CLINICAL CASE REPORT

Submitted by: Shakirullah

Roll Number : 191410

Semester: 8th

Department of psychological studies,

University of Swat
 CERTIFICATE

It is certified that Mr.Shakirullah, Registration No UOS191061010 has successfully

completed Psycho Diagnostic Report under the supervision of Mr.Israr Muhammad.

__________________________

Internship Supervisor, Mr. Israr Muhammad

Main campus,

University of Swat

___________________________

Head of Department of Psychology, MS. Palwasha Rahim

Main Campus

University of Swat

___________________________

External Examiner
 TABLE OF CONTENTS

DEDICATION………………………………………………………………...1

ACKNOWLEDGMENT……………………….……………………………...2

CASE # 1(OBSESSIVE-COMPULSIVE DISORDER)....................................3

CASE # 2(POSTPARTUM DEPRESSION)………………………………......10

CASE # 3(SOCIAL ANXIETY DISORDER)…………………………….......17

CASE # 4(BIPOLAR I DISORDER)……………………………………….....24

CASE # 5(SCHIZOPRENIA SPECTRUM DISORDER)…………………......30

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DEDICATION

I dedicate all my efforts and struggles of the educational life to my dear parents; without them

I,m meaningless. Also ,I devote the work of this internship report to respectable and honourable

teachers who taught and supported me in developing my personality as a hard work student.
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ACKNOWLEDGEMENT

First of all, I would like to thank Allah Almighty who gave me the courage and strength to

complete my internship and made me able to overcome all the difficulties that I had during

the clinical internship.

My special thanks to my internship supervisor for his facilitating and encouraging attitude.

Thanks to my family, friends and internship colleagues for their moral support,

encouragement and guidance, this was a big support for me throughout my placement.

Shakirullah
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CASE # 1:

(OBSESSIVE-COMPULSIVE DISORDER)
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SUMMARY OF CASE # 1

The client was born in Mingora Swat. She is 3rd child out of 5 siblings and 30 years old .she

lives in Mingora in a nuclear family and got married in mangle when she was 25 years old.

She shared really good bond with her parents and siblings. She has stable relationship with

her husband but her mother in law is disappointed with her repetitive behaviors and blames

her parents for giving an ill daughter-in-law to us. There is no history of abuse.The client

belongs to the middle social class with good economic conditions. She lives in a nuclear

family. She has 3 brothers and 2 sisters; her birth order is 3rd amongst them. The client‘s

relationship with immediate family is very good. She got married at the age of 25 it was an

arrange marriage. She is happily married with her husband with 2 children‘s 1 boy and 1 girl,

the girl is 1 year old and the boy is 3 years old. Her father has OCD.The history of symptoms

comes from 7 years ago when the client was attentive towards her father as she took care of

him. Her father would always wash his hands and would rearrange items in the room and

some other repetitive behaviors. Because she spends a lot of time with her father she would

unconsciously copy his behavior. At the beginning the client would only wash her hands

frequently but after sometime she had problem with praying. To treat this she went to doctor

Nizam Ali. Because she adhered to the medication and treatment she treated at that time. But

after her marriage she experienced these symptoms again with period problems too. The

client reported that she has been experiencing the symptoms for the past 7 years. She finds it

difficult to pray and when she does she spends hours completing the prayers. When washes

her hands frequently and always keeps herself and her clothes clean but when she is on her

period she does not touch anything as she is doubtful that the person/thing will become

impure.
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CASE # 1

(OBSESSIVE-COMPULSIVE DISORDER)

BIO DATA

Name OP

Age 30

Gender Female

Marital status married

Education FA

Occupation Nil

No. of siblings 5

Birth order 3rd

Socio Economic Status middle class

Religion Islam

Referred by Dr. Nizam Ali

+
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REASON FOR REFERRAL

The client was brought to the hospital by her husband with complaints of always washing

hands and avoiding people due to hygiene issues, she had doubts in her mind whilist she

prayed that she‘s not reading correctly so she would start her prayer again.

PRESENTING PROBLEM

I have repetitive behavior of washing hands .When I‘m on my period I feel dirty and unclean

and .I do not touch anything or my children because the will become impure. I have

interfering thoughts about praying .I overthink about my situation and I feel helpless about

not having control over it.

HISTORY OF COMPLAINTS

The client reported that she has been experiencing the symptoms for the past 7 years. She

finds it difficult to pray and when she does she spends hours completing the prayers. When

washes her hands frequently and always keeps herself and her clothes clean but when she is

on her period she does not touch anything as she is doubtful that the person/thing will become

impure.

PAST HISTORY

The history of symptoms comes from 7 years ago when the client was attentive towards her

father as she took care of him. Her father would always wash his hands and would rearrange
 7

items in the room and some other repetitive behaviors. Because she spends a lot of time with

her father she would unconsciously copy his behavior. At the beginning the client would only

wash her hands frequently but after sometime she had problem with praying. to treat this she

went to doctor Nizam Ali. Because she adhered to the medication and treatment she treated at

that time. But after her marriage she experienced these symptoms again with period problems

too.

PERSONAL HISTORY

The client was born in Mingora Swat. She is 3rd child out of 5 siblings and 30 years old .she

lives in Mingora in a nuclear family and got married in manglor when she was 25 years old.

She shared really good bond with her parents and siblings. She has stable relationship with

her husband but her mother in law is disappointed with her repetitive behaviors and blames

her parents for giving an ill daughter-in-law to us. There is no history of abuse.

SCHOOL HISTORY

The client has a good academic background with good participation in co-curricular

activities.She completes studies and did FA.

FAMILY HISTORY

The client belongs to the middle social class with good economic conditions. She lives in a

nuclear family. She has 3 brothers and 2 sisters; her birth order is 3rd amongst them. The

client‘s relationship with immediate family is very good. She got married at the age of 25 it
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was an arrange marriage. She is happily married with her husband with 2 children‘s 1 boy

and 1 girl, the girl is 1 year old and the boy is 3 years old. Her father has OCD.

PSYCHOLOGICAL ASSESSMENT

Behavioral observation

The client was sitting uncomfortably. She was cooperative in answering all the questions and

was very anxious.

Talk

The client had normal and organized speech with high volume.

Mood

Subjective: Overwhelmed, frustrated.

Objective: Tensed, overburdened.

General appearance

The client appeared to be a young adult with low height and an average weight. She was very

clean and organized.

Orientation

The client was oriented regarding the place and time.

Thought: unwanted thoughts

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DIAGNOSIS: Obsessive-Compulsive Disorder

PROGNOSIS

The client has good insight about her disorder. She‘s willing to have her disorder treated and

adherence to treatment. The prognosis is satisfactory with anticipated benefits as the client is

cooperative and came to seek therapy regularly.

RECOMMENDATIONS

 Mindfulness – Based Cognitive Therapy (MBCT)

 Exposure and Response Prevention (ERP)

 Progressive Muscle Relaxation (PMR)

SUGGESTIONS

Even when things are going well, Obsessive – Compulsive Disorder can hijack your life.

Obsessive thoughts and compulsive behaviors and the anxiety that comes with them can take

up massive amount of time and energy. Though medication and therapy are the main ways to

treat this lifelong condition, self – care is the secret weapon for it with plenty of side benefits.
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CASE # 2

(POSTPARTUM DEPRESSION)
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SUMMARY OF CASE # 2

The client was born in madyan SWAT. She was the 1st child among five siblings and she was

25 years old. She lives and got married in median too in joint family. She had good

relationship with her siblings, parents in childhood, in teenage years and even now but her

aunt is such a strong women and she abused her mother and siblings in childhood. The client

belongs to lower class family. Her father died after her marriage and her mother is alive, she

is the 1st child among 3 brothers and 2 sisters. She got married at the age of 19 to that aunt

son who abused her and her family and it was an arrange marriage. She has stable

relationship with spouse. She has 3 sons and 2 daughters. There is no family history of

disease. The client had been experiencing symptoms for the last 6 months as severe headache,

sadness, irritation, aggression, insomnia, fatigue, low mood most of the time, lack of appetite,

loss of energy. She said that I like being in a calm environment and didn‘t want to talk to

anyone. She‘s a maid so she can‘t work properly and gets tired quickly and cannot

concentrate on her work. She has been given injections for severe headache which make her

unconscious for 2-3 days. Her main problem is that her husband financial condition is not

good because of which she works in someone‘s house they gave them home and do not give

salary. She had to work for them and for her children‘s too and the landlord threatens to evict

them from house for not working from which she is a victim of depression. They are having 5

babies to feed and educate them.

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CASE # 2

(POSTPARTUM DEPRESSION)

BIO DATA

Name KL

Age 25

Gender Female

Marital status Married

Birth order 1st

Socio Economic status lower class

Education Uneducated

Occupation House wife

No 0f siblings 5

Religion Islam

Referred by Dr.Gohar Ali

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REASON OF REFERRAL

The client was brought to the hospital by her neighbor with the complaints of severe

headache,excessive crying, difficulty sleeping, lack of energy, being uninterested in her baby,

not feeling connected to baby and low mood.

PRESENTING PROBLEM

I find myself crying all the time for no specific reason. I have no interest in taking care of my

baby or fulfilling his needs of my child. I have difficulty sleeping because I have a lot on my

mind. I feel moody and restless and have no energy to take care of my baby.

HISTORY OF COMPLAINTS

The client had been experiencing symptoms for the last 5 weeks after giving birth such as

severe headache, crying spells ,difficulty sleeping, lack of energy, being uninterested in her

baby, not feeling connected to baby and low mood. The client had stated that she struggles to

speak to her in-laws and prefers to sit alone and is always crying. She does not have any

interestin caring for her baby other family members take care of the baby.

PAST HISTORY

The client experienced stressful events during the past years her main problem is that

herhusband financial condition is not good because of this her in laws do not treat her well.

Her husband used to work in Dubai but he left work and came back to Pakistan to take care

of his wife as she was not well. Her husband does not have a stable job in Pakistan due to this
 14

her mother in-law constantly blames her for his decision which made her really anxious. She

experienced pregnancy complications in the past too. She had 3 babies, 2 boys and 1 girl.

PERSONAL HISTORY

The client was born in madyan SWAT. She is the 1st child among five siblings and she‘s 27

years old. She lives and got married in madyan at the age of 20, it was an arranged marriage.

She stated that her childhood was spent well with her parents. After her wedding the

relationship with her in-laws was not good and her mother in-law abused her.

SCHOOL HISTORY

The client was uneducated.

FAMILY HISTORY

The client belongs to lower class family. Her father died after her marriage and her mother is

alive, she is the 1st child among 3 brothers and 2 sisters. Her relationship with them was

good. She got married at the age of 18 and it was an arrange marriage. She has a stable

relationship with her husband but not with her in laws. She has 2 sons and 1daughter. There

is no family history of disease.

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PSYCHOLOGICAL ASSESSMENT

Informal assessment was carried out with the help of behavioral observations during taking

history.

Behavioral observation

The client constantly cries and does not pay attention to my words. She was not cooperative

at the beginning but after I had interacted with her she was feeling at ease and respond to the

questions that have been asked. Her motor behavior was not normal.

Talk: The client‘s talking manner was not good enough as she would jump back and forth

from different conversations.

Mood: The client‘s mood was low.

General appearance: The client was a middle age adult women of low weight and an

average height. She was wearing shuttlecock abaya and had bad hygienic condition.

Orientation: The client was well oriented to time, place, and person. She has a good

memory.

Thought: She was constantly thinking of her situation which makes her disturbed.

DIAGNOSIS

Major depressive disorder with peripartum/postpartum onset.

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PROGNOSIS

The client now has a good insight about her disorder. The client has gained an insight about

her disorder. The prescribed treatment techniques were described to her. After speaking to

her she decided to cooperate with me and take therapy session regularly.

RECOMMENDATIONS

● Family therapy

● interpersonal therapy

●mindfulness

SUGGESTION

Seek help. Don't hesitate to accept help from family and friends during the postpartum

period, as well as after this period. Your body needs to heal, and practical help around the

home can help you get much-needed rest. Friends or family can prepare meals, run errands,

or help care for other children in the home.

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CASE # 3

(SOCIAL ANXIETY DISORDER)

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SUMMARY OF CASE # 3

The client was born in Matta SWAT. She is the 2nd child among 7 siblings, and she‘s 22

years old. She lives in Matta Swat and single. She stated that her childhood was spent well.

She had good relationship with her siblings, parents and friends in childhood, in teenage

years and even now and no history of abuse. The client belongs to middle class family. Her

father is property dealer and mother is housewife. Her relationship with family and close

friends is good. Her parents are neither too strict nor too free. She grew up in a caring

environment. She is the 2nd child among 6 brothers. There is no history of family disease.

The client had been experiencing symptoms for the last 3 years as feelings of fear,

nervousness, blushing, low self-esteem, trembling, shaking, and difficulty in speaking,

sweating, rapid heart rate. She can‘t give presentation in class room and can‘t even ask

question during class. She stated that I can interact with my family and close friends without

any fear but difficulty In interacting with university people and outsiders or my second

cousins she said that I am afraid of doing something wrong in front of them and everyone

will laugh at me and make fun of me. She believes she may be judged negatively,

embarrassed or humiliated. The history of social illness date back to 3 years. The main

stressor is that she can‘t interact anyone without her family and speak in front of teachers,

university students or strangers. She‘s afraid of doing something wrong in front of them.
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CASE # 3

(SOCIAL ANXIETY DISORDER)

BIO DATA

Name EF

Age 22

Gender Female

Marital status Unmarried

Education doing BS zoology

Occupation Nil

No of Siblings 7

Birth order 2nd child

Socio Economic status Middle class

Religion Islam

Referred by Dr.Ashfaq hussain

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REASON OF REFERRAL

The client was brought to the hospital by her brother with the complaints of nervousness,

intense fear about specific social situation because she believes she may be judged

negatively, embarrassed or humiliated.

PRESENTING PROBLEM

I have intense fear when presenting in front of my class. During lectures I cannot ask

questions when I am confused as I am scared the teachers and students will laugh at me. I am

also scared if my class fellows asking me a question and I may answer them wrong. I cannot

interact with strangers or someone out of my family.

HISTORY OF COMPLAINTS

The client had been experiencing symptoms for the last 3 years such as feelings of fear,

nervousness, blushing, low self-esteem, trembling, shaking, and difficulty in speaking,

sweating, rapid heart rate. She can‘t give presentation in class room and can‘t even ask

question during class. She stated that I can interact with my family and close friends without

any fear but difficulty in interacting with university people and outsiders or my second

cousins. She said that I ‗m afraid of doing something wrong in front of them and everyone

will laugh at me and make fun of me. She believes she may be judged negatively,

embarrassed or humiliated.
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PAST HISTORY

The history of social illness date back to 3 years. The main stressor is that she can‘t interact

with anyone without her family and cannot speak in front of teachers, university students or

strangers. She‘s afraid of doing something wrong in front of them and social embarrassment.

She has low self-esteem and no social skills to have successful interaction. She is not

prepared for her presentations because of this she has had many occasions where class

fellows have asked her questions and she couldn‘t answer them. Due to this she is always

anxious and worried.

PERSONAL HISTORY

The client was born in Matta SWAT. She is the 2nd child among 7 siblings, and she‘s 22

years old. She lives in Matta Swat and is single. She stated that her childhood was spent well.

She had good relationship with her siblings, parents and friends in childhood, in teenage

years and even now and no history of abuse.

SCHOOL HISTORY

The client was a good student in school. She has taken positions 3rd or 2nd up to class fifth

but after that she was an average student. And now she‘s a little weak in studies.
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FAMILY HISTORY

The client belongs to middle class family. Her father is property dealer and mother is

housewife. Her relationship with family and close friends is good. Her parents are neither too

strict nor too free. She grew up in a caring environment. She is the 2nd child among 6

brothers. There is no history of family disease.

PSYCHOLOGICAL ASSESSMENT

Behavioral observation

The client was not cooperative and was not responding properly to the questions that have

been asked to her. She would refuse to answer the questions that were asked. She was

nervous and had a poor eye contact with me.

Talk: The client‘s talking manner was not good enough and rapid changes in tone of voice.

Mood: The client‘s mood was anxious.

General appearance: The client was an adult woman of an average height and weight. Her

hygienic condition was very good.

Orientation: The client was well oriented to time, place, and person. She has good memory.

Thought: she was constantly thinking that I will end up like a fool as I usually do, during

presentation my voice starts shaking and I humiliate myself. I will not be able to present my

work with confidence.

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DIAGNOSIS: Social Anxiety Disorder

PROGNOSIS :The client has gained an insight about her disorder. The prescribed therapy

was discussed with her.She agrees to take the therapy sessions and is cooperative.

RECOMMENDATIONS

 Daily healthy routine tasks

 Mindfulness

 Cognitive restructuring
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CASE # 4

(Bipolar 1 disorder)
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SUMMARY OF CASE # 4

Client was 40 years old. She did not go to school and is uneducated. She has the symptoms of

complaining about disturb mood, excessive talking, flight of ideas, easily distractible,

increased activity and agitated movements. She was complaining about significant weight

loss. Along with these, she also complains about appetite and sleep disturbance. She also

reported low self-esteem and helplessness due to her marriage with a person who already had

one wife and 8 children. After Marriage she was unable to tolerate the first wife. She got

admitted in the hospital because she felt a little frustrated and was unable to control her

persistent crying episode in night. Client believe that people with mental are dangerous and

having hallucinations disturbed and illogical thinking. . The signs and symptoms are

indicating towards Bipolar 1 disorder due to severe mood swings and frustration. But
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CASE # 4

(Bipolar 1 disorder)

Bio Data

Name case-4

Age 40 Years

Gender Female

Religion Islam

Marital Status Married

Education Nil

Occupation House wife

Birth Order 6th

No of Siblings 9
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SOURCE OF REFERAL

Case-4 approached hospital for the treatment for continuous violent behaviors that were

becoming severe day by day. He was referred by his family to Saidu group of teaching

hospital.

PRESENTING COMPLAINTS

She was admitted in the hospital as a Bipolar I patient in the central Hospital. She has the

symptoms of complaining about disturb mood, excessive talking, flight of ideas, easily

distractible, increased activity and agitated movements. She was complaining about

significant weight loss. Along with these, she also complains about appetite and sleep

disturbance. She also reported low self-esteem and helplessness due to her marriage with a

person who already had one wife and 8 children.

HISTORY OF COMPLAINTS

During his interview he reported that he has this problem from last 12 years and during these

conditions she even tried to harm herself and the second wife of her husband as well. She was

unwilling to get married under married under a condition when a man already has one wife,

but she was left with no choice. After Marriage she was unable to tolerate the first wife. She

got admitted in the hospital because she felt a little frustrated and was unable to control her

persistent crying episode in night.

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PREVIOUS MEDICAL HISTORY

No serious medical history

PREVIOUS PSYCHIATRIC HISTORY

Client doesn’t have any previous Psychiatric history.

JOB RECORD

House wife

SCHOOL RECORD

Client has not gone for the basic of school, and there is no such record because she does not

attend education.

HISTORY OF FRIENDSHIP/SEXUAL HISTORY

Client does not have any history of friendship and sexual relation or close relationships.

FAMILY HISTORY

Client marriage status is unstable. Because she is the second wife of her husband in unable to

tolerate the first wife.

MENTAL STATUS EXAMINATION (MSE)

Throughout the whole session the client was attentive, cooperative and was sharing most of

the information. Her appearance was unhygienic and dirty with agitated motor behaviors. She

was having disturb mood. The orientation was also not so good.

MINI MENTAL STATUS EXAMINATION (MMSE)

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Client was aware of the time: year, month, and day and of his surrounding places such as

floor, city, country etc.

PERCEPTION

Client believe that people with mental are dangerous and having hallucinations disturbed and

illogical thinking.

DAIGNOSIS

The client was diagnosed on the basis of DSM-5 criteria; there were no use of such

psychological scales and tests. Which we assessed in the client current suffering and his

present symptoms is according to DSM-5.

PROGNOSIS

The presenting complaints indicate that case-4 has a severe psychological problem. The signs

and symptoms are indicating towards Bipolar 1 disorder due to severe mood swings and

frustration. But as only a single session has been taken so accurate prognosis is not possible.

RECOMMENDATIONS

 Cognitive behavioural therapy(CBT)

 Family focused therapy(FFT)

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CASE # 5

(SCHIZOPHRENIA SPECTRUM DISORDER)

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SUMMARY OF CASE REPORT 5

Client was 15 year old teenager, he don’t go to school nor work, he is having poor and not so

good relation with his family, friends and want to be alone, he was addicted to substance use.

He come to us at rehabilitation center with complaints of failure to remember

things,headache, and aggression, less sleep, appetite problem, self destructive behavior,

hallucination, low concentration, and suicidal tendencies from 8 years with severe condition.

He has been through head injury and hospitalization, his appearance was not good, he was

aggressive, abnormal speech, low mood, negative thought process, low memory, and suicidal

ideation. The symptoms are often directed to reveal about the schizophrenia disorder, thus

client is diagnosed with schizophrenia spectrum disorder.

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CASE #5

(SCHIZOPHRENIA SPECTRUM DISORDER)

BIO DATA

Name SL

Age 15

Gender Male

Marital status Single

Education 4th

Religion Islam

Occupation Nil

No of sibling 5

Birth order 1st

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SOURCE OF REFFERAL

The client was referred to us as a trainee psychologist for the assessment of the nature and

extent of psychological disorder; he was referred to New Swat Psychotherapy and

Rehabilitation Centre by his father.

PRESENTING COMPLAINTS

A client come up to clinic and revealed about current presenting complaints, the symptoms of

client was failure to remember things, headache, and aggression, less sleep, appetite problem,

self destructive behavior, hallucination, low concentration, and suicidal tendencies.

HISTORY OF COMPLAINTS

The client reported that his problems was started to appear from last 8 years with above

symptoms of schizophrenia due to substance uses and head injury, the thoughts and behavior

and symptoms are severe as a result client personal, social, educational life is impair.

PREVIOUS MEDICAL HISTORY

Client has medical history of head injury, and substance uses and free from other illnesses,

surgeries, and hospitalization.

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PREVIOUS PSYCHIATRIC HISTORY

Before his treatment from rehabilitation center, client has no any other appointment or visits

with psychiatrists for his treatment; he only went through some religious treatment for his

problems.

JOB RECORD

Client presently not working and nor have experience or previous history of working he only

attend education till 4th standard, and free from job.

SCHOOL RECORD

Client educational record was average till 4th class at the time and there is no broad record of

the client in educational settings and his family was financially unable to support him.

FAMILY HISTORY

Client is teenager, his relationship with parents is not good, his father is addiction of

cannabis, client does not miss his home and parents, while being in the rehabilitation center,

client also tried to suicide.

MENTAL STATUS EXAMINATION (MSE)

Client appearance was not good; he was aggressive, abnormal speech, low mood, negative

thought process, low memory, low concentration, and suicidal ideation.

 35

MINI MENTAL STATUS EXAMINATION (MMSE)

Client was not aware of the time; year, month, and day, nor from his surrounding places such

as floor, city.

PERCEPTION

Client pays no attention, he remains in motor behavior throughout the session such as hand

shivering, moving his head to different sides. He suffers from hallucination, appetite problem,

insomnia, aggression, and suicidal ideation.

DAIGNOSIS

The client was diagnosed on the basis of DSM-5 criteria; there were no use of such

psychological scales and tests. Which we assessed in the client current suffering and his

present symptoms is according to DSM-5 schizophrenia spectrum disorder.

PROGNOSIS

Client seems to be complicated; his childhood was too dark, drugs lead him to schizophrenia,

the symptoms of the client are serious, client needs more care and supervision, there will be

chances of a client reducing his symptoms, if he made a commitment with himself and agree

to treatment, further more treatment is needed to client condition can be dangerous.

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RECOMMENDATIONS

 Cognitive behavioural therapy

 Skill training