022).
Zeev and other researchers conducted this research to study the impact of major
depressive disorder under code 298.22, especially in children. Exposure to major depressive
disorder has a long-term impact on the life of children. Nowadays children are the major victim
of major depressive disorder. There are multiple reasons behind this disorder in children.
Multiple stages of this disorder affect the mental ability of the children and they are unable to

18
carry on their day-to-day activities of life. For example, in the early stages, children do not
participate in family or friends gatherings (Zeev-Wolf, Dor-Ziderman, Pratt, Goldstein, &
Feldman, 2022). They like to sit alone and not communicate with anyone. There is a continuous
feeling of loneliness in individuals which affects their productivity. The children do not consider
anyone enough important with whom they can share their issues. The study has used the unique
cohort that is followed from birth to pre-adolescence. The multiple effects of major depressive
disorder were studied in it so that comprehensive results can be drawn on a factual basis.
The study has divided the children into three different categories i.e. 6 months, 9 months,
6 years, and 10 years. It was observed that children of 6 months face continuous depression
along with their mother. The most important reasons were the lack of feeding, reduced sleep, and
disturbed sleep. While the MDD observed in the 6 and 10 years old explained that they are
facing a great workload from schools and other educational institutions. The reason is that they
face depression t the early years of life and their mind is developed in the same situation which
has a great impact on the overall growth of the individuals. The results of the study have
indicated there should be no extra burden on the children either in the perspective of education or
any other activity of life. The parents should be actively involved in communication with
children so that they do not feel alone and live life like normal child (Zeev-Wolf, Dor-Ziderman,
Pratt, Goldstein, & Feldman, 2022). So, there should be more focus on relationship building
with children.
Moar et. al., conducted this research to study the causes of major depressive disorder.
Major depressive disorder is the main cause of different diseases in the human body the most
important and common causes of this disorder are sugar and hypertension. The reason is that
patient continuously thinks about the loneliness and hopelessness in the activities of life. It
affects the brain ad heart activities of the patient. The flow of blood increases which ultimately
affects mental and physical activities. The psychological well-being of an individual is one of the
neglected phenomena which needs great importance (Maor, Zukerman, Amit, Richard, & Ben-
Itzhak, 2022). The reason is that there should be more focus on the mental health of the
individuals so that they can be healthy from both mental and physical perspectives.
The individuals must have the ability to adjust according to the surrounding environment
so that their health is maintained and they can actively participate in day-to-day activities. Once
the sugar is increased then it causes multiple other diseases in the human body. The results of
the study have indicated that there should be a positive change because mental well-being should

19
be the priority of individuals so that they can live happily. Human psychology has an impact on
physical activities so individuals should focus on mental and physical health. In this way, the
major depressive disorder can be overcome (Maor, Zukerman, Amit, Richard, & Ben-Itzhak,
2022).
Abdel basset et al., researched to study the impact of exercise and other factors for curing
major depressive disorder individuals so that they can remain healthy and live a normal life. The
research has especially focused on the diseases that are caused by major depressive disorder.
Heart failure is one of the most common diseases that is increased around the world over the past
few years. There must be the treatment of individuals on time so that they can be treated
effectively and chances of diseases can be overcome. Once the individual is suffering from a
major depressive disorder there are higher chances that it can affect their mental health. The
extreme pressure and tension situation cause the increased and fast blood flow that ultimately
leads to high blood pressure or hypertension. The study took up the time frame of 12 weeks and
a random controlled trial has been conducted.
The results of the study have indicated that mainly the individuals that are facing extreme
depressive situations suffer from hypertension. Their age ranges from 40 to 60 years. They may
face the pressure of building a home, getting a required job, or any other necessary activity.
Individuals should engage in different exercise programs because exercise enables body
movements and the body remains active. The mind becomes fresh that ultimately leads to better
and positive results. So, there is a need to focus on the mental health of the individuals so they
can be cured of major depressive disorder (Abdelbasset, et al., 2019).
Psychological disorders have more effect as compared to the physical illness of the
individuals. The reason is that individuals who face the great depression often tend to lose their
life at the early stages rather than those individuals that are more focused on treating their illness.
The self-reported questionnaire was developed so that actual results can be collected from the
patients. Based on these results the conclusions can be drawn effectively. For analyzing the
results the significant co relations results have been drawn.
The results of the study have indicated that there must be effective and proper treatment
for patients that are suffering from major depressive disorder because it is one of the most
common diseases. The recognition should be done at the initial stages so that medication can be
avoided to treat this disorder (Zukerman, Maor, Reichard, & Ben-Itzhak, 2022). There are higher
chances of severe conditions once the individuals are not treated at the early stages of depression

20
because overthinking causes hypertension that ultimately leads to severe cardiovascular diseases
in the individuals.

21
 CHAPTER 3: EXPERIMENTAL CASE
3.1 Insomnia
3.1.1 Identifying Data
Name M. K

Age` 29 years

Gender Male

Education Engineering

Occupation Engineer

Siblings 1

Birth order 1st

Marital status Married

Religion Islam

Socioeconomic status Middle class

Informant Wife and client

3.1.2 Source and Reasons for Referral

The client was referred to the trainee psychologist for the psychological assessment and
management of his complaints.
3.1.3 Presenting Complaints
Table 1: Presenting Complains Reported by the Client
Duration Presenting Complaints
‫ مہینے سے‬2 .‫مجھے نیند مشکل سے آتی ہے‬
‫ مہینے سے‬2 .‫میں ٹھیک سے سو نہیں پاتا‬
‫ مہینے سے‬2 ‫میری بیوی کا کہنا ہے کہ رات کو سوتے وقت میری ٹانگوں کو جھٹکا لگتا ہے۔مجھے دن میں‬
‫ مہینے سے‬2 ‫تھکاوٹ محسوس ہوتی ہے۔‬

22
3.1.4 History of Present Illness (HOPI)
The client M.K, age of 29 years was in an adequate state two months ago. The client’s
problem was started 2 months back when his sister died. He was unable to fall sleep until at
least an hour after going to bed. He consumed 4 cups of coffee during the day and lately took
self-recommended sleep medications at night to aid sleep. The client’s wife has noted that his
legs jerk occasionally during the sleep though he was not aware of these movements.
According to the client, he had the satisfactory relationship with his wife and other
family members. Client was attached with his sister. He shared everything with her and
enjoyed her company. But after the death of his sister client was likely to be alone and had
sleep difficulty although his sleep was appropriate before the incident. Client reported that he
did not face any big problems in his routine because of sleep issues but still he remained tired
after waking up and couldn't perform daily tasks well. For the sleep difficulty he took self-
recommended sleeping pills too but of no use then his wife suggested him to visit the
psychologist.
3.1.5 Background Information
3.1.5.1 Family History
Client birth was normal at hospital. He was born in Government hospital. He achieved his
milestones at appropriate time. The client had no difficulty or no delay in sitting, crawling,
standing, walking talking. Client was healthy person from his childhood. He never had any
physical problem in his childhood. He never had any traumatic injury in his childhood. He used
to suck his thumb in his childhood.
Client lived in the joint family system with his wife and parents after his sister death. He
belonged to the middle class family. His father was the head of family. His father was the
retired school teacher of the age of 65 years. Client described his father as dominating and
friendly person. He was closed to his father and had sharing and congenial relationship. He
reported that he was very kind and the most respected person in his house. His mother age is 60
years and she is housewife. He described his mother as kind and loving. He reported that he had
congenial relationship with his mother as well.
Client had one sister. Client’s birth order was 1 st. His sister passed away 2 months ago
after suffering from typhoid. He reported that she was doing her masters and was unmarried.

23
He said that she was the only one with whom he was comfortable and shared his problems. He
reported that he had congenital and loving relationship with his wife. He described his wife as
loving, kind and cooperative. After his sister he was close to his wife.
3.1.5.2 Sexual History
Client reported that he achieved puberty at the age of 14 years. His reaction towards
pubertal changes was satisfactory. He was well aware of those changes. He did not report any
homosexual or heterosexual relationship before marriage. He reported that his peer group was
good so they didn't get involved in any of such activities.
3.1.5.3 Educational History
The client started his schooling at the age of 4 years in his town. He was satisfactory in
his studies and passed with very good grades always. His relationship with his peers at school,
college and university was congenial. He had studied till graduation. According to him, no
complaints related to his behavior ever came from any institute.
3.1.5.4 Marital History
Client had been married for one year. It was arranged marriage but with the consent of
both. He reported their emotional and intimate relationship with each other had always been
satisfactory. They did not fight a lot and even if one was angry, the other one tried to end the
fight and say sorry. He reported that they both always had each other’s back.
3.1.5.5 Occupational History
Client reported that he started working in a company as soon as he completed his studies.
He had been doing work as a chemical engineer in the same company for 4 years now. He
reported that his job was quite demanding but he was satisfied with his job. Client also reported
he had congenial relationship with his colleagues and he enjoyed working with them.
3.1.5.6 History of Psychiatry/Medical Illness
None of the family members previously or in present have medical or psychiatric illness
but his mother had sleep difficulties. As the client was the eldest in the family everyone around
him have been supportive and loving.
3.1.5.6.1 Premorbid Personality
Client described himself a responsible and lively person before the onset of symptoms.
His hobbies were playing snookers and going for hosteling. He had lot of friends with whom he
spent most of the time. His reaction towards stress was not healthy according to him. He used to
share his problems with his sister and wife.

24
3.1.6 Psychological Assessment
Assessment is the process of collecting information from multiple and diverse source in
order to develop a deep understanding. There are two types of assessment.
Informal Assessment
Formal Assessment
3.1.6.1 Informal Assessment
Informal assessment includes interview from client’s family, attendant and client
himself and behavioral observation of client.
 Behavioral Observation
 Clinical Interview
 Mental Status Examination
 Subjective Ratings of Presenting Complaints
3.1.6.1.1 Behavioral Observation.
It is widely used method of behavioral assessment which relies on live watching and
recording the behavior of a person in typical environment (Boman, Psychology, & Sociology,
1979). Client was observed through participant observation in outdoor setting. Participant
observation is type of observation in which therapist becomes the active member of the session
and participate with client.
In behavioral observation, it was observed that client was 29 years old male with tall
height, average weight and fair complexion. He was seated comfortably in a chair. His gait
seemed appropriate. His tone and pitch of voice was polite and soft. His quality and quantity of
speech was appropriate and relevant as he was responding properly to every question asked by
therapist. Hence, he was very cooperative and complying with the therapist. He established and
maintained eye contact throughout the session. Rapport seemed to be established in the very
first session as client was complying with every question and instructions of the therapist.
3.1.6.1.2 Clinical Interview.
Interview is qualitative method for obtaining information. A clinical interview is a
conversation between a clinician and a client that is typically intended to develop a diagnosis. It
is basically the conversation with a purpose that the therapist does to gather all required
information about client’s background, social, cultural and present condition to process his
further assessment and management.

25
 In present case quality of information was obtained from the client. The clinical
interview was taken in the early 2-3 sessions in which therapist asked open-ended questions
about client’s past life like family, education, occupation etc with rationale to better understand
his present condition and further proceed to his assessment and management accordingly. It was
during interview that the rapport was well established with the client and he shared a lot of
useful information about his past and present condition.
3.1.6.1.3 Mental Status Examination (MSE).
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that
describes the mental state and behaviors of the person being seen. It includes both objective
observations of clinician and subjective description given by the patient. Focused questions and
observations reveal “normal” or pathological findings. It paints a picture of patient’s
appearance, thinking, emotion and cognition. The data from Mental Status Exam, combined
with clinical interview forms the data on the basis of which assessment of client is completed
present case MSE served as tool to explore level of general appearance, psychomotor behavior,
mood and effect, speech, cognition and thought pattern.
Mental Status Examination of the client was conducted with the same purpose to
complete his picture of present and past symptoms. The MSE of the client revealed that he was
23 year old male, tall heighted with average weight and fair complexion. He was well groomed
with satisfactory hygienic condition. He was wearing light brown shalwar kameez with black
slippers. His hairs were short and combed, nails were trimmed and dress was clean. He was
seated comfortably in a chair with appropriate posture in a session with no irritability agitation.
Although he seemed bit quiet and reserved but was complying with all the instructions and
responding appropriately to every question of the therapist.
His mood was euthymic and affect was also observed to be congruent with what he
reported. The appearance of client was according to his age. He maintained the eye contact
throughout the sessions. The rapport was built quite easily, he was alert and co-operative. His
eye contact was glaring and fixed. His thought process during the session seemed relevant and
coherent as no flight of ideas or odd behaviors were observed. He was well oriented with time
and place. Judgement, attention and concentration span was satisfactory. Insight was partial as
he take self-prescribed medications for sleep issues but also consumed 4 cups of coffee during
the day and was unaware of leg jerking during sleep.

26
3.1.6.1.4 Subjective Ratings of Presenting Complaints.
Subjective ratings of presenting complaints were taken from the client with rationale to
better understand the intensity of his symptoms. It was also done as a pre-assessment rating so
that after intervention post assessment rating can be done in order to find out any improvement
in his symptoms. Client was asked severity of his presenting complaints which includes his
sleep related issues from 0 to 10. 0 being not at all and 10 being the most.
Present Severity of presenting complaints According to the Client
Table 2: Present Severity of Presenting complaints According to the Client
Presenting Complaints Ratings (0-10)

Difficulty falling asleep 8

Fatigue during day 8
Difficulty staying asleep 7

Leg jerking during sleep 5

Severity ratings also helped the therapist to identify the present issues of the client so he
would make goals accordingly and devise the intervention plan to help client recover more
effectively.
3.1.6.2 Formal Assessment
Formal assessment is the process of gathering information about client using
standardized, published tests or instruments with specific administration and interpretation
procedure and used to make general instructional deacons.
Following formal assessments were used:
3.1.6.2.1 Pittsburgh Sleep Quality Index.
The Pittsburgh Sleep Quality Index (PSQI) assesses self-reported sleep quality and
disturbances over the last one-month time period. The PSQI includes 19 items to measure seven
domains which are subjective sleep quality, sleep latency, sleep duration, habitual sleep
efficiency, daytime dysfunction, sleep disturbance and use of sleeping medications.
The rationale behind the usage of this test was to assess the sleep issues of the client
with respect to his own self perceptions and to diagnose the underlying problematic areas.
Client as usually was seated at ease for the session, later on he was provided 2 pages scale along

27
with the pencil and eraser and he was told to answer all 19 questions related to his sleep habits
during last month. Proper instructions about items that represents his majority of days and
nights were provided to client.
Quantitative Interpretation:
Table 3: Showing score of PSQI to identify the level of sleep disturbances
Categories Raw Score

Sleep Quality 2
Sleep Latency 3
Sleep Duration 3
Habitual Sleep Efficiency 3
Sleep Disturbance 2
Use of Sleep Medications 3
Daytime Dysfunction 2
Global Score 18

The client score was below the cut off score which indicated moderate severe sleep
difficulties. The items filled by the client showed it took him more than 2 hours to fall asleep
after going to bed and due to that client remained tired after waking up. The items revealed that
client had severe difficulties in sleep latency, habitual sleep efficiency and he had been using
sleep medications but of no use. Items showed that client had moderate problem in sleep and
daytime dysfunction. Sum of the seven components score indicated that client have moderate
severe sleep difficulties.
3.1.6.2.2 Insomnia Severity Index.
The ISI is a self-report instrument designed to evaluate the severity and impact of
insomnia symptoms over the past 2 weeks. The ISI consists of 7 items. The rationale behind the
usage of this test is to assess the degree of difficulty in falling asleep, staying sleep, and waking
up. The client was seated comfortably on a seat. Then he was provided with one forum paper
along with pencil and eraser. He had to select options given under sentences. Simple and
complete instructions were given to him.
Quantitative Interpretation.

28
Table 4: Showing score, ranges and severity of the client on Insomnia Severity Index
Raw score Cutoff range Severity level

17 15-21 Moderate Severity

Client was asked to fill the scale. All information related to scale was given to client.
The room was ventilated and peaceful. The client was instructed to sit comfortably; he
completed the scale in 25 min. The client scored 17 on Insomnia severity scale which indicated
that the client had moderate severity level of Insomnia as he had shown the symptoms of
difficulty falling asleep, staying asleep, leg jerking during sleep and fatigue.
3.1.7 Case Formulation
Client was 29 years old male. He belonged to middle class family. He had studied till
graduation. Client had one sister. Client was presented with the complaints of difficulty falling
asleep, staying asleep, leg jerking during sleep and fatigue. The client’s mother had sleep issues.
So, the predisposing factor in the client’s case was genes as it runs in family. This hypothesis
was also supported by various researches that stated that predisposition towards developing
insomnia is likely largely based on genetics, which influences the processes that direct sleep
and wakefulness. After the death of his younger sister whom he was attached to, he became
very sensitive and started having sleep difficulties. Another research study conducted in which
345 patients evaluated for developing insomnia stated that negative valence of family can
precipitates the sleep problems(Bastien, Vallières, & Morin, 2004). In this case, stress and death
of client’s sister precipitating the disorder.
Client’s consumption of 4 cups of coffee during the day maintaining the illness. In
general, an extremely large and unquestionable body of research establishes that increased
consumption of caffeinated beverages is associated with higher insomnia symptoms
(Chaudhary, Grandner, Jackson, & Chakravorty, 2016). Another study stated that higher
probability of experiencing insomnia is also associated with interaction between higher caffeine
consumption and lower sleep duration. Distressing thoughts about not being able to sleep
properly was also maintaining the disorder. As researches indicated that many people with
insomnia report that mental events, such as intrusive thoughts or a racing mind, prevent them
from achieving or maintaining sleep. Dysfunctional cognition may play an important role in
perpetuating insomnia, with many individuals with psycho physiological insomnia reporting a
distorted perception of sleep. (Berry et al., 2012).
29
 The client’s motivation to overcome the problem and supportive family which
encouraged and motivated him to recover soon and client’s wife was caring and concerned
about his health and sleep issues. Various researches have suggested that patient’s insight into
treatment is a significant predictor of adverse clinical outcomes. It may be essential to include
that improving insight into treatment might be a promising objective for final outcome.
((Lobbezoo, Ahlberg, Aarab, & Manfredini, 2021).The Management plan that would be used on
the basis of problems which are rapport building used to build trust with client,
psychoeducation about the disorder would be done, Relaxation Techniques would be used for
relieving stress, Thought stopping would be used for distressing thoughts before going to bed,
Stimulus control therapy and Sleep hygiene would be used for resolving sleep difficulties.

30
3.1.8 Case Conceptualization

PresentinComplaint
g s
Difficulty
fallingasleepDifficulty
stayinasleep,lejerking
durin
, slee an gfatigug
g p d e

Assessme
ClinicalInterviews
Behavioural
nt observation Mentalstatu
examinatio
, (MSE),Subjectiv, rating of complaints
s
Pittsburg
n Slee Quality
eIndex(PSQIs )an Insomni
, Severit
h p Index(ISI). d a y

Maintaining
Predisposing factor
Factor Precipitating Protectiv Factors
Consumption of 4
Factor e
Client’s mother cupsof coffee Supportivfamily
duringth day.
hadsleep Deat ofhissiste. e
Distressing
e Caringan
difficulties. h r thoughtsaboutnot supportiv
d wife
beingabletosleep e
properly.

Management
Diagnosis
Outcome
Otherspecified Rapport Building, Therat of
insomniadisorder Psychoeducation, change
e in th
withacutestres Relaxation client
’s e
underth DSM
s 5 Techniques (deep symptoms
code780.52
e (G47. breathingand16- was30%
09) PMR), Thought
stopping,Stimulus
controltherapyand
Sleephygiene.

Figure 1:3.1.8 Case Conceptualization

31
3.1.9 Diagnosis
On the basis of formal and informal assessment, the client was diagnosed with other
specified insomnia disorder with acute stress under the DSM 5 code780.52 (G47.09).
3.1.10 Prognosis
As for the prognosis there are chances for recovery exist due to supportive sister and
client’s willingness for the treatment.
3.1.11 Management Plan
3.1.11.1 Short Term Goals
 Rapport would be built with the client to develop trustful relationship between client and
therapist.
 Psycho-education would be done through diagram on which client will be taught about the
disorder.
 Alternate nose breathing and 16 progressive Muscle Relaxation exercise would be used to
make the client realize that he had control upon his muscles of the body by making them
tense and relax during the pain and stress in the muscles. Training would be start by
explaining the rationale and prerequisites of relaxation exercise.
 Client would be suggested to moderate his caffeine consumption routine within
recommended guidelines along with the rationale.
 Sleep guidelines would be provided to client in order to making sleep quantity or quality
better.
3.1.11.2 Long Term Goals
 Continuation of Short- term goals.
 To reduce overall frequency, intensity, and duration of underlying stress related to sleep
issues so that daily functioning would not impaired.
 Follow up sessions of the short-term goals would be done to increase efficacy of the
therapy.
3.1.12 Summary of Therapeutic Interventions
3.1.12.1 Rapport Building
Rapport is the development of a therapeutic relationship based on mutual understanding
i.e. respect, empathy and trust (Gremler & Gwinner, 2008). Developing a positive relationship
with a patient enables the health practitioner to elicit pertinent information and make informed

32
clinical decisions about their treatment and ongoing care. However, rapport is more than that. It
promotes communication, collaboration, and a shared understanding of the patient’s perspective
(Abbe, Brandon, & research, 2014).The rationale behind using this technique was to make
client comfortable in sharing his feelings and telling his symptoms and history to the therapist
so they can work collaboratively and effectively for the betterment of client. Rapport building
was built by active listening, empathetic attitude, warmth & geniuses toward the client by
therapist.
3.1.12.2 Psycho Education
Psycho-education refers to the education offered to individuals with a mental health
condition and their families to help empower them and deal with their condition in an optimal
way. Psycho-education is a general term for the educational approach for assistance to offer
accurate knowledge and information about the nature and method of treatment and addressing
disease needed for cure and added with consideration for psychotherapy (Steele et al., 2013). The
rationale was educating the client to increase his knowledge and understanding of the nature, and
effects of illness.
Psycho-education was done though diagram on which client taught thoroughly the
nature of the problem and the symptoms of the problem. Client was taught that how it affect or
personal health and daily life functioning. He was also educated about the medication
compliance and therapeutic process.
3.1.12.3 Relaxation Exercises
A person who feels anxious most of the time has trouble relaxing, but knowing how to
release muscle tension can be a helpful strategy. Relaxation techniques include: progressive
muscle relaxation, abdominal breathing, Alternative nostril breathing and isometric relaxation
exercises. The rationale behind using relaxation exercises with client was to help him to relax, to
attain calmness and to reduce levels of pain and stress which was contributing in client sleep
issues.
Firstly, alternate nostril breathing was applied on the client, as he was made sit with
spine straight and feet flat on the floor. He was asked to close the right nostril with his right
thumb, and inhale through the left nostril into the belly, for a count of 4 3. After inhaling, he
was asked to hold his breath for 4 seconds to exhale through his right nostril while closing the
left with his ring and pinky finger of his right hand for 4 counts. He was further asked to repeat
steps 1 to 3, but this time start inhaling through the right nostril and vice versa. In the middle of

33
this exercise, he was asked to imagine one his best moments in his life to its fullest for best
better results. He was asked to start off practicing this breathing exercise for 2 minutes at a time
and then increase to 10 minutes for maximum benefits for at least twice a day.
Secondly, 16 progressive Muscle Relaxation exercise was used to make the client
realize that he had control upon his muscles of the body by making them tense and relax during
the pain and stress in the muscles. The training was started with the explanation of rationale of
relaxation exercise. Before starting relaxation exercise client was instructed about the
prerequisites of relaxation training. The client was asked to follow the instruction he had to
close his eye throughout the exercise and if any question raises into his mind or he wanted to
discuss something he can discuss after the exercise.
Client was instructed to make him relax and take off his glasses and watches before
relaxation exercise wear loose clothes, exercise always practice in lonely noise free room with
dim lights. There was no distractions or interruption, sitting in relaxed posture. Deep breathing
also taught to the client by demonstration. The client was demonstrated. The client was
introduced with 16 muscle group and asked him to produce tension in a group of muscle and
then gradually relax it. Subjective rating was taken before and after the exercise on0-10 scale.
Client was asked about the feedback and any difficulty he felt while performing the exercise but
he was satisfied with the procedure and feel relaxed.
3.1.12.4 Sleep Hygiene
The purpose of sleep hygiene was to educate the client and create an awareness of
lifestyle and resolve his sleep disturbances. This also helped in making sleep quality and sleep
quantity better.
The sleep guidelines provided by the therapist to client regarding his sleep issues which
included avoiding caffeine and energy drinks, try to do some walk or any exercise before sleep,
and go to the sleep when client is fully tired and don’t lay on bed when client was not sleepy at
all. If still client is awaking so leave the bed and go to any other room where he lights are dim
and try to read some book. Get up early in the morning and go to the bed early on the same time
to set down the circadian rhythms and avoid long naps in afternoon. The client was asked to
monitor his sleep time and awaking time to make it regular for every day. Client was instructed
not to use mobile when he is going to sleep. Lastly client was instructed to do muscle relaxation
exercise before sleep and repeat the steps daily to have an effective sleep patterns.

34
3.1.12.5 Thought Stopping
Client with insomnia might have inaccurate or dysfunctional thoughts about sleep that
may lead to behaviors that make sleep more difficult, which then reinforce the dysfunctional
thoughts as in prior experiences of insomnia may lead to worry about falling asleep. This worry
may lead to spending excessive time in bed to try to force sleep. Both worry and excessive time
in bed can make falling and staying asleep more challenging. This can become a frustrating,
nightly cycle that can be difficult to break. Rationale behind using this technique was to keep
the record of client’s thought and teach him the technique of thought stopping every time he
indulge in negative thoughts before going to sleep. Cognitive restructuring was used to break
this cycle through identifying, challenging, and altering the thoughts and beliefs that contribute
to insomnia. Common thoughts and beliefs of client was mostly related to anxiety about past
experiences of insomnia, and worry about daytime fatigue.
3.1.12.6 Stimulus Control Therapy
Stimulus control therapy was designed to help individuals suffering from insomnia to
strengthen the bed and bedroom as cues for sleep, to weaken the bed and bedroom as cues for
arousal, and to develop a consistent sleep wake schedule to help maintain improvement
(Bootzin & Perlis, 2011). Stimulus control therapy is the set of instructions which were given to
the client regarding his sleep issues.The first instruction was intended to help client become
more aware of his body’s cues for sleepiness and go to bed based on sleepiness, not on the
clock.
Instruction 1 is an aspirational goal to be achieved gradually over the first few weeks,
rather than as an imperative to be started immediately.
The second instruction was intended to help strengthen the cues of the bed and bedroom
with falling asleep, and weaken the cues of bed and bedroom with arousal and wakefulness.
This helped the client to create a new bedtime routine that was better suited to facilitate sleep
onset. The third and fourth instructions was about Instructing client to get out of bed if he was
not sleeping and limits him from being awake in bed, and further strengthens the association
between the bed and bedroom and falling sleep. Instruction four was incorporated for use with
sleep maintenance issues. Getting out of bed to engage in other activities when unable to sleep
strengthens a perception of control over insomnia. This makes the client’s problem less
distressing and more manageable.

35
 The goal of Instruction five was to establish client’s consistent sleep rhythm. This was
accomplished by setting a consistent wake-up time for all 7 days of the week, with less than 1
hour of discrepancy between days off and workdays it will also reduce daytime fatigue and
sleepiness. The rationale for the final instruction about not napping to strengthens the cues of the
bed and bedroom with falling asleep, and provides a success experience for the client to help
maintain compliance with the instructions.
3.1.13 Post Assessment
3.1.13.1 Subjective Rating of the Symptoms
It included comparison between pre and post assessment. The client was reassessed after
the management to determine the degree of improvement in client’s problems. Overall there
was reduction in the client’s presenting complaints.
Table 5 Showing pre and post management ratings of the client’s presenting complaints
Presenting Complaints Pre-ratings Post-ratings

Difficulty falling asleep 8 5

Fatigue during day 8 4
Difficulty staying asleep 7 4
Leg jerking during sleep 5 3

Graph 1

36
3.1.13.2 Graphical Representation of the Outcome of Management

Outcome
The overall therapeutic outcome was 30%. The pre and post rating showed that client
was improved and all of the symptoms of difficulty falling asleep, staying asleep, leg jerking
during sleep and fatigue was improved due to the implementation of therapeutic techniques.
3.1.14 Termination of Therapy
Overall, 11 sessions were conducted. The therapy was terminated because client’s
condition was improved and our time period of placement was also ended. In the 10 th session,
the client was informed by trainee clinical psychologist that sessions would be terminated after
2 days. Client was told about improvement by pre management and post management ratings of
presenting complaints. The therapy was terminated after taking client’s feedback about the
sessions which was positive.
Furthermore, therapeutic blueprint was given to client for the future management.
3.1.15 Limitations
 Proper place was not available where we can take session of the client in distraction free
environment and comfortable environment.
 Due to COVID-19 we could not do therapies in a proper settings.
3.1.16 Recommendations
 Follow up session for further improvement in the client’s problem.
37
 Family counseling should be done in order to improve client’s relationship and make the
family members aware about nature of the illness and their role in improvement.
 Sleeping schedule should be continued after termination of sessions to avoid
relapse.

38
3.1.17 Session Report
3.1.17.1 Session No. 1
Session 1 was taken with the client. The session was conducted to take the history of
client’s problem from informant and the client himself and also to build rapport with him.
Unstructured interview was done with the client to take detailed history from the client.
Client was very cooperative. He seemed little low during the session. Detailed information
was taken about the client’s present problem.
3.1.17.2 Session No. 2
Session 2 was taken with the client. Detailed history taking was continued during the
session. Mental State Examination was done with the client to assess current state of his
mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought
process, thought content, perception, cognition, insight and judgment.
3.1.17.3 Session No. 3
Session 3 was taken with the client. The goal of the session was to administer
Pittsburgh Sleep Quality Index on the client to assess his subjective sleep quality, sleep
latency, sleep duration, habitual sleep efficiency, daytime dysfunction, sleep disturbance and
use of sleeping medications. Subjective Rating was also taken from the client on 0-10 rating
so that therapist could understand the client problem form client’s perspective. Psycho-
education of the client’s problem was also done.
3.1.17.4 Session No. 4
Session 4 was taken with the client. The goal of the session was to administer
Insomnia Severity Index on the client to assess his severity of sleep issues. The information
about daily schedule of client was also taken to understand the maintaining issues of the
client’s problem.
3.1.17.5 Session No. 5
Session 5 was taken with the client. The goal of the session was to teach the client
how to make himself relax before sleep. For this purpose alternate nostrils breathing was
administered on client. Psycho-education about the sleep hygiene was also done. Client was
recommended to restrict the intake of caffeine and also given the rationale of its adverse
effects on circadian rhythms.
3.1.17.6 Session No. 6
Session 6 was taken with the client. The goal of the session was to administer
Progressive Muscles Relaxation Exercise on the client. Client was informed about the

39
purpose and pre-requisites. Then, therapist asked the client to follow the instructions given
by him. At the end client’s feedback was taken which was quite satisfactory.
3.1.17.7 Session No. 7
Session 7 was taken with the client. The goal of the session was to make client aware
of the underlying distressing thoughts that are contributing in his sleeping issues. Client was
asked to make those distressing thoughts stop every time he had them before going to sleep
by saying stop in loud voice and do previously taught relaxation exercises.
3.1.17.8 Session No. 8
Session 8 was taken with the client. The goal of session was to psych educate the
client about stimulus control therapy and its purpose which was to weaken the bedroom cues
for arousal, and to develop a consistent sleep wake schedule to help maintain improvement.
Stimulus control therapy is the set of instructions which were given to the client regarding
his sleep issues. For currently just first two instructions were given to client as it was a
gradual process. The instructions were lie down to go to sleep only when you are sleepy and
not use client’s bed for anything except sleep.
3.1.17.9 Session No. 9
` Session 9 was taken with the client. The goal of session was revision of previous
sessions and client was asked to set down his circadian rhythms by the third and fourth
instructions given in SCT which were about not to go on bed before sleep. The client was
motivated to follow the instructions to make is sleep better.
3.1.17.10 Session No. 10
Session 10 was taken with the client. The goal of session was to give remaining two
instructions mentioned in SCT and setting the realistic and short-term goals in
Client’s life.
3.1.17.11 Session No. 11
Session 11 was taken with the client. The goal of session was to terminate the
session by providing him therapy blue print. The client was recalled about all the activities
which therapist has done with the client and told him to follow those instructions in the
future.

40
3.2 Borderline Personality Disorder
Client was 22 years old widow female. She belonged to middle class nuclear family
in Multan. She studied till masters. She had 1 sister and 1 daughter. Client was presented
with the complaints of aggression, irritability, unstable relationships and abusive tendency to
control others. Both formal and informal assessment were carried out. For the informal
assessment Clinical interview, Behavioral observation, Mental Status Examination (MSE),
Subjective ratings of complaints were used. McLean Screening Instrument for BPD (MSI-
BPD) was used for formal assessment. On the basis of assessment, the client was diagnosed
with borderline personality disorder under code301.83 (F60.3). The Management plan was
applied on the basis of presenting complaints. Rapport Building was used to build trust with
client, psychoeducation about the disorder was done, and relaxation exercise was done for
relieving stress. Dialectical behavioral therapy (DBT) was used in different modules along
different techniques with client.
Mindfulness (Journaling), Distress tolerance (STOP skills, SOS box) and
Interpersonal Effectiveness (assertive training) were used. Mindfulness technique of
journaling was administered on client to identify her negative thoughts about controlling her
loved ones and her aggression along with deep breathing. STOP and SOS box techniques of
distress tolerance were administered on client for reducing the likelihood that she would
engage in behaviors that destroy relationships when she was upset. Assertive training
technique was administered to reinforce client’s self-esteem because she was standing up for
herself. Therapy was completed within 11 sessions. Client symptoms improved after the
continuation of therapeutic sessions. Client reported 30 % improvement at the termination of
sessions.
3.2.1 Identifying Data
Name J. P.

Age 22 years

Gender Female

Master in
Education
Science

Siblings 1 (Sister)

Birth Order last born

Marital status Widow

41
Children 1 daughter

Socioeconomic status Middle class

Religion Islam

Informant Client’s sister

3.2.2 Source and Reason for Referral

The client was referred to the trainee psychologist for the psychological assessment
and management of her complaints.
3.2.3 Presenting Complaints
Table 1 Presenting complaints reported by the client’s sister.
Duration Presenting Complaints

‫کچھ سالوں سےکچھ‬ .‫اسکو بہت غصہ آتا ہے‬

‫سالوں سےکچھ سالوں‬ .‫چھوٹی چھوٹی بات پہ چڑ جاتی ہے‬
‫سےکچھ سالوں‬ .‫اس کا بیٹھے بیٹھے اچانک موڈ بدل جاتا ہے‬
‫سےکچھ سالوں سے‬ .‫تالقات ٹھیک نہیں رکھ پاتی‬
.‫چاہتی ہے اسکی ہر بات مانی جائے نہیں تو غصہ کرتی ہے‬

3.2.4 History of Present Illness (HOPI)

The client J.P, age of 22 years was in an adequate state few year back. The client’s
problem of unstable relationships was started at the age of 16 after she lost her father. She
described herself as never be the same person after her father death. She developed abusive
tendency to control others who love her as if she needed attention. She had constant fights
with her friends and used to beat them. Later on, she could not make friends at university,
kept herself away from others, and did not had much activity.
Her symptoms got worsen 1 year back when her husband died, she couldn’t stand
and accepted his separation and developed intense aggression. Although she had unstable
relationship with her husband as she used to had fights on small things with him on daily
basis. After her husband’s death she became irritated and aggressive on everything. She
couldn't spend quality time even with her daughter and became irritated instead when she
cried and needed her mother. Client reported that the condition was getting worse day by
day and it had affected her personal, social and vocational life from long time.

42
3.2.5 Background Information
3.2.5.1 Personal History
J.P was born in year 1999 in a nuclear middle-class family in Multan. She was born
through normal delivery at home. Client birth order was last. She was healthy person from
her childhood and all milestones were achieved adequately such as sitting, crawling,
walking. There was no significant illness or an early neurotic trait in her childhood such as
shyness, stammering, sleep- walking etc.
As a child she was very friendly and loving. She had congenial relationship with her
friends, but after her father’s death she used to had fights with her friends and beat them.
The client had conflicted relationships with her family as well apart from her sister. She was
not good in making friends. Her hobby was watching movies and listening to songs. She
also liked going out and travelling.
3.2.5.2 Family History
Client lived in nuclear family system. She belonged to middle class family. She had
one sister whom was married and settled in life. Client herself was a last born. Client’s
father was a school teacher. He died in a road accident at the age of 54 when client was 16
years old. Client’s relation with her father was congenial. Her father was a kind person. He
used to give her full attention. The relationship of client’s parents was also congenial.
Her mother was 50 years old educated housewife. After death of client’s father, she
managed home’s expenses in pension. She described her mother as loving but strict. Her
mother treated her children equally but pampered the client more than others as she was the
youngest of all. She had conflicted relationship with her mother after her father’s death as
she was fed up from client’s aggressive and unbearable behavior towards others and with
her as well.
Client’s sister was very responsible and caring. Her sister was quite close to her and
used to share things with her and wanted her to do better in life and take care of her
daughter. Client got married at the age of 20 when she completed her B.Sc. Her husband
was supportive and caring. She was also attached with him and took good care of him but
she had unstable relationship with her husband too as because of her mood swings and
aggression, she used to have fights on small things with him on daily basis but after his
death she became quite disturbed. Client had congenial relationship with her daughter one
day and also got irritated by her other day. Client reported the environment of the home was
congenial but conflicted too when it comes to her.

43
3.2.5.3 Educational History
Client started her schooling at the age of 4 years in an English medium school .She
studied till matriculation from the same school. She was an intelligent student and never
missed her classes. She was very active in extracurricular activities and loved to go on
school trips. She had congenial relation with class mates and teachers. Her teachers loved
her as she was very obedient and friendly. Her friend circle was also quite big and all of her
friends loved her. She got 80% marks in her matriculation and was satisfied with her marks
After passing matric, her father died and then she done her intermediate and BSc from govt
college. Client reported that at that time she had conflicted relationship with all of her
previous friends and couldn't make any new friends afterwards. Moreover, she completed
her masters from the university after her marriage. She described her time at university was
better than all her education career as she married her batch mate and was much satisfied.
3.2.5.4 Sexual History
Client reported she reached her puberty at the early age of 14 years. The source of
her puberty was her eldest sister. Her reaction to puberty was satisfactory. The client didn’t
report any sexual or childhood abuse or harassment. There was also no history reported
regarding self-satisfactory acts or any repressed desire. She doesn't had any intimate
relationships.
3.2.5.5 Marital History
Client got married at the age of 20 with her batch mate of university. Her husband
was a businessman. She was attached with her husband as he was loving and caring.
Overall, her relation was congenial with her husband but because of her mood swings and
need for constant assurance and aggression, it had affected her marital life. Client’s intimate
relationship with her husband was also satisfactory. One year back, her husband died in a
car accident and it had affected client’s life.
3.2.5.6 History of Psychiatry/Medical Illness
There was no history of psychiatric or medical illness in family reported by the client
apart from mother who had high diabetes and paranoid tendencies.
3.2.5.6.1 Premorbid Personality
Client was lively person before the onset of symptoms. Her hobby was going for
outing. She had lot of friends with whom she loved to spent time. Her reaction towards
stress was not healthy. She used to share her problems with her father. After his death she
became quite disturbed.

44
3.2.6 Psychological Assessment
Assessment is the process of collecting information from multiple and diverse source
in order to develop a deep understanding. There are two types of assessment.
Informal Assessment
Formal Assessment
3.2.6.1 Informal Assessment
Informal assessment includes interview from client’s family, attendant and client
herself and behavioral observation of client.
 Behavioral Observation
 Clinical Interview
 Mental Status Examination (MSE)
 Subjective rating by client
3.2.6.1.1 Behavioral Observation.
It is widely used method of behavioral assessment which relies on recording the
behavior of a person in typical environment. Client was observed through participant
observation in outdoor setting. Participant observation is type of observation in which
therapist becomes the active member of the session and participate with client.
In behavioral observation, it was observed that client was 22 years old female with
tall height, average weight and fair complexion. She entered the room with appropriate gait
and sat on chair comfortably leaning forward towards the psychologist. Her dress was neat
and tidy. Her hair was properly tied in a ponytail. Her nails were properly trimmed. She was
able to maintain eye contact throughout the session her tone and pitch of voice was loud and
fast. She was looking furious and anxious. Restless mood was evident from client’s body
posture. Her facial expressions also revealed aggression and non-compliance. Client’s
memory was appropriate and didn’t report any delusions and hallucinations. Client was a
little resistant but willing to recover. Rapport seemed to be established with difficulty in
start as client was not friendly and was not feeling comfortable to share everything but
gradually hesitation was reduced and rapport was built.
3.2.6.1.2 Clinical Interview.
Interview is qualitative method for obtaining information. A clinical interview is a
conversation between a clinician and a client that is typically intended to develop a
diagnosis. It is basically the conversation with a purpose that the therapist does to gather all
required information about client’s background, social, cultural and present condition to
process his further assessment and management.

45
 In present case quality of information was obtained from the client and her sister.
Client was seated in the comfortable posture on the chair. She was talking in a loud tone and
she was distracted by irrelevant external stimuli. Trainee psychologist noted down client’s
information on the clinical form provided by the clinic/hospital. The clinical interview was
taken in the early 3 sessions after the rapport was developed and the client was comfortable
enough to share the history.
3.2.6.1.3 Mental Status Examination (MSE).
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam
that describes the mental state and behaviors of the person being seen. It includes both
objective observations of clinician and subjective description given by the patient. Focused
questions and observations reveal “normal” or pathological findings. It paints a picture of
patient’s appearance, thinking, emotion and cognition. The data from Mental Status Exam,
combined with clinical interview forms the data on the basis of which assessment of client is
completed.
For present case MSE served as tool to explore level of general appearance,
psychomotor behavior, mood and effect, speech, cognition and thought pattern. The client
was seated comfortably on her seat. The appearance of client was according to her age. She
maintained the eye contact throughout the sessions. The rapport was built with a little
difficulty, she was alert and tall. Her hygiene and grooming were neat and clean. The client
was responsive and interested gradually during the session. Her eye contact was glaring and
fixed. Her gait was appropriate. Her mood was dysthymic. She was noticed trying to control
her anger by tapping her legs. Her speech was loud and fast. Her attention and concentration
were intact apparently. Her short-term, long-term and remote memory was also intact. Client
was also oriented to time, place and person. Client had insight about her illness. After the
session the MSE was noted down carefully through the observation made in the session.
Table 2
The client’s Current status on area of mental Status Examination

Area of MSE Status

Appearance Appropriate

Speech Fast

Mood Aggressive

46
 Eye contact Partial Maintained

Grooming Maintained

Hallucinations Absent
Delusions Absent

Orientation of Time Present

Orientation of Person Present

Attention and concentration Average

Abstract Thinking Average

Memory Present

3.2.6.1.4 Subjective Rating.

Subjective rating helps understand subjective experience of negative symptoms, i.e.,
awareness, causal attribution, and disruption or distress. A rating 0-10-point scale is used to
identify the intensity and severity of the target problematic behaviors. 0 indicates no severity
5 indicates moderate level and 10 indicates high level of severity. The subjective rating was
taken from the client on 0-10 scale to understand the severity of client problems.
Table 3
Pre-Management Rating of Client’s Problematic Behaviors
Problematic Behavior Ratings by Client
Aggression 9
Controlling others 8
Unstable Relationships 8
Irritability 8

3.2.6.2 Formal Assessment

Formal assessment is the process of gathering information about client using
standardized, published tests or instruments with specific administration and
interpretation procedure and used to make general instructional deacons.
Following formal assessment tool was used:

47
3.2.6.2.1 McLean Screening Instrument for Borderline Personality Disorder (MSI-
BPD).
The McLean Screening Instrument for Borderline Personality Disorder (MSIBPD) is
a commonly used 10-item measure to screen for BPD. This measure was developed as a very
brief paper-and-pencil test was developed by Dr. Mary Zamorin and her colleagues to detect
possible BPD in people who are seeking treatment or who have a history of treatment.
McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) was
administered on the client and completed in 10 minutes.
Table 4
Showing raw scores with corresponding Ranges and Interpretation
Raw score Cutoff range Severity
8 7-10 Moderate
Qualitative Analysis.
Client as usually was seated at ease for the session and the room was also ventilated
and peaceful. Later on, she was provided 1 page scale along with the pencil and the eraser
and she was asked to fill the forum as per most relatable choice to her. Proper instructions
were given. She completed the scale in 10 minutes and obtained the raw score of 9 which
suggested she met the criteria for borderline personality disorder as she had complaints of
aggression, irritability, abusive tendency of controlling others and unstable relationships.
3.2.7 Case Formulation
Client was 22 years old widow female. She belonged to middle class nuclear family
in Multan. She studied till masters. She had 1 sister and 1 daughter. Client was presented
with the complaints of aggression, irritability, unstable relationships and abusive tendency to
control others. Client’s mother had paranoid tendencies and also she don’t consider her
condition that her daughter was suffering from any psychological disorder which make the
client more aggressive and it contributed in client’s current problem as predisposing factor.
According to different research studies. Children whose parents meet the criteria for BPD
are at five times greater risk than other children in the general population to acquire this
personality disorder.
The death of her father and husband one after another whom she was attached with
and also used to spend most of her time with them precipitated in her illness. Client’s father
was the only person who cared about her like no one else did and her husband loved her
despite all of her heightened emotions so, their deaths were unacceptable for client and
afterwards she became unstable in managing her relationships. Emotional pain experienced

48
by individuals with BPD is thought to be an adaptive response to repetitive traumatic
experiences in childhood such as loss of a parent. Emotional pain can lead to self-injury as
well as social problems related to difficulties regulating emotions (Holm, Berg &
Severinsson, 2009). Client then became irritable which also played a role of precipitating
factor in her illness. Multiple studies have showed that girls with greater BPD symptoms
reported more hostile irritability on occasions.
Client’s mother didn't considered her mental condition that her daughter was
suffering from any psychological disorder which makes the client more aggressive and it
boosted her tendency to control her loved ones. Her mother negligence had precipitated in
her illness. Numerous studies have suggested that BPD arises as the result of environmental
risk factors on an underlying vulnerability. Client’s sister was very caring and loving toward
the client. Apart from this, her sister constant tried to make her willing for treatment had
served as protective factors in this case. Her illness had affected her personal and social life.
Various research studies had also shown that family support can reduce the impact of stress
in individuals (Kahn, Kasky-Hernández, Ambrose, French, & Transition, 2017).
The Management plan would be used on the basis of clients’ problems that are
Rapport Building to develop trust with client. Psychoeducation about the underlying issues
would be done. Relaxation exercise would be done for relieving stress. Dialectical
behavioral therapy (DBT) would be used in different modules along different techniques
with client. Mindfulness (Journaling), Distress tolerance (STOP skills, SOS box) and
Interpersonal Effectiveness (assertive training).Mindfulness technique of journaling would
be administered on client to identify her negative thoughts about controlling her loved ones
and her aggression along with deep breathing. STOP and SOS box techniques of distress
tolerance would be administered on client for reducing the likelihood that she would engage
in behaviors that destroy relationships when she was upset. Assertive training technique
would be administered to reinforce client’s self-esteem because she was standing up for
herself.

49
 3.2.8 Case Conceptualization

Presentin Complaints
g
Aggression, Abusivetendencies
controlling
others,
Irritability
andunstablerelationships.

Assessmen
t
ClinicalInterviews,Behavioralobservation,
Mentalstatuexamination
(MSE), Subjective ratings
byclientandTheMcLean sScreening
Instrument for Borderline
Personality
Disorder (MSI-BPD).

Precipitating
Predisposin Factor
g Factor Maintaining factor
Deathof herfather. Protectiv Factors
Unawarenessof her
Hermother’s e
motherregarding Supportiv
sister
paranoid Herhusband
’s
disorder. e .
tendencies. death
.

Management

Diagnosis RapporBuilding, Outcome

Psychoeducation
t
Borderline ,RelaxatioTechnique The rate of
(dee
n breathing),cos
s change in the
Personality benefi
p t analysisDialectal
Behavioral
t , Therap client’s
Disorder under code (Journaling,STOP
y
301.83 (F60.3). skills,SOSboxan symptoms
assertivtraining
d was 30 %.
e )
Figure 2:3.2.8 Case Conceptualization

50
3.2.9 Diagnosis
On the basis of formal and informal assessment, the client was diagnosed with
Borderline Personality Disorder under code 301.83 (F60.3).
3.2.10 Prognosis
As for the prognosis there are chances for recovery exist due to supportive sister and
client’s willingness for the treatment.
3.2.11 Management Plan
3.2.11.1 Long Term Goals
 Continuation of Short- term goals.
 To reduce overall frequency, intensity, and duration of underlying negative thoughts
about abandonment by loved ones.
 Follow up sessions of the short-term goals will be done to increase efficacy of the
therapy.
3.2.11.2 Short Term goals
 Rapport would be built with the client to develop trustful relationship between client
and therapist.
 Psycho-education would be done through diagram on which client would be taught
about illness.
 Alternate nose breathing exercise along with guided imagery would be used for
relieving stress. Training would be start by explaining the rationale and prerequisites of
relaxation exercise.
 Cost-benefit analysis would be used for acknowledging her about cost and benefits of
her negative thoughts and irritable behavior.
 Journaling would be used to keep track of client’s negative thoughts.
 STOP skills would be used for controlling her impulsive emotions.
 SOS box would be used for self-soothing in stressful situation.
 Assertive training would be used for interpersonal effectiveness.
3.2.12 Summary of Therapeutic Interventions
3.2.12.1 Rapport Building
Rapport is the development of a therapeutic relationship based on mutual
understanding i.e., respect, empathy and trust (O'Toole, 2008). Developing a positive
relationship with a patient enables the health practitioner to elicit pertinent information and

51
make informed clinical decisions about their treatment and ongoing care (Barnett, 2001).
However, rapport is more than that. It promotes communication, collaboration, and a shared
understanding of the patient’s perspective (Norfolk, Birdi &Walsh, 2007).
The rationale behind using this technique was to make client comfortable in sharing
her feelings and telling her symptoms and history to the therapist so they can work
collaboratively and effectively for the betterment of client. Client was seated comfortably in
the chair. Rapport established with difficulty in start as client was not friendly and was not
feeling comfortable to share everything but gradually hesitation was reduced and rapport
was built during the session by active listening, empathetic attitude, warmth & geniuses
toward the client by therapist.
3.2.12.2 Psycho Education
Psycho-education refers to the education offered to individuals with a mental health
condition and their families to help empower them and deal with their condition in an
optimal way. Psycho-education is a general term for the educational approach for assistance
to offer accurate knowledge and information about the nature and method of treatment and
addressing disease needed for cure and added with consideration for psychotherapy. It is
useful to achieve most realistic goals and for motivation of the client and family.
The rationale behind using this technique was to initiate intervention plan as
therapist comprehensively explains nature, etiology, management of illness, prognosis, and
time required therapy. Client herself and her sister were psycho-educated regarding the
nature of the problem, management and relapse.
3.2.12.3 Relaxation Techniques
A person who feels anxious most of the time has trouble relaxing, but knowing how
to release muscle tension can be a helpful strategy. Relaxation techniques include:
progressive muscle relaxation, abdominal breathing, Alternative nostril breathing and
isometric relaxation exercises (Matsumoto & Smith, 2001). The rationale behind using
relaxation exercises with client was to help her to relax, to attain calmness and to reduce
levels of pain and stress which is contributing in her aggressive behavior as well.
Alternate nostril breathing was applied on the client, as she was made sit with spine
straight and feet flat on the floor. She was asked to close the right nostril with her right
thumb, and inhale through the left nostril into the belly, for a count of 4 3. After inhaling,
she was asked to hold her breath for 4 seconds to exhale through her right nostril while
closing the left with her ring and pinky finger of her right hand for 4 counts. She was further
asked to repeat steps 1 to 3, but this time start inhaling through the right nostril and vice

52
versa. In the middle of this exercise, she was asked to imagine one her best moments in her
life to its fullest for best better results. She was asked to start off practicing this breathing
exercise for 2 minutes at a time and then increase to 10 minutes for maximum benefits for at
least twice a day. Along with it one of her best life events was used as Guided Imagery.
3.2.12.4 Cost Benefit Analysis
In cognitive behavioral therapy (CBT), this technique has been adapted for use in
cognitive restructuring. Put more simply, a cost/benefit analysis can be used to challenge
old, unhealthy patterns of thinking, allowing them to be replaced by new, more adaptive
thought. The client was seated comfortably in the chair and after doing relaxation exercise
client asked to write down costs and benefits of her negative thoughts to explain her that the
costs of her irritability for loved ones would always be more than the benefits and it was
nothing but making her cost her mental health.
3.2.12.5 Dialectical Behavioral Therapy (DBT)
Dialectical behavioral therapy (DBT) is a type of cognitive behavioral therapy. DBT
may be used to treat BPD and other self-destructive behaviors. It teaches patients skills to
cope with, and change, unhealthy behaviors. Dialectical behavioral therapy (DBT) was used
in different modules along different techniques with client. Mindfulness (Journaling),
Distress tolerance (STOP skills, SOS box) and Interpersonal
Effectiveness (assertive training) Mindfulness technique of journaling was
administered on client to identify her negative thoughts about controlling her loved ones and
her aggression along with deep breathing. STOP and SOS box techniques of distress
tolerance were administered on client for reducing the likelihood that she would engage in
behaviors that destroy relationships when she was upset. Assertive training technique was
administered to reinforce client’s self-esteem because she was standing up for herself.
3.2.12.6 Journaling
Journaling used to focus on what client’s thinking, feeling, and writing about. In the
process, client may just get to know herself and what she think a little bit better. Client was
instructed to start journaling by checking in with herself just once a day. The rationale
behind using this technique was to keep the track of client’s negative thoughts and to make
her aware about where they are coming from. Client was asked to set intentions for her day
when she wake up, wind down before going to sleep and refocus mind during an afternoon
energy slump.

53
3.2.12.7 STOP Skills
The STOP skill stands for stop, take a step back, observe, and proceed mindfully. It
is helpful to think of what we would do when approaching a stop sign to remember this
acronym. It also allows time for us to feel back in control over our emotions, instead of the
other way around. The rationale behind using this technique was to reduce the likelihood
that she would engage in behaviors that destroy relationships (e.g., physical aggression)
when she was upset. Client was asked to picture a stop sign and follow its steps. Firstly,
Stop do not just react because her emotions might try to make her act without thinking so
stay in control and take a step back from the situation by taking the deep breath and do not
let feelings put her over the edge and make her act impulsively then, observe the situation
and take know how of her feelings and emotions. Lastly, act with awareness of her thoughts,
actions and consequences.
3.2.12.8 SOS box
SOS box basically contains range of sensory things and something to focus person
mind on. It could include something to smell, something to touch, something to look at and
maybe even something to taste according to the preference of person. The rationale behind
using SOS box to indulge client in self-soothing task when she wanted to act with
impulsively or irritably in a situation. The SOS box given to the client contained candles,
soothing music tape, incense, chew gum and creamy lotion.
3.2.12.9 Assertive Training
Assertiveness is an important weapon in the BPD recovery toolbox because it allows
the person to maintain healthy relationships with the people they most care about. Without
knowing assertive communication, the person may be backed into one corner after another
where they can become either aggressive or passive-aggressive in order to make themselves
heard. These kinds of communication strategies can erode trust in relationships and destroy
intimacy. When a person learns how to speak assertively, many things happen. The rationale
behind using this technique was to reinforce client’s self-esteem because she was standing
up for herself. It would give her an opportunity to say how she feel about things and without
allowing herself to feel invalidated by the other person’s response. Assertive training
administered on client with the brief instructions that it would help her learn to love herself,
because it gives her a productive way of dealing with her negative feelings and,
consequently, her bad perception of her selves. Instead of acting out, she now had a way to
talk about things bothering her, meaning more people can be open to listening to her instead
of either tuning them out or just dismissing and/or pushing them away.

54
3.2.13 Post Assessment
3.2.13.1 Subjective Rating of the Symptoms
It included comparison between pre and post assessment. The client was reassessed
after the management to determine the degree of improvement in client’s problems.
Overall there was reduction in the client’s presenting complaints.
Table 5
Comparison of Pre-management and Post-management Severity Rating of the Client’s
Problem
Problem Behavior Pre-management Post-management
Aggression 9 7
Controlling others 8 6
Unstable Relationships 8 6
Irritability 8 6

Graph 1
3.2.13.2 Graphical Representation of the Outcome of Management

Outcome.
After applying therapeutic interventions, the overall therapeutic outcome was
satisfactory as client’s irritable mood and sleep issues were reduced. The pre management
rating of the client’s symptoms were 85 % and post management ratings were 55 %. The
rate of change in the client’s symptoms was 30 % according to the subjective ratings of the
symptoms of the client.

55
3.2.14 Termination of Therapy
Overall, 11 sessions were conducted. The therapy was terminated because client’s
condition was improved and our time period of placement was also ended. In the 10 th
session, the client was informed by trainee clinical psychologist that sessions would be
terminated after 2 days. Client was told about improvement by pre management and post
management ratings of presenting complaints. The therapy was terminated after taking
client’s feedback about the sessions which was positive. Furthermore, therapeutic blueprint
was given to client for the future management.
3.2.15 Limitations
• There were many sources of distractions for the client during sessions.
• The seating was not appropriate for taking individual sessions.
3.2.16 Recommendations
• A separate place for individual sessions should be available.
• Family therapy should be done to make her relationship effective with her family
members.
• Management techniques should be continued after termination of sessions to avoid
relapse.

56
3.2.17 Session Report
3.2.17.1 Session no 1
The first session of the client was focused on rapport building and history about the
present illness which was established by asking the client’s likes dislikes following with a
clinical interview. The client was told about the purpose of the meeting and the role of the
therapist.
3.2.17.2 Session no 2
The second session a formal interview was taken from the client in order to explore
the history of the client’s problem and family background. Psycho-educate the client about
her problem and helped her to gain insight. Rapport was built.
3.2.17.3 Session no 3
A clinical interview was conducted along with mental status examination. In this
session client was asked to do deep breathing for relaxation. Compliance was observed and
the client seemed to respond well in the session.
3.2.17.4 Session no 4
The session started with the bridges of the previous session so that the client can
realize that the counsellor has been listening to her carefully which builds the rapport more
strongly. Along with the bridging more history was taken from the client and the client was
opening up easily. A lot of bio data was gathered in the session. After history taking
mindfulness was practiced and subjective rating was taken from client.
3.2.17.5 Session no 5
As the session started the client was welcome and mirroring was done throughout the
session to evaluate data which the client has yet not opened up about. The interview was left
unstructured and the client was made comfortable to speak as her will. After the discussion
MSI-BPD test was introduced to the client and given to attempt.
3.2.17.6 Session no 6
In the session bridging and mirroring was done to relate this session with the past one
to techniques. Cost benefit analysis technique was used to help the client know about the
risks of negative thoughts and behavior.
3.2.17.7 Session no 7
In this session, DBT was introduced to the client and afterwards client was asked to
keep the journal of her thoughts on daily basis. The goal of journaling was to keep track of
client’s negative thoughts

57
3.2.17.8 Session no 8
The session started with bridges and active listening the client was explaining how
workful the assignments and techniques had been for her. STOP skills was introduced to the
client, the goal was to control her impulsive emotions.
3.2.17.9 Session no 9
The session was moved over with welcome and bridges of previous session.
Information related assignment and progress was done. In this session self-soothing skills
were taught to the client and given SOS box for using in stressful situations.
3.2.17.10 Session no 10
In this session discussion about the whole process and techniques was taka place and
effectiveness of the treatment course was discussed. Assertive training was given for
interpersonal effectiveness. Termination were introduced.
3.2.17.11 Session no 11
In this session the client’s debriefing were conducted. In this session the client was
recommended to come for follow-up if she feels reverse in her illness.She was asked to keep
practicing techniques taught. The case was terminated.

58
3.3 Cocaine Use Disorder
A.A a male of 27 years of age He belonged to middle class nuclear family in Multan.
He studied till matric. He had two brothers. Client was presented with the complaints of drug
addiction, cravings, irritable mood, restlessness, sleep issues and arguments at home. Both
formal and informal assessment were carried out. For the informal assessment Clinical
interview, Behavioral observation, mental status examination (MSE) and Subjective ratings
of complaints were used. Drug Abuse Screening Test (DAST 10) was used for formal
assessment. On the basis of assessment, the client was diagnosed with Cocaine use Disorder
under code 304.20 (F14.10). The Management plan was applied on the basis of presenting
complaints. Rapport Building to develop trust with client. Psychoeducation about the
underlying issues was done.
Deep breathing along with alternative nostril breathing would be done for
restlessness. Motivational interviewing would be used to make positive changes from the
client’s problem. Cost-benefit analysis would be used for acknowledging him about benefits
of leaving drugs and consequences of continuing drug use. Thought stopping would be used
to control his cravings. STOP skills was used for controlling his aggressiveness. The Double
column technique was used for the purpose of educate and shake the irrational belief of the
client about cocaine intake. Covert sensitization was used to control his cocaine addictive
behavior by linking the worst aversive situation to the craving of cocaine use. Sleep hygiene
was used to manage his sleep issues. Therapy was completed within 11 sessions. Client
symptoms improved after the continuation of therapeutic sessions. Client reported 23%
improvement at the termination of sessions.
3.3.1 Identifying Data
Name A.A

Age 27 years

Gender Male

Education Matric

No. of Siblings 2 brothers

Birth Order 1st

Occupation Worker

Marital Status Single

Socioeconomic status Middle class

59
Religion Islam

Client
Informant himself

3.3.2 Source and Reason for Referral

The client was referred to the trainee psychologist for the psychological assessment
and management of his complaints.
3.3.3 Presenting Complaints
Table 1
Presenting Complaints of the Client as reported by the Client
Duration Presenting Complaints

‫ سال سے‬2 .‫مجھے نشے کی طلب محسوس ہوتی ہے‬

‫ سال سے‬2 .‫نشہ نہ کروں تو بے چینی محسوس ہوتی ہے‬
‫ سال سے‬2 .‫لڑای جھگڑے ہوتے ہیں‬
‫ سال سے‬2 ‫نید نہیں آتی‬

3.3.4 History of Present Illness (HOPI)

A.A a male of 27 years of age. He belonged to a middle-class nuclear family. He was
14 years old when he was sent to a madrassa to study Holy Quran. The Qari there used to
give marijuana to his students who himself was an addict. Even though the client left the
madrassa after 2/3 months but he became addicted to it. He used to get marijuana from one
of his madrassa’s friends despite family opposition. The frequency of marijuana was 1/2
gram for everyday for 1 year. Later on, his father restricted his pocket money and stopped
him from going out with his madrassa’s friends for 6 months. In that time duration, his
father who was chain smoker himself handled his withdrawal symptoms at home. After that,
client never used any kind of drug.
Then in 2018 after a relationship breakup client started sniffing Cocaine (white
powder). A friend of him was on drugs so he went to him to get some because he couldn't
accept the reality. The first time he took cocaine was as much as a pinch of a salt, later on he
increased the amount into half gram. After about half gram, he started taking cocaine in
injections. One of his friends used to take cocaine in injection. His friend would inject him
with cocaine (white powder). The frequency increased from half gram to 2 grams per day.
His family couldn't bear his addictive behavior anymore and as a result arguments on daily
basis started at home and now client himself was tired of this situation and wanted to get

60
recovery from drug addiction due to his argumentative behavior and disturbed environment
of the home. He was admitted at clinic as inpatient. He had gone through the procedure of
detoxification which also triggered his complaints from past 3 weeks.
3.3.5 Background Information
3.3.5.1 Personal History
A.A was born in year 1992 in a middle-class nuclear family in city Multan. He was
born through normal birth. He was healthy child and all milestones were achieved
adequately such as sitting, crawling, walking. There was no significant illness or an early
neurotic trait in his childhood such as shyness, stammering, sleep- walking etc.
He grew- up in a home environment where he was loved and cared. He had always
been aggressive as a child. The client was devoted towards the religion and used to read
Quran and would try his best to offer his daily prayers. He had always been helping needy
people. His hobby was playing cricket and watching movies.
3.3.5.2 Family History
The client belonged to a middle-class nuclear family. He had 2 brothers. Client
himself was a first born. His father was 65 years old. He had done matric and had his own
business of wall decor. He was head of the family. Client’s father had congenial relationship
with his children but a little conflicted after client’s drug addiction. Client’s father was a
chain smoker from his teenage. Client’s mother was 40 years old. She was a house wife.
Client described her as strict in part of rules and obedience for her sons yet she was caring
and loving. She had a congenial relationship with her husband.
Client’s brothers were younger then him and used to obey him. They were respectful
to him and would abide by his instructions. When client started taking drugs his brothers got
angry with him and avoided to talk to him. Overall, his home environment was congenial
but because of strictness of obeying rules he became aggressive and irritated.
3.3.5.3 Educational History
He was 4 years old when he started schooling at a govt. school near his home. When
he turned 14 years old his father sent him to the madrassa nearby to learn Quran and
religious affairs. He used to spend lot of his time in madrasa. Along with that he had made
friends in school with whom he used to spend most of his time. He had great interest in
cricket sport for which he used to skip his school at times. He was active in co-curricular
activities. His relationship with his teachers was satisfactory. Islamiyat was one of his
favorite subjects. He never liked math as a subject. He had done his matric with above
average grades from the same school and he was satisfied about it.

61
3.3.5.4 Occupational History
Initially, client worked in a tile shop as his first job in 2016 for 6 months because he
wanted to prove himself to his father that he could do work and earn money independently
but then he left this job as he wasn’t satisfied with his work and salary. Then in 2017, he
started working in his own wall decor shop. He worked responsibly and guided his juniors
when needed. He was completely satisfied with his job. Later on, in 2018 after his drug
addiction he used to get in arguments and fights with his employees because of which his
father keep shouting on him at workplace. In 2019 he left this job and was currently
unemployed.
3.3.5.5 Sexual History
The client reached his puberty when he was 15. He got educated about puberty and
development of secondary sex characteristics from his friend. His reaction to puberty was
uncomfortable but he got adjusted to it later on. The client didn’t report any sexual or
childhood abuse or harassment. There was also no history reported regarding self-
satisfactory acts or any repressed desire. He developed likeliness for one of his cousin and
he was in relationship with her and also wanted to marry her but her parents rejected him
after which he went through a severe heart break.
3.3.5.6 History of Psychiatric Illness in Family
There was no history of psychiatric or medical illness in family reported by the client
apart from his father was a chain smoker and younger brother had epilepsy.
3.3.6 Psychological Assessment
Assessment is the process of collecting information from multiple and diverse source
in order to develop a deep understanding. The client was assessed in order to obtain
information about his strengths and needs that could be worked upon. Assessment was done
to assess the level of the problematic behaviors, their nature and stimulus leading and
strengthening his behavior. In order to do the complete assessment apart from observation,
other procedures were also used such as the following:
Informal Assessment
Formal Assessment
3.3.6.1 Informal Assessment
Informal assessment includes interview from client’s family, attendant and client
himself and behavioral observation of client.
• Clinical Interview
• Behavioral Observation

62
 • Mental Status Examination
• Subjective rating
3.3.6.1.1 Behavioral Observation.
It is widely used method of behavioral assessment which relies on recording the
behavior of a person in typical environment. Client was observed through participant
observation in outdoor setting. Participant observation is type of observation in which
therapist becomes the active member of the session and participate with client.
In behavioral observation, it was observed that client was 27 years old male with average
height and weight along with fair complexion. He entered the room with hesitant gait and sat
on chair leaning forward towards the psychologist. He was wearing shirt and trouser. His
appearance was clean. His clothes were neat and tidy. His nails were unclipped and dirty.
His hairs was not properly combed. Restless mood was evident from client’s body posture.
His facial expressions also revealed aggression. Client’s memory was appropriate and he
didn’t report any delusions and hallucinations. His eye contact was maintained throughout
the session. The pitch of his voice was loud and clear. Rapport seemed to be established
with difficulty in start as client was not friendly but gradually hesitation was reduced and
rapport was built.
3.3.6.1.2 Clinical Interview.
Interview is qualitative method for obtaining information. In present case quality of
information is obtained from the client. The information is noted down on the clinical form
provided by the clinic/hospital (Hacker & Thorpe, 2004). In present case clinical interview
was obtained from the client. Client was seated in the comfortable posture on the chair. He
was talking in a loud tone and he was distracted by irrelevant external stimuli. Trainee
psychologist noted down client’s information on the clinical form provided by the clinic.
The clinical interview was taken in the early sessions after the rapport was developed and
the client was comfortable enough to share the history. According to the client he was
having somatic complaints due to detoxification and had hard time controlling his cravings.
3.3.6.1.3 Mental State Examination (MSE).
The Purpose of Mental State Examination to get detail information about
individual’s conscious condition along with mood, thought process and insight of individual.
For present case MSE served as tool to explore level of general appearance, psychomotor
behavior, mood and effect, speech, cognition and thought pattern. The client was seated
comfortably on his seat. After the session the MSE was noted down carefully through the
observation made in the session. The appearance of client was according to his age. He

63
maintained the eye contact throughout the sessions. He was alert and attentive. His nails
were long and dirty. The client was responsive and interested during the session. His eye
contact was glaring and fixed. His gait was hesitant and uncoordinated. Mild anxiety was
evident from his mood. His speech was rapid, soft but loud. His clarity was mumbled and
offered a lot of information.
3.3.6.1.4 Subjective Rating.
Subjective rating helps understand subjective experience of negative symptoms, i.e.,

awareness, causal attribution, and disruption or distress. A subjective rating was taken from
the client to understand the severity client experiences.
Table 2
Pre-Management Rating of Client’s Problematic Behaviors
Problematic Behavior Ratings by Client

Sleep disturbance 6

Cravings 5

Restlessness 5

Argumentative behavior 4

3.3.6.2 Formal Assessment

Formal assessment is the process of gathering information about client using
standardized, published tests or instruments with specific administration and interpretation
procedure and used to make general instructional deacons.
Following formal assessment tool was used:
3.3.6.2.1 Drug Abuse Screening Test (DAST).
The Drug Abuse Screening Test (DAST-10) is a 10-item brief screening tool which
can be self-reported or administered by a clinician. Each question requires a yes or no
response, and the tool can be complete in less than 8 minutes (Skinner, 1982).
The rationale of the test was to access drug use (not alcohol or tobacco use) in the
past 12 months. The client was seated comfortably on the chair. Then he was provided with
a forum paper along with pencil and eraser. He had to complete the given sentences.
Simple and complete instructions were given to him.
Table 3
Representing the Interpretation of DAST.

64
 Rawscore Range Degree
6 9-10 Moderate
level

Qualitative Interpretation.
Client as usually was seated at ease for the session and the room was also ventilated
and peaceful. Later on, he was provided 1 page scale along with the pencil and the eraser
and he was asked to fill the forum as per most relatable choice to him. Proper instructions
were given. The client was asked 10 questions regarding his drug intake behavior which
required yes and a no. Client scored yes on 6 items and no on 4 items. He confirmed that he
used drugs other than medical reasons (item 1), had been using more than 1 drug at a time
(item 2), felt bad and guilty because of drug use (item 5), parents complaining about
involvement in drugs (item 6), neglected family because of drug use (item 7), has
experienced withdrawal symptoms when stopped taking drugs (item 9). He scored no in
item 3 i.e., “are you always able to stop using drugs when you want to”, item 8 “engaged in
illegal activities in order to obtain drugs”, item4 “had flashbacks as a result of drug use” and
item 10), “had medical problems as a result of drug use” .The client overall showed
moderate level of drug addiction.
3.3.7 Case Formulation
A case formulation is a hypothesis about the psychological mechanisms that cause
and maintain an individual’s symptoms and problems (Kuyken et al., 2009; Persons, 2008).
A.A was a 27-year-old single male. He belonged to a middle-class nuclear family. He had 2
brothers and was first born himself. He was referred to the trainee psychologist, for the
assessment and management of his presenting complaints which were drug addiction,
cravings, irritable mood, restlessness, sleep issues and arguments at home. His father was a
chain smoker and Qari from whom he learned Quran used to give marijuana to his students
who himself was an addict. So, client himself started taking marijuana which played a role
as a predisposing factor in contributing his illness. Goldman (2009) study have suggested
that an individual’s risk tends to be proportional to the degree of genetic relationship to an
addicted relative.
Client had a breakup with his cousin whom he wanted to marry but her parents
rejected him after which he went through a severe heart break and started taking drugs
which contributed as a precipitating factor in his illness. A growing clinical literature
indicates that there is a link between substance abuse and life stressors. He used to stay with
his social group of friends who were also addicts and he also had access to drugs through

65
them because of which his illness was maintained. He was also stubborn and would prefer to
make his own decisions. Researches have suggested that young people abuse drugs due to
complex social and peer groups influence, frustration, depression, curiosity, sub-cultural and
psychological environment that induce the youths to take drugs (Ahmed,2019).His parents
were completely supporting him and wanted him to recover which served as protective
factor in this case. He himself had insight about his illness and wanted to get rid of
addiction. Various research studies had also shown that family support can reduce the drug
intake in individuals (Kahn, Kasky-Hernández, Ambrose, French, & Transition, 2017).
The Management plan would be used on the basis of problems that are Rapport
Building to develop trust with client. Psychoeducation about the underlying issues would be
done. Deep breathing along with alternative nostril breathing would be done for restlessness.
Motivational interviewing would be used to make positive changes from the client’s
problem. Cost-benefit analysis would be used for acknowledging him about benefits of
leaving drugs and consequences of continuing drug use. Thought stopping would be used to
control his cravings. STOP skills would be used for controlling his aggressiveness. The
Double column technique would be use for the purpose of educate and shake the irrational
belief of the client about cocaine intake. Covert sensitization would be used to control his
cocaine addictive behavior by linking the worst aversive situation to the craving of cocaine
use. Sleep hygiene would be used to manage his sleep.

66
3.3.8 Case Conceptualization

Presentin Complaints
g
Drugaddiction,cravings,
irritablemood,restlessness,
sleepissuesandarguments a home
t

Assessmen
t
ClinicalInterviews,
Behavioralobservation,
Mentalstatuexamination
(MSE), SubjectiveratingsbyclientandDrugAbusesScreening
Test(DAST
10).

Predisposing Maintaining
Factor Precipitating factor
Factor ProtectivFactors
Fatherwasa chain His addictive
social e
smoker. His relationship circle. Supportive
family.
breakup withhis
Client’s Qariwas Easyaccess
to Clientwillingness
cousin.
anaddictandused drugs. for treatment
togivemarijuana .
tohim.

Management
Rapport Building,
Psychoeducation,
Diagnosi Relaxation Techniques Outcome
s (deepbreathing),cost
benefitanalysis, Therat of
Motivational e in th
change
CocaineuseDisorder ’s e
client
interviewing,Thought
undercode304.20 symptoms is
stopping, STOP
(F14.10). skills,d
oublecolumn 23%
technique, andSleep
hygiene.

Figure 3:3.3.8 Case Formulation

67
3.3.9 Diagnosis
On the basis of formal and informal assessment, the client was diagnosed with
cocaine use disorder under code 304.20 (F14.10).
3.3.10 Prognosis
As for the prognosis there are chances for recovery exist due to supportive family
and client’s willingness for the treatment.
3.3.11 Management Plan
3.3.11.1 Short Term Goals
 Rapport would be built with the client to develop trustful relationship between client
and therapist.
 Psycho-education would be done through diagram on which client would be taught
about illness.
 Alternate nose breathing exercise along with guided imagery would be used for
managing client’s restlessness. Training would be start by explaining the rationale and
prerequisites of relaxation exercise.
 Motivational interviewing would be used to make positive changes from the client’s
problem.
 Cost-benefit analysis would be used for acknowledging him about benefits of leaving
drugs and consequences of continuing drug use.
 Thought stopping would be used to control his cravings.
 STOP skills would be used for controlling his aggressiveness.
 The Double column technique would be use for the purpose of educate and shake the
irrational belief of the client about cocaine intake.
 Covert sensitization would be used to control his cocaine addictive behavior by linking
the worst aversive situation to the craving of cocaine use.
 Sleep hygiene would be used to manage his sleep issues.
3.3.11.2 Long Term Goals
 Continuation of Short- term goals.
 Follow up sessions of the short-term goals would be done to increase efficacy of the
therapy.

68
3.3.12 Summary of Therapeutic Interventions
3.3.12.1 Rapport Building
Establishing rapport is central to any health professional-patient encounter (Leach,
2005). Rapport is the development of a therapeutic relationship based on mutual
understanding i.e., respect, empathy and trust (O'Toole, 2008). Developing a positive
relationship with a patient enables the health practitioner to elicit pertinent information and
make informed clinical decisions about their treatment and ongoing care (Barnett, 2001).
The rationale behind using this technique was to make client comfortable in sharing
his feelings and telling his symptoms and history to the therapist so they can work
collaboratively and effectively for the betterment of client.
Client was seated comfortably in the chair. Rapport established with difficulty in
start as client was not friendly but gradually hesitation was reduced and rapport was built
during the session by active listening, empathetic attitude, warmth & geniuses toward the
client by therapist.
3.3.12.2 Psycho Education
The first and foremost step of the treatment should be to make the client and his
family fully aware of the nature of his problem, the factors responsible for it, prognosis,
the nature of treatment and the intended duration of the treatment (Davison & Neale,
2014).
The rationale behind using this technique was to initiate intervention plan as therapist
comprehensively explains nature, etiology, management of illness, prognosis, and time
required therapy.
Client’s family was also psycho-educated about the nature of problem of the client
and etiology and management of the problem. It was explained to the client’s family that
how they would participate in the management and what they have to do.
(D3)
3.3.12.3 Relaxation Training
A person who feels anxious most of the time has trouble relaxing, but knowing how
to release muscle tension can be a helpful strategy. Relaxation techniques include:
progressive muscle relaxation, abdominal breathing, and Alternative nostril breathing and
isometric relaxation exercises.
Alternate nostril breathing was applied on the client, as he was made sit with spine
straight and feet flat on the floor. He was asked to close the right nostril with his right
thumb, and inhale through the left nostril into the belly, for a count of 4 3. After inhaling, he

69
was asked to hold his breath for 4 seconds to exhale through his right nostril while closing
the left with his ring and pinky finger of his right hand for 4 counts. He was further asked to
repeat steps 1 to 3, but this time start inhaling through the right nostril and vice versa. In the
middle of this exercise, he was asked to imagine one his best moments in his life to its
fullest for best better results. He was asked to start off practicing this breathing exercise for
2 minutes at a time and then increase to 10 minutes for maximum benefits for at least twice
a day.
3.3.12.4 Motivational interviewing
The motivational interview is defined as “A client-centered, directive method for
enhancing intrinsic motivation to change by exploring and resolving ambivalence. “The
rationale behind the use of motivational interviewing was to engage clients, elicit change
talk, and evoke motivation to make positive changes from the client’s problem. Engaging
would be used to involve the client in talking about issues, concerns and hopes, and to
establish a trusting relationship with a counselor. Focusing would be used to narrow the
conversation to habits or patterns that clients want to change. Evoking would be used to
elicit client motivation for change by increasing clients' sense of the importance of change in
his behavior, their confidence about change, and their readiness to change in his addiction.
3.3.12.5 Cost Benefits Analysis
In cognitive behavioral therapy (CBT), this technique has been adapted for use in
cognitive restructuring. Put more simply, a cost/benefit analysis can be used to challenge
old, unhealthy patterns of thinking, allowing them to be replaced by new, more adaptive
thoughts the rationale behind using this technique would be for acknowledging him about
benefits of leaving drugs and consequences of continuing drug use. The client was seated
comfortably in the chair and after doing relaxation exercise client was asked to write all the
benefits of leaving cocaine use and consequences of continuing cocaine use that how it can
be damaging for himself. By acknowledging it he would be able to leave the addiction habit.
3.3.12.6 Thought Stopping
Thought-stopping refers to the process of deliberately ignoring a self-defeating
thought, and replacing it with an empowering one. To stop a negative or self-destructive
thought one has to follow cease, calm and change strategy. The rationale behind the usage of
this technique was to control his cravings. Client was explained that in cease the client had
to distract himself such as ways to stop drugs cravings, it would be clapping one’s hands
loudly several times, suddenly standing up and jumping, snapping a rubber band on one’s
wrist, and picturing a huge “stop: burning lungs!” sign in one’s mind. In calm, execute

70
breathing exercises, listen to relaxing music, and visualize a peaceful seaside or mountain
top. Prayer would also help at this stage; surrender to God as you understand him to be all
your worries, tiredness, and frustration. At last, in change it’s time to deliberately transform
negative thoughts into positive ones. This process is called reframing: changing perspective
on a situation so that client can see an angle you haven’t thought about before. For example,
client can stop thinking of his craving as a withdrawal symptom. Instead, think of it as a
symptom of recovery. If you can conceptualize your frustration as a positive thing, you can
better manage your emotions.
3.3.12.7 Double Column Technique
The Double column technique was used for the purpose of educate and shake the
irrational belief of the client about cocaine intake. Client was asked to give alternative
thought or behavior to yourself in those all situations by imaging that what would you do in
those situations if you don’t have the choice of cocaine. In this way after doing the practice,
firstly with help and suggestions and then without assistance client was asked to provide
himself an alternative behavior in same situation.
3.3.12.8 STOP Skills
The STOP skill stands for stop, take a step back, observe, and proceed mindfully. It
is helpful to think of what we would do when approaching a stop sign to remember this
acronym. It also allows time for us to feel back in control over our emotions, instead of the
other way around. The rationale behind using this technique was to reduce the likelihood
that he would engage in behaviors that destroy relationships (e.g., physical aggression) when
he was angry. Client was asked to picture a stop sign and follow it’s steps. Firstly, Stop do
not just react because his emotions might try to make him act without thinking so stay in
control and take a step back from the situation by taking the deep breath and do not let
feelings put him over the edge and make him act impulsively then, observe the situation and
take know how of his feelings and emotions. Lastly, act with awareness of his thoughts,
actions and consequences.
3.3.12.9 Covert Sensitization
Covert sensitization is a behavioral therapy used in the reduction of addictive
behavior. Covert sensitization is based on the principles of classical conditioning and
involves a person creating an imagined unpleasant association between the addictive
behavior (e.g. smoking, gambling) and an unpleasant stimulus for example the pain created
by an electric shock (Suneel & Siddique, 2020). The rationale behind this technique was to
control his cocaine addictive behavior by linking the worst aversive situation to the craving

71
of cocaine use. Client was asked to write a list of situations in which he had urge of cocaine
intake and after that client was asked to write the most aversive situations for himself along
with brief instructions. When client completed both lists then he was asked to rate 10 to the
most aversive situation. After that client was asked that he had to imagine that he went to his
friend for taking cocaine and asked him that when he imagined the whole situation then
raise his finger, when he raised his finger client was then asked to imagine a dead dog was
lying there where he used to sit and inject cocaine and accidently he stepped onto the dead
dog and the smell was unbearable. He imagined that situation and raised his finger and then
after that client was asked to imagine that there was a scented flowers garden nearby, go
there, the client went there and took deep breaths then, client was asked to open his eyes and
terminates the situation. Client was asked that whenever he had craving about cocaine then
he had to repeat this step.
3.3.12.10 Sleep Hygiene Therapy
The purpose of sleep hygiene is to educate the client and create an awareness of
lifestyle and resolve his sleep disturbances. This also help making sleep quality and sleep
quantity better (CDC, 2016).The sleep guidelines provided by the therapist to client
regarding his sleep issues which included avoiding caffeine and energy drinks, try to do
some walk or any exercise before sleep, and go to the sleep when client is fully tired and
don’t lay on bed when client was not sleepy at all. If still client was awaking so leave the
bed and go to any other room where the lights are dim and try to read some book. Get up
early in the morning and go to the bed early on the same time to set down the circadian
rhythms and avoid long naps in afternoon. The client was asked to monitor his sleep time
and awaking time to make it regular for every day. Client was instructed not to use mobile
when he is going to sleep. Lastly client was instructed to do muscle relaxation exercise
before sleep and repeat the steps daily to have an effective sleep pattern.
3.3.13 Post Assessment
3.3.13.1 Subjective Rating of the Symptoms
It included comparison between pre and post assessment. The client was reassessed
after the management to determine the degree of improvement in client’s problems. Overall
there was reduction in the client’s presenting complaints.
Table 4
Comparison of Pre-management and Post-management Severity Rating of the Client’s
Problem

72
 Problem Behavior Pre-management Post-management

Sleep Disturbance 6 2
Cravings 5 3
Restlessness 5 3
Argumentative behavior 4 3

Graph 1
3.3.13.2 Graphical Representation of the Outcome of Management

Outcome.
After applying therapeutic interventions, the overall therapeutic outcome was
satisfactory as client’s symptoms were reduced. The pre management rating of the client’s
symptoms were 50% and post management ratings were 27%. The rate of change in the
client’s symptoms is 23% according to the subjective ratings of the symptoms of the client.
3.3.14 Termination of Therapy
Overall, 11 sessions were conducted. The therapy was terminated because client’s
condition was improved and our time period of placement was also ended. In the 10 th
session, the client was informed by trainee clinical psychologist that sessions would be
terminated after 2 days. Client was told about improvement by pre management and post
management ratings of presenting complaints. The therapy was terminated after taking

73
client’s feedback about the sessions which was positive. Furthermore, therapeutic blueprint
was given to client for the future management.
3.3.15 Limitations
• There were many sources of distractions for the client during sessions.
• The seating was not appropriate for taking individual sessions.
3.3.16 Recommendations
• A separate place for individual sessions should be available.
• The room for taking sessions should be away from the waiting area.

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3.3.17 Session Report
3.3.17.1 Session No. 2
The session started, the consent forum was get assigned by the client’s after clearing
all the ethics to him. The client seemed uncomfortable at the beginning but went well
gradually. He was in a moderate mood and his clothing’s were neat and tidy. He maintained
complete eye contact during the session. After the consent forum bio data of the client was
taken with an open interview and he seemed uncomfortable while sharing his history.
3.3.17.2 Session No. 2
The client was seated comfortably in neat and tidy clothes. Rapport was built with
client and he was also in a mood to talk so we continued the clinical interview and he told
relevant events from his life and his detailed major history was taken.
3.3.17.3 Session No. 3
The session started with the bridges of the previous session so that the client can
realize that the counsellor has been listening to him carefully which builds the rapport more
strongly. Along with the bridging more history was taken from the client and the client was
opening up easily. A lot of bio data was gathered in the session.
3.3.17.4 Session No. 4
After feedback from previous session and mental status examination was conducted.
His appearance, behavior, mood, orientation, insight, memory and perception were
observed. It helped to understand which domains of clients were affected. Client was asked
to fill a subjective rating scale according to his complaints to gain insight about the severity
of issues.
3.3.17.5 Session No. 5
In this session formal assessment was conducted. The client was asked to fill a
questionnaire along with it he was psycho educated about his problems. Alternate nose
breathing exercise along with guided imagery was done for managing client’s restlessness.
Training was started by explaining the rationale and prerequisites of relaxation exercise.
3.3.17.6 Session No. 6
In this session, the motivational interviewing was done to make positive changes
from the client’s problem after which client was given proper instructions about cost-benefit
analysis technique and was asked to write down benefits of leaving drugs and consequences
of continuing drug use to make him acknowledged of its worse consequences so that he
would be able to leave addictive behavior.

75
3.3.17.7 Session No. 7
In this session, thought stopping was introduced to control his cravings. Client was
explained that he had to distract himself such as ways to stop drugs cravings, it was be
clapping hands loudly several times, suddenly standing up and jumping, snapping a rubber
band on wrist, and picturing a huge “stop: burning lungs!” sign in mind. Client was given
homework assignment of practicing it throughout the day whenever he had cocaine
cravings.
3.3.17.8 Session No. 8
The feedback of last session was taken from client. Client was psycho educated about
the purpose of double column technique which was to shake the irrational belief of the client
about cocaine intake. He was asked to give alternative thought or behavior to himself in those
all situations by imaging that what would he do in those situations if he don’t have the choice
of cocaine. In this way after doing the practice, firstly with help and suggestions and then
without assistance client was asked to provide himself an alternative behavior in same
situation.
3.3.17.9 Session No. 9
In this session first of all feedback of previous session was taken from client and he
was asked to picture a stop sign and follow its steps. The purpose was to manage his
aggression. Firstly, Stop do not just react because his emotions might try to make him act
without thinking so stay in control and take a step back from the situation by taking the deep
breath and do not let feelings put him over the edge and make him act impulsively then,
observe the situation and take know how of his feelings and emotions. Lastly, act with
awareness of his thoughts, actions and consequences.
3.3.17.10 Session No. 10
After the feedback of the previous session. In this session, covert sensitization was
administered on client with proper instructions. The technique was used to control his
cocaine addictive behavior by linking the worst aversive situation to the craving of cocaine
use. Later on, sleep guidelines provided to client regarding his sleep issues which included
avoiding caffeine and energy drinks, do exercise before sleep, and go to the sleep when
client was fully tired and don’t lay on bed when client was not sleepy at all. At the end of
session, termination of sessions was introduced.
3.3.17.11 Session No. 11
In the last session post assessment was taken by asking him to rate his symptoms
again that how much improvement he felt after all these session. Furthermore, feedback of

76
the client was taken which was satisfactory and client was asked to keep practicing the
techniques which he had learned. The case was terminated.

3.4 Generalized Anxiety Disorder

Client was 20 years old single female. She belonged to middle class nuclear family
in Multan. She studied till matriculation. She had two sisters. Client was presented with the
complaints of anxiousness, irritability, difficulty falling asleep and excessive worry. Both
formal and informal assessment were carried out. For the informal assessment Clinical
interview, Behavioral observation, mental status examination (MSE), Subjective ratings of
complaints were used. Beck Anxiety Index (BAI) was used for formal assessment. On the
basis of assessment, the client was diagnosed with Generalized Anxiety Disorder under code
300.02 (F41.1). The Management plan was applied on the basis of presenting complaints.
Rapport Building was used to build trust with client, psychoeducation about the disorder
was done, relaxation technique ( alternate nostrils breathing ) was done for relieving stress,
cost benefit analysis, evidence and role playing were used to manage anxious thoughts and
constant worry, worry time was used to manage worry throughout the day and sleep hygiene
was done for resolving sleep difficulties. Therapy was completed within 11 sessions. Client
symptoms improved after the continuation of therapeutic sessions. Client reported 38 %
improvement at the termination of sessions.
3.4.1 Identifying data
Name B.M

Age 20

Gender Female

Education Matric

Occupation Telesales operator

Number of siblings 2

Birth order 3rd

Marital status Unmarried

Religion Islam

Socioeconomic status Upper Middle Class

Informant Client

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3.4.2 Source and Reason for Referral
The client was referred to the trainee psychologist for the psychological assessment
and management of her complaints.
3.4.3 Presenting Complaints
Table 1
Presenting complaints reported by the client.
Duration Presenting Complaints

‫ مہینے سے‬7 .‫مجھے بہت بےچینی ہوتی ہے‬

‫ مہینے سے‬7 ‫میں چیڑنے لگ‬۰‫مجھے اپنی جاب کو لے کر بہت پریشانی رہتی ہے‬
‫ مہینے سے‬7 .‫گئ ہوں بات بات پر‬
‫ مہینے سے‬7 .‫مجھے نیند بہت مشکل سے آتی ہے‬

3.4.4 History of Present Illness (HOPI)

The client B.M, age of 20 years was in an adequate state seven months ago. The
client’s problem of anxiousness was started at the age of 16. When she was studying in
matric, she described herself as being incapacitated with anxiety. She left her studies and
refused to take further admission because she was unable to cope with the pressure. At that
time, Client’s family was unsatisfied and disappointed about the decision of the client. Later
on, seven months ago, client’s grandmother died whom she was attached with which was
unacceptable for her and she had started having sleep difficulties.
She had feelings of constant worry regarding her job and future because she was
facing issues at her work place as her job was quite demanding. She was working as tele
sales operator in the age of 18 years and was quiet satisfied from her job but from few
months she got irritated when customer asked her about the product details or when
customers were not ready to buy the product but she had to convince them but she couldn't
and became anxious instead. Client reported that the condition was getting worse day by day
and it had affected her personal, social and vocational life all of a sudden.
3.4.5 Background Information
3.4.5.1 Personal History
B.M was born in year 2001 in a nuclear middle-class family in Multan. She was born
through normal delivery at home. Client birth order was 3 rd. She was healthy person from her
childhood and all milestones were achieved adequately such as sitting, crawling, walking.
There was no significant illness or an early neurotic trait in her childhood such as shyness,
stammering, sleep- walking etc.

78
 From early age, she depended on her family and most of her decisions were taken by
her family. As a child she was very friendly and loving. She had congenial relationship with
her friends. She was interested in traveling from childhood. Now she tried to spend her time
doing job but she faced troubles while dealing with daily routine work.
3.4.5.2 Family History
Client lived in nuclear family system. She belonged to middle class family. She had
two sisters whom were married and settled in life. Client herself was a last born. Though she
had quite an age difference with her siblings but they loved and cared for her dearly.
Client’s father was 54 years old business man and he had Master degree. He was head of the
family. Client’s relation with her father was congenial. He was overprotective toward the
client. Her mother was 50 years old educated housewife. She described her mother as kind
and loving. She had congenial relationship with her mother as well. Her mother treated her
children equally but pampered the client more than others as she was the youngest of all.
But she was not satisfied about the client’s studies. Apart from parents, client was more
attached to her grandmother. Client reported that she used to spent most of her time with her
grandmother and also that her grandmother was the only person who didn’t criticize her
decision of leaving studies. Client used to share everything with her grandmother. After her
death she became disturbed.
Client’s siblings were very responsible and sharing. Her sisters were quite close to
her and used to share their things with her and wanted her to do better in life. Client reported
the environment of the home was congenial but a minor conflicted too when it comes to
client’s education.
3.4.5.3 Educational History
Client started her schooling at the age of 4 years in an English medium school .She
studied till matriculation from the same school. She was an average student but she never
missed her classes. She was very active in extracurricular activities and loved to go on
school trips. She had congenial relation with class mates and teachers. Her teachers loved
her as she was very obedient and friendly. Her friend circle was also quite big and all of her
friends loved her. She got 70% marks in her matriculation and was satisfied with her marks
after passing matric she refused to take further admission and left studies. Client reported
that she left study because of worry that she would be unable to cope with pressure. Client’s
family was unsatisfied and disappointed to this decision of the client as the other family
members of the client were well educated.

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3.4.5.4 Sexual History
Client reported she reached her puberty at the early age of 13 years. The source of
her puberty was her eldest sister. Her reaction to puberty was satisfactory. The client didn’t
report any sexual or childhood abuse or harassment. There was also no history reported
regarding self-satisfactory acts or any repressed desire.
3.4.5.5 Occupational History
After leaving the studies, client did nothing for 2 years. At the age of 18, client
started job as a telesales operator. Client also reported that she had congenial relationship
with her colleagues and she enjoyed working with them. She reported that her job was quite
demanding and now she was unsatisfied about her work and remained anxious and worried
about her future.
3.4.5.6 History of Psychiatry/Medical Illness
There was no history of psychiatric or medical illness in family reported by the client.
3.4.5.6.1 Premorbid Personality
Client was responsible and lively person before the onset of symptoms. Her hobbies
were playing Pubg and going for outing. She had lot of friends with whom she loved to
spent time. Her reaction towards stress was not healthy. She used to share her problems with
her friends and sisters.
3.4.6 Psychological Assessment
Assessment is the process of collecting information from multiple and diverse source
in order to develop a deep understanding. There are two types of assessment.
Informal Assessment
Formal Assessment
3.4.6.1 Informal Assessment
Informal assessment includes interview from client’s family, attendant and client
herself and behavioral observation of client.
• Behavioral Observation
• Clinical Interview
• Mental Status Examination (MSE)
• Subjective rating by client
3.4.6.1.1 Behavioral Observation.
It is widely used method of behavioral assessment which relies on recording the
behavior of a person in typical environment. Client was observed through participant

80
observation in outdoor setting. In behavioral observation, it was observed that client was 20
years old female with tall height, average weight and fair complexion. She entered the room
with appropriate gait and sat on chair comfortably leaning forward towards the psychologist.
Her dress was neat and tidy. Her hair was properly tied in a ponytail. Her nails were properly
trimmed. She established and maintained eye contact throughout the session Her tone and
pitch of voice was polite and soft. Her quality and quantity of speech was appropriate and
relevant as she was responding properly to every question asked by therapist. Hence, she was
very cooperative and complying with the therapist. Rapport seemed to be established in the
very first session as client was complying with every question and instructions of the
therapist.
3.4.6.1.2 Clinical Interview.
Interview is qualitative method for obtaining information. A clinical interview is a
conversation between a clinician and a client that is typically intended to develop a
diagnosis. It is basically the conversation with a purpose that the therapist does to gather all
required information about client’s background, social, cultural and present condition to
process his further assessment and management.
In present case quality of information was obtained from the client. Client was seated
in the comfortable posture on the chair. She was talking in a low tone and she was not
distracted by irrelevant external stimuli. Trainee psychologist noted down client’s
information on the clinical form provided by the clinic/hospital. The clinical interview was
taken in the early 2 sessions after the rapport was developed and the client was comfortable
enough to share the history.
3.4.6.1.3 Mental Status Examination (MSE).
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam
that describes the mental state and behaviors of the person being seen. It includes both
objective observations of clinician and subjective description given by the patient. Focused
questions and observations reveal “normal” or pathological findings. It paints a picture of
patient’s appearance, thinking, emotion and cognition. The data from Mental Status Exam,
combined with clinical interview forms the data on the basis of which assessment of client is
completed.
For present case MSE served as tool to explore level of general appearance,
psychomotor behavior, mood and effect, speech, cognition and thought pattern. The client
was seated comfortably on her seat. The appearance of client was according to her age. She
maintained the eye contact throughout the sessions. The rapport was built quite easily, she

81
was alert, friendly co-operative and tall. Her hygiene and grooming were neat and clean.
The client was responsive and interested during the session. Her eye contact was glaring and
fixed. Her gait was appropriate. Her mood was euthymic. She was noticed fidgeting and
tapping her legs. Her speech was soft and smooth. Her attention and concentration were
intact. Her short-term, long-term and remote memory was also intact. Client was also
oriented to time, place and person. Client had fair insight about her illness. After the session
the MSE was noted down carefully through the observation made in the session
3.4.6.1.4 Subjective Rating.
Subjective rating helps understand subjective experience of negative symptoms, i.e.,
awareness, causal attribution, and disruption or distress. A rating 0-10-point scale is used to
identify the intensity and severity of the target problematic behaviors. 0 indicates no severity
5 indicates moderate level and 10 indicates high level of severity. The subjective rating was
taken from the client on 0-10 scale to understand the severity of client problems.
Table 2
Pre-Management Rating of Client’s Problematic Behaviors
Problematic Behavior Ratings by Client
Excessive worry 9
Irritable mood 8
Worry about job 8
Sleep issues 8

3.4.6.2 Formal Assessment

Formal assessment is the process of gathering information about client using
standardized, published tests or instruments with specific administration and interpretation
procedure and used to make general instructional deacons.
Following formal assessment tool was used:
3.4.6.2.1 Beck Anxiety Inventory (BAI).
The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other colleagues,
is a 21-question multiple-choice self-report inventory that is used for measuring the
severity of anxiety in children and adults. The BAI was specifically designed as "an
inventory for measuring clinical anxiety" that minimizes the overlap between depression
and anxiety scales.
Quantitative Interpretation.
Table 3

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Showing raw scores with corresponding Ranges and Interpretation
Raw Score Cutoff Range Severity

24 17-29 Moderate
Client as usually was seated at ease for the session and the room was also ventilated
and peaceful. Later on, she was provided 1 page scale along with the pencil and the eraser
and she was asked to fill the forum as per most relatable choice to her. Proper instructions
were given. She completed the scale within 20 minutes. The quantitative interpretation of
the result showed that she had moderate symptoms of generalized anxiety disorder as she
had complaints of anxiousness, irritability, difficulty falling asleep and excessive worry
about things.
3.4.7 Case Formulation
Client was 20 years old single female. She belonged to middle class nuclear family
in Multan. She had 2 sisters; both were married. She was the youngest one. Client was
presented with the complaints of anxiousness, irritability and difficulty falling asleep. She
constantly worried about her job, her financial situation, and family matters. Client left her
studies due to inability to cope up with the pressure which played a role as a predisposing in
her illness. According to studies anxiety disorders are more likely to be associated with
premature school withdrawal and have lifetime diagnosis of generalized anxiety disorders
(Ameringen et al. 2003).
The death of her grandmother whom she was attached with and also used to spend
most of her time with her grandmother precipitates in her illness. Client’s grandmother was
the only person who didn’t criticize her decision of leaving studies so her death was
unacceptable for client. According to research study, People who experience intense grief
symptoms that interfere with daily life and occur more than 6 months after a loss may have
complicated grief, which is frequently associated with an anxiety disorder (Smith, K. 2019).
Client then became irritable which also played a role of precipitating factor in her illness.
According to a recent research study have found roughly 90% of a sample of treatment-
seeking youth with GAD showed persistent irritability (Comer, J. 2012).
Client stressed about her job as she was facing issues at her work place and her job
was quite demanding. She got irritated when customer asked her about the product details or
when customers were not ready to buy the product but she had to convince them but she
couldn't and became anxious instead. Along with this, her family also questioned her
abilities which were maintaining her illness According to National Institute of Mental
Health, people with generalized anxiety disorder (GAD) feel extremely worried or feel

83
nervous about things, even when there is little or no reason to worry about them (NIMH,
2016).
Client’s sisters were very caring, loving and wanted her to do better in life and also
client’s insight into treatment is served as protective factors in this case. Her illness had
affected her personal, social and educational life. Numerous research studies have also
shown that family support had a moderating effect on anxiety and cam reduce the impact of
stress in individuals (Kahn, Kasky-Hernández, Ambrose,
French, & Transition, 2017).
The Management plan would be used on the basis of problems that are Rapport
Building to develop trust with client. Psychoeducation about the underlying issues would be
done. Relaxation techniques would be used for relieving stress. Cost benefit analysis,
evidence and role playing would be used to manage her anxious thoughts and constant
worry. Worry time would be used to schedule client’s time to worry throughout the day.
Sleep Hygiene Therapy would be used for management of her sleep problems.

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3.4.8 Case Conceptualization Presentin
Complaints
g
Anxiousness,
irritability,
difficultyfallingasleep
and
constant worry.

Assessmen
t
ClinicalInterviews,
Behavioral
observation,
Mental
statuexamination (MSE), Subjective
ratings
andBeck
Anxietyinventory
s (BAI ).

Predisposing Precipitating Maintaining factor

Factor Factor Distressin thought Protectiv Factors
Discording
her Deathof her abou
g future
s e
studies. tParent
. question Supportiv siblings.
grandmother. e
Inabilitytocope abou
s clien
s abilities Clientwillingnessfor
tLackof
t self-
. treatmen
upwithth study
actualization t.
pressure.
e
.

Diagnosis ManagementOutcome
Generalized AnxietyRapport Building,The rate of
Disorder under codePsychoeducation,change in the
300.02 (F41.1) Relaxation client’s
Techniques (deep
symptoms is
breathing), Cost
38 %
benefit analysis,
Worry time,
roleplay,evidence,
and Sleep hygiene.

Figure 4: Figure 4:3.4.8 Case Formulation

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3.4.9 Diagnosis
On the basis of formal and informal assessment, the client was diagnosed with
Generalized Anxiety Disorder under code 300.02 (F41.1).
3.4.10 Prognosis
As for the prognosis there are chances for recovery exist due to supportive siblings
and client’s willingness for the treatment.
3.4.11 Management Plan
3.4.11.1 Short Term Goals
 Rapport would be built with the client to develop trustful relationship between client
and therapist.
 Psycho-education would be done through diagram on which client would be taught
about ABC model of illness.
 Alternate nose breathing exercise along with guided imagery would be used for
relieving stress. Training would be start by explaining the rationale and prerequisites of
relaxation exercise.
 Cost Benefit Analysis, Evidence and Role playing would be used for managing anxious
thoughts and constant worry.
 Worry time would be used to manage client’s time to worry throughout the day.
 Sleep guidelines would be provided to client in order to making sleep quantity or
quality better.
3.4.11.2 Long Term Goals
 Continuation of Short- term goals.
 To reduce overall frequency, intensity, and duration of underlying stress related to
future and studies so that daily functioning is not impaired.
 To boost her decision-making ability in further sessions.
 Follow up sessions of the short-term goals will be done to increase efficacy of the
therapy.
3.4.12 Summary of Therapeutic Interventions
3.4.12.1 Rapport Building
Rapport is the development of a therapeutic relationship based on mutual
understanding i.e., respect, empathy and trust (O'Toole, 2008). Developing a positive
relationship with a patient enables the health practitioner to elicit pertinent information and

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make informed clinical decisions about their treatment and ongoing care (Barnett, 2001).
However, rapport is more than that. It promotes communication, collaboration, and a shared
understanding of the patient’s perspective (Norfolk, Birdi &Walsh, 2007).
The rationale behind using this technique was to make client comfortable in sharing
her feelings and telling her symptoms and history to the therapist so they can work
collaboratively and effectively for the betterment of client.
Client was seated comfortably in the chair. Rapport was built during the session by
active listening, empathetic attitude, warmth & geniuses toward the client by therapist.
3.4.12.2 Psycho Education
Psycho-education refers to the education offered to individuals with a mental health
condition and their families to help empower them and deal with their condition in an
optimal way. Psycho-education is a general term for the educational approach for assistance
to offer accurate knowledge and information about the nature and method of treatment and
addressing disease needed for cure and added with consideration for psychotherapy. It is
useful to achieve most realistic goals and for motivation of the client and family.
The rationale behind using this technique was to initiate intervention plan as therapist
comprehensively explains nature, etiology, management of illness, prognosis, and time
required therapy. Client herself and her siblings were psycho-educated regarding the nature
of the problem, management and relapse.
3.4.12.3 Relaxation Techniques
A person who feels anxious most of the time has trouble relaxing, but knowing how to
release muscle tension can be a helpful strategy. Relaxation techniques include: progressive
muscle relaxation, abdominal breathing, Alternative nostril breathing and isometric relaxation
exercises (Matsumoto & Smith, 2001). The rationale behind using relaxation exercises with
client was to help her to relax, to attain calmness and to reduce levels of pain and stress
which is contributing in client sleep issues.
Alternate nostril breathing was applied on the client, as she was made sit with spine
straight and feet flat on the floor. She was asked to close the right nostril with her right
thumb, and inhale through the left nostril into the belly, for a count of 4 3. After inhaling,
she was asked to hold her breath for 4 seconds to exhale through her right nostril while
closing the left with her ring and pinky finger of her right hand for 4 counts. She was further
asked to repeat steps 1 to 3, but this time start inhaling through the right nostril and vice
versa. In the middle of this exercise, she was asked to imagine one her best moments in her
life to its fullest for best better results. She was asked to start off practicing this breathing

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exercise for 2 minutes at a time and then increase to 10 minutes for maximum benefits for at
least twice a day. Along with it one of her best life events was used as Guided Imagery.
3.4.12.4 Cost Benefit Analysis
In cognitive behavioral therapy (CBT), this technique has been adapted for use in
cognitive restructuring. Put more simply, a cost/benefit analysis can be used to challenge
old, unhealthy patterns of thinking, allowing them to be replaced by new, more adaptive
thoughts, The client was seated comfortably in the chair and after doing relaxation exercise
client asked to write down costs and benefits of her negative thoughts to explain her that the
costs of her worry would always be more than the benefits and that her worry was nothing
but making her cost her mental health.
3.4.12.5 Worry Time
Worry time is a technique that people use to help them manage their worries and
anxiety. The rationale behind this technique was to make client understand rather than
worrying and feeling anxious throughout the day, he could make a note somewhere of his
worries and then he schedule a specific time each day when he work through his worried
thoughts. Client was instructed when a worried thought appear during the day, rather than
dwelling on it there and then, he could make a note of it, park it for later on and feel free to
get on with his day, knowing that he had allotted some specific worry time later on.
3.4.12.6 Evidence
The technique of questioning the evidence in CBT assists patients in questioning the
facts related to their cognitions and conclusions. This procedure investigates whether their
information is based on facts or assumptions (CBT, 2002).The client was seated comfortably
in the chair and after revising previous techniques, client was asked to show evidence that
she would lose her job or other family members. Despite trying out several times she failed
to do so and had to agree that her worries were irrational and had no proof and that the
probability for this to happen was quite low.
3.4.12.7 Roleplay
Role play is a technique used by counselors of different theoretical orientations with
clients who need to develop a deeper understanding of, or change within, themselves.
Within a role play, clients can perform a decided-upon behavior in a safe, risk-free
environment. Role play is a blend of “Salter’s conditioned reflex therapy, Moreno’s
psychodrama technique, and Kelly’s fixed-role therapy”. Moreno’s psychodrama process
involved three facets warm up, enactment, and reenactment. Hackney and Cormier
described four aspects commonly found in role plays (Liness et al., 2019). In most role

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plays, a person reenacts herself, another person, a set of circumstances surrounding a
situation, or her own reactions. The person then receives feedback from the professional
counselor or from group members when the role play is instituted in a group-work context.
Role plays occur in the present, not the past or the future; it is common to begin with scenes
that are easier to reenact and to work progressively toward scenes that are more complex
(Lam, 2004).
Client was seated comfortably in the chair and then she was asked to do a role play
where she was supposed to act as her boss or other family member and play the situations
that she worries about, CBA and Relaxation Techniques were used side by side to help her
get over her negative thoughts and symptoms.
3.4.12.8 Sleep Hygiene Therapy
Sleep hygiene therapy is defined as a set of behavioral and environmental
recommendations intended to promote healthy sleep, and was originally developed for use
in the treatment of mild to moderate insomnia (Stepanski & Wyatt, 2003). The purpose of
sleep hygiene was to educate the client and create an awareness of lifestyle and resolve her
sleep disturbances. This also help making sleep quality and sleep quantity better.
The sleep guidelines provided by the therapist to client regarding her sleep issues
which included avoiding caffeine and energy drinks, try to do some walk or any exercise
before sleep, and go to the sleep when client is fully tired and don’t lay on bed when client
was not sleepy at all. If still client is awaking so leave the bed and go to any other room
where the lights are dim and try to read some book. Get up early in the morning and go to
the bed early on the same time to set down the circadian rhythms and avoid long naps in
afternoon. The client was asked to monitor her sleep time and awaking time to make it
regular for every day. Client was instructed not to use mobile when she was going to sleep.
Lastly client was instructed to do nostril breathing exercise before sleep and repeat the steps
daily to have an effective sleep pattern.
3.4.13 Post Assessment
3.4.13.1 Subjective Rating of the Symptoms
It included comparison between pre and post assessment. The client was reassessed
after the management to determine the degree of improvement in client’s problems. Overall,
there was reduction in the client’s presenting complaints.
Table 4
Comparison of Pre-management and Post-management Severity Rating of the
Client’s Problem

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 Problem Behavior Pre-management Post-management
Constant worry 9 5
Irritable mood 8 5
Worry about job 8 5
Sleep Disturbance 8 5

Graph 1
3.4.13.2 Graphical Representation of the Outcome of Management

Outcome.
After applying therapeutic interventions, the overall therapeutic outcome was
satisfactory as client’s irritable mood and sleep issues were reduced. The pre management
rating of the client’s symptoms were 84 % and post management ratings were 46 %. The
rate of change in the client’s symptoms was
38 % according to the subjective ratings of the symptoms of the client.
3.4.14 Termination of Therapy
Overall, 11 sessions were conducted. The therapy was terminated because client’s
condition was improved and our time period of placement was also ended. In the 10 th
session, the client was informed by trainee clinical psychologist that sessions would be
terminated after 2 days. Client was told about improvement by pre management and post
management ratings of presenting complaints. The therapy was terminated after taking
client’s feedback about the sessions which was positive.
Furthermore, therapeutic blueprint was given to client for the future management.

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3.4.15 Limitations
• There were many sources of distractions for the client during sessions.
• The seating was not appropriate for taking individual sessions.
3.4.16 Recommendations
• A separate place for individual sessions should be available.
• Family therapy should be done to improve client’s relationship.
• Management techniques should be continued after termination of sessions to avoid
relapse.

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3.4.17 Session Report
3.4.17.1 Session No. 1
As soon as the session started the consent forum was get assigned by the client’s
after clearing all the ethics to her. The client seemed uncomfortable at the beginning but
went well gradually. She was in a moderate mood and her clothing’s were neat and tidy. She
maintained complete eye contact during the session. After the consent forum bio data of the
client was taken with an open interview. The client seemed hesitant at the beginning while
sharing her history.
3.4.17.2 Session No. 2
The client was seated comfortably in neat and tidy clothes. She felt fresh today. She
was in a mood to talk so we continued the clinical interview and she told relevant events
from her life. The session was gone till 30 mins.
3.4.17.3 Session No. 3
The session started with the bridges of the previous session so that the client can
realize that the counsellor has been listening to her carefully which builds the rapport more
strongly. Along with the bridging more history was taken from the client and the client was
opening up easily. A lot of bio data was gathered in the session. After history taking
mindfulness was practiced. The session was gone till 30 mins.
3.4.17.4 Session No. 4
As the session started the client was welcome and mirroring was done throughout the
session to evaluate data which the client has yet not opened up about. The interview was left
unstructured and the client was made comfortable to speak as her will. After the discussion
BAI test was introduced to the client and given to attempt. The session took almost 30 mins.
3.4.17.5 Session No. 5
At the beginning of the session active listening and bridges was done that help make
and maintain the rapport with the client. The left history was evaluated with the help of
prompting. Side by side MSE was observed and solved by the client. The goal of the session
was to teach the client how to make herself relax when she has feeling of anxiousness. For
this purpose, alternate nostrils breathing was administered on client. The session took almost
35 mins.
3.4.17.6 Session No. 6
At the beginning of the session all the history of the client was told with the help of
paraphrasing technique. Psycho-education about the sleep hygiene was also done. Client
was suggested to go to bed only when she was sleepy and restrict the intake of caffeine and

92
also given the rationale of its adverse effects on circadian rhythms. This session took
approximately 40 mins
3.4.17.7 Session No. 7
In the session bridging and mirroring was done to relate this session with the past
one to techniques. Worry time was introduced to make client’s specific time to worry in a
day. Roleplay was introduced and worked on like greeting and spending time with friends.
Relaxation techniques was again given as an assignment and asked to practice at home along
with roleplay. The session took almost 30 mins.
3.4.17.8 Session No. 8
The session started with bridges and active listening the client was explaining how
workful the assignments and techniques have been for her. For the fears of clients
Techniques of Cognitive Therapy i.e., Cost benefit analysis was applied and used,
Mindfulness and Relaxation Techniques were used. The session took almost 30 mins.
3.4.17.9 Session No. 9
The session was moved over with welcome and bridges of previous session.
Information related assignment and progress of inferiority complex was done. For fears of
client Evidence was used for client. She was asked to prove the fears leaving home only to
come and find none there would come true and that something bad would happen at her job.
As she couldn’t prove her believes she had to admit they are unrealistic. The session took 45
mins.
3.4.17.10 Session No. 10
In this session overall techniques were revised with relaxation techniques.
Relapse prevention and Termination were introduced. The session took almost 40 mins.
3.4.17.11 Session No. 11
In this session the client was recommended to come for follow-up if she feels reverse
in her illness also for boosting her ability of decision making. She was asked to keep
practicing Relaxation techniques. The case was terminated.

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3.5 Major Depressive Disorder
Client was 24 years old single female. She belonged to middle class nuclear family. She
studied till post-graduation. She had one brother. Client was presented with the complaints of
low mood, crying spells, hopelessness, difficulty concentrating, difficulty falling asleep and
recurrent thoughts of death. Both formal and informal assessment were carried out. For the
informal assessment Clinical interview, Behavioral observation, mental status examination
(MSE), Subjective ratings of complaints were used. Beck depression Inventory (BAI) was
used for formal assessment. On the basis of assessment, the client was diagnosed with Major
Depressive Disorder under code 296.22 (F32.1).The Management plan was applied on the
basis of presenting complaints. Rapport Building was used to build trust with client,
psychoeducation about the disorder was done, relaxation exercise was used to reduce levels
of pain, ABC model was taught to client to challenge her negative thoughts and cognitive
distortions, cost Benefit Analysis was used for managing her low and depressive mood, role
playing was used for managing her negative thoughts about death and hopelessness,
Backward counting was used for her concentration issues and sleep hygiene therapy was used
for management of her sleep problems. Therapy was completed within 9 sessions. Client
symptoms improved after the continuation of therapeutic sessions. Client reported 22 %
improvement at the termination of sessions.
3.5.1 Identifying data
Name A. A.

Age 24 years

Gender Female

Education Post graduation

Occupation Content writer

Siblings 1

Birth Order last born

Marital status Unmarried

Socioeconomic status Middle class

Religion Islam

Informant Client herself

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3.5.2 Source and Reason for Referral
The client was referred to the trainee psychologist for the psychological assessment
and management of her complaints.
3.5.3 Presenting Complaints
Table 1
Presenting complaints reported by the client
Duration Presenting Complaints

‫ ہفتے سے‬3 ‫میں بہت اداس رہنے لگی ہوں۔بس روتی‬

‫ ہفتے سے‬3 ‫رہتی ہوں۔‬
‫ ہفتے سے‬3 ‫مجھے نہیں لگتا کے میرے االت کبھی ٹھیک ہوں گے۔میری توجۂ نہیں‬
‫ ہفتے سے‬3 .‫رہتی کسی بھی چیز پر۔مجھے نیند بہت مشکل سے آتی ہے‬

‫ ہفتے سے‬3 ‫مجھے موت کے خیال آتے ہیں۔‬

‫ مہینے سے‬3

3.5.4 History of Present Illness (HOPI)

The client A.A, age of 24 years was in an adequate state 4 weeks ago. The client’s
problem of her recurrent thoughts of death started after she faced domestic violence as a
result of argument she had with her father 3 months ago. Later on, her low mood along with
crying spells was started 3 weeks ago. When her mother and brother had a intense fight over
her brother’s girlfriend because client’s parents had familial conflicts with that girl’s family.
She described herself helpless as she was unable to resolve their fight and started crying
every time when she had thoughts of their arguments and her mother because her brother
was quite aggressive.
After that incident, client was unable to concentrate on her job as her job was quite
demanding. She was working as a content writer and from few weeks she started making
mistakes in every social media content posted on the behalf of the company because of
which her boss scolded her many times and she started having feelings of hopelessness and
stop going to job for a week without informing anyone from the company. Now, she also
faced problems in initiating sleep after all these things. Client reported that the condition
was getting worse day by day and it had affected her personal, social and vocational life all
of a sudden.

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3.5.5 Background Information
3.5.5.1 Personal History
A.A was born in year 1997 in a nuclear middle-class family. She was born through
normal delivery at home. Client birth order was 2 nd. She was healthy person from her
childhood and all milestones were achieved adequately such as sitting, crawling, walking.
There was no significant illness or an early neurotic trait in her childhood such as shyness,
stammering, sleep- walking etc.
From early age, she depended on her mother and most of her decisions were also
taken by her mother. As a child she was very friendly and loving. She had congenial
relationship with her friends. She was interested in traveling from childhood. Now she tried
to spend her time doing job but she faced troubles while dealing with daily routine work.
3.5.5.2 Family History
Client lived in nuclear family system. She belonged to middle class family. She had
one brother. Client herself was a last born. Client’s father was 54 years old landlord and he
had F.A degree. He was head of the family but doesn't spend a penny on his children and
wife. Client’s relation with her father was conflictual. Her mother was 50 years old primary
school teacher. She described her mother as kind and loving. She had congenial relationship
with her mother. Her mother treated her children equally but pampered the client more than
others as she was the youngest of all. Client also took care of her mother. Apart from mother,
client was more attached to her grandparents. Client reported that she spent most of her
childhood in her grandparents’ home. She had congenial and loving relationship with her
grandparents.
Client’s brother was 27 year old boy. He was quite close to her and used to share
personal things with her. Client’s relationship with her brother was congenial but now
conflicted too regarding his girlfriend’s issue. Client’s brother had conflictual relationship
with his father and mother too after her mother and brother had a intense fight over her
brother’s girlfriend because client’s parents had familial conflicts with that girl’s family and
they don’t want to marry their son to that family. Client reported the environment of the
home was conflicted.
3.5.5.3 Educational History
Client started her schooling at the age of 4 years in an English medium school .She
studied till matriculation from the same school. She was an average student but she never
missed her classes. She was very active in extracurricular activities and loved to go on
school trips. She had congenial relation with class mates and teachers. Her teachers loved

96
her as she was very obedient and friendly. Her friend circle was also quite big and all of her
friends loved her. After passing matric with quite satisfactory result she took further
admission in college and then in university.
Client reported that she had the best time of her life there.
3.5.5.4 Sexual History
Client reported she reached her puberty at the early age of 12 years. The source of
her puberty was her mother. Her reaction to puberty was satisfactory. The client didn’t
report any sexual or childhood abuse or harassment. There was also no history reported
regarding self-satisfactory acts or any repressed desire.
3.5.5.5 Occupational History
After leaving the studies, client started job at the multinational company as a content
writer. Client reported that she had congenial relationship with her colleagues and she
enjoyed working with them. But after her brother’s fight client was unable to concentrate on
her job and started making mistakes in every social media content posted on the behalf of
the company because of which her boss scolded her many times and she did stop going to
job for a week without informing anyone from the company. She reported that she loved her
job but now she was questioning her abilities regarding it and remained low all the time.
3.5.5.6 History of Psychiatry/Medical Illness
There was no history of psychiatric or medical illness in family reported by the
client.
3.5.5.6.1 Premorbid Personality
Client was responsible and lively person before the onset of symptoms. Her hobbies
were reading books and watching animated movies. She used to spend most of her time with
her friends.
3.5.6 Psychological Assessment
Assessment is the process of collecting information from multiple and diverse
source in order to develop a deep understanding. There are two types of assessment.
Informal Assessment
Formal Assessment
3.5.6.1 Informal Assessment
Informal assessment includes interview from client’s family, attendant and client
herself and behavioral observation of client.
• Behavioral Observation

97
 • Clinical Interview
• Mental Status Examination (MSE)
• Subjective rating by client
3.5.6.1.1 Behavioral Observation.
It is widely used method of behavioral assessment which relies on recording the
behavior of a person in typical environment. Client was observed through participant
observation in outdoor setting. Participant observation is type of observation in which
therapist becomes the active member of the session and participate with client.
In behavioral observation, it was observed that client was 24 years old female with
tall height, above average weight and ivory complexion. She entered the room with
appropriate gait and sat on chair comfortably leaning forward towards the psychologist. Her
dress was neat and tidy. Her hairs were properly combed and straightened. Her nails were
properly trimmed. She was unable to establish eye contact at first but after sometime she did
established it. Her tone and pitch of voice was low and soft. Her quality and quantity of
speech was appropriate and relevant as she was responding properly to every question asked
by therapist. Hence, she was very cooperative and complying with the therapist. Rapport
seemed to be established in the very first session as client was complying with every
question and instructions of the therapist.
3.5.6.1.2 Clinical Interview.
Interview is qualitative method for obtaining information. A clinical interview is a
conversation between a clinician and a client that is typically intended to develop a
diagnosis. It is basically the conversation with a purpose that the therapist does to gather all
required information about client’s background, social, cultural and present condition to
process his further assessment and management.
In present case quality of information was obtained from the client. Client was
seated in the comfortable posture on the chair. She was talking in a low tone and she was
easily distracted by external stimuli. Trainee psychologist noted down client’s information
on the paper. The clinical interview was taken in the early 2 sessions after the rapport was
developed and the client was comfortable enough to share the history.
3.5.6.1.3 Mental Status Examination (MSE).
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam
that describes the mental state and behaviors of the person being seen. It includes both
objective observations of clinician and subjective description given by the patient. Focused
questions and observations reveal “normal” or pathological findings. It paints a picture of

98
patient’s appearance, thinking, emotion and cognition. The data from Mental Status Exam,
combined with clinical interview forms the data on the basis of which assessment of client is
completed.
For present case MSE served as tool to explore level of general appearance,
psychomotor behavior, mood and effect, speech, cognition and thought pattern. The client
was seated comfortably on her seat. The appearance of client was according to her age. She
maintained the eye contact throughout the sessions. The rapport was built quite easily, she
seemed low but co-operative and tall. Her hygiene and grooming were neat and clean. The
client was responsive and interested during the session. Her eye contact was not fixed at first
but gradually it did. Her gait was appropriate. Her mood was dysthymic. Her speech was
low and smooth. Her attention was intact and concentration was not intact. Her short-term
memory was not intact. Client was also oriented to time, place and person. Client had fair
insight about her illness. After the session the MSE was noted down carefully through the
observation made in the session.
3.5.6.1.4 Subjective Rating.
Subjective rating helps understand subjective experience of negative symptoms, i.e.,
awareness, causal attribution, and disruption or distress. A rating 0-10-point scale is used to
identify the intensity and severity of the target problematic behaviors. 0 indicates no severity
5 indicates moderate level and 10 indicates high level of severity. The subjective rating was
taken from the client on 0-10 scale to understand the severity of client problems.
Table 2
Pre-Management Rating of Client’s Problematic Behaviors
Problematic Behavior Ratings by Client
Low mood 7
Crying spells 6
Hopelessness 6
Difficulty concentrating 5
Difficulty falling asleep 5
Recurrent thoughts of death 4

3.5.6.2 Formal Assessment

Formal assessment is the process of gathering information about client using
standardized, published tests or instruments with specific administration and
interpretation procedure and used to make general instructional deacons.

99
 Following formal assessment tool was used:
3.5.6.2.1 Beck Depression Inventory (BDI).
Beck Depression Inventory (BDI) by Dr Aaron. T. Back, is a twenty-one questions
multiple choice self-reported inventory, that is one of the most widely used instruments such
as low mood, difficulty in decision making, hopelessness and irritability, cognitions such as
guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight
loss and of interest in sex. The BDI is widely used as an assessment tool by health care
professionals and researches in a Variety of setting.
The rationale behind the usage of this test was to assess the range of depression of
the client with respect to his own self perceptions and to diagnose the underlying
problematic areas.
Client as usually was seated at ease for the session, later on she was provided 1 page
along with the pencil and the eraser and she was told fill the forum as per most relatable
choice to her. Proper instructions were given to the client.
Quantitative Interpretation.
Table 3
Showing raw scores with corresponding Ranges and Interpretation
Raw Score Cutoff Range Severity

22 21-30 Moderate

Client as usually was seated at ease for the session and the room was also ventilated
and peaceful. Later on, she was provided 1 page scale along with the pencil and the eraser
and she was asked to fill the forum as per most relatable choice to her. Proper instructions
were given. She completed the scale within 20 minutes. The quantitative interpretation of
the result showed that she had moderate symptoms of major depressive disorder as she had
complaints of low mood, crying spells, hopelessness, difficulty concentrating, and difficulty
falling asleep and recurrent thoughts of death.
3.5.7 Case Formulation
Client was 24 years old single female. She belonged to middle class nuclear family.
She had one brother. She was the youngest one. Client was presented with the complaints of
low mood, crying spells, hopelessness, difficulty concentrating, difficulty falling asleep and
recurrent thoughts of death. Her problem started with recurrent thoughts of death as a result
of argument she had with her father 3 months ago which played a role as a predisposing in
her illness. Various research studies have also suggested that family conflict and cohesion are

100
risk factors for the development of psychological distress and depression in individuals (Gil-
Rivas, Greenberger, Chen, & Montero y López-Lena, 2003).
Her low mood and crying spells started right after her mother and brother’s fight
which precipitated in her illness. Client was concerned about her family because of home’s
conflictual environment According to research study, people with higher levels of perceived
stressfulness of life events and ruminative coping style were correlated with higher
frequency of depressive symptoms (Michl, McLaughlin, Shepherd, & Nolen-Hoeksema,
2013).
Client stressed about her job as she was facing issues at her work place and her job
was quite demanding. Client was unable to concentrate on her job and started having
feelings of hopelessness about future which was maintaining the illness. Researches have
suggested that difficulties that influenced patients’ performance at work and in their careers
were strongly correlated or had a tendency to be correlated with the depressive patients
(Harvey, Velligan, & Bellack, 2007).
Client’s mother was very caring, loving and wanted her to do better in life and also
client’s insight into treatment is served as protective factors in this case. Her illness had
affected her personal, social and educational life. Various research studies have also shown
that family support had a moderating effect in reducing psychological disorders (Kahn,
Kasky-Hernández, Ambrose, French, & Transition, 2017).
The Management plan would be used on the basis of problems that are Rapport
Building to develop trust with client. Psychoeducation about the underlying issues would be
done. Relaxation techniques would be used to reduce levels of pain which was contributing
in client’s crying spells. ABC model would be taught to client to challenge her negative
thoughts and cognitive distortions. Cost Benefit Analysis would be used for managing her
low and depressive mood. Role playing would be used for managing her negative thoughts
about death and hopelessness. Backward counting would be used for her concentration
issues and sleep hygiene therapy would be used for management of her sleep problems.

101
 3.5.8 Case Conceptualization

Presentin Complaints
g
Low mood, cryingspells, hopelessness,
difficulty
concentrating,
difficultyfallingasleep
andrecurrent
thoughts of death.

Assessmen
t
ClinicalInterviews,
Behavioral
observation,
Mental
statuexamination (MSE), Subjective
ratings
andBeck
s
Depression inventory
(BAI ).

Precipitating Maintaining factor

Predisposing Factor
Issuesrelated
to ProtectivFactors
Factor
Motherand job. e
Supportive
mother
.
Conflictswithher brother
’s fight.
Distressing
father. Clientwillingness
Conflicted
home thoughtsabout
future. for treatment
environment.
.

Management Outcome
Diagnosis
Rapport Building, The rate of
Major Depressive
Psychoeducation, change in the
Disorder under code
Relaxation Techniques client’s
296.22 (F32.1)
(deep breathing), ABC symptoms is
model, Cost benefit 22 %
analysis, Role playing,
Backward counting and
Sleep hygiene.
Figure 5:3.5.8 Case Formulation

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3.5.9 Diagnosis
On the basis of formal and informal assessment, the client was diagnosed with
Major Depressive Disorder under code 296.22 (F32.1).
3.5.10 Prognosis
As for the prognosis there are chances for recovery exist due to supportive mother
and client’s willingness for the treatment.
3.5.11 Management Plan
3.5.11.1 Short Term Goals
 Rapport would be built with the client to develop trustful relationship between client
and therapist.
 Psycho-education would be done through diagram on which client would be taught
through vicious cycle of depression.
 Alternate nose breathing exercise along with guided imagery would be used for
relieving stress. Training would be start by explaining the rationale and prerequisites of
relaxation exercise.
 ABC model would be taught to client to challenge her negative thoughts and cognitive
distortions.
 Cost Benefit Analysis would be used for managing her low and depressive mood.
 Role playing would be used for managing her negative thoughts about death and
hopelessness.
 Backward counting would be used for her concentration issues.
 Sleep guidelines would be provided to client in order to making sleep quantity or
quality better.
3.5.11.2 Long Term Goals
 Continuation of short-term goals.
 To reduce overall frequency, intensity, and duration of underlying stress related to
future and job so that daily functioning is not impaired.
 To involve client’s family in the treatment to enhance the process of recovery through
family therapy.
3.5.12 Summary of Therapeutic Interventions
3.5.12.1 Rapport Building
Rapport is the development of a therapeutic relationship based on mutual
understanding i.e., respect, empathy and trust (O'Toole, 2008). Developing a positive
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relationship with a patient enables the health practitioner to elicit pertinent information and
make informed clinical decisions about their treatment and ongoing care (Barnett, 2001).
However, rapport is more than that. It promotes communication, collaboration, and a shared
understanding of the patient’s perspective (Norfolk, Birdi &Walsh, 2007).
The rationale behind using this technique was to make client comfortable in sharing
her feelings and telling her symptoms and history to the therapist so they can work
collaboratively and effectively for the betterment of client.
Client was seated comfortably in the chair. Rapport was built during the session by
active listening, empathetic attitude, warmth & geniuses toward the client by therapist.
3.5.12.2 Psycho Education
Psycho-education refers to the education offered to individuals with a mental health
condition and their families to help empower them and deal with their condition in an
optimal way. Psycho-education is a general term for the educational approach for assistance
to offer accurate knowledge and information about the nature and method of treatment and
addressing disease needed for cure and added with consideration for psychotherapy. It is
useful to achieve most realistic goals and for motivation of the client and family.
The rationale behind using this technique was to initiate intervention plan as therapist
comprehensively explains nature, etiology, management of illness, prognosis, and time
required therapy. Client herself was psycho-educated regarding the nature of the problem,
management and relapse. Client was also psycho educated about her vicious cycle of
depression.
3.5.12.3 Relaxation Techniques
A person who feels anxious most of the time has trouble relaxing, but knowing how to
release muscle tension can be a helpful strategy. Relaxation techniques include: progressive
muscle relaxation, abdominal breathing, Alternative nostril breathing and isometric relaxation
exercises (Matsumoto & Smith, 2001). The rationale behind using relaxation exercises with
client was to help her to relax, to attain calmness and to reduce levels of pain which was
contributing in client’s crying spells.
Alternate nostril breathing was applied on the client, as she was made sit with spine
straight and feet flat on the floor. She was asked to close the right nostril with her right
thumb, and inhale through the left nostril into the belly, for a count of 4 3. After inhaling,
she was asked to hold her breath for 4 seconds to exhale through her right nostril while
closing the left with her ring and pinky finger of her right hand for 4 counts. She was further

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asked to repeat steps 1 to 3, but this time start inhaling through the right nostril and vice
versa. In the middle of this exercise, she was asked to imagine one her best moments in her
life to its fullest for best better results. She was asked to start off practicing this breathing
exercise for 2 minutes at a time and then increase to 10 minutes for maximum benefits for at
least twice a day. Along with it one of her best life events was used as guided imagery.
3.5.12.4 ABC Model
The ABC model is a basic CBT technique. It’s a framework that assumes beliefs
about a specific event affect how individual react to that event. In ABC model, A stands for
adversity or activating event. B is for beliefs about the event. It involves both obvious and
underlying thoughts about situations, self and others. C stands for consequences which
includes behavioral or emotional response.
The rationale behind using ABC model was to challenge client’s negative thoughts
and cognitive distortions. The client was seated comfortably in the chair and after doing
relaxation exercise, she was asked to write an activating event which was recent fight at
home and job related issues. Then she was asked to write its consequences which was
feeling of hopelessness about the future which resulted in crying spells/ low mood.
Afterwards her underlying beliefs was identified was “I cannot do anything right, I should
die because my life means nothing, I make things more worse”. Later on, ABC model was
explained in detail to the client to make her understand the connection between her own
beliefs and consequences.
3.5.12.5 Cost Benefit Analysis
In cognitive behavioral therapy (CBT), this technique has been adapted for use in
cognitive restructuring. Put more simply, a cost/benefit analysis can be used to challenge
old, unhealthy patterns of thinking, allowing them to be replaced by new, more adaptive
thoughts. The client was seated comfortably in the chair and after doing relaxation exercise
client asked to write down costs and benefits of her negative thoughts to explain her that the
costs of her depressive thoughts would always be more than the benefits and that her low
mood was making her cost her mental health.
3.5.12.6 Roleplay
Role play is a technique used by counselors of different theoretical orientations with
clients who need to develop a deeper understanding of, or change within, themselves.
Within a role play, clients can perform a decided-upon behavior in a safe, risk-free
environment. Role play is a blend of “Salter’s conditioned reflex therapy, Moreno’s
psychodrama technique, and Kelly’s fixed-role therapy”. Moreno’s psychodrama process

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involved three facets warm up, enactment, and reenactment. Hackney and Cormier
described four aspects commonly found in role plays (Liness et al., 2019). In most role
plays, a person reenacts herself, another person, a set of circumstances surrounding a
situation, or her own reactions. The person then receives feedback from the professional
counselor or from group members when the role play is instituted in a group-work context.
Role plays occur in the present, not the past or the future; it is common to begin with scenes
that are easier to reenact and to work progressively toward scenes that are more complex
(Lam, 2004).
Client was seated comfortably in the chair and then she was asked to do a role play
where she was supposed to act as her boss or other family member and play the situations
that she was sad about, CBA and Relaxation Techniques were used side by side to help her
get over her negative thoughts about death and hopelessness.
3.5.12.7 Concentration Exercise
Mastering the mind comes as a natural process. Mind is just a tool or an instrument
that has enormous power and value. It has to be trained or taught to obey the person. The
rationale behind usage of this technique was that through concentration exercises one can
train the mind to focus on things that they want to do.
The client was as usually seated comfortably in the chair. Before starting the
exercise, client were given proper instruction to make her body relax right from toes to head
and then client was asked to close her eyes gently in the same relaxed sitting posture. And
behind the closed eyes start counting backwards from 100 to 1 also make sure give enough
pauses between each number. Client was instructed to do this exercise at least once a day to
improve her concentration span.
3.5.12.8 Sleep Hygiene Therapy
Sleep hygiene therapy is defined as a set of behavioral and environmental
recommendations intended to promote healthy sleep, and was originally developed for use
in the treatment of mild to moderate insomnia (Stepanski & Wyatt, 2003).
The purpose of sleep hygiene was to educate the client and create an awareness of
lifestyle and resolve her sleep disturbances. This also help making sleep quality and sleep
quantity better.
The sleep guidelines provided by the therapist to client regarding her sleep issues
which included avoiding caffeine and energy drinks, try to do some walk or any exercise
before sleep, and go to the sleep when client is fully tired and don’t lay on bed when client
was not sleepy at all. If still client was awaking so leave the bed and go to any other room
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where the lights are dim and try to read some book. Get up early in the morning and go to
the bed early on the same time to set down the circadian rhythms and avoid long naps in
afternoon. The client was asked to monitor her sleep time and awaking time to make it
regular for every day. Client was instructed not to use mobile when she was going to sleep.
Lastly client was instructed to do nostril breathing exercise before sleep and repeat the steps
daily to have an effective sleep pattern.
3.5.13 Post Assessment
3.5.13.1 Subjective Rating of the Symptoms
It included comparison between pre and post assessment. The client was reassessed
after the management to determine the degree of improvement in client’s problems. Overall
there was reduction in the client’s presenting complaints.
Table 4
Comparison of Pre-management and Post-management Severity Rating of the Client’s
Problem.
Problematic Behavior Pre-management Post-management
Low mood 7 5
Crying spells 6 4
Hopelessness 6 4
Difficulty concentrating 5 3
Difficulty falling asleep 5 2
Recurrent thoughts of death 4 2
Graph 1

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3.5.13.2 Graphical Representation of the Outcome of Management

Outcome.
After applying therapeutic interventions, the overall therapeutic outcome was
satisfactory as client’s low mood and sleep issues were reduced. The pre management rating
of the client’s symptoms were 55 % and post management ratings were 33 %. The rate of
change in the client’s symptoms was 22% according to the subjective ratings of the
symptoms of the client.
3.5.14 Termination of Therapy
Overall, 9 sessions were conducted. The therapy was terminated because client’s
condition was improved and our time period of placement was also ended. In the 8 th session,
the client was informed by trainee clinical psychologist that sessions would be terminated
after 2 days. Client was told about improvement by pre management and post management
ratings of presenting complaints. The therapy was terminated after taking client’s feedback
about the sessions which was positive. Furthermore, therapeutic blueprint was given to
client for the future management.
3.5.15 Limitations
• There were many sources of distractions for the client during sessions.
• The seating was not appropriate for taking individual sessions.

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3.5.16 Recommendations
• A separate place for individual sessions should be available.
• Family therapy should be done to make her relationship effective with her family
members.

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3.5.17 Session Report
3.5.17.1 Session no 1
As soon as the session started the consent forum was get assigned by the client’s
after clearing all the ethics to her. The client seemed hesitated at the beginning but went well
gradually. She was in a low mood and her clothing’s were neat and tidy.
After the consent forum bio data of the client was taken with an open interview.
3.5.17.2 Session no 2
The client was seated comfortably in neat and tidy clothes. Clinical interview
continued and she told relevant events from her life. Rapport was built. MSE was noted
down on the paper.
3.5.17.3 Session no 3
The session started with the bridges of the previous session so that the client can
realize that the counsellor has been listening to her carefully which builds the rapport more
strongly. Along with the bridging remaining history was taken from the client in the session.
After history taking deep breathing with guided imagery was practiced. Compliance was
observed and the client seemed to respond well in the session.
3.5.17.4 Session no 4
In this session, interview was left unstructured and the client was made comfortable
to speak as her will. After the discussion BDI test was introduced to the client and given to
attempt.
3.5.17.5 Session no 5
At the beginning of the session active listening and bridges was done that help make
and maintain the rapport with the client. The goal of the session was to taught ABC model to
client to challenge her negative thoughts and cognitive distortions and to psychoeducation
her about its mechanism. Deep breathing was also practiced.
3.5.17.6 Session no 6
In the session bridging and mirroring was done to relate this session with the past
one to techniques. The goal of the session was to administer cost benefit analysis for
managing her low and depressive mood and role playing was also done for managing her
negative thoughts about death and hopelessness.
3.5.17.7 Session no 7
The session started with bridges and active listening the client was explaining how
workful the assignments and techniques have been for her. Backward counting was

110
administered for her concentration issues.
3.5.17.8 Session no 8
At the beginning of the session feedback of previously administered techniques was
taken. Along with this, psycho-education about the sleep hygiene was also done. Client was
suggested to go to bed only when she was sleepy and restrict the intake of caffeine and also
given the rationale of its adverse effects on circadian rhythms. At the end of the session
termination was also introduced.
3.5.17.9 Session no 9
In this session the client was recommended to come for follow-up if she feels reverse
in her illness. She was asked to keep practicing the techniques taught. The case was
terminated.

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 CHAPTER 4: CONCLUSION
4.1 Insomnia
The customer complained of insomnia, leg jerks, and weariness. Assessments were
official and informal. Clinical interviews, observational research, mental status exam (MSE),
subjective complaints ratings, Sleep Quality Assessment (PSQI), and Apnea Severity (ISI)
were utilized for assessment. Other defined insomnia syndromes with acute stress (DSM 5
code 780.52) (G47. 09). Complaints prompted the management plan. Psychoeducation
regarding the disorder or Muscle Relaxation (breathing deeply and 16-PMR) was employed
to reduce stress. Thought stopping, Cognitive treatment, and Sleep hygiene were utilized to
resolve sleep problems. 11 sessions were completed. Therapy improved the client’s
symptoms. The customer improved 30% after sessions.

4.2 Borderline Personality Disorder

It is concluded that BPD is one of the most dangerous mental illnesses. These diseases
create a lot of problems for people. There are many symptoms of the disease which create
problems for them. The people do not control their emotions and they focused on self-harm
activities and some of them commit suicide. People suffer from different problems, but there
are some therapies that are useful for BPD patients. These therapies are used to improve their
behaviors and help them to control their emotions. There are many therapies that are
beneficial to reducing the rate of mental diseases, so most doctors offer different therapies
that help to improve their health.
There are recommendations for patients who suffer from BPD. It is a disease that
affects mental health. If the person has a mental illness, it is very difficult for him or her to
maintain relationships with others and many other issues (Skodol, 2022). So, those who
suffer from this disorder should emphasize the different behavioral therapies which will
oblige them to improve their health. They should focus on communication with their friends
and family if they feel any symptoms. This step will be useful for them to improve their
health and also help to build strong relationships with their families. Patients should develop
trust in doctors and tell each and every problem that they face, it will help to improve their
mental health. They should follow all the guidelines of the doctors.

4.3 Cocaine Use Disorder

From an interpretation of the above data, Information stated that the use of Cocaine is
more. Individuals are adopting this drug widely. Due to an adaptation, many negative effects

112
are raised in an individual who will adopt this. Individuals should not use it, depending on the
Cocaine when they will use, they will decline the number of days in their life. Additionally,
in the case study of IV code (304. 20 (F14.10), in this case, person A. A is suffering from the
disorder of Cocaine. As his age is 27-year education is matric. A is a single person who is not
married and belongs to the religion of Islam. From addiction to till many changes that have
occurred in the life of A.A.
The results of the report are obtained by the usage of different types of methodologies
like clinical interviews, behavioral observations, mental examination, and an approach of
subjective rating. From an analysis of the reports which are irritating to the A.A. During the
use of cocaine disorder, the sleeping rating result of A. A is 6, craving for the drug is 5,
restlessness condition rating is 5 and the capacity to give an argument for anything was low
which is 4. Additionally, the evaluation of the test DAST (drug addiction test) stated that the
total rating score is achieved by A.A in an examination of DAST is 6 which represents the
moderate level of intensity of the disease.
Thus, these are results that are extracted from the personal reports of AA. The
conclusion of the results recommended that A.A and other individuals should not direct
themselves to any types of drugs because these drugs destroy the life of an individual. They
should invest themselves in social gatherings which are full of information. Additionally,
entire individuals should take exercise, diet, and nutrients to spend healthy and good life.
Thus, when individuals will use adopt these precautions then they will not get addicted to that
disease and also will not try any type of drugs. The life expectancy rates will be high,
individual will not die from the effects of the disease.

4.4 Generalized Anxiety Disorder

In this study, the case of generalized anxiety disorder with the different treatment
options. Especially we did the experimental work about Generalized Anxiety Disorder. The
use of different types of scales and other informal and formal assessments helps us to
understand the client’s real situation in which we analyze and identify why the client is facing
this issue and what are the symptoms and how the issue-level should be decreased. We can
assess the client by looking at it in the clinic, general appearance, speech, eye contact, heart
rate, memory, and other techniques. Although more research is needed, research shows that
certain long-term effects of stress on the body include heart problems, such as an increased
risk of heart disease.

113
 A weakened immune system can lead to various diseases. Irritable bowel syndrome is
one of the most common gastrointestinal diseases. However, there is another side to the
matter. Persistent anxiety creates significant psychological pain and, in the worst-case
scenario, can lead to illness and the development of anxiety disorders such as panic attacks,
fears, and behavioral disorders. Self-examination may help you to determine what to do next.
If these feelings persist, you may be suffering from depression, anxiety, or both. These
exercises include important questions that will help you assess your current status and plan a
plan to feel better immediately. Anxiety is a common thing that has an existence in all
individuals of the world. There is no wonder that feeling anxiety is very ridiculous and
dangerous for humans. It is natural and habitual. It is a common thing that arrives easily in
the personality characteristics of humans. Yes, it is a good thing on some occasions in our
lives. The types of anxiety disorders such as panic and external agoraphobia, social anxiety
disorder, phobias, compulsive disorder, generalized anxiety disorder, and post-traumatic
stress will define and analyzed in detail in this article.

4.5 Major Depressive Disorder

According to case study the patient was diagnosed with the major depressive disorder.
The symptoms of the patient were according to the symptoms there were great behavioral
changes. As she was observed to have low moods, anxiety and continuous depression. These
symptoms usually show when the patient is having any trauma or any injury in their life
because it has a sudden effect on the mind of the patient. In such a situation the patient needs
to be treated with psychotherapy so that sudden treatments can be provided and the recovery
rate of the patient can be increased. The psychologist needs to develop a healthy relationship
with the patient so that she can feel relaxed. Once the patient is relaxed then there are higher
chances that she can discuss all the issues she is facing in her life. It is expected that she will
have a positive attitude towards her life which will be shown in her actions. Besides that,
multiple other techniques can be used to treat such issues as depression is the major reason
behind such issues so the first aim of psychologists is to treat depression and the cause of
depression. Once it is treated positive changes can be observed in the attitude of the patient
that will ultimately lead to better health and recovery.
Patients that are suffering from major depressive disorder should be treated on time so
that this depression does not take the shape of extreme depression and anxiety. Individuals
that are suffering from issues of depression and anxiety should formulate a routine and work
according to their routine. This will help the individuals to continue all the day-to-day
activities according to their routine and maintain a healthy lifestyle. The goals should be set
114
for the patients so that they have an aim in their life and all their efforts should be toward that
aim. Once they will achieve one goal in life they will be more motivated in life which
ultimately will help in achieving the further steps. In this the patient may feel better about
himself and the negative emotions can be controlled.
Exercise is one of the most important parts of a healthy lifestyle. The patient must be
engaged in exercise activities either at home or outside the home. The activities may involve
running, jogging, etc. so, in this way, the mind and body will remain active and there are
higher chances that the individual will feel more productive and have a positive mind. The
major depressive disorder should be recognized by the parents and guardians of the patients
because if the patient is treated at the initial stages then there are higher chances that he will
recover from it and have a positive life. So, there should be mutual coordination among
individuals and the patient himself should take the initial actions to cure this.

115
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 Appendix-I

Appendix-II
Plagiarism Report

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