PSYCHODIAGNOSTIC REPORT

Name Ms. R.B

Father Name Mr. NB
Age/Date of Birth 24 years/ 10th Feb, 2001
Date of Assessment 17th , 18th ,19th and 21th May, 2025
Case No 04
Examiner Miss Musfira Nisar

Identifying Information
Ms. P.Q is 24 years old. Her father is retired. Her mother is housewife. Her birth order is first
among 3 siblings. Her family structure is joint and middle socio- economic status. Her religion
is Islam. She belongs to “Urdu” speaking Muslim family and she is resident of “Haripur”.

Referral Source and Presenting Problems

Miss R.B approached Department of Psychology for psychological assessment purpose. Client
reported that she is experiencing the following symptoms like headache, excessive worry about
future, insomnia, difficulty in making decisions, fatigue, concentration issues, body pain.

Interview Information

The client reports experiencing persistent headaches, insomnia, excessive worry about the
future, difficulty in making decisions, body pain, fatigue, and poor concentration from past
seven months. This anxiety is affecting her academic and professional performance. She
reports a consistent pattern of overthinking and anticipatory worry, especially about family
responsibilities and future uncertainty.

The client belongs to a supportive family system. She shares positive and healthy relationships
with her parents and siblings. Her father is retired but continues to work to support the family
financially. One of her sisters is currently studying at college, while she works to support the
household financially.

The client studied in the same school throughout her academic years. She participated in extra-
curricular activities and maintained positive relationships with both peers and teachers.
The client is currently working as a teacher in an institution near her home and has been in this
role for the past 8 months. Although she maintains a good relationship with her colleagues, her
income is not sufficient to support the family. The client describes herself as introvert selective
and prefers to maintain a small circle of close friends. The client follows a structured daily
routine. She feels fatigued after returning from work, which affects her ability to engage in
other activities. She reports feeling emotionally drained and socially withdrawn due to her
constant worry. She is not interested in sports and prefers reading books in her leisure time.

The client is a religious person and finds comfort in spiritual practices. Her speech was
coherent, her thought process was logical, and her affect was anxious but appropriate to
content. The client has a clear and stable gender identity. The client reports experiencing
frequent headaches and painful menstruation, which may be contributing to her psychological
distress.

There is no history of addiction or substance abuse in her family. The client exhibits some traits
of a dependent personality. She tends to rely on others for emotional support and decision-
making. During the interview, the client appeared anxious but was open, cooperative, and
responsive to the assessment process. The client shows an average level of intellectual
functioning. She demonstrates a fair level of insight and motivation to understand and
manage her condition.

Behavior During the Session

Client was fully oriented. Her body gestures and posture appear normal. She is cooperative
during sessions and openly shares information. She is able to maintain eye contact and engages
appropriately in communication.

Test Administration
 Bender Gestalt Test (BG)
 Standard Progressive Matrices (SPM)
 Human Figure Drawing (HFD)
 Thematic Apperception Test (TAT)
 Beck Anxiety Inventory (GAD)

Psychological Evaluation
The client is scored 3 on Bender Gestalt Test suggesting that the individual mild impairment
in visual-motor integration or mild emotional or cognitive stress, but not necessarily serious
pathology.
The client scored 41 on the Standard Progressive Matrices (SPM), placing her in the 50th
percentile, which indicates intellectually average.
On Human Figure Drawing test suggest that the client displays tendencies of suspiciousness,
difficulty in decision making, introvert and overthinking.
On projective test (TAT) analysis client reveals a strong need for dejection, affiliation,
achievement, counter action, infa avoidance, passivity, succrance, harm avoidance,abasement,
understanding. The client employs a defence mechanism rationalization,denial,regression,
altruism, isolation.
The client scored 15 on the Generalized Anxiety Disorder Assessment, indicating a severe
level of anxiety.

Tentative Diagnosis

Generalized Anxiety Disorder

Prognosis
Client has a positive prognosis, demonstrates insight into her issues, and is willing to engage
in psychological support.
Recommendations
Following recommendations were given to the client to treat her problem.

 Cognitive Behavioral Therapy (CBT) is recommended to help the patient identify and
restructure maladaptive thought patterns, reduce worry, and develop effective coping
strategies.
 Provide psychoeducation regarding the nature of anxiety, its physical and cognitive
symptoms, and the impact on daily functioning.
 Relaxation Training and Mindfulness Techniques such as deep breathing, progressive
muscle relaxation, and mindfulness-based stress reduction (MBSR) to help manage
physiological symptoms like headaches and body pain.
 Sleep Hygiene Education providing guidelines for healthy sleep habits, such as
maintaining a regular sleep schedule, limiting screen time before bed.
  Introduce tools and techniques to help the patient improve their time management and
decision-making abilities, which may reduce daily stress and cognitive overload.
 If symptoms such as persistent headaches and body pain continue, consider a referral
 Schedule regular therapy sessions to monitor progress, reassess symptoms, and adjust
the treatment plan as needed. Involve the patient in goal setting and progress tracking
to enhance motivation and engagement.

Summary
Miss RB is 24 years old girl . Her presenting complains were headache, excessive worry about
future, insomnia, difficulty in making decisions, fatigue, concentration issues, body pain. BG,
SPM, HFD, TAT and GAD were implemented on her that gives a clear insight of problem.
Cognitive Behavioral Therapy, Provide psychoeducation, Relaxation Training and
Mindfulness Techniques,Sleep Hygiene Education were recommended to the client to resolve
her problem.

Internship Supervisor Examiner

Ma’am Somia Shabbir Ms. Musfira Nisar

Lecturer Psychology/Clinical Psychologist PGDCP Internee 2nd Semester, AUST

Department of Psychology, AUST Date 22/05/2025

 TREATMENT PLAN

Case No 04

Gender Female

Age 24 years

headache, excessive worry about future, insomnia, difficulty in

Symptoms
making decisions, fatigue, concentration issues, body pain

Tentative Diagnosis
According to DSM-5- Generalized Anxiety Disorder
TR

 Excessive worry about the future

 Difficulty in making decisions
 Impaired concentration
 Sleep disturbances (e.g., insomnia)
 Avoidance of decision-making tasks
Targeted Symptoms  Reduced daily functioning or productivity
 Headache
 Fatigue
 Body pain (e.g., muscle tension, general discomfort)

 Reduce excessive worry and anticipatory anxiety through

Cognitive Behavioral Therapy (CBT) interventions such as
cognitive restructuring, worry time scheduling.
 Enhance focus and concentration through attention-
training exercises, mindfulness-based practices, and
Treatment Goals for
reduction of cognitive distractions caused by chronic
Targeted Symptoms
worry.
 Sleep disturbances by introducing sleep hygiene education,
establishing consistent routines, and incorporating
relaxation strategies (e.g., deep breathing, guided imagery)
before bedtime.
  Reduce physical symptoms of anxiety (e.g., headaches,
body pain, fatigue) using psychoeducation
 Build emotional resilience and improve emotional
regulation through mindfulness-based stress reduction
(MBSR), Acceptance and Commitment Therapy (ACT),
and distress tolerance techniques to manage emotional
discomfort and restlessness.
 Increase energy levels and reduce fatigue by addressing
sleep issues, promoting physical self-care routines.
 Encourage engagement in daily responsibilities by using
behavioral activation to counter avoidance patterns and
increase motivation in daily life.

• Cognitive Behavioral Therapy (CBT)

- Cognitive restructuring
-Worry Time Scheduling.
• Mindfulness-Based Interventions
- reduce overthinking
- reduce mental fatigue
• Acceptance and Commitment Therapy (ACT)
Treatment Approaches - Defusion Techniques
- Values-Based Goal Setting
• Psychoeducation
- Psychoeducation on Anxiety
- Sleep Hygiene Education
• Relaxation and Somatic Techniques
- Deep Breathing
- Grounding Techniques

✓ Establish a trusting and supportive therapeutic relationship

✓ Conduct a comprehensive assessment of symptoms about the
Initial Phase
client’s psychological, cognitive, emotional, behavioral, and
somatic symptoms. This includes identifying core fears, cognitive
 distortions, avoidance behaviors, functional impairments, and
potential contributing psychosocial or environmental factors.
✓ Identify patterns of excessive worry and cognitive
✓ Provide psychoeducation about Generalized Anxiety Disorder
and Introduce the client to the treatment framework
✓Introduce foundational mindfulness, relaxation, and grounding
techniques to reduce anxiety
✓ Establish baseline functioning and treatment goals

• Implement Cognitive Behavioral Therapy interventions to

identify, challenge, and reframe maladaptive thought patterns
contributing to anticipatory anxiety and decision-making
difficulties.
• Introduce problem-solving and decision-making strategies to
manage daily stressors, reduce indecisiveness, and increase
confidence in making choices.
Middle Phase
• Mindfulness-Based Stress Reduction (MBSR) and Acceptance
and Commitment Therapy (ACT) to help the client accept
distressing thoughts and feelings without judgment, improving
tolerance for emotional discomfort.
• Continue applying relaxation and somatic regulation techniques
to manage physical symptoms.
Monitor progress and adjust interventions as needed

✓ Review progress and consolidate therapeutic gains

✓ Strengthen relapse prevention skills

Termination Phase ✓ Develop a personalized coping and maintenance plan.

✓Prepare for ending the therapeutic relationship

✓ Offer booster sessions or group support referrals, if needed.

Number of Sessions
Required to Achieve • 8-10 sessions, depending on individual response and severity.
Goal (Approximately)
Internship Supervisor Examiner

Ma’am Somia Shabbir Ms. Musfira Nisar

Lecturer Psychology/Clinical Psychologist PGDCP Internee 2nd Semester, AUST

Department of Psychology, AUST Date 22/05/2025