Summary

Miss GH was 33 years old lady. She belongs to a middle-class family. She got education till
B.Sc. She was self-referred in Fountain Hospital Sargodha. She was married 8 years ago..
She had 1 daughter and 1 son. Her developmental milestones were normal and she was a
good student and passes a memorable time in school and college. She had normal
relationship with her father and siblings but she was too attached with her mother and had a
close relationship with her. Miss GH was 23 years old when her mother died. Since then,
she feels symptoms like lack of energy, hopelessness, pessimism, insomnia, indecisiveness,
poor self-esteem, lack of appetite and difficulty concentrating. These symptoms decreased
when she got married at the age of 25 but after 5 years of her marriage, symptoms increased
as her husband went abroad for business. These symptoms and their time period show that
she had been suffering from persistent depressive disorder that is a chronic mental illness.
According to DSM-5 She had Persistent Depressive Disorder (Dysthymia)300.4 (F34.1).
For the assessment of presenting complains different tests were used like by using cross
cutting symptom measures level 1 to get assure his main disorder after that I have founded
his score high at domain of depression and anxiety. Then cross cutting level 2 somatic
symptoms, anxiety, depression and sleep disturbance, RISB, and BDI was applied and
House Tree Person (HTP) was also applied.
Psychological interventions used that were Rapport Building, Relaxation Training (deep
breathing exercise and yoga), CBT and medications. She was taking medicines from
Fountain Hospital Sargodha. Total 6 sessions were conducted. Some improvement had been
seen in the patient
 Demographic information
Name G.H
Age 33
Gender Female
Education F.sc
Marial status Married.
Occupation Housewife
Children 2
Siblings 2
Parents Mother died
Birth order 2nd
Religion Islam
Residence Sargodha

Reason for Referral

The patient was self-referred in fountain house Sargodha during OPD

Presenting Complaints and Duration

Presenting complaints Symptoms Duration

‫اکثر اوقات اداسی محسوس ہوتی ہے‬
Sadness 2 years
‫کوئی کام کرنے کی ہمت نہیں ہوتی‬
Lack of energy 2 years

‫فیصلہ کرنے میں مشکل ہوتی ہے‬ Indecisiveness 2 years

‫نیند کی کمی بہت زیادہ ہے‬ Insomnia 2 years

‫بھوک پہلے سے بہت کم لگتی ہے‬ Change in appetite 2 years

‫مجھے اپنا اپ باقیوں سے کم تر لگتا ہے‬ Low self esteem 2 years

‫کسی بھی کام پہ دھیان نہیں لگتا‬ Trouble focusing 2 years

History of presenting problems

Miss GH was 33 years old women. Her mother died when she was 23. she was very
attached to her mother as compare to father and siblings. She became very sensitive and
emotional after death of her mother. At that time symptoms were initiated when she experienced lack
of energy, lack of sleep, hopelessness, and pessimism. She got married at the age of 25. symptoms
were decreased after marriage and she became busy her with life partner and children. She had 1son
and 1 daughter. After 5 years of her marriage her husband went abroad for his job. At that time
symptoms (lack of energy, insomnia, hopelessness, and pessimism) appeared again. According to her
she often feels these symptoms and it affect her daily functioning.

Figure:-

sadness

Lack of Lack of
energy esteem

Persistent depressive

Disorder

Lack of
nervousness
appetite

Lack of
interest

Background Information:

Family History

Miss GH belongs to a middleclass family. She had 1 brother and 1 sister. She was 2 nd among
siblings. Her parents were in good relationship and she was very attached to her mother as compare
to father and siblings. Her mother died and she lived 2 years with her family after death of her mother
and got married at the age of 25. she has 1 son and 1 daughter. she has normal relation with his
husband and strong relation with her children.

History of Psychiatric illness in the family

There was no psychiatric history in her family.

Personal History

Her developmental milestone stages were normal. She suffered mild level of depression when
her mother died. His relationship with other family members was normal.

Educational history

She completed her FSC from a government institute. According to her she was a good student
and always tries to get good grades. She passed a memorable time in school and college.

Premorbid Personality

She was very gentle to everyone. Her way of thinking was very positive.
Psychiatric history

Psychological Assessment

Mental status examination

Clinical interview
Clinical observation
Cross cutting measurement level 1 Adult
Cross cutting measurement level 2 depression
Cross cutting measurement level 2 Sleep disturbance
Beck depression inventory
HTP (House, Tree, Person

informal and Formal Assessment Measures Used.

Informal Assessment Formal Assessment
Clinical interview Cross cutting measure level 1
Mental status examination Cross cutting measure level 2 depression
Clinical observation Cross cutting measure level 2 sleep disturbance
Subjective rating of presenting complaints
 Beck anxiety inventory
House tree person

Informal assessment

Clinical interview

MSE

Subjective rating of the presenting complaints

Clinical Interview

she was 33 years old women. Her hygienic condition was good, and she was well dressed. she was in
good mood and maintains a proper eye contact. her talking style was so humble. she was manner able
and sophisticated his orientation about time, place and person was intact. she thoughts were logical
and goal oriented.

Mental State Examination.

Mental State Examination is a comprehensive workup of a client, based on interviews,

tests, and other sources of information and including details of mental status, personality
characteristics, diagnosis, prognosis, and treatment options.

Mental Status Examination of the Client

Domains Status
Appearance & Behavior
General Appearance Casual and well dressed
Attitude Calm and cooperative
Posture and Movement Restless postures
Social Behavior Normal
Speech Low tone
Mood Sadness ,confused
 Depression and Mania Depressed

Suicidal Ideation Sometime

Anxiety Sometime
Depersonalization/Derealization Mostly
Thoughts Disorganized
Obsessional Phenomena No
Delusions No
Perceptions Fair
Hallucinations No
Cognitive Function Normal
Orientation Oriented with time ,date, year
Attention and Concentration Distractable
Memory Short term intact
Insight Fair

Subjective Ratings of the Presenting Complaints. On a scale from 0-10, ratings were taken
from the patient of the presenting complaints and problematic areas of client.

Symptoms Rating

Sadness 5

Hopelessness 5

Lack of sleep 8

Lack of appetite
6
Restlessness
6
 Formal Assessment

Cross cutting measures level 1 self-report

Quantitative interpretation
Scoring of Level 1 Cross Cutting Measures by the PATIENT

Statement No Clinical Labels Scoring

1 Depression 8
2 Anger 1
3 Mania 0
4 Anxiety 6
5 Somatic symptoms 1
6 Suicidal Ideation 0
7 Psychosis 0
8 Sleep problems 4
9 Memory 1
10 Repetitive thoughts and behaviors 0
11 Dissociation 0
12 Personality functioning 1
13 Substance use 0

Quantitative interpretation
Patient scored greater on domain of depression, anxiety, and sleep disturbance. Level 2 were applied
to check the range of domains.

Quantitative interpretation of Level-2 depression- Adults

Table 3
Statement No. Clinical Labels Scoring
1 Worthlessness 4
2 Pessimism 4
3 Helpless 3
4 Loss of pleasure 4
5 failure 3
6 Depressed 4
7 Unhappy 3
8 Hopeless 4

Total 29
Quantitative analysis :
(Raw sum x number of items on the short form) Number of items that were answered.
Raw score= 29/8 divided by 8 =29
T score= 66.4
T-scores are interpreted as follows: 66.4 score interprets that patient has moderate level of
depression.
Category of scores:
Less than 55 = None to slight
55.0—59.9 = Mild
60.0—69.9 = Moderate
70 and over = Severe

Qualitative Analysis:
Level 2- depression Adult was applied on patient and according to interpretation the patient raw-
scores were 29 and T-scores were 66.4, which fall under the category of “moderate level” of
depression.

Level 2-Sleep Disturbance-Adult Table 6

Quantitative Interpretation
Quantitative interpretation of Level-2 Sleep Disturbance- Adults
Statement No Labels Scores
1 Restless 3
2 satisfies sleep 3
3 Refreshing 3
4 difficulty falling asleep 3
5 trouble staying asleep 3
6 trouble sleeping 3
7 enough asleep 4
8 poor asleep quality 4

Total score 26

Quantitative interpretation:
Raw score= Raw sum x number of items on the short form / number of items answered
Raw score = 26 x 8 / 8
T-score are interpreted as follows: 56.3 score interprets that patient has mild level of sleep.
disturbance.
Categories of score table 7
Score Range
Less than 55 None to slight
55.0-59.9 Mild
60.0-69.9 Moderate
70 and over Severe

Qualitative Interpretation:
Level 2- sleep disturbance scale was applied on patient and according to interpretation the patient
raw-scores were 26 and T-scores were 56.3, which fall under the category of “mild level” of sleep
disturbance.

Beck depression inventory:

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures
characteristic attitudes and symptoms of depression (Beck, et al., 1961). Internal consistency for the
BDI ranges from .73 to .92 with a mean of .86. (Beck, Steer, & Garbin, 1988). Similar reliabilities
have been found for the 13-item short form (Grohman, 1990). The BDI demonstrates high internal
consistency, with alpha coefficients of .86 and .81 for psychiatric and non-psychiatric populations
respectively (Beck et al., 1988)
Table 11
Quantitative Interpretation of BDI:
Statement no. Clinical labels Scoring
1 Sad feelings 1
2 Hopeless 2
3 Failure 1
4 Dissatisfaction 1
5 Guilty feelings 1
6 Feeling of being punish 1
7 Self-dislike 1
8 Self-critical ness 1
9 Feeling of suicide 0
10 Frequent cry 1
11 Agitation 1
12 Loss of interest 2
13 Lack of decision making 1
14 Worthlessness 1
 15 Loss of energy 2
16 Lack of sleep 2
17 Irritability 2
18 Lack of appetite 2
19 Concentration Difficulty 1
20 Tiredness or Fatigue 1
21 Loss of Interest in Sex 1
Total 26

Qualitative interpretation:
Total score was 26 which fall under the category of moderate level of depression.

Total Score Levels of Depression

1-10____________________ These ups and downs are considered
normal
11-16___________________ Mild mood disturbance
17- 20__________________ Borderline clinical
depression
21-30___________________ Moderate
depression
31-40___________________ Severe depression
over 40__________________ Extreme
House
depression
tree
person (HTP) interpretations:
House interpretation
closed door defensiveness
weak lines weakness of ego
doorknob poor interpersonal relationship with siblings
smoke from chimney emotional turbulence
mountains depression
shading anxiety
birds anxiety.

Tree interpretation;
Heavy lines anxiety
large branches need for satisfaction
thin trunk unstable adjustment level
dead roots anxiety
no leaves feeling barren
knot holes traumatic experience.
Person interpretations:
Large head mistrusting
Closed arms defensiveness.
Hidden hands anxiety
Large feet need for security.

Diagnosis:

Persistent Depressive Disorder (Dysthymia) DSM-5 300.4 (F34. 1)

Prognosis

Patient have insight of her mental condition , so the psychotherapies and psychoeducation along
with medication will be helpful for better outcomes.

Case conceptualization

Miss GH was 33 years old lady. She belongs to a middle-class family. She got education till
B.Sc. She was self-referred in Fountain Hospital Sargodha. She was married 8 years ago.. She
had 1 daughter and 1 son. Her developmental milestones were normal and she was a good
student and passes a memorable time in school and college. She had normal relationship with her
father and siblings but she was too attached with her mother and had a close relationship with
her. Miss GH was 23 years old when her mother died. Since then, she feels symptoms like lack
of energy, hopelessness, pessimism, insomnia, indecisiveness, poor self-esteem, lack of appetite
and difficulty concentrating. These symptoms decreased when she got married at the age of 25
but after 5 years of her marriage, symptoms increased as her husband went abroad for business.
These symptoms and their time period show that she had been suffering from persistent
depressive disorder that is a chronic mental illness. According to DSM-5 She had Persistent
Depressive Disorder (Dysthymia)300.4 (F34.1).

Predisposing factors Her family history was clear.

Precipitating factors Mothers’ death and husbands’ absence
Perpetuating factors Ongoing stressors, loneliness
Protective factors Supportive family and friends
 Trigger

Mother’s death

Type 1 worry

Sadness ,wryness

Type 2 worry

Lack of sleep, and appetite, trouble

concentration

Emotions
Thought
Behavior Control No control on
emotions like
Irritability Provoke
crying over
tension
great
Management plan

Long term goals

 Continuation of Short-term goals

 Working on cognitions of patient about worry
 Working on memory and concentration issues
 Follow up sessions.

Short term goals

Short term goal Therapeutic intervention

 Exercise for 30 minutes ,three times per week
Health and fitness
 Increase daily water intake to eight glasses
Education  Complete a specific reading assignment in a
week
 Attend any mental health session
Mental health  Practice mindfulness or meditation
for 10 minutes daily.
Social engagement  Reach out of family or a friend for social
interaction once in a week
Self-care practice  Engage in a self-care activity daily like taking a
warm bath, going for a short walk practice deep
breathing exercise
Nutrition  Plan and prepare at least one nutritious meal per
day

Summary of Therapeutic Intervention

For someone dealing with depression, these short-term goals are designed to be
achievable ,providing step toward self-wellbeing. These short-term goals are aim to create
structure ,foster social connections encourage self-care and provide therapeutic support all
contributing to a holistic approach to managing depressive symptoms.
Target behavior;

 To improve depressive symptoms

 Enhancement of coping skills
 Improvement in functioning
 Social engagement
 Enhancement of self esteem

Interventions :

1. Psychotherapies
i. Cognitive behavioral therapy (CBT): CBT was applied on patient to help to
identify her cognitive distortions and negative thoughts and behaviors as CBT is
effective in addressing distorted thinking and developing coping strategies.
ii. Interpersonal therapy (IPT): IPT is helpful in improving interpersonal
relationships and communication to alleviate depressive symptoms. Particular
helpful in social difficulties.
iii. Mindfulness and meditation; Practices such as mindfulness-based stress
reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) can help
individuals develop awareness of their thoughts and emotions, reducing the
impact of depressive symptoms.
iv. Problem solving therapy : patient was introduced through the problem-solving
skills . that will help her out from the problematic behavior.
v. Family therapy : As family play an important role in recovery of patient , family
was also involved in therapy sessions.
vi. Medication : Anti-depressants were given to the patient.
vii. Lifestyle changes :
 Regular exercise
 Healthy diet
 Adequate sleep
 Goals:

 Symptom reduction
 Improvement in daily functioning
 Enhancement of coping skills
 Identification and modification of thoughts patterns
 Improvement in sleep patterns
 Improvement in social relations
 Adherence to treatment plan

Procedure :

First of all the psychological tools were used ,after the diagnosis through these tools’ patient was
ready for therapy sessions, in first step of therapy patient was informed that this will not be
harmful at all and it will be very helpful for you to reduce your depression. Patient started taking
session willingly, in first session CBT was used to introduce the patient with her negative
thoughts and she learned the coping strategies. In second session the interpersonal therapy was
used for development of interpersonal relationships better. Patient was also given the family
therapy and medications including anti-depressants.

Outcomes :

 Enhanced coping skills

 Learn to reduce negative thought
 Happy mood
 Relaxed
 Socially engaged
 Better sleep