CASE REPORTS

Submitted to

Dr. Asma Riaz

Submitted by

Hooria Amer(230617 )

Registration number

(2023-GCUF-0022 )

Semester 3rd

Session 2023-2025

Report submitted in partial fulfillment of

the requirements for the degree of MS Clinical Psychology

MASTER OF SCIENCE

IN

CLINICAL PSYCHOLOGY

DEPARTMENT OF APPLIED PSYCHOLOGY

GOVERNMENT COLLEGE UNIVERSITY FAISALABAD

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DECLARATION

I am Hooria Amer, Roll No. 230617, student of MS Clinical Psychology,

Session 2023-2025 hereby declare that the matter presented in this case
report is my original work.

Dated: _____________ Signature of Deponent

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CASE REPORTS COMPLETION CERTIFICATE

It is certified that the work contained in these Case Reports has been
completed by Ms. Hooria Amer, Roll No. 230617 under my
supervision.

Dated: _________________ Supervisor

Dr. Asma Riaz

Assistant Professor,

Department of Applied Psychology

Govt. College University, Faisalabad

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Table of Contents
Sr. No Title Page No.

1 Case 1 (substance induced psychosis)

Appendix

2 Case 2 ( )

Appendix

3 Case 3 ( )

Appendix

4 Case 4 ( )

Appendix

5 Case 5 ( )

Appendix
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Case No. 1(Shizophrenia)

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CASE 1
Bio Data
Name F.I
Father Name M.I
Age 36
Gender Male
Education B.COM
Religion Islam
Birth Order 1st
Siblings 2 Bro+4 Sis
Parents Alive
Father Occupation Laborer
Mother Occupation House wife
Social Economic Status Lower class
Address Faisalabad
Examiner Initial

Identifying Information
The client’s name is F.I. His father’s name is M.I. He is male and 36 years old. He is an employee in factory. He
has 2 brothers and 4 sisters. His birth order is 1st. He belongs to a lower-class family. He is married. He has four
children. He lives in Faisalabad.
Reason and Source of Referral
The client was referred to me by DR. Imtiaz Dogar for the assessment of psychological problem
Presenting Complaints
Presenting Complaints Duration
According to the patient he had not been feeling well. The duration of illness is for one month.
According to the informant the patient had been
talking to self, increased activity, reduced sleep and
reduced appetite. the following prominent symptoms
• Auditory Hallucination
• Visual Hallucination
7 months
• Self-Talk
• Self-laugh
• Delusions
7 months
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• Beating others.
• Isolation
• Stubbornness
• Decreased Sleep

Clinical Interview
 Clinical history
The patient was well before one month. The time of onset was one month back. The symptoms were
talking to self, increased activity, reduced sleep and reduced appetite. No suicidal ideas.

 Developmental History
Delivery was normal and client was born in house. No history of birth defects. Development milestones
were achieved on time.

 Personal History
Client was brought up by his father and mother. Breast feeding was adequate and weaning startedon 6th
month of age. No history of maternal deprivation. Milestones were normal and had temper tantrum during
childhood.

 Family History
Client belongs to a nuclear family. He is married and staying separately with his wife and son. He has 18
months old son. Client is the only son is the family and share good bond with them. Hisgrandfather had
some psychotic symptoms but not much information could be elicited.

 Educational History
Client’s formal education was started at the age of 5 years. He had good relationship with his peer group
and teachers during the school life. He had no school phobia.

 Social History
Client had good relation with family members, workmates, friends and superiors. He is introverted. He
had less social interaction. He uses his leisure time watching television. He has good self-confidence and
self-esteem. He never abused drugs or alcohol.

 Occupational History
Client worked as a accountant. Now he had no job due to illness. He had no job
Satisfaction.
 History of Drug Use/Abuse: (if applicable)
Nill

 History of Psychiatric/ Medical Illnesses

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The first episode of illness started when client was 25-year-old. At that time the client ran away from home
and after 1 year came back with mental illness. So, no history of precipitating factor isavailable. At that time, he
was treated in hospital. After that his condition got better and he went back home. 1 year back he again had
relapse and had been on medication.
Mental Status Examination
GENERAL APPEARANCE & BEHAVIOR: -
General appearance is well dressed. Facial expression was apathetic. mannerism was present. he maintains eye
contact. Gait and posture are normal. Hygiene was poor. Attitude towards the examiner was cooperative and
attentive.
MOVEMENT AND BEHAVIOR:
Motor disturbance present (stereotype movement, hyperactivity and compulsion).
SPEECH:
Pressure of speech was accelerated. Flight of ideas was present. Thought block was absent.
Monotonous pitch was observed. Speed was increase and reaction time was slow.
MOOD / AFFECT:
• Subjectively: “I am happy and joyful”
• Objectively: laughing
• Pleasurable affect: present, Euphoric.
THOUGHT:
Form of thought disorder: absent
Delusion: present
Client says, “I am the CEO of many companies”.
PERCEPTION
Hallucination is present. client says he can see and talk with God.
COGNITIVE FUNCTIONS:
• Not oriented to time, place and person.
• Attention & Concentration is aroused and sustained
• Memory:
Immediate memory: intact Recent memory
• Abstract thinking impaired.
• Intelligence is impaired
• General fund of knowledge: adequate
• Judgment: Personal: Social: impaired
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INSIGHT:
Insight absent
Psychological Assessment
I assess client’s condition by clinical interview and by administering some psychological tests according to the
client’s condition and her consent.
Test Administered: -

 Schizophrenia test and Early Psychosis Indicator (STEP) question.

 Human Figure Drawing.
 Pannas

Test Result:

Schizophrenia Test and Early Psychosis Indicator (STEP) Questionnaire.

Quantitative analysis

Score Category
27 Severe

Qualitative analysis: -

Client has 27 score in (STEP) which shows that the client has severe level of schizophrenia.

PAANAS

Quantitative Interpretation

Negative Affect (NA): 35/50

Score Interpretation: The client scored 35 out of a possible 50 on the Negative Affect scale. This score is
considered high, indicating that the client frequently experiences negative emotions such as distress, anger, fear,
and nervousness.
Positive Affect (PA): 10/50
Score Interpretation: The client scored 10 out of a possible 50 on the Positive Affect scale. This score is
considered low, suggesting that the client rarely experiences positive emotions like joy, enthusiasm, and alertness.
Qualitative Interpretation:
High Negative Affect:
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The client's high score on the Negative Affect scale suggests that he is frequently overwhelmed by negative
emotions. This is consistent with his reported symptoms, such as sudden aggression, paranoia, and feelings of
being controlled by others. These high levels of negative affect may be contributing to his disturbed behavior,
poor social functioning, and overall distress. The client's inability to regulate these emotions likely exacerbates his
symptoms, leading to further deterioration in his mental health and interpersonal relationships.

Low Positive Affect:

The low score on the Positive Affect scale indicates that the client experiences very few positive emotions. He
likely struggles to find joy or enthusiasm in daily activities, which is in line with his loss of appetite, disturbed
sleep, and social withdrawal. This low level of positive affect is also a common symptom in schizophrenia, where
negative symptoms such as anhedonia (inability to feel pleasure) and avolition (lack of motivation) are prevalent.
The absence of positive emotions might further contribute to his overall sense of hopelessness and emotional
disengagement.

Human figure drawing (HFD)

35 years old figure drawing with 6 emotional Indicators (Monster figure, Broken lines, asymmetric Arms and
Legs, Omissions of Neck, Poor Coordinator of Body and Arms clinging to body) shows instability,
aggressiveness, immaturity and schizophrenia in the client.
Case Formulation
According to 4P’s
The sessions was conducted with the client and his mother to get the information about the present complaints,
history and nature of presenting complaints and background information, also to have a clear picture of client’s
problem.

The client has several predisposing factors contributing to his condition. A family history of psychotic
symptoms (grandfather) suggests genetic vulnerability to schizophrenia. Growing up in a lower-class family with
limited resources and bearing the burden of being the eldest sibling may have increased his stress levels, while his
introverted personality reduced his ability to cope with challenges.

The precipitating factors include the relapse of psychotic symptoms one month ago, likely influenced by
inconsistent medication adherence and unemployment. Additional stressors such as family responsibilities and
financial challenges may have triggered this episode. The illness is being perpetuated by the absence of insight
into his condition, persistent hallucinations and delusions, and aggressive behaviors that isolate him from his
family and community. The family’s distress and lack of knowledge about the illness further exacerbate the issue.
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Which is the perpetuating factor towards the client illness. However, there are several protective factors: the
client has family support, a history of positive response to treatment, and no substance abuse history. His
cooperative attitude during assessment also indicates some level of motivation for recovery. These factors can be
leveraged to provide effective treatment and support.

Diagnosis
Schizophrenia, Unspecified Type (F20.9)
Treatment Plan

Management Plan

Objectives Short-Term Goals Long-Term Goals Interventions

- Achieve complete
Stabilize remission of psychotic - Administer antipsychotic medication
- Reduce hallucinations and
Psychotic symptoms through (e.g., Risperidone or Olanzapine) and
delusions within 2-4 weeks.
Symptoms consistent medication monitor side effects.
adherence.
- Reduce aggressive - Psychoeducation for the client and
- Teach emotional regulation
behaviors and improve family about schizophrenia, triggers,
strategies to manage
emotional stability within and the importance of treatment
stressors without relapse.
2-3 weeks. adherence.
- Increase the client’s - Help the client develop
- Use Cognitive Behavioral Therapy
understanding of his illness insight into his condition and
Improve Insight (CBT) techniques to challenge
and symptoms in 2-4 foster self-management
irrational beliefs and improve insight.
weeks. strategies.
- Minimize social isolation - Conduct family therapy to reduce
- Reintegrate the client into a
Enhance Social by initiating positive conflict, improve communication, and
supportive social network
Functioning interactions with family educate family members about the
and workplace environment.
and peers within 4-6 weeks. client’s condition.
- Gradual exposure to social settings to
rebuild confidence and reduce
isolation.
- Help the client regain
- Vocational rehabilitation, including
Restore - Enhance the client’s employment or participate in
job skill training and support in
Occupational motivation and self-esteem productive activities to
identifying suitable employment
Role within 2-3 months. enhance self-sufficiency and
opportunities.
well-being.
- Achieve long-term
- Improve sleep patterns
Regulate Daily maintenance of healthy - Introduce structured routines for
and appetite within 2-4
Functioning routines, including diet, sleep hygiene and balanced nutrition.
weeks.
sleep, and exercise.
- Use relaxation techniques (e.g., deep
breathing, progressive muscle
relaxation) to improve sleep quality
and reduce hyperactivity.
Prevent Relapse - Establish a relapse - Maintain long-term - Create a tailored relapse prevention
prevention plan with client stability and prevent future plan, including early warning signs,
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Objectives Short-Term Goals Long-Term Goals Interventions

coping strategies, and regular follow-
and family in 1-2 months. relapses. ups with the psychiatrist and
psychologist.
- Alleviate distress caused - Develop long-term
Address - Provide emotion-focused
by negative emotions (fear, emotional regulation and
Emotional interventions using CBT and
anger, nervousness) within resilience strategies to
Distress relaxation techniques.
4-6 weeks. manage daily stressors.
- Encourage leisure
activities or hobbies to
Enhance - Foster a balanced and - Encourage participation in
promote joy and
Quality of Life fulfilling lifestyle. recreational activities and hobbies.
engagement within 4-6
weeks.
- Educate family about the - Conduct psychoeducational sessions
- Strengthen the family’s
Family Support nature of schizophrenia, with the family to improve
role as a support system for
and Education symptoms, and coping understanding of the illness and their
the client.
strategies within 2-3 weeks. role in supporting recovery.

Differential Diagnosis
Schizoaffective Disorder:
Consideration of this disorder is due to the presence of mood symptoms (euphoric affect) alongside psychotic
symptoms.
Bipolar Disorder with Psychotic Features:
The client’s increased activity and euphoric mood could be indicative of a manic episode with psychotic features.
Substance-Induced Psychotic Disorder:
Although there is no history of substance abuse, this should be ruled out.
Major Depressive Disorder with Psychotic Features:
While less likely given the absence of depressive symptoms, this could be considered if further depressive
episodes are observed.

Prognosis
The client is cooperative and has motivation to recover that's why his prognosis seems to be better.
Sessions
Session 1 to 3
In the first session, we will focus on establishing a therapeutic relationship with the client. This will involve
conducting a comprehensive assessment of his current symptoms, medical history, family background, and other
relevant information. We will also discuss the treatment plan, outline the goals of therapy, and ensure that the
client and his family understand the process and expectations.
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The second session will be dedicated to educating the client and his family about schizophrenia. We will discuss
the nature of the disorder, its symptoms, and the importance of treatment adherence. This session aims to provide
a solid understanding of the illness, reduce stigma, and emphasize the role of medication and therapy in managing
the condition.
In the third session, we will develop a safety plan to manage the client's aggressive behaviors. This will involve
identifying potential triggers, outlining steps to de-escalate situations, and providing the family with strategies to
handle crises. The goal is to ensure the safety of the client and those around him, creating a structured approach to
managing potential outbursts.
Session 4 to 6:
During this session, we will discuss medication options with the psychiatrist and closely monitor the client's
response to treatment. We will address any side effects and concerns the client may have about his medication.
This session aims to ensure that the client adheres to his medication regimen and understands its importance in
managing his symptoms.
The fifth session will introduce the client to the basic concepts of Cognitive Behavioral Therapy (CBT). We will
start addressing distorted thoughts and beliefs that contribute to his symptoms, such as delusions and
hallucinations. The goal is to help the client develop a more realistic and balanced perspective, reducing the
impact of psychotic symptoms.
In this session, we will teach the client various coping strategies to manage stress and psychotic symptoms. This
will include relaxation techniques, grounding exercises, and other methods to reduce anxiety and improve
emotional regulation. The goal is to equip the client with practical tools to handle distressing situations.
Session 7 to 9:
The seventh session will focus on improving the client's social interactions. We will work on enhancing his
communication skills, practicing common social situations, and role-playing appropriate responses. This session
aims to help the client build better relationships with family, friends, and colleagues.
During this session, we will identify potential triggers and early warning signs of relapse. We will develop a
detailed relapse prevention plan, outlining steps the client and his family can take to prevent a recurrence of
symptoms. The goal is to empower the client and his support system to recognize and address issues before they
escalate.
The ninth session will involve a family therapy session to address family dynamics and provide support to the
client's relatives. We will discuss the impact of the client's illness on the family, improve communication, and
offer strategies for managing stress and supporting the client. This session aims to strengthen the family unit and
enhance their ability to cope with the challenges of the illness.
Session 10:
In the final session, we will review the progress made during the previous sessions and adjust the treatment plan
as necessary. We will set future goals, discuss ongoing therapy needs, and plan for regular follow-up
appointments. The goal is to ensure that the client continues to receive support and maintains the gains made
during therapy.
Limitations and Recommendations
Psycho - education to the client: -
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Psycho-education to the Client's regarding his problem will be useful to treat him and reduce the intensity of
problem.
Psycho - education to the family: -
Family Therapy can bring a change in the client behavior. It will be useful.
Deep breathing: -
Deep breathing exercise can be useful to reduce the anxiety and aggressive.
Art Therapy: -
Art Therapy will also be useful to reduce anxiety and stress and it will help the client to relax.
1) Medications: Medications are the cornerstone of schizophrenia treatment, and antipsychotic medications
are the most commonly prescribed drugs. They're thought to control symptoms by affecting the brain
neurotransmitter dopamine. The goal of treatment with antipsychotic medications is to effectively manage signs
and symptoms at the lowest possible dose.
2) Psychosocial interventions: - Once psychosis recedes, in addition to continuing on medication,
psychological and social (psychosocial) interventions are important. These may include:
• Individual therapy -Psychotherapy may help to normalize thought patterns. Also, learning to cope with
stress and identify early warning signs of relapse can help people with schizophrenia manage their illness.
• Social skills training - This focuses on improving communication and social interactions and improving
the ability to participate in daily activities.
• Family therapy- This provides support and education to families dealing with schizophrenia.
• Vocational rehabilitation and supported employment- This focuses on helping people with
schizophrenia prepare for, find and keep jobs.
3) During crisis periods or times of severe symptoms, hospitalization may benecessary to ensure safety,
proper nutrition, adequate sleep and basic hygiene.
4) Electroconvulsive therapy: - For adults with schizophrenia who do not respond to drug therapy,
electroconvulsive therapy (ECT) may be considered. ECT may be helpful for someone who also has depression
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APPENDIX
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Case No.2(Drug Induced Psychosis)

CASE:2

Bio Data

 Name H.B
 Father's Name: Ahmed Bakhtyar
 Age: 35 years
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 Gender: Male
 Education: matric
 Religion: islam
 Birth Order: 1st among 3 siblings
 Siblings: 2 sisters
 Parents:
o Father's Occupation: Laborer (sole breadwinner)
o Mother's Occupation: Housewife
 Socio-Economic Status: Low-income family
 Address: Saiyanwala
 Examiner: H.A

Reason and Source of Referral

The client self-referred for treatment, accompanied by his parents, who acted as informants. He presented with
complaints of substance dependence, aggressive behavior, delusions, and hallucinations, which have severely
impacted his relationships, employment, and quality of life.

Presenting Complaints

Presenting Complaint Duration

Drug dependence 12 years (charas), 8 years (opium & alcohol), 2 years (afeem), 2 months (ice)
Aggressiveness and anger outbursts 6 months
Paranoid delusions 6 months
Auditory and visual hallucinations 6 months
Increased appetite 2-3 months
Lack of sleep 6 months
Suicidal and hostile ideation 6 months
Irregular and irrelevant talk 6 months

History of Present Illness

The client’s symptoms began escalating over the past six months, following years of long-term substance abuse.
He became increasingly aggressive, often experiencing paranoid and grandiose delusions. His drug use
intensified, and he began taking ice (methamphetamine) two months ago, which coincided with increased
psychotic symptoms, including auditory and visual hallucinations. He separated from his wife two months ago
after attempting to harm her postpartum, and his relationships with family members have since deteriorated.

Clinical Interview

Developmental History

No significant developmental delays were reported. He grew up in a low-income household with limited access to
education and resources.

Personal History
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The client was married with two sons but has been separated from his wife for two months due to his aggressive
behavior and an attempt to harm her. He has strained relationships with his family and frequently isolates himself.

Family History

The client’s father is a laborer, and his mother is a housewife. No history of mental illness in the family was
reported. The family dynamics are poor, with the client being a source of stress for his parents and siblings.

Educational History

The client completed only up to the 4th grade due to financial constraints and lack of motivation.

Social History

The client is socially withdrawn and hostile toward others, with a history of physical and verbal aggression.

Occupational History

Previously worked as an auto driver but has been unemployed for the past six months due to his worsening
symptoms and drug dependence.

History of Drug Use/Abuse

 Charas: 12 years
 Opium and alcohol: 8 years
 Afeem: 2 years
 Ice (methamphetamine): 2 months, currently dependent
 Smokes excessively and craves ice frequently.

Mental Status Examination (MSE)

Appearance and Behavior

 The client appeared disheveled, unkempt, and poorly groomed.

 His posture was slouched, and he maintained poor eye contact throughout the session.
 Behavior was uncooperative initially, becoming hostile and aggressive when asked about his substance
use.
 Frequent hand movements and pacing were observed, indicative of restlessness.

Orientation

 The client was disoriented to time, place, and person.

 He frequently displayed confusion, indicating impaired cognitive function likely due to substance use or
psychosis.

Speech

 Speech was pressured, rapid, and often irrelevant to the context of the discussion.
 There were noticeable tangential and circumstantial speech patterns, making it difficult to follow his
thoughts.
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Mood and Affect

 Mood was elevated, with underlying irritability and hostility.

 Affect was inappropriate and exaggerated, failing to align with the content of his speech or the discussion
topic.

Thought Process

 Thought process was disorganized, with frequent derailment and irrelevant associations.
 The client’s thinking was marked by paranoid and grandiose delusions.
o Paranoid delusions: He expressed beliefs that people were conspiring against him.
o Grandiose delusions: Claimed he had significant power and abilities beyond reality.

Perception

 The client experienced auditory hallucinations, reporting hearing voices that threatened or ridiculed him.
 Visual hallucinations were also reported, such as seeing shadows or figures moving around him.
 He also mentioned feeling sensations he couldn’t explain, possibly related to psychotic misperceptions.

Insight and Judgment

 Insight was completely absent.

o The client denied having any mental health or substance-related issues, attributing his problems to
external causes (e.g., family conflicts, financial stress).
 Judgment was severely impaired, as evident from his ongoing substance use, aggressive behaviors, and
social withdrawal.

Memory

 Short-term memory: Impaired; the client showed difficulty recalling recent events or information
provided during the session.
 Long-term memory: Intact, as he could recall events from his past and childhood with relative ease.

Cognition and Attention

 The client displayed marked deficits in attention and concentration.

 He was unable to complete simple tasks that required sustained focus.

Level of Consciousness

 Fluctuating between drowsiness and hyperalert states, likely due to recent substance use (e.g., ice).

Behavior and Psychomotor Activity

 Psychomotor agitation was evident in his frequent pacing, fidgeting, and restlessness.
 He displayed impulsive behaviors, such as interrupting the session and attempting to leave multiple times.

Dress and Hygiene

 Hygiene was poor, with an unshaven appearance and stained clothing, reflecting neglect of self-care.
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PANSS (Positive and Negative Syndrome Scale)

Quantitative Interpretation:
The client scored high on positive symptoms, particularly in delusions, hallucinations, and hostility. This indicates
the presence of severe psychotic symptoms such as paranoid and grandiose delusions, auditory and visual
hallucinations, and aggressive tendencies. The negative symptoms scale revealed moderate impairments,
including emotional withdrawal and poor personal hygiene, which highlight the client's inability to engage
meaningfully with others and maintain basic self-care.

Qualitative Interpretation:
The elevated scores on positive symptoms suggest that the client is experiencing an acute psychotic state, likely
triggered or exacerbated by prolonged substance use. The paranoia and grandiosity associated with the delusions
impair his judgment and increase his hostility toward others, contributing to aggressive behavior. Meanwhile, the
moderate negative symptoms, such as emotional detachment and neglect of hygiene, point to difficulties in social
and occupational functioning, further isolating him from support systems.

SAMISS (Substance Abuse and Mental Illness Symptoms Screener)

Quantitative Interpretation:
The client demonstrated severe co-occurrence of substance dependence and psychotic symptoms. His responses
indicated a high likelihood that his mental illness symptoms are directly linked to his substance use, particularly
methamphetamine and alcohol.

Qualitative Interpretation:
The results underscore a significant interplay between substance abuse and psychosis, with the client relying on
drugs to cope with emotional distress. The persistent substance use has likely intensified his delusions and
hallucinations while contributing to his social withdrawal and aggressive behavior. The SAMISS findings
highlight the need for integrated treatment addressing both mental illness and substance dependence.

DAST (Drug Abuse Screening Test)

Quantitative Interpretation:
The client scored in the severe range for substance use disorder, indicating dependency on multiple substances,
including charas, opium, alcohol, and methamphetamine ("ice").

Qualitative Interpretation:
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The DAST results confirm the chronic and escalating nature of the client’s substance use. His dependency on
multiple drugs has not only impaired his physical and mental health but has also contributed to the development
of psychotic symptoms, aggressive tendencies, and poor interpersonal relationships. The results point to the
urgent need for detoxification and long-term rehabilitation to break this cycle of addiction.

AUI (Alcohol Use Inventory)

Quantitative Interpretation:
The inventory revealed chronic alcohol abuse, with the client demonstrating problematic patterns of alcohol
consumption over the past eight years.

Qualitative Interpretation:
The results suggest that alcohol abuse has been a significant contributor to the client’s behavioral issues, including
irritability, aggression, and impaired decision-making. The prolonged use of alcohol likely served as a gateway to
experimenting with other substances and exacerbated his psychological distress. Addressing alcohol dependency
will be a key component of the client’s treatment plan.

CAGE (Cut-Down, Annoyed, Guilty, Eye-Opener)

Quantitative Interpretation:
The client provided positive responses to all four items, indicating severe alcohol dependence and difficulty
controlling his drinking habits.

Qualitative Interpretation:
The CAGE results highlight the client’s internal conflict regarding his alcohol use, as reflected in feelings of guilt
and frustration with his inability to quit. His reliance on alcohol as a coping mechanism has perpetuated his
behavioral and psychological issues, making it critical to address his alcohol dependency alongside his other
substance use.

The psychological assessment results reveal a severe and chronic pattern of polysubstance abuse, with co-
occurring psychotic symptoms. The client's high scores on PANSS for positive symptoms and on substance use
screening tools (SAMISS, DAST, AUI, and CAGE) underscore the need for an integrated treatment plan
targeting both his substance dependency and psychotic features. The findings suggest that addressing the client’s
substance use will be critical in reducing his psychotic symptoms, improving his social functioning, and
preventing further deterioration.

Case Formulation

Predisposing Factors
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The client’s early life circumstances played a significant role in predisposing him to his current condition. He
grew up in a low-income household with limited access to education, completing only up to the 4th grade. Being
the eldest of three siblings, he may have experienced additional pressure to support the family financially, leading
to feelings of burden and frustration. His father, a laborer, was the sole breadwinner, and the family struggled to
meet basic needs. The client’s early exposure to an environment marked by financial instability and low
educational opportunities likely contributed to his vulnerability to developing maladaptive coping mechanisms,
such as substance use. Furthermore, the lack of effective communication within the family and potential neglect
of his emotional needs may have predisposed him to emotional instability and reliance on external substances to
cope with stress and challenges.

Precipitating Factors

The escalation of the client’s substance use and psychotic symptoms can be traced to several recent life events.
The separation from his wife two months ago following an attempt to harm her postpartum was a major
precipitating factor. This incident likely heightened feelings of guilt, frustration, and isolation, further fueling his
substance use as a way to escape emotional distress. Additionally, his transition to using methamphetamine
(“ice”) two months ago exacerbated his psychotic symptoms, leading to auditory and visual hallucinations,
delusions, and paranoia. His unemployment for the past six months also contributed to his deteriorating self-
esteem and increased dependency on substances. These stressors acted as a catalyst for the worsening of his
aggressive behavior, emotional instability, and hostility toward family members.

Several factors are maintaining the client’s current symptoms and preventing recovery. His long-standing
substance abuse, including charas, opium, alcohol, and ice, has created a cycle of dependence, cravings, and
withdrawal symptoms that perpetuate both his psychotic symptoms and his emotional instability. The client’s lack
of insight into his condition is another significant perpetuating factor, as he denies the harmful impact of his
substance use and psychotic symptoms on his life and relationships. His strained family relationships, marked by
hostility and aggression, have left him socially isolated, limiting his support network. Additionally, his
unemployment and idleness perpetuate his substance use, as he lacks structure and purpose in his daily life. The
continued presence of paranoid and grandiose delusions, along with auditory and visual hallucinations, further
reinforces his distrust of others and keeps him trapped in a state of fear and hostility.

Despite the severity of the client’s condition, there are several protective factors that can support his recovery.
His parents’ involvement and willingness to seek help for him indicate a strong support system that can be
leveraged during therapy. Their active participation in family therapy and their provision of a stable home
environment during his detoxification process are critical assets. The client’s age of 35 also serves as a protective
factor, as he still has the capacity for significant behavioral and lifestyle changes if he engages in treatment.
Furthermore, the client’s willingness to self-refer, despite his lack of insight, suggests some level of motivation to
address his condition, even if it is driven by external pressures. With proper intervention and family support, these
protective factors can be strengthened to promote recovery and prevent relapse.

Diagnosis:

Substance-Induced Psychotic Disorder, With Delusions and Hallucinations (F15.259)

Treatment Plan

Management Plan
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Objective Short-Term Goals Long-Term Goals Interventions

1. Antipsychotic medications
1. Achieve stable mental
Stabilize Psychotic 1. Reduce hallucinations and (e.g., Risperidone or
health with reduced
Symptoms delusions. Olanzapine) to manage
psychotic symptoms.
delusions and hallucinations.
2. Prevent future psychotic 2. Regular psychiatric follow-
2. Decrease paranoia and
episodes through long-term ups to monitor medication
grandiosity.
medication adherence. effectiveness and side effects.
Substance 1. Begin detoxification from 1. Inpatient detoxification
1. Achieve and maintain
Detoxification and methamphetamine, alcohol, program, if necessary, for safe
sobriety from all substances.
Management and other substances. withdrawal.
2. Reinforce a drug-free 2. Supportive counseling to
2. Manage withdrawal
lifestyle through cope with cravings and
symptoms and cravings.
rehabilitation. withdrawal.
1. Improve emotional
1. Anger management therapy
Address Aggression 1. Reduce violent outbursts regulation and reduce
to teach emotional control
and Anger and aggressive behavior. hostile reactions in social
techniques.
situations.
2. Cognitive-behavioral therapy
2. Teach alternative coping 2. Improve interpersonal
(CBT) to address irrational
strategies to deal with relationships by addressing
thoughts contributing to
frustration. anger issues.
aggression.
1. Re-establish family 1. Strengthen family support 1. Family therapy to improve
Improve Social
communication and reduce system to aid long-term communication and reduce
Functioning
conflict. recovery. hostility within the household.
2. Social skills training to
2. Rebuild social
2. Begin reintegrating into the enhance interpersonal
connections and support
community with supervision. interactions and reduce
networks.
isolation.
1. Achieve long-term 1. Development of a
1. Identify high-risk situations
Relapse Prevention abstinence from all personalized relapse prevention
for relapse and avoid triggers.
substances. plan.
2. Integrate into sober
2. Begin practicing 2. Encourage participation in
support networks (e.g.,
mindfulness and coping support groups and sober
Narcotics Anonymous,
strategies for cravings. activities.
Alcoholics Anonymous).
1. Increase the client’s
Improve Insight 1. Improve the client’s
awareness of the impact of 1. Motivational interviewing to
and Motivation for commitment to ongoing
substances on his mental enhance readiness for change.
Treatment treatment and recovery.
health.
2. Psychoeducation on the
2. Build motivation to reduce 2. Foster sustained
consequences of substance
substance use and improve engagement in therapy and
abuse and the benefits of
quality of life. treatment.
recovery.

Differential Diagnosis
 24

1. Schizoaffective Disorder (F25.0)

 Considered due to psychotic symptoms (delusions, hallucinations) and mood instability.

 Excluded because the psychotic symptoms are directly linked to substance use and do not persist
independently.

2. Bipolar I Disorder with Psychotic Features (F31.2)

 Considered due to mood elevation, irritability, and psychotic symptoms during manic-like states.
 Excluded as the symptoms are substance-induced and resolve during abstinence.

3. Primary Psychotic Disorder (e.g., Schizophrenia, F20.9)

 Considered due to core psychotic features like hallucinations and delusions.

 Excluded because the psychosis is substance-induced and lacks the six-month duration required for
schizophrenia.

4. Antisocial Personality Disorder (F60.2)

 Considered due to aggressive, impulsive, and hostile behavior.

 Excluded as these traits are better explained by substance use and psychosis rather than a lifelong
personality disorder.

5. Substance-Induced Mood Disorder (F19.94)

 Considered due to mood symptoms (irritability, grandiosity).

 Excluded as mood symptoms are secondary to substance-induced psychosis.

Prognosis

The prognosis is guarded due to the client’s lack of insight and long-term substance abuse. However, active
family involvement and structured therapy may improve outcomes.

sessions

Sessions 1 to 3

Session 1: Initial Assessment and Rapport Building

The primary goal of the first session was to establish rapport with the client, who presented with significant
hostility and resistance. To address this, the therapist used a non-confrontational and empathetic approach,
focusing on creating a safe and open environment. Initially, the client was hesitant to engage, but through active
listening and the use of open-ended questions, the therapist was able to gently encourage the client to share more
about his concerns and current struggles. The client, who had a long history of substance abuse and psychotic
symptoms, was assessed for his mental health and drug use patterns. Information was gathered from both the
client and his parents, who were present during the session and provided additional context regarding his
aggressive behavior, marital issues, and psychotic symptoms. Psychoeducation was introduced about the impact
of drug use on mental health, particularly in relation to psychosis. Despite some resistance, the client began to
 25

acknowledge that his substance use may be contributing to his mental health symptoms. The session concluded
with an agreement to move forward with treatment, focusing on stabilizing his aggressive behavior and psychotic
symptoms as the initial treatment goals.

Session 2: Psychoeducation and Motivation Enhancement

In the second session, the therapist focused on deepening the client’s understanding of the connection between his
substance use and his psychotic symptoms. The client was educated about how long-term drug use, specifically
methamphetamine ("ice"), alcohol, opium, and charas, could lead to symptoms such as hallucinations, delusions,
and aggressive behavior. The therapist used motivational interviewing techniques to explore the client’s
ambivalence about quitting his substances, acknowledging the difficulties involved in breaking free from
addiction while highlighting the negative consequences of continued use. The client was prompted to reflect on
the ways his substance abuse had impacted his relationships, job prospects, and mental health. Although initially
resistant, the client began to acknowledge the harm his substance use had caused in his life. Motivational
interviewing techniques encouraged him to weigh the benefits of recovery against the ongoing costs of addiction.
The session helped the client explore the possibility of making changes, and although he still expressed some
reluctance, he was open to considering treatment options aimed at reducing his substance use. By the end of the
session, the client had agreed to work on decreasing his drug use and stabilizing his psychotic symptoms, showing
an increased willingness to engage in the recovery process.

Session 3: Detoxification and Coping with Withdrawal

The third session focused on preparing the client for the detoxification process, a crucial step in addressing his
severe substance use disorder. The therapist provided detailed education about the detoxification process,
explaining both the physical and psychological aspects of withdrawal, including symptoms like cravings,
irritability, mood swings, and sleep disturbances. The client was made aware of the challenges he would face
during this period, and various coping strategies were introduced to help him manage withdrawal symptoms.
These strategies included staying hydrated, engaging in light physical activity, and practicing relaxation
techniques, such as deep breathing exercises. The therapist also emphasized the importance of avoiding
environmental triggers for substance use and discussed how to identify high-risk situations. The client was
encouraged to develop a plan for managing cravings and preventing relapse. During this session, the client’s
parents were also involved, as their support would be crucial during the detoxification phase. The therapist
discussed the option of inpatient detoxification if the client’s withdrawal symptoms became too severe. Although
the client expressed some anxiety about the detox process, he appeared willing to commit to the plan and take the
necessary steps to begin the detoxification process. His parents expressed their support and readiness to assist the
client in managing this phase of treatment. The session concluded with a sense of cautious optimism, as the client
agreed to start the detoxification process and actively engage in managing his withdrawal symptoms.

Sessions 4 to 6

Session 4: Anger Management and Behavioral Control

In the fourth session, the focus shifted to addressing the client’s aggressive behavior and anger outbursts, which
had been significant barriers to his emotional well-being and relationships. The session began by identifying
 26

specific triggers for his anger, including feelings of frustration, perceived disrespect, and his ongoing substance
cravings. The therapist introduced cognitive-behavioral strategies to help the client identify and challenge the
thoughts that fueled his aggression. These irrational thoughts included beliefs such as "people are out to get me"
or "I can’t let anyone disrespect me." The client was taught to pause and reconsider his thoughts before reacting,
using techniques such as counting to ten or removing himself from stressful situations. Through role-playing
exercises, the client practiced these skills, learning to communicate assertively without resorting to violence or
verbal aggression. The therapist also introduced the concept of emotional regulation, explaining that the ability to
manage emotions like frustration and anger is key to building healthier relationships and avoiding conflict. By the
end of the session, the client reported feeling more in control of his reactions and expressed a desire to continue
practicing the skills learned in the session. He acknowledged that his aggression had been harming his family and
was willing to put effort into change.

Session 5: Addressing Delusions and Hallucinations

The fifth session focused on managing the client’s psychotic symptoms, particularly his paranoid delusions and
hallucinations, which significantly impaired his ability to function. The session began by exploring the client’s
experiences with delusions and hallucinations, with particular attention to his fears of being persecuted and his
grandiose beliefs. The therapist used cognitive restructuring techniques to challenge these distorted thoughts and
helped the client recognize the connection between his substance use and the onset of psychosis. The therapist
emphasized that these hallucinations and delusions were likely a result of his long-term drug abuse, especially
methamphetamine, which is known to trigger psychotic episodes. The client was encouraged to practice
grounding techniques when he experienced hallucinations, such as focusing on tangible objects in his
environment or engaging in a sensory activity to distract himself from the hallucinations. Mindfulness exercises
were also introduced to help the client stay present and reduce the impact of his delusional thoughts. While the
client showed some resistance in fully accepting the cognitive restructuring, he was able to begin practicing the
grounding techniques and agreed to continue working on managing his psychosis without relying on substances.
By the end of the session, the client reported feeling less fearful of the hallucinations and more equipped to cope
with them.

Session 6: Relapse Prevention Strategies

The sixth session focused on developing a relapse prevention plan for the client, a crucial component of his
treatment given his long history of substance use. The therapist and client worked together to identify high-risk
situations that could trigger substance use, such as social environments with drug use, stressful situations, or
emotional distress. The therapist introduced strategies for managing cravings and maintaining sobriety, including
identifying early warning signs of relapse and implementing coping strategies, such as avoiding triggers or
seeking social support. The client was encouraged to create a daily schedule to keep him engaged in meaningful
activities, which would help reduce idle time and prevent the temptation to use drugs. The importance of
maintaining a strong support network was emphasized, and the client was encouraged to reach out to family
members, support groups, or the therapist whenever he felt the urge to relapse. The client seemed receptive to
these strategies and expressed a commitment to remain sober. However, he also acknowledged the difficulty of
staying drug-free, especially given his strong cravings for methamphetamine. The session concluded with the
client agreeing to continue using the coping tools discussed and to remain vigilant about the risk of relapse.

Sessions 7 to 9

Session 7: Family Therapy for Improving Relationships

 27

In the seventh session, the focus shifted to improving the client’s relationships, particularly with his parents, as
family support plays a vital role in recovery. The therapist guided a family therapy session, involving the client
and his parents. The parents were given the opportunity to express their concerns, particularly about the client’s
aggressive behavior, substance use, and lack of cooperation in treatment. The therapist facilitated communication,
allowing the client to hear his family’s perspective without becoming defensive. The session included discussions
about boundaries, with the therapist helping the parents understand how to support the client while also setting
limits on enabling behaviors. The client, initially defensive, began to express some remorse for his actions and
acknowledged the impact his behavior had on his family. The therapist emphasized the importance of creating a
balanced support system, where the family could provide emotional support without enabling destructive
behaviors. The session also focused on improving communication within the family, teaching the client and his
parents how to express concerns and needs in a constructive and non-confrontational manner. By the end of the
session, the client agreed to work on building a more positive relationship with his parents and acknowledged the
importance of their support in his recovery.

Session 8: Enhancing Emotional Regulation and Stress Management

In the eighth session, the therapist worked with the client to enhance his emotional regulation and manage stress
without turning to substances. The session began by identifying the client’s primary emotional triggers, such as
feelings of frustration, anxiety, and social rejection. The therapist introduced mindfulness techniques, including
deep breathing exercises, body scanning, and guided imagery, to help the client become more aware of his
emotional state and intervene before his emotions escalated. The client was encouraged to practice mindfulness
daily, even in small moments, to increase his awareness of his feelings and bodily sensations. Additionally, the
therapist introduced stress management techniques, such as progressive muscle relaxation and engaging in
calming activities like walking or reading, to help the client manage anxiety without relying on substances.
Although the client was initially skeptical of mindfulness, he was willing to try the techniques and expressed
interest in learning how to manage his emotions more effectively. By the end of the session, the client reported
feeling somewhat calmer and more able to cope with stress without immediately resorting to substance use.

Session 9: Reintegrating into Social and Occupational Roles

The ninth session focused on helping the client reintegrate into his social and occupational roles. The client’s
unemployment and social isolation had been major barriers to his recovery, and the session aimed to explore
potential avenues for re-engagement. The therapist encouraged the client to consider vocational training or part-
time work to provide structure and purpose to his daily life. The session also included social skills training, where
the therapist worked with the client to practice effective communication, conflict resolution, and boundary-
setting. Role-playing exercises were used to simulate difficult social situations and help the client learn how to
navigate them without resorting to aggression or substance use. The client was hesitant about returning to work,
citing feelings of inadequacy and fear of failure, but the therapist helped him break down these concerns into
smaller, more manageable steps. By the end of the session, the client agreed to explore part-time job opportunities
and commit to improving his social interactions. He also expressed a desire to rebuild relationships with family
members and friends, recognizing that a supportive social network was essential for his recovery.

Sessions 10 to 12

Session 10: Termination and Future Planning

 28

The tenth session focused on reviewing the progress made throughout therapy and preparing the client for the
next steps after the conclusion of formal sessions. The therapist began by summarizing the client's achievements,
including his increased awareness of the relationship between his substance use and psychosis, his improved
emotional regulation, and the positive steps he had taken toward rebuilding his relationships with his family. The
client was encouraged to reflect on the changes he had made in his behavior, particularly in managing aggression
and reducing substance use. The session also involved reinforcing the importance of maintaining sobriety and
continuing to apply the coping skills learned in therapy. Together, the therapist and client discussed a long-term
plan for ongoing recovery, including strategies for dealing with stress, avoiding relapse, and seeking further
support if needed. The client was encouraged to maintain contact with support groups and continue to engage in
activities that promoted his well-being, such as exercise, hobbies, and social engagement. The session concluded
with a sense of accomplishment, as the client expressed his commitment to stay sober and continue his personal
growth. While the client had not yet fully addressed all his deep-rooted psychological issues, the session was
framed as an important step forward in his recovery.

Session 11: Consolidating Skills and Fostering Independence

In the eleventh session, the focus was on consolidating the skills the client had learned throughout therapy and
fostering his independence in managing his recovery. The therapist revisited key strategies, such as anger
management techniques, coping with cravings, and using mindfulness to stay grounded during moments of
distress. The client was encouraged to share his experiences of using these skills in real-world situations. While
the client had made significant progress, the therapist helped him recognize areas where further work was needed,
particularly in handling high-stress situations without resorting to substance use or aggression. The session also
included discussing the client’s goals for the future, both short-term (staying sober, improving relationships) and
long-term (securing stable employment, rebuilding trust with family). The therapist encouraged the client to take
greater responsibility for his recovery, fostering a sense of ownership over his progress. Together, they worked on
reinforcing the client’s belief in his ability to stay sober and overcome future challenges. The session concluded
with the client feeling more confident in his ability to manage his recovery independently, though with the
understanding that periodic follow-ups would be necessary.

Session 12: Final Review and Long-Term Strategy

The final session was dedicated to a comprehensive review of the client’s progress and the development of a
long-term strategy for maintaining the changes he had achieved. The therapist began by reviewing the treatment
goals and reflecting on the client's journey, from struggling with substance abuse and psychosis to making
positive strides in managing his emotional health and rebuilding relationships. The client was praised for his
commitment to treatment, including his efforts to control aggression, reduce drug use, and improve his family
relationships. The discussion then turned to maintaining these gains and preparing for potential challenges. The
therapist provided strategies for coping with triggers that could lead to relapse, such as stress, peer pressure, or
emotional distress. The client was encouraged to continue using the coping tools he had learned, such as
mindfulness, anger management, and seeking support from family members or support groups. The therapist and
client developed a contingency plan in case the client faced difficulties or relapse triggers in the future. The
session ended with the client expressing gratitude for the progress he had made and feeling empowered to face the
future with the tools and strategies learned in therapy. The therapist emphasized the importance of ongoing
 29

support and reminded the client that recovery is a continuous process. The session concluded with a sense of
closure, but with the understanding that therapy could be reinitiated if needed.

Limitations and Recommendations

Limitations

Lack of Complete Insight:

One of the main limitations of this treatment was the client's limited insight into the severity of his mental health
condition, particularly his substance-induced psychosis. Throughout the therapy, the client demonstrated
resistance to fully acknowledging the extent of his substance dependence and its role in exacerbating his
psychotic symptoms. This lack of insight hindered the client’s ability to fully engage with all aspects of treatment
and delayed his readiness to accept the need for long-term sobriety.

Co-occurring Personality Issues:

The client exhibited antisocial personality traits, including aggression, impulsivity, and a lack of empathy for
others. These traits created additional barriers to treatment, particularly in family therapy, where the client often
became defensive or oppositional. These personality traits also hindered his ability to form stable and healthy
relationships, which is crucial for his long-term recovery.

Substance Use Cravings:

Despite engaging in therapy, the client continued to experience strong cravings for methamphetamine and
alcohol, which posed a significant challenge to his recovery. The temptation to relapse into substance use
remained high, particularly in situations where the client experienced stress or conflict. Although coping
mechanisms were introduced, these cravings persisted, requiring ongoing support to manage.

Limited Support Network:

While the client’s family played a supportive role during therapy, their involvement was limited in some areas.
For example, the family struggled to set consistent boundaries, which at times led to enabling behaviors.
Additionally, the client’s social network outside of his family was largely unsupportive, which contributed to his
feelings of isolation. A stronger external support system would have been beneficial in promoting sustained
recovery.

Potential for Relapse:

Given the client’s long history of substance abuse and the severe nature of his psychotic symptoms, the potential
for relapse remains a significant concern. While the client made progress in therapy, the chronic nature of his
substance dependence and the psychosocial stressors in his life suggest that without ongoing support, the risk of
relapse remains high.

Recommendations

Continued Substance Abuse Treatment:

Given the severity of the client’s polysubstance dependence, it is recommended that he continue participating in a
comprehensive substance abuse rehabilitation program, which could include inpatient detoxification, outpatient
 30

therapy, and participation in support groups like Narcotics Anonymous (NA) or Alcoholics Anonymous (AA).
Long-term sobriety will require continued monitoring and support to manage cravings and prevent relapse.

Increased Family Involvement:

The client would benefit from further family therapy sessions to help improve communication, reduce conflict,
and address enabling behaviors within the family. It is crucial for the family to maintain consistent boundaries
and provide a supportive environment while avoiding behaviors that enable the client’s substance abuse. Family
members should also be educated on how to better support the client’s mental health and recovery process.

Psychiatric Follow-up for Medication Management:

Ongoing psychiatric follow-up is recommended to monitor the effectiveness of antipsychotic medications and
manage any side effects. A tailored pharmacological treatment plan, possibly including long-acting injectable
antipsychotics, could help reduce the likelihood of psychotic relapses and improve medication adherence. Regular
monitoring of the client’s mental health is critical to managing the substance-induced psychosis.

Address Antisocial Personality Features:

It is recommended that the client undergo therapy specifically designed to address his antisocial personality traits.
This could include cognitive-behavioral therapy (CBT) focused on improving interpersonal relationships, impulse
control, and empathy. Addressing these underlying personality traits will help the client form healthier
relationships and improve his social functioning.

Social Reintegration Support:

The client should be encouraged to gradually reintegrate into social and occupational roles, with a focus on
establishing positive social connections and finding stable employment. Vocational training or part-time
employment could provide structure and a sense of purpose, which would support his long-term recovery. Social
skills training and continued exposure to supportive environments will help reduce isolation and build healthier,
more stable relationships.

Relapse Prevention and Stress Management:

To prevent relapse, the client should continue practicing stress management techniques, such as mindfulness,
progressive muscle relaxation, and engaging in physical activity. Developing a structured daily routine and
avoiding high-risk situations (e.g., places or people associated with substance use) will be essential in maintaining
sobriety. Ongoing access to support groups and therapy should be a priority to manage stress and prevent
potential relapse triggers.

Ongoing Monitoring of Mental Health:

Given the chronic nature of both the client's substance abuse and psychotic symptoms, regular mental health
evaluations and continued engagement in therapy are recommended. Frequent check-ins with the therapist or case
manager will help ensure the client stays engaged in treatment and continues to make progress.
31
 32

APPENDIX
 33

Case No:3 (Major Depressive Disorder with somatic

hallucinations)

CASE:3
Bio-Data:
Name: Mr. SK
Age: 62
Marital status: Married
Gender: Male
Occupation: Retired Dentistry Tehnician
Education: 12th pass
Religion: Islam
Mother tongue: Pakistani
Location of residence Samnabad,Faisalabad
Socioeconomic status: middle
Informant: nephew
Reliability: Reliable and consistent

Identifying Information:
 34

The client is a 62-year-old male, retired dentistry technician, referred by a physician for psychological assessment
and diagnosis. The informant for the case is his nephew. He was admitted to Allied Hospital 2, psychiatry ward
OPD, for treatment.

Reason and Source of Referral:

The client was referred for psychological assessment and diagnosis after a suicide attempt. He ingested wheat-
saving tablets after experiencing severe tingling sensations and physical distress. A physician referred him for
psychological evaluation due to his self-harm attempt and ongoing symptoms.
Presenting Complaints:
Presenting Complaints Duration
 Suicidal attempt by ingesting wheat-saving 2 days
tablets
 Sensations of insects crawling on the body, face,
mouth, and toes
 Choking sensation, difficulty breathing 2 years
 Rapid heartbeat, sweating, numbness in hands and
feet
 Aggressiveness during episodes
 Settles down by himself after episodes
 Lack of sleep, low mood, low appetite
 Lack of motivation, irritability, mild aggression
 Fatigue, feelings of hopelessness, guilt, regret over
past extramarital affairs
 Loss of money on purposeless activities
 Emptiness, despite financial support from children

Clinical Interview
Developmental History
The client’s developmental history was not reported in detail. There is no documentation of any significant
developmental delays or issues during childhood or adolescence. This lack of information limits insight into any
early life factors that might have contributed to the client’s current condition.

Personal History
The client expressed deep regret over past extramarital affairs and impulsive financial decisions, which he
believes have contributed to his current feelings of emptiness and guilt. These regrets appear to weigh heavily on
his mental and emotional well-being, exacerbating his depressive symptoms and contributing to his sense of
hopelessness. His impulsive spending habits, particularly on purposeless activities, have caused financial strain
and a lingering sense of guilt and failure, despite financial support from his children.

Family History
 35

The client is married, and his wife suffers from asthma, adding to his household responsibilities. They have five
children: four sons and one daughter. Among his children, one son is a dentistry technician, two sons run parlor
businesses, one son works abroad in Qatar, and his daughter is married. Despite their independent lives, the client
expresses dissatisfaction, feeling unsupported emotionally, even though his children provide him with financial
assistance.

The client is the eldest of seven siblings, including four sisters and three brothers. Being the eldest, he may have
experienced the pressure of familial expectations early on, which could have influenced his current stress and
sense of responsibility. However, no specific conflicts with siblings were reported.

Educational History
The client completed his education and training as a dentistry technician, which allowed him to pursue a stable
career until his retirement. His educational background reflects vocational competence but does not include
formal higher education, which may have limited his career advancement opportunities.

Social History
The client resides in Samnabad, Faisalabad, and belongs to a middle-class family. His social environment reflects
traditional familial and community values, which might have contributed to his feelings of guilt and failure,
particularly regarding his extramarital affairs and financial difficulties. The client reports limited social
interaction and feelings of isolation, indicating a lack of meaningful social connections outside of his immediate
family. His dissatisfaction with his financial status and personal relationships contributes to his overall sense of
emptiness.

Occupational History
The client worked as a dentistry technician for most of his professional life. After retiring, he has struggled to find
purpose and structure in his daily life. His sense of loss and unproductiveness in retirement appears to have
worsened his depressive symptoms and feelings of worthlessness. The absence of a regular occupational role has
also contributed to his feelings of dependency and frustration, despite financial support from his children.

History of Drug Use/Abuse

The client has no reported history of drug or substance abuse. This lack of substance use eliminates a potential
confounding factor in his current psychological condition and suggests that his symptoms are not substance-
induced.

History of Psychiatric/Medical Illnesses

There is no documented prior history of psychiatric illness for the client. His current symptoms of depression and
psychotic features appear to have developed within the past two years, coinciding with significant stressors in his
life, such as feelings of emptiness and dissatisfaction with his personal and financial situations. The client’s wife
 36

has asthma, which adds to the client’s stress, as he feels burdened by her health condition alongside his own
struggles.

Mental Status Examination (MSE)

Thoughts

The client displays significant preoccupation with suicidal ideation, which he has experienced during episodes of
despair. These thoughts appear to be linked to his feelings of regret over past actions, including extramarital
affairs and impulsive financial decisions that caused emotional and financial strain. He also expresses deep guilt
about these actions, particularly regarding the financial losses incurred due to purposeless spending. These
thoughts contribute to his low self-esteem, sense of hopelessness, and emotional instability.

Level of Consciousness

The client is fully alert and demonstrates the ability to engage in the interview process without any signs of
drowsiness or confusion. He remains oriented throughout the session, indicating an intact level of consciousness
that allows for active participation in therapeutic discussions. His ability to comprehend questions and respond
appropriately reflects his cognitive clarity despite his emotional distress.

Memory

The client exhibits short-term memory loss, reporting difficulty recalling recent events or conversations. This may
stem from his depressive state, which often impairs attention and memory consolidation. However, his long-term
memory remains intact, as he can recall past events, life experiences, and personal history with relative ease. This
discrepancy highlights the cognitive impact of his current emotional state rather than an underlying
neurocognitive disorder.

Orientation

The client is well-oriented to time, place, and person, demonstrating an intact understanding of his surroundings
and the context of the assessment. He can accurately identify the current date, his location, and the individuals
present during the session. This level of orientation supports the absence of significant cognitive disorganization
or confusion.

Mood

The client presents with a low mood, which he describes as persistent sadness and a lack of motivation. He also
exhibits signs of irritability, particularly when discussing topics that elicit feelings of regret or frustration, such as
his financial struggles or past relationships. Additionally, he shows mild aggression during episodes of emotional
distress, often becoming short-tempered or defensive when challenged. His mood reflects the pervasive impact of
his depressive symptoms.

Affect

The client’s affect is restricted, meaning his emotional expression is limited and fails to convey the full range of
feelings that might be expected in various contexts. For example, his facial expressions and tone of voice remain
 37

subdued even when discussing topics that would typically elicit stronger emotional responses. This restriction in
affect aligns with the overall depressive tone of his presentation.

Dress/Hygiene

The client’s dress and hygiene are adequate, reflecting his ability to maintain basic self-care despite his depressive
symptoms. He appears appropriately dressed for the setting, with no noticeable signs of neglect in grooming or
hygiene. This suggests that while his depressive state affects his emotional and cognitive functioning, it has not
yet significantly impaired his capacity for self-maintenance.

Speech

The client’s speech is clear, coherent, and goal-directed. He is able to articulate his thoughts and feelings without
any signs of disorganization or tangentiality. His speech rate, tone, and volume are within normal limits, and he
responds appropriately to questions. This indicates intact communication abilities and cognitive processing.

Insight

The client demonstrates insight into his condition, acknowledging the connection between his current symptoms
and his past actions, including financial mismanagement and relationship issues. He is aware of the need for
psychological support and is motivated to address his depressive symptoms. This level of insight is a positive
prognostic factor, as it increases his likelihood of engaging with therapeutic interventions.

Behavior

The client’s behavior during the session is cooperative, as he actively engages in the assessment and responds
appropriately to questions. However, he exhibits mild aggression during emotionally charged discussions, such as
those involving his regrets or feelings of guilt. This aggression is expressed through irritability rather than
physical outbursts, and he is able to regain composure quickly. His overall behavior reflects a willingness to
participate in therapy despite moments of emotional difficulty.

Psychological Assessment

The client was evaluated using the following tools:

 Depression Anxiety Stress Scales (DASS): Assessed the severity of depression, anxiety, and stress.
 Zung Self-Rating Depression Scale: Measured the level of depression, with specific attention to somatic
symptoms.
 Mood Scale: Evaluated the client’s overall mood fluctuations and irritability.
 Patient Health Questionnaire (PHQ): Used to screen for mental health disorders, particularly focusing
on depressive symptoms.
 Mini-Mental State Examination (MMSE): Tested cognitive function, with findings indicating short-
term memory loss.

Positive and Negative Syndrome Scale (PANSS): Focused on the assessment of somatic and tactile
hallucinations, identifying the presence of hallucinations like insects crawling on the body.

Quantitative and Qualitative Interpretation:

 38

The DASS showed significant levels of depression and anxiety.

The Zung Scale confirmed a moderate to severe level of depression with physical complaints.

The Mood Scale revealed mood instability, marked by irritability and aggression.

The PHQ indicated moderate depression, including physical symptoms such as fatigue and somatic complaints.

The MMSE suggested cognitive impairment in short-term memory while long-term memory remained intact.

The PANSS identified tactile hallucinations related to the somatic symptoms (e.g., sensations of insects on the
body).

Depression Anxiety Stress Scales (DASS)

Quantitative Interpretation:

Depression: Severe (score indicates marked symptoms of low mood, hopelessness, and lack of interest).

Anxiety: Severe (client experiences high levels of anxiety marked by physical symptoms like heart palpitations,
sweating, and restlessness).

Stress: Moderate (chronic tension, irritability, and difficulty relaxing were present).

Qualitative Interpretation: The client demonstrated severe levels of depression and anxiety, contributing to his
overall sense of hopelessness and fatigue. The stress levels, though moderate, indicate that he struggles with
emotional regulation, particularly during hallucinations or episodes of irritability.

Zung Self-Rating Depression Scale

Quantitative Interpretation:

Depression Score: Severe depression (above 70 on the scale).

Qualitative Interpretation: The client reports a significant amount of somatic complaints, such as fatigue, sleep
disturbances, and a general lack of energy. His depressive symptoms are also characterized by feelings of guilt
and regret, especially concerning his past financial and relationship decisions. His mental state suggests profound
psychological distress that has persisted for over two years.

Mood Scale

Quantitative Interpretation:

Fluctuating scores across mood parameters, with predominantly low mood ratings.

Mood instability with high irritability and episodes of aggression (scoring high on irritability/aggression items).

Qualitative Interpretation: The client exhibits significant mood instability. His depressive episodes are
interspersed with moments of irritability and aggression, particularly during his hallucinations. This suggests an
affective component to his hallucinations and may reflect deeper emotional dysregulation. He also reports
feelings of worthlessness and hopelessness that further exacerbate his low mood.
 39

Patient Health Questionnaire (PHQ-9)

Quantitative Interpretation:

Depression Score: Moderately severe depression (15-19 range).

Qualitative Interpretation: The PHQ-9 results indicate a high level of depressive symptoms, especially fatigue,
feelings of guilt, lack of energy, and low interest in daily activities. The client’s sense of hopelessness and
suicidal ideation (as indicated by his recent suicide attempt) is a key risk factor. His difficulty sleeping, lack of
appetite, and emotional exhaustion are all consistent with his depressive state.

Mini-Mental State Examination (MMSE)

Quantitative Interpretation:

Short-term memory impairment (scored below normal on recall tasks).

Long-term memory intact.

Qualitative Interpretation: The client’s cognitive functioning is generally intact, but his short-term memory shows
signs of impairment. This may be related to his depressive symptoms, which often affect concentration and
memory. His orientation to time, place, and person remains stable, which rules out severe cognitive decline or
dementia at this point.

Positive and Negative Syndrome Scale (PANSS)

Quantitative Interpretation:

Elevated scores on positive symptoms related to somatic and tactile hallucinations.

Qualitative Interpretation: The client’s experiences of tactile hallucinations (sensation of insects crawling on his
body) were strongly endorsed. These hallucinations have been ongoing for two years and cause significant
distress, particularly when paired with physical symptoms such as sweating, choking, and numbness. The client’s
insight into these hallucinations is present, as he recognizes them as part of his mental illness, but they still
contribute to his severe emotional distress.

The assessments highlight severe depression with moderate-to-severe anxiety, stress, and tactile hallucinations.
The presence of hallucinations, combined with mood instability, indicates a significant mental health condition,
likely a major depressive disorder with psychotic features (tactile hallucinations). His cognitive abilities remain
intact, except for some short-term memory loss, which may be a result of his depression.

Case Formulation:

The client’s current psychological condition is shaped by a combination of predisposing vulnerabilities (early
family pressures, impulsivity, and maladaptive coping), precipitating life events (retirement, financial losses, and
tactile discomfort), perpetuating factors (regret, isolation, and rumination), and protective factors (insight,
family support, and willingness to seek help).

Diagnosis:
 40

Major Depressive Disorder (MDD) with Somatic Symptoms and Tactile Hallucinations (F32.2 - Severe, With
Psychotic Features)

Treatment Plan

Management Plan

Objective Short-Term Goals Long-Term Goals Interventions

1. Achieve sustained
Stabilize 1. Reduce low mood, 1. Initiate antidepressant medication (e.g.,
emotional stability with
Depressive feelings of worthlessness, Selective Serotonin Reuptake Inhibitor
improved quality of
Symptoms and hopelessness. - SSRI, such as Escitalopram).
life.
2. Address fatigue, poor 2. Regular psychiatric follow-ups to
2. Prevent recurrence of
appetite, and sleep monitor medication efficacy and side
depressive episodes.
disturbances. effects.
1. Reduce tactile 1. Eliminate 1. Add antipsychotic medication (e.g.,
Address Psychotic
hallucinations and hallucinations and Olanzapine or Quetiapine) to manage
Features
associated distress. psychotic features. psychotic symptoms.
2. Foster insight into
2. Improve the client’s 2. Use reality-testing techniques in
the connection between
sense of control over therapy to help distinguish hallucinations
mood and psychotic
hallucinations. from reality.
features.
1. Teach the client to
Improve Coping 1. Reduce preoccupation manage somatic 1. Introduce Cognitive-Behavioral
with Somatic with tactile sensations and symptoms without Therapy (CBT) to challenge catastrophic
Symptoms somatic complaints. distress or functional thoughts about physical sensations.
impairment.
2. Help the client attribute 2. Promote acceptance
these sensations to and normalization of 2. Use grounding techniques (e.g.,
psychological causes somatic symptoms focusing on sensory reality) during
rather than physical within the context of hallucinations or somatic complaints.
ailments. depression.
1. Eliminate active 1. Promote a sense of 1. Develop a crisis safety plan, including
Address Suicidal
suicidal thoughts through hope and purpose in emergency contacts and coping strategies
Ideation
safety planning. life. for suicidal thoughts.
2. Build emotional
2. Conduct regular risk assessments and
resilience to reduce risk of
provide supportive therapy.
future suicidal ideation.
1. Improve
1. Foster stronger,
Rebuild Family communication with 1. Engage the family in family therapy to
healthier relationships
and Social family members and address misunderstandings and improve
within the family and
Support reduce interpersonal support dynamics.
social network.
conflict.
 41

Objective Short-Term Goals Long-Term Goals Interventions

2. Increase emotional 2. Enhance the client’s 2. Teach the family how to support the
support from family ability to seek support client without enabling dependency or
members. when needed. isolation.
1. Improve the client’s
1. Strengthen the
understanding of the link 1. Use psychoeducation to explain the
Enhance Insight client’s engagement in
between his depression relationship between depression,
and Motivation treatment and long-term
and psychotic/somatic hallucinations, and somatic symptoms.
recovery.
symptoms.
2. Increase the client’s 2. Use motivational interviewing
commitment to therapy techniques to reinforce the importance of
and medication adherence. active participation in treatment.
1. Help the client manage 1. Equip the client with
Develop 1. Teach mindfulness-based techniques
irritability and aggression effective tools for long-
Emotional to manage emotional distress and reduce
during distressing term emotional
Regulation Skills irritability.
situations. regulation.
2. Introduce progressive muscle
2. Reduce impulsive
relaxation (PMR) and breathing
reactions during episodes
exercises to manage acute emotional
of frustration or guilt.
spikes.
1. Prevent future
1. Identify triggers for 1. Develop a relapse prevention plan,
Relapse relapses of depressive
depressive episodes and including recognition of early warning
Prevention episodes or psychotic
hallucinations. signs and coping strategies.
symptoms.
2. Maintain progress
2. Encourage sustained achieved in therapy 2. Encourage participation in support
engagement in therapy and through ongoing self- groups and ongoing therapy sessions for
follow-ups. monitoring and accountability and continued growth.
adaptive coping.

Differential Diagnosis:

Generalized Anxiety Disorder (GAD): Due to the anxiety-like symptoms such as heart palpitations, sweating,
and irritability.

Delusional Disorder (Somatic Type): The persistent belief in physical sensations like insects on the body could
suggest a delusional component.

Psychotic Disorder (due to a medical condition or substance use): Rule out any underlying medical or
substance-related causes for tactile hallucinations.

Schizophrenia or Schizoaffective Disorder: If other psychotic features develop, such as auditory hallucinations
or disorganized thinking.

Prognosis:

The prognosis for this client, diagnosed with Major Depressive Disorder (MDD) with Somatic Symptoms and
Tactile Hallucinations, is cautiously optimistic, provided he adheres to treatment. Positive factors include his
insight into the condition, cooperative behavior, family support, and absence of substance use, all of which
 42

increase the likelihood of recovery. With pharmacological interventions (antidepressants and antipsychotics) and
psychotherapy (CBT, grounding techniques, and family therapy), the client can achieve symptom stabilization,
reduced hallucinations, and improved emotional resilience. However, challenges such as the chronicity of
depression, persistent guilt, and suicidal ideation pose risks that require vigilant monitoring. With sustained effort,
the client has a moderate-to-good chance of long-term improvement, including remission of depressive
symptoms, restoration of relationships, and enhanced quality of life.

Sessions

Session 1-4

Gather detailed background information, assess the client's immediate needs, and establish rapport.Explore the
client's presenting problems, including tactile hallucinations, mood disturbances, and guilt/regret. Conduct a
detailed life history interview focusing on personal, familial, and occupational aspects. Set initial therapy goals
with the client, including reducing suicidal ideation and improving emotional regulation. Active listening, open-
ended questioning, reflective statements. Rapport established, initial therapy goals set, and client engagement in
therapy initiated. Psychoeducation on Depression and Hallucinations Educate the client on the nature of
depression and tactile hallucinations. Provide psychoeducation on Major Depressive Disorder (MDD), focusing
on how depressive symptoms manifest and impact daily functioning. Psychoeducation using handouts, cognitive
explanations. Client gains an understanding of their condition, creating the foundation for managing their
symptoms. Cognitive Behavioral Therapy (CBT) Introduction Begin cognitive restructuring to address negative
thought patterns.

Introduce the CBT model (thoughts-feelings-behaviors) and how negative thoughts contribute to depressive
symptoms. Work with the client to identify automatic negative thoughts, particularly around guilt, hopelessness,
and worthlessness. Begin a thought record to monitor thoughts during the week. Thought records, Socratic
questioning. Client starts identifying negative thoughts and begins to understand how these thoughts contribute to
emotional distress. Addressing Cognitive Distortions Challenge and restructure negative automatic thoughts.
Review the client’s thought record and identify cognitive distortions (e.g., catastrophizing, overgeneralizing).
Work on disputing these thoughts by replacing them with more balanced, realistic alternatives. Introduce
behavioral activation strategies to encourage engagement in meaningful activities. Cognitive restructuring,
behavioral activation. Client starts practicing more realistic thinking patterns and engaging in activities to
improve mood.

Session 5-8:

Use CBT techniques to address and reduce the impact of tactile hallucinations.Explore the tactile hallucinations in
detail, helping the client understand the relationship between stress and the onset of hallucinations.Introduce
distraction techniques and relaxation exercises (e.g., progressive muscle relaxation) to manage distress when
hallucinations occur. Continue challenging distorted beliefs about the hallucinations (e.g., insects crawling on
him).

Relaxation techniques, CBT-based hallucination management strategies.

Outcome: The client develops strategies to cope with hallucinations, reducing their emotional impact.

Session 6: Enhancing Sleep and Appetite ,Improve sleep and appetite through lifestyle modifications Activities:
Discuss the client’s sleep patterns and develop a sleep hygiene routine. Explore appetite issues and encourage
 43

small, frequent meals. Introduce mindfulness techniques to reduce anxiety before sleep and improve appetite by
reducing stress.Techniques: Sleep hygiene education, mindfulness exercises. Outcome: Client begins adopting
healthier sleep and eating habits, helping improve overall mood.

Session 7: Exploring Guilt and Regret (Past Affairs and Financial Losses) Objective: Address unresolved guilt
and regret from past actions. Discuss the client's feelings of guilt about past extramarital affairs and financial
losses. Use cognitive restructuring to challenge the client’s self-blame and promote self-forgiveness. Begin
exploring values and self-compassion exercises to move past the regrets. Techniques: Cognitive restructuring,
self-compassion exercises. Outcome: The client starts to develop a more balanced perspective on past actions,
reducing feelings of guilt.

Session 8: Improving Social Relationships and Family Dynamics Objective: Strengthen the client’s relationships
with his family, particularly his children.

Explore the client’s feelings about his current family relationships and financial support from his children. Work
on communication skills and assertiveness to express his needs without becoming irritable or aggressive.
Encourage engagement in family activities to improve relationships.Techniques: Communication training, role-
playing. Outcome: Client starts improving communication with his family, enhancing social support and reducing
isolation.

Session 9-12:

Relapse Prevention and Coping Skills Develop strategies for managing future depressive episodes and
hallucinations. Identify triggers for depressive symptoms and hallucinations (e.g., stress, financial worries).
Create a relapse prevention plan with coping strategies such as mindfulness, relaxation, and cognitive
restructuring. Encourage the client to maintain a routine of healthy activities. Techniques: Relapse prevention
planning, problem-solving. Client becomes more confident in managing potential relapses and maintaining
progress.

Session 10: Review of Progress and Addressing Remaining Symptoms Review the client’s progress and fine-tune
treatment to address remaining symptoms. Review thought records, sleep patterns, and the effectiveness of coping
strategies. Address any remaining symptoms, including ongoing feelings of emptiness or residual hallucinations.
Refine techniques or add new coping strategies as needed. Techniques: Review and fine-tuning of therapeutic
interventions. Client reflects on improvements and continues practicing coping techniques.

Session 11: Promoting Long-Term Well-Being and Emotional Resilience Build emotional resilience and well-
being for the long term. Introduce mindfulness-based techniques for ongoing emotional regulation and well-
being. Explore the client’s strengths and how they can be applied to future challenges. Develop a gratitude
practice to shift the client’s focus away from negative thoughts. Techniques: Mindfulness, gratitude exercises.
Client develops a long-term approach to maintaining emotional resilience and well-being.

Session 12: Termination and Future Planning Summarize progress and plan for the future after therapy. Review
the client’s journey, highlighting improvements in mood, coping with hallucinations, and emotional regulation.
Discuss how the client can maintain progress without therapy, including the use of self-help tools and coping
strategies. Plan for periodic follow-up sessions if needed. Techniques: Review, future planning, closing
statements.Outcome: Client feels confident in managing his condition independently and has a clear plan for
maintaining progress.
 44

Limitations and Recommendations

The client’s long-standing depressive symptoms, persistent guilt, and tactile hallucinations pose significant
challenges, complicating treatment and delaying recovery. His chronic rumination, suicidal ideation, and limited
social connections further perpetuate his emotional distress and isolation. To address these, an integrated
treatment plan combining pharmacological interventions (antidepressants and antipsychotics) and psychotherapy
(CBT and grounding techniques) is recommended. Psychoeducation can enhance insight, while family therapy
can strengthen support and improve relationships. Crisis management with a safety plan is essential to address
suicidal thoughts, and mindfulness techniques can aid emotional regulation. Gradual social reintegration and
long-term monitoring with relapse prevention strategies will ensure sustained recovery and improve the client’s
quality of life.
 45

APPENDIX
 46

Case No: 4 (Major Depressive Disorder)

CASE 4
Bio Data
Name Z.A
Father Name A.F
Age 28
 47

Gender Female
Education MBA
Religion Islam
Birth Order 1st
Siblings 3 Sis
Parents Alive
Father Occupation Business man
Mother Occupation House wife
Social Economic Status Middle Class
Address Faisalabad
Examiner H.A
Identifying Information
A Female age 28 years old. She is a house wife. Her education is M.A. She has 2 sisters. Her father is a
businessman. Her birth order is 1st. She belongs to an upper middle-class family. She is married. She has two
children. She lives in Faisalabad.
Reason and Source of Referral
The client was referred to me by DR. Imtiaz Dogar for the assessment of psychological problem
Presenting Complaints
According to client
The client is dealing with continuous sadness, stress, worthlessness, helplessness, loss of interest from last 7-8
months. The restricted environment of her home is her main problem. She wants to run away from the house and
little of time feels suicidal.
According to informant
Husband reported that he is not sleeping and eating well. He sits alone in room most of time and talks with
himself. The symptoms started 2 months ago when client’s father died in an accident.
After the accident he didn’t talk with anyone for long time and slowly started behaving differently. The client was
referred to me with the following complaints:

Presenting Complaints Duration

Sadness
Tearfulness

7-8 months
Low appetite
 48

Insomnia

Worthlessness

Loss of interest

Depressive mood

Clinical Interview

The interview was reported by client herself and her sister. According to client her education is MA. She has
two sisters. Both of her sisters are unmarried. She was a good student at school. She always passed her
examinations with good grades. There was problem to her home environment because of which she could not
stay in touch with her friends. Her relationship with her sisters and mother was good but had a little conflict with
her father. After completing her M.A she got married at the age of 25. The client had a very restricted
atmosphere at her home before marriage. They were not given permission for outings or going anywhere alone.
But she was not really affected by this when she was unmarried. She used to have the hope that after marriage
her life will be change and restrictions will be finished. When she got married, she was happy in the beginning
thinking that she is now going to live her ideal life. What happened was totally different from what she assumed.
Her husband was supportive and humble but her mother-in-law was totally different from what she was before.
She had no restrictions from her husband but her mother-in-law was very strict about this. She had to even wear
the clothes of her mother in law’s choice otherwise mother-in-law would create issue and disturb the atmosphere
of house. Her desire to have freedom and liberty was doomed. The first child of a client was a daughter but her
mother- in-law was not so happy about it and forced her to have a second child as soon as possible. Luckily her
second kid was a baby boy. Meanwhile the environment her own home was transformed. Her sisters got
freedom and were allowed to go on tours and have outings with friends and were doing job. She was not even
allowed to do job. This made her more depressed. She used to feel left out. Her daily life and activities were
disturbed. She became passive aggressive. She showed her anger on her children and fought with her husband.
Her husband supports her but also cannot stand against her mother. All these situations lead her to the stage of
clinical depression. But now she decided to cope with this and discussed all these things with her sister. Her
sister supported her and brought her to the psychologist.

 Clinical history
 49

Patient was very restless and agitated. She was not in position to answer anything. She kept repeating that
I want to be normal. Patient was accompanied by his husband. According to husband she became quiet
and distant after his father’s death. She couldn’t sleep well so he took sleeping pills which helped her in
getting sleep. Recently before 1 week she stopped going to anywhere restricted to just room for most of
the time. From last 2 days she was not slept for 24 hours.
Mode of onset: insidious
Duration of illness: - 7-8 months
 Developmental history
Data not available

 Personal History
Birth order: 1st
Birth and development history: normal delivery and milestones were achieved on, time no childhood
disorder present.

 Family History
There is no consanguinity between parents of the client. Patient lives with her mother-in-law and husband
and she had arranged marriage 2.5 years ago. She does not have any child.
 Educational History
The client was very good in academic. She felt anxious when she had to talk or give presentation in front
of people. She once fainted in school because she was asked to give speech. she likes to go on solo trip.
 Social History
The client has been very introverted since childhood. She didn’t have any friends growing up. She talked
very less and focused on his studies. She does not share much with anyone and talk very less with his
mother and husband. She prefers to go on a solo trip.
 Occupational History
Client has been working as house wife after being married, and she did not have any job before that.

 History of Drug Use/Abuse: (if applicable)

Occasionally consume alcohol.
 History of Psychiatric/ Medical Illnesses
Client does not have any prior psychiatric or medical history
 TREATMENT HISTORY
The client took sleeping pills from few days

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOR:

General appearance was untidy. She hadn’t combed for two days. Today she didn’t brush and bath. She
was staring at one place and constantly blinking. Client was lean and looked unhealthy. No eye contact
maintained. Rapport could not be established with the client and there was rude attitude towards the
examiner. Client was not cooperative.

MOVEMENT AND BEHAVIOR:

 50

Slow psychomotor movement was observed from the client. She was staring at one place and
movement was slow. But she was blinking constantly.

SPEECH:

Thought block was absent. Monotonous pitch was observed. Speed was increase and reaction time was
slow.

MOOD / AFFECT:

• Subjectively: “I am worried about my life”

• Objectively: cautious

THOUGHT:

Form of thought disorder:

absent Delusion: present

Client says, “I don’t want to do anything”.

PERCEPTION

Hallucination is absent.

COGNITIVE FUNCTIONS:

• Oriented to time, place and person.

• Attention & Concentration around but not sustained

• Memory: Immediate memory: intact Recent memory: intact Remote memory: intact

• Abstract thinking impaired.

• Intelligence is impaired
• General fund of knowledge: adequate
JUDGMENT:
Personal: impaired
Social: impaired
INSIGHT:
Level 2- slight awareness of being sick and needing help, but denying it at the same time.

PSYCHLOGICAL ASSESSMENT:

I assess client’s condition by clinical interview and by administering some psychological tests

according to the client’s condition and her consent.

 51

TEST ADMINISTERED

1. Human Figure Drawing Test (HFD)

2. Depression, Anxiety and Stress Scale (DASS)
3. Zung self-rating Depression Scale.
4. Beck’s Depression Inventory (BDI)

Depression, Anxiety and Stress Scale (DASS)

Quantitative Interpretation:

Scoring Level
Depression 24 Severe
Anxiety 12 Moderate
Stress 33 Severe
Total 69

Qualitative Interpretation:
Depression Anxiety & Stress Scale reveals that the client has severe level of depression but suffering from
moderate level of anxiety and severe level of stress due to her current conditions.

Zung Self-Rating Depression Scale

Given below is the qualitative and quantitative analysis of the test administered on the client

Quantitative Analysis:

Scoring Category
64 Moderate Depression

Qualitative Analysis:
Zung Self-Rating Test reveals that the client lies in the category of moderately depressed.

Beck’s Depression Inventory

Given below is the qualitative and quantitative analysis of the test administered on the client

Quantitative Analysis:

Score Range category

 52

38 31-40 Severe Depression

Qualitative Analysis:
Client has 38 score in BDI which shows that the client has severe level of depression.

Human Figure Drawing Test(HFD-Emotional Indicators)

The Human Figure Drawing (HFD) test for this client is likely to reveal themes of restriction, powerlessness, and
emotional turmoil. A small or slumped figure may indicate feelings of inadequacy, depression, and vulnerability,
reflecting her controlled and unsatisfying life. Facial expressions and posture might show sadness or underlying
anger, while details like plain clothing could represent her lack of autonomy. Overall, the drawing is expected to
highlight her struggles with self-expression, feelings of isolation, and the tension between her desires for freedom
and the constraints imposed by her home environment.

Case Formulation:
The client’s depressive symptoms are rooted in predisposing factors like a restrictive upbringing and unmet
expectations of marriage, triggered by marital conflicts and lack of autonomy. These issues are perpetuated by
strained relationships, ongoing restrictions, and social isolation. However, her supportive sister, insight into her
struggles, and willingness to seek help serve as strong protective factors that, with targeted interventions, can aid
her recovery.
Diagnosis:
Major Depressive Disorder, Moderate (F33.1)
Differential Diagnosis.
Adjustment Disorder with Depressed Mood:
Considering the recent significant stressor (the death of her father), the symptoms could be a maladaptive
response to this event.
Generalized Anxiety Disorder (GAD): Although the primary symptoms are depressive, the client also shows
moderate levels of anxiety, which could be part of GAD.
Dysthymia (Persistent Depressive Disorder): Given the duration of symptoms, it’s important to consider a chronic
form of depression like dysthymia.
Post-Traumatic Stress Disorder (PTSD): The trauma of her father's sudden death and subsequent behavioral
changes might suggest PTSD.
Prognosis:
She has good chances of recovery if proper attention and diet provide to her. Her prognosis is possible she has
insight of her problem and she is motivated enough to solve her problem.
Treatment plan
 53

Management Plan

Objective Short-Term Goals Long-Term Goals Interventions

1. Achieve sustained
Stabilize 1. Reduce feelings of 1. Initiate antidepressant therapy
emotional stability and
Depressive hopelessness, isolation, and (e.g., SSRI such as Sertraline) to
improvement in overall
Symptoms emotional distress. address depressive symptoms.
mood.
2. Improve daily functioning 2. Regular psychiatric follow-ups
2. Prevent recurrence of
and ability to engage in family to monitor medication efficacy and
depressive episodes.
activities. adjust doses if needed.
1. Improve emotional 1. Cognitive-Behavioral Therapy
Address Passive- 1. Help the client recognize
regulation to foster (CBT) to identify triggers and
Aggressive and regulate anger directed at
healthier family develop positive communication
Behavior her children and husband.
relationships. strategies.
2. Introduce assertiveness training
2. Teach alternative ways to
to enable the client to express her
express emotions
needs and frustrations in an
constructively.
appropriate manner.
1. Build a sense of
Promote 1. Address the client’s feelings 1. Encourage the client to explore
autonomy and self-worth
Autonomy and of being "left out" by hobbies or interests that provide a
through meaningful
Self-Esteem promoting her independence. sense of achievement and identity.
activities.
2. Involve the husband in couples
2. Discuss and set goals for 2. Foster a sense of
counseling to negotiate her desire
future independence, such as empowerment and
for autonomy while maintaining
starting part-time work. fulfillment in her life.
family harmony.
1. Build healthier and 1. Engage the client and her
1. Reduce conflicts with her
Improve Family more cooperative husband in family therapy to
mother-in-law and improve the
Dynamics relationships with family address conflicts with her mother-
home environment.
members. in-law.
2. Strengthen her relationship 2. Create a supportive
2. Teach problem-solving skills to
with her husband by improving family atmosphere that
handle family disputes
mutual understanding and promotes emotional well-
constructively.
support. being.
1. Strengthen her external
Enhance 1. Leverage the support of her 1. Encourage regular discussions
support system to prevent
Emotional sister for emotional with her sister to reinforce
future feelings of
Support encouragement. emotional connection and support.
isolation.
2. Expand her social 2. Introduce group therapy or
2. Help the client rebuild social network for better social skills training to improve
connections and friendships. emotional and social social interactions and reduce
fulfillment. isolation.
1. Develop a more
Reduce 1. Address her feelings of 1. Use CBT techniques to
positive self-image and
Comparisons and inadequacy when comparing challenge negative thought patterns
reduce self-critical
Rumination herself to her sisters. and reduce self-comparison.
thoughts.
2. Encourage focus on her 2. Introduce mindfulness-based
personal strengths and practices to help the client stay
achievements. present and manage rumination.
 54

Objective Short-Term Goals Long-Term Goals Interventions

1. Identify triggers for 1. Maintain progress 1. Develop a relapse prevention
depressive episodes, such as achieved in therapy plan, including recognizing early
Prevent Relapse
family conflict and feelings of through sustained coping warning signs and implementing
powerlessness. strategies. coping mechanisms.
2. Foster long-term 2. Regular follow-ups with a
2. Build emotional resilience to
emotional and therapist to monitor progress and
handle future stressors.
psychological well-being. provide continued support.

Sessions:
Sessions 1-3:
In the first session I tried to Establish a therapeutic relationship and gather comprehensive information about the
client’s symptoms, history, and current situation.
Second session moves to educate the client and her family about depression, its symptoms, and the importance of
treatment adherence. Discuss the impact of recent life events and the significance of her environment.
And the third session works on developing a safety plan to manage suicidal ideation. Identify triggers and provide
the family with strategies to handle crises and ensure the client’s safety.
Sessions 4-6:
Introduce the basic concepts of CBT. Start addressing distorted thoughts and beliefs contributing to depressive
symptoms.
Teached the client techniques to manage and stabilize mood, such as identifying negative thought patterns and
replacing them with more balanced thoughts.
Encouraged participation in pleasurable and meaningful activities to counteract the tendency to withdraw and
isolate.
Sessions 7-9:
Equip the client with practical coping strategies to manage stress and anxiety. Techniques may include relaxation
exercises, deep breathing. Address sources of stress in the client’s life and develop a plan to reduce and manage
stressors. This may involve setting boundaries and assertiveness training.
Teach the client problem-solving skills to address challenges in her daily life and improve her ability to handle
difficult situations.
Sessions 10-12:
Work on enhancing the client’s social interactions and communication skills. Practice common social situations
and role-play appropriate responses. Involve the client’s husband and sister in a session to improve family
dynamics and support systems. Discuss ways to create a more supportive home environment. Review the progress
made during the sessions. Adjust the treatment plan as necessary and set future goals. Plan for regular follow-up
appointments to ensure ongoing support.

Limitations and Recommendations:

 55

The client faces several limitations that may hinder progress in therapy. These include family resistance,
particularly from her mother-in-law and husband, which complicates efforts to improve family dynamics.
Additionally, the cultural constraints of traditional gender roles and societal expectations limit her autonomy,
creating internal conflict. The client’s limited independence and restricted social life, especially before and after
marriage, have contributed to her depression, and she may struggle with emotional fluctuations due to unresolved
family conflicts. Furthermore, the client may feel reluctant to engage in group therapy or social interactions due to
past isolation, and if medication is prescribed, potential side effects could discourage adherence.
To address these challenges, several recommendations are made. Family therapy should be incorporated to
engage her husband and, if possible, her mother-in-law, to improve communication and reduce relational
conflicts. Cultural sensitivity in therapy is essential to understand and navigate traditional gender roles, allowing
the client to regain a sense of autonomy. Gradual empowerment through setting small, achievable goals will help
her regain confidence and independence. The client should also be encouraged to strengthen her emotional
support system, particularly through her sister and expanding her social network. Assertiveness training and
boundary-setting will assist in managing relationships, especially with her mother-in-law. Mindfulness-based
practices and Cognitive Behavioral Therapy (CBT) can address rumination and improve emotional regulation.
Regular monitoring and adjustment of the treatment plan will ensure progress, and medication adherence should
be supported with education about potential side effects and its benefits.
 56

APPENDIX
 57

Case No:5(Bipolar disorder currently manic episode)

 58

CASE: 5

Bio-Data:

Name: MH
Age: 23
Marital status: unmarried
Gender: Male
Occupation: tailor
Education: F.A
Religion: Islam
Mother tongue: Urdu
Location of residence Samundri, Faisalabad
Socioeconomic status: lower
Informant: mother
Reliability: Reliable and consistent but inadequate
Reason and Source of Referral:

The client was approached for psychological assessment and treatment.

Identifying Information:

The client, a 23-year-old male, is the eldest of four siblings, with two brothers and one sister. His
father is a fruit shop owner, and his mother is a homemaker. The family lives in a low-middle
socioeconomic environment. The client has discontinued his education due to a lack of interest
and is currently unemployed, having previously worked as a tailor. His family relationships,
particularly with his father and siblings, are strained, and he exhibits possessiveness toward his
cousin. The client was referred for academic purposes, and his current presentation includes
manic symptoms with psychotic features.

Presenting Complaints:

Complaint Duration
Over-talkativeness, hypersexuality 1 month
Paranoid thoughts regarding marriage sabotage 1 month
Aggressive behavior towards family members 1 month
Excessive energy and grandiosity 1 month
Overdressed and overfamiliar behavior 1 month
Repeated episodes of similar symptoms 6-7
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months
ago

History of Present Illness:

The client has been exhibiting symptoms for the past month, including hyperactivity,
hypersexual behavior, paranoia, and grandiosity. This is not the first episode, as similar
symptoms were reported 6-7 months ago, triggered by conflict with his father regarding
education.

Clinical History:

Developmental History:

The client exhibited normal developmental milestones, including appropriate motor, cognitive,
and language development during childhood. There were no significant delays or abnormalities
noted in early childhood, and he had an average trajectory of growth and development compared
to peers. There were no signs of neurodevelopmental disorders or major disruptions during his
formative years.

Personal History:

The client has a history of impulsive behavior and mood instability, with marked changes in his
social interactions and emotional responses. He was previously employed as a tailor but has been
unemployed for some time, which has contributed to a sense of loss and decreased self-worth.
The client reported feeling unfulfilled in his personal and professional life, which may have
exacerbated his mental health symptoms. He also showed a tendency to over-engage with others,
demonstrating overfamiliarity, which has led to strained social interactions. His family members,
particularly his father, report significant difficulties in managing his behavior due to his mood
swings and aggressive tendencies. He tends to seek excessive attention and validation from
others, which has contributed to interpersonal conflicts.

Family History:

There is a history of familial conflict, particularly with his father, which has been a significant
stressor in the client’s life. This conflict seems to have contributed to the onset of manic
episodes, with the client becoming increasingly agitated and aggressive during disputes with his
father. His father and siblings have difficulty understanding and coping with his mood
fluctuations, which has led to further estrangement. The client has exhibited possessive behavior
toward his cousin, showing signs of jealousy and paranoia. The family environment lacks
adequate emotional support, and there is little understanding of mental health conditions, which
has hindered the client’s ability to seek help or adhere to treatment.

Educational History:
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The client attended school up until his teenage years but discontinued his education due to a lack
of interest and motivation. He expressed feelings of inadequacy and frustration regarding
academic performance, which may have been a contributing factor to his current psychological
state. His disengagement from education reflects a broader pattern of instability and lack of
structure in his life.

Social History:

The client’s social interactions are marked by over-familiarity and boundary issues. He engages
excessively with peers and ward patients, often invading personal space and attempting to
impress others. This behavior reflects his need for validation and attention. His social
interactions are often shallow, and he has difficulty establishing meaningful, long-term
connections. He appears to be more focused on seeking admiration than forming genuine
friendships. These patterns have led to social isolation and feelings of alienation from those who
are less tolerant of his behavior.

Occupational History:

The client worked as a tailor before the onset of his current symptoms, but he has since become
unemployed. His work as a tailor provided structure and purpose, but after experiencing
symptoms of mania, including impulsivity and irritability, he found it difficult to maintain his
employment. This loss of work has significantly impacted his sense of identity and self-worth.
The client’s lack of engagement in meaningful daily activities has contributed to his emotional
instability.

History of Drug Use/Abuse:

There is no reported history of drug use or abuse. The client has not engaged in substance use,
which may be a protective factor in his overall clinical presentation. However, his manic
episodes have been marked by impulsivity, hyperactivity, and poor judgment, which could
increase the risk of substance misuse in the future if not properly managed.

MENTAL STATUS EXAMINATION

Appearance:

Subjective: The client reports feeling "on top of the world" and "unstoppable." He describes his
attire as an expression of his self-confidence.

Objective: The client appears overdressed, with excessive clothing meant to impress others,
reflecting grandiosity. Grooming is neglected, which aligns with his lack of insight into his
condition.

Behavior:
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Subjective: The client feels "full of energy" and describes the need to constantly engage with
others, as he is “too energetic” to sit still.

Objective: The client is visibly overactive, socially intrusive, and attempts to engage everyone
around him, interrupting conversations and disregarding social boundaries. This behavior is
consistent with manic symptoms.

Speech:

Subjective: The client acknowledges speaking quickly, in a “fast-paced” manner, without

considering the impact on others. He doesn’t view his speech as problematic.

Objective: The client’s speech is loud, pressured, and over-talkative, jumping from topic to topic
without coherence. This pressured speech is a hallmark of mania.

Mood:

Subjective: The client describes his mood as elevated, euphoric, and full of excitement, feeling
“invincible” and confident.

Objective: The client displays an elevated mood with noticeable periods of euphoria,
accompanied by high energy levels. He lacks emotional regulation and often shifts between
euphoria and irritability.

Thought Content:

Subjective: The client expresses a strong belief in his abilities, thinking he can achieve
extraordinary things, and fears others are sabotaging his marriage.

Objective: The client exhibits grandiosity and delusional thoughts, believing in his inflated
abilities and perceiving external threats to his marriage without substantial evidence. These
delusions align with manic symptoms with psychotic features.

Perception:

Subjective: The client denies hallucinations but expresses paranoia, feeling others are conspiring
against him, particularly regarding his marriage.

Objective: The client’s perception is distorted by paranoia and mistrust, indicating a significant
departure from reality, despite no sensory disturbances.

Cognition:

Subjective: The client reports feeling mentally sharp, confident, and capable of managing
multiple tasks simultaneously.
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Objective: The client is alert and oriented but exhibits impaired cognition, showing
overconfidence in his abilities and making poor decisions, such as engaging in impulsive
behaviors without assessing consequences.

Insight and Judgment:

Subjective: The client denies any problem with his behavior or emotional state, viewing his
symptoms as part of his personality.

Objective: The client shows poor insight, lacking awareness of the severity of his condition. His
judgment is compromised, as he fails to recognize the consequences of his actions, such as
disrupting relationships and social boundaries.

Psychological Assessment:

Human Figure Drawing (HFD):

Quantitative Interpretation:

The client’s drawing exhibited exaggerated features and excessive decorations, which are
indicative of grandiosity and a heightened self-focus. Such characteristics suggest that the client
has an inflated sense of self-worth and may seek admiration or validation from others. The
overly large figures in the drawing may also symbolize the client’s perception of himself as
being larger-than-life or superior to others, which aligns with his manic symptoms of grandiosity
and impulsivity.

Qualitative Interpretation:

The lack of structure and grounding in the drawing is reflective of the client’s hyperactivity and
impulsivity, as well as his lack of organization and planning in real life. This correlates with his
behaviors of over-talkativeness, impulsivity, and difficulty focusing on structured tasks or ideas.
The overemphasis on appearance in the drawing, such as exaggerated physical features, mirrors
his over-dressing behaviors and excessive focus on outward image, further pointing to his need
for external admiration and validation, consistent with manic symptoms.

Bipolar Depression Rating Scale (BDRS):

Interpretation:

The client scored low on depressive symptoms, which suggests that at this point, depressive
episodes are not a significant concern. However, the client exhibited signs of heightened
irritability, aggression, and mood swings, all of which are consistent with manic presentations.
This aligns with the clinical observations of the client displaying grandiosity, hyperactivity, and
impulsivity rather than depressive symptoms. These findings support the diagnosis of Bipolar I
Disorder, Current Episode Manic with Psychotic Features, with a focus on the manic phase of
the disorder.
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Young Mania Rating Scale (YMRS):

Interpretation:

The client scored high on the YMRS, particularly in the domains of elevated mood,
hyperactivity, pressured speech, and grandiosity. These high scores confirm the presence of a
manic episode. The client’s elevated mood and hyperactivity are significant indicators of his
current manic state, as is his pressured speech, where he speaks quickly and at length, often with
difficulty staying on topic. Grandiosity, another hallmark of mania, is reflected in the client’s
inflated self-image and excessive self-confidence. These results confirm that the client is
experiencing an active manic episode, consistent with the clinical diagnosis.

Mood Scale:

Interpretation:

The Mood Scale indicated a significant elevation in mood, with the client displaying impulsive
behaviors and a lack of emotional regulation. These symptoms are consistent with manic
episodes, where the client’s mood swings between euphoria and irritability. His impulsivity—
engaging in reckless or inappropriate behaviors without considering the consequences—is also a
key feature of manic episodes. The oscillation between euphoria and irritability further reinforces
the diagnosis of mania, demonstrating the client’s difficulty in maintaining emotional stability
and regulation.

Case Formulation:

Based on the 4 P’s:

Predisposing Factors:

Family history of conflicts, low socioeconomic status.

Precipitating Factors

Disagreement with father over education and possessiveness about cousin.

Perpetuating Factors:

Poor family support, lack of insight, and untreated manic symptoms.

-Protective Factors

Supportive mother, previously employable skills as a tailor.

Diagnosis
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Bipolar I Disorder, Current Episode Manic with Psychotic Features (F31.1)

Differential Diagnosis:

- Schizoaffective Disorder (less likely due to episodic nature and clear mood symptoms).

- Delusional Disorder (ruled out due to presence of mood disturbances and grandiosity).

Prognosis:

With appropriate treatment, including medication and psychotherapy, the client’s prognosis is
fair. However, adherence to treatment and family support are critical for long-term stability.

Management Plan

Objective Short-Term Goals Long-Term Goals Interventions

1. Reduce 1. Initiate mood stabilizer
1. Achieve sustained
Stabilize Manic hyperactivity, over- therapy (e.g., Lithium or
emotional and
Symptoms talkativeness, and Valproate) to control manic
behavioral stability.
impulsivity. symptoms.
2. Address 2. Introduce antipsychotic
2. Prevent recurrence of
hypersexuality and medication (e.g., Olanzapine)
manic episodes.
paranoid ideations. for paranoia and agitation.
3. Regular psychiatric follow-
ups to monitor medication
efficacy and adjust doses if
needed.
1. Use anger management
Address 1. Reduce aggression 1. Improve family
training to help regulate
Interpersonal toward siblings, father, relationships and social
emotional outbursts and
Conflicts and relatives. interactions.
aggressive behaviors.
2. Decrease
2. Foster healthier 2. Engage in family therapy to
possessiveness and
communication and improve familial understanding
conflict related to his
relational boundaries. and cooperation.
cousin.
1. Build awareness of 1. Conduct psychoeducation
1. Help the client
Promote Insight his triggers and sessions about bipolar disorder
recognize and accept
into Illness symptoms for early to increase understanding of
his condition.
intervention. his condition.
2. Develop a relapse
2. Encourage 2. Foster long-term
prevention plan that includes
adherence to treatment adherence to treatment
identifying triggers and
and medication. and coping strategies.
creating a structured routine.
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1. Introduce Cognitive
1. Develop healthier
Enhance 1. Address feelings of Behavioral Therapy (CBT) to
coping mechanisms for
Emotional paranoia and jealousy challenge paranoid thoughts
managing stress and
Regulation related to his marriage. and develop emotional
emotional instability.
regulation skills.
2. Help the client 2. Incorporate mindfulness-
manage his strong based practices to reduce
desires for marriage impulsivity and improve focus
constructively. on the present.
1. Encourage
1. Explore vocational training
engagement in 1. Build a sense of
Reintegrate into or reintegration into tailoring
meaningful, structured purpose through
Daily Activities work to rebuild his identity and
activities to avoid productive engagement.
confidence.
idleness.
2. Create a daily activity
2. Develop a
schedule to ensure balanced
structured routine to
social, occupational, and
stabilize his daily life.
leisure activities.
1. Involve family 1. Encourage family
Strengthen 1. Ensure long-term
members to create a participation in therapy to
Support support from family and
supportive home foster understanding and
Systems social connections.
environment. provide emotional support.
2. Encourage
2. Introduce group therapy to
constructive
improve interpersonal skills
interactions with his
and reduce isolation.
social circle.
1. Regular follow-ups with a
1. Identify early 1. Maintain emotional
Monitor and psychiatrist to monitor
warning signs of and behavioral stability
Prevent Relapse symptoms and adjust treatment
manic episodes. in the long term.
as needed.
2. Prevent further 2. Use relapse prevention
2. Develop coping
hospitalizations and strategies, including stress
strategies to handle
improve overall quality management and adherence to
future stressors.
of life. treatment.

Sessions:

Session 1-4

The first session focused on providing psychoeducation about Bipolar I Disorder. The client was
educated on the key features of the disorder, particularly the manic episodes, which include
elevated mood, hyperactivity, impulsivity, and grandiosity. The importance of medication
adherence, including the use of mood stabilizers like Lithium and antipsychotics like Olanzapine,
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was emphasized. The therapist outlined the treatment plan, which would include therapy
(particularly CBT) and regular follow-ups with a psychiatrist. The goal of this session was to
help the client understand their condition, normalize their experience, and empower them to
engage in treatment.

The second session focused on cognitive-behavioral therapy (CBT) to address the client’s
paranoid thoughts and grandiose beliefs. The client was encouraged to track and monitor their
thoughts using a thought record. The therapist used cognitive restructuring techniques to
challenge distorted thinking, particularly the beliefs about their inflated self-worth and fears of
being persecuted. Reality testing was introduced to help the client assess whether their paranoid
thoughts were justified. Mindfulness techniques were also introduced to help the client manage
impulsivity and intrusive thoughts.

In this session, the therapist introduced family therapy to address ongoing conflicts, especially
with the client's father and siblings. The client’s possessiveness and strained family dynamics
were discussed. The therapist facilitated communication exercises, teaching family members
active listening and conflict resolution techniques to improve their interactions. Emphasis was
placed on setting healthy boundaries within the family system. This session aimed to reduce
tension within the family and create a more supportive environment for the client’s recovery.

The fourth session focused on anger management and the development of strategies to help the
client manage their emotional outbursts. The client was introduced to relaxation techniques such
as deep breathing and progressive muscle relaxation to help them cope with anger. The therapist
explored triggers for the client’s anger and worked with them to identify healthier responses. The
ABC model (Activating Event, Belief, Consequence) was used to challenge irrational beliefs
contributing to anger. Role-playing was also used to help the client practice alternative responses
to frustration.

Session 5-8:

This session focused on introducing a structured daily routine to the client. The therapist helped
the client develop a schedule that balanced work, rest, and leisure activities. The session also
focused on vocational exploration, where the client was encouraged to consider returning to
work as a tailor or engaging in new vocational training. Barriers to engagement, such as low
motivation and lack of purpose, were discussed, and positive reinforcement was used to
encourage active participation. The session aimed to provide the client with a sense of structure
and purpose.

The sixth session focused on relapse prevention. The therapist helped the client identify early
warning signs of a manic episode, such as elevated mood and pressured speech, and taught them
strategies to intervene early to prevent full-blown episodes. Stress management techniques, such
as deep breathing, mindfulness, and progressive muscle relaxation, were introduced to help the
client cope with stress. The therapist worked with the client to develop a relapse prevention plan,
which included identifying potential triggers and creating a support system to help them manage
symptoms effectively.
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This session was dedicated to psychoeducation about medication adherence. The therapist
reviewed the prescribed medications, such as Lithium and Olanzapine, explaining how these
medications help stabilize the client’s mood. The importance of consistent medication adherence
was emphasized, and potential side effects were discussed. The therapist addressed concerns the
client had about the medications and reassured them about the benefits of following the treatment
plan. This session reinforced the idea that medication is essential to managing the symptoms of
Bipolar I Disorder and preventing relapse.

The eighth session continued with family therapy, specifically addressing the client’s
relationship with their father. The therapist helped the client and their family members recognize
unhealthy patterns of interaction and taught them boundary-setting techniques to foster healthier
relationships. The client’s possessiveness was discussed, and the therapist helped the family
members understand how this behavior impacted their relationships. The session aimed to reduce
conflicts and improve communication within the family system, which is crucial for the client’s
overall recovery.

Session 9-12:

In session nine, the focus was on CBT for emotional regulation and impulse control. The
therapist continued to work with the client to identify impulsive behaviors and challenge
irrational beliefs contributing to these behaviors. The client was encouraged to practice
mindfulness and delay gratification in situations where they might feel emotionally
overwhelmed. The session included discussions on developing healthier responses to intense
emotions and impulsive actions, with a focus on managing emotions more effectively.

Session ten was dedicated to vocational exploration and goal setting. The therapist worked with
the client to explore their interests and skills, particularly in tailoring and potential vocational
training. The client was encouraged to set career goals and develop a plan to achieve them.
Obstacles to employment, such as low self-esteem or lack of opportunities, were discussed, and
the client was provided with strategies to overcome these challenges. This session aimed to
promote career engagement and provide practical steps for improving the client’s future
employment prospects.

In session eleven, the therapist addressed the client’s relationship issues, particularly with their
spouse and family. The client was introduced to social skills training, which focused on
improving communication and interactions with others. The therapist taught the client active
listening and assertiveness techniques to enhance their social interactions. The session also
explored the dynamics of the client’s relationships, aiming to foster healthier interactions and
reduce feelings of isolation.

The final session focused on reviewing progress and reinforcing the client’s relapse prevention
plan. The therapist and client reviewed the goals achieved during therapy, such as improvements
in anger management, family relationships, and vocational engagement. The therapist also
emphasized the importance of continuing medication adherence and regular psychiatric follow-
ups. Long-term goals for the client’s recovery were discussed, and the therapist encouraged the
client to continue engaging in therapy and maintaining a support system. The session aimed to
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ensure the client felt empowered and prepared for the future, with ongoing support for their
mental health.

Limitations and Recommendations:

Limitations:

Lack of Insight: The client’s poor understanding of their condition can hinder treatment
adherence, despite psychoeducation.

Family Dynamics: Strained relationships, especially with the father, can obstruct the therapeutic
process and create an unsupportive home environment.

Impulsivity and Mood Instability: The client’s impulsive behavior, grandiosity, and mood swings
may interfere with therapy and medication adherence, making long-term stability challenging.

Social Isolation: Excessive engagement with others and over-familiarity can limit the formation
of meaningful relationships, contributing to social alienation.

Vocational Challenges: Emotional instability may hinder the client’s ability to return to work or
engage in vocational training.

Relapse Risk: The client is at risk of relapse if stress management and relapse prevention
strategies are not consistently followed.

Recommendations:

Enhance Medication Adherence: Regular psychiatric follow-ups should ensure the client adheres
to medication and monitors side effects.

Family Therapy: Continue family therapy to improve relationships and create a supportive home
environment.

Cognitive Behavioral Therapy (CBT): Focus on addressing grandiosity, paranoia, and

impulsivity, and improving emotional regulation.

Vocational Support: Provide vocational support for reintegration into the workforce or to explore
new training options.

Social Skills Training: Incorporate training to improve interpersonal communication and reduce
over-familiarity in social situations.

Relapse Prevention: Develop a more structured relapse prevention plan with stress management
and early warning sign identification.
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Ongoing Psychoeducation: Continue psychoeducation for both the client and family to improve
insight into the disorder.

Peer Support Groups: Encourage participation in support groups to reduce isolation and enhance
social skills.
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APPENDIX