Professional Documents
Culture Documents
Case 01
Name of the client: M.A (female)
Case No: 01
Examiner: M.A.B
Identifying information:
M.A is 40 years old. Client is married. She is 1 st born among 2 siblings, 2 brothers. She is house
wife and belongs to urdu speaking family, she is Muslim. Clients parents are alive and they
belong to middle class family. Her father is 65 years old. He has done a textile administration
course, and was a well-paid managing director until retirement. And her mother is 58 years old,
and is a housewife. The clients husband is 46 years old, and is currently working as an
administrator at Allama Iqbal Medical College. The client has two brothers. The older brother is
36 years old. He did not take a lot of interest in studies and only completed Intermediate. He has
The patient was brought to Jinnah hospital by her husband with the complaints of chronic
depression, which has worsened over the course of the last few months. She was referred by the
The patient was referred because of severe depression punctuated with several suicidal attempts.
The patient reports she has been a patient of depression ever since shes been married, i.e. since
20 years. When her first child (daughter) was born she was especially depressed and admitted in
hospital for 3 months. This happened because she was made to work excessively by her sister-in-
law, who made her cook day and night and clean the house, too. The patient suffered from
extreme vomiting and pains during her pregnancy, and went into depression after that. She stayed
symptom free for 1 year, but soon relapsed, because of her sister-in-law, and the psychological
torture she inflicted upon the patient. Consequently she visited a consulting psychiatrist at Jinnah
Hospital for one year, but her condition did not improve.
Soon after that, they left their sister-in-laws house and moved into their own house. The patient
was then able to function normally, and according to the patient although there were times when
she felt depressed, this was not the most prevalent feeling, until some five years back when she
experienced severe depression and a year later also started having incessant and recurrent
The patient reports that her suicidal thoughts are activated when somebody is rude, because she
says that she tries to keep everybody happy. She is immensely disappointed by the behavior of
her brothers specifically. The patient has tried cutting veins, and the mark was prominent on her
right hand. She used to inflict cuts on her forearms, and legs. Some of these cuts were so deep,
she had to go and get herself stitched up, but she never felt pain, and felt relaxed after doing it,
when probed, she added: main ye iss liye karti thi kyun k mera aur meray bhaiyoh ka khoon ek
hi hai. Jab mera khoon girta tha tu mujhay lagta tha unka khoon zaya ho raha hai, tu yeh un hi
ka nuksan hai.
No guilt after these suicide attempts was reported and all of these attempts were made either in
the presence of people or the episodes were narrated later in great detail. She has also tried
jumping in front of a train, and the patient says that is the perfect way to commit suicide. She has
also run on roads on a number of occasions, in front of cars. Moreover, she has tried burning
herself and she drank phenyl on one occasion too. She reports: Im very sensitive, which is why
when my brothers mean to me, I feel like committing suicide, because these people will only be
happy when I am gone. I feel they are troubled because of me. Albeit, she acknowledges the
underlying assumption that they might realize her importance once she is dead.
After marriage suicidal attempts, she went to see a consulting psychiatrist at Combined Military
Hospital (CMH) in 2009, for 1.5 years and his treatment proved efficacious for the patient, and
suicidal attempts stopped. However, when the same psychiatrist said that Escitalopram was not
really working and suggested trying ECT, the patient terminated therapy. This happened in 2011.
Her husband then took her to the consulting psychiatrist at Jinnah Hospital again in August 2012,
when she made another attempt to take her life using a razor blade. Now she is under going
treatment from psychiatrist of Jinnah hospital for her treatment. She is currently on Ciproxin and
Quetapine and the patient has reported marked improvement in the quality of sleep and increase
in appetite.
The client shares a warm relationship with her father. She says her father is her ideal, and
that she had an amazing childhood. Also, she says her father was the one she was very close to,
when she had anything to say, she would say that to her father. Her father would pamper her, and
see to all her needs. On the other hand, her father was very strict with his sons, and her brothers
were very afraid of their father. Even now, she says she can share anything with her father, and
The client shares a somewhat ambivalent relationship with her mother. According to her,
her mother always preferred her sons over her, but she did see to her needs and was considerate
most of the time. Sometimes, she would beat her up, and her father would usually save her, and
take her side. After her marriage, however, she says her mother and her relationship strengthened
and they understood each other better. She reports having a friendlier relationship with her
mother now.
The client says that her parents have always had a very warm, balanced relationship. She says
her mother was dominating and controlling, while her father was very compromising. However,
when making decisions, her fathers word was the last. They did fight, but no more than anybody
else does. Most of the time, they were supportive of each other.
The client says she gets along with her sister-in-law and loves their children like her own. But
she says her brother is very rude to her, and even to her husband and her children. Also she feels,
that her sister-in-law is not as kind to her children, as she is to hers. The client says she becomes
very upset when her brother is rude to her and she keeps thinking about it day in and day out.
The clients younger brother has done ACCA. He is currently working in a prominent business
firm. He is 32 years old and is unmarried. The clients hares a congenial relationship with him,
and she says the younger brother behaves in a better manner, and is usually civil and courteous
towards her. However, sometimes he too says something that upsets her.
The client reported history of depression in the family. According to the client, her
mother suffered from severe depression 2.5 years back, when her brother went away to London,
for giving his ACCA exams, and her mother fell ill. She would often hear her sons voice, was
irritable most of the time and sometimes would sit alone and cry for hours. She had trouble
falling asleep and would hardly eat anything. She was treated for a year at Iqra Complex. Some
improvement was witnessed, but she recovered completely when her son returned after two
The client says the home atmosphere was pleasant and very comforting. They were
financially stable and they never had any money problems. They did not fight a lot amongst
themselves, except for the occasional fights between her brothers, or with herself. They were
According to the patient, no birth complications were experienced by the clients mother.
Her birth was a normal and she was delivered by a midwife at home. The developmental
milestones of walking, sphincter control and talking were achieved at time. The patient recalls
that as the eldest child, she was spoilt and pampered by her parents. However, when her brother
was born, her mothers attention shifted to him, but her father still showered her with attention.
She also adds that she did not have a lot of fights with her brother during their early childhood,
because there was considerable age difference between them that assured respect and
subservience.
The patient says that she was an intelligent student and worked hard. In her earlier
classes, she was one of the top students, however, at college level, she was an average student,
because she there was a lot of competition, and even though she worked hard, she still
The patient says her depression worsened when she married her husband. The patient has
been married for 20 years. Her husband was her fathers choice and she complied with it, even
though one of her cousins wanted her hand in marriage. She says her maternal uncle wanted her
to marry his son, but her father and paternal grandfather were against it, her mother was also
reluctant, so she ended up marrying the man her parents had selected for her. She adds that her
husbands behavior is often rude to her. She recalls that her mother-in-law died one year after
engagement, and her father-in-law died when her husband was very young, and her husband had
to live with his elder brother. Her husbands sister-in-law was a very mean, selfish, and
manipulative woman. She used to throw them out of the house when her husband was away, and
would not give them any food. The patient had to stay with her sister-in-law for three years and
she said that this time period was more traumatic than her entire life put together. She reports this
as the trigger for her depression. She says she had to clean the whole house when she was seven
months pregnant, and then her sister-in-law would intentionally make the house messy. She says
she has always supported her husband through thick and thin and been very nice to her in laws,
however her husband has never appreciated her. Also, she says they used to go to their sister-in-
laws house to continue contact, but her sister-in-law and her children completely ignored her,
and shed remain in depression for days, sometimes a week, after visiting their home.
They managed to construct a house of their own 3 years later, and their situation has been better
since then, but she still feels that her husband takes pleasure in taunting her and is often harsh
and mean. She says the reason for this is her reluctance to engage in sexual relations with him
since a year. She reports feeling impure and dirty after engaging in sexual intercourse, and often
took hour long baths and scrubbed herself, specifically her genitals. She also said prayers seeking
forgiveness after this act and would perform ablution again and again. She says her husband has
maintained an even stern demeanor since her refusal to engage in sexual intimacies with him.
She says she never felt a need or a sexual desire ever in life, but performed it as a duty to her
husband, but now she cannot bring herself to engage in this act again. No court or police cases
reported.
The patient worked as a primary school teacher in a private school near her home for 2.5
years, seven years back. She says she liked to work and found a lot of satisfaction in teaching.
But she says since her illness worsened she stopped working.
The patient describes herself as reserved but confident, introvert and inhibited even
before her illness, but she was also self-reliant and independent. She says she liked working
before she got ill, and liked watching TV, reading books. She says she liked to visit friends and
relatives too, but now she does not like to meet people on a regular basis. She adds that before
her illness, she was religious, but ever since she has been depressed her faith has strengthened
Tests Administered
During the initial sessions, the client was not willing to share the information, she was
aggressive and secretive, but gradually she developed trust on the psychologist and then she was
open about her problem and history and showed compliance. She had a sad and low mood, but in
later sessions, she was getting better and happy. She was talkative. Her motor movements were
mostly lethargic and slow. She maintained eye contact throughout the sessions. She got very sad
when she told about her previous experiences and telling conflicts with the family members. She
was very hopeless while talking about her marriage. Her level of attention and concentration
were intact.
Psychological Evaluation:
Human Figure Drawing test was administered on client. The patient was very much
hesitant to draw the pictures in the beginning. The drawings were mostly inclined towards left
side of the page showing impulsivity in behavior for gratification of needs. The stiff drawing of
human figure showed rigidity traits as well. The analysis of the human drawing figure is that she
is striving for achievement. She is anxious over interpersonal relationship, as it was also noted
that her needs of autonomy were hampered by the constricting domestic and martial situation at
home. Her feeling of inferiority, inadequacy, tension and helplessness were clearly shown by tiny
shoulders, arms extended outwards and also by small hands and arms.
RISB reveals that the patient has obtained a score of 159. The cut-off for RISB for females is set
at 121, thus this slight elevation is indicative of some maladjustment on part of the individual.
The social and sexual as apparent in the sentence-completion of the individual indicates that the
patient is somewhat disturbed because of her marital relationship; she has also expressed some
concern about not being a good mother. The sentence-completion shows that the individual
indicates that she does not enjoy being in overwhelming social environments, (especially when
shes ill). In her sentences, she has expressed concern about not being good enough for other
people. The general attitude as indicated by sentence-completion is worry about the future, and
failure to get better. The most dominant theme is worry about not getting completely cured, and
regrets about thinking negatively and doing self-harm. The character traits that are evident in the
Beck Depression Inventory (BDI) in this patient scored a total of 38 in BDI (Beck, 1996). This
Tentative Diagnosis
296.23 (F32.2) Major Depressive Disorder, Recurrent, Severe without Psychotic Features
Prognosis:
The patients prognosis is guarded. The prognosis is favorable because the patient has:
Perfectionistic tendency
Recommendation
Case Summary
Patient M.A., 40-year old female, was referred to trainee clinical psychologist with
presenting complaints of depressed and sad mood, lack of pleasure and history of self-harm.
Depressed mood had been experienced since twenty years, and self-harm history since the last
2.5 years. The patients psychological assessment included informal (Clinical Interview, Mental
State Exam) and formal (Beck Depression Inventory, Rotters incomplete Sentence Blank,
Human Figure Drawing). The results of psychological assessment along with the subjective and
objective symptoms indicated Major Depression. The patients strained relationship with
husband and oversensitive nature might have been acting as maintain stressors of her depression.
Restructuring, Positive Self Coping Statements, Mastery and Pleasure, Mood diary, Paper
Tearing, Activity Schedule, Identifying Cognitive Distortions, and Homework Assignments) and
Relaxation Techniques (Progressive Muscle Relaxation, Guided Imagery, and Deep Breathing).
The 13 therapeutic sessions proved to be effective in stopping self-harm acts, and coping with
Rapport building
Clinical interview
Middle Phase
Cognitive Restructuring
Mood Diary
Paper Tearing
Activity Schedule
Homework Assignments
Termination Phase
Relapse prevention
Self-management planning
Middle 6-11
Termination 12-14
Individual Session
Session 2
Session 3
Session 5
Homework Assignments
Last sessions homework assignments were reviewed,
and an updated activity schedule was provided to
them.
A-B-C worksheet, Cost-benefit analyses, DTR, and
positive quality identification worksheet was given
as homework.
Session6
Session 7
Goals Sleep hygiene was briefed to the patient,
because her quality of sleep had suffered
Mood diary was briefed and given to the
patient
Psychotherapeutic techniques implemented Mood Diary
Sleep hygiene
Outcome The patient was briefed upon sleep hygiene
in order to improve the quality of her sleep
The patient was briefed and administered a
mood diary. They were then given this
dairy for homework in order to better
monitor their progress and mood
Homework Assignment The previous assignments were reviewed
and advised to continue
Mood diary was given as additional
homework.